The Get Healthy Tampa Bay Podcast

E101: Understanding Memory Loss and Alzheimer’s with Dr. Diana Barratt

• Kerry Reller

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Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I’m joined by Dr. Diana Barratt, a board-certified neurologist and sleep medicine expert with a focus on Alzheimer’s and cognitive health. In this episode, we explore the nuances of memory loss, when it’s considered normal, and when it may signal something more serious. Dr. Barratt shares her insights on the latest advancements in Alzheimer’s treatments, the importance of early diagnosis, and how lifestyle modifications can slow cognitive decline.

Dr. Diana Barratt is board-certified in Neurology and Sleep Medicine. She studied Engineering and Medicine at the University of Florida and earned a Master’s in Public Health degree from Harvard. Her research experience includes participating as a sub-investigator in clinical trials on stroke and Alzheimer’s disease. She received numerous awards from the American Academy of Neurology and independent funding from the American Board of Psychiatry and Neurology. Dr. Barratt serves on national committees and is a peer-reviewer for Neurology, the most widely read and highly cited peer-reviewed neurology journal. 

A lifelong learner, she regularly attends conferences and continuously searches the medical literature for cutting-edge treatments and clinical trials to offer her patients. Prior to scheduling the first appointment, Dr. Barratt speaks with each patient. In advance of the visit, she reviews medical records and views imaging. Because she maintains a small patient panel, she is able to maintain regular communication with her patients. She personally responds to phone calls or messages within 24 hours. 

Dr. Barratt's concierge-style practice is located in Boca Raton, Florida next to the Town Center Mall. If you would like to experience a comprehensive approach to optimizing your brain and overall health that includes not only medications, but diet, exercise, sleep, and lifestyle modification, call 561-300-4178 to speak directly with Dr. Barratt. 

0:28 - Introduction to Dr. Diana Barratt and Her Expertise
2:13 - Is Memory Loss Normal?
3:25 - Signs of Cognitive Decline to Watch For
4:55 - Reversible Causes of Cognitive Impairment
9:35 - Differentiating Types of Dementia
15:21 - Hope Through Diagnosis and Treatment Options
25:08 - Anti-Amyloid Therapies: Who They’re For and How They Work
27:55 - Lifestyle Interventions for Cognitive Health
32:56 - Social Connections and the Role of Exercise
40:05 - The Importance of Early Evaluation and Diagnosis

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DianaBarrattMD.com

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Kerry:

Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. And today we have Dr. Diana Barratt coming in from, I guess, Miami Boca area. Right. And we are so excited to have you and your expertise on today. And why don't you tell us a little bit about who you are and what you do?

Diana:

Okay, so I'm Diana Barratt and in Miami it's Barratt, but the rest of the world is Barratt, but I'll answer to either one. I am boarded in neurology and sleep medicine. I am a neurology educator, so I ran a neurosciences course at Florida International University, developed course content for second year medical students, and then I ran the neurology clerkship for third year medical students. And I did that for 10 years. And then I went on to become a neurology residency program director, and now I am in Boca Raton. And I have a solo practice and it's, it's similar to a concierge type practice, and I am treating Alzheimer's patients, and I've also participated in the clinical trial. So before these new Alzheimer's drugs were available, I was involved in the clinical trial. So administering them and monitoring patients, and I'll probably get involved in a couple other Clinical trials as well.

Kerry:

Awesome. Yeah. So you're definitely an educator and, you know, kind of, I guess an expert in this area as, you know, being a teacher, like when you know something and you're able to teach it, it's a whole nother level, I think. So yes, very thankful for everything that you do with it, with that. So I think our, we were kind of talking before and I wanted your expertise to teach us about Alzheimer's disease and memory loss. So where should we begin? I guess basically is memory loss normal?

Diana:

So some amount of memory loss is normal. And I always say that children learn languages very quickly. They can pick up multiple languages. They learn things more quickly than we do. And as we age, we can start to forget things and some Forgetfulness is benign, right? Not harmful. I forgot where I put my keys or I can't think of that person's name. and then at some point the memory loss becomes mild cognitive impairment. and mild cognitive impairment can be a step toward mild dementia. And so it's really important to test it. So see a neurologist become tested for this and find out because there are a lot of new treatments available now for mild cognitive impairment due to Alzheimer's and for mild Alzheimer's dementia. And so if you missed that window where the treatment is available, then, you know, there it is. There are fewer options once the person's in the moderate or severe stage.

Kerry:

what kind of things would a person notice that might make them concerned? Maybe, maybe they go to their primary first and then be referred, but what kind of things would you say that they would notice that they should bring up to their doctor?

Diana:

So if there's persistent forgetfulness, so if they're, if they're forgetting, the date often, if they're not sure where they are, so orientation, there's a, there's a whole screening that I do called the clinical dementia rating scale and memory is the, the top row. So is it benign occasional forgetfulness? Is it persistent or consistent forgetfulness, and then it's orientation. So does somebody remember the date and time or are they saying, you know, I'm retired. I don't need to know what year it is. That, that kind of crosses the line there. You should know what year it is, even if you're retired and you don't go to a job every day, you should know what year it is. So some of them fall into that mild category and then they qualify for this new class of drugs that's available. And then there are more severe things where, they can't remember how to drive a car anymore. they're getting lost. Those are more obvious findings. they can lose interest in their hobbies. So that's another category on the clinical dementia rating scale that you're not performing your normal duties. You're not socializing like we did before. And, and that begs the question of, do they have depression? You need to be screened for, for other things other than dementia.

Kerry:

Yeah, that was like screaming in my brain. I'm like thinking of all the other things that it could be. So what are some things that could be mimicking this or maybe a reversible cause of, impaired cognition at this point, what

Diana:

Yeah, we should probably call it cognition, but I think most people are familiar with the term memory loss, but it can be multiple different things affecting your cognition, your planning, your, your ability to control impulses, you know, switch tasks. So a main one that I'm trying to address, and I've been doing this for so many years, is polypharmacy. So I just feel like our population. is overmedicated. You know, they go to the doctor, they have complaints falling asleep. They're given a pill to make them go to sleep. And a lot of times it's, you know, Xanax, right? Alprazolam, something long acting and, you know, they, they take it and it helps them fall asleep. And then 30 years later, they're on the same dosage of that pill and their metabolism is no longer fast. And that medication is building up in their system. So I see this very, very often in patients. They might be on a medication for depression. They might be on a medication for anxiety. And then they're tired during the day and they might be prescribed something to help wake them up in the morning. So that that's a big thing. I think polypharmacy. A lot of drugs will cross the blood brain barrier. So, have your doctor look at your list of medications and start taking things away or reducing things if they're not absolutely needed. We screen everybody for thyroid disease, so that's a big cause of people slowing down in many ways, and that can affect your cognition. Depression, it's easy enough to screen people with a really quick questionnaire to find out if they have depression and there are treatments available for that. Vitamin deficiencies are very common in, in people in general, but especially in older adults. I mean, you don't have the appetite you did when you were 20, when you were 20, maybe you were ravenous and you ate everything in sight. And then, when you get older, you're not as hungry, or maybe you're worried about weight loss. You're trying to lose weight. You're cutting calories. And then lots of vitamin deficiencies can pop up. And even like vitamin D deficiency, even here in Florida, so many people are vitamin D deficient. And that can cause you to have problems with cognition and sleep disorders. I screen everybody for sleep disorders. This is very common. So obstructive sleep apnea is a huge cause of cognitive dysfunction, but other people I've noticed older adults and we live in a hot climate in Florida. They keep the blinds closed during the day to save on their air conditioning bill. And Shades pull down, they're not getting enough sunlight during the day. They're sitting in a more darkly lit room and then they're not sleeping well. You're not getting sunlight during the day. You're not suppressing melatonin, which is a normal hormone that's expressed during darkness. And then maybe you're up at night looking at your iPhone, the bright screen, and then you're suppressing melatonin. which is supposed to help you get to sleep at night. So sleep disorders are another really big contributor to cognitive issues.

Kerry:

On a comment on the polypharmacy thing. So I think with the generation that is approaching more memory issues now, it was always like, yeah, you got a symptom treated with the medicine symptom tree with the medicine. And I think we're hopefully trying to get away from that, like, as you know, the I guess the medicine world changes a little bit, but hopefully otherwise, it's still like, you know, everybody's just, you're tired, you can't sleep automatically, you're put on a medicine or depression when it could really be mimicking something else. Like I'm on a menopause kick. So maybe it could be menopausal symptoms where somebody is like having depression, anxiety, sleep problems, but they are only going to a doctor who's giving them a medication for one symptom instead of looking at the whole picture. So I can see how these patients end up on all these different types of medicines to treat this, that, or the other. And that can be hard to de I don't know, de prescribe, right? It's really difficult, especially when I get a new patient to, Say, Hey, I don't, I don't think this is the best thing for you change it. And it's something they've probably done for years and years. So, I mean, I can imagine that it's difficult and then it's unfortunate cause you know, I didn't, I'm not sure if I'm even aware that it can impact your cognition later in life way down the road too. So I think that's super, super important thing that you mentioned there. I think you kind of covered a lot of the things that can, be needed to rule out before we think that it's safe. You know, some sort of thing like my cognition related to Alzheimer's or anything like that. But there are definitely lots of types of dementia. So can you kind of differentiate some of those?

Diana:

So we'll get to Alzheimer's, I guess, a little bit later at the end. Aside from Alzheimer's, there's vascular cognitive impairment, and that occurs when people have strokes and they can be large vessel strokes that affect large areas of the brain. They can be smaller vessels, or even the microscopic vessels in the brain start collapsing. And then for a while your brain can compensate, you know, reorganize itself. But after enough damage to the brain, everything starts to slow down. So, so vascular cognitive impairment is a big cause of dementia after Alzheimer's. And you can diagnose that by getting an MRI and that, and then you exclude the other things that we've talked about in the months that we will discuss. And then when you're left with that, then that's the cause.

Kerry:

You see that with hypertension in general, or does it really mean that they had like many, many strokes that are not evident on MRI, or what would you say?

Diana:

there are lots of things that can contribute to vascular cognitive impairment, like hypertension, like diabetes like hyperlipidemia, all the risk factors for stroke are the same risk factors for vascular cognitive impairment. And then there's another class of dementia called frontotemporal dementia. and then they reclassified them. So there are a few things under it now. So there's frontotemporal dementia. And that can occur in younger individuals. So, you know, less than 65, they start having these behavioral abnormalities. They do things they never did before, maybe impulsive things. And, It presents initially like a psychiatric condition, so they might start saying inappropriate things, you know, getting in trouble with the law, doing things that they never did before. And they're not always diagnosed right away because it looks like something psychiatric, but they call it frontotemporal because the frontal lobes of the brain, which are the four behind your forehead and the temporal lobes around your temple, so shrink. And it, it can cause that. problem with behavior. And then there's another category under frontal temporal dementia besides the behavioral variant that I just discussed. And that's primary progressive aphasia. And I don't know if you've seen the reports in the lay press, they say that Bruce Willis has aphasia. So that's what they're saying that he has primary progressive aphasia. And it's also due to shrinkage of the frontal and or temporal lobes. And first it affects the frontal lobes. Language. So the patients the first sign you see if you can catch it early enough is that they're just not talking normally. Either they there's very little verbal output, or they're making sentences but they don't really make sense. And, and, and then later much later in the course of the disease the other memory problems come about, but it can be hard to tease out because they can't think of the word they're trying to say so maybe. You say to somebody who's this gentleman that brought you to the doctor, and the patient might say, Oh, that's my, that's my brother, when he really knows it's his son, because You, you might say the son's name later on in the conversation, but he can't think of the word son. So he substitutes it with brother. So you think a memory problem. He doesn't remember son, but it's really a language problem. So that's, that's primary progressive aphasia. I'm sorry, what were you

Kerry:

I said, oh, that's interesting. I remember learning the pathways of like Broca's region and things like that. That's like going through my head and I will share, you know, so I had a family member who has frontotemporal dementia and his 1st thing that he presented with was facial recognition. And I think when we look back and then foot drop later on, and then that, you know, kind of went to diagnose it, but so I, I definitely not the aphasia part, but I think that, you know, I think more of the behavioral thing as well, but it was interesting because he was not able to distinguish people in the family, like who differentiate us, it was interesting. So that's just kind of how he presented and it's a super sad disease really. But yeah, so I, I think that the aphasia thing is very, very interesting of how they just kind of want to say something and they are unable to, So are there other types of dementia as well?

Diana:

Yeah. And I wanted to add to that. It is very sad when they have these conditions, but it's important to differentiate them because There are new treatments and old treatments available for Alzheimer's and they don't necessarily work for primary progressive aphasia. So you don't want to have somebody on a medication lifelong because you thought they had Alzheimer's, right? So it might cause side effects or just not work or worsen their disease. But yeah, there are other conditions. So there's dementia with Lewy bodies. And have you heard of you've heard of Robin Williams, but they, they say that he had dementia with Lewy bodies. And that can be a very tough diagnosis also. So they have hallucinations, and then they have periods of time during which they are very normal. And so they're, they fluctuate quite a bit. And that can be hard to diagnose too. Sometimes it presents more like a, a psychiatric condition. But again, needs to be differentiated so we can treat it properly.

Kerry:

Yeah. I don't, I didn't know that about Robin Williams either, but all of these are, you know, pretty sad diagnoses, I think, but at least you're, you're pointing out that there is, different treatments and making sure that they go see a neurologist so they can differentiate them is very important, right?

Diana:

Well, right, but there is hope available. So there are clinical trials. I mean, I had a patient with primary progressive aphasia and I referred him to a clinical trial where they're giving him speech therapy free and online so he doesn't have to travel for it. and there are treatments for some of these other conditions and even just having a diagnosis, I think can be a comfort to the family. So it gives them some level of closure because they at least know what it is. And then you can look for treatments that are appropriate to that specific type of dementia.

Kerry:

Yeah, absolutely. What about Parkinson's? Does that fall under this

Diana:

Yes. So Parkinson's disease usually starts with motor, the motor component of it. So the Bradykinesia, so slowness of movement usually comes with a tremor. And then later on the dementia. can develop, and Parkinson's has a different treatment pathway, of course. And, and then there's there's other things too, like HIV can cause dementia, and there, there are treatments available for HIV, there are a lot of good treatments available now, so it's worth diagnosing and treating. And syphilis is also a cause of memory problems or cognitive problems. It's very treatable with penicillin and, for decades, neurologists were ordering, studies for syphilis because it can affect the nervous system at any level. And we weren't finding it. And then suddenly there's like a resurgence of syphilis. So it's definitely something you should just, test people for, or if you're a patient, just get tested for all these things and get the treatment for it.

Kerry:

Yeah. Very easy test too, right? So it's definitely something that can be done by your primary doctor first to rule out anything going on. So what makes Alzheimer's disease different? Tell us about that.

Diana:

well. So originally Alzheimer's was described in 1906 by Dr. Alzheimer. So he,

Kerry:

I didn't know that.

Diana:

well, he didn't name it. Somebody else named it after him, but he had a patient that he was following and she had memory disturbances. She had sleep disturbances. She had paranoia. And he followed her for five years and after her death, he performed an autopsy and he saw these strange looking protein plaques in her brain. These strange looking protein aggregates and now they're defined as amyloid plaques and tau tangles. And now we understand what they are. But so this was 1906, and then that, that's now the, the definition of, Alzheimer's and now a biological one by core biomarkers. But for so many years, I mean, we did not have the availability of amyloid pets to diagnose them. So you want to see if there's. amyloid accumulations in the brain at an abnormal level, and so for a long time, you could do a spinal tap and test to see if there was amyloid in their spinal fluid and quantify that and also the tau in the spinal fluid, but patients did not want to get spinal taps, and doctors weren't pushing it for obvious reasons, and so for the longest time, we were saying, you know, we've excluded vascular dementia. We've excluded you know, these infectious causes, we've been excluded hormone and vitamin deficiency. So you probably have Alzheimer's. So let's go ahead and put you on Aricept or Denepazil as the generic or Nomenta or Romanti. And now that these anti amyloid therapies are available Medicare has approved amyloid PET. So the amyloid PET scans, can find and determine how much amyloid is in the brain while the patient's alive, because for the longest time it was an autopsy diagnosis. And so that, you know, that doesn't help the patient when they're alive. So, so now the diagnostic criteria that you have to have amyloid in your brain, right? So if you don't have amyloid and your brain are at an abnormal level, you don't have Alzheimer's. And so go back to the drawing board and look for one of these other conditions.

Kerry:

Yeah, I was going to point that out. So it used to be a diagnosis by autopsy. And now, like, to prove it doesn't have to be a clinical diagnosis, you can actually do this amyloid positron emission tomography test, right? Where they can find the amyloid in the brain and make a real, you know, diagnosis rather than with definitive, you know, data and markers rather than just like clinically you ruled out these other things, right?

Diana:

Yes, that's correct. But I mean, I'm not ordering them in normal asymptomatic patients. So if somebody comes in and they're normal and they say, I want an amyloid PET, I would say, I don't, I don't recommend you getting one because you're, you're asymptomatic. I mean, that it could change and over time, but right now that's not recommended. And then as we were discussing before the podcast, Do you need to buy health insurance or long term care insurance or life insurance? And then if you have amyloid in your brain and you're, you have to disclose that to your insurance company, what, what are the chances you're going to get a good rate on, on these insurances? So, so right now, I mean, if, if a patient comes in with symptoms and there's somebody that could, benefit from one of these treatments and I'm ordering them. But, but if they, if they don't have symptoms, I'm not ordering it.

Kerry:

Right. So we're not using amyloid PET for a screening method.

Diana:

Right. Right.

Kerry:

Okay. But like we were saying before, there are these new things that patients can go to like quest and order on their own. But like you just said, you know, you got to be careful because if you want to invest in life insurance and, you know, long term care insurance, which I didn't even know was a thing then, you know, maybe that you don't want those kinds of tests done. Right. But can you just explain a little bit, like, what are those and what is their limitation at this point?

Diana:

Right. So I know there are people who are going to, non certified labs. Well, Quest is a certified lab. So if you want to get something done, I would test it at a certified lab, but you know, people were getting 23andMe and they were getting all these genotypes done. And so there's, there's APOE4, right. And it's, it's a genotype. So if you have. One copy of APOE4, you're at a slightly higher risk of developing Alzheimer's than the normal population. And if you have two copies, you're at an even higher risk of developing Alzheimer's. But, but you could live to be 85 or longer with two copies and never develop Alzheimer's dementia. So like for me, I have not tested myself because I might want to switch health insurance plans. And what am I going to do with the information? I'm asymptomatic. But I do order these genotypes and anybody that is qualifying for the anti amyloid therapy. So the anti amyloid therapy pulls amyloid out of the brain and it does it very effectively. And we have studies that show and they, they, they got the patient's consent, of course, and they scanned them that had advanced Alzheimer's disease, and they saw significant amount of amyloid in the brain. And then after the patients passed away, they did autopsies, and they found a significant amount of amyloid plaque in the brain, so they can, it correlates very well. So we know that these drugs we know that we can image amyloid accurately with these studies, and we know that the medications are pulling amyloid out of the brain. So if I were considering somebody for this therapy, I would, must definitely get the genotype, because if you have one copy of the gene, you're at a slightly increased risk of bleeding due to this medication. And then if you have two copies of the gene, you're at a much higher risk of bleeding. And so at that point, if you had two copies of APOE4, I personally would not offer the treatment. I would advise against it. And if the patient really wanted the treatment, I would. Probably send them to an academic center for a second opinion, but there are many people who wouldn't offer it because of that.

Kerry:

What and what kind of bleeding are we talking about

Diana:

So, we know that these anti amyloid medications can cause micro hemorrhages, so it's just like it sounds. It's a tiny little hemorrhage in the brain, and it's, it can be hard to see unless you use a very specific sequence on MRI. So we screen people before we start these medications. And some of them already have it in their brain. They might have a very low level of these micro hemorrhages. And then the radiologist counts how many they have, if they have one or two in the brain, then they're still Qualified for this study, and then you follow that every so often depending on what drug they're on there. There's a treatment. There's a treatment program protocol, and there's a monitoring protocol. And then if they start to accumulate these micro hemorrhages and it reaches a certain threshold, then you have to stop the medication

Kerry:

So is it given by mouth, by IV injection, or how do they, and what are some names of them, for example?

Diana:

Right now it's infusion. So there's one medication that's a once a month infusion and there's another medication that's every two week infusion. So they go to an infusion center they are monitored by the staff and then yeah, and then they, they can leave and go about their business, but they're monitored for a while for, for allergic reactions or any side effects.

Kerry:

Mm hmm. So you definitely told us who it's not for, right? But is there any particular patient that it's good for? Mm

Diana:

Well, yes, it's, it's good for people with mild cognitive impairment. So they haven't even reached the threshold of dementia yet. So they're, they're, they're still accomplishing all their activities of daily living. Maybe they have some forgetfulness. Maybe they can't remember the date very well. They can't keep up the way they used to. That would be a good candidate for them and they don't have any, micro hemorrhages in the brain or mild Alzheimer's. So say someone's had to take over certain functions for them, but they're still performing well on cognitive tests. So those are people that would qualify for it.

Kerry:

and, well, first, before I switch the topic, I wanted to ask you, Well, if you had anything more to say on the amyloid therapies, that would be great, but I just wanted to say, what are the traditional ways that we've been treating this and like, do those help? Do they not help? How, how does that play into role with your treatment plans?

Diana:

So we've been using Aricept or Dinepisil for a very long time. It, it works. I mean, it's, it's worth doing. It's a cholinesterase inhibitor. So acetylcholine is a neurotransmitter that's in all of our bodies. It's in the, it's in the periphery and it's also in the brain and the central nervous system. And there's a decrease in cholinergic function. People with Alzheimer's. And so this, this prevents or slows the breakdown of acetylcholine, this essential neurotransmitter. So definitely, I mean, start Aricept or, or donepezil and mild Alzheimer's dementia, and it's really not proven to work in mild cognitive impairment. Lots of people get started on it, but I've been waiting until they develop mild Alzheimer's. I mean, not waiting, waiting for them to develop it, trying to do something else to prevent the progression of their disease. but I don't start it too early. And then there's Namenda or Mamantine and that you can start in moderate Alzheimer's disease. And these, if they tolerate it, these can be continued for the rest of their lives and they've been shown to be helpful. So go ahead and

Kerry:

So do they stop the progression or do they reverse it or?

Diana:

I mean, that's a great question. So None of these drugs can stop the progression or reverse the, the disease course. The, the antiamyloid therapies change the trajectory. So they've shown in their studies, patients still progress in terms of cognitive impairment, but they do so at a slower rate. So it buys you some time.

Kerry:

What about I guess lifestyle modifications or any other strategies to help manage Alzheimer's?

Diana:

So I'm really excited about the lifestyle modifications and the non medical things and I'm, you know, trying to employ and so I, I do start with cognitive training to what are this patient's deficits? Oh, she can't remember any of the names of her grandkids. We'll put them out, like put their pictures out where she can see them instead of like her being embarrassed that she can't remember the names and withdrawing socially or not wanting to see people or not wanting to talk. You know, let her study in advance. So put the pictures of all the kids. Or, or all the dinner guests that are coming, you know, give the person that the names of all the people that are coming and let them try to memorize them again. And then when they come, like I have a patient who said, I can, now that I'm doing this, I can remember everybody's name. My wife gives me the seating chart and I remember all their names and I'm able to fully engage with my patients. community. So that, that I love doing, just figuring out exactly where their deficits are and, and trying to just give them reminders, give them a lot of help. And then you know, some people are using these little computer game, they're doing crossword puzzles or little math games. Like, I don't think that helps very much because it's activating only a really small part of your brain and going out socially. Interacting with somebody, you're involving so many different areas of your brain, you know, you're involving your emotional intelligence. You know, you're, you're watching their body language, you're using language, you're using all of your skills when you're interacting with people. And so the social engagement is extremely important. And when people withdraw from their social life, they, they actually decline quite a bit in terms of cognition. Another thing is hearing. So hearing loss has been identified. As a way to intervene in terms of preventing dementia, so a couple of things happen with hearing loss. one is you know, when people get into a crowded, noisy environment. They're trying so hard to listen to what's going on and focus on the conversation that you're, you're expending so much energy, doing that, that it's, it's stresses your brain. The other thing that happens is those pathways, when you get decreased input to your auditory systems, those pathways in your brain start to shrink because you're not using them. So they should get tested for hearing loss, and they should get hearing aids and I have patients who say, Oh, I just got a new hearing aid. But they still can't hear what I'm saying unless I speak very loudly and, deliberately. And so I know they're missing a lot of what's going on around them. So, I mean, get another type of hearing aid. Get your hearing aid adjusted if it's not working properly.

Kerry:

So you said those games and things don't help really for treatment stuff. Do they help with prevention of Alzheimer's or mild cognitive impairment or

Diana:

little game like the little crossword puzzles. I don't think it's a good use of their time sitting there alone doing a crossword puzzle or doing a little math game on your phone. I mean, what would help a lot more is going out exercising with your friends, you know, go in a long walk with your friends. Talk to them, interact with people, and that's what's helping to prevent decline. And then in terms of exercise, aerobic exercise is very effective. And you can see changes in people's brains after they start an aerobic exercise program. So parts of the brain can actually grow. I mean, we used to think that, you know, your brain doesn't grow at all, but it does. It can respond to different, different forms of exercise. So they've looked at, you know, cab drivers and cab drivers parts of their brain are larger than normal because they have to memorize all the streets and navigate. Whereas, you know, when you look at a similar study of, of people that are just driving a bus, they go the same route every day. They're, they're different than the cab drivers. So, so definitely using your brain, exercising in terms of cardio. You know, aerobic exercise is very helpful, but also using your brain in its full capacity is very helpful.

Kerry:

It's interesting, you know, all the social connection things. And I think when we look at things like on Netflix with like, they talk about the blue zones and stuff. You're seeing these people that live a very long time and it's not just, you know, the physical activity and the, you know, the food they eat, but like, like you said, the social connection, right. So they're staying engaged. It's really big community atmosphere there. And I think maybe that's why they live to like their hundreds and stuff. And in those areas, there's not really like nursing homes or, you know, dementia care units. That take care of these people. So there's something to be said about, well, all the components that are involved in those, you know, areas of living, but definitely the social component as well, from what, from what you're saying.

Diana:

And the exercise too is very important. You brought up a good point that they're, you know, they don't have a lot of nursing homes out there. I just saw an octogenarian yesterday and he was there for a different reason, but, I started talking to you about exercise and diet and, and, and sarcopenia is the age related loss of muscle mass. And it starts at the tender age of 30. I mean, 30 years old, you start losing muscle mass unless you do something about it. And I think it's never too late to start trying to prevent the loss of muscle mass and trying to build muscle. And there was a study on people in their 90s that were living in a nursing home and they were frail. And they put them on an exercise program and they were able to make gains in strength. And they measured the size of their thighs. So as I was talking with this patient yesterday, he said, well, what kind of exercise do I do? I don't want to go to the gym and expose myself to infections. And he said, but I could start lifting with my upper body. Well, that's really important you want to work out with your upper body. But to me, I said, lower body is, Probably even more important. I mean, you need to be able to get yourself up off the floor. So why do we fall when, when we get older? We fall because our muscles are weaker than they used to be. Our reflexes aren't as strong and maybe we have sensory neuropathy also, but we want to prevent falls because that could change everything. That could be life changing one fall for an older adult. So I said, you know, can you do a, just do a body weight squat? Can you squat on the floor? and get yourself up without using your hands. And he said, well, that's a little hard for me. So that that's probably where you should start then. Like, you know, have something nearby, maybe furniture nearby that you can use to help yourself get up, but strengthening those leg muscles, the thigh muscles, the calf muscles would be really important. And it does something in the brain too. It releases a hormone called brain derived neurotrophic factor, which makes the brain grow, which is really interesting because we didn't know that there was a connection between, muscle and the brain.

Kerry:

Yeah. That's, I mean, it's such a super interesting topic and I need, and, you know, going back to the subject of. It starts at 30 thing, you know, and the menopause thing, like, it's amazing that you know, it starts so young. Right. And that's usually when we become more sedentary. So we're losing our muscle mass anyway. And I mean, this is something I'm always talking about too, is like building muscle mass in patients and most of it, cause I do a lot of obesity medicine. If you were trying to lose weight and I'm trying to make sure it's not. You know, fat loss, not muscle mass loss. So that's super important. And then I know there's like doing research studies to see if, you know, hormonal therapy, which helps you like estrogen therapy, which helps maintain the muscle mass. If it has anything to do with preventing dementia too. I think that's all like TBD, like when you're treating menopause with hormonal therapy, but it's really kind of exciting to see if that can help Quote, prevent or help improve the prevention of dementia. But yeah, definitely a hot research topic, I think too. So muscle mass is super important. And I think once again, like going to that generational gap, I think everybody, you know, always knew cardio was important. But it kind of missed that weight training aspect of things too. So typically sometimes if I see a frail older patient, I might suggest, you know, Hey, why don't you go to like physical therapy and start there and they can teach you some things, you know, and build that muscle. So you're less likely to fall and have, you know, injury and things like that too. Yeah.

Diana:

Are you measuring body composition in your patients?

Kerry:

Yeah. So that's one thing. I want to do it on everybody, especially in the older patients. We haven't really done that yet, mostly because of staffing, but I think it's time to see that because it would be very, almost scary, I think, to see the muscle and like the muscle, lean muscle mass composition and like the older patients. I've done it on several, especially if they're like seeing me frequently for weight management, but, you know, yeah. I'm nervous to, to do that on some people just to see how low it is. It was kind of be enlightening actually, but

Diana:

Well, I do think it is, it is kind of disappointing if you don't get the numbers that you want. And, and there are different ways to measure sarcopenia. There's not one agreed upon definition, but you know, grip strength is one, so I have like a, a hand dynamometer in my office. There, there's also sarcopenia obesity syndrome where the patient's just, maybe they were muscular at one point in time and then they, they've lost muscle mass, but they've. gained body fat. And then, they're very weak and they could even be a normal BMI. Their body mass index is normal, but they have very little muscle mass and most of it's fat. But I mean, it is, it can be disappointing when you do your own study and you're like, Oh, I wish I had more muscle mass or whatever, whatever your score was, but there's, you could start from anywhere. I mean, like I said, these 90 year old frail institutionalized patients made gains in strength and the size of their, their legs. And so if they could do it, the rest of us could do it too.

Kerry:

every now and then I come across something on social media where there's like some 90 year old lady or guy who is just like crushing it in the gym. And I feel like it's so inspirational, especially when they're the stories that they like just started, right. It wasn't something that they've been doing their whole lives.

Diana:

it is, it is really inspirational. I had to give a talk on dementia for medical students, so like a really introductory level talk. And I thought, have I wanted to pick the elderly? Like do I want to show a bunch of people on walkers and wheelchairs sitting there? And I didn't, I picked, you know, marathon runners, and I picked bodybuilders that were octogenarians. These are the possibilities, you know, and, and you have to look out for injuries. I mean, if you, if you have an injury or if you're having pain, go to your doctor and get it evaluated and get it rehabilitated. So I'm not saying, you know, accumulate all these injuries. But, but definitely there, you could start an exercise program at any point.

Kerry:

is there any anything else that we missed that you wanted to mention to our listeners?

Diana:

Well, okay. So we were talking about Alzheimer's disease. So, so I think if a person has. problems with their memory or cognition. I think it's normal to be a little afraid, right? But, but I think there are so many things that you can do, so many interventions, multimodal therapies, that the first step is to get a diagnosis. So go to your doctor, get evaluated for your, your cognitive issues. And it might turn out to be something completely reversible. B12 deficiency, for example, that could be treated easily. Or it might turn out to be one of these neurodegenerative conditions. And, you know, if it, if it does, you should know about all the treatments that are available. And you should get diagnosed early. Because some of these treatments are only available early in the disease course.

Kerry:

I have a, I don't know how you want to answer this question. I'm just going to ask it, but how, is it all just old age or how do you know when it's not like, is everybody going to lose some, you know, cognitive impairment or what would you. How would you answer that question? I think it's a crazy one.

Diana:

think people age so differently. You've probably seen patients who are in their 50s that are already having a lot of medical problems. And, you know, when the body is impacted, the brain is impacted. So, and you've probably seen people in their 80s that are very sharp, that are very physically fit, that are very sharp, that are very, Socially engaged. So how would you know, I think, you know, going going in and getting an evaluation would be a good way to find out.

Kerry:

So don't just chalk it up to old age, right? Like actually go seek help if you're concerned or your loved one is concerned about, you know,

Diana:

I think too many people want to do that. I part of the disease I think is denial. So like I said, I've had patients tell me. I don't need to know what year it is because I'm retired. And then you ask them what their grandkids names are. They can't remember their grandkids names. And they say, you know, that's, that's okay. I don't know my grandkids names. So that that's not normal. So go ahead and get evaluated. And if there's a treatment, at least know about it. And you can decide if you want to, to get that treatment or not.

Kerry:

Unfortunately, I see similar things with hearing, like some people just think, Oh, it's part of old age. Like I, I can't fix it, but you know, there, I guess it could be the same thing as a denial, but you could go, you know, get a hearing test and get hearing aids and they can help you. So I don't know if you see that at all. Probably not. Yeah.

Diana:

you know, people, people, when their vision goes, they get eyeglasses. And they have really stylish eyeglasses. No one's ashamed to put on glasses, right? But hearing aids are not cool, right? At this point in time, there's some stigma associated with aging and hearing loss. But now they're making hearing aids that just look like regular earbuds, you know, for headsets. So I think, you know, rather than let your brain, those pathways of hearing in your brain atrophy, Go ahead and get tested and get get a type of hearing aid that looks, you know, appropriate for you and I think we need, we need to do a lot more public education about hearing loss and and to destigmatize it also.

Kerry:

Mm hmm. No, I agree. Absolutely. Yeah. Well, is there anything else like you'd like to share or where can people find you if they want to work with you?

Diana:

So I'm in Boca Raton, Florida, and they can call my office. We'll be posting my website and contact information. Okay, so I have a website, it's just my name. DianaBarrettMD. com And they can call me and I talk with everybody before I make the appointment. I want to make sure that I can help them in advance. And and then I make an appointment for them.

Kerry:

Awesome. Well, thank you so much for, you know, sharing everything that you know about this and sorry for butchering your name, but

Diana:

no, no, that's what I'm called in Miami. But it's just, I've been out of Miami since since COVID really. So it's kind of like when I hear it, like, Oh, that's what they used to call me. Yeah. Diana Barat.

Kerry:

can, I can hear that. Maybe that's why I'm like, have a little bit of Cuban ancestry. Maybe that's where it came from.

Diana:

Yeah, that's fine.

Kerry:

Yeah, well, thank you so much for joining me on the podcast today. And everybody tune in next week for another great episode. And if you need a primary care doctor or allergy, asthma, immunology, or obesity medicine, you can find us at Clearwater family medicine and allergy. Thank you, everybody.

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Dr. Kerry Reller

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