← The Peter Attia Drive

#164 - Amanda Smith, M.D.: Diagnosing, preventing, and treating Alzheimer's disease, and what we can all learn from patients with dementia

Jun 7, 2021 2h 1m 26 insights
<div><span> Amanda Grant Smith is a geriatric psychiatrist with decades of experience treating patients with dementia and Alzheimer's disease. In this episode, Amanda shares how she developed a passion for geriatric psychiatry as a means to support dementia patients. She explains how to recognize, define, and diagnose dementia—a process that still remains somewhat elusive. They also talk about the significance of ApoE genotype and compare the various forms of dementia including differentiating between Alzheimer's disease and Lewy body dementia. They discuss the current landscape of clinical trials, the drug pipeline, and talk about a very promising monoclonal antibody directed at amyloid beta that has the potential to be a disease-modifying drug. They conclude with a discussion about how to define "healthy aging" and reflect on how understanding dementia can shape one's life philosophy.</span></div> <div> <div> <p> </p> </div> <div> <p>We discuss:</p> <ul type="disc"> <li>How Amanda developed a passion for geriatric psychiatry [3:15];</li> <li>Defining and diagnosing dementia and Alzheimer's disease [13:30];</li> <li>Medical tests for dementia and their relationship to clinical symptoms [22:45];</li> <li>The pathology of dementia, and the role of the tau and beta-amyloid protein in Alzheimer's disease [33:15];</li> <li>The significance of ApoE genotype, and differentiating Alzheimer's disease from Lewy body dementia [43:15];</li> <li>The evolution of Alzheimer's disease prevention, care, and medications over the last 20 years [52:45];</li> <li>Psychiatric support for dementia patients (and caregivers) with depression and anxiety [1:02:45];</li> <li>Drug pipeline, clinical trials, and major challenges to overcome [1:13:45];</li> <li>Redefining Alzheimer's disease and designing effective trials [1:23:00];</li> <li>The promise of monoclonal antibody treatments for Alzheimer's disease [1:34:15];</li> <li>How we should measure outcomes in dementia trials and define "healthy aging" [1:42:30];</li> <li>How understanding dementia can reshape our life philosophy [1:53:45]; and</li> <li>More.</li> </ul> <p>Learn more: <a href="https://peterattiamd.com/">https://peterattiamd.com/</a><br /> <br /> Show notes page for this episode: <a href="https://peterattiamd.com/AmandaSmith">https://peterattiamd.com/AmandaSmith</a><br /> <br /> Subscribe to receive exclusive subscriber-only content: <a href="https://peterattiamd.com/subscribe/">https://peterattiamd.com/subscribe/</a><br /> <br /> Sign up to receive Peter's email newsletter: <a href="https://peterattiamd.com/newsletter/">https://peterattiamd.com/newsletter/</a><br /> <br /> Connect with Peter on <a href="http://Facebook.com/PeterAttiaMD"><u>Faceboo</u></a><u>k</u> | <a href="http://Twitter.com/PeterAttiaMD"><u>Twitter</u></a> | <a href="http://Instagram.com/PeterAttiaMD"><u>Instagram</u></a>.</p> </div> </div>
Actionable Insights

1. Prioritize Emotional Health, Relationships

Shift your identity and focus towards emotional health and the quality of your relationships, as these aspects are less tied to age-related decline and are key determinants of well-being and happiness throughout life.

2. Cultivate Positive Mindset for Aging

Age successfully by focusing on how you see yourself, fostering positive interactions with the world, nurturing strong relationships, letting go of past losses, and actively focusing on the positive aspects of life.

3. Engage in Aerobic Exercise

Engage in regular aerobic exercise, as a growing body of data shows it can improve cognitive testing scores even in individuals with existing cognitive impairment or full-blown dementia, making it beneficial beyond just prevention.

4. Manage Cardiovascular Risk Factors

Actively manage risk factors like high blood pressure, high cholesterol, smoking, and diabetes to reduce the accumulation of tiny strokes and vascular disease in the brain, which can contribute to cognitive impairment.

5. Act on Life Goals Now

Don’t postpone significant life goals or experiences until retirement, as unforeseen health issues may prevent you from enjoying them; live in the present and pursue what brings you joy now.

6. Reframe Challenging Behaviors

Caregivers should understand that challenging behaviors in loved ones with dementia are symptoms of the disease, not intentional acts to annoy; respond with patience and reframe interactions to reduce personal frustration and improve care.

7. Focus on Present in Alzheimer’s

For both patients and caregivers, prioritize focusing on the present moment and making each day better, rather than dwelling on the inevitable progression of Alzheimer’s, as patients often live in the moment.

8. Regularly Review, Deprescribe Medications

For elderly individuals, especially those with dementia, regularly review all medications with a healthcare professional to identify and deprescribe unnecessary drugs, ensuring treatment targets symptoms with the safest, lowest dose.

9. Seek Early Intervention for Alzheimer’s

Overcome embarrassment or isolation associated with Alzheimer’s symptoms and seek early medical help, as current medications, while not cures, can slow cognitive decline and preserve function for a period.

10. Recognize Alzheimer’s as Treatable Disease

Understand that Alzheimer’s is a disease, not a normal part of aging, and that early intervention and treatment can slow decline and preserve function, encouraging timely help-seeking.

11. Use Positive Reinforcement for Caregiving

When a loved one with dementia resists a necessary task (e.g., showering), use positive reinforcement by offering a favorite reward (e.g., a snack) immediately after the task, rather than engaging in a struggle.

12. Combat Social Isolation

Actively combat social isolation by nurturing relationships and engaging with others, as strong social connections are a crucial determinant of quality of life and emotional well-being as you age.

13. Ensure Separate Interviews for Diagnosis

When seeking a dementia diagnosis, ensure that the patient and an observer (e.g., spouse, adult child) are interviewed separately, as this prevents crucial information from being omitted due to discomfort or desire to protect feelings.

14. Rule Out Reversible Memory Loss

If experiencing memory loss, undergo comprehensive lab tests (e.g., for thyroid disturbance, vitamin deficiencies) to identify and treat any reversible causes before assuming a neurodegenerative condition.

15. Avoid Benzodiazepines for Elderly

For elderly patients with dementia, avoid chronic use of benzodiazepines (e.g., alprazolam, lorazepam) due to their high risk of increasing confusion and significantly raising the incidence of hip fractures.

16. Tailor Prevention Based on APOE

If you know your APOE genotype, use it to inform your approach to preventative measures; while a protective genotype doesn’t eliminate risk, a higher-risk genotype should prompt a more serious commitment to prevention.

17. Adapt Activities to Enjoy Life

Even with a diagnosis or physical limitations, adapt your favorite activities and pursue things you enjoy, rather than giving them up entirely, to maintain quality of life.

18. Seek Support as Caregiver

Caregivers should seek opportunities to vent and talk to others who understand their experiences, as sharing insights and receiving validation can provide significant emotional support and practical advice.

19. Implement Practical Travel Safety

When traveling with a loved one with dementia, implement simple safety measures like having them wear a lanyard with their room number and your cell phone number, allowing for continued enjoyment of activities with necessary adjustments.

20. Differentiate Normal vs. Dementia

When concerned about memory issues, consider the context: stress, poor sleep, and normal aging can cause forgetfulness. True concern arises when memory problems become a daily, frequent, and intense pattern.

21. Cultivate Empathy for Elderly

Develop patience and understanding for elderly patients by considering their life stories and experiences, which can provide context for their current state and foster better care.

22. Challenge Ageism in Healthcare

Be aware of and challenge the tendency to dismiss or ‘brush off’ the elderly, as this can lead to misdiagnosis or inadequate care and reflects an attitude of ageism.

23. Understand APOE Genotype Limitations

Recognize that APOE genotyping is not diagnostic for Alzheimer’s disease and can cause undue worry; its primary utility is in research settings to understand treatment responses and risk, not routine clinical care.

24. Focus on Clinical Outcomes

When evaluating treatments for Alzheimer’s, prioritize clinical outcomes (patient improvement, symptom reduction) over biomarker changes (e.g., amyloid removal), as biomarker success does not guarantee clinical benefit.

25. Be Aware of ARIA Risk

If considering anti-amyloid drugs, be aware of the risk of amyloid-related imaging abnormalities (ARIA), such as brain swelling or microhemorrhages, especially if you are an APOE4 carrier, as this may influence dosing or suitability.

26. Prioritize Prevention for Cure

Understand that prevention trials, which aim to stop Alzheimer’s before symptoms begin, represent the most promising path towards a cure, similar to intervening early in cardiovascular disease.