Latest / OT Potential Podcast | Occupational Therapy CEUs / #156 Risk Factors for Cognitive Decline with Ganesh Babulal

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#156 Risk Factors for Cognitive Decline with Ganesh Babulal · OT Potential Podcast | Occupational Therapy CEUs

0:00
SPEAKER_00: Unfortunately, the world is heading towards a dementia crisis.
0:04
SPEAKER_00: The number of people living with dementia is projected to nearly triple by 2050.
0:10
SPEAKER_00: But there is real hope for changing this trajectory, and that is prevention.
0:16
SPEAKER_00: A Lancet Commission estimates that nearly half of dementia cases could be prevented or delayed by addressing 14 modifiable risk factors, including hearing loss, hypertension, physical activity, and social isolation.
0:31
SPEAKER_00: And our guest research points to another incredibly important piece of this prevention puzzle, the role of environmental risk factors.
0:40
SPEAKER_00: It is estimated that nearly half of individual differences in Alzheimer's risk may be attributable to environmental influences, like access to green space and light pollution.
0:51
SPEAKER_00: In today's course, we will talk with Ganesh Babulal about addressing those risk factors, recognizing cognitive decline early, and whether early intervention can slow or in some cases even reverse decline.
1:04
SPEAKER_00: We will close with a vision for a team approach to care, where public data on environmental risk is synced into the EMR system, and physicians can recognize risk earlier, and a therapy referral can help mitigate that risk before problems arise.
1:19
SPEAKER_00: We have so much to cover today, so let's dive in.
1:26
SPEAKER_00: Welcome to the OT Potential Podcast.
1:29
SPEAKER_00: I'm your host, Sarah Lyon, OTRL, and I wanted to let you know that this podcast may qualify as continuing education for you.
1:37
SPEAKER_00: You are probably listening to this podcast on a free podcast platform, but to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education Platform.
1:49
SPEAKER_00: You can go to OTpotential.com to learn more.
1:52
SPEAKER_00: Okay, here we go.
1:56
SPEAKER_00: As I mentioned at the top, joining us today is Ganesh Babulal, PhD, OTD, M S-C-I-M-O-T, O T-R-L-F-A-O-Gan is a professor in the departments of neurology and quantitative health sciences at the Mayo Clinic and director of two laboratories, the DRIVES Project and Arches.
2:19
SPEAKER_00: He is also a research associate at the University of Johannesburg in South Africa.
2:25
SPEAKER_00: Ganesh's research seeks to understand the relationship between cognition and mental health and its impact on instrumental activities of daily living, such as driving, in healthy older adults and those with chronic neurological diseases.
2:39
SPEAKER_00: His research intentionally focuses on healthy aging, protective factors that support brain health, and risk factors for dementia.
2:47
SPEAKER_00: The overarching research program among older adults has investigated and connected biomarkers and complex functional outcomes like driving, mental health, and health disparities as risk factors for Alzheimer's disease and related dementia, while also identifying points of intervention, especially for minoritized populations.
3:07
SPEAKER_00: Ganesh holds dual bachelor's degrees in biology and English, dual master's degrees in occupational therapy and clinical investigation, and dual doctorate degrees in OTD and a PhD in health sciences.
3:20
SPEAKER_00: Okay, without further ado, we will patch Ganesh into our live studio.
3:24
SPEAKER_00: Welcome, Ganesh.
3:26
SPEAKER_00: It's so great to have you today.
3:27
SPEAKER_01: Good afternoon, Sarah.
3:28
SPEAKER_01: It's a pleasure to be back.
3:30
SPEAKER_01: Thank you for having me again, and welcome to everyone else.
3:33
SPEAKER_00: Oh, thank you so much for being here today.
3:35
SPEAKER_00: I want to start us off with almost a warning to people like this research that we are talking today, I feel like once you learn about it, it's like you can't unsee it.
3:45
SPEAKER_00: Like it has just been sitting in my mind all week.
3:48
SPEAKER_00: It just makes you think about, well, for me, it makes me think about one, just protecting ourselves from some of the downsides of modern life.
3:57
SPEAKER_00: Like this comes up when we talk about cancer, when we talk about heart conditions.
4:03
SPEAKER_00: And then again, looking at dementia, like there is just this common thread there of things that we can do to be protecting ourselves.
4:11
SPEAKER_00: And two, how do we shift more of our healthcare system to addressing things earlier?
4:17
SPEAKER_00: Like I think we have so much capacity and potential as therapists to really shift our focus earlier.
4:23
SPEAKER_00: And this is just another conversation that's gonna really get our wheels turning about that.
4:29
SPEAKER_00: Before we get to these like big picture thoughts, though, I would love to just open again with your story and how you came to this place where you are researching cognitive decline.
4:42
SPEAKER_01: Well, thank you so much, uh, Sarah.
4:45
SPEAKER_01: I think it's it's been quite a journey.
4:46
SPEAKER_01: Um, and it's been one that I've been very fortunate to have shared with a lot of other people that have helped me along the way.
4:52
SPEAKER_01: Um, and ultimately, I think it started back many moons ago when I was a director of rehab and the interim director of memory care in Colorado, um, in actually rural Colorado, so um the Western Slopes, which is, you know, absolutely amazing country.
5:06
SPEAKER_01: And uh I saw a lot of patients that had their overall deconditions and older adults as well.
5:12
SPEAKER_01: Um overall deconditions did my share of, you know, ortho, hips, knees.
5:16
SPEAKER_01: Um, but then, you know, I started to notice that there was a lot of cognitive impairment and would use, you know, screens like the MMSC and the slums to assess their cognitive function to better understand, you know, where are they?
5:29
SPEAKER_01: Can they follow the directions of the recommendations?
5:32
SPEAKER_01: And then when I um started managing the uh the memory care, this was a lot memory care.
5:37
SPEAKER_01: I saw patients uh and clients in there that just had a significant array of different responses, how they were active, you know, whether it was the evenings or the mornings, um, whether or not they recalled you, how quickly they forgot you.
5:54
SPEAKER_01: And the heterogeneity really always stuck with me.
5:57
SPEAKER_01: And it ultimately led me to going back for more schooling and being a broke student for another 10 years.
6:04
SPEAKER_01: And so when I went to Wash Uh for my first doctorate, I actually did a lot of research in stroke, uh, specifically first stroke survivors, and we really wanted to understand how the environment influence recovery, both short-term and long-term.
6:19
SPEAKER_01: And I was fortunate enough to be able to create and validate and then uh measurements called measure of the stroke environment to look at patients that had aphasia and to understand how did aphasia itself was impacted by their environment, how they're able to feel supported or not feel supported to be able to do their activities.
6:37
SPEAKER_01: And then once I finished that work for my postdoc, I eventually transitioned into driving.
6:44
SPEAKER_01: And uh, in the context of Alzheimer's disease, and I'll talk about this a little bit later in terms of the complexities associated with that disease.
6:52
SPEAKER_01: And it really, as an IEDL, struck an internal and very important chord for me as an OT.
6:58
SPEAKER_01: And then we really started to focus on how did the subtle breakdowns in that specific IEDLs could that potentially influence and help us understand the disease trajectory and decline?
7:09
SPEAKER_01: And eventually, as a junior faculty into more tenured faculty, I worked on establishing my own research cohorts to better understand how the environment exert influences to support cognitive function, a construct called cognitive reserve and cognitive resilience.
7:27
SPEAKER_01: And essentially to understand why some folks age better in place and others don't.
7:33
SPEAKER_01: Um, and why do some folks get dementia versus others?
7:37
SPEAKER_01: And so it really was this menagerie of you know so many different complex diagnoses, the conditions that were influenced by the environment, and conversely, um, how did they interact with the environment?
7:50
SPEAKER_01: And ultimately, I think it led me into just really focusing more on IADLs.
7:55
SPEAKER_01: And as an OT, core to my internal identity, we really wanted to understand early detection and could we potentially use that as a marker to identify those who are at the highest risk and then intervene well before they actually progressed and saw somebody in the clinic?
8:14
SPEAKER_00: I love your story because I think we can all relate to being in practice and having those kind of questions like why was this person susceptible to this condition?
8:27
SPEAKER_00: Um, were there factors that could have prevented this?
8:30
SPEAKER_00: And you took all those questions and you got to follow it into a career and you're still following it, and it's such a fascinating part of research.
8:38
SPEAKER_00: I want to start, I think, with just some foundational knowledge, um, getting oriented to the different stages of cognitive decline.
8:49
SPEAKER_00: I can totally relate to what you were saying, like being the therapist on the floor, doing the slums, I would do the Allen's cognitive level.
8:58
SPEAKER_00: I was really pegged as like the cognitive person in every setting I was in, in the SNF, in the hospital, in the psychiatric setting.
9:06
SPEAKER_00: And I remember getting the scores.
9:09
SPEAKER_00: But I would love for to hear from you now, like what I want to call it the buckets or the stages of cognitive decline.
9:20
SPEAKER_00: And starting with what healthy looks like.
9:23
SPEAKER_00: Where's healthy?
9:24
SPEAKER_00: And then what are the stages from there?
9:26
SPEAKER_00: What are the words now that you would use to describe those?
9:29
SPEAKER_01: Happy to, happy to elaborate.
9:30
SPEAKER_01: And and like you, I did many of those measures as well.
9:33
SPEAKER_01: And I would have never, you know, in a million years imagined myself being here, um, you know, for continue to pursue this.
9:40
SPEAKER_01: So I think the the most important thing to communicate is that um things a lot of folks have heard the words like Alzheimer's disease and dementia.
9:49
SPEAKER_01: Um, and so I'll sort of set the stage.
9:51
SPEAKER_01: Those are what we call non-normative parts of aging.
9:55
SPEAKER_01: And so the consensus is that um nor normal aging, you know, we might experience slower, you know, processes that might tend to um attenuate as, you know, we're not able to respond as quickly as we used to, occasionally forgetting things.
10:10
SPEAKER_01: Um, you know, you're at a party, you're meeting a lot of people, you may not remember everyone's names or all their stories.
10:17
SPEAKER_01: You might have, you know, struggle finding your keys, um, like me most most days.
10:22
SPEAKER_01: But the the key aspect of it is that new learning still occurs without any issues.
10:28
SPEAKER_01: Now, when it becomes a problem is when that process becomes disrupted.
10:34
SPEAKER_01: And the we start to hear words like Alzheimer's or dementia.
10:38
SPEAKER_01: And so I want to start off really quickly that dementia itself is this umbrella construct or term that subsumes all types of different dementias.
10:48
SPEAKER_01: So just like cancer is an umbrella, dementia is an umbrella, and Alzheimer's disease just happens to be the most prominent form of uh dementia.
10:57
SPEAKER_01: Specifically, it impacts roughly about 60 to 80 percent of the population.
11:02
SPEAKER_01: Then we have other forms like vascular dementia.
11:05
SPEAKER_01: Typically, if you have cardiovascular issues like a heart attack or a stroke, you're at a much higher risk where the vascular infrastructure of your body is compromised.
11:13
SPEAKER_01: And uh, you know, blood is of course pumped to the brain and takes nutrients in addition to removing waste products as well.
11:19
SPEAKER_01: And then there's other etiologies like frontotemporal dementia that's uh currently impacting, you know, a significant portion of the population, but not as big as Alzheimer's disease, dementia with Lewy body.
11:31
SPEAKER_01: And then you can also have mixed dementia pathology.
11:34
SPEAKER_01: So um, because Alzheimer's is such a prominent piece of the pie, um, I'll focus on that for a little bit.
11:41
SPEAKER_01: And for my research, what we've done over the past decade is actually looking at a specific phase of it.
11:47
SPEAKER_01: It's called the preclinical stage of the disease.
11:50
SPEAKER_01: This is where the individual is cognitively normal, but the proteins, the two key proteins, beta amyloid and tau, that aggregates within the brain itself, specifically some that aggregate within the neurons and those outside of the neurons, they start to sort of break down the cerebral architecture of the brain.
12:09
SPEAKER_01: And what happens is that you start to, the activities that you do on a daily basis, they, you know, are no longer, you're not efficient.
12:17
SPEAKER_01: They may take a little bit longer to do.
12:20
SPEAKER_01: And that stage is massive.
12:22
SPEAKER_01: It can take anywhere from 15 to 20 years.
12:25
SPEAKER_01: So, for example, if a person's diagnosed at age 65, the disease itself maybe has started in their late 40s or early 50s.
12:31
SPEAKER_01: And that's where a lot of the energy and the resources are being poured into is to better understand what we can do right now, how can we intervene to stop the disease from progressing to the latter stages.
12:42
SPEAKER_01: So the next stage after preclinical AD is a term that we've all heard, which is mild cognitive impairment.
12:49
SPEAKER_01: And this is measurable, particularly uh there's two forms amnestic and non-amnestic.
12:53
SPEAKER_01: Amnestic is just what it sounds like.
12:55
SPEAKER_01: Um, there's challenges with memory and thinking.
12:57
SPEAKER_01: And non-amnestic is struggles in other cognitive areas.
13:02
SPEAKER_01: But basic ADLs are intact usually, but I ADLs typically take a hit.
13:06
SPEAKER_01: So managing your checkbook, driving to familiar places or to new places may not be as efficient as we would expect.
13:13
SPEAKER_01: And that's normally where a client or a patient might see a neurologist or neuropsychologist or go to their PCP and say, hey, really struggling, but usually it's their family members that see those signals earlier on.
13:25
SPEAKER_01: And then the rest of the stages really is the mild, moderate, and the severe stage.
13:31
SPEAKER_01: The mild stage is roughly about two years that an individual might spend there.
13:35
SPEAKER_01: And this is where they need a lot, you know, moderate to significant assistance with their IADLs.
13:41
SPEAKER_01: And then they can do most of their ADLs.
13:43
SPEAKER_01: It's roughly intact.
13:45
SPEAKER_01: Moderate dementia, about two to four years.
13:47
SPEAKER_01: This is where ADLs are significantly impacted, and it becomes the focus of the um of the treatment and therapy.
13:54
SPEAKER_01: And the severe stage, unfortunately, is roughly about one to two years.
13:57
SPEAKER_01: This is when they're in a locked memory care unit often, um, and that their end stage where maximum assistance is needed for ADLs and IDLs.
14:05
SPEAKER_01: Now, the causes may vary.
14:07
SPEAKER_01: And what I want to, you know, also make note of is that you can have a lot of different diseases that might influence the risk of different forms of dementia.
14:17
SPEAKER_01: But that's kind of, you know, a few of those buckets that you alluded to and of where we're doing a lot of the research and focused on right now.
14:24
SPEAKER_00: That's super helpful.
14:25
SPEAKER_00: I have them written down on my paper.
14:28
SPEAKER_00: I wasn't expecting to ask this, but I want to sneak this in because I heard you say cognitive reserve towards the beginning.
14:36
SPEAKER_00: And as a therapist, we're usually working with someone in an acute situation.
14:42
SPEAKER_00: And it feels like we're not really seeing their baseline usually.
14:47
SPEAKER_00: It's usually, especially thinking of the hospital setting, their cognition, you can tell it's just off, like that they're in a dip.
14:56
SPEAKER_00: How would you talk about that dip in an acute situation?
15:00
SPEAKER_00: And how can we understand this on this uh uh these stages that I just wrote out?
15:08
SPEAKER_01: Certainly, yeah.
15:08
SPEAKER_01: So cognitive preservant resilience really uh encapsulates sort of the hardware of your brain.
15:14
SPEAKER_01: Um, so you know, how much like neurons do you have?
15:17
SPEAKER_01: Um, you know, do you have some different uh conditions, for example, like white matter hypertensities, a stroke that might impact the hardware itself?
15:26
SPEAKER_01: And then resilience is sort of uh the the neuronal connection, how they the, you know, how does the prefrontal cortex communicate with the amygdala or the parietal lobe and how resilient are they?
15:37
SPEAKER_01: So typically what we do know is that education is a great um supporter of reserve and resilience because it helps to um hone and strengthen the communication between different brain regions, and also it can withstand the damage to, you know, for example, like a traumatic brain injury or seizures or a stroke.
15:57
SPEAKER_01: You're able to bounce back quicker.
15:59
SPEAKER_01: And in an in an acute setting, you're and you're you're spot on correct.
16:03
SPEAKER_01: Um, a lot of folks don't want to be there.
16:05
SPEAKER_01: They're not sure why they're there because you're taking them out of their natural elements, their environment.
16:09
SPEAKER_01: But if they have chronic conditions or we're starting to see a change in terms of their status, cognitive function can take a hit.
16:17
SPEAKER_01: And this is typically one of the reasons why you'll do, you know, test of orientation to time, date, place to make sure that they know where they are.
16:25
SPEAKER_01: But, you know, reaction time, um, how quickly they're able to respond to competing tasks can be impacted, and especially within that acute stage.
16:34
SPEAKER_01: So you kind of want to assess, you know, do a baseline assessment, but then also multiple assessments to see how they improve and if they get back to where they were pre-hospitalization or admission into any kind of institutional care.
16:50
SPEAKER_00: Which leads me to my next question about this.
16:57
SPEAKER_00: And that is just capturing those changes that we're suspecting with some kind of data.
17:06
SPEAKER_00: Knowing what you know now, what's your advice to us as therapists on the floor?
17:11
SPEAKER_00: Like, how would you be capturing, if we suspect something's off, how would you be capturing those changes?
17:18
SPEAKER_01: Yeah.
17:19
SPEAKER_01: That's a that's a phenomenal question.
17:20
SPEAKER_01: And I get that quite often too from not just therapists, but also, you know, other healthcare practitioners.
17:26
SPEAKER_01: So uh I'm sure.
17:27
SPEAKER_01: So I've got a fly out later on this afternoon um for a meeting.
17:30
SPEAKER_01: And, you know, like when you go to the TSA, it says like, if you see something, say something, right?
17:35
SPEAKER_01: So it's it's it's corny as it is, but I I like that adage because it's the same thing as therapists, we're really trained to truly be scientists and the experts in behavior, and specifically ADLs and IEDLs.
17:50
SPEAKER_01: So if you see, you know, change that seems to not necessarily follow a trajectory, really comment about it or make a note and connect with others to say, hey, are you observing the same thing?
18:01
SPEAKER_01: Whether it's another therapist or it could be nursing or you know, it could be a PCP.
18:05
SPEAKER_01: Where I'd like to start is that I always ask about IEDLs first.
18:10
SPEAKER_01: And the reason why is I think it's the canary in the coal mine.
18:13
SPEAKER_01: You start to see subtle shifts there.
18:15
SPEAKER_01: And that usually is indicative of something larger coming down the pipeline.
18:21
SPEAKER_01: And and the reason why IEDLs is because these are highly overlearned activities that we do, but they're also very complex.
18:29
SPEAKER_01: So any perturbations, anything that impacts it, you'll see the ripple effects occur within that first.
18:36
SPEAKER_01: And what I study is driving, but you certainly can see this in medication management, preparing a meal, cooking, you know, just managing finances if folks still do manage a checkbook or balance a checkbook these days.
18:49
SPEAKER_01: And the reason I say that is because, as you mentioned, things like, you know, the ACL, the Mocha, or the slums, those are screens.
18:56
SPEAKER_01: They're not meant to be a comprehensive assessment of function.
19:00
SPEAKER_01: And I want to delineate that because they're paper and pencil measures, right?
19:03
SPEAKER_01: For the most part, of how are they functioning right at that time.
19:07
SPEAKER_01: It doesn't tell you what they were beforehand or you know, the variation or the fluctuations over time.
19:14
SPEAKER_01: And what we look at, um, Sarah, is in terms of driving as a window within the brain, what we've shown is that we can actually predict and differentiate individuals who are in that preclinical stage just based on the proteins that are starting to build up, we start to see subtle changes in their driving behavior.
19:34
SPEAKER_01: And this is many years before they ever see a neuropsychologist or a neurologist that can evaluate them and say, aha, you've got this.
19:41
SPEAKER_01: So IEDLs really help to provide that.
19:44
SPEAKER_01: And we can able to flag that with anywhere from an 80 to 90% accuracy.
19:50
SPEAKER_01: Now, granted, this isn't the research end of things within our own cohort, but the our goal and what we're working actively right now is to take this into the clinic.
19:59
SPEAKER_01: And so the other thing though is you also want to, you know, look at subtle shifts or changes within their behavior.
20:05
SPEAKER_01: So I'll stick uh with the driving, you know, for for right now, maintaining that lane.
20:10
SPEAKER_01: What we what we do know is when they're significant changes, like they may not drive in the night versus a year ago they used to drive in the night, or they no longer drive on the highway when they didn't have any issues whatsoever with that.
20:23
SPEAKER_01: Or they might prefer to go in non-rush hour times because it's so challenging to navigate multiple stimuli, you know, too many things occurring, or taking a different route than they normally take.
20:35
SPEAKER_01: All of those might be uh, you know, telling you that, all right, this self-regulation or this modification, something is happening there.
20:44
SPEAKER_01: But there's also other signals too, I would note in terms of sensory motor changes, other things in terms of, you know, um their daily function that could signal and you know, sort of like this domino effect is starting to topple.
20:57
SPEAKER_01: And the other thing I would tell therapists is that monitor, actively monitor everything, because you never know when that one observation might be that first pull of that thread that'll unravel, you know, a condition that you know healthcare is not even prepared to detect right now.
21:16
SPEAKER_00: Let me repeat back and put together some of the things I think I'm hearing, and you can tell me if it's accurate.
21:24
SPEAKER_00: I mentioned at the top that like as OTs, we tend to get pegged with cognition.
21:31
SPEAKER_00: I'm putting together for the first time, based on what you're saying, that because we're typically doing something functional with the patient, I wonder if we're catching the changes more so than our colleagues who are just having short conversations.
21:48
SPEAKER_00: Is that accurate?
21:49
SPEAKER_00: Yes.
21:50
SPEAKER_00: Yeah, that changes tend to show up in function first.
21:53
SPEAKER_01: Oh, yeah.
21:54
SPEAKER_01: Hands down, Sarah, tenfold.
21:56
SPEAKER_01: Uh, you know, and simply, you know, the ethnographic act of observing.
22:00
SPEAKER_01: How they're doing a simple meal prep, like cucking an egg or something, or um, you know, trying to figure out, hey, what this is the weather situation that you're given.
22:09
SPEAKER_01: How would you prepare to dress for it?
22:10
SPEAKER_01: Right.
22:11
SPEAKER_01: Going back to all the things we learned in OT school and also have seen in practice.
22:15
SPEAKER_01: You know, you can you can see how they sequence through a task and where that potential breakdown is.
22:22
SPEAKER_01: So that's absolutely massive data that's so precious that, you know, your conventional paper and pencil tests are not capturing.
22:31
SPEAKER_01: And this is not a knock to, you know, a lot of my colleagues are neuropsychologists.
22:35
SPEAKER_01: And the conversations we're having is that that very static paper and pencil measure that you're doing, you know, that's been validated since the 1970s, may not be capturing the complexities associated with the change.
22:49
SPEAKER_01: And because you're only typically measuring one single domain of typical cognitive function, you're not measuring how the different brain regions are communicating with each other and where that breakdown might occur.
23:02
SPEAKER_01: Because it's that's that complexity that I'm that you know keep alluding to that I think we're we're you know truly the experts and to be able to say, we're seeing this.
23:12
SPEAKER_01: How does that transfer into other aspects of their daily life?
23:15
SPEAKER_01: And then should we be concerned about their ability to age in place, their independence to be able to conduct their activities, you know, that they're selecting, you know, in a meaningful way?
23:27
SPEAKER_00: I'm thinking about literally just like what to write in my notes.
23:31
SPEAKER_00: I'm imagining someone who during my intake, I was suspecting changes in cognition.
23:37
SPEAKER_00: I asked about driving.
23:39
SPEAKER_00: They said the hallmarks of what you said, like they stopped driving at night, they've stopped driving on the interstate as I'm seeing the sequence, them sequence during ADLs, I'm seeing difficulty there.
23:51
SPEAKER_00: What's the sentence I write in my notes?
23:53
SPEAKER_00: Like, does cause I'm not diagnosing anything, I'm not saying anything definitive, but I see these red flags.
24:00
SPEAKER_00: Like, what's the what's the right wording to capture that that's clinically accurate?
24:06
SPEAKER_01: That's a fantastic question.
24:07
SPEAKER_01: Um, and so what I would say is if they've never done the activity before, um, or you know, or whatever it might be, then obviously it's it's not clinically significant or noteworthy.
24:17
SPEAKER_01: What we want what we're interested in is that intra-individual change over time.
24:22
SPEAKER_01: So if a year ago they didn't have any issues whatsoever, but then they've self-reported, or perhaps it's a collateral source, like a loved one, a spouse, a caregiver, an adult child, whatever it might be, self-reported, like, yeah, they're doing this, we're seeing this.
24:38
SPEAKER_01: That's critical.
24:39
SPEAKER_01: And you would say, you know, whether it's the client or the caregiver self-reports a significant change from baseline due to it's either secondary to X, Y, and Z, but here's the resulting change.
24:53
SPEAKER_01: And this may signal potential impairments in other domains that require further evaluation.
25:01
SPEAKER_01: So, so again, I think it's it's an initial marker to say we're observing this.
25:08
SPEAKER_01: This requires further investigation.
25:11
SPEAKER_01: It requires additional testing that needs to be done for a more comprehensive evaluation, whether that's sending them out for a full neuropsychic evaluation that's you know, two to three hours, something, you know, like the road test to ensure that they're still safe on the road.
25:25
SPEAKER_01: Or it very well could be, you know, maybe they have uh, yeah, thinking about potentially a tumor doesn't have to be dementia that's influencing or impacting one potential region of the brain that requires a scan to detect it.
25:39
SPEAKER_01: So I think, uh, you know, you might observe it and think, yeah, it's nothing really, you know, important.
25:44
SPEAKER_01: It's trivial.
25:45
SPEAKER_01: But I think documenting it is really important.
25:48
SPEAKER_01: As we know, you know, if it's not documented, it didn't happen, right?
25:51
SPEAKER_01: And so that itself could be the very, very earliest signs of something occurring, some departure from baseline that might then portend additional change in their in their daily activities.
26:04
SPEAKER_00: The one other foundational question that I wanted to be sure to ask is when we see this early cognitive decline, and maybe it's in an acute care and we don't even know if it's a long-term thing or if we're just seeing like a big dip, when we see it, is there hope of slowing that decline?
26:26
SPEAKER_00: Can it be reversed?
26:28
SPEAKER_00: Is it going to progress through these four stages no matter what we do?
26:32
SPEAKER_00: What does that mean for the future?
26:35
SPEAKER_01: Yeah, it's it's a phenomenal question, Sarah.
26:36
SPEAKER_01: So I'll start with a the quick epi shot right now.
26:39
SPEAKER_01: So, you know, my focus is um older adults' geriatrics by the year 2050.
26:44
SPEAKER_01: So literally in 24 years, we are going to have roughly about 88 million older adults.
26:49
SPEAKER_01: That's age 65 and older.
26:50
SPEAKER_01: And um, spoil alert, I will be joining that strata of the population um by that time.
26:56
SPEAKER_01: So I, you know, I'm acutely aware of that.
27:00
SPEAKER_01: There are not enough neurologists, neuropsychologists, therapists, practitioners to be able to screen populations, right?
27:07
SPEAKER_01: And worldwide, it's uh it's even more stark.
27:10
SPEAKER_01: And I can throw numbers out that um, you know, that you initially started with to show that, you know, these issues are going to become much bigger if we don't start addressing them right now.
27:19
SPEAKER_01: And so I think slowing things down or progression is a significant focus from both public health.
27:26
SPEAKER_01: What I want to potentially clarify for everyone listening right now is that it's not a sentence.
27:31
SPEAKER_01: If you're starting to see these changes occurring, it could be a plethora of other conditions that are influencing or mimicking it.
27:39
SPEAKER_01: And so that's what you know we need further evaluation for.
27:42
SPEAKER_01: And so, you know, having a, for example, diagnosis of MCI or you know, Alzheimer's disease, it's not destiny.
27:49
SPEAKER_01: It's not fixed or written.
27:50
SPEAKER_01: Um, if you've got a genetic marker, it's it's not fixed.
27:53
SPEAKER_01: It's a combination of that nature versus nurture.
27:55
SPEAKER_01: And what I want to say is that MCI doesn't always progress into dementia.
27:59
SPEAKER_01: A person can be there for the entirety of their life or you know, if they're older.
28:04
SPEAKER_01: So what I tend to look at from a therapy standpoint, inclusive of all allied health, is what are the potential things that could, you know, are reversible?
28:14
SPEAKER_01: And an immediate one of those is depression.
28:17
SPEAKER_01: So long-like depression, late life depression, um, you know, dysthymia, bipolar disorder.
28:23
SPEAKER_01: I mean, you slice and dice it anyway.
28:24
SPEAKER_01: Mental health is a massive, massive area, and depression specifically, because it can mimic the symptoms of both cognitive decline and also mild cognitive impairment and even dementia.
28:35
SPEAKER_01: Now, what makes it more complicated is depression is also a risk factor for Alzheimer's disease and other forms of dementia.
28:42
SPEAKER_01: And conversely, when you're diagnosed with it, your risk of depression also grows up.
28:46
SPEAKER_01: So it's sort of this chicken and the egg thing, like which one comes first and how are they all, you know, coalescing?
28:51
SPEAKER_01: And so doing quick screens that are free, like the PHQ nine or even the PHQ two in your in your therapy session, very easy to see.
28:59
SPEAKER_01: Hey, are they endorsing symptoms of depression?
29:01
SPEAKER_01: Do they have something going on in their life that's impacting?
29:04
SPEAKER_01: Because you can see cognitive slowing, you can see breakdowns in executive function or the uh ability to recall is not as sharp as it should be.
29:14
SPEAKER_01: The other thing is sleep.
29:16
SPEAKER_01: Sleep is immense, it is massive.
29:19
SPEAKER_01: Really quickly, when we sleep, actually, the brain's lymphatic system turns on and it starts to remove the toxic proteins that build up over the course of the day.
29:28
SPEAKER_01: So, sleep deprivation that leads into chronic conditions like sleep apnea or obstructive sleep apnea, more specifically, insomnia, RBD, these are important things that are actively treatable.
29:40
SPEAKER_01: But because you're not able to sleep, it can influence your daily behavior.
29:46
SPEAKER_01: As a matter of fact, we had a study that was uh published in the journal Sleep that patients with uh obstructive sleep apnea, for every eight-point increase on the apnea hypoxic index, we saw a roughly 27% increase in heartbreaking, sudden acceleration, and speeding behavior.
30:04
SPEAKER_01: And again, they're all cognitively normal, no dementia whatsoever, no, not even any preclinical Alzheimer's disease.
30:10
SPEAKER_01: But because they're not getting that restorative component to be able to sort of reset, it's impacting their ADLs and IDLs.
30:18
SPEAKER_01: Medications are another one.
30:20
SPEAKER_01: So um opioids, for example, are massive.
30:22
SPEAKER_01: They've been known on to influence your ability to think.
30:25
SPEAKER_01: So looking, and of course, polypharmacy is really a big thing right now in not just medicine, but also for the field of pharmacy right now.
30:32
SPEAKER_01: So there's a lot of uh work being done on deprescribing to make sure that you don't have drug-drug interaction that is impacting their ability to age in place, but also just to do their daily activities.
30:43
SPEAKER_01: And other chronic conditions, neurological conditions like traumatic brain injury and seizures, can also, again, mimic, you know, forms of cognitive impairment.
30:53
SPEAKER_01: Again, are all treatable, that can, you know, um be intervenable as well.
30:57
SPEAKER_01: There's been a lot of work uh in the field thus far in biomarkers.
31:02
SPEAKER_01: Um, that's one of the hot topics right now, especially in preclinical Alzheimer's disease.
31:06
SPEAKER_01: We can detect these rogue proteins that are rapidly, you know, um accumulating within the body.
31:12
SPEAKER_01: And then the question is, well, how do we address that?
31:14
SPEAKER_01: What do we do to ensure that, you know, they're not going to continue to transition into um dementia?
31:21
SPEAKER_01: And so a lot of those is they're really mainly being used for monitoring the disease progression and to also eliminating other pathologies so that we can get closer into precision medicine.
31:35
SPEAKER_01: And where I hope the field goes to one of these days is precision rehabilitation.
31:39
SPEAKER_01: So we can identify patients and clients that are at the highest risk and intervene well before that point.
31:45
SPEAKER_01: And the last thing I kind of want to touch on right now for individuals that are either working in long-term care or you know in geriatrics, or you have maybe your family members there that have a diagnosis, is that for the first time in probably about 30 plus years, we actually have treatments that are available.
32:03
SPEAKER_01: I'm not advocating for any of these, it's just sharing more of what's available.
32:06
SPEAKER_01: Anti-amyloid treatments, lakanamab and denatomab, which has been shown to essentially um clear out beta-amyloid, one of the toxic proteins within the brain.
32:16
SPEAKER_01: And what it does is it effectively pauses the disease treatment for Alzheimer's, or the progress specifically for Alzheimer's disease, so that um they're not starting to decline further.
32:28
SPEAKER_01: Now, you do have to have a diagnosis of MCI, and it does have to have confirmation that your beta amyloid level is high enough to be able to be prescribe the treatment.
32:37
SPEAKER_01: But it gives hope for millions that are suffering for this disease.
32:41
SPEAKER_01: Now, it doesn't fix it.
32:42
SPEAKER_01: There's no cure.
32:43
SPEAKER_01: I want to be very clear.
32:44
SPEAKER_01: There's no cure for the disease, and it doesn't fix the damage that's already been done.
32:49
SPEAKER_01: So the neurons that have died, the deregulation between the communications between regions of the brain, that damage is already there.
32:57
SPEAKER_01: But what it does is it does pause it.
32:59
SPEAKER_01: And um, folks do have to stay on it for the rest of their life.
33:02
SPEAKER_01: But the hope is that we have more treatments that come on board to help folks that are in that, you know, that prodromal stage of the disease.
33:11
SPEAKER_01: But what we're focusing on right now is that preclinical stage.
33:14
SPEAKER_01: What can we do now?
33:16
SPEAKER_01: And, you know, I'll I'll end my answer really quickly.
33:18
SPEAKER_01: All the things that your mom told you when you were growing up, get lots of sleep, do your homework, go to school, work on, you know, mental cognition, eat healthy as well.
33:28
SPEAKER_01: I know we didn't get into that right now, but eating healthy is also a significant part of it, and get exercise as well.
33:34
SPEAKER_01: Those are things that you can continue to do throughout the life.
33:36
SPEAKER_01: It's free to help preserve your ability to age in place and support brain health.
33:42
SPEAKER_00: I'm hearing you say that it's not a sentence, and there's sounds like there's a lot that we can do.
33:50
SPEAKER_00: So it is worth having the conversation when we start to notice the change or like the changes um, hopefully early.
33:58
SPEAKER_00: I had someone in the comments ask about how we can bring it up in a compassionate way with our patients, with our families.
34:07
SPEAKER_00: Um, I'm going to say just try a pass at it out loud to hopefully lead you into the next question.
34:13
SPEAKER_00: It sounds like we might want to say something like, hey, we've no, we've noticed a change that's been going on in the daily, in your, your or your loved one's daily routine.
34:27
SPEAKER_00: That makes me concerned that there might be a cognitive change going on under that.
34:33
SPEAKER_00: But there's a lot of things that we can do at this early stage.
34:37
SPEAKER_00: I'd like to focus some of our therapy on those protective factors.
34:42
SPEAKER_00: Is that like an okay?
34:44
SPEAKER_00: Sarah, I think that's brilliant.
34:46
SPEAKER_00: Okay.
34:46
SPEAKER_01: Yeah.
34:47
SPEAKER_01: No, I wish I had you for there's many of conversations that I've had to have that have been challenging, both with clients, patients, and their family members.
34:55
SPEAKER_01: We're like, hey, this, we're seeing this happen.
34:57
SPEAKER_01: You know, do you see this happen?
34:59
SPEAKER_01: And and it is a very sensitive area.
35:01
SPEAKER_01: And um and so and it's also very scary for a lot of folks, not just, you know, the patients themselves, but also their family members, their larger support network.
35:08
SPEAKER_01: So a lot, I love the way that you framed it in terms of, you know, this altruistic but very positive way that, hey, we're noticing this.
35:15
SPEAKER_01: Can we focus on other things to help support that are saltatory to good health?
35:19
SPEAKER_01: It's definitely a great way to do it.
35:20
SPEAKER_01: And then that continuous monitoring as well, I think is helpful.
35:24
SPEAKER_01: Making them, being transparent about it, making them a partner within that conversation, I think is absolutely critical.
35:32
SPEAKER_00: We're going to talk about two layers of risk factors that we could address at this stage.
35:38
SPEAKER_00: Ones in our environment and ones like in our person.
35:42
SPEAKER_00: I think we tend to think about the personal risk factors the most.
35:46
SPEAKER_00: Could you just spend a couple of minutes saying what those personal level risk factors are?
35:50
SPEAKER_00: And then I definitely want to get to environmental because those actually feel some of those feel easier to modify to me.
35:57
SPEAKER_00: Exactly.
35:57
SPEAKER_01: Yes, yes, yeah.
35:58
SPEAKER_01: So for folks that are attending, this is such a big uh topic of interest.
36:02
SPEAKER_01: So the Lancet convened a special commission in 2016.
36:06
SPEAKER_01: And every four years they put out a new updated sort of, you know, what are the big risk factors that we need to be aware of.
36:12
SPEAKER_01: And it's it's really transformed over the past 10 years now.
36:15
SPEAKER_01: So what they've shown is that in early life, the more education you get protects your ability to age in place and helps to withstand the um the impact of cognitive decline.
36:25
SPEAKER_01: In midlife, there's a lot of things that come online, unfortunately.
36:29
SPEAKER_01: And I'll quickly go through them in terms of risk factors.
36:32
SPEAKER_01: So hearing loss, high cholesterol or hypolipidemia, depression as another risk factor, traumatic brain injury, physical inactivity, um, so inability to exercise, diabetes, smoking, hypertension, obesity, pun intended, is a significant global health problem that we're all intending to focus on.
36:53
SPEAKER_01: And then excessive alcohol intake or alcohol use.
36:56
SPEAKER_01: Those are the really the crux to focus on in midlife to addressing and ameliorating them to preserve good brain health.
37:03
SPEAKER_01: And then in later life or older age, um, social isolation, air pollution, which is one of the only environmental pieces that they've added in there, and vision loss are all of those 14 account for roughly about 45% of the risk of dementia, encompassing all of them.
37:21
SPEAKER_01: And so a lot of the research that we've done in our lab, um along with other colleagues as well, has really shown that hearing depression, traumatic brain injury, uh, and we've published on these ink are all associated with a faster progression from being cognitively normal and or cognitively intact, more appropriately, um, to a mild cognitive impairment staged to then a prodromal or a, you know, you definitely got the disease, this is the point of no return.
37:48
SPEAKER_01: And honestly, to sort of segue into that, a lot of these individual or personal risk factors that you touched on, Sarah, are also being influenced by the environment.
37:59
SPEAKER_01: So for example, if you can't get out and go exercise because you you live in a rural area and maybe there is no gym or recreational activities and you've got to drive an hour, you know, you may that's not conducive.
38:12
SPEAKER_01: Or you live in the inner city, and um, there again, is not uh uh available areas for you to recreate, that's going to influence your ability to, you know, try to get exercised so that you can age in place and and sort of be healthy.
38:25
SPEAKER_01: So there's a lot of the environment, these upstream factors that are feeding into these individual personal factors.
38:34
SPEAKER_00: I'm picturing after a therapist has had that tough conversation, I might have a handout with those 14 things from the Lancet.
38:43
SPEAKER_00: I can picture a conversation with a patient to be like, we've noticed these changes.
38:48
SPEAKER_00: Cognitive change is not a life sentence.
38:50
SPEAKER_00: There's things that we can do.
38:53
SPEAKER_00: Here's the 14 risk factors.
38:55
SPEAKER_00: Is there one that stands out to you that you feel like we could address?
38:58
SPEAKER_00: And let's spend time talking about your hearing.
39:02
SPEAKER_00: Like, why are there any barriers to getting that hearing testing that I can help you with as a therapist?
39:08
SPEAKER_00: There's those uh personal risk factors, as you've started to allude to interlink with the our environmental risk factors.
39:18
SPEAKER_00: You have this awesome article called The Association of Environmental Exposome and Cognitive Function Among Older Adults with and Without Preclinical Alzheimer's disease.
39:30
SPEAKER_00: This was a great read.
39:31
SPEAKER_00: I definitely recommend it to people.
39:33
SPEAKER_00: Um, what have you learned about environmental risk factors?
39:37
SPEAKER_00: And can you define exposome for me?
39:40
SPEAKER_00: Yes.
39:40
SPEAKER_01: Yes.
39:41
SPEAKER_01: So for all the OTs listening, um, believe it or not, our work is getting out, but it's not under the guise of the OT banner.
39:47
SPEAKER_01: So really the exposome is the environment.
39:50
SPEAKER_01: It's the totality of what we've been exposed to since birth, pretty much up until death.
39:55
SPEAKER_01: And there's a significant focus on the environment.
39:58
SPEAKER_01: So think about you know the PEOP or the COWA model or any of the theoretical, you know, frameworks that we've used.
40:04
SPEAKER_01: It always has the individual, the environment, and then either occupation or performance or participation, right?
40:10
SPEAKER_01: So what I call, you know, behavior.
40:12
SPEAKER_01: Again, I'm an OT in neurology.
40:15
SPEAKER_01: Um, and so I've got to adopt the language of the language tables that they use.
40:19
SPEAKER_01: So, so there's actually um there's like a renaissance right now, this massive uh explosion of work being done to quantify the exposome.
40:28
SPEAKER_01: And so to give a quick example, it's like the physical environment.
40:31
SPEAKER_01: So think about the air that you breathe, the noise that you hear, the light that's afforded to you, the green space that you're in, the neighborhood that you live in, the social environment that you are a part of.
40:42
SPEAKER_01: Um, and the social environment is very, very dynamic and complex.
40:46
SPEAKER_01: It can include poverty, isolation, discrimination, you know, all of those softer pieces that are oftentimes challenging to measure.
40:54
SPEAKER_01: And it's also the body's response to the environment.
40:59
SPEAKER_01: So it's really the fusion of both of those in terms of trying to understand how do the genes, what you have, what you bring to the table, interact with the environment and to really uh predispose you to good health or to you know certain diseases and risk factors.
41:16
SPEAKER_01: And really quickly before I dive into that article, one of the things that we've known that's been well established in the field itself, is that air pollution, specifically particulate matter 2.5, that's the finest grain that we can measure, at least right now, and nitrous oxide, these two things, if you're you know in inner in certain cities and you're exposed to a higher concentration, they can actually cross the blood-brain barrier, alliteration there, say that 10 times real fast, and actually um catalyze buildup of toxic proteins within the brain, inflammation that leads to um a higher risk of cognitive impairment and eventual risks of dementia.
41:55
SPEAKER_01: We also know that chronic stress being exposed to environments like war, for example, drives up the risk factors for um neuroinflammation within the body and a plethora of different neurological disorders.
42:07
SPEAKER_01: Getting less sleep at night because you're in a city that's just gotten a lot of bright lights and you know there's you know leakage into your bedroom and you can't sleep, that's gonna disrupt your circadian rhythm and the ability of the pineal gland to reset so that you can get that restorative sleep that you need.
42:25
SPEAKER_01: And if obviously noise, if you're living in higher construction environments or just a lot of background noise, it's gonna impact your ability to also just shut down and sort of get the restorative rest that you need.
42:37
SPEAKER_01: So there is a significant influence of all these risk factors on your ability to age in place.
42:42
SPEAKER_01: And what our studies showed that you were alluding to, Sarah, is that walkability, if individuals resided in areas that had more walkable routes and environments, it was associated with a higher, better cognitive function.
42:56
SPEAKER_01: Individuals that resided in places that had more green spaces, a higher dense, more green uh tree canopies, also they were able to had faster reaction time, better cognition, um abilities to recall things much faster.
43:11
SPEAKER_01: The same thing with light pollution.
43:13
SPEAKER_01: So if they lived in areas that had greater light pollution, we saw poor cognitive function compared to those that reside in areas that didn't have as much light pollution.
43:23
SPEAKER_01: And then what we saw, interestingly enough, because I know I talked about the preclinic stage of disease, these biomarkers that we're measuring used to be via pet uh pet MRI, cerebrospinal fluid, and now blood, did not play a role, at least in our study.
43:38
SPEAKER_01: So what it was saying is that the environment seems to exert a much higher risk.
43:43
SPEAKER_01: And maybe that biomarker signal comes down much later down the line.
43:46
SPEAKER_01: So the one thing that I want to note, Sarah about the study is that it was a cross sectional study.
43:51
SPEAKER_01: So we're looking at associations.
43:53
SPEAKER_01: We couldn't look at causations.
43:55
SPEAKER_01: However, there are a lot of longitudinal epidemiological studies that are currently being Done right now across the world to establish the risk factors within the environments that we live in.
44:06
SPEAKER_01: And actually, I saw the Landsat just put out a separate call to arms, so to speak, for all populations globally.
44:14
SPEAKER_01: Air pollution was definitely up there.
44:16
SPEAKER_01: War and conflict was also up there.
44:17
SPEAKER_01: And some of the research that we won't get to talk about now, I do research in LMICs, in particular in conflict and fragile states.
44:24
SPEAKER_01: And we do show that individuals that live in environments that have high conflict, high war rates, climate change as well, there is a much higher risk of dementia and cognitive impairment.
44:42
SPEAKER_00: I might be taking too much of a leap here in how to use this information, but because I feel like we get this information because we're looking at big groups of people and we're making associations.
44:55
SPEAKER_00: Like you said, it's not causation.
44:58
SPEAKER_00: But I'm wondering as a therapist how to use this.
45:02
SPEAKER_00: And I'm wondering if we're at this stage where I can start treating them as protective factors, where I'm like, okay, I can, I from what we're seeing, it looks like you're in early, we're seeing some early cognitive decline based on what I know in the research currently.
45:21
SPEAKER_00: I would love to spend some time looking at your sleep, getting you into green space and looking at your air quality.
45:28
SPEAKER_00: Like if I was, can I take these risk factors and use them as protective factors?
45:33
SPEAKER_00: Do you feel like we're at that stage?
45:35
SPEAKER_00: Is that clinically appropriate?
45:37
SPEAKER_00: Or is how that you is that how you would use this data if you were a therapist?
45:41
SPEAKER_01: I certainly would.
45:42
SPEAKER_01: And and and you know, uh treating clients is exactly what I would do is sort of make a report card and uh to show that, hey, these this is where things are, because they're risk factors and protective factors at the same time, right?
45:52
SPEAKER_01: It's it's it's really a spectrum.
45:54
SPEAKER_01: And it's just depending on where they are on that spectrum, it transfers from risk to um protection or protection to risk itself.
46:03
SPEAKER_01: And and what I would say too is, you know, we do a lot of home health evaluations within within um therapy.
46:09
SPEAKER_01: You know, instead of just assessing the home itself to ensure that it's safe, um, you know, do you have throw rugs?
46:14
SPEAKER_01: Uh are there trip other trip hazards, you know, how accessible is the home?
46:18
SPEAKER_01: Evaluate the neighborhood as well.
46:20
SPEAKER_01: Um, you know, ask the client, like, hey, how often do you go for walks?
46:23
SPEAKER_01: Do you feel safe in the neighborhood that you that you live in?
46:26
SPEAKER_01: How close is you know the park or green space relative to where you are?
46:30
SPEAKER_01: And do you have adequate transportation perhaps to, you know, to go from point A to point B?
46:35
SPEAKER_01: But then you could also measure, you know, just using like uh a smartphone nowadays, they all have these, you know, noise uh uh meters built into it.
46:45
SPEAKER_01: You can measure how high is the decibel, and even smart watches too.
46:48
SPEAKER_01: My Apple Watch is able to measure decibels, like what's the ambient background noise look like?
46:53
SPEAKER_01: And is that potentially disrupting their ability to rest?
46:56
SPEAKER_01: So there's a lot of tools that we can use that are already in our toolkit and our arsenal to be able to quantify and measure how much is the environment impacting their ability to age in place.
47:07
SPEAKER_01: And and the I I want to make something uh as a caveat.
47:10
SPEAKER_01: You know, when I was in OT school, um, aging in place was this very positive thing, it's like we want our clients to age in place because, you know, they're not going into long-term care to where we know it things inevitably decline.
47:22
SPEAKER_01: But for some populations, they're stuck in place.
47:26
SPEAKER_01: They don't have the ability to leave in their environments that are not conducive to good health.
47:32
SPEAKER_01: And so figuring out what we can modify about the environment to support their ability to still age in place in a positive way.
47:39
SPEAKER_01: And and I would, you know, think about treating sort of these external environments as all part of their treatment plan, you know, getting good sleep, modifying, you know, noise and light so that they are able to sleep more peacefully and get that restoration that they need.
47:55
SPEAKER_01: Addressing things like hearing as well within the home, I think is really useful.
47:59
SPEAKER_01: Granted, we're not audiologists, but you can confer with your audiology colleagues or speech language there, uh, you know, pathologists to say, hey, I'm seeing this.
48:07
SPEAKER_01: You know, do we need to get here, you know, hearing uh aids on board?
48:10
SPEAKER_01: And I will, this is a generalizable.
48:12
SPEAKER_01: Um, men are the worst about this.
48:14
SPEAKER_01: They're the last to get hearing aids because they're vain about it.
48:17
SPEAKER_01: Um and that's well established in the literature.
48:19
SPEAKER_01: That's, you know, we we we have data to back this up.
48:23
SPEAKER_01: And so addressing and having that conversation is really, really important.
48:26
SPEAKER_01: But the other piece, too, thinking about building social participation and support within the community, um, a lot of studies and some of our work has shown is that you can be in what I call an environment that's not necessarily conducive to good health.
48:39
SPEAKER_01: But if you have social support to create a buffer, you know, collaboration, support, you know, friends, social network, that can help to really allow them to really age in place without, you know, having to deal with the overall day-to-day onslaught for, you know, contending with poor health because of the air that they're breathing or the sound that they're they're hearing.
49:00
SPEAKER_01: There's so there's a lot of things that can be done within the environment itself.
49:06
SPEAKER_00: Yeah, and I love thinking about addressing the environment.
49:11
SPEAKER_00: Honestly, it just feels easier sometimes than to change behavior to think about changing the bedroom.
49:17
SPEAKER_00: Like it's, I don't know, feels less threatening, I think, to the individual to talk about the environment first.
49:25
SPEAKER_00: It almost feels like the low-hanging fruit to pick off.
49:28
SPEAKER_00: Um, and I love the visual of like turning something from a risk factor to a protective factor and kind of having the scale.
49:36
SPEAKER_00: And I can picture people like marking where they're at on the scale.
49:40
SPEAKER_00: I really quick want to link this to some other content that we've had on the podcast.
49:45
SPEAKER_00: We've talked about life's essential eight, which is a similar list.
49:49
SPEAKER_00: We've talked about the list of risk factors for cancers, which is another similar list.
49:55
SPEAKER_00: As I'm saying this, I wish there was just one list that we could work off because they're all very similar.
50:01
SPEAKER_00: But that feels like a shared concept of like taking the risk factor and turning it into a protective factor.
50:07
SPEAKER_00: And like you said, making it like a report card.
50:11
SPEAKER_00: I had one question in the comments that might be too hard, but I'm going to ask it.
50:18
SPEAKER_00: Sure.
50:18
SPEAKER_00: Uh, there was a question about water quality and forever chemicals related to dementia.
50:24
SPEAKER_00: We've talked about that with related to cancer here on the podcast.
50:28
SPEAKER_00: Off the top of your head, does anything jump to your mind with that question?
50:32
SPEAKER_01: It's it's a fantastic question.
50:33
SPEAKER_01: And what I can say is I'm not familiar with any research or any work being done right now to investigate that linkage.
50:39
SPEAKER_01: I anticipate, though, um, that to really come on really more heavily, just because um, so I'm from a third world country and back in the um 70s and 80s when DDT, which worked brilliantly in the United States, when it was problematic and they found out let's all these neurodevelopmental disorders and birth defects, they shipped it to third world countries.
50:59
SPEAKER_01: My country was one of those, and my father is a rice farmer and he used it heavily.
51:02
SPEAKER_01: And like, oh, so my concentration is much higher than the rest of the population.
51:06
SPEAKER_01: I think we're gonna start to see a lot of research, um, specifically in the in the endocrine disruption area, where we know it impacts it, um biological health and endocrinology, but we're not really sure how what that long-term impacts or that dosage looks like.
51:23
SPEAKER_01: But I think it's a critical and important area for us to start paying attention to because where we live is it's a closed loop.
51:30
SPEAKER_01: Um, everything that goes out to the environment comes back and impacts us.
51:35
SPEAKER_01: And there's a concept called biological magnification.
51:37
SPEAKER_01: And this is where a lot of that research and the literature started to take um place from is all the toxins, the pesticides, the herbicides that we're using.
51:46
SPEAKER_01: It's going out there, but guess what?
51:47
SPEAKER_01: We're consuming it.
51:48
SPEAKER_01: And the animals that are all being exposed to it as well, we're consuming those as well.
51:52
SPEAKER_01: And so starting to pay attention to that, I think is really, really important.
51:55
SPEAKER_01: So I really appreciate the question.
51:57
SPEAKER_01: I wish I wish I had more data or uh research on it, but I just don't.
52:03
SPEAKER_00: Yeah, I think it's a really interesting question.
52:06
SPEAKER_00: And I want to link it to something that you taught me about, which was that there are large data sets out there in resources related to things like light pollution to sound levels.
52:19
SPEAKER_00: And I know that there's starting to be more public data sets about water quality.
52:24
SPEAKER_00: So, like address by address, you can look at the exposure to that.
52:28
SPEAKER_00: Now that I know that exists, I see a reality where that public data is mapped into our EMR, people's addresses are flagged if they're in one of those risk factor areas, and they get offered a therapy referral to come out and maybe can't change the whole um lighting on the street, but we can change their bedroom.
52:49
SPEAKER_00: Exactly.
52:50
SPEAKER_00: Is that the direction you think you need to go?
52:53
SPEAKER_00: Is that the best solution?
52:55
SPEAKER_01: I I think there's a lot of folks actually that there's a big movement that's uh moving towards that direction, which is using the the geocoded locations of our clients and our patients their home address to better understand what they have access to in their home environment.
53:09
SPEAKER_01: Um, so there's something called the area deprivation index.
53:12
SPEAKER_01: This is free of charge to use.
53:14
SPEAKER_01: Dr.
53:14
SPEAKER_01: Amy Kind and Barbara Bedlam are uh two actually epi researchers and physicians as well that created it.
53:21
SPEAKER_01: And uh what you can do is you can look at typing in the you know an address and you can find what your area deprivation index is within the state.
53:29
SPEAKER_01: It goes, I want to say zero to 10, where the higher, the more deprived of an environment you live in.
53:35
SPEAKER_01: And then nationally, so you can compare individuals across states, goes from zero to 100.
53:39
SPEAKER_01: And so researchers use it immensely to quantify, you know, what does that home environment look like where our patients and clients live?
53:46
SPEAKER_01: And I'm I think that's starting to be pulled into a lot of EMRs right now so that you can understand where they live, what they're exposed to, how deprived their environment might be, or perhaps not conducive to health.
53:58
SPEAKER_01: And where I can see this playing a significant role, and this is where as therapists, we need to start advocating for like, hey, we can help with X, Y, and Z.
54:06
SPEAKER_01: We can, you know, help to start thinking about how to, you know, bring more therapy within the community itself, or address the impact of the external environment onto the client's house to ensure that it is a you know, perhaps a protective pocket.
54:21
SPEAKER_01: And the, you know, the adverse effects of these um environmental teratogens and risk factors are mitigated to a certain degree.
54:30
SPEAKER_01: And really, because these all influence function.
54:33
SPEAKER_01: They influence ADLs and IEDLs and the ability to engage within them.
54:38
SPEAKER_01: And that's where we're starting to see if there's shifts occurring, we want to figure out what's you know influencing.
54:43
SPEAKER_01: Is there perhaps a new development coming into town that's causing a lot more night, you know, noise pollution and light pollution that needs to be addressed, you know, at City Hall.
54:52
SPEAKER_01: Like these are areas in which I think are brand new and so exciting and novel for us to start thinking about expanding um, you know, our toolkit into and truly having a significant impact on the environment itself.
55:06
SPEAKER_00: And I love this environmental or this environment level lane lens because it feels like it takes like the personal blame off the patient and not as therapists that we're ever trying to like give the impression that we're blaming someone.
55:23
SPEAKER_00: But when you're talking about sleep and eating and weight, like those just feel personal.
55:30
SPEAKER_00: Um, and it feels really different to talk about like you live in a food desert, so this is really hard versus like exactly making it feel more feel more personal than that.
55:41
SPEAKER_00: I think this is all so helpful.
55:44
SPEAKER_00: This has been such a wide-ranging conversation from just having the foundational knowledge, kind of what to do when we walk in and we see changes to really zooming out and thinking at the society level.
55:56
SPEAKER_00: We've touched on so many things today.
55:58
SPEAKER_00: I could go into all of them in more detail.
56:00
SPEAKER_00: What, but what's like the final thing that you want to leave us with today?
56:05
SPEAKER_01: Certainly.
56:06
SPEAKER_01: And I know there's been a lot of questions that I we didn't get a chance to touch on.
56:09
SPEAKER_01: So feel free to email me.
56:10
SPEAKER_01: I'm happy to follow up with you and uh individually via email.
56:13
SPEAKER_01: I think uh the main takeaway is you know, for all the therapists listening um to this, is that function itself, in my opinion, is the first, and I'm gonna say biomarker, but I'm gonna uh annotate that and say it's a neurobehavioral marker.
56:25
SPEAKER_01: And all of my studies that I put out, that's how I've been quantifying it.
56:28
SPEAKER_01: So ADLs and I ADLs are function.
56:31
SPEAKER_01: It is neurobehavioral marker, and it's one of the first things that we can see changing in the environment, in the actual before they see a clinic, before they they go into a hospital, before they go into a SNF, an ALF, any of these institutional cares to get treatment.
56:47
SPEAKER_01: The changes actually start at home and they start in their community itself.
56:51
SPEAKER_01: And we are trained to measure, to observe, to quantify and understand what might be occurring.
56:57
SPEAKER_01: And so that is immense.
56:59
SPEAKER_01: That is so valuable.
57:01
SPEAKER_01: It, you know, to a certain degree, trumps any biomarker, any test, any quantification or any exams.
57:07
SPEAKER_01: Um, so don't let that go.
57:10
SPEAKER_01: Continue to measure that, continue to document it.
57:13
SPEAKER_01: Um, and I can preach on and on about this, you know, at task analysis, um, you know, any formal testing, whether you know it's assessment on the road or doing a home evaluation itself, we're measuring all of that right now.
57:27
SPEAKER_01: And then we can actually follow up on that and treat, create treatment plans that are detailed, that are inclusive of beyond the client, but their family members and their community itself.
57:36
SPEAKER_01: But then also getting that function into EMR, I think is so critical.
57:41
SPEAKER_01: And as a researcher, as a former clinician, still a clinician to heart, but I can't since I'm not actively treating, my mandate, what I'm gonna be doing, the deal, the the hill that I'm gonna die on is getting function into EMR, getting function outside of OT, PT, SLP, into neurology, neuropsychology, into all the massive associations that are starting to see the light in my in my mind.
58:05
SPEAKER_01: Um, and so I think, you know, if I before I do the closing sound bite, I think focus on function would be the key area.
58:14
SPEAKER_00: Oh.
58:16
SPEAKER_00: Well, Ganesh, this I wasn't expecting this topic to come back to uh the heart of what we're doing to come back to function, the importance of observing it, the importance of capturing the changes that are going on, and then to really use it as protective factors.
58:33
SPEAKER_00: Like it truly is our through line here.
58:36
SPEAKER_00: I'm so thankful for you to help us understand this topic in this way, and just for the research that you're doing and the advocacy that you're doing to elevate this super important marker and really concrete thing for us to work on.
58:51
SPEAKER_00: So thank you so much for this conversation and for all you're doing on this front.
58:56
SPEAKER_00: I just appreciate it so much.
58:58
SPEAKER_01: You're very welcome.
58:59
SPEAKER_01: Thank you so much for having me, sir.
59:01
SPEAKER_01: It's always a pleasure.
59:06
SPEAKER_00: Thank you for joining us on the OT Potential podcast.
59:09
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59:19
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59:26
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59:35
SPEAKER_00: Okay, I want to thank you for joining us today, and we'll see you next time.