Some 46 million Americans already have the early brain changes that are the harbingers of a dementia that won’t reveal itself for decades. Dr. Richard Isaacson, Director of the Alzheimer’s Prevention Clinic at Weill Cornell Medicine, talks about the three stages of cognitive impairment, how to distinguish “senior moments” from symptoms of dementia, and whether multitasking puts our overloaded brains at risk.
Dr. Stieg: I'm very happy to have Dr. Richard Isaacson with me today. He is one of the leading authorities on Alzheimer's Disease and director of Weill Cornell's Alzheimer's Prevention Clinic and Memory Disorders Program. He has just completed a groundbreaking clinical study of patients with a family history of Alzheimer's Disease. Richard, welcome. You've got an interesting family history in regard to Alzheimer's disease. Try to give us a little bit of a sense of that and what role that played in your interest in this topic.
Dr. Isaacson: Sure. So when I was in high school, my uncle Bob was diagnosed with Alzheimer's disease and back then there were nothing, zero treatments, nothing at all a person can do. I then went to medical school and finished all of my training and ready to get going. And I was actually sitting next to my dad's cousin at a wedding and she asked me the same question no less than five times in maybe 20 minutes. And I asked her husband, "Hey, what's, what's going on here?" And I was told, "Oh, that's just normal aging. That's just normal. She saw her doctor and everything's fine." Senior moments is what it was called. And that's when I had a flashback... And I had a little flashback to my great-uncle Max and great-uncle Max was my cousin's father. And I said, "No, something's not right here. There's overlap." And there's something my gut told me and whether it was an observation, a mannerism, whatever it was, and I said, something's wrong here. And six years later she ended up being diagnosed with Alzheimer's disease and six years is too long. And if my gut felt it, is there something we can do in science? Is there something we could do that's verifiable, that can detect these changes? And now we know that Alzheimer's disease starts in the brain 20 to 30 years before the first symptoms. And that's really why it's been a focus of my professional career.
Dr. Stieg: So I won't ask how old you are, but have you noticed anything in yourself?
Dr. Isaacson: Huh, great question. So actually two of my cousins are in the clinic. So we definitely have evaluated our family members. I've had a cognitive baseline myself and I've had my kind of full workup. I know what my genetics are. I actually feel pretty comfortable about my Alzheimer's risk. And I feel that right now my brain is functioning well.
Dr. Stieg: That's good. You're practicing what you're preaching.
Dr. Isaacson: I am. I'm doing everything that I tell people to do by far and I feel like things are in check right now.
Dr. Stieg: How much of a problem is this? Is this really prevalent in the United States?
Dr. Isaacson: So many have heard that the numbers that, 5.6, whatever it is nowadays, million Americans currently have Alzheimer's disease and that means Alzheimer's disease, dementia, where the person has cognitive changes where they can no longer take care of themselves. But I think a staggering number that people aren't aware of is that 46 million Americans currently have Alzheimer's disease beginning in their brain, but no symptoms. And that's really the—
Dr. Stieg: That begins in... their thirties.
Dr. Isaacson: Well, it could, depending... it could begin in their 30s, 40s, 50s, or 60s.
Dr. Stieg: Can you differentiate for me when we use the term Alzheimer's versus dementia, is it an age related thing? A specific disease entity? Clarify for me.
Dr. Isaacson: Great question. So dementia is any condition that causes a person's cognitive and memory and thinking skills to decline to the point where they can no longer take care of themselves. Alzheimer's disease is the most common form of dementia. About 60-70% of the time a person has dementia, it's going to be Alzheimer's disease, but 10, 20, 30% of the time it's going to be something else. Maybe it's caused by vascular problems. It could be caused by, you know, a long period of Parkinson's disease. It could be caused by frontotemporal dementia, could be caused by medical conditions, B12 deficiency, even people with depression can, can really have something called a pseudodementia. So the take home point here is Alzheimer's disease is dementia, but not all dementias are Alzheimer's disease.
Dr. Stieg: Back in the dark ages, when I started in medicine, they used to think of the diagnosis of Alzheimer's disease. When people develop that problem in their sixties and it was dementia. When it came on, and the at that time living to the 70 was a long time, and so it was more of an age related thing that's differentiated, correct?
Dr. Isaacson: It is. So age is still the number one risk factor for Alzheimer's disease. As people get older, their likelihood to develop cognitive decline and Alzheimer's goes up. But actually we're learning that there is a genetic component. Women are actually at higher risk than men. Two out of every three brains affected by Alzheimer's disease are women and we don't exactly know why. We're, we're learning more and we think we know more now, but we don't exactly know why. So there's a variety of risk factors that put someone down the road or on the path to Alzheimer's. Age is the number one risk factor, but there's several things, especially there's several modifiable things that people can do to reduce their risk.
Dr. Stieg: Just for a point of clarity, my mother passed away from dementia as well, so I have the unfortunate circumstance of watching her decline over 10 years. It didn't start off full swing, you know, it was a progressive decline. So there are levels of dementia. Is there a typical progressive decline or is it just every patient is a little bit different? And what are those levels?
Dr. Isaacson: So there's a saying, "Once you've seen one person with Alzheimer's, you've seen one person with Alzheimer's." It's a very heterogeneous disease. And what that means is different people can have Alzheimer's but have different symptoms and different presentations. So what I mean by that is the most common symptom of Alzheimer's, progressive, short term memory loss — they may forget their keys, or they may forget an appointment, or they may forget a person's name and that could be associated with the normal aging process. But with Alzheimer's disease, it progresses. They lose their keys and they never find them. They get lost while driving and they forget an appointment and never remember in the place that they had the appointment. Further, Alzheimer's disease is a neuropsychiatric disease. And what I mean by that is it's not just memory loss and changes in cognitive skills, but it can be increased depression, anxiety, mood changes, behavioral changes as well, and also changes in sleep patterns. So Alzheimer's disease is a progressive brain disease and depending on which part of the brain that disease starts, the clinical symptoms or the complaints of the patient and the family members will differ.
Dr. Stieg: Is there the, "I forget the keys" — progresses to what is it, mild cognitive injury, then it goes to moderate and then severe cognitive disorders... Is that the progression?
Dr. Isaacson: Yeah. So there's, there's really different terminology and whether you're a neurologist or a psychiatrist, you may actually use different terminology because the guidelines use different words. The way that I usually characterize it as there's stage one, stage two and stage three. And in the past we've called Alzheimer's disease as what we now understand is Alzheimer's disease dementia, which is now stage three or the end stages of the process. Alzheimer's dementia is where a person can no longer care for themselves. The precursor phase is something called stage two: mild cognitive impairment due to Alzheimer's disease. It means that there's Alzheimer's disease in the brain, the pathology that the bad proteins that build up called amyloid. Mild cognitive impairment means that the person is having glitches in their memory, but they can still take care of themselves. And then finally, this new stage is really now called stage one preclinical or pre-symptomatic Alzheimer's disease. And this is where the disease is starting silently in the brain, but there are no symptoms. And this is the striking thing where again, 46 million Americans currently have this condition and we need to do something about it.
Dr. Stieg: There was just an article in the newspaper this past week about college football players. I don't know if you saw it, in injuries to their brain. In your mind, as a person who is an expert in this field, is there a distinct difference in the process of chronic traumatic encephalopathy and the progression of Alzheimer's disease?
Dr. Isaacson: I get this question a lot. My nephew Bobby plays football. Uh, my sister Sue decided to call me and text me and email me and ask me. So I can tell you this, I don't think we have all the answers to give a perfect, you know, maybe characterization of, of what is the exact risks and what, what CTE or chronic traumatic encephalopathy and how it's related to Alzheimer's. But I can say is I think different people are different, meaning certain people who are genetically predisposed to either Alzheimer's disease or brain injury may manifest symptoms of cognitive decline and behavior change after several concussions and after playing a life lifetime of football, I think other people are going to be more resistant to that. Just like people can smoke for 50 years and never get cancer. Other people smoke for five years and get lung cancer. So I think the field is gonna hopefully figure this out, but it's not a one size fits all answer.
Dr. Stieg: So do you believe in the sports gene?
Dr. Isaacson: There is definitely a sports gene. I don't, I don't have it. I can run fast and far, but I can't play football or baseball.
Dr. Stieg: Yeah. And I don't see that baseball coming in a hundred miles an hour.
Dr. Stieg: A lot of people are worried about this. Let's face it. Certainly the baby boomers, what are the early signs of dementia?
Dr. Isaacson: So the glitches that happen can be barely noticeable initially. I think a lot of times people come up to me, whether it's a cocktail party or a social event and say, "Oh, you know, I'm, I'm terrible at names. I keep forgetting someone's name. You know the name, it's on the tip of my tongue. And then I remember it later. But is that Alzheimer's disease?" So actually that symptom is super common, but that's not, that's actually more of a symptom of age related cognitive decline or cognitive aging. If the word is on the tip of your tongue, but you remember it later, or it takes longer for a person to learn something or it takes longer for a person to recall something. But they do recall it, that's actually okay. That's part of the aging process. And, and that's distinct from Alzheimer's disease, progressive short term memory loss, behavioral changes, sleep changes, mood changes. Uh, these are really the most characteristic, early signs of, of Alzheimer's disease.
Dr. Stieg: As we age does our ability to concentrate, change. Cause I, a lot of times people ask me multiple questions and I, you know, normally I would remember somebody's name and I can't remember it, you know, then two seconds later when everything's calmed down I remember it.
Dr. Isaacson: We're living in a different world nowadays. You know, we have the cell phones blinging and you know, impulses and the stimulation coming from every angle. Um, I think the brain can only handle so much. And I, and I don't know if it's an aging thing or if it's advances in technology thing or if it's just, you know, people are "on the, go, go, go" so much. Attentional problems need to be distinguished from memory. You know if someone's, for example, texting on their phone and not paying attention and they're asked, "Hey, what did I just say to you?" And they don't remember it. It's not a memory problem. It's an attention problem. They didn't remember it in the first place. You know, the names that are on the tip of your tongue. That's that, that's a little bit of a different situation. But I think in today's world there's so much stimuli and I'm not sure that the brain can handle, you know, more than a few different stimuli at a time sometimes.
Dr. Stieg: Focusing more on this attentional problem. One of the things we hear about with social media is this concept of multitasking. Is that a reality or do people do things in parallel? And as we age we're less able to do things in parallel.
Dr. Isaacson: Yeah, I think different brains have different strengths and weaknesses. I think when people are born as an example, you've heard of a condition ADD or attention deficit disorder and you know, certain brains are wired to have trouble with attention and other brains are wired to be really efficient with the multitasking. So I'm not exactly sure if, if the aging process affects that. I think in some ways it may, but I also think our world has changed so much. Uh, you know, whether it's social media and texting and always being connected to the internet and, and you know, multiple stimuli coming at a person at multiple times. I just don't think the brain has really been used to, uh, those technological advances. And I think it's hard for the brain to process everything at once.
Dr. Stieg: The reason for asking this is because earlier you said that the disease develops in earlier age and the last thing I want is everybody to think, Oh my God, I can't multitask and I must be getting Alzheimer's then your clinic will be so filled that you won't be able to handle all the patients. So to the best of your ability, can you differentiate between that, quote, multitasking, social media overload and the true signs of memory loss, concentration and cognitive deterioration?
Dr. Isaacson: Yeah, the best way to differentiate is by doing a cognitive assessment and really where the field is going and, and, and really where the field will continue to go is advocating to get a baseline cognitive assessment. Meaning how is your brain doing now and has brain function changed over time? Um, what we're doing in our program is using computer based tests. We even, um, are offering computer based testing on a website before the person even comes into the clinic. So this electronic computer based testing that can be done at a baseline and can be repeated at intervals is a way to truly understand A, is there a problem, B, has there been a change over time and, C, is that problem in memory? Is it attention, is it language, is it speed of processing or is it something else?
Dr. Stieg: And then you correlate the results of those tests with the social setting of the person. Correct? They're going through a divorce or somebody died. I would in their family, I would suspect that severe stress would affect these test results.
Dr. Isaacson: Absolutely. Stress, depression, and sleep deprivation as as an example, as well as some medical conditions can cause really the same problems. And that's a problem with attention and processing speed.
Dr. Stieg: Richard, it's been really encouraging talking with you. I think for both myself and also for a number of people out there, you have highlighted that this is a progressive disease and something that we all need to take seriously much earlier in our life than when all of a sudden we notice that we have some of the symptoms. I want to thank you so much for being with me today, and I look forward to talking in the future about the results of your recent clinical studies. Thank you for being here.
Dr. Isaacson: Thanks so much.
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