Ask Us Anything About… Alzheimer’s Disease

Description – The video begins inside the Penn State Biomedical Research Building in front of a window overlooking the Penn State Health Milton S. Hershey Medical Center™s west campus. Two individuals are standing next to each other looking at the camera. From left to right is, Dr. Paul Eslinger and Scott Gilbert.

Scott Gilbert  – From Penn State Health Milton S. Hershey Medical Center, this is Ask Us Anything about Alzheimer’s Disease. I’m Scott Gilbert. More than 5 million Americans are living with Alzheimer’s disease. It’s the most common form of dementia. Researchers are trying to learn more about it and find better treatments, and even a cure, for this devastating illness. But here today to talk to us about what we do know about this illness is Dr. Paul Eslinger. He’s a clinical neuropsychologist here at the medical center. Thanks for being here, Dr. Eslinger. I want to start with the questions that I think you must get a lot in clinic about how you can tell the difference between normal aging and dementia. What are just some of those signs that it could be one or the other?

Dr. Paul Eslinger – That’s a very good question. The first thing to understand is that there’s a spectrum of cognitive change that naturally happens with age. So we use the labels such as age-associated cognitive change. And that’s some of the normal forgetfulness or word-finding difficulties that we have day-to-day. And there is also a category called mild cognitive impairment, or MCI. This is a bit of watch and wait stage where we can see that a person is having a little more difficulty in their day-to-day cognition and memory, but it hasn’t reached a point where it’s really interfering with their ability to drive, manage their finances, shop and so forth. And then finally, there’s a stage of early dementia. And that’s where these cognitive changes do begin to interfere with everyday functions of shopping and driving, remembering, for example, directions and how to pay for things and keeping track of conversations and appointments. So it’s when these cognitive changes, they begin to spill over into a person’s ability to function independently and their typical activities. That’s when it starts to be a change that we think is clinically important. So some of these, it’s also at a point at which a key difference is that when you’re aware of these minor cognitive changes, that’s a good sign. You say oh geez, I typically remember that. Let me just focus a little bit better. Or let me write that down next time so as to be a better reminder. That’s a very good sign. And we should be making those kind of minor adjustments day-to-day. It’s when we are not aware of that or we fail to make those changes that it starts to indicate that we’re not quite keeping up with those demands for cognitive function on a day-to-day basis. So that awareness of the minor changes that occur and that ability to make minor adjustments, that’s a very good sign. But it’s when we start to fail to do that and when it starts to interfere with our judgment and decision making and our functioning day-to-day. That’s when it begins to be, I think, a clinical concern.

Scott Gilbert  – Amber, speaking of good questions along these lines, Amber had posted a question to our Facebook post that was promoting this interview today. She asked, how can you tell if someone has Alzheimer’s or is just stressed out? She says, I feel like I’m seeing many signs of it in my grandmother, but she claims it’s just stress.

Dr. Paul Eslinger – Yeah, that is possible. So if you think about your ability to function, you know, with a sharp mind, if you’re not sleeping well, if you’re feeling depressed and irritable, if you’re stressed, if you’re not eating right, if you’re too fatigued, that is going to interfere with your ability to remember and keep up with things. It’s also possible that you may have some mild thyroid dysfunction or B12 deficiency that, if you have diabetes, that your blood glucose levels may be fluctuating too high or too low. So there are, you know, reasonable factors that can cause you to fluctuate with your cognitive and memory abilities. So the first thing to do is to see whether any of these physical factors, poor sleep or stress or metabolic alterations, are in fact contributing in. Usually in about 10 to 20% of cases, we do find a cause for some of this fluctuation or some of this memory loss. And that’s a good reason to be checking regularly with your primary care doctor, be sure you’re getting your bloodwork. If you’re having trouble with your sleep or if you’re feeling depressed and not motivated as you typically should, you need to tell your doctor because it may be that these can be treated. And those kind of changes in memory and cognition can actually be reversed. If all those things are carefully examined and ruled out, and a person is still continuing to experience it, that may be an indication that it is an early dementia that’s starting to occur.

Scott Gilbert  – You’re watching Ask Us Anything about Alzheimer’s Disease from Penn State Health Milton S. Hershey Medical Center. I’m Scott Gilbert alongside of Dr. Paul Eslinger. He’s a clinical neuropsychologist here, and he’s going to field your questions as well. If you want to type a question or a comment into the field below this Facebook post, we’ll pose it to Dr. Eslinger, whether you’re watching this video live or even after the fact, we’ll get you a written response to whatever questions you may have about Alzheimer’s Disease, a disease that seems to affect all of us or at least people who we know somewhere in our family or circle of friends. I’m curious as to what the differences are, Dr. Eslinger, between Alzheimer’s and other forms of dementia. We mentioned Alzheimer’s is the most common form, but what are some of those differences, and why is that an important distinction?

Dr. Paul Eslinger – And you’re correct in that Alzheimer’s is the most common and accounts for about 2/3 of the total number of cases of dementia. But there are more than 50 causes of dementia, things like too much fluid on the brain or normal pressure hydrocephalies. There’s mini strokes or, for example, silent strokes in the brain that may be occurring. There may be a slow-growing tumor in certain areas of the brain that can cause dementia symptoms. Chronic insomnia or sleep disturbance, sleep apnea, are also causes of mental decline. If someone has diabetes and they’re blood glucose levels are fluctuating and are not under control. That will lead to cognitive decline.

Scott Gilbert  – And these could dictate different types of treatment that would be needed.

Dr. Paul Eslinger – That’s right. And many of these are treatable conditions. Alzheimer’s disease is one particular kind that’s been, what was described by Dr. Alzheimer over 100 years ago. There are other kinds that individuals may hear names of such as Lewy bodies dementia or frontotemporal dementia. And these have other characteristics. They’re kind of like a family of neurodegenerative diseases or diseases that are characterized by the brain shrinking in size. And if we can show over on the first slide here, on the left-hand side is a cross section of the brain that shows kind of the normal configuration and contour. But over on this right-hand side here, we see the shrinkage that occurs throughout the brain. And this is the effect of a dementing condition, whether it be Alzheimer’s disease or Lewy body dementia or frontotemporal. To where essentially, cells are dying off slowly due to underlying molecular factors. Now, the reason for that is still under a lot of research investigation. We think it may be tied in with certain genetic factors, possibly certain environmental exposures and certain other health factors. Things like diabetes, things like heart disease, things like obesity, things like hypertension, seem to be risk factors that increase the likelihood of the brain being overstressed, overloaded, metabolically.

Scott Gilbert  – It sounds like you’re saying there’s a lot that we don’t know about the exact causes. You can’t really pinpoint a cause with an individual per se.

Dr. Paul Eslinger – That’s right. We can’t really identify a single cause.

Scott Gilbert  – Interesting.

Dr. Paul Eslinger – At the moment, yes.

Scott Gilbert  – And that’s scary to think of one’s brain shrinking. But that’s literally what’s happening. The cells are dying off. The brain is shrinking throughout the course of the disease.

Dr. Paul Eslinger – Yes, and so we have fewer cells to try to do the same kind of mental and memory tasks that we’re, you know, that we typically do. And that’s why the decline in those functions will start to occur.

Scott Gilbert  – Another question is about how long people tend to survive with Alzheimer’s disease. And I know the answer is, it can vary widely. I read between 4 and 20 years. Why is that?

Dr. Paul Eslinger – The reason we get a span like that is because it depends on the age of diagnosis. So if you’re diagnosed at the age of 85, which is actually about one in two persons at that age, you’re going to have a much shorter lifespan, probably about four to five years. But if you’re diagnosed at age 65, if you’re physically healthy, you know, without heart disease and diabetes and obesity, you could live as long as 20 years. So depending on other health factors, you may live quite a few years with Alzheimer’s disease. Or you may live a relatively short time.

Scott Gilbert  – And I know that they say age is a major risk factor for the illness. However, there are people who get it younger, say before age 65 even. Are the causes thought to be the same in people who get so-called early onset Alzheimer’s versus those who get it later in life?

Dr. Paul Eslinger – That’s a great question. So the distinction is what we call young onset, typically before age 65 or older onset, or senile dementia. It’s interesting. The young onset cases seem to have a strong family history of it having occurred in prior generations. There seem to be different genetic factors that contribute to the risk of them developing, and different genes have been identified. And in a few families around the world, as many as 50% of the members of each generation develop the disease. So this is called a dominant gene pattern.

Scott Gilbert  – You’re watching Ask Us Anything about Alzheimer’s Disease from Penn State Health Milton S. Hershey Medical Center. Dr. Paul Eslinger, a clinical neuropsychologist here providing some answers for us about this devastating illness. Telling us what we do know at this point in time. And one of the more interesting, and by the way we welcome your questions and comments. Please feel free to add them to this Facebook post, and we’ll be sure to pose them to Dr. Eslinger and get you some answers. Some people may wonder if there’s a genetic test available. Is there a way to know definitively whether someone is at least at risk for developing this disease later in life?

Dr. Paul Eslinger – The research done to-date has identified in, excuse me, in most individuals, that there’s one gene called the APOE 4 gene. [Coughing] excuse me. And this is a gene that appears to carry a slightly increased risk for developing the disease later in life. It’s not by any means, there are many people who are APOE positive who’ve never developed the disease. So it’s by no means very predictive. It just increases the risk from about 10 to 20%. So we generally don’t recommend that a person have genetic testing because it’s not really very helpful. Some of the research centers, if a person enrolls in a research trial, they may run a genetic test because they’re trying to learn more about it. But it usually is not very helpful, and we usually don’t recommend it. For those who have the young onset type of Alzheimer’s disease, the genetic test actually may be helpful if they have one of the genes that seems to be what they call a dominant gene pattern. Because the chance of passing that on to the younger generation would be quite strong.

Scott Gilbert  – What about preventing Alzheimer’s disease? A lot of people seem to equate being active, especially with your brain, maybe doing puzzles, maybe doing computer games, especially as you get older, as a way to try to stave it off. Is there any evidence that that does work?

Dr. Paul Eslinger – Yeah, there actually is pretty good evidence. The Alzheimer’s Association, as well as some national committees of the National Institute of Health, for example, have looked at these data, and they use the word encouraging in the sense that there is some preliminary evidence that lifestyle factors can actually cut the incidents of Alzheimer’s disease. So they’re project is that for those who are in their 20s and 30s and 40s now, that if they actually implement these lifestyle changes and can keep to them, that we would be able to cut the number of cases by probably 35%. It’s almost 1/3, or at least 1/3 of the number of cases, may actually be preventable. So these revolve around the aspects of having consistent sleep. Sleep seems to be therapeutic and seems to clear out some of these amyloid plaques or these toxic proteins that accumulate in the brain. A Mediterranean-style diet. So if anyone looks up Mediterranean-style or what’s called a mind-style diet, M-I-N-D, that seems to be associated with greater brain health as we age. Daily exercise, particularly aerobic exercise. That can take almost any form from walking to biking to swimming.

Scott Gilbert  – Get the blood flowing.

Dr. Paul Eslinger – Oh actually, you know, that blood that glucose and oxygen to the brain, when they measure the brain MRIs of people who exercise regularly, they actually find the volume of the brain increases. And that can occur at any age. There’s no limit on that.

Scott Gilbert  – So it’s not like well, I haven’t exercised earlier in life. It’s too late now. You can start at any time.

Dr. Paul Eslinger – It’s absolutely not too late. And it’s better than any medicine than any doctor can give you at this point in time. It’s just a natural therapeutic value to it in terms of the blood flow with the oxygen and glucose to the brain.

Scott Gilbert  – Yet another illness for lifestyle factors play an important role.

Dr. Paul Eslinger – A final one I’ll mention is social and recreational activities. That staying involved with your family, with your community, with things that are interesting and challenging in terms of your communication skills, your creativity, you know, artistic, musical, dance, hobbies and interests. That seems to be another big area that really separates people who cognitively age well and those who become too sedentary and kind of slow in their thinking and memory.

Scott Gilbert  – This is Ask Us Anything about Alzheimer’s Disease from Penn State Health Milton S. Hershey Medical Center. We welcome your questions for Dr. Paul Eslinger. Just leave a comment in the field below this Facebook post, and we’ll get that question to him. One of the questions I imagine you must get in clinic when a diagnosis is made is, can I still travel? Can I still drive? What do you tell a patient?

Dr. Paul Eslinger – It does depend on the severity of the condition. For people who are in mild stages of cognitive change, typically, they can continue with most of their activities. They may need some extra cuing in terms of reminders about the time of day or what’s coming up or where they are, or directions, for example, when they’re driving. But until a person reaches the, what they call the moderate stages of the disease, where their ability to react, for example, when they’re driving. Or they keep track of traffic patterns. Or to be able to go to a store by themselves then navigate a shopping list and paying, for example. That they typically can continue with things that they’ve done for a long period of time. The key there is not to be under too much stress or pressure, time pressure, for example, or to not to try to do too many things at once. And as long as they stay in their typical patterns within their home and community settings, they often can continue with most of their activities for quite a period of time.

Scott Gilbert  – Now we know there’s no cure for Alzheimer’s disease, but there are some treatments out there. Where are things at right now? What kind of treatments are available to at least perhaps show the progression of the illness?

Dr. Paul Eslinger – Well, the key thing with your doctor is, first of all, be sure of all your metabolic parameters, your B12, your thyroid and so forth, are at, you’re meeting your targets, blood pressure and glucose. That’s the first thing. And that your sleep and nutrition and exercise and so forth are also at the recommended targets. In addition to that, there are two FDA-approved medicines. One is called Aricept, and the other one is called Namenda. And both of these have been approved by the FDA for treatment of Alzheimer’s disease. Now, the effect of these are primarily to stabilize the symptoms and to slow the progression of them. So they don’t really reverse the symptoms as we would like them to. But there are other treatments under trials now, in clinical trials, that we think may work more effectively. And we have our hopes that in the next few years we’ll see more effective treatments emerge. But at the moment, the Aricept and Namenda should certainly be two of the treatments that they talk about with their doctor and see if they’re appropriate for them.

Scott Gilbert  – And I was going to ask you about what may be in the pipelines. Sounds like some possibly encouraging news down the road.

Dr. Paul Eslinger – So there are some new ideas. These first two medicines are essentially medicines that help cells signal each other more effectively. And cell signaling in the brain is key to cognitive functions. Because our cognition emerges from big areas of the brain interacting and sharing communication. So these new medicines that are being tested are looking at clearing out the accumulation of toxic proteins, like amyloid plaque. So if I can go to the next slide, we can show you what happens. So for example, on the left-hand side here, this bright area of yellow and orange that you see is accumulation of what’s called amyloid plaques. And these essentially are toxic proteins that clog up the signaling of the areas in the brain so that cells essentially start to dysfunction and eventually to die off. Over here on the right is what’s called tau, T-A-U, proteins, which are another type of toxic protein. And these new treatments are geared to try to clear out these plaques and these toxic tau proteins. Almost like taking out trash in a way or debris that’s clogging up the brain’s signaling system. So that’s one track that’s being investigated right now. Another one is a treatment called intranasal insulin, which is getting insulin directly up into the brain to try to increase the metabolic activity of cells. There’s also some drugs that can boost the immune system in the brain. So by boosting the immune factors in the brain we may be able to stave off the development of the amyloid plaques and the neurofibrillary tangles. So there’s kind of different approaches being tried now. Some out of the box thinking about other ways to protect the brain from the onslaught of these amyloid plaques, to help boost its signaling capacity among the different cells.

Scott Gilbert  – We’ll get you out of the direct light, if we can come this way. But it sounds like what you’re saying is, we talked earlier about how part of this illness is about the brain actually shrinking. The other part sounds like it involves plaques that inhibit communication between the cells that are still there.

Dr. Paul Eslinger – That’s correct.

Scott Gilbert  – Okay.

Dr. Paul Eslinger – Yeah.

Scott Gilbert  – It’s a little bit, causes are a little bit of both. Well, I guess as we bring things to the close, one question some folks may have is, okay, I’ve heard some things during this interview that might serve as warning signs for someone I know and love. Or maybe even myself. How can I get more information? Does it start with that conversation with your primary care physician?

Dr. Paul Eslinger – That would be a great place to start. The other would be the website for the Alzheimer’s Association. That has a ton of resources. We have a great association right here in Central Pennsylvania, with an office in Harrisburg, for example. They do also have counselors where you can call in and talk directly with a counselor and a case manager to find out more about resources in the area. The Commonwealth of Pennsylvania has also developed, the Department of Aging has also developed a plan for Alzheimer’s Association, not only for patient care but also for caregivers, those family members who are caring for individuals within their family. Resources in terms of day programs, in terms of transportation, and even in-home help to the area agencies on aging. So I think there are a lot of resources that are starting to become more available for family members, for patients, local support groups, and again, the Alzheimer’s Association would know about local support groups, for example. Not only for Alzheimer’s disease but Lewy body disease, for example, where you can find out a lot about other people’s experiences in their day-to-day lives and how they cope with some of these challenges as a caregiver.

Scott Gilbert  – A lot of resources out there. We’ll put some of these links, by the way, with the Facebook post here in just a little while. So be sure to check back for those, and we’ll make sure we put a link to the Alzheimer’s Association and some of these other great resources.

Dr. Paul Eslinger – Yes, that would be a great start.

Scott Gilbert  – Fantastic. And a lot of people are on the front lines of research trying to improve treatments, find a cure, fight this devastating disease, so I appreciate your insights into this today, Dr. Paul Eslinger. Thanks for your time.

Dr. Paul Eslinger – Oh, you’re very welcome. Thank you.

Scott Gilbert  – Dr. Eslinger is a clinical neuropsychologist here at Penn State Health Milton S. Hershey Medical Center. Whether you’re watching this video live, or even if you’re watching it after the fact, do feel free to post a question, and we will get you some answers. Thank you very much for watching Ask Us Anything about Alzheimer’s Disease from Penn State Health.