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Welcome to “Should I Call a Doctor?” The podcast where we dive into trending health topics to separate fact from fiction. We bring in experts to talk about all things health, to empower you with knowledge and answer your questions hosted by Inova Health.
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Welcome to should I Call a
Doctor?
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The podcast where we dive into
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the questions you have about
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your health and today's trending
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health topics.
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To separate fact from fiction.
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I'm one of your hosts, Doctor
Samuel Galli, an internal
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medicine physician at Inova.
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I'm Tracy Schroeder.
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I lead communications for Inova.
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Doctor Sam will give you the
clinical perspective while I ask
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the questions that keep patients
up at night.
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Today we're going to talk about
Alzheimer's disease.
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Joining us is Doctor Jennifer
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Palmieri, a cognitive behavioral
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neurologist at Inova who
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specializes in memory disorders
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and dementia.
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Thank you so much for having me.
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So as you said, I'm a cognitive
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thinking doctor and behavior
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doctor.
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So neurologists are specialists
in the brain, of course.
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But there's this esoteric,
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almost abstract way of thinking
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of the brain as a thinking
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leading organ.
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Like, for example, the knee
helps us to walk.
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You know, our mouth helps us to
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digest food and chew food, but
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the brain helps us do all of
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that.
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The brain is actually in charge
of the mouth, in charge of the
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knee, in charge of our feet.
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Right?
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So as the CEO or the boss of
this body, this organism, the
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brain, when it dysfunctions, can
have changes in thinking and
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memory and walking and talking
and chewing and feeling.
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So the brain is this all
encompassing organ, and I find
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it kind of significant to be
able to help someone with a
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brain dysfunction, because it's
not just like a broken leg.
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When you've got changes in the
brain, you can have a change in
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your life and who you are as a
person and in your family.
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So that's kind of what I do all
day, every day.
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So tell us what Alzheimer's is.
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How does that differ from other
types of dementia?
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Yeah, that's a very good
question.
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Whatever a healthy brain is
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supposed to do is to lead this
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body, to be able to take our
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pills, to eat, to manage our
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human life on this planet
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independently.
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That means even if we're like
one hundred and fifty years old,
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our brain should be able to help
us as animals live alone.
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So if we can't do that because
of a cognitive dysfunction, like
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if I need somebody to help me
with my pills, if I need someone
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to help me with my bills, if I
need someone to make meals for
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me because cognitively I won't
be able to do that.
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That's a generic broad term
called dementia.
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So dementia just means my brain
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needs a buddy, needs assistance
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to do day to day survival human
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things.
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Within that general umbrella
term, though, different causes
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of dementia exist.
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Okay.
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Just like headache can be caused
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by migraine or stroke or head
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injury, dementia can be caused
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by Alzheimer's, Lewy body,
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Parkinson's, frontotemporal.
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There's a slew of other causes
of dementia.
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Alzheimer's is arguably the most
common one.
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As we get older, though, that's
why everybody hears about it or
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talks about it.
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But Alzheimer's is not like the
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worst, severest form of
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dementia.
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I get that question a lot.
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That's not true.
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It's just dementia as a
description.
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Alzheimer's is one specific
cause.
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And why do you think?
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I mean, if I put one hundred
people in a room and said the
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word dementia, Alzheimer's would
be the number one name or word
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that would probably be
recognized by the layperson.
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Why is that?
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Like, why is that the most
recognized dementia?
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It's the most common.
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It's when you hear about it in
the news and in movies, even or
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even in books.
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It's like that, you know, kind
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of elderly person who repeats
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their stories but is very
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pleasant and gets confused, like
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that's the typical picture of
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Alzheimer's.
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And that idea is perpetuated
over and over again, I think.
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But there are other symptoms of
dementia, like for example, some
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dementias cause movement change,
like falling down.
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That's not that typical of
Alzheimer's.
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So people just don't know what
they don't know I think.
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So what we do hear about in the
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news or TV, we're like, okay,
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Alzheimer's.
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There also weren't a whole lot
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of biomarkers and ways to
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diagnose these different
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diseases too.
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So everybody was just kind of
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calling everything Alzheimer's
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before nobody really figured out
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the distinction.
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Although now I would argue
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there's great value in figuring
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out what's what, because now we
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have disease modifying
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therapies.
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We have treatments for
Alzheimer's.
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We have different medicines that
I give for Alzheimer's, but not
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for Lewy body, for example.
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So maybe ten years ago, it
wouldn't have made a difference
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if we had it right or wrong, but
now it makes a difference.
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What is Lewy body?
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Lewy body is another type of
dementia.
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The second most common one that
I diagnose.
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It's caused by a buildup of
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synuclein, which is the same
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kind of plaque that builds up in
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Parkinson's disease.
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Lewy body.
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This kind of dementia, though,
it changes like our attention
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and alertness levels.
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So they're not necessarily
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forgetful as much as
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inattentive.
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They're like falling asleep on
you all day.
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And because we're inattentive,
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our brain can actually fill in
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the blank spots with
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hallucinations.
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We might think there's a dog or
a cat or somebody in the yard,
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so it has a little bit more
delusional aspect to it.
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Delusions and hallucinations can
happen with any type of
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dementia, but Lewy body is more
particular for that,
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particularly early on.
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So how do you tell the
difference between someone who
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has a type of dementia versus
somebody that's just having
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natural forgetfulness, either
because they're overtired or
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they're in perimenopause or
whatever the reason might be?
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Um, as we age, we all get a
little bit slower.
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It might take a little bit
longer for us to find that name
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or that word.
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That's probably a little bit of
word searching.
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Yeah, that just what was that
tip of the tongue syndrome is
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what I call it.
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It's not a real thing actually.
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What is the explanation for
that?
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Yeah, it means I know the word.
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It's like, for example, I had
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somebody trouble with the word
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kangaroo.
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I know it.
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It's that jumping thing.
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It's the one in Australia.
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It's really strong.
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But I couldn't find the word
kangaroo.
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And why does that happen?
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Like in the absence of dementia
diagnoses?
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Yeah.
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What?
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You know, there is that.
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Okay, I'm getting older.
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I'm getting more forgetful.
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You know, it's a phrase.
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Yeah.
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Everyone says that other than us
saying it.
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Is there a clear biological
explanation for that?
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There's a couple of different
things that could be going on.
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So aphasia means I am having
trouble with language.
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I actually cannot find that word
because the language center in
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my brain is broken.
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The language center just so
happens to be near the memory
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centers, where a lot of these
dementias tend to happen.
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Alternatively, and more
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commonly, I would advocate we
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have that trouble finding the
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word because our brain is less
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efficient.
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So when we are stressed, when we
are tired, when we are low on
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our vitamins, when we have so
many other things in our mind,
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our brain doesn't have room to
focus and pay attention to
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things like kangaroo or whatever
word we're searching for.
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So there's hardware problems
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like brain cells dying, tumor in
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head stroke, you know, too much
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blood.
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Whatever it is, those are
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structural hardware changes in
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the brain that can cause
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dysfunction.
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But more common is software
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dysfunction, as in the wires are
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not connecting.
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Well, because I am too tired,
I'm not treating my brain well.
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I'm not eating my fruits and
vegetables.
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I've been eating French fries
all day, every day.
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Those are all going to cloud our
thinking.
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And it can cause that, like,
what's that word?
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What's that word?
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Inefficiency.
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It's kind of like not giving the
brain the right fuel we need.
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Okay, that's really helpful.
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And then so getting back to how
can you tell the difference when
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you're seeing a patient that
it's normal forgetfulness versus
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something more serious.
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So some of the red flags I
always screen for are are you
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actually having dysfunction in
your day to day affairs.
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Remember dementia means I cannot
live on my own.
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So if you are kind of younger
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and having tiredness, fatigue,
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menopause, all those things that
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you talked about earlier, you
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should still be able to pay your
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bills.
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Kind of make it to your
appointments.
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You should still be able to do
your survival things well.
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So if they're still managing
your life.
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Yeah, even if it's sloppy, we're
managing our life.
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And that's usually a red flag
when we're having declines in
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function, when you can't manage
those day to day functions and
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somebody else is bringing you
into the appointment, that's
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always a red flag.
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To me, that means it's not just
you.
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Somebody else is noticing it.
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But we do have ways to check,
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for example, the forgetfulness,
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the kind of slower thinking that
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we experienced in menopause or
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with stress is very different
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from the kind of memory changes
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that happen with Alzheimer's
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disease.
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We have ways to categorize the
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pattern of cognitive change
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using neuropsychological
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testing, cognitive testing,
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memory testing, where we sit you
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down and have you remember this,
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draw this, figure out this
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pattern.
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Often it can take hours, but
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it's not a pass fail kind of
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experience.
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It's rather for me to understand
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what domains of cognition are
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broken.
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We're troubleshooting the brain,
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essentially, because I know that
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Alzheimer's looks different than
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Lewy, then looks different than
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frontal, then looks different
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from menopause.
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And so first and foremost, I
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need that test of sorts a
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cognitive test to tell me what's
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wrong.
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And then we also do other things
like MRI scans, blood tests.
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Like if I do a blood test and I
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can tell that your kidneys off,
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well, maybe we got to fix that
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before we start exploring this
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Alzheimer's business.
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So there's certainly different
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risk factors throughout life
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that can increase our
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forgetfulness and our ability to
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focus.
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And not always is it dementia.
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But we do have to take that
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seriously the older we get,
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because the older we get, the
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more we are at risk for
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dementias.
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Yes, that makes sense.
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You know, when you see a patient
that has dementia, what's the
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care plan look like?
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By definition, it is a
neurodegenerative disease.
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It gets worse over time and
there are no dementias that have
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a cure per se.
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That means they get worse over
time.
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But that doesn't mean we don't
have treatments.
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So for every single symptom, we
have something to make your life
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a little bit better.
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It's kind of like having
arthritis in your brain.
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A lot of us have arthritis in
our back or our knees.
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Right?
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And we don't really cure
arthritis, but we have rehab and
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we have ways to support our knee
and our neck.
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Right?
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Similarly, the brain dementias
do not have a cure per se, but
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we connect people with the
resources and they and the team
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they need to be able to live
life the way they fully want to.
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There's a lot of change in
autonomy and agency.
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There's a lot of changes in
relationships and caregiving and
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kind of building the foundation
of, okay, who is going to help
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me through this?
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Chronic illness is very
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foundational in all of our
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treatment plans.
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There are medications that can
help.
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For example, Alzheimer's disease
has disease modifying therapies
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now on the market.
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These just got approved in the
last couple of years.
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Lewy body I've got medications
for that frontotemporal.
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If you're having trouble
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sleeping we've got sleeping
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things.
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If you're having trouble eating
we have medications to help you,
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you know, maintain hunger.
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So we do have ways to help the
symptoms of your disease.
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Even if we don't have a way to
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slow down or reverse the
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disease.
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So care plan what you know.
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How do I treat this first?
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First and foremost is defining
what it is because not all
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dementias are treated the same.
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Right.
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And after I figure out
diagnostically what's going on,
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the second part of treatment is
just really helping the family
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and the patient understand what
changes to expect.
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Is this normal?
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Is this not normal?
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Is this something worth
exploring, or is this something
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that I'm not worried about?
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And then from there, as symptoms
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pop up, we target those
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symptoms.
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I'm sure many patients ask you
this question, but if you
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receive a diagnosis like that,
I'm sure they want to know, like
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how long am I going to maintain
sort of where I am presently.
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Like, I'm obviously coming to
see you because I'm noticing
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some sort of deficit, however
long that's been building up and
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whatever threshold sort of led
them to come seek help.
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How do you answer that question?
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Because I'm sure it's a little
bit unique for every patient.
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Right.
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And unique to every disease.
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Right.
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For example, Alzheimer's disease
typically runs its course over
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ten to fifteen years.
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Lewy body is closer to seven to
ten years.
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Frontotemporal is again closer
to seven to ten years.
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Then there's other types of
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dementias, like some people have
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dementia after having a
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traumatic brain injury, and that
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is just something they live with
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forever.
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That's just how it is.
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It doesn't really get better or
it doesn't really get worse.
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It's just kind of their
cognitive impairment.
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That's just their way of life.
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So really, I can't answer that
question without knowing what
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their specific diagnosis is.
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It's kind of like when you go
see a doctor for headache,
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you're not just going to be
like, well, is it?
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What is my prognosis?
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You have to figure out what the
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headache is from, and then we'll
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be able to better answer that
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question.
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And how much are you?
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You know, you were talking about
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obviously treatments for
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Alzheimer's mainly revolving
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around or focusing on the
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symptoms or the circumstances
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that arise because of
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Alzheimer's.
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Right.
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Um, and to use your arthritis
analogy, you know, if we're
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talking about an inflammatory
arthritis, a lot of the
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treatments are calming, the
inflammation, etc., but a lot of
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the progress in inflammatory
arthritis treatment over the
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years has been actually disease
modifying drugs, right.
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And trying to at least slow the
progression of the disease.
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How much of an area of research
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focuses that right now with
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Alzheimer's?
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And are there actually any drugs
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in the pipeline that are more in
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that direction?
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Right.
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Not the hunger drug or the or
the drug or the more the okay,
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we're actually targeting some of
the root of the problem.
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Love this question.
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Alzheimer's disease is caused by
a plaque amyloid plaque that
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builds up in the brain.
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We now have amyloid targeting
monoclonal antibodies.
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So we do have two drugs on the
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market La Combi and Kisunla,
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also known as lecanemab and
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donanemab.
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These two medications were
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approved in the last couple of
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years, and Alzheimer's is the
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only type of dementia that
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actually has disease modifying
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therapies.
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That means we have ways to get
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rid of the amyloid from the
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brain at at risk, and it's
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really only targeting towards
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people who don't have a lot of
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amyloid burden.
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That means I got to catch you
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early on in the disease after
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somebody has moderate severe
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advanced dementias.
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That means the burden of the
disease, the amyloid is eating
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away at the brain so much that
it would probably be more risk
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than benefit to treat.
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But if I catch you very early
on, you know that person who's
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just having mild symptoms and
you're like, wait, what is it?
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If we figure out that it's early
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stages of Alzheimer's, now we
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have a way to kind of clean up
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this amyloid from the brain and
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stave off that progression into
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dementia.
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It's very exciting.
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And it reverse.
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Can you clean out the plaque and
get you back to kind of like
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optimal brain health, not
optimal brain health?
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Because the reason the plaque is
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there is because of a misfolded
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protein.
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So that DNA thing that's causing
the protein to actually misfold
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is still a problem.
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We will probably, at some point
in the future, come out with
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some kind of gene therapy to
reverse that DNA mistake.
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But in the meantime, imagine DNA
mistake.
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Amyloid.
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Itty bitty particles, bigger
particles.
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Amyloid plaque that causes the
brain cells to die.
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Now, at least we can target
those plaques and amyloid
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precursors to clean it out.
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so no more damage is being done
to the brain.
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It has been very successful at
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cleaning out amyloid, by the
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way.
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Like I'm getting some Pet scans
back with no amyloid.
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Like, make that real in terms of
the patient.
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Yeah.
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So that usually means stability.
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So if you imagine Alzheimer's
kind of like a like a cliff of
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everybody gets worse over time,
this slows down the decline by
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about thirty percent.
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So instead of going at it at one
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hundred miles an hour, we're
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going at it at seventy miles an
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hour.
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So not a reversal, not a cure,
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but I think we're headed in the
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right direction.
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I also think if I can slow it
down by that thirty percent
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right, then something else will
come out, maybe an additional
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kind of agent over the next few
years that could maybe cure it,
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maybe get you even better.
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Right?
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So I'm really hopeful about
these things.
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How do you approach prevention?
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Yeah, I look at somebody's risk
factors.
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Like for example, if you're a
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boxer, martial artist, something
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like that, where you've gotten
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hit on the head many, many
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times, that is going to increase
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the inflammatory response, the
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cytokines, your brain is going
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to be a little bit more on edge,
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even apart from the structural
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damage that you may have
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suffered, people with head
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injuries are more likely to get
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dementias.
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People that had diabetes,
metabolic dysfunction,
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hypertension that is
uncontrolled in middle life.
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That means middle life, not even
older.
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You are more likely to get
dementia.
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This is a systemic illness.
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People that smoke and drink more
than they should are more likely
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to get dementias.
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People with untreated mental
health disorders, anxieties,
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depressions, PTSD are more
likely to get dementia.
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So when we delve into this world
of, well, let's start treatment
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early before you have symptoms,
it's not just about the amyloid.
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If you're going to have amyloid
and take this drug, but then
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keep smoking, it's actually not
going to do that much for you.
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So we have to be very
intentional about the health of
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our brain and what we are
feeding our brain.
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That means, are we doing our
best to stay engaged?
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Are we doing our best to not
have exposures to stressors, to
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toxins, to head injuries?
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Are we wearing seatbelts?
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Are we wearing helmets?
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Those kind of things to protect
our children because it starts
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from day one and maybe even
before day one.
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There's a lot of research shows
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that when we are still in the
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womb, we have exposure to
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maternal stressors.
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If mom had, you know, not enough
access to food or was in a
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household of violence or abuse,
that stress response from mom
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crosses the placenta and makes
the baby more at risk for
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diseases later in life.
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So obviously there are some
things we can't control, right?
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Like, I can't control what kind
of stress my mom had, but I can
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control if I am going to go to
bed on time and get my eight
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hours of sleep, because if I
don't let my brain get rest now,
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then it builds up over time to
at eighty years old, I'm going
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to be like, wait, why did this
happen to me?
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It's a lifetime of stressors.
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So that's what prevention is all
about.
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Thinking about your brain.
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Just like we would think about
our heart and how we take care
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of our heart.
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Similar thing.
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Am I staying active and using my
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brain and protecting my brain
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before you reach later stages in
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life?
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How would you decide who are
going to be your best candidates
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for the preprint?
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A yeah.
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You know, Um, protection?
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Yeah.
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And it really depends, because
it has to be Alzheimer's.
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I think the greatest research
right now is Alzheimer's.
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Right.
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And remember, we talked about
how there are several other
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types of dementia.
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So I would have to define that
there's amyloid.
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How we define that.
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There's amyloid that plaque we
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have blood tests now that just
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got approved in the last six
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months.
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By the way.
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We have Pet scans that light up
amyloid in the brain.
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And we have spinal fluid.
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So when you do a lumbar puncture
or spinal tap you can remove it
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and measure the amyloid there.
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So that one of those three has
to be done.
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If that's not there then you
have brain health risks because
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of something else.
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Maybe, Louis, maybe you have
TBI, maybe you have concussion,
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some other cause of cognitive
decline because you can have
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cognitive impairment, because
you have ADHD.
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That's undiagnosed.
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Right.
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And I'm not going to give you a
strong Alzheimer's medicine when
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it's all ADHD.
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So it goes back to step one.
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Get it sorted.
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Not all memory loss is the same.
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What is the cause of my
cognitive change?
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Is it untreated and undiagnosed
ADHD?
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Is it just menopause and sleep
deprivation?
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Or is this the early signs or
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early risk factors for
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Alzheimer's?
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And that's defined by that
presence of amyloid.
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And how how much before symptoms
show up, would you expect to see
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these things light up on these
tests you're talking about?
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Amyloid can be positive like ten
years before symptoms show up.
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So it's not a hard defined line,
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of course, but I would go based
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off of what the risk factors
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are.
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So if I meet you and you're the
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healthiest person I've ever met,
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no family history of
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Alzheimer's, no family history
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of dementia.
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You're taking really good care
of yourself.
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Not on any medications.
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My first instinct is not to go
looking for amyloid.
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Likely you are going to do all
the preventative things that I
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would want you to do, that I'm
not going to go out of my way
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to, you know, look for trouble.
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But if you have four or five
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generations of Alzheimer's in
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your family, we already work a
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stressful job, and I know that
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you're not getting as much
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sleep.
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I know that this is a brain.
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This is a human that is more
susceptible to Alzheimer's.
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And I would take that a little
bit more seriously.
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So what else can somebody that's
in that middle age kind of
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category be doing to protect
their brain health later.
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You talked about sleep.
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You talked about fruits and
vegetables.
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Are there supplements?
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Are there things vitamins that
we should be thinking about or
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what do you suggest kind of help
somebody give themselves the
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best chance at longevity when it
comes to brain health?
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Use your brain the way it was
made to be used.
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I think in this middle age, when
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people are retiring, when people
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are changing careers, this is
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when we lose a little bit of our
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brain exercise.
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We get into routines and we
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don't try new things when we're
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young.
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Remember, we're trying day care
and let's just put them in
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soccer practice and art practice
and let's just see what happens.
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Remember that excitement and
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that cognitive exercise we got
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from that?
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We don't do that so much as we
get older.
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And that's actually very, very
important.
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So one of the best things you
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can do to protect your brain, go
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do something fun, something new,
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something challenging.
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Don't stay stuck in your
routine, whether that means a
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new hobby or a new travel
experience, or making a new
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friend, that social, cognitive
and physical engagement is
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exercise for the brain.
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That's great news and fun.
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But to answer more specifically
about supplements in general, if
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you are deficient in vitamin D,
supplement, vitamin D, if you
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are deficient in vitamin B12.
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B as in boy, that's another one
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you should take a supplement
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for.
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I don't like the idea of adding
supplements when you might
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already have enough in your diet
and your intake.
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So I'm not one to support, you
know, kind of those
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multivitamins brain stronger
neurofocus kind of medications.
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I think they're based on good
science.
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I think most of the time they
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don't hurt, but they are usually
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additive and they don't
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necessarily actually provide
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anything that you couldn't get
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from doing a good job with your
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health.
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So I vitamin D and B12 those.
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Yeah, I would focus on B12.
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D magnesium is a very good brain
chemical, brain health chemical.
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So if you have some kind of
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magnesium in your diet or in
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your cabinet, that would be
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good.
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And I like omega three fish
oils.
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Those are the four I only really
ever recommend.
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Um everything else.
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That's one I hear a lot of
associated with brain health
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that has that.
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Have you heard that too, I
assume?
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Yes.
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So there's a lot of research
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going into like creatine and,
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you know, Sam and a, a cholines
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and there's so many things we
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can talk about, but most of the
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time people are not deficient in
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those things.
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And taking them is kind of like
an easy way to say I'm doing
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something, but it doesn't lead
to cognitive change that I, I
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would say do what helps keep
your brain protected.
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You don't need to go above the
norm on the creatine and some of
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these other supplements.
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There's not enough research
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behind it to say you have to
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take it.
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That's really good advice.
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I know we're getting close on
time, but I'd be remiss if I
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didn't ask you to talk about the
role of the caregiver.
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This is a disease that can be
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very daunting and taxing for a
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caregiver, especially as it
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progresses.
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What advice would you give
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somebody caring for somebody
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that has Alzheimer's or
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something else?
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Yeah, very good question.
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Uh, be gracious to yourself.
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You're going to mess up.
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Nobody has a rulebook or a
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manual for how to take care of
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somebody with Alzheimer's or
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another dementia.
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Not even doctors.
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We don't even know the best
thing to say.
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Not not a therapist.
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Nobody has a rulebook.
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Humans are very complicated, and
we get even more complicated
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when we have dementia.
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That being said, caregivers
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often need a care partner
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themselves.
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Don't try to do it all on your
own.
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This is a giant journey ahead of
us.
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It's a chronic illness.
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It's going to change your life.
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It's going to change their life.
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So create a team, a village, a
community of who's going to help
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you and make sure that you have
the opportunity to get away and
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take care of yourself.
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I know we get into these roles
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of, well, I'm a wife, I'm a
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husband, I'm his person, I'm his
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mother.
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I have to, but that's not that
doesn't mean you have to
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sacrifice your own time and
health to make that happen.
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That this is not a foreign idea
to us.
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Dementia is something that we
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have known about for hundreds of
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years.
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We have care managers.
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We have therapists.
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We have patient care
coordinators.
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We have nonprofit organizations.
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We have research.
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Believe me when I say you are
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not in this alone, reach out to
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the people who can help you,
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because we are here waiting to
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help you.
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And and honestly, we want to
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help you because it's more about
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the care partner at some point
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in the disease than it is even
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about the person with the
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cognitive impairment.
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I imagine at first the person
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knows and understands they have
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it, but over time they don't
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even realize exactly the full
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weight of this is on the
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caregiver.
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Yeah, like a lot of people will
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be like, isn't it so sad to like
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go through the stages of
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dementia?
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And I say, well, usually the
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person doesn't realize they have
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dementia.
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After about mild or moderate
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stages, the people who have it
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the most or feel it are the care
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partners.
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So it's the care partners that
need the support groups, that
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need the community, that need
the support and buffering.
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And luckily they're out there.
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We are so lucky to live in this
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area where we have so many
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dementia resources.
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We just have to get you
connected.
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When we first get a diagnosis
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like dementia, it can feel very
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daunting.
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But one of the best parts of my
job is to see somebody at a six
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month follow up.
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And when I first met them and
gave them a diagnosis, it was
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life changing and upside down.
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What are we going to do?
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And I have to quit my job.
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And what about insurance and
this and that?
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But then in six months they have
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that confidence of I have a
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plan.
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I got a financial advisor.
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We know what we want to do and
if he needs more help, we got a
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nurse set up.
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And if he needs this and if she
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needs this, having a plan gives
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you power.
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And that's what I'm hoping to do
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with this early detection, early
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diagnosis stuff is take power
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back into your hands because a
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lot of medical illness takes
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away agency.
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That's a great note to end on.
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Thank you so much for being with
us.
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This was enlightening and so
helpful.
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And I think something that
people that deal with this
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disease, whether you know,
they're facing this or dealing,
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you know, they're a caregiver,
this is a very weighty issue.
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And so it's great to have you
help us shed some light on it.
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Thank you so much for having me.
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Thanks for tuning in.
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We hope you enjoyed this
episode.
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