Alzheimer's Disease and Dementia Advisory Council

In that we've had so far we have some great information to be shared with everyone for those who cannot attend the UAMS meeting back in December we're A lot of uh knowledge come out of the S. and we can learn a lot and hopefully there's a lot of people we can help with this information throughout the state of Arkansas. With that being said up my co chair not able to attend today please keep her in your prayers she has a daughter that's in the hospital and so I would like up to for everyone to keep her in your mind thousand prayers if we could everyone got a copy the minutes looks the look at those in. Once already had a chance to read over David cook has made a motion to approve do we have a second. Second doctor way. That being said we're gonna skip around the only agenda they were going to go to D. first name will back up to see. So doctors are if you would like to take over now in your presentation. Thank you so much as an exhibit the is in your packet. I want to make sure can be heard by the. Okay so today I'm going to give an update on the diagnosis and treatment of as endless disease and. Some of you may be familiar with some of the things I'm talking about but some things might be a little bit and you. So I'm going to talk. Mostly about major Nero degenerative disorders or dementia. But the focus on as I'm as disease which is a major Nero degenerative disorder. In the US those animals diseases the fifth leading cause of death in people over the age of sixty five. In addition the five million people who suffer from mild cognitive impairment due to us and was disease in the country the six point five million who suffer from as an was disease. And the projected increase in the prevalence of as them as a disease in the State of Arkansas as you can see from the map over here sixty seven thousand which will be in twenty twenty five. And the one of them twenty new cases of as I must disease diagnosed every minute there's three per second. So that's. A lot of burden of as Emma's disease and it just seems to be very common so we asked the question should in the diagnosis of as I'm as disease to be straightforward. And the answer is no as Emma's dimension may be misdiagnosed but experts in up to thirty percent of cases. We know this because patients misdiagnosed for those I must disease when they had that autopsies they did not display classic neuropathy logical changes of plaques and tangles on autopsy and some had normal and like that and almost see assent. Fans the dimension was not due to as I'm as disease it could have been due to vascular disease. Symptoms predominant. The predominant memory changes which will also called amnesty dementia is not specific for them was disease and it could be due to other types of dementia as example vascular dementia of a commonly. The non member related cognitive difficulties and what you have is a special language and executive function problems might be an early features as Emma's disease and this could be mistaken for other kinds of dimensions that frontal temporal dementia is or the dimensions. And finally a thirty to forty percent of cognitively normal people talking normally Florida does have some as the most disease neuropathology good changes like plaques and tangles that autopsy but the never experienced any member changes. So this is a schematic and a diagram which shows how complex the overlap is between as Emma's disease which is up kind of dementia and other kinds of dementia the known as M. as type of dementias. As you can see over here the yellow circle on the left hand side. That represents as I'm as disease the right on the right hand side this blue circle represents all the non as and this type of dementias. So as I'm as disease the pathological change is you get plaques like this you get Daniels due to tolerate this and when the progress the cost dementia. And the other kinds of dimensions which may be them the. Many residents flood reasons for it like vascular strokes bleeding from minor infections especially nowadays COVID nineteen inflammation sorry Frontotemporal dementia new body dementia and hippocampus chlorosis except for a those that the non as Emma's dementias and that's represented in the blue circle. And they also progressed slowly and day to symptoms of dementia and Wendy's to suckle so we'll have the yellow and blue that there's a direct second in between and you can eat have a mixed kind of dementia which it may be an overlap of as I months last known as I'm was kind of dementias. What is noteworthy in this light is that you see these big adults at the bottom. So as I'm as disease it has been determined that it stops in many cases fifteen to twenty five yes before any any symptoms develop before any memory changes occur and the person may be totally Committee naman or they may have S. C. D. S. CT status false objective cognitive decline that the person feels that they have memory issues but they're not detected on clinical testing are they may have and see I would just might connective impairment. And the same with the nana's M. was dementia the. IBM's in the brain can stock many years before they can start in the twenties or thirties due to trauma or they can start because of strokes and they finally ran you reach a cumulative number of strokes or damage in the brain then the dementia develops. So to have a diagnosis of dementia this section correct eighty and features that need to be fulfilled and these a based on the diagnostic and statistical manual of mental disorders and these are the great data given over here that that has to be significant cognitive impairment in at least one of the following domains and these are learning and memory language executive function which is complex decision making complex attention being attentive to your environment and to lead to be cues but sexual and what the function which has to do with coordination and social cognition behavior and emotion. The impairment must be acquired economy present from birth and represent a significant decline from previous level of functioning these cognitive deficits must interfere with independence and everyday activities and the cognitive disturbances do not occur exclusively during the course of delirium. R. should not be accounted for by another mental disorders like major depression or schizophrenia when you fulfill these criteria then you can see that the person does have omitted uniformity of disorder or dementia. So I just put you go what the risk factors which are non modified bill because someone modify ability just mention some of the non modifiable respective age is the greatest respect over the age of fifty five that thirty three percent individuals may have some cognitive impairment agenda slightly more in females this may be a longer survival effect in women family history not that kind of dementias gone dominance leak and had acted as I'm as disease it doesn't only one percent of people but it is due to mutations in genes and these are given at the bottom over here different mutations and I'm like because of a gene I presenilin one presenilin to these genes because dominantly inherited dimension if you have one of these genes is a hundred percent chance that the person would have dementia. Apart from this dominantly inherited genes you have the other genes that conferred at risk they don't the only confined at risk and they're not inhabited and those genes that the employee for an A. B. C. A. seven there's a slightly higher risk off of people having these teens developing the as I'm as disease and these are higher in prevalence in African Americans than European competitions. That many other factors lifestyle factors which also factored into the development of the disease that just because people have this gene it does not mean that they will get the disease. Of course I know that a condition that can result in dementia earlier in life in the fifties and sixties is down syndrome. And which that allowed three chromosome trying to so. So now I want to just give us a little bit of an outline of what the difference between non aging my connective impairment and dementia. So knowledge and also we have you know people become tend to become a little bit forgetful that freed the developing dementia but actually innominate agent you don't have to have much cognitive decline you up may be perfectly fine in fact nominating the positive of normal aging is to have more expediency of that the fund of knowledge you can be more creative you can make better decisions based on your experience and your fund of knowledge one does in to decline with naman agent is the speed of processing so the speed of processing maybe a little bit less that reflects this I'm not operating as well but that does not need to be any significant ma'am the decline in normal aging. This but in dementia if someone has as I'm as disease which missed out fifteen to twenty five years earlier there is a PDF van it's going to be clinical and this phase of patients may complain it may be a stage with the patient knows but the doctor doesn't as it just said when the patient complains that they're having memory issues but the adopted does that tested in the clinic and is not able to detect and that disclosed subjective cognitive decline after that period. The changes in memory become more noticeable to family friends and the person who has some cognitive decline in one of the features that I've mentioned maybe they cannot make complex decisions maybe the visual spatial skills I'm not as good maybe the language skills are not as good but they can still live independently and they preserved activities they can drive they can pretty much do everything but after that. ET at which may lost three to five years are a little bit longer dementia develops which then progresses to my moderate to severe so the period time period of this this can be changed depending on the age can change because of the genetics and had an addict is the life does gender many factors influence the time period so the the approximate time periods and at the bottom that I've written and this BDS of being in the preclinical stage to MCI to dementia is because as I'm as disease continuum because it's almost like a continuous process which is not detectable and then MCI than dementia. I want to touch on the prognosis and typical progression of dementia is because you need to be able to to be able to diagnose a some of these things we take into account how's the dementia progressing with all dementias the stock office might connective impairment fifty percent of people with my cognitive impairment may not develop dementia they may demand with Michael native impairment and in some cases might connective impairment is even give us a bill an idol would later and that might connective impairment that does progress to dementia approximately one third have mild cognitive impairment due to as I'm as disease. So. This. Graph over here shows on the top of the red line which invented that the steps and decline shows how the vascular dementia people progress every time they have a stroke number of strokes there's a steep decline in the memory and function depending on how big the stroke is people with Lewy body dementia on the other hand the fluctuate a lot and but the ultimately declined people with aye aye dimension which is the yellow line you. Going down progressively and it says unfortunately under nine relentless course. It diagnosis of Michael native impairment or MCI do does Emma's disease is crucial is crucial in identifying individuals who might benefit from early treatment initiation of treatment early and the disease obviously is a soap might be associated with lower overall health care costs and benefits the patient and benefits the care giver and that will be reduced need for placement and not in a long term care facility so we have to be able to diagnose might connective impairment if we are going to be able to treat people a year. So what are the steps and diagnosis. And the patient comes to the plan and the first thing we have to get the patient's perspective and their history second we have to get the can give us perspective and the history from the K. give us point of view they may be totally different. We have to examine to the physical examination and then to the mental examination cognitive test we have to exclude confounding and potentially reversible factors and then many of us to be factors we do level entry tests be made to brain imaging we do sums. Nowadays we might suggest some should special test so what I did was to be causes of cognitive decline my cognitive impairment or dementia. Well for my cognitive impairment the many of us to be causes but I just want to mention the confounding factors in the diagnosis of dementia that embody common and that three common types of brain dysfunction here depression dementia delirium and that all three very big so. The brain has operates with a lot of chemicals inside the brain them more than hundred neural transmitters in the brain with that I mentioned in this a couple of these major neurotransmitters acetylcholine. Is a man near transmitted from memory when that city calling levels go down and to go down gradually people develop many disorders and dementia my Senate bill and always go down B. B. develop depression said Tony levels may also be implicated in development of dementia mental coming let me slow down people can develop Parkinson's but dopamine levels also falls. A little bit with normal aging and also falls sometimes and dementias and not happy nothing levels go down people can become slow and blunted they're not as fast they also can sometimes be implicated and development of dementia and depression glutamate levels also can be a good deal to me so that was may be higher and it that may be more X.. X. excited brewery effect of glutamate on the neurons and that can also create problems and dementia so and the other all the other neurotransmitters also important and then many but when done neurotransmitters suddenly go. Wacky are the Senate go out of balance. And the ratio changes suddenly then people develop delirium. Delirium is reversible. A person would delete it is important to recognize deleting because delete I'm can occur in a building on my bus and with you are you need tract infection in an order dated being in a strange environment I believe I'm gonna cut on top of dimension it can be confusing because then thank god the dementia suddenly become voters vestiges delirium and day and needs to be identified and needs to be treated. So deleting them as it is at a loss to be costs of memory loss or cognitive decline it can persist would be days weeks months. The committee common causes ability I mean we don't have to be confused about what are the causes of deleting be just have to remember the word confused. So for example constipation meant is very severe is causing obstruction can cause delirium operations and STC access and because delete and ban back so they can cause delirium Nicorette many nutritional deficiencies can cause delirium over hydration and dehydration can cause delirium inspections of any kind urinary NO one yeah can cause delirium very often sleep apnea causes delirium and impairs the memory environmental factors being and and the hospital having fluid and electrolyte imbalance thyroid disorders can cause delirium many drugs is especially medications that act on the central nervous system opiates medication for Stephens ID a quality what that'd be all can cause delirium the important thing also to remember is that repeated a longstanding delirium increases the risk for dementia so when people get admitted for deleting more than once or twice in the hospital. They become worse and and the dementia can get worse. So the screening tests that we do and the clinic may include a number a screening test I'll just mention a few one is going to committee mental status examination this is the oldest and has been and I'm use the most and clinical studies as well as clinically and tries the other is the Montreal cognitive assessment or moca which we use frequently in our clinic another test is called eighty eight as I'm as disease eight questions these are questions that we asked the informant of the care giver then there's not that to which is relatively new is gone that you would be at S. quick dimension rating scale. And that is a good to adopt person can do it themselves or the care giver inform and can answer the questions and this that doesn't have it is the way it is designed it calculates an I just finally proceeding education levels and even different languages so um it is it has an advantage over the other tools in which the person might have to be fluent in Latin language or have to have a budget appropriate educational status even though we are just for that in most of the tools however if you the screening test a negative the patient is still complaining of memory disorders this borderline dysfunction other features that kind of indicated that it is a little bit of as I was a little bit of vascular of little bit differently temporary then we should build more clinical studies and with the fund the patient for the recycling because studies which can determine the cause of dementia so different kind of dementias have different profiles on unisex logical studies of these neural psychologically test also provide many valuable opportunities for cognitive rehabilitation patient and caregiver counseling and. Some of the counseling can be in the form of cloud cognitive behavior therapy which is also very useful and people who have might cognitive impairment really benefit from this Committee behavior therapy and improve. So basically cognitive behavior therapy informs people about the personalities the strands and the veto missus and tells them how to improve it also give them some tools and ideas and instruments that they can games that they can play and activities and exercises that they can do to improve the memory. They also do live by treat as we look for any factors that we can correct which may influence memory and in Minneapolis eighty man and the print disease disease a papal hypothyroidism homocysteine elevation vitamin deficiencies high lipids high glucose infections original insufficiency C. S. of examination is not done as a routine but if it is indicated it can be done what is important also to note is that when a patient comes into the clinic and if they have an irregular pulse but that is decorated me I already read mia and they have a memory issue everyone should check the EKG because sometimes it has not been checked by the primary care physicians and this could be the cause that they're having memory problems because if they have a tribulation they could be having strokes because of a traffic violation. So then we have to decide upon the clinical impression that what is the clinical impression and the presumptive diagnosis off this memory problems or dementia is it subjective cognitive impairment and not dementia in which the person has the issues but the school but even on the test and we can to fund them to know secretary asking is it Michael native impairment what is it a major neurocognitive disorder dementia and if it this dimension what type of dementia is it what is the underlying cause or ideology for the MCI or dementia is it as I'm as disease. So we can do brain imaging and we can that is great value in doing an MRI NMR ACT of CT CT a and dementia diagnosis mostly we do MRI's so one thing that I want to explain is that does the navy and the brain the hippocampus which is very much like the hard drive of your computer it is very important for memory. Let me see if a compass shrinkage our intro fee on the MRI or a CT that may indicate as I'm as disease it can also happen and other kinds of dimensions but it is one that's more like it what as as I'm as disease with hippocampal atrophy then with without hippocampal atrophy for example at and studies it has been shown than one hippocampus size was found to be below normal and my patients with mild cognitive impairment that was a four four four increase in the percentage of individuals conflicting to dementia within five years so at that is important to note of the structural changes which may impact memory like bleeding and fox you must aneurysms Mike ranger but the and another condition called normal pressure hydrocephalus may also impact the memory so I'm I have a really very useful if a patient has metal in the body for an artificial knee or hip or anything like that the cannot do when am I read those some machines are compatible nowadays then we go for a CT. We also do pass scans to diagnosed further as I'm as disease and different kinds of dimensions and they have a useful especially and differently diagnosing frontotemporal dementia from as M. as dementia from vascular disease so that many kind of places that are using pet scans the amyloid pet scan which uses the amber light tracer is good and bagging the amyloid in the brain and it's very specific files Emma's disease insurance does not cover it it is between four to five thousand dollars and if me quit with the what to do with here at UAMS or and and it's a rock we have to get the tree so from Dallas on Memphis so that increases the expense so usually we send up patients to Memphis or Dallas and this day though when I didn't get up and like that scan done I understand and that is done is FDG eighteen fax scan which looks at the locals in the brain this is covered by insurance and this is a useful especially in different yeah diagnosing frontotemporal dementia read as hyper metabolism or the glucose is not metabolized bell in the front part of the brain the other scans because dolphins games but they only being used currently in research. So back imaging can provide more accurate information regarding the diagnosis of exam was offered to temporarily regarding purposes management and treatment of the imaging that techniques that may be useful I do ACT scan the eighty day ACT scan D. stands for dopamine and this is useful if you're if you suspect Parkinson's and efficient this sometimes happens because these bit patients come into the clinic and they have been misdiagnosed as having as a must for many years and getting treatment for it and it turns out that they actually have a type of Parkinson's disease so unlocked can be clarified with the use of scans. So that many possible causes as you can see for MCI or dementia which is related directly to intrinsic brain pathology the exam was disease vascular Lewy body front MP dementia limbic age related and cephalopod TV just cause to correlate a cause in people over the age of eighty five mostly Parkinson's disease mixed dementias and NPS. And we do have some clinical indicators to suspected in the clinic what the it what may be going on I think doctor will be covered some of these and how talks I want everyone to go over it but I'll be talking mostly about as in most. But when the person is in the clinic and you're seeing the person that I've never factors you have to consider which outside the brain which may also contribute to cognitive decline and dementia you have to identify the suspect as you have to investigate these factors and you have to treat these factors because regardless of the technology with this as I must dementia known as M. as dementia you have to treat the hypertension you have to create the if the blood pressure is very low you have to treat the heart failure because in heart failure you may not be getting enough for fusion to the brain and the brain might not be functioning that even you have to treat the it'd me as people who have bypass surgery usually have some cognitive decline which may occur within the next few yes and may get worse you have to treat the enemy now police say the man hyperlipidemia all these factors you also have to treat the depression which factors very much into dementia and up people who have suffered from major depression DO experience cognitive decline I sleep apnea which is very important because if you don't get enough oxygen when you're sleeping it will need to noon on a loss and may contribute to dementia many times we have done scans and be a phone brain aneurysms and people that you are an and the it wouldn't never have been find out if it's not done to scan a suspected brain aneurysms which was causing memory issues so hearing and visual impairment has to be fixed because it contributes to dementia so. All these factors have to be identified investigated and created and the medications have to be appropriately looked at and medicines that the contributing to cognitive decline have to be removed. And we have to discuss all these issues with the patient and the caregiver and yes it is time consuming but it is very worth it because you can improve so many things at the forty percent of dementia factors associated dementias can be improved if you take a very good history and look over the medications and create all the other factors. Not about what I want to specially to attest that they use for the diagnosis of as I'm as disease nowadays these are changes in biomarkers nobody'll Marcus maybe proteins which you can see on brain imaging on CSS and the blood and these may be evident fifteen to twenty five years before the patient and caregivers express any problems with the patient's memory these biomarkers a useful for identifying appropriate patients for of interventions and treatment and this is just a schematic which shows you all the potential biomarkers that have been discovered of course we know about amyloid. And that two kinds of amyloid proteins forty two and forty we know about how proteins because both amyloid and tau accumulate amyloid outside then you're on tile inside the newer on and cost near degeneration and then the committee of the proteins which associated with neutral on your on an injury which can be detected in the blood some of them and some of them can be detected on scanning so this is just a schematic that you'll do that them anybody might cause and the more that that that being discovered. So. Though in and as I'm as disease and I come back to them as disease the man protein is ammolite which funds blacks and dials tangles so does the. BDN when the patients don't have any symptoms this is a period in which potentially we can do primary prevention. Then there's a period in which the tile and the amyloid plaques accumulate. And the brain doesn't function as well it doesn't use glucose advise this neural degeneration this is a period during which we can build secondary prevention then. Mission starts having symptoms utility generation accelerates and this symptomatic and during this period. What we have been doing for the past few decades is being we have been using medications to treat people to bring up the acidity Colleen so that them memory cells can operate. So the question is not whether to intervene or not to intervene the question is when should we intervene and now it is with the latest that abuse the monoclonal antibodies we will be able to intervene earlier and earlier but to be able to intervene onion onion we need to be able to diagnose it early in a year we have to diagnose it in the M. C. I. stage we have to diagnose it and the early dementia stage because by that time you know there's a lot of neural degeneration and there's a lot of accumulation of tau and amyloid it might be too late. So the National Institute on aging and does I'm association formed a research framework for biological bio Marcus. In two thousand eleven and this. Biomarkers which I use for the diagnosis and to categorize people into different stages of dementia appointed the ATN framework ammolite down utility generation AT and so let's focus on amyloid it stands for ammolite and we can see ammolite unpacks again like this we can see amyloid and we can evaluated in the CSF up last month and we can get a ratio off and Malard the the forty two to forty would give that gives us an idea that there is as I'm as disease. So that's one. Eight. Not be go to T. D. stands for dial these are the top tangles in the brain and shall also we can see on that scan but it just want mostly use in research now is not available and but we can see tile in the CSF and we can see in the plasma force without. Adaa is also a protein that is elevated in as I'm as disease in addition to and the light and may be elevated up before for it could just also elevated in that kind of dementia's though. Not N. stands for. Nero degeneration and you can see this side of the brain is building on this site has S. shrinkage quite a bit of shrinkage and a trophy and we can see the shrinkage on cat scan on MRI and we can also do local stand as standing affects can and we can do FBG glucose and we can see that the nude on Senate using locals appropriately because this new neural degeneration the other also proteins that are in this and network and their call Nero filament elected election and deal fairly astrocyte proteins GFAP these can also be detected in the blood to look at new utility generation. This ATN framework is Can be quite useful it has been used in recess now for a couple of years but it is kind of like very similar to cancer staging when people tell you when you go to a non colleges that the kinds of stage one stage to stage the what stages my cancer well and as I'm as disease now we have that AT and classification and that each individual can be placed into one of the eight profiles based on the biomarkers by the East positive these positive and is positive. And that is going to as I'm as disease continue on it doesn't reflect on that denotes either as a must but the logic is change but a positivity of clinical as I'm as disease so you see these are the eight profiles and the last two you don't have a positive these are non as I must but the logical change and but these these ones which have a positivity to these four they have as I must amyloid and tau protein present and when you also have to present and you have neurological. structural changes present. You have more symptomatic as an was disease. So in the future when you go to the doctor and when all these biomarkers I move freely available they will tell you what's did you are you are and they won't say your stage one stage two was the three that within you and that you have a positive the positive and positive and then we'll give you your classification according to the A. T. and classifications. We have not talked about the usual treatment how we have been treating as I'm as disease previously and they have been treated we have been treating as I'm as disease for the past few decades but drugs that increase the acidity Colleen of drugs that inhibit the glutamate receptor and those drugs the ready common drugs that be known by the name of eighty seven done donepezil realistic mean Absalon are galantamine resident does a dying and these drugs all have certain side effects of the drugs that we use in one big dementias memantine which inhibits the glutamate receptor so since I'm going to talk about the new address that don't have a you know a whole lot of slides on that except to mention some common side effects of the drugs that the currently being used and have been used for decades and those side effects are not minimal either added gastrointestinal done a position all the cholinesterase inhibitors that three in that class every step exit lan and galantamine the only because they can cause gastritis that can cause diarrhea and ready that can cause a G. I believe that this happened to my patients cardiovascular side effects a quite significant they can cause severe hypotension bradycardia of any slow heart rate dizziness the Bill pass out the bus so to an extent that they fall and break the bones they can be serious so all these things have to be monitored they can cause nightmares they can cause increased liver enzymes and especially you have to be careful with the drugs that slow your heart rate like be to block us because they can precipitate severe bradycardia so we have to watch for the side effects of these drugs but let me not go and talk about the new what that if these. The drugs that we had been using in the past few decades have not been treating the root cause of as I'm as disease. But the root cause of as I'm as disease which is that queue Malaysian of amyloid. And in part tiled is not treatable and it is treatable with monoclonal antibodies in the fuss monoclonal antibody and event at Slater did approval by FDA and you won last year it is known by the brand name I do home and is the human immunoglobulin IDG monoclonal antibody directed against accumulated soluble and insoluble forms of amyloid beat and it reduces it backs onto the amyloid and then the amyloid is destroyed by the body's own immune system. these this monoclonal antibody is approved for my connective impairment and C. I. O. only as I'm as disease. And this MCSO early as I'm as disease has to be confirmed by either the presence of beta amyloid and CSF. Our the beat I'm logged on brains brain not pet scan and like pet scan unless you have confirmation with either of these two test the person does not qualify for treatment. We can do the CSF test at accu M. S. we do it within you today delegitimize that we have a contract with the company that pays for the test so that test is done free but the but that if you want to get a pet scan that will cost you would send out of pocket cost up to five thousand dollars so how is it given it is given as an injection as an infusion over an hour and that twelve injections given upbeat PDF one year and. The requirement is you get an MRI in the beginning get an MRI in the middle at six months and get an MRI twelve months and the reason why we're getting the MRI is this to make sure that there is no dental strokes that no hemorrhages because if you have strokes and hemorrhages you cannot get the drug because one of the side effects of the drug is that when it pulls them aside from the blood vessels it can cost a small small bleeding sports. You also conducted the drug if someone is on And a quick glance for example for atrial fibrillation are deep and thrombosis I would also say that in one should probably be not give the drug if someone has low platelet count because low platelet counts the time aside to being in the lead to more bleeding bleeding bleeding tendencies so um. The person has to be the individual has to be monitored very carefully they have. We have to monitor for the side effects for headaches because the side effects of the drugs are you know pretty frequent about forty forty one percent of people what they can this drug had side effects. This drug is not approved for moderate not from my duty severe dementia and it's certainly not approve for patients who don't have as as dementia because they don't have an allied and I mentioned how does give in the seat at the side effects may be allergic reactions headaches dizziness legend changes. But the CVS the more serious side effects article idea and ideas stencil and allied related imaging abnormalities that two kinds of aria area ease a temporary increase in fluid in the brain was E. stands for the month and ari Act you small spots of bleeding in the brain on the surface the S. stands for hemosiderin which a small deposits of I'd and related to the bleeding so these can happen and and the bill up to forty percent most of the time they resolve because this months box and most of the side effects occurred within the first three months that they have occurred in the fall and that tries that they did in the first two to four months doing treatment and more than ninety percent of them resolve and if you have to wait a little bit before you give the next injection your rate if the patient is not able to tolerate the injections for some reason then you stop giving the injections. So as I said earlier this was an excellent or good approve an excluded approval by FDA is given for CDS diseases for which there is no current treatment so it came up with a lot of controversy this is this FDA approval but this is still a breakthrough in therapy for autism was disease so drug companies there are required to conduct additional studies to determine whether that is in fact clinical benefit off the drugs approved through the accelerated approval by committee so this particular drug and to have them have to do another study which will be a face full really wanted clinically tried for conforming its benefit. If the follow up trial phase four trial fails to verify clinical benefit that I've given it may withdraw approval of this drug. There are many other monoclonal antibodies on the horizon in phase three trials going on the same company but I didn't as well as other companies like lady and they may be seeking FDA approval next year so and they claim that they made the of obviously can and that they might be a little bit better but the mechanism by which they work mostly it's going to be the same as I described earlier. The more than in addition to more than a hundred clinical trial as far as I'm was dimension other dementias some of the stress free to focus on creating things like gingivitis because the bugs and the organisms in you at the that also I found in the brain the bacteria and they cause inflammation and date because neural degeneration so that all companies that have been trying to develop one of clonal antibodies to treat gingivitis and creed those bacteria that can go to the brain and cause inflammation and you know degeneration so then many treatments that that a committee tries of the data being conducted. And lastly I want to and on some of that does that we are doing here and then run as Institute on aging on memory we have one observational study which will be in which we would use the apple watch and iPhone which will be hopefully we hope to distinguish normal aging from my cognitive impairment this is an observational study which we are doing with with an industry that would be supplying these watches and iPhones then we have another doctor I'll which is an and I extracted which is a pragmatic evaluation of events and benefits of lipid loading and or diagnose Scott preventable and which we would be using Statens it will be a randomized busy placebo controlled might that site study and we will look at but the the stacked ins not only improve all the cardiovascular endpoints but also prevent. The cognitive decline and dementia. And people who take statins so it will be a prospective trial we also studying cognitive dysfunction cognitive decline and be billed and Marshallese and the northwest of Arkansas and this is a study also from the National Institute of health. In addition we have another industry tried which is a fish three month that Senator randomized double blind placebo controlled study which will test the efficacy of the drug um for educated dementia so all of the struggles are going on and then we have a couple of others that are under development and that runs Institute on aging so if you know of people who are interested in participating in any of the strides please contact us. And thank you very much and I have listed the phone number of the welcome and we clinic of faxes not that and the Thomason line longevity clinics so for for your convenience but any questions. Thank you for that the doctor A. Clark I've got a couple questions for you myself then we'll kind kind of reach out to to the. To the members the end of I guess this to start with. The number you said that are increasing. Not only in Arkansas but throughout the United States if someone contacted y'all's office today. Anyone to make an appointment to get the test how far out would they be. I'm. We have hired a few more people who. Hi there is a freeze on hiring but. Usually it used to be six months but not all it is less than less than three months the that's good yes in a you you mentioned while ago the the treatment for for all timers the At a at a Liam ever had them yeah I do have that at what stage do you give that me give it and the mind cognitive impairment stage are early stage as I must I know that most is moderate then there's to much plaque but barred in and it will be difficult to remove it and that tries that they had done they had used it in one because I'm was but FDA has. Came back and revise the policy and the restricted due to early stage and my commitment payment. So that that's actually the one you're using early on now to try to get treatment going. Yes okay thank you the. Representative Mayberry you're with us now I know you have some questions written down as well first of all do that tells how your daughter's doing I also thank you I I have a care giver weather right now so I can come here and was just getting some updates but shall be in the hospital for a few days but thank you she's doing okay or I wouldn't be here if I thought that I need to be there I promise you the the the monoclonal antibody and I I cannot pronounce the other word eighty D. you say that again I'm mad at you no matter and you have yes that word. is it covered by insurance. No our Medicaid not so those of us that pricing on it was fifty six thousand Dennis come down to twenty six thousand for twelve months what I tell people is that the company has said that it will help people who are needy and we cannot afford it so it's really Fay and box for the drug how much it would be case by case basis and in addition not everyone might need twelve injections this is what the trial was done that they use the twelve injections every month for twelve months people might start benefiting earlier on are they may have side effects and you might have to stop the injection so. It's it's not yet covered by insurance and Medicare is depicting how much coverage if we provide and and and forgive me how much is the treatment every time as a two thousand dollars a little bit over two thousand dollars for one injection one injection but it is much cheaper you have to realize that cancer treatment and this disease is just like and so yes absolutely and then all the care that you need on top of that right right okay. Has a question what would your question. I just wanted to mention that it is anticipated that Medicare will pay in part for this medication the ad you home and the reason we know this is because when CMS came out with your budget this last winter and what they said was there raising the premiums of Medicare for the all the beneficiaries because they anticipated a twenty percent increase in the cost because they anticipated having to pay for part of this medicine so it's right now they haven't yet decided who didn't know. Agreed to cover what they're gonna be agreed to cover for some of the patients okay so. Thank you another question I have for you doctors are is a mention the amyloid pet scans were done in Dallas and Memphis I think closes to Memphis and Dennis yes that why are we not doing on. With them here we can definitely do them yeah we just have to get the tracer from Dallas we don't have the factory here you see in Arkansas make made the tree so they have the factories so we have to get them to get the president delivered then there's a window of beauty and off within seventy two hours you have to do this again so it is difficult you know to a range on that. Thank you think of Raymond has a question for you as well so we talked preventive medicine right to notice of some of the bigger trigger is probably in effect the south more than any other region yes you're okay we're probably going to have the big issue due to our diets so do we have any preventative measures any like natural supplements dietary changes exercise to be mental physical that can be done to reduce the need of pharmaceutical medicine because she's a pharmaceutical medicine and what side effects it cause more harm than good it really does a lot more damage the the hills so then what can we do preventive medicine duly slow down that process for us yes you're absolutely right exercise has been shown to be very very beneficial not only for the heart but also for the brand rate so I will begin to say then you know know what keep your cholesterol normally all the things that are good for the heart actually a good for the brain doctor may even talk about it but that different tires the little Saudi died the Mediterranean diet of mine died which is a combination of the law sought and the Mediterranean diet a lot of studies have been done during tests on benefit so those things definitely other than that but when the neurons actually they've been they've any delay that all these things we do tell people to do that connective exercises are useful if people when people retire and then are no longer engaged and and using the brain as they used to use the brain you see a decline so I advise people to work for as long as they can work and remain engaged socially for as long as they can demand engaged because all that is good isolation is not good to read and write actually I tell people to write a paragraph every day because writing is more beneficial than just reading and it has been shown in some studies that writing you know because you have to focus you have to think you have to remember the spelling you have to do is sentence construction and all of that may be more beneficial if you can write a billion date is. Better than one half a page of the but writing is a very good exercise simple things like that all go a long way in helping the cognition you reduce the inflammation reduce foods that increase inflammation you're right but when then unity generation stocks and the acid choline levels start dropping in the brain you need to bring that chemical back up so these drugs that we use in spite of the side effects if used carefully are useful but the benefit after sometime Blackpool's off because of an a number of. In a massive neutron dies no matter how much of the drug you give it's not going to have. Thank you donors are thank you for that and what I'd like to do that like you're going to write your questions down and let Dr Waco because she may actually answer your question I should have done that the beginnings to me asking the question and so hopefully she can actually they will have the two of them that the and then you can pick and choose who you want to ask your questions to. Thank you to. Right. It's stuck to his presentation you can you put to any to speak to it. Did you pretty loaded already. Yes this should already be on. If the. Well my part was on the board I don't see it does so with ease. I don't need the power point well I would like to have it like to do it without it the fund. The bill Mr you do okay because. It will let me see if we can at least find it somewhere. While Brandon yes looking for helping me I'd like to just thank you doctor sorry this is the most comprehensive thorough up to date latest greatest presentation we have heard Dr way please get a Mike secondary on their. I'm sorry I wanted to just let everybody know this is the most comprehensive thorough latest presentation of all the development announce summers that any of us I have heard I want to congratulate Dr aides are for this thank you thank you so much. Okay I do see on here either call idea okay okay so I I would like to introduce myself very briefly I would like just to tell you that course my name is Jean late in United States I went to grammar school high school and college in Chicago I went to medical school Richmond Two zero two two. Because it. I went to medical school at university of Illinois we were ready to get in the microphone and for all the members were backing up to exhibit C. okay I usually can speak very loud I'm sorry if you can hear me I'll do better next time okay so what I want to just tell you is I went to medical school at the university of Illinois and I graduated with both my M. and my PhD in four years it was one of the historic first State University on the way after that I was recruited to go to Johns Hopkins hospital well I trained in internal medicine and cardiology and I also did research and I H. and I am board certified in internal medicine cardiology and geriatrics after my training at Hopkins I was recruited to Harvard Medical School where I became later the Director of the Division on aging at Harvard and that's to similar position as what I have now which is to institute on aging at you land that and I'm just so glad that I finally saw the light and came to Arkansas because this is the coolest place and the people are much warmer and much friendlier stole it is true it's a well kept secret and I'm just so glad that I'm here and I'm staying here okay. So let's talk about the medical contributors. The impairment and dementia and I'm so glad I got a chance to follow up and Dr aides arts presentation because I'm going to give you more of that. If you well some nation of some of the things that she talked about. So many people up until recently used to think that the brain was separate from the rest of the body in terms of its disorders and it's not unreasonable to think that when you think that the brain sits inside a well guarded firm if you will container and usually it should be protecting the brain in addition to that there's the blood brain barrier that should be protecting the brain so the brain should be going on its own independent of what's happening to the rest of the body well we've now come to understand that's not the case at all and as a matter of fact. Whatever happens to the rest of the body will affect the brain and sometimes extensively and over a long term so we're understanding a whole lot more than we used to okay so what I'd like to do then is to go to the next slide I want to just start by saying and people ask me all the time what is normal aging versus what is not what should we be aware of and how do I differentiate because you know I can't remember as many thousand things is I used to so here. Under the green tide of normal cognitive aging you see that we become more easily distracted when we get a little bit older we all know this because you know we walk from one room to the next so we're supposed to get something and we think she would I come in here for that is absolutely normal eight we also have a little bit more difficulty multi tasking. And this is what I'm saying now all the women in this room know very well what I'm talking about because everyone of us have done eighteen things simultaneously all the time I didn't even think about it and then all of a sudden things start to change and we're not able to do as many multi tasking tasks like we've done from dawn to dusk without even thinking okay women are better at multi tasking by the way maybe because of practice. That we need more time to process information so in other words if somebody tells me something it takes me a little bit longer than it used to to try to get it all sorted through and send the size and stored away in my brain I used to be able to do that in a split second but I can't do that now so I have to be aware that. In addition we get diminished working memory which means that what we used to be able to remember A. B. C. D. E. F. G. H. I J. K. the whole everything we can't now we have to parse select we have to take it a little bit at a time so for example for a study looking at how many numbers we can remember okay these are tests that we previously conducted in healthy young versus healthy mature. Adult so what we have found is that younger people can remember many more digits for example than older person so these are the things we need to be aware of but they're all normal that there's diminished visual spatial abilities and this is where you know. When somebody gives is a puzzle. In three dimension it's a little bit more difficult now to figure it out we can do it but it'll take longer however here's the good news and I'm so happy to share this with you because you're probably standing there saying this is a Downer everything is getting worse well guess what I have good news things do get better with age and what am I talking about I'm talking about verbal abilities your I have better vocabulary than when we were younger you want to have better able to be able to express ourselves and with younger and guess what else we have more creativity than we ever again so these are all very positive so there are very good things that happen when we get a little bit more mature okay now I want to talk about the early signs of dementia remember everything we just went over is normal what about dementia okay. Early signs of dementia include the possibility of repeating yourself in other words you know when somebody says listen you just told me that story five minutes ago and use or did I I don't remember what that's it's okay if you do that once but if you do that like over and over. We better look at it again okay so much repetition if you do it for your mom or dad or his loved one does it. You have to think. Okay. They also start have difficulty with daily tasks and I'm talking brushing your teeth you know washing your face doing daily things sometimes they forget so sometimes they make poor coffee into their serial and he didn't mean to do that but they you know they get a little bit mixed that. And they have trouble communicating and this would involve sentence construction they would have trouble with word finding and they would have trouble expressing a sentence that makes sense okay another sign of dementia would be getting lost in this is getting lost in your own property at home maybe getting lost at home inside the house and for sure getting lost when you trying to drive to go somewhere some of my patients get lost driving to the hairdresser or the grocery store they've gone for six three decades or more all of a sudden they forgot how to get there Kate and then our personality changes and and this is really of interest because people do change sometimes date on change and turning to very pleasant very cooperative very congenial very nice but sometimes they also can turn into grumpier more arrests of all individuals so we have to be aware that now there is a frequent confusion of time and place so you know they may not know where they are they may not know the time or the date or year or the month sell these things now are signs of dementia. And then of course they could manifest troubling behavior and this is when we start to worry because they may not want to continue to pay attention to personal hygiene or proper attire things that you notice are not what you would have expected knowing them for decades. Adduct is R. one over this I'm just going to say this very quick there are six main types of dementia okay and L. timers we spent a whole lot of time talking vascular is getting more coming every day and I'll talk a little bit more about that it has to do with injury to the small blood vessels deep inside the brain so if you get an MRI or CT that says white matter hi FOR intensity or deep matter hyper intensity that means just a small blood vessels these are the small blood vessels that supply the bundles of neurons that communicate different regions of the brain with each other if you just rock this communication then. You're gonna have deficits the deficits are not necessarily in memory but the deficits are in other aspects of thinking eventually they'll it will also be deficits in memory thank you we talked briefly about Lewy body and leave body dementia is something where it's characterized by these protein deposits that are called alpha synuclein which is also found in the back and. It's characterized by people having hallucinations often they have they think they're seeing little people or animals or whatever it depends on what it is they prefer to see to. Most the time it's not scary and many people know that they're having hallucinations they just you know it's part of every day. There's frontal temporal and this is occurring more in the younger age people usually in the forties to the low sixties and this is characterized by if you will. What we call frontal temporal dischi inhibition and these are the people who gonna say off the wall things to you that they should the sad and after which is a key I'm sorry but they don't say I'm sorry is that I don't know what made me say that you know like if somebody walks in with the new address or has a new hair do when you say that looks dreadful thank you know none of this would say that to someone and if someone we do. We might have some frontal temporal this inhibition I need you know to people we like anyway. Then there's Parkinson and I want to mention this because eight up to eighty percent of people with Parkinson's disease eventually will develop dementia. And then there's of recently diagnosed what we call L. A. T. E. which stands for Olympic predominant age related TDP forty three and stuff like that. You are so sweet statement thank you and it's just a emerging take the dimension data course mostly of people over the age of eighty and we're still in the process of understanding it and getting better biomarkers for it. So what we can say is of the six major types of dementia actually even though the sale time which is the most common mixed dementia is probably even more common because you have Alzheimer's you can have that skill you can absolutely body in front of temple Parkinson so the truth of the matter yes dementia is a diagnosis that you ascribe to the end result but the etiology could be any of the six and Nicks dementia really probably is the most common. This is just a a drawing of the brain with neurons and accent and I'm just calling your attention to the orange If you will gathering of fibrils and these are the amyloid beta protein fibrils are all clumped together and outside the neurons okay. Your plaques are outside nor have they squish the axon and then the Noront dad's. The total protein which you heard a little bit about occur inside the no run to you got outside and inside and. The top four teams accumulate within the Noront and the destruction affect from the body of the no run to the to the games right and to the axon and so pretty soon you can't communicate because a train tracks have been disrupted if no more than a car's gone back and forth up and down the accent and the dendrites well that didn't have cancer by the okay and I want to just mention that in amyloid disease these orange of fibrils clump around an orange but I wanted to point to your call to your attention the fact that women are at greater risk than men and they also tend to progressively worse and faster than men. In their symptoms are usually in thinking learning and in memory we can talk about that later as to why that is this is a schematic that shows a number of causes I'm not going to go over all I'm trying to tell you is that the many many factors that contribute to our ability cannot remember and to a not be able to function like we used to so I'm gonna go now to the next slide if I may I want to talk about call the very briefly and the reason is because it is now becoming of Preciado it especially in twenty twenty to two papers just came out last month to talk about the fact that cozy survivors especially older call that survivors. First of all they have long called the you know what I'm talking about is symptoms persist for a long time second of all they have brain fog and the brain fog persists even longer third of law they lose their memory and they can't function like they used to there are many many of our colleagues loved ones and neighbors a family who have had this covid and who are not themselves and. They may or may not regain some of that back but they may not regain all of the back so we have people who come in to work for example. But they're not quite themselves. And this has to do with what call the. I should say it's not really covid that did it it's our. auto immune response that did it and I'll talk a little bit more about that. This is just a on a cartoon that tells you all the different ways that COVID nineteen can affect. All of us but it affects the brain the most because. It actually is the most sensitive in this situation because you guessed it affects the heart you know that many many patients half pericarditis cardiomyopathy acute myocardial infarction or heart attack or stroke thank all of those things are going to have to Kweli on the brain okay. So then you say well wait what about what about the fact we know that there are certain subpopulations study even more affected so wanna show this light which is a study that we conducted thank you M. S.. And it's called health care disparities in the assessment of dementia in the outpatient setting and we just did this last year and I'm pleased to report to you that we were we received a first place award for this quality improvement and competition in the mid south region and what we found in a jiffy is that most of our clinicians. I I'm not. Doing sorrow diagnostic evaluation of some of our minority elderly ambience so Frank about this because you know we have to and so what did we DO to try to improve it we used to good old P. D. S. Hey you know what that is it's plan. DO study. And yes so the bottom line is you know you think about it thank you started thank you see doesn't work or not and then you try to improve it and this is exactly what we did so we first we did a questionnaire asked are clinicians how they thought they would diagnosing dementia where they thorough what are they good L. course everybody said oh yeah I know how to do this anyway then we followed and we've you've reviewed their chart question nine in this league and we found that many of them did not thoroughly look at our different. S. make subpopulations and in particular a number of our ethnic minorities did not get fully valuation so we went back and we just want everybody and say Hey maybe we can you review with you how to do this how did you decide to do this and they took it very positively after we did all this I'm so pleased to report that there was substantial improvement in everybody's assessment diagnosis and treatment of our elderly with memory loss and this is really important because if you can't even do it right we need somebody come Cecile how you're going to treat him and yet our patience and you know we're I mean we're trying to do the best we can and yet many of our other clinicians were not doing as well as they thought they were but now they are you know because we brought it to their attention so just so proud and I'll follow up and give you more follow ups later but this is a major juncture for us for you and that's for everybody by the way nobody else had done this study until we did which is why we were able to and I'm grateful at least we see first place award okay now let me just talk about a couple more things. I want to talk about the fact that many of our friends colleagues loved ones and family members tell us about being dizzy or lightheaded tell us about feeling tired and fatigue and some of them also have memory loss not a small number so what I want to tell you here is this is now getting to the meat okay thank you regular heart rhythms which doctor our goal are has mention are associated significantly with memory loss of paper just came out yesterday. This is a new concept in its call an atrial myopathy so all of you have heard about cardiac you know cardiomyopathy it mainly refers to the ventricles if you think of your heart as a four engine four chamber engine you know you got to smaller chambers Jean that to bigger chambers or you think of it as an apartment building with two smaller rooms on top and to bigger rooms on the bottom. We're talking about one of the smaller rooms on top it now turns out that have that little atrium functions or wanted that to your chambers. Is a determinant for whether you can have cognitive impairment and dementia and this just came out yesterday who knew okay now I want to tell you about medications and we can go on a nine yeah he added but the bottom line is hard medicines antidepressant medicines even anti cholinesterase inhibitors I have sent to either mention themselves cause memory loss so we have to think about that here's something we didn't quite know before which is that low blood pressure can cause memory loss big time you know why because it's about twelve inches say between your heart and your brain that you have to pump the blood to get up there if you can't popping up there because you what pushes too low there's no action you know nutrients getting up there and this is why people think you know what people think they think because there's not enough blood flow and the body knows enough to make you fall flat so you can get blood flow to the brain so it's actually a life saving measure but don't hit your head. Well you know what I'm trying to say okay that's blockages these are when the blood vessel for fusing the brain get black ages it could be helpful for fusion of the stroke but this can cause memory loss the other thing is we just published a paper reporting that if your blood pressure goes down. We used to have higher blood pressure that's not necessarily a good sign especially if you're over the age of seventy five or over seventy because what that means is that five years from then you may end up being diagnosed with. Cognitive impairment and dementia and we reported this and I'm afraid others have also corroborated that this is the case so I'll summarize it in a minute. So this is a summary of the heart and vascular and brain connections and of course there's been many important clinicians who've talked about this and this is an area of interest for me because I mention I'm also cardiologists as well as a geriatrician and these are some of our papers that we have found and the whole bottom line is if you're nice to your heart your heart will be nice to your weight. And they have to be nice to one another because what what makes the heart happy makes the brain happy and vice versa but at the heart being happy the plane happen for sure and if the plane a happy heart will be happy to okay so here I'm going to summarize it this is the Hall everything in a nutshell okay. And this is so true there are multiple plug publications not out to support this between one half to two thirds of members of the Alzheimer's related dementias are actually preventable. I am so serious and this comes back to Brandon Smith question what can we do about it well here's the whole bottom line take care of your heart and take care of your blood vessels I am so serious okay that means there's a lot of food you're going to have to reduce and minimize. Exercise and strength training are still good for you got to do both they'll just Arabic isn't enough thank you some resistance. And then we do we did talk about diet doctor Acer talked about that yet you like here's what I want to recommend thank green okay I tell all my patients it's okay if you like me but I want you to have more of the green meat and they look at me would include me and I say well you know what I'm talking about I'm Tucker broccoli I'm talking leads I'm gonna spare guess and I'm so serious because there is a good choice there's gold in them Thar green. Thank you okay okay. Now here's one more last thing I want to talk about which is the importance of sleep. None of us knew that sleep was more important than anything it's more important than food I. Believe me and if you can get a good night's sleep you're going to be better the next day no matter what no matter where on that full and you know why now here's the answer. Until two and a half years ago we didn't really know for sure that there was the lymphatic system inside the brain in a human finally two and a half years ago and I H. was able to document that there is such a thing and that's a picture of the lymphatics in the brain. we were the first to share this in Arkansas anyway here it is. We have washing machines in our brain okay it's like a dishwasher or washing machine it doesn't get turned on until we are asleep well what I sleep the valves open and we can flush through all the waste products from my brain because we've been working so hard every time you work hard you brain has to use up nutrients and oxygen and it has it makes the waste products if you will if you don't wash it out if you don't like a dishwasher or washing machine turn nine it's going to build that and then you do not feel terrible the next day all of us have had a good night well we did sleep as much as we need it to and we wake up I would feel terrible whether it's a hang over whether it's partly due to the hang over apart because we can sleep well I can tell you it's both but the most important thing is you got to get to sleep it's sleep is more important than food. Okay so. I am happy to answer any questions or entertain any jokes. I want to thank you for your attention. Thank you Dr wise I know we have several here have questions doctors or if you'd like to go to inner join and will expect this to be all answer any questions from nothing directed to you want to and let's let the two of them give the professional professional answer. The Mavericks will start with you. Mr cook. This is a thank you Dr where doctors are free presentations a really appreciate that especially the issue placed on the mind diet and course the importance of diet and exercise doctors are had a question for you in your presentation you mentioned some of the cognitive screenings that you use your clinic eighty eight QT R. five is there is there one that you prefer or over the other or is there is it is zero sum games are role for all of them or is there one that's better than the other that performs better it gives you more of an accurate reading. The new stuff all got all of the bill okay Sir please give by Mike. Do you smoke up because of most of the people and the planet could do it US cert notice you have to dig a certification course and we practiced in it and M. M. M. so and I Missy is a copy right it's kind of expensive but mocha is very good when people are not able to do the walk up because this school ready badly then be used in all of their other screening measures we also send them for neural psych testing senior secretary sting takes three of us but we tried to standardize and since then many versions of the mocha the next time they come in we use another version of the mock up but that's and I'm not the one that the use of which has not been copyrighted and we just built into a computer system slumps. Is there what it is my okay will be delivered in more of like a but as a committee cognitive test yes actually there is a five minute mocha version also it can also be done over the telephone so that at that school is out of thirty the same school but it is a five minute mocha version which we can deliver over the phone and we have done some studies in which we use the phone woke up. How difficult or that is there a certification process for someone to actually be able to do the committee cog or is it is it something that you know what a clinician in a rural town could do that many entry committee does not fit but I mean you just require a little practice motor quest the certification and they want you to do it in a standardized way is up thirty five I believe it's a thirty five dollar fee to be certified when you do the model on the computer and the when you pass it then just such a fight to perform the mocha in a standard way. Thank you Mr. Can you very great presentation thank you both I had a quick question on doctor waste presentation you talked about diet and exercise I wonder what role does the microbiome play and hoping to prevent. Thank you listing that is an excellent question so they can fly again we now understand that we are nothing but containers of billions and billions of living organisms and what they want is what we think we want but they make us want to have chocolate or they make us want to have a soda they make us want to have a beer it's really them so the next time you need to blame somebody you say it's not me it's my microbiome okay but seriously the microbiome really does interact and it has a huge effect on the plane as I mentioned for example lead by a dementia has partly the interaction between alpha synuclein in your. And they go to your brain more than that that the microbiota ordered the living organisms themselves can travel up order my provider. Order okay wait thank you. More. But the travel up and they've been getting your brain and I'm not only talking about the guy but even well you know your mouth is connected to the rest you've got anyway so what we You know ingest food and everything it is the perfect place for all these guys to be sitting there waiting to be fed and they have certain favorites to win I have to tell you sweet stuff is their best favorite and they just love it and then the one they digested the leave behind lease finance and then we end up having gum problems right and if we don't get our gums clean and we don't get rid of them we're going to end up with gingivitis you know what I'm talking about your gums to get ready me get sore in the lead when you brush your teeth well the blood in there are there's a special. Group of organisms that are resistant to most antibiotics they're resistant to almost everything and the other ones that have not been found in the brain of many people with dementia and I'm talking about he ginger by ginger Vallas it's a special organism that love to thrive under Neath the gums to make the whole long story short there are clinical trials right now to try to address those microbiota. But you hold that so here here's the take home please take probiotics I thank you please take probiotics I know it's a stupid thing and people say well how do you know if anything because I go to the drug store may see if a a bottle it says fifteen billion with a B. and why do I need so many why am I taking this and how do I know if they're still alive so the answer is. These are sports of the friendly bacteria you know all of us have friendly bacteria and then we have some opportunist we have opportunists we get sick but when we were first born we started to have them and we metabolize milk okay whether it was mom's milk or soy milk or cow's milk we started to be able to metabolize those lactobacilli are your friends the R. B. nine don't make you sick and you need them but when we get older they're not longer residents and I got unless we drink a lot of milk every day which by the way you should but in any case if you take probiotics it'll help you because you'll have more friendly bacteria why do you need fifteen billion with a B. well because you take it in a capsule my time to go through your digestive system less than six percent are still alive by the time it gets to your distilled got you know in the colon that's where they need to be ready to set up house and hopefully take over some of the Crips in there so that the opportunist on takeover that's why you have to do it now how often do you have to take it well you should take it pretty often how long do these guys living there if they're in there only up to two weeks okay they get turned over so that's why you should take it take it at least once a week that's what I would recommend okay. And we have done studies with Act microbiome and hi ordered a heart failure patients and we are writing the paper right now. To make it to make a long story short it made these people healthier and stronger and we even had some of the patients say you know I've never been this good and my husband cannot keep up with me you guys listen. Okay. I don't know if you if you follow that are not David. Go ahead your coincidence of. One of the things you you mentioned doctor where you're a presentation was the presence of of mixed dimensions yes being very prevalent in this one if you qualify that a little bit more or or E. suggesting like it's possible someone have vascular in front answer below and several different types of dementia at the St time okay so what I'm really saying is that the criteria for each of these types of dementia was formulated before we had better diagnostic tools so some of our diagnostic tools have now superseded the sensitivity that we haven't re referred to find it so for example you know we used to give everybody outsiders to mention and I think I told you this once before the reason the else irises so prevalent in the United States has to do with politics and someone else is new right so in order for us to be able to fund research to try to advance research for dementia the National Institute on aging received funding. What else is disease but the National Institute for neurological diseases wanted to keep some part of the pie and so they sent one notice it we want this part and the heart lung and blood shed yet but we all. Nestles so you've got National Institute on aging and still no real logical disease heart lung and blood in there and they still are by the way they're still fighting but the point of it is in order for National Institute on aging to continue to go forward they made a big push for outsiders so now what we have we have Alzheimer's without amyloid L. timers without doubt we have. You know what I'm trying to tell you because outside which is the big one it has to be the one because that's where the funding is. Okay so one day while the numbers find some of our criteria one day we're going to say well you know it's a little bit more complicated which is what that is are said this is why you know we can't just say Mister Jones you have such and such and Mrs Smith you have to I can say because it usually next. J. he'll appreciate talking about the funding part. The. Okay. I'm follow up will not a follow up question doctor where you talked about your health care disparity study yes and I just have a question what were some of them the tweaks or suggestions that you made to the clinical staff to come up help them to do a little bit more with there. minority patients yes thank you so much NO a nobody wants to do something intentionally that might be less favorable to somebody so if you call up if we call attention to somebody and say you know there's a possibility that you might not have email unintentionally of course you know overlook something you patients you know would you like would you like us to share with you some ways that you could do better a question for you can say yes so we go over again how they do what we go over again what it is they should look for and they say oh yeah I know this well now they know okay but the point of that is is that we do it in a very supportive encouraging way so that they feel like they own it they feel like yeah I know that's important. And so then they do it sometimes it's very important ACT eight stars. Implicit bias training we have it at the university and we send videos and audios and there's also face to face on the zoom implicit bias training and edition how to approach patients with cultural sensitivity of patients so maybe not inhibited of our You know they they're reluctant to admit the diagnoses of dementia cultural issues. fear get it give us stress doctrine them and the appropriate approach. Two words a patient. To try to reduce. The implicit bias whatever their device maybe. so we did some talks about that how to approach difficult patients with different disabilities hearing vision all of that how to reduce the fear of the diagnosis how to do handholding and say that we will be with you through of this journey because you just kind of give a diagnosis for the patient and let them cool you have to tell them that you would be with them and you will help them so that I approach to which the patient to support and also try to serve me track to support. Right to provide resources and support to the provider so they can make more time. And also looked at all the obstacles that they will you know that they didn't have the time to act too many students that don't to many responsibilities provide education support and handouts so we needed to make a pronged approach in which we trained the providers we also elicited feedback from the patients and they can give us some awful offered was negative feedback that we were not given good explanations we didn't have enough time you didn't feel comfortable and we give that feedback back to the provide does that you know this is how the patients and caregivers fee and all so you have to improve. And I think all those things made a difference but we still have a lot to do. Yes I think it's the beginning it's a good beginning but there is quite a bit still but the bottom line really I think to take calls from all this is if we can talk heart to heart. I think that makes a big difference email he just we just go right without heart today harden. And they know that we care bottom they know that we're here to help them I think that's a big a big deal. Thank you Mr Mr Jordan yes I have a question about the employed pet scan hello how much does that contribute to the diagnosis given that people have to pay out of their pocket for that I'm I'm curious as to. Like let's say someone has a neural psych exam and it's pretty clear that there have a pattern for out for Alice timers would you. Suggesting that scan or not so in that early on in the disease as I had mentioned you know it can look very vascular dementia and as as dementia early on in the disease can look very similar very similar when it is my understanding when you have been seeing the patient **** up a couple of years and you've been seeing you can you can pretty much stay by this sounds like aye aye then on Westcliff he just this no hypertension this no entry for Blake Shinn that I'm not I shows no strokes the land and you have hippocampal atrophy thank you can see pretty much it is says I must without your wrist even without the respective sting ray but when the patient has strokes and the patient has a it's only on and they just have memories some deficits you saying that that non amyloid plaques and that you can say that you know that amyloid racial be if it beat the forty two has not gone down in the CSF you can see that so you're basically making an educated guess at that time and if you want to CPAC treatment you have to be really see yes you have to prove that this is as I must go and backstage and the early stage it is very important to documented in any way possible and the only two ways of documenting it the spinal tap with a lot of people don't like a needle in this fine but it's really very simple. That is that number one is very yes it will be covered this financed that but the cost of up we send the sample the tool mail or outside so that may be a little cost associated with it but right now the ones that I've done I threw the company by region because the make the drug service it is about you know free of cost it is free of cost. But it even if there was a cost it is you know very small and compact to the packs can cost is very high but the build up I'm willing to get it done yeah thanks thank you for that Now decide on doctor way and Dr aides or be around afterwards to answer any questions we've got one more thing to cover on our agenda today the so thank you very much that great presentation from both of you in we appreciate you hanging around answer any other questions that someone may have someone in the audience may have. The end of Nashville to or. Yeah I'd. I would expect this to be a compliment to two very fine presentations as you can see our exhibit E. one two three I was very expensive so we won't go through the entire reports today what I thought I would do is just year a few of the insights that were that we we kind of saw of course the Alzheimer's association puts out this report every year round in the spring time we also have provided a state specific factsheet it's kind of a compliment to the report I wanted to just I guess before I start just do a follow up to a question that representative Mayberry asked earlier about CMS's coverage Medicare's determination about I. G. Home the compliment what what doctor ways said we we we know that in January CMS issued a emergency decision on the coverage of at the drug um in its preliminary decision we we thought that the association as I say we held the opinion that we thought that the preliminary decisions is extremely prejudicial and limits access to the drug because under the current ruling in order to have access to as the home you have to be enrolled in a clinical trial and since we know that as of now Arkansas does not have any planned clinical trials that basically limits anyone from Arkansas having access to the drug um so we we have taken a congressional routes just to encourage Congress to encourage CMS to rethink that decision we do expect a final decision to be released in the next couple weeks we were told April eleventh was kind of a target dates or we anticipate one coming out soon of course that'll lead to other you know decisions having state impacts on Medicaid and who can access access to drugs so that's something that as that comes out will certainly keep you Stated on. just just really thought I would go over the highlights as it pertains to our work specifically I do want to practice my presentation by saying that the also associations vice president health policy is going to do a weapon are around our facts and figures report a week from tomorrow at twelve noon to be a virtual presentation he's going to go over more of a deep dive in our facts and figures report me available talked and ask of or be answer any questions you might have just in terms of the number that Dr Gohara referenced we do anticipate by twenty twenty five here in Arkansas over sixty seven thousand R. Kansans over the age of sixty five will be living with some form of Alzheimers we do we we kind of stayed with those numbers over the last couple years that's our our projection hasn't really changed our methodology around capture care givers change two years ago we do stand by the number that they're ninety three thousand care givers here in the state of Arkansas providing a were two point one Million hours of unpaid care and we we asked to a season high thirty nine million hours of unpaid care and we estimate the value of that care to be at a cost savings of two point one billion to the state. I wanted to just talk a little bit about some of the work force we did do a special component around workforce every year in addition to the numbers we also do a special report I will say here in Arkansas we have fifty five Jerry tissue geriatricians currently working in the state we do anticipate to meet the needs twenty fifty that number needs increased by a hundred forty three percent I will tell you that we are outperforming some of our neighboring states Tennessee by comparison only has thirty seven current geriatricians Mississippi has twenty three Kansas has twenty in Oklahoma has twenty six so we are out performing are Our neighboring states but the need is going to continue to go up. because the cost of treating diseases again one of the most expensive to treat we do anticipate that number to continue to climb We have it of lost my other cheek she notes. I found it has she she noted pulled out the the economic impact of course in twenty twenty two on a national scale is a three hundred twenty one billion dollars to treat Alzheimer's sixty four percent of those costs are diverted to Medicare and Medicaid and so as you can see one of the other numbers are sheet we we think that it's important to invest in home health also investing in respite services to support the growing number of care givers we've talked about here in the state from the hospital side down the hall on the side over the last few months the impact that COVID has had on our healthcare workforce certainly the adverse impact is also impacted our population so investments in in respite and and providing support for care givers it is extremely important for the state to continue to look at we we know that some of the cost of treating the disease going to continue to climb so one way or the other we are going to spend the money we just need to look at where we can invest in support services that allow folks to remain at home and age in place and that the places that they want to HM. again some some strategies other states have taken to address some of the work force shortages we're beginning to see is increased investment and tuition reimbursement for healthcare workers I also establishing career pathways so the someone who comes in as a CNA has the opportunity to advance in their career in the healthcare profession to become a nursing student and position or A nurse practitioner which become extremely more popular here in our state as well so they that's been home health services is going to be important currently we have twenty three thousand home health personal care aides we do need an increase of thirty three percent to close at thirty percent to be demand by twenty twenty eight so there was a lot about the healthcare workforce shortage in our extensive report specials this section allocated to the need for more geriatricians and more focus on again the geriatric feature it geriatric field there was also an emphasis around a mild cognitive impairment which doctors are to a wonderfully portrayed and I think in her presentation she highlighted the need for early detection and diagnosis and this is where I I think we're starting to see the health department address this need with Arkansas receiving a bold grant one of the areas of emphasis that the health department has identified is doing more public education around the importance of or the Texan and diagnosis even though we have this treatment out there on on agit biology how huge of the advancement in the research field doctors are noted in her presentation that in order to receive that drug it has to be in the early stages of the disease and that's why or detection diagnosis is needs to be a pivotal part of the health departments of public health campaign and we've talked about that in the programmatic work with the bold act that they will be doing exploring some different ways to encourage folks to have this conversation early with their doctor if they're starting to notice some changes in memory loss and I think a education issues only for the population in general population the public but also in the provider front talking to providers about the importance of having these initiating these come. Ations early because we know that four out of five Americans do not really know or understand the concept of of all cognitive impairment and that of course crosses ethnic lines as well so talks about operative parent or making connections like doctors are made between the importance of heart health and also bring health is one strategy that we are encouraging the health department to take it does it develop PSAs around this South Carolina has done that connected you know what's good for the heart is good for the brain and so anyway that we can re emphasized the importance of brain health and existing PSAs as we talk about tobacco cessation of the natural bridge you know we know that tobacco is good for not tobacco is not good but tobacco as an adverse effect on on your heart health but it's will be very easy to connect to that you know cessation tobacco is also good for the brain Insurance Corporation brain health messaging and an existing public health campaigns is something that we're encouraging health department to do with the existing ball fund that we have. prevalence again that is something we've always talked about we we know there's going to be more cases I think the research is starting to show that that COVID is going to have an impact on the number of dementia cases so that's certainly something that will log of all watching a trend line and I don't have much more to share in terms of that because I didn't want to belabor my presentation going to to the details again we have that coming next week I want to make that available to everyone but I'm certainly willing to answer any questions you might have. And all the time that you had to review the the huge facts and figures report we've put out. We have any questions for me to cook. I just wanna thank you David that was really really a supplier or overview summary and comprehensive presentation this is one of the best documents that exist for everybody to be able to access as a resource and thank you for calling it to our attention and will want to be part of that weapon our next week thank you for. Thank you Dr way I will add for the the council's information that in any existing all summer state plan that we have we we do have a statutory obligation to provide a report in the fall the legislature okay I do suggest we do try to take a look at updating some of the information a lot of that was put down the pre covert world Alanis changed since then so we may need to rethink and review so that and make some edits before November. And as if time is flying like you guys of like it is for me November will be here tomorrow so. The thank you appreciate everyone coming out today if you have any questions for you to one of our dynamic speakers today please feel free enough to grab them afterwards and then be glad to give you some information begin the right direction in. We'll get with you on the the next meeting for next month's so thanks everyone pertaining were now turned.