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Special Report: An Update on Treatments for Alzheimer's Disease · The Medical Mind

0:11
All right, everybody, welcome back to the podcast with the Psych News Special Report
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Podcast for the month of September.
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We are in this last quarter of the year now.
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and to welcome us, we have our returning guest,
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Dr. Tempe, Dr. Raj Tempi, ~ to talk about his article,
0:32
an update on treatments for Alzheimer's disease.
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This is a follow-up of part two of the article from last month.
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Talking about some of the behavioral differences of Alzheimer's disease.
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So we're going to be talking about ~ again,
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like an update. And the interesting part about this is more
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not necessarily an update, but more of a a stepping back and asking
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how should we diagnose, prevent,
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and actually treat Alzheimer's disease in twenty twenty six.
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So Dr. Tempi, welcome back to the podcast.
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How are you?
1:05
I'm good. Thank you. Thank you,
1:06
Dr. Mirza, for having me on the podcast again.
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~ so the important question ~ we are going to talk about is
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the diagnosis and treatment of Alzheimer's disease.
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You heard about the behavioral symptoms last month.
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~ now we're going to talk about the disease itself.
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~ so you know, ~ remember Alzheimer's disease is the most common neurodegenerative
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disease in the world. ~ it is more common than Parkinson's disease,
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which is the second most common neurodegenerative source.
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So before we go there, I also want to talk a little bit about
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the difference between the mild and the major neurocognitive disorder,
1:40
the mild cognitive impairment and dementia,
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as we used to call it in the past.
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So in the DSM 5, we have the new terminology is the mild neurocognitive disorder
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and major neurocognitive disorder.
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So they are similar to what we used to use as mild cognitive impairment
1:56
and dementia. ~ In the difference between these two conditions is that
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In the mild neurocognitive disorder,
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individuals have modest cognitive decline,
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but no functional decline, and they may or may not have behavioral symptoms.
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So behavioral symptoms can come at any time.
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~ Whereas in major neurocognitive disorder,
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or what we used to call as dementias,
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they have profound cognitive impairment and they have functional decline.
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~ And they may or may not have behavioral symptoms.
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And like I said, behavioral symptoms can come at any time.
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They also have different etiologies.
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So just because you say dementia,
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dementia is the umbrella term,
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but under that you have many different etiologies for why people can have dementia,
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and Alzheimer's disease is most common cause.
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About 50 to 70 percent of the cases are because of Alzheimer's disease.
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So Dr. Hempy, when I was reading the paper,
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one of the things that really stuck out to me,
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we said the title of the article is an update,
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but after reading the paper, it seems almost like a shift,
3:03
a paradigm shift in how we should be approaching ~ Alzheimer's as a whole.
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So tell me about that. What what what is different now as opposed to what
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it was ten years ago, fifteen,
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twenty, thirty years ago?
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Yeah, so you know but over the period of time we have come to learn a
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lot more about the modifiable ~ risk factors for Alzheimer's disease.
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So, you know, ~ Dr. President Regan's daughter ~ you know actually
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had talked about the fact that when her dad was first diagnosed with Alzheimer's
3:34
disease, we're all talking about treatments.
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Now we're actually starting to talk about prevention and treatment.
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~ so Alzheimer's disease, as you know,
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is a chronic degenerative condition.
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It has modifiable and non-modifiable risk factors.
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The non-modifiable risk factors,
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you know, three things are very,
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very important: age.
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Family history and sex.
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Age, older you are, more your chance of having Alzheimer's disease dementia.
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~ as people age, so about the age of 65,
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it is about five to ten percent.
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About the age of eighty, it's about twenty to twenty-five percent.
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By the time you hit ninety and more,
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it's about thirty percent. And by the time you're a centenarian,
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seventy-five percent meet the criteria,
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clinical criteria for Alzheimer's disease dementia.
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Then ~ when when you look at s ~ family history,
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majority of the cases of Alzheimer's disease is sporadic,
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so it can happen to anyone. But there is ~ autosomal dominant variety
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of Alzheimer's disease, it's about three to five percent of the cases where
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it does run in families. And these individuals have Alzheimer's disease earlier
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in subsequent generations. So people,
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the grandmother has in their 50s,
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the mother has in their forties,
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and ~ the granddaughter has in their
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Early 40s. So that that can happen.
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But that's a minority. And then sex.
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Female ~ gender is ~ is ~ Alzheimer's disease is more common in women than men,
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~ is due due to various reasons,
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including the biological changes,
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the hormonal changes, and the psychosocial aspects,
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including ~ the social determinants of health.
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So then we have the modifiable risk factors.
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You know, ~ if you see the article,
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it'll tell you about the Lancet.
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Commission article, which has 14 modified risk factors,
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both in ~ young age, middle age,
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and old age. The majority of the modified risk factors are in the middle age,
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~ including the vascular risk factors.
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In young age, it is education.
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So this discussion we're having today is part of the education process.
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You know, does is protect it is protective.
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So more the education, more the cognitive reserves,
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~ more the lifestyle modifications people do,
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more healthy lifestyles.
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So the in incidence is less. In the middle age,
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it's the main 10 risk factors,
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you know, hypertension, hyperlipidemia,
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obesity, diabetes, depression,
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~ traumatic brain injury,
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~ then there is ~ alcohol use,
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tobacco use, and all of those things.
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And in late age, ~ it is depression,
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~ visual impairment, ~ and environmental factors.
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So if you can if you can try to modify all of these.
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45% of cases of Alzheimer's disease can be preventable.
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So that's a big number. So social prescribing becomes very,
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very important ~ now. So any middle-aged patient that you're seeing,
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you should discuss all of these factors as a way of protecting their
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not only their heart, but also their brain.
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~ so we are in that era of trying to prevent ~ Alzheimer's disease because
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you know it's a very ~ difficult illness to treat.
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And very difficult illness ~ in terms of ~ you know by giving the medications,
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you know, preventing the cognitive decline,
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and also for families who are providing caregiving for a long time.
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So it becomes a caregiving career.
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So ~ and it's a costly, very costly illness.
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I think $210 billion we spend on ~ treating Alzheimer's disease.
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And with the number of cases of Alzheimer's disease increasing,
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that is going to be over a trillion dollars,
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which is cost prohibitive.
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For our healthcare and for our economy.
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So prevention, I think, is the name of the game in the next couple of decades.
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Hopefully, we will have biological treatments that are available that'll help
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in reducing the ~ severity of the Alzheimer's disease,
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but I don't think we are going to ever see a silver bullet that is going to cure it.
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~ you know, I think that's a that's a very far reach.
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The main thing that I I like about this framework of looking
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at it's preventa preventable is that I feel like before,
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like when I was in training and even like in in med school and a training,
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it felt like Alzheimer's was almost this inevitability.
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Like, you know, it was it was a feeling that like it's you know,
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you're damned if you do, damned if you don't,
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like no matter what's gonna happen,
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like this is a roll of a dice,
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like you're
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Going to get Alzheimer's, or some people are going to get Alzheimer's since this
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is how things are you're gonna go out.
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You know, like we were joking insensitively potentially joke around that,
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like, I'll remember this forever until I get Alzheimer's,
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right? And with commonly saying those kind of things.
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And this idea that we have now multiple factors that
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we can work to to promote it or to prevent this.
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And I think there was even a shift when I was in training,
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you know, 10 plus years ago where I started to be like,
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well, now we're saying that diabetes type three or al Alzheimer's
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is diabetes type three. I think that was like some of the movement at some point
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in time. But now it seems like there's it's more than just like diabetes type three,
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and there's different types of prevention that we have to do.
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So a bit more optimistic, a little bit more control,
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a little bit more of like this is some sentence that you're gonna be and this
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is how your life is going to end,
8:58
correct? Yeah.
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Correct. Correct. And you know,
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~ as as you all know that ~ you know,
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~ we are an aging society. So we are living longer.
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all of us, unless of course there is an accident or any kind of event,
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people are going to be living much longer,
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both men and women. ~ with you know,
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modern medicine, ~ with better lifestyles,
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people are living ~ longer. ~ but not necessarily they're living well.
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So, you know, ~
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A lot of the mortified risk factors are re related to
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the cardiovascular risk factors,
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you know, hypertension, hyperlipidemia,
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diabetes, and all of those. So I think social prescribing becomes very,
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very important. We are so focused on treatments that we pro
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we forget that prevention is the name of the game.
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if ~ if our healthcare system,
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again, I don't want to get on a motor high horse,
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but our healthcare system rewards treatments for problems that can be prevented.
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And prevention is not it's taken in a backseat.
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But I think for chronic disease management,
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which is very different from acute care,
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~ you know, prevention becomes the name of the game.
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it's far easier to prevent than treat.
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so I think we now need to do a lot of social prescribing,
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especially ~ for middle aged and older individuals.
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so that's that
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I would
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kind of push back on your not wanting to get on the moral high horse part
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in regards to saying that I mean we do.
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We almost need to kind of we we need to shift that focus into prevention because
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I think we are all overloaded as healthcare healers,
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like you said last time, as healers instead of providers,
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that we're all overloaded with patients.
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We all have too many people that we're taking care of and that like,
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yes, please, prevention is totally fine.
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You know, we I when I'm talking with
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Whether it's online and we're doing whether I fight misinformation,
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disinformation in psychiatry, they'll constantly,
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you know, one of the things that critics will say is,
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you guys are gonna r you'll run out of patients if you cure them.
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You're not you're not in the business of curing your patients.
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You're quote unquote curing your patients because you'll run out of run
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out of like a an endless pocket of bank supply or whatever it may be.
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And I'm like, No, trust me, I have wait lists that are out there for months.
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Like
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I could do with less patients.
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I would love to have less patients.
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So yes, I think social prescribing kind of prevention is what we want.
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And it's important to remember that if you're if you're looking at treating,
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you know, br you know, orthopaedic procedure with a similar type
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of mentality as you're treating psychiatric issues,
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you know, paying them similarly.
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So you more you do get it more you're paid.
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~ but for psychiatric conditions,
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that don't work. Psychiatric conditions are chronic illnesses,
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especially ~ you know, ~ disorders that you see in late life.
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So I think we need a better
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~ sort of equation where we can calculate the effort put in
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in treating these illnesses. And I that I think that that will be the future.
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And I I'm sure it'll come as people become more cognizant of that.
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So I don't think you can equate them as the same and treat them the same.
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I think we need a little more different or a wider strategy
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for treating chronic disease management.
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The other thing with the article that was showing up by,
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you know, again, part of the old school way of thinking was that you
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you know you diag or Alzheimer's is a clinical diagnosis,
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and then you can only correct ~ diagnose it on autopsy by your
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tau proteins or amylide proteins and everything that's there.
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And now the article says that we are shifting and that's more biological diagnosis
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and we have ~ biomarkers. So yes.
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Correct. Tell us a bit more, dive into that a little bit more.
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Y yeah, so you know the biomarkers have always been there.
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~ as as technology advances, we are having ~ better and easier ways
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of getting the biomarkers done.
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so you know hippocampyl atrophy is a biomarker,
12:55
right? So you we could have done MRIs and seen,
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but that's a lot you know, you have to do a lot of those serially over
13:00
a period of time. Now we have ~ both CSF biomarkers,
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you know, cerebrospinal fluid biomarkers,
13:07
and then blood biomarkers. These are the brain pathology that is changing.
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shows up in the blood. So you can do ~ you know beta amyloid ~ you know
13:16
~ tracking in the in the blood,
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we can do the tau proteins in the blood,
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which is much easier and it becomes more accessible ~ to people.
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But misuse can become an issue.
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So if you do the biomarkers and you find out that the biomarker is elevated
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or the ratios indicate an Alzheimer's disease,
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well should you be doing that for a 40 year old?
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You know, ~ or should you be doing it for ~ a person who is having
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a workup for cognitive impairment?
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So these biomarkers the FDA has has approved,
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there are two of them, they are to be used as part of the assessment
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for cognitive impairment among individuals who are 55 years and older
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who are presenting with cognitive impairment.
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So they should not be done ~ ahead of time because what if you have a
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~ positive but you have other chronic illnesses like kidney disease,
14:09
head injury and all?
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there's a false positive, you're it's like a death sentence for that person.
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Then are people insurers going to use that diagnosis against that individual?
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So that's the moral consideration we have to go is it's great having these things,
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but we don't have any treatments that are can help cure this illness.
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So are we confining somebody to a long you know three to four decade history
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of depression, anxiety and ~ other ~ mental problems and
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~ psychosocial problems because in trying to get the diagnosis.
14:43
So biomarkers are great when used appropriately during an assessment.
14:48
Yeah. Do you feel I mean, do you see that this is where the future is going to be,
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that we're gonna be doing again,
14:55
these plasma biomarkers just as routine as like getting a hemoglobin
14:59
C or lipid panel or
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Well, that that might happen. ~ you know,
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as part of your routine screening,
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you will be able to f find out who are the people at higher risk.
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But then you also need how you're going to use that information
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to help the individual. So it should not be just you're making a diagnosis.
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Okay, what do you do now that you have the diagnosis?
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What treatments do we have that are available?
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So I think focusing on prevention,
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focusing on early diagnosis and appropriate treatment are the three steps
15:30
in management.
15:30
Yeah.
15:32
Which brings us to like again treatment a little bit.
15:34
So we have disease modifying therapy.
15:37
~ talk to us about that. We have a couple of our monoclonal antibodies that
15:42
are out there that are maybe newer that we're maybe not as familiar with.
15:46
~ but yeah, tell us about those.
15:48
The way of the canomab and dana mab,
15:50
right?
15:51
Donanimab, correct, correct. So you know we ~ the if you remember
15:55
the in the nineties and early two thousands,
15:58
~ the hypothesis was that there was cholinergic deficit.
16:02
So we had all of those medications,
16:03
~ the coline acetylcholinesterase inhibitors,
16:07
there are four of them now, you know,
16:09
~ donapazil, rivastigmine, galantamine,
16:13
and benzgalantamine. ~ and then we have memantine,
16:16
which is an NDA receptor antagonist.
16:18
These were not
16:19
Disease modifying in any way. You know,
16:21
they were approved for mild, moderate,
16:22
and severe stages of ~ Alzheimer's disease.
16:25
Right. ~ then, you know, we started working on these ~ you know,
16:29
immunomodulators, you know, disease modifying drugs.
16:33
And, you know, we had Adecanamab,
16:35
which was the first one that was approved,
16:37
but then the company has now not stopped marketing it because of all
16:41
the issues that that we had. And then Lacanimab was a second
16:45
one and dynamab dunanimab were was a third one.
16:47
So they're different compounds.
16:49
But they decrease the beta-amyloid levels ~ in the brain.
16:53
~ They are approved for mild cognitive impairment and dementia stage
16:59
of Alzheimer's disease. So they're not approved for more severe stages.
17:02
And again, the data is about 18 to 24 months long,
17:07
but not longer data, which will come in the future.
17:11
So they're still, we're still in the infancy of treating these with these
17:15
new biological treatments.
17:18
What are some of the benefits,
17:21
the risks of these medications currently right now that we have?
17:25
So what yeah. Why should we choose these versus maybe some of our older ones that
17:29
you mentioned, like the Dinepazel,
17:31
Rivasigmine, etcetera? Yeah.
17:33
Yeah, so ~ let's talk about, you know,
17:35
~ these different medications.
17:37
So if you want to give ~ you know Lacanamab and Dunanomab,
17:41
you know, you need to have a process,
17:43
like you have a whole setup done because you need to have PET scans,
17:46
you need to have MRIs, you know,
17:49
you need to have trained neuroradiologists who can read the levels,
17:52
you need to have infusion centers.
17:54
You know, Lacanamab is coming out with ~ a different version
17:57
of introducing you know, subcutaneous ~ infusions.
18:03
But access to those specialized centers that can provide all of them
18:08
and constantly monitor them is is ~ is an issue for a lot of the people.
18:12
And if you look at people who get Alzheimer's disease,
18:15
it is people who are of the lower socioeconomic strata,
18:18
some of the people who are ~ you know,
18:21
have social determinants of health ~ access issues.
18:26
So are we providing it for only people who can have access?
18:30
So equity becomes an issue.
18:32
there. So that is the main problem.
18:34
Then the the side effect profile,
18:36
if you actually look at the the drugs,
18:38
they're very well tolerated except for one major side effect,
18:42
which is called area amyloid related imaging abnormality,
18:45
which is either it's edema or it's microhemorrhages.
18:49
And that happens more in people who are homozygotes for APOE4.
18:55
So you have to have genetic testing and genetic counseling.
18:58
you know, in the article we go through the appropriate use criteria
19:01
for both of those things. So and then if that happens,
19:04
then you have to monitor those very carefully because the severe ones
19:08
can cause significant problems.
19:09
Majority of them are mild, but then the severe ones ~ you can cause problems.
19:13
So again, does all of America have access to all of these?
19:17
No. I mean these are all in major centers.
19:19
~ so the person in rural America actually misses out on these on these medications,
19:24
which are actually helpful.
19:26
And I also want to say that we are still in the infancy of these treatments.
19:29
In the next two to three decades,
19:30
you will see an explosion of all of these new drugs and repurposing
19:34
of other drugs that can help. ~ But ultimately the choice depends upon
19:39
the patient and their family. So whenever patients come to see me,
19:42
if the diagnosis is that of Alzheimer's disease,
19:45
then we give all the options available and then we let them choose which
19:50
one is available. And one of the
19:52
the cases that I have described it as a real case.
19:54
I just modified some of the information.
19:56
~ the patient's family said no they don't want any infusion.
19:59
It's too much for them to take care of.
20:01
And they they went with the their colonesterase inhibitors as their first choice.
20:08
And those old medications are still doing the job,
20:11
correct? They they're not something correct.
20:13
Right,
20:13
correct. And it's like turning back the clock six twelve to sixteen,
20:16
twelve to eighteen months, months time.
20:19
But it's not f you don't just prescribe and forget.
20:22
You continue to have to do all of the modifiable risk factors.
20:26
Remember in ol older age, depression,
20:29
~ environmental factors and here ~ and vision are three of
20:34
the modifiable risk factors. So you need to continue to do
20:36
all the social prescribing, including treatment of depression,
20:40
treatment of diabetes, hypertension.
20:42
while you're prescribing this these medications,
20:44
which are fairly well tolerated if if prescribed appropriate.
20:49
Yeah. It's there's a couple of like of those again later in life risk factors that
20:55
really jumped out to me as well.
20:56
You know, the vision loss was one that was like,
20:59
this is interesting. And then also like this is social isolation.
21:02
We know that we have a lot of people when they get older,
21:05
they can get isolated and that can be terrible.
21:10
Yes, yep. ~ and you know there remember there are four D's in geriatric psychiatry.
21:14
Dementia, depression, delirium,
21:16
drugs. ~ all sensory deprivation is a risk factor for majority of these things other
21:23
than drugs, right? So you have to do the social aspects of making sure that
21:28
the older patient ~ older person is engaged,
21:31
~ they are socially connected.
21:33
And it's not the number of social connections,
21:35
it is the meaningfulness of the social connections that really matter.
21:39
And with available technology through Zoom and ~ other technologies,
21:44
you can connect even if you cannot go and beat with them together.
21:47
So that there is actually a lot of work that is being done
21:50
on improving ~ connections for older adults.
21:52
And you know, if so the older adult group is very interesting because
21:56
you have the young old, which are the 65 to 75 year olds,
21:59
the old and the very old. The old is the 75 to 85,
22:03
and the very old is over 85. The 65 year olds,
22:06
and it's no joke when you say that.
22:08
You know, sixty-five is the new forty-five or sixty is the new forty,
22:12
because majority of these young old are doing things what you know,
22:17
middle-aged people do. They are dating,
22:19
they're getting divorced, they're working,
22:22
~ they're doing all kinds of things.
22:24
So doing one intervention for the entire age group is not going to work.
22:28
So you have to have different interventions for different age groups.
22:32
~ and that
22:34
That's why you need geriatric psychiatrists because it's becoming starting
22:37
to become more complex and you have to be trained because it's not very obvious
22:41
to you.
22:42
Yeah. It is something that we are,
22:47
you know, again seeing that the the age of psychiatrists as they get older.
22:52
Again, we know that they're shifting towards being older.
22:56
~ the aging population that's there.
22:59
So we we need to take care of ourselves as well as we go through those stages too,
23:03
correct? So
23:05
Correct. And fifty f fifty f fifty f nine percent of psychiatrists
23:10
are fifty five years and older.
23:12
~ so we are an aging population and you know,
23:14
a lot of the psychiatrists and there's a lot of w work that is done being done
23:17
at the APA and other organizations on people being in practice way longer than they
23:23
ever expected to be. So you y it it would not be uncommon for you to
23:27
see eighty plus year old physicians still working in the hospital,
23:30
still doing those things and doing really well.
23:33
but we need to do a lot more for helping them when things start to change.
23:38
And ~ there is a lot that can be done.
23:40
And you don't want to be ageist and say,
23:42
okay, you know, after the age of eighty nobody should be working as a physician.
23:45
You probably should not be doing visuospatial things and,
23:49
you know, surgical stuff. I'm not saying that you shouldn't,
23:52
but I think those things decline.
23:54
But cognitively, if they're intact,
23:57
they could do a lot of the other things like outpatient and all of that.
24:00
So it that needs to be a little more of a of a ~ thought out
24:06
Yeah. I know we see this a lot of times too is I mean,
24:09
it's one of the main reasons we get worried about when people retire.
24:12
We see that as like a danger period for suicide,
24:15
right? And or death is like once people retire,
24:18
you know, that lack of purpose almost,
24:20
that lack of routine, ~ everything just gets thrown out the window.
24:25
And then we know we have that that second spike of ~ suicidal risk and
24:29
and or just dementia. Yeah.
24:31
Correct
24:31
~ I mean eighty eighty five plus suicide risk,
24:35
eighty five I mean, I'm I'm sure people are taught during their
24:38
for their board preparation that eighty five year old Caucasian men,
24:42
it's usually men more than women,
24:44
~ are the is the highest risk for suicide in this country.
24:47
And that is true because, you know,
24:48
remember, the the the the older adult,
24:54
most of them may a lot of them are getting divorced.
24:56
~ their livings alone.
24:59
Social isolation becomes an issue,
25:01
medical s problems start to happen,
25:03
pain starts to be a problem. So it it becomes doom and gloom.
25:07
So I personally think this whole retirement thing is overrated.
25:11
Everybody doesn't just ride out to the sun fet sunset and play golf and have
25:16
a great life. It doesn't happen that way.
25:17
It's it's it's a very simplistic assumption when that happens.
25:21
And I think we need to plan ahead.
25:23
Well whether it's for our own our profession,
25:25
but also for with the aging population.
25:28
You know, I I use example I guess like of my my mom,
25:31
right? So you know, maybe I'm saying too much,
25:34
but you know, we'll say, who knows?
25:35
but my mom is like seventy ish something years old and she's a physician as well.
25:41
She's a family physician. She's still practicing,
25:44
still working right now, seeing patients,
25:45
outpatients and stuff. She essentially like,
25:48
you know, separated, left my dad up in upstate New York,
25:52
~ because of the things that we're kind of saying,
25:55
right? She was like, I feel like I'm stagnating over there.
25:58
Right. My dad was kind of taking a little bit more laid back,
26:00
let's just kind of hang out and isolate a little bit more.
26:03
Friends were unfortunately sadly like passing away or getting sick,
26:08
right? myself, my sister had moved down to like this Northern Virginia,
26:13
DC area. She's like, I'm away from my kids and my grandkids,
26:18
you know, so she made the decision like a couple of years ago now to like leave
26:23
and move down over here. Right.
26:25
She's living on her own and practicing and,
26:26
you know
26:27
She's got her own place with, you know,
26:29
n in between me and my sister in the area and she's,
26:33
you know, like a s a renewed lease on life,
26:35
right? Because you know, we could
26:37
Yeah, no th thank you for sharing and I all all power to your mom.
26:41
And you know, she should continue to do what she wants to do and as long
26:45
as she's able to do. ~ and you know,
26:47
then then you have the just like kids,
26:50
you know, you have the scaffolding around them ~ when and if they need it.
26:54
Not that they will need it, but if they need it you have it available.
26:56
So ~ I think I think ~ work is I mean,
27:00
we spend
27:01
~ majority of our adult life at work.
27:03
So taking that big part away and not replacing it s with something meaningful,
27:09
it really does hit to the core of the older person.
27:12
~ and self reliance is a very,
27:14
very important thing with a lot of people and especially physicians who have been,
27:17
you know, who have been told you need to take care of this yourself,
27:21
taking that away I think is a mistake.
27:23
So I think that's part of the social prescribing.
27:25
~ people always ask me physicians who come,
27:28
hey, you know, ~ I'm thinking about that.
27:30
I'm like, you know what?
27:31
Play it by year, do what you want to do,
27:32
but no have no finality. There's no final end date to doing anything.
27:37
You decide how long you want to.
27:38
Yeah.
27:39
And it's like she's like, you know,
27:40
she's like, I'll retire when I feel like I'm gonna retire.
27:43
And like right now she's able to do it.
27:45
She's got like, you know, she's not doing like,
27:46
you know, forty, fifty hour weeks anymore,
27:48
but still like she's sure she's doing what she feels is reasonable for her.
27:52
And you know, I mean another story in a way is we had at my job,
27:57
like old job or not my current job,
27:59
~ we had an older child is psychiatrist and I think he was seventies
28:05
or something like that, seventies,
28:07
maybe eighty years old.
28:08
And he had been doing it for again a long,
28:10
long time and he retired. And then I think,
28:13
you know, unfortunately like he died within like a year of retirement.
28:16
Right. It was just
28:17
Yeah,
28:17
that happens to a lot of people.
28:19
Yeah. because you know, despair becomes a huge issue.
28:23
See, ~ when you look at the Ericsson stage,
28:25
I was talking to a friend of mine who's also an old aid psychiatrist in England,
28:28
~ and I was telling him that I was gonna do this podcast.
28:31
So one of the things we were talking about is aging for both of us.
28:34
You know, we we're medical school classmates,
28:36
good friends for a long time. And that's the one of the things is that
28:40
we are our identity is that as old aid psychiatrists or geriatric psychiatrists,
28:45
that's what we love doing.
28:47
And if that is taken away, there's a huge problem that happens.
28:50
So remember the Ericsson stages.
28:52
Integrity versus despair ~ comes from generativity versus stagnation.
28:58
So generativity goes to integrity,
29:00
~ you know, stagnation goes to despair.
29:04
You will never go from ~ generativity to stagnation.
29:07
That is very difficult to happen.
29:09
So I think ~ people who have to people need to plan their life.
29:14
It's just like planning your career.
29:16
Old age and retirement and those kind of things also need a lot of work
29:21
to decide what you're going to do and what is what is appropriate for you.
29:24
So I think that's why psychotherapy is so important.
29:27
You know, we don't talk about psychotherapy,
29:29
~ but if you look at the evidence,
29:30
psychotherapy has so much role to play in geriatric psychiatry.
29:36
Evidence, overwhelming evidence,
29:37
shows that psychotherapy is as good ~ as med management.
29:41
And also in more severe conditions,
29:43
combination treatments are very good for.
29:45
So a older patient with Alzheimer's disease can still have psychotherapy
29:49
on some of the issues of loss of there's a lot of losses,
29:53
you know, loss of self reliance,
29:55
loss of ~ living situation, loss of employment,
29:58
loss of meaningfulness. So I think those you need to you need to sort
30:02
of work around. So if you could have well trained psychotherapists,
30:06
I mean that would be such a boon for
30:08
And not just, you know, using Chat GPT for therapy,
30:11
correct? So
30:13
Not at all. Not at all. Yeah. Yeah.
30:15
No, I think it was interesting because there was I think one of
30:18
the other recent articles was about how I think they were showing
30:21
the satisfaction of you know, I think we we know this and people in
30:25
the field know this is that like chat GPT,
30:28
all these AIs are being used for therapy,
30:30
unfortunately. And, you know, I think this one of the top two or three
30:33
use cases for those is for therapy,
30:35
unfortunately. And
30:37
we know or from as psychiatrists and mental health professionals that like that
30:41
is a terrible, terrible idea. But the average Joe Schmo does not realize that.
30:45
And I think we see this with older populations as well.
30:48
They kind of get sucked into these technologies and misusing them.
30:53
Things like Facebook and then the social ex social exploitation that can occur,
30:57
financial exploitation that can occur with with these.
30:59
And then similar kind of thing with these chat bots out there.
31:03
Like it bec it can become very,
31:04
very easy to
31:06
fall into those traps that are there.
31:09
Correct. And I as you know, the one of the most important predictors
31:12
of outcome in psychotherapy is the interaction between
31:15
Yeah.
31:15
the human connection. So it's not this it's not the experience of
31:19
the therapist or the age of the therapist or the education level.
31:22
It is that human connection. So again,
31:24
as people grow older, that connectivity is so important.
31:28
It's the meaningfulness of that connectivity that is so important.
31:33
Coming back to the article a little bit,
31:34
I we went off on a little bit of tangent,
31:36
but that's totally fine. and, you know,
31:38
ageism aspect, we'll we'll use that in a way.
31:41
So again, we talked a little bit about Danepozile Mementine,
31:44
been around for a while. Do you feel like those medications,
31:47
you know, a lot of times we see this with general psych patients that people
31:51
go away from things like a Prozacs or those Olafs for to grab the new,
31:57
the shiny medications that are out there?
31:58
Do you feel like these ones that Denepozel mementine are are gonna get
32:04
Horse aside almost because they've been around.
32:08
So, you know, that's a very good question and thank you for asking that.
32:11
You know, and as a geriatric psychiatrist when I was training,
32:13
you know, one of the things that was told to me is that we never
32:17
use medications unless they have been around for at least ten years or so.
32:20
So you not only learn about the efficacy part of it,
32:23
you l ~ learn about the adverse effects and you learn about the long term effects
32:27
of these. All the medications that you just said,
32:29
you know, the SSRIs, including the older SSRIs,
32:32
have a use in a particular patient.
32:35
You know, the older drugs
32:37
If you look at the efficacy of all the antidepressants around,
32:40
you know, the efficacy is the same.
32:42
Tolerability is different because the newer medications people have experienced,
32:46
so they try to change the molecules so that the adverse effects become less common.
32:51
That's why you know S cytaloprime and surtraline are more used in older adults than
32:56
you would say fluoxetine or peroxetine,
32:58
you know. So there but the the use is always there,
33:01
just like that. In the armamentarium of treatment for Alzheimer's disease.
33:06
colonesterase inhibitors and the memente group still have a role
33:09
to play because ultimately it is personal choice.
33:13
You know, if somebody doesn't want to get the biological treatments when I say,
33:17
you know, the immunoglobulins,
33:20
then that's their choice. We should not restrict them from having access
33:25
to those medications if they choose to have them.
33:27
So even today I present the menu of options,
33:30
then the patient and their families make an ultimate decision.
33:32
And in the hands of the right person,
33:34
you know, any tool
33:36
is a better than placebo or nothing,
33:38
you know, or treatment as you
33:40
Yeah. And I know we talked a little bit about equity in the past,
33:45
or not in the past, but like a little bit earlier.
33:47
We talked about equity in regards to potentially getting the the million dollar kind
33:53
of work up. Do we risk this this kind of separation,
33:58
these two different standards of Alzheimer's care with some
34:01
of these advancing technologies that are there?
34:05
so for me the way I look at it is technologies are very helpful if
34:08
you have them available. But I I don't think at any stage we will have
34:12
all the technology that is available to every person in this world
34:16
who has Alzheimer's disease. So equity becomes a major issue for me.
34:20
So the workup even today is a good history,
34:24
including collateral sores, lab appropriate lab work to rule
34:28
out modifiable conditions, ~ a cognitive screening test.
34:33
Neuropsychological testing if the diagnosis is in doubt.
34:36
Biomarkers, if if they are you have the availability for the plasma biomarkers.
34:40
If you have access to a PET scan,
34:43
absolutely. You know, ~ you you can do ~ the MRI scanning
34:49
to ~ look at you know abnormality in the frontal cortex versus
34:52
the temporal cortex so as to separate,
34:54
you know, fr Alzheimer's disease from frontotemporal dementias.
34:58
So whatever technology you have available,
35:00
you can use it.
35:02
to get a full picture of what is going on.
35:03
If you don't have all of those things,
35:05
still you can get, you know, basic workup,
35:08
you can do neuropsychological testing and still to some with great with
35:13
f fairly decent certainty say that this individual has probably Alzheimer's disease,
35:18
you know, probable Alzheimer's ~ disease,
35:21
and then decide on the treatment.
35:22
I mean if you're going to wait for technology to come and rescue you,
35:26
I think we're missing a whole bulk bulk or a whole group of people
35:30
who need the treatments.
35:31
And then if if they have access to infusion centers and all
35:35
of the other technologies, that's great.
35:36
But I don't think we should stop reading just because we don't have access,
35:40
because we don't know when those access will be made available for us.
35:47
Last kind of question, I would say wrapping up a little bit.
35:50
So we've done two special reports.
35:53
We've had or you've got two special reports there.
35:54
We're talking about, you know,
35:56
the behavioral symptoms last month.
35:58
And now we have the again, zooming out,
36:00
we're doing the diagnosing and the treating.
36:02
we zoom out, we talk about biomarkers,
36:06
we talk about monoclonal antibodies,
36:08
new technologies. What do you hope patients and families will actually experience
36:14
differently because of where the field is heading?
36:16
I mean, in other words, like
36:17
What does success in Alzheimer's care,
36:19
what does that mean to you or look like to you?
36:21
Yeah.
36:23
Thank you, Dr. Merza. I think you asked a very good question.
36:25
I think this was you know, it's like the gestalt of what we are talking about
36:29
in these two major articles. First and foremost,
36:31
every interaction is a human interaction for me,
36:34
you know? Respect being respectful for the patient,
36:37
spending time listening to them,
36:39
learning about their difficulties,
36:42
I think is ninety percent of the work.
36:44
If they trust you, they're able to tell you your story,
36:47
you're able to hear it, you know,
36:49
you have done a lot of work.
36:53
Then you can start to do all the ~ details that you need to go.
36:57
Like we talked about the last time,
37:00
even with behavioral symptoms,
37:01
a good history, collateral source,
37:03
rolling out medical conditions,
37:05
inappropriate medications, cognitive evaluation,
37:10
appropriate lab work, neuropsychological testing,
37:13
doing rating scales, and then other emerging technologies will come to
37:17
a point where you can make a decision and then offer the treatments available
37:22
to people.
37:23
What's happening now is because we have all these things available,
37:27
people are forgetting the basics of good medicine.
37:30
You know, basics of good medicine will never change.
37:33
You have all the chat GPT, all of those information.
37:36
They will only tell you what information you feed to it,
37:40
right? So you have to get the information first,
37:43
make a decision, have your differential diagnosis,
37:47
work through those, and then ~ do the treatments.
37:50
And then continue to support the patient.
37:53
and their families. I think that's why I personally,
37:56
this is again not a bias, it's based on my experience,
37:59
is that I think psychiatrists are best suited to treat neurocognitive disorders
38:04
because we can not only treat the the biological aspects,
38:08
the cognitive decline, but you can also provide the humanistic value
38:12
of taking care of the whole individual,
38:14
which includes their their families as well.
38:17
You know, ~ other specialties are not trained to doing that.
38:22
And we have the skill set to both be providing medication management
38:26
and psychotherapy, family therapy on all of those things.
38:29
I mean as as a child psychiatrist,
38:30
you know that. It's not all about the medication.
38:33
It's about the whole person and their family unit together.
38:36
Yeah,
38:37
I I you know, I work with the pediatric ped pediatri.
38:41
I work with the pediatric residents at the hospital.
38:44
~ they come and rotate with me and you know,
38:46
we have our thirty minute appointments and we you know,
38:50
we'll have a session and then I'll ask them.
38:52
I was like, you know, how much of the time did we spend talking about medicines?
38:55
It's like maybe five minutes from that whole period.
38:59
It's like we talk about everything,
39:00
everything else and like the medicine is the easy part of it.
39:03
You know, that's the the the non consequential part of it is like
39:06
we'll make an adjustment or we won't make an adjustment,
39:08
whatever it is. But like it's just a little thing.
39:11
And I think, you know, kind of the way what you're talking about,
39:14
you're gonna bring in that human connection there,
39:16
that humanistic aspect, I think that's something that we have
39:19
to remember with psychiatry moving towards maybe like biomarkers
39:23
and trying to become more objective.
39:25
I think there's a fear that like we're losing what brought a lot of people into
39:30
the field, right? Which which is just like
39:33
the human connection, just sitting in the room with somebody and getting
39:36
to know them and what's going on with them and their situation and how
39:39
we can help them out the best way.
39:41
And it's like that comes from just sometimes just sitting there in the room with
39:44
the person, right? And talking.
39:47
and so so the the important point is how we are training.
39:49
~ I mean if you're if you're if you can't train a radiologist and
39:53
a pathologist and a psychiatrist the same.
39:56
There are elements that are the same.
39:58
You know, you need to know the physiology,
40:00
you need to know biology, you need but certain specialties have more human
40:04
interaction and more human connection.
40:06
And that will never change. You know,
40:08
and I think that is where, you know,
40:11
initial part should be the same,
40:12
the internship is the same the same,
40:14
but the rest of the training
40:16
should be focused on what they're going to be doing.
40:18
And if it's a human connected specialty,
40:20
you need to be able to understand that.
40:23
You need to be able to you know,
40:25
if you don't have empathy, it's never going to work,
40:28
~ as a psychiatrist. And as as you can see,
40:30
you know, medication prescribing may work on the inpatient services,
40:33
but majority of the services are outpatient.
40:36
If you look at the the data for the growth,
40:38
outpatient services are gonna grow thirty percent in the next few years,
40:42
whereas inpatient is going to go six percent.
40:45
So you need to have that, you know,
40:47
not not not saying that on the inpatient unit you don't need more connection,
40:50
but it's because very fast paced,
40:52
right? Whereas the outpatient,
40:53
it's five year longitudinal connections that you had to make,
40:56
ten years. So I think we need to be very cognizant of not losing losing touch with
41:01
what makes psychiatry as a specialty unique and try to sort of sort
41:07
of enhance that aspect.
41:09
Try to get away from sometimes we have to go a little analog instead
41:13
of digital stuff with that.
41:15
Digital is great, but what if digital fails?
41:17
You need to have analog. It's like a pilot.
41:19
I mean, if all your instruments fail,
41:21
only thing that's gonna save you your is is your adspear indicator,
41:24
which may be just a old knob that tells you and the it it's it's as common as that.
41:30
You have to have redundancies.
41:32
You have to have things that are important for each thing for survival.
41:36
And I think for us it's the humanistic
41:39
Awesome. All right. Well Dr. Tempi,
41:40
any other kind of like parting words before we wrap it up for today?
41:45
No, and I wanna thank everybody for listening.
41:47
If ~ if I can be of any help with their patients,
41:50
I'm happy to do that. But my request to you is don't forget your basics because
41:54
that's what makes psychiatry as a specialty unique.
41:57
So no matter what technologies you have,
42:00
that part the human connection,
42:02
the human interaction will never
42:04
Change.
42:04
All right. Thank you so much, Dr.
42:06
Tempe, for your time. This was the special report in Psych News for September 2026,
42:11
an update on
42:12
Trimmants for Alzheimer's Disease.
42:14
Thank you again for listening to the podcast.
42:16
Make sure to give us a like, review,
42:18
five stars on iTunes or Spotify or whatever platform you're listening on.
42:24
And subscribe to this. And then check again if you want to check out
42:28
the article in print. That's in the upcoming September issue
42:32
of Psychiatric News through the APA.
42:34
right. We will see you next month.
42:36
Thank you for listening.
42:37
Thank you. ~