Dementia and Memory Loss with Dr. James Leverenz

Podcast Transcript

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Kate Kaput:
Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput and I'll be your host. Today we're talking about dementia, memory loss and more with Dr. James Leverenz, Director of the Center for Brain Health at the Cleveland Clinic Main Campus and the NIH Funded Cleveland Alzheimer's Disease Research Center. Dr. Leverenz it's great to have you here.

Dr. James Leverenz:
Thank you for having me.

Kate Kaput:
I'd like to start by asking you to tell us a little bit more about your practice here at the Cleveland Clinic. And so what kind of patients do you typically see and what kind of work do you typically do?

Dr. James Leverenz:
So I direct the Center for Brain Health here on the main campus in Cleveland, and we have a pretty diverse practice, we see 150 to 200 patients a week. We have seven physicians, four advanced practice clinicians, large nursing staff, and really focused on people who are already experiencing memory or other issues, but also people who are concerned about that. We also have a large research program, so we have close to 30 research coordinators, that includes clinical trials, the Cleveland Alzheimer's Disease Research Center we mentioned earlier. So it's really quite a diverse group.

Kate Kaput:
Great, thank you for that background. I think it's helpful to start out by figuring out exactly what we mean when we're talking about dementia. Can you tell us a little bit about what exactly the term dementia refers to? Not all memory loss is dementia, correct?

Dr. James Leverenz:
That's correct. There are some that we see with normal aging. Most people kind of link Alzheimer's disease and dementia together, but dementia is more of an umbrella term. Generally, what it means is that you've lost, you've had a change in your thinking skills that has occurred as you're aging, and that it starts to interfere with your day-to-day functioning. Another term we often use is mild cognitive impairment, which really first people who are having some memory changes, but it's not interfering with their day-to-day activity. As we look at that umbrella of dementia, we'll talk a little bit later I believe, about sort of the subtypes, which includes Alzheimer's and other diseases that people have heard about.

Kate Kaput:
Got it. So you talked a little bit about aging, is some amount of memory loss considered normal as we age? What qualifies as standard memory loss versus an actual dementia issue?

Dr. James Leverenz:
Sure. So the thing that we typically see as people age and that I'm noticing as I age, I'm getting a little bit grayer here, is pulling up information rapidly, pulling up names and words rapidly, but then it comes back to you later, either you get off topic or you see a hint, those sorts of things. One of the common questions I'll ask my patients and their families are, "Does the memory come back if you get a hint?" And they go, "Yeah, then the name will come to me," that sort of thing. That tends to get worse as you get a little bit older, again, getting back to that dementia term, when that gets so bad, that we start to interfere with your ability to manage your day-to-day functioning, that's when we start to get a little bit more worried about the dementia component.

Kate Kaput:
Got it. So you mentioned that there are various types of dementia, including the most prevalent type, which is Alzheimer's, I know that you and I are going to record a separate episode of the podcast, it goes a little bit more in depth on Alzheimer's in particular, but can you just go through for us the different varieties of dementia? What are the most common types of dementia?

Dr. James Leverenz:
Probably again, as you mentioned, the most common changes that we see in the brain are linked to Alzheimer's disease. We also see changes linked to stroke and what we call vascular disease. One of my particular interests is dementia with Lewy bodies or Parkinson's disease dementia, very uncommon, Huntington's disease, Huntington's chorea, and probably second only to Alzheimer's is what we call mixed dementia, which is frequently more than one of these different causes of dementia combined together. And in fact, if you look at older individuals, let's say 65, 70 and older, usually people have multiple changes in the brain that are likely contributing to the memory loss and their other thinking skill changes.

Kate Kaput:
So that was actually one of my next questions was can a person have more than one type of dementia at a time? Talk to me a little bit about how those types of dementia present, do they present differently or have some symptoms in common? And in a diagnosis, how do doctors differentiate between types of dementia or sort of figure out that someone is having more than one type of dementia?

Dr. James Leverenz:
So a typical evaluation that we will do here, and we are a dementia specialty center, so we're pretty aggressive about evaluating, we'll include obviously a history, taking some more detailed memory testing to look at what kinds of memory and thinking skills are impaired. We'll typically do a brain image, usually MRI scan, that tells us particularly around whether there's stroke or vascular disease. And sometimes we'll move on to more specific what we call biomarkers, either blood, spinal fluid, or brain, specialty brain imaging, that tells us specifically what kind of biological process is going on underneath. As we put all that information together, that gives us a sense is this just... I would say just Alzheimer's, but it's Alzheimer's? Or do we see Alzheimer's with stroke? Could there be a Lewy body process going on? Just a variety of things.

As the research has moved forward, we're starting to get better and better at identifying these biologic underpinnings for what's causing the changes in thinking skills. I think that'd be very relevant, similar to what cancer does now is starting to subtype people in terms of their biology so that we can specifically treat their biological changes that are going on. I think that's sort of the big next step for this field.

Kate Kaput:
Sounds like there's some exciting things happening. You talked about this a little bit, but I know that many of us are nervous for our parents and other loved ones as they grow older, and keeping a close eye on them for signs of memory loss or dementia, what are some of the symptoms of dementia? And when should when should we be worried that something that we're seeing in our loved ones is more than just that standard memory loss that we talked about associated with age?

Dr. James Leverenz:
Sure. So as we talked about before, sort of normal age-related phenomenon are difficulty pulling up names and words on the spur-of-the-moment. Maybe not being quite as good at multitasking that they used to be. When we start to get worried are when, for example, in Alzheimer's probably the most typical presentation, although there are some variants there, the most typical presentation is not only the memory loss, but that when we get those hints later, it still doesn't come back to us. It's as if the event or the discussion had not happened. We all forget things a few times or may need a few hints to pull up an event or some sort of specific memory information. But we worry more about it when putting new information and you've had a conversation with say a parent, and they don't remember that conversation later and even with hints, it's not coming back to them. That's sort of one of the things that we worry about.

When it also starts to interfere with a person's day-to-day functioning, a pretty good example, when you're having that kind of Alzheimer's related memory loss, is bills start not getting paid, or they think they've paid them and they're not getting paid. Things like that that normally weren't a big problem for somebody, that's when we start to get a little bit more worried about that.

Kate Kaput:
Got it. So on that topic, can you talk a little bit about the progression of dementia and what it means for people's everyday lives, where it starts out and how it gets worse and a little bit about what that means for where people live? How do we know if someone that we love is okay to be living home alone, versus needing to live with someone who has good cognitive health? When might we need to consider moving our loved one into assisted living because of dementia?

Dr. James Leverenz:
So a lot of questions there. So I'll address each one. So again, we talked about what we see early on, I think as we, again, we worry about dementia when it starts to impact ability to take care of day-to-day activities. I'd say the most common thing I see is that family members will start stepping in, it may be a spouse, it may be a child, and start taking on, say, for example, the bill pain, or they switch it to automatic payments, that sort of thing, which can be very helpful in the earliest stages. As time goes along in terms of when do we decide to recommend somebody be moved, really depends a little bit on the resources that the individual has, maybe if they have a spouse and several children, and they're all working together to help them at home, and there's some home services we can pull in, they can keep them at home for quite a long time.

When that can't happen or when it gets overwhelming even for that whole support group, that's when we start to talk about moving somebody into a long-term care facility. I had often recommend if you're starting to see symptoms like that, and it's a spouse and a patient that they might start to think about assisted living, or a place that has assisted living. So kind of simplify their life a little bit, they don't have to worry about making meals necessarily, somebody's coming by to take care of their apartment. That sort of thing can be really helpful for making sure that they've got adequate support. And a lot of those places have transitions and then if somebody gets severely impaired, they can them move to a memory care unit where they can get more nursing help.

Kate Kaput:
Now we often associate dementia with age, but are there kinds of dementia that impact younger people?

Dr. James Leverenz:
There's some rare forms of familial say Alzheimer's disease, Lewy body disease. There are some very rare forms of vitamin deficiencies, linked to like alcohol consumption that can happen at a relatively early stage, but most dementia does occur after age 60 to 65. As you age, your risk goes up part because of these multiple processes we talked about earlier can be starting to kick in, somebody might have a small stroke, they may start to get some of the Lewy body changes we have, we were talking about earlier, and now they're also getting maybe some Alzheimer's disease. But yes, there are kinds of dementia that occur under the age of 60, obviously very sad situation, but it's also a good one where people really need to get an evaluation because that is uncommon, and it's good to make sure that we're not missing something that's correctable.

Kate Kaput:
And how do we treat dementia? Are there any types of dementia that are treatable and for incurable dementia, is there any way to mitigate or slow the effects?

Dr. James Leverenz:
Well, for years, we've had some medications that are helpful for some of the subtle symptoms of dementia that really work on a couple of chemical systems in the brain that tend to get depleted in Alzheimer's disease and related dementias, and we've been using those often across the board with several of the different kinds of dementia that we treat. But they are symptomatic, they're treating the symptoms.

There is a lot of excitement, but also controversy around a new medication that was just approved by the Food and Drug Administration, just last week called aducanumab. It's a monoclonal antibody that's infused and tries to attack one of the changes in the brain we see in Alzheimer's disease, it is specific for Alzheimer's disease. And I would say, we're still not sure exactly how helpful it will be, but it is hopefully the first in a number of medications that we're working on that are really going to try to treat the disease itself, not just the symptoms. I like to say, if you have a headache and it's due to stress or due to a brain tumor, it can still be helped with an aspirin or a Tylenol. So some of the early medications we had were more for those symptoms of dementia, now we're starting to try to get into some specific therapies that treat the disease itself.

Kate Kaput:
Got it, I think that's a really helpful analogy. Is there anything in our lives that speeds up memory loss? Can anxiety and depression contribute to memory loss? What about drugs and alcohol?

Dr. James Leverenz:
Sure. Well, we talked a little bit about alcohol earlier, there's a kind of alcohol dementia, that's relatively rare because physicians are often very good at recognizing it. Alcohol induces a certain vitamin deficiency. In terms of general, usually what I mention to people is, "What's good for your heart, is good for your brain." So a little bit exercise, social interaction, healthy diet, those sorts of things can be really helpful. What we've noticed is that the changes of, say Alzheimer's disease and other dementias are often starting to percolate in the brain many years before symptoms kick in. And when those symptoms emerge often are in the context of other illnesses. So we all probably have a relative who went in for a surgery or something and came out and they're not quite the same, and it seems like that almost kicked the Alzheimer's or other dementia on.

Probably what happened is you lowered that threshold for emergence of those symptoms, and people only have so much resilience and you start to see those symptoms kick in. So the better your general health, the better you'll do with dementia. And it's also, again, going back, it's good to get a solid diagnosis so we know exactly what's going on, and what kind of things can be mitigated.

Kate Kaput:
That makes sense, I like the, "What's good for your heart is good for your brain." Let's talk a little bit about caregivers, it can be very difficult for people who are acting as caregivers to navigate their loved ones' dementia. What kind of insight can you share with folks who are in these scenarios for how they can interact with people who have dementia and try to be patient and understanding? How can caregivers take care of themselves during what can be emotionally painful times?

Dr. James Leverenz:
Well definitely in terms of caregivers, number one, I always tell my caregivers, "If you burn out, if you can't manage things, just think about what happens to your loved one." And this is generally a marathon, not a sprint, so you need to call for help. Alzheimer's Association is a really good resource, centers like ours are really good resource, we have a full-time social worker that helps us with helping manage support for caregivers. It's a good time to bring in family members.

Again, this is sort of a team effort for helping... to help the person who's suffering with dementia, and burning yourself out will not help that person. I also tended to tell people, "Don't make promises that you can't keep." I see a lot of caregivers burnout as disease gets very severe and they've made promises that for example, not to put somebody in a memory care unit, those units are much better than they were decades ago, and really can be helpful. And in a person, a caregiver can then go and visit the patient and worry about that interaction rather than worrying about toileting, feeding, all these other things that really burn people out very quickly.

Kate Kaput:
I think that's really important to talk about. You touched on this, but is there anything else that we can do, any other healthy living habits that we can adopt now, that overall lessen our risk factors for developing certain types of dementia as we age? Or just things in general that are good for our brain health that we can adopt at an earlier stage in life?

Dr. James Leverenz:
Well again, as I mentioned, I'll do the, "What's good for your heart, is good for your brain," from a exercise of view. Staying socially active as much as you can and you're comfortable with. There's this natural tendency within the dementias for people to become less interactive, sometimes it's interpreted as depression, sometimes it is depression, but often it's what we call apathy, just people get less interested in activities.

And so it's good for the caregiver and the family to get them out, and we've noticed this even in our drug trials, that when people are on the placebo, they're getting the sugar pill. They do better than people who didn't participate in the trial at all, that getting out, participating in the trial, a little bit of a memory testing, just getting them out of the house is helpful. That's what's been so difficult with the COVID crisis right now. Finally, we're coming out of that. I would encourage people to consider getting the vaccination so that you can get back out, be safe, not get sick in another way, and have those sorts of social interactions that really helpful for people, especially in the early and middle stages of the dementias.

Kate Kaput:
Is there anything that we haven't talked about today related to everyday dementia or prevention, anything that we haven't discussed that you think is important for us to know on this topic?

Dr. James Leverenz:
Again, reiterate a good healthy lifestyle, get an evaluation, if there's a concern for yourself or for a loved one, to make sure that we're picking up any kind of changes that might be reversible.

Kate Kaput:
Perfect. Thank you so much, Dr. Leverenz for being here with us today. If you'd like to schedule an appointment with a specialist in Cleveland Clinic's Lou Ruvo Center for Brain Health, please visit clevelandclinic.org/brainhealth, or call 866-588-2264. Thanks for joining us.

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