Asking for a Friend - Health, Fitness & Personal Growth Tips for Women in Midlife

Ep.129 Dr. Mitchell Clionsky on Dementia Prevention, Cognitive Vitality, and Brain Health Strategies

• Michele Henning Folan • Episode 129

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When pursuing a healthy lifestyle and longevity, many of the risk factors and behaviors discussed on the podcast, and with my clients, also go hand-in-hand with the prevention of dementia. Yes, we can prevent about 50% of dementia by living a more healthy, intentional life. This is great news!

Unlock the secrets of brain health and dementia prevention with insights from Dr. Mitchell Clionsky, a leading neuropsychologist specializing in cognitive impairments. Gain a deeper understanding of dementia's complexities, including the distinct characteristics of Alzheimer's, vascular dementia, and Lewy body dementia. Dr. Clionsky helps us navigate the impact of these conditions on memory, emotions, and daily life, as well as the importance of recognizing mild cognitive impairment early on. This episode is a treasure trove of information for caregivers and anyone keen on understanding dementia beyond surface-level misconceptions.

Explore actionable strategies to reduce your risk of dementia by addressing lifestyle and vascular factors. From the significance of sleep, exercise, and sensory health to the potential role of medications like GLP-1s, we cover a wide range of proactive measures. Delve into the research-backed findings, including those from the Lancet Commission, which suggest that nearly half of dementia cases could be preventable. Understanding personal risk factors is crucial, and this episode provides you with tools and insights to make informed choices for your cognitive well-being.

Join us on a journey toward comprehensive brain health, where we discuss accessible resources for dementia prevention, including personalized assessment tools and the book Mitchell and his wife, Emily Clionsky, MD, co-authored called "Dementia Prevention: Using Your Head to Save Your Brain." Learn about key lifestyle changes that can foster cognitive vitality, such as maintaining healthy blood pressure and nurturing social connections. We also touch on the latest Alzheimer's treatments, examining their potential and the need for ongoing research. Dr. Clionsky's expertise and our candid discussion equip you with the knowledge to take control of your brain health, ensuring a future brimming with cognitive resilience.

You can find Mitchell Clionsky, PhD and his wife, Emily Clionsky, MD at:
https://braindoc.com/

The book, "Dementia Prevention: Using Your Head to Save Your Brain", is available wherever books are sold, on audiobooks, and Kindle.

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Michele Folan:

I had a conversation with a client today who was struggling to keep up with everything. Her duties as a mom, a daughter, wife, were all spreading her so thin that she was feeling very defeated when it came to focusing on her health and nutrition. And as much as her family wants her to be healthy, feeling good about herself and happy sometimes, making that commitment to ourselves is the hardest part. What if it doesn't have to be perfect? When you're learning something new, do you expect to be an expert out of the gate? Of course not. If you're wanting to begin your own fitness journey, the most important step is to just get started. I will give you a custom nutrition plan, daily 30-minute workouts for any fitness level, delicious, easy meal plans and plenty of hand-holding and accountability. Reach out to me via email at mfollinfasterway at gmailcom, or on social media or on social media Health, wellness, fitness and everything in between. We're removing the taboo from what really matters in midlife. I'm your host, Michelle Folan, and this is Asking for a Friend.

Michele Folan:

In episode 114, we address the challenges and resiliency in caring for a loved one with dementia. Can we actually prevent the onset of dementia? We exercise, we try to eat well and focus on self-care. But how do we know our risks and the steps to take to ward off this insidious and sometimes scary disease? Mitchell Kleonski is a board-certified neuropsychologist who specializes in evaluating and treating patients with cognitive impairment, dementia, adhd and traumatic brain injury. He and his wife, emily have a combined 70 years of professional and clinical experience in medicine and neuropsychology and have treated 20,000 patients. They partner at a private practice, kleonsky Neurosystems Incorporated, based in Springfield, massachusetts. Dr Mitchell Kleonsky, welcome to Asking fora, friend, and it's really nice to have you here. And I did mention that we have done a show on dementia and that was Lewy body dementia. I'm just so excited to dig into this with you. But first I would love for you to just kind of fill in some of the personal details, like where you studied and where you're currently living.

Mitchell Clionsky, PhD:

So this is really a joint effort with my wife, Emily, who's a physician, and she was an internal medicine doctor for many years and then went back and got board certified as a psychiatrist by doing a second residency at Dartmouth Hitchcock Medical Center. We're now living in Western Massachusetts where I've been for the last 40-some years, having gone to college at Dickinson College in Carlisle, Pennsylvania and then doing a PhD in clinical psychology in Bowling Green State University up in the northwestern corner of Ohio, and then I spent a year in Los Angeles an internship and then has been here in Western Mass ever since.

Michele Folan:

All right, and we did talk a little bit before we started, and I think the best place to start is defining dementia and then how Alzheimer's and Lewy body dementia all those fit under that umbrella.

Mitchell Clionsky, PhD:

Okay, so what I think is the best way of approaching this is to say that dementia is a wide ranging group of conditions, all of which have some commonalities. They represent neurological problems, brain problems. They are progressive in nature, so they start out being mild and then, if untreated and if we're not really lucky about things, they get continually worse and impair more and more different mental and physical functions. So it affects how we think memory, attention, problem solving. They affect how we feel. Depression, anxiety, uncontrolled emotional expression at times for some conditions, apathy or loss of interest is a common kind of finding when people have dementia, and also it affects daily function. Starts off typically before dementia sets in, at a state called mild cognitive impairment, where we're starting to lose a little more than normal aging. I mean. Truth of the matter is, as we get older we do lose a little bit of efficiency in our thinking and a little bit of memory and a little bit of speed. That usually is not a big deal. It's when it becomes more than that that it gets into the way of doing things the way we used to. So we have to really have to compensate that state is. We refer to it as mild cognitive impairment. It's not yet dementia, but about half of the people with mild cognitive impairment will go on to develop dementia, where it really begins to take its toll on their abilities to function. So this mild cognitive impairment, or MCI, is a precursor state. It's like a wake-up call in many regards, and in that state we are less efficient. We can still get there and do the things we used to do. It's just harder when we really begin to lose more abilities. That's when we start talking about this as a dementia.

Mitchell Clionsky, PhD:

Now, dementias come in a variety of flavors, so to speak, variety of brands. The one that most people are aware of is Alzheimer's dementia, and some people think that it's the most common form. By itself. It's really not. Part of it is that the Alzheimer's Association has done a very good job of making people aware of this form of dementia, which is a good thing, but it's also led to a misperception that of dementia. Another third are made up of what we call vascular dementias. Years ago we used to call this hardening of the arteries. Basically, it means that our blood is not circulating effectively, usually to the very ends of the blood vessels that go into our brains, the capillaries. It means also that people who have vascular dementias often will experience small or large strokes, otherwise known as cerebrovascular accidents. It means that oftentimes they're having other kinds of circulatory problems high blood pressure or high cholesterol or diabetes which really impacts our circulation as well as our blood sugar. So there's about another third that are made up of vascular dementias, but there's also this overlap of vascular and Alzheimer's disease, which is really the most common form.

Mitchell Clionsky, PhD:

Now, what you're talking about before, which was Lewy body dementia, is really not as common as these other forms. Oftentimes it's a part of Parkinson's disease. About a third of the people with Parkinson's develop dementia or cognitive loss. Some people within that group have this particular type of decline. If you look at this from a brain structure perspective, it's because they've got these things in the frontal parts of their brain called Lewy bodies. They're actually structures in the brain and they've got more of them and they interfere with our thinking. Very often people with Lewy body dementia have a lot of hallucinations. That's. One of the defining features is that they will see things, oftentimes families or animals, oftentimes not very frightening. It's just that they'll tell you that there's a family living in their house. They're not really sure who they are, but they're there and you talk to them, but they don't talk back. You touch them, they're not really there, but they visit and they're not too bad. They can be frightening at times, but by and large they're not.

Michele Folan:

Yeah, the woman that I had her name was Diane on the show. Her husband at times doesn't recognize her and gets sometimes violent because he thinks she's an intruder in the home. So I guess that's similar to what you're discussing right now.

Mitchell Clionsky, PhD:

Well, you can also see that in other forms of dementia. There's some centers in the brain that are particularly sensitive to the sense of familiarity. You ever have that experience of deja vu where you say, man, I feel like I've been here before. Or you meet someone for the first time and they feel like somebody you used to know. You know you never met them, but they're just. I like this person, not because I've known much about them, but they're just. I like this person not because I know much about them, but they're so much like my cousin or my friend in school or whatever and we have that sense of familiarity. You can also have the other end of that, where things that are familiar seem foreign and in more advanced phases of dementia some people will fail to recognize someone who they've lived with for 40, 50 years. They can even fail to recognize themselves. They'll look in the mirror and they'll think it's someone else.

Mitchell Clionsky, PhD:

That sense of familiarity is lost and that can be frightening, can also cause major problems in caring for that person. I've had patients who will say major problems in caring for that person. I've had patients who will say well, I know that I've got a wife, but there's also this other woman. Maybe she's her twin, I'm not really sure, but could be her sister. The wife has no siblings. But they then, despite knowing this wife for 45, 50 years, suddenly think well, she looks like her, sort of acts like her. But she's not the same, she must be someone else. Maybe it's her twin.

Michele Folan:

Oh, wow.

Mitchell Clionsky, PhD:

So there's a lot of very interesting from the outside but painful kinds of things that go about with Lewy body dementia and it can be very hard to be a caregiver for that person. I mean, it's hard being a caregiver for anyone with dementia. It's specifically hard when the person you're caring for doesn't recognize you, has forgotten your name, doesn't view you as being the same person.

Michele Folan:

Yeah, I have a question Is the diagnosis on the rise? Do we see more dementia diagnoses now?

Mitchell Clionsky, PhD:

Well, there's more of it and we also see more of it. So let me break that down a little bit.

Michele Folan:

Okay.

Mitchell Clionsky, PhD:

There's more dementia because people are living longer. Dementia is a disease of aging. When you're in your mid-60s you have about a 10% risk. When you get to be in your mid-70s that doubles to about 20%, and when you get into your mid-80s there's about a 40% likelihood at that point. Now it sort of flattens out at that point because you have another phenomenon that happens then, which is that people who have conditions that make them likely to get dementia have problems with their health. They start dying. So if you make it into your mid-90s you're still about the same risk you did when you were in your mid-80s. So what we do have with the aging of our population healthcare is generally better, people are living longer, less accidental deaths, fewer deaths by illnesses and other things early in life, better hygiene, things like that. So people are living longer. So we have also this post-World War II baby boomer bubble with more of us born in the 46 to 60, 1960 age range, so that you're having more of those people around as well. So it's sort of a double whammy.

Michele Folan:

Okay.

Mitchell Clionsky, PhD:

The other thing that's happening is we're also paying more attention to it, which is a good thing, because we're more aware of it and people are taking greater interest in their cognitive health, which sort of helps us to not only see more of it, but also to recognize it, perhaps at earlier stages than we might have 20 years ago, when people didn't think there was anything that could be done. So why bother even talking about it?

Michele Folan:

What is the earliest early onset you've seen in your experience?

Mitchell Clionsky, PhD:

I've seen people as early as their 40s get this very rare. One of the things that's so interesting about this diagnosis of Alzheimer's disease is that the patient that was identified by Alwa Alzheimer in the early 1900s was in her 40s and for a very long time, including when I first was in graduate school, we thought of and characterized Alzheimer's disease as an early onset dementia. It was a dementia before the age of 65. And I can remember having a conversation with one of my professors where I said I think that this person has Alzheimer's disease and he said to me no, no, no, she's over 65. Well, we now know that it includes all forms and all ages, and so we try to break it down onto how old the person was when they first got it, but it's clearly age-related.

Mitchell Clionsky, PhD:

If you have somebody who has it that early, they usually come from a family with a high level of genetic loading, which are rare in the United States, or they've suffered for some kind of significant medical event. They've inhaled carbon monoxide accidentally or perhaps as a suicide attempt, and this causes earlier onset Alzheimer's. They've gotten a terrible brain injury or repeated brain injuries that start this process earlier. So you include some of these people. We now you know sports players, particularly with chronic traumatic encephalopathy, repeated blows to the head. They can get this in their 40s and 50s but by and large, again, it's a condition of aging. We're really not seeing people getting it at earlier ages at a greater rate now than we used to hour.

Michele Folan:

Because when I think of vascular and you talk about metabolic syndrome and there being that link there with hypertension and other vascular disease, can we prevent dementia? Yes, that type of dementia, okay.

Mitchell Clionsky, PhD:

We can actually prevent all forms of dementia. There's about a 50% dementia prevention possibility one out of two cases and this is not my data, this is data from very large scale studies that have been repeated, and we first started seeing this degree of predictability in prevention back in about 2017, when the Lancet Commission in Great Britain examined all kinds of health records because they keep incredibly more detailed and complete health records where you have a national health service than we do in the United States, where it's more fragmented. So they looked back on what they called the UK Biobank, where they had all this information on millions of people Biobank, where they had all this information on millions of people and they back then identified this is a blue ribbon panel like 27 different very eminent physicians and psychologists and back then they found nine factors that they calculated could prevent 40% of dementias. Three years later, in 2020, they found another couple factors and raised their probability into the low 40%. A couple years after that, in the United States, a separate group, using their model and these 12 factors, determined that about 62% of dementia cases could be prevented.

Mitchell Clionsky, PhD:

So when we wrote our book and it went to press, it goes to press about a year before it actually comes out. So that was back in 2022. The numbers were 40 to 60% that we were using. We decided just to split the difference and say one out of two cases. Well, the most recent stuff just coming out a couple months ago in 2024, again from the Lancet Commission is they've added a couple more factors now and they raised their estimate to 49%. So I feel incredibly comfortable saying that at least 50% of cases and here's something else In our model of dementia prevention we have another eight factors that they have not even considered that we believe, based on the research, can also reduce the risk of dementia.

Mitchell Clionsky, PhD:

So I'm very bullish on this whole concept. I'm very optimistic about it. The trick is that people really have to determine what their factors are, and I'll be happy to talk about how we do that and then be willing to make some changes. If you know anything about human behavior, you know that change is a hard thing to come by once we get beyond the age of about 18 to 20.

Michele Folan:

All right, I want to talk about these factors. So, beyond like doing a DNA test or just merely going by your family history, what are the other factors that you would consider?

Mitchell Clionsky, PhD:

Yeah, actually, genetics plays a fairly small role in direct dementia risk. It actually plays more of a role in the medical conditions that lead to dementia. So, for example, diabetes is a high genetic risk for diabetes. High cholesterol again significant genetic risk for that. Hypertension about 40% of the people with high blood pressure don't even know they have high blood pressure. It's asymptomatic, so consequently, unless they get their blood pressure taken, they think they're fine, but they actually have elevated blood pressure. A lot of these are mediated by obesity. We have an obesity crisis in the United States and it's getting worse, and we have more and more people who are eating more than their body really can tolerate and so their blood sugar goes up. They develop type 2 diabetes. One of the reasons why we're now seeing these new medications for diabetes being important not just for lowering the blood sugar but for preventing dementia. I'm talking about what they call the GLP-1s.

Michele Folan:

Yeah, GLP-1s yeah, we talk about those all the time on the show. Okay, good.

Mitchell Clionsky, PhD:

Well, what they do is it's not directly hitting your brain in a positive way, not usually it's more the secondary effects. They lower your weight, allow you to get back to a more stable blood sugar, allow you to now also have the energy for exercise. They also, especially in younger people, reduce the risk of obstructive sleep apnea. Now, when you get into your 70s, even in your 60s, weight is not as much of a determinant of who has the sleep disordered breathing we call sleep apnea. But if you're under that age and you're overweight, that's going to really increase your risk of not getting enough air down your lungs and enough oxygen to your brain while you're asleep. And that does have an effect both on your vascular system, your circulation, but also it produces more beta amyloid in your brain, the underlying factors that we're now focused on in terms of Alzheimer's disease. So all of this one of the interesting and unique things about dementia is that there's a lot of stuff that's involved in this, this, and it's not simplistic. People want simplistic answers. They want to know what berries they can eat, what supplement they can take, what exercise is better than another. Most of the people I see doing any exercise is better than nothing, because they're very sedentary in their lifestyle. But if you look at what gets popularized on the internet, it's oh, here's some supplement, here's some food, here's some diet. All of that is like spitting in the ocean. It has a really minimal effect because you have to look at these other factors.

Mitchell Clionsky, PhD:

So we look at sleep apnea, we look at the amount of time people are sleeping. A lot of folks don't sleep enough and therefore not only do they feel tired and not only do they then maybe eat more to try to give themselves energy or get anxious because they're tired and that can produce anxiety, but also their brain does not have enough time to recover at night from what goes on during the day. So you start seeing people who are very proud to sleep only four to five hours a night and I see a brain that's cruising for a bruising. That's not going to work out well in the long run. It's not a point of pride to say, oh, I only sleep four to five hours because I've got such a wonderful brain. You're only sleeping four to five hours because something's going wrong and that's not enough time for your brain to heal from the trauma of the day, from the thinking, the byproducts that your brain produces while it's thinking.

Mitchell Clionsky, PhD:

We also see a lot in terms of sensory loss. One of the real interesting issues is hearing loss and vision loss, and a lot of times people say, well, I can really hear, okay, if you would just speak louder and if someone just turns the volume up and if I'm just speaking one-to-one, and it's like, okay, we can twist ourselves into all these different pretzel shapes in order to do it, but the chances are you have a hearing deficit and that's actually causally related to your risk of dementia, and then we need to address that, and the earlier we address it, the better off you're going to be.

Michele Folan:

What's the correlation between your hearing and dementia?

Mitchell Clionsky, PhD:

A couple of things. The most obvious, but probably not the one really causing this, is that people pull back from social engagement when they're not hearing well, because things that go on interpersonally are not very interesting. They're more painful to try to figure out and so they just pull back, so they don't get enough stimulation From a physical level. There's some really interesting research that shows that the background noise of everyday life has a positive effect by stimulating the surface of your brain in a region called the auditory association cortex, the surface part of your brain that perceives and manages sound. So those birds singing outside, you really do want to hear them. That pesky dog next door it's a pain in the butt but it's actually stimulating your brain. You want to hear everything that's going on at the best acuity possible.

Mitchell Clionsky, PhD:

The other thing that happens and we could see this from some research using a technique called functional magnetic resonance imaging or otherwise known as fMRI is that when people, even with subtle hearing loss, get put into an fMRI machine, there is a downregulation of one of the background resting networks called the salience network. So anything that's salient is meaningful. So people who don't hear well don't pay attention well. Things get by them and therefore, they're not using their brain in a routine way and making those connections. So we have a couple of physiological things that are involved here, and it's probably, as with many aspects of dementia, probably due to several different but interrelated factors, and that's what I want to get, is. It's complex, but that doesn't mean that you can't do something. It just means you have to appreciate that it's more than one thing.

Michele Folan:

Okay, I did have a question. So I'm on the internet all the time. I read a lot because I try to stay up on the latest, because I'm doing this podcast and I've been hearing a great deal about statins and the lowering of LDL cholesterol too much, in that our brains need cholesterol to function. Is there a correlation between cholesterol-lowering drugs and the increase in dementia?

Mitchell Clionsky, PhD:

Maybe several years ago. That implicated one of the particular statins, lipitor, otherwise known as atorvastatin, as a potential cause for cognitive loss. So I've seen a bunch of people who were taking off their statins because their doctor thought, well, let's clear the deck and let's take you off this. I have not seen anyone who did better as a result of that. The other thing is elevated cholesterol, which is why the person started taking these in the first place has its own vascular risk factor. So when you take someone off and I don't think the study with showing a decline has ever been replicated that's one of the dangers of the internet is the headline looks great. You actually read the study.

Mitchell Clionsky, PhD:

I've read stuff and it's like oh, this is a theoretical model, or this is done in a Petri dish, or this is a mouse study, and maybe five years from now we'll know the answer to this if it makes it up through the various levels of testing. But it makes for a great headline. And so it's like new factor, new protein now associated with Alzheimer's disease, and you think, okay, let me read that, that's interesting. And then you find out well, there was one study done somewhere else using some mice and the team pulled out this particular protein. Well, that's at least five years from being even worthy of consideration, hasn't been replicated, hasn't gone up to mice or to chimps, to higher animals, never been tried on people.

Mitchell Clionsky, PhD:

There's been a lot of that over the years, a lot of false flags. So I read these only to then dismiss them and say come back when you got something to talk about. It makes one of the things that you know. It used to be that there's only so much news that could fit in the newspaper, in the magazine or on the airwaves. Nowadays there's a much wider amount of this and you have to fill the space. So there's a lot of stuff that's now talked about that people would have looked at and said well, that's interesting, come back when you have something to talk about. That doesn't happen anymore. Everyone's looking for stories.

Michele Folan:

Yeah, and my disclaimer with even bringing that up is if you are currently on a cholesterol-lowering medication, do not stop taking it or cut back on anything unless you speak to your doctor, because I don't want anybody that's listening to the show right now not take their pravastatin or their torvastatin or whatever they're taking.

Mitchell Clionsky, PhD:

Absolutely.

Michele Folan:

Okay, I just want to make sure that we're clear on that. There was some of the environmental factors that may have some association with dementia, and this one goes way, way back. So a friend of mine actually an old roommate did not like to use aluminum pans. Roommate did not like to use aluminum pans.

Mitchell Clionsky, PhD:

Wow, that's been going on since the 1980s.

Michele Folan:

Well, I just pretty much told you how old I am. Yeah so it was a roommate back in the 80s and there was dementia that ran in her family and they did not use aluminum pans. So we had all these fancy Le Creuset pans in our apartment.

Mitchell Clionsky, PhD:

Is there any truth to that? No, so here's what happened is, someone did a study and they looked at autopsies of people who died from Alzheimer's disease and they found out there was a higher level of aluminum in their brain tissue than they expected. And so they jumped to the conclusion that that was due to aluminum pans, which had now replaced much of the previous iron cookware or cast iron pots and pans. So it was like when I think it was Clark Gable stopped wearing a t-shirt on some movie years ago and suddenly the t-shirt industry took a dive. People stopped using aluminum pans because of this study, because they thought, okay, this is it. We found the Holy Grail, we're there, get rid of the aluminum pans.

Mitchell Clionsky, PhD:

Well, turns out that one of the things that happens as a cause of dying is that brain tissue changes and starts to give off more aluminum. So what they were measuring was a perfectly normal process, but because their sample was specific to people with dementia, they made the wrong conclusion. To people with dementia, they made the wrong conclusion. So if you still got those aluminum pans or you want to use them, go back to using them. One of the advantages of using cast iron pans, however, is there's a lot of people walking around with low levels of iron. They have some iron deficiency anemia, and if you use cast iron frying pans, you'll actually get higher levels of iron in your blood just as a function of that. Oh wow, so it's still a good thing, but no, don't avoid the aluminum cookware.

Michele Folan:

Okay, thank you for telling me that, because there's someone else that I know very well who. They came back and they had a high level of metals in their blood and they quit using their that's a different question.

Mitchell Clionsky, PhD:

That's different. Okay, the blood test that someone is alive, that's not based on a study of someone who has died. If you've got high levels of certain metals in your blood that can cause dementia, so you do want to have your doctor look at that. Now, I had a patient some years ago who used to do, uh, these shades lampshades with tiffany glass, and they would use a lead-based solder, and this guy was doing this kind of work for years. This was his. He did it in his basement and I said to him what form of ventilation do you use? He says well, there's a window there, but suddenly in the winter I don't open it.

Mitchell Clionsky, PhD:

Of course, I had him go to his doctor who sent him off for a lead test and he had huge levels of lead in his blood. The problem was he was way too far gone to do anything to remove the lead because it had also gotten into his bones. So they said, if we tried to rechelate out the lead, basically his skeleton's going to collapse. So we just stopped him from doing that hobby but realized that this was something. He had excessive levels of lead. We weren't going to be able to fix that.

Mitchell Clionsky, PhD:

But that can do it and, uh, you know, a lot of exposure to metals. That's why, if anyone has unusual onset of memory or cognitive problems and they live out in the country, I always ask them if they're on well water or if they're in an old house, Because up here in Massachusetts there's still a lot of people who live out in the country on wells or who live in 200-year-old houses. They may still have lead pipes in some parts of their plumbing and that can cause a problem, and also their wells can get contaminated and that can cause a problem and also their wells can get contaminated. So you really have to be a detective in many cases and try to turn over all the stones that are possibly there to make sure that you've not just ignored something which is really contributing to this problem.

Michele Folan:

All right, this is like so incredibly interesting, because I didn't know any of this and I am enlightened, very enlightened. Today you wrote a book. Yes, Dementia Prevention.

Mitchell Clionsky, PhD:

Using your Head to Save your Brain, so you need the last part of it too.

Michele Folan:

Yes, using your Head to Save your Brain. Who did you write it for?

Mitchell Clionsky, PhD:

A whole wide range of people. Basically, we wrote it for all the people we cannot see in our office in our lifetime. Because that's the limiting factor here is that there's this really important information that we've had the privilege of accumulating, both in terms of the wide range of research that we've read but also in terms of our clinical experience. But we're also limited. I can't work more than 70 hours a week, so it's like how many people can we talk to about this? So we wanted the book to be a guide both for people in the general population and for doctors. So by writing it in first a very scientific way, but then explaining it in terms that everyone would understand as we say, translating, not dumbing down the concepts because that's really important. People need to understand sort of how this all fits together, but we don't want to throw a bunch of terms at you that you don't know. And we also realized that most people are not going to go back and read 400 journal articles to get this information and be able to evaluate them. That's where having an MD or a PhD helps out. So that was our target audience for caregivers for children of people whose parents have dementia like I am, my mom had dementia. So partly it was written for me, partly it was written for the people like me, but also for anyone at any age really to try to say what can I do to increase my brain function, to decrease my chances of losing my ability to think? How can I think? Well, until the last day I'm alive. That's really how I view it. I want to wake up dead some morning. I want to be able to think the whole way through until whatever happens to me. And the funny thing is, if you do the things that we talk about to preserve your brain, you will actually improve your lifespan possibilities as well, because they're very similar. You don't want to smoke. You want to manage all of your correctable conditions your blood pressure, your blood sugar. You want to exercise on a daily basis. In my world, you want to sleep well and breathe while you're sleeping. You want to exercise on a daily basis. In my world, you want to sleep well and breathe while you're sleeping.

Mitchell Clionsky, PhD:

You want to avoid excessive alcohol use. Some people would say avoid all alcohol use, but at least you want to avoid excessive alcohol. You don't want to take anti-anxiety medications for long periods of time. You don't want to become isolated and socially withdrawn, not have contact with people in a close, supportive way. There's a whole variety of things and also there's a couple other things that are people who don't know.

Mitchell Clionsky, PhD:

You want to get routine vaccinations, because getting a bad case of RSV, getting COVID, getting pneumonia, getting the shingles, will impact your brain functioning. You want to get routine dental hygiene care. I tell people you have to use the F word that being floss because your dental health actually impacts your brain health. And you want to avoid hitting your head, because we know that concussions are bad and the older we get, the more prone we are to falling and hitting our heads, and so one of the big causes of disability and dementia in people over the age of 75 or 80 is that they don't move, they don't keep their bones strong, they fall, they hit their head and they go downhill after that. So there's a lot of stuff to do and it's a question of seeing what your profile is and then acting on it.

Michele Folan:

And I love this sense of self-care and really empowering people to really care for their health. We didn't really touch on pharmacology and what in terms of beyond Aricept, which is the only drug that I know of offhand that was for Alzheimer's right, but what else are they doing to treat dementia and Alzheimer's?

Mitchell Clionsky, PhD:

Okay, so this is almost a whole other topic by itself.

Michele Folan:

It really is Okay, give me the Reader's Digest. Version of that Reader's Digest version.

Mitchell Clionsky, PhD:

There have been four medications that have FDA approval since the late 1990s. There's three in one category. Aricept was the brand name of what's now prescribed as donepezil. There is a second medicine that's fairly similar to it that's called. That was called Razodine. It's now prescribed as galantamine. There's a third medication used to be called Exelon now is prescribed as Rivastigmine.

Mitchell Clionsky, PhD:

All three of these medications help to support a chemical in our brain called acetylcholine or, as some people pronounce it, as acetylcholine. This is a memory transfer chemical. It's really important to have your acetylcholine levels at their best. Unfortunately, we cannot add more acetylcholine to compensate for the decline that occurs. It occurs normally to some extent as we age, but even more so with people with dementia. But what we can do is use these medications to help preserve the existing levels of acetylcholine. One of the reasons that these medications do not make memory better but prevent it from getting worse, is that we can't put more acetylcholine into the system.

Mitchell Clionsky, PhD:

Sometimes, unfortunately, people will be prescribed these medications. The doctors will sort of poo-poo it and say well, you know, it doesn't really make your memory better or it's really not all that effective. And I disagree entirely. It doesn't make your memory better. But if you stay at the same level of cognitive functioning the day you come in to see me and are at that same level five years later, I regard that as a win. That means you're still living on your own. If you were living on your own before, you're still doing the same stuff. You're driving a car. That's a win.

Mitchell Clionsky, PhD:

We will apply the same standard when we talk about diabetes. Who cures diabetes? We don't standard. We talk about diabetes. Who cures diabetes? We don't. We limit its effect on your body by controlling your blood sugar, but no one restores the pancreas. So, in the same way, these are very effective. There's a fourth medication used to be called Namenda, now called Memantine, which is used primarily for more severe forms of dementia moderate to severe dementia or in combination, which is very effective oftentimes with the medications like the nepezil or irisept. There's two new medications. I don't know if you want to get into this at all, but there's two new medications in the past year.

Michele Folan:

No, it's okay, because I was going to ask you what was on the horizon, so this is good.

Mitchell Clionsky, PhD:

Well, this is not horizon. This is real. You can actually get these medications. One of them is called licanumab, it's otherwise known by its trade name licembi, and the other one is known as bananumab. So they both are MAPs, they're monoclonal antibodies, but that one's known as by the brand name Kizunla. It's a really interesting name.

Michele Folan:

Some of these names are just so bad I know they run out of names is the problem. I think so too. I know, back when I was in the pharmaceutical industry they had a cache of names that they had licensed right and they'd throw one out and see if it would stick in the marketing focus groups and stuff.

Mitchell Clionsky, PhD:

But yeah, oh, yeah, still do that.

Mitchell Clionsky, PhD:

I don't know how to get to some of these, except they've run out of the other ones and they can't sound too much like something else or else it creates confusion, so you get kicked out for having a name that's too familiar in that sense.

Mitchell Clionsky, PhD:

So anyway, both of these medications are specifically for the Alzheimer's form of dementia and at mild stages, either mild Alzheimer's or at mild cognitive impairment. Both of them are target. They're infusion medications. In other words, rather than taking a daily pill or putting on a round kind of band-aid patch, transdermal patch, you have to go into an infusion center like chemotherapy center and spend and I don't know how long it takes typically to infuse, whether it's like a half an hour or an hour, but every two weeks you have to get one of these infusions. And what these infusions do is that they identify and connect with the levels of beta amyloid plaque that are in your brain if you've got Alzheimer's disease. So you first have to get some tests to find out if you have a lot of beta amyloid plaque and assuming you do, then you're a candidate for these medications. They identify these as targets so that your body's own immune response attacks the beta amyloid breaks it up and flushes it out. Oh, which would seem like a wonderful thing if it improved memory, but it doesn't.

Michele Folan:

Okay.

Mitchell Clionsky, PhD:

And that's why people say, oh, this is wonderful, what help we have. And I say, no, actually this is exactly the same complaint you've had for the medications we've had out for the past 25 years. They don't make memory better. So what the research for both of these shows is that if you take these once every two week infusions for a year and a half, your memory declines, but it declines to the same degree as if you didn't take the medicine but was only 15 months into the decline. So in other words, you're three months ahead of where you might have been had you not taken the medication a year and a half after you start. For most people this is not a noticeable difference.

Mitchell Clionsky, PhD:

The other problem I have problems I have with these drugs is that we don't have any data beyond a year and a half. We don't have any data beyond a year and a half. We don't know if removing the amyloid is just going to grow back or if we're sort of restarting the clock where the person was years ago, whether there's going to be a downstream problem a couple years from now, because we needed that amyloid. We just didn't know it. There's a real debate as to whether it's the amyloid causing the dementia or if the amyloid is caused by the dementia. So we got that problem to contend with. But the other issue is that they never compared the new medicines with the old ones.

Mitchell Clionsky, PhD:

Now, as a clinician, what I'm going to recommend because as a psychologist I cannot prescribe, but I certainly can recommend I'm going to recommend something new. I want it to be better than what we had before, especially if it's much more of a pain in the neck to do you can't just take a pill every day, especially if it's much more expensive and this runs about $25,000 a year, whereas the previous medications are maybe $1,000 a year and especially if the new medication has a potentially severe side effect. So these new medications can cause brain swelling and hemorrhaging, blood vessel breaking in the brain, bleeds in the brain Not a high percentage, but the most recent patient I saw who was started on this, they calculated that she had about a 10% chance of having one of these bleeds. So she has to be monitored on about a monthly or every other month basis to make sure her brain's not swelling. Well, if I'm going to recommend that to someone, I want it to be a whole lot better than what I already have. That's the problem.

Michele Folan:

Yeah, I look at this and you know again, I am a layman, but I sometimes wonder how some of these drugs get FDA approved without better data and longer studies.

Mitchell Clionsky, PhD:

And there is a question about that, and there's some politics involved and there's actually a lot of public sentiment. The Alzheimer's Association really got behind having the FDA approve these, based on the fact that this would bring hope to people. Well, hope is great. I'm better with real hope than false hope. However, and no matter what your stage of your life you are at, and no matter if you are still having normal cognition or mild cognitive impairment or even dementia, there are so many things that you can do to slow down that progression that you want to do all of those things and then think about medication as well. But it's not. Oh, I'll take this medicine. I can keep on doing the same things that may have raised my risk before, but now I'm taking this medicine. I can keep on doing the same things that may have raised my risk before, but now I'm taking this medication. I'm okay, it doesn't work that way.

Michele Folan:

Well, I'm pro-prevention, which is why I wanted you on the show, because we're all about that on Asking for a Friend. So, thank you for all of that, and I have a kind of a personal question for you. I may even be able to take a stab at what this would be, but what is one of your core pillars of self-care? What's something you do for yourself?

Mitchell Clionsky, PhD:

I can do a couple of things. Because I'm having a mom with dementia. This is job number one in some ways for me, so I exercise every day and most of my exercise is walking, because I can do it easily and I don't hurt myself and I can squeeze it into my schedule If I break it down into small pieces. I can do other things while I'm doing it. So I can listen to podcasts, I can talk to people on the phone, I can listen to sports, I can listen to political, so that's one of the things I do sports. I can listen to political stuff, so that's one of the things I do.

Mitchell Clionsky, PhD:

The other thing is I was diagnosed 20 years ago with sleep apnea. I use a CPAP machine every night and I believe that I think better now than I did 20 years ago. I know I am much less scattered. I'm much more focused scattered. I'm much more focused. I don't lose things like I used to, and I still am able to create and to see lots and lots of patients and to do talks, and do it without notes. So getting oxygen to your brain turns out to be a really critical thing. And what most people don't realize is that if you're 58 years or older. The most recent research tells us you have a 50-50 chance of having sleep apnea. It's just not getting diagnosed. So getting an overnight home sleep test in your own bed can be a lifesaver for many people with dementia. And sort of as part of the general kind of self-care that we do, I want to make sure I'm breathing.

Michele Folan:

Well, I'm sure Emily would let you know too.

Mitchell Clionsky, PhD:

Well, she's also on a CPAP machine. So she decided that she was going to get her own sleep test. After I was diagnosed and found out that when she was sleeping, her oxygen level at one point dropped into the 70% range. And yeah, so she, even though she didn't snore and I snored horribly she got tested. And so we travel everywhere we go with two CPAPs and a couple of little extension cords, because there's still hotels that don't have enough outlets for everything we need.

Michele Folan:

That's so cute Nice.

Mitchell Clionsky, PhD:

Want to stay young? Yeah, exactly.

Michele Folan:

So, Dr Mitch Clionsky, where can the listeners find you and your book?

Mitchell Clionsky, PhD:

Best place to find us is on our website and your book Best place to find us is on our website, which is called Braindoc B-R-A-I-N-D-O-C braindoccom. So in our website we've got a lot of information about each of us. We also have a link to Amazon where you can get the book. It's available in paperback for libraries. It's available in hardcover. It's also an audio book, which is really fun because we've got a great actor who read the book.

Mitchell Clionsky, PhD:

Her name is Nan McNamara. She's really interesting to listen to. It's on Kindle. If you have an iPad, you can download it on your iPad. So it's ubiquitous, it's everywhere. The other thing is we have at this point a whole bunch of other podcasts, articles, information and, most importantly perhaps, is our dementia prevention checklist, which you can fill out in about 15 minutes and is going to give you a really good assessment of where your personal profile is, where your habits and health are on target or near target or off target. So it becomes essentially a blueprint for going forward, which figuring out what you're going to do to improve your odds to get your dementia prevention index up close to 100%, rather than where it starts out.

Michele Folan:

That is wonderful. Thank you for mentioning that. I will put all of this in the show notes. Mitch, thank you so much for being here today.

Mitchell Clionsky, PhD:

This has been great fun. Thank you for inviting me.

Michele Folan:

I am so grateful for the ratings and reviews from our listeners. Did you know that your reviews help other people find Asking for a Friend? If you like what you hear, won't you please leave a review on Spotify or Apple? Thank you from the bottom of my heart.