There are many disorders that can cause memory problems, which fall under the category of “dementia” when those memory problems interfere with daily living. The most common dementia is Alzheimer’s disease, which afflicts more than seven million people in the U.S. As Dr. Kristina Zdanys, geriatric psychiatrist at UConn Health, explains, we can’t cure dementia; our best bet is to try to slow its progression, or even delay its onset with healthy habits in our younger years. Dr. Zdanys, who co-directs the James E. C. Walker Memory Assessment Program in our UConn Center on Aging, also discusses with Dr. Anthony Alessi how genetics factor into dementia, the “mind diet,” the challenge of taking away a loved one’s car keys, and what drew her into the field of geriatric psychiatry.
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Transcript
Dr Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery in addition to a grant from Coverys. It is not designed to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it gives me great pleasure to welcome today, Dr. Kristina Zdanys. Dr. Zdanys is a geriatric psychiatrist here at the University of Connecticut where she serves as an associate professor of psychiatry. Kristina, welcome to the show.
Dr. Zdanys: Good morning. Thanks for having me.
Dr Alessi: Let’s talk. Can you describe your background and what it takes to become a geriatric psychiatrist?
Dr. Zdanys: Absolutely. So, after medical school, I completed four years of a general adult psychiatric residency down at NYU. And treating adults, you also treat older adults, but I wanted to really enhance my understanding of working with the older adult population, so I went to Yale for a fellowship in geriatric psychiatry, which focuses on the mental health of folks who are 65 and over generally. And that may be a primary psychiatric problem like depression or anxiety or a sleep disorder, but it can also be dementia, which I think we’ll talk about quite a bit today.
Dr Alessi: Why did you choose that field?
Dr. Zdanys: Well, I think going back a long way, I’ve always been very connected to older adults in my family and my community, and have really enjoyed listening to their stories from when they were growing up and when they were younger adults and raising their kids, and there just seemed to be just this, you know, beautiful tapestry that every individual can present to you that I just found so enticing. So that’s how I initially got that interest. But at the same time, I also was really interested in the idea of memory problems because when you think about illnesses that affect older adults, you can kind of wrap your head around, okay, somebody’s heart’s not working the way it’s supposed to be, or somebody’s kidneys aren’t working the way they’re supposed to be, and you can kind of point to what that is.
But a memory problem seems much more abstract. And, not just abstract, but I also think it affects the individual in a way that’s so unlike any other illness because in a way it robs them of their core identity and I just felt very compelled to try to work with them. And even if I don’t have a cure for their problem, just to try to help improve their quality of life.
Dr Alessi: You know, just thinking of the field of geriatric psychiatry and geriatrics in general, it’s gotta be interesting because it’s such a growing field. We’re living longer.
Dr. Zdanys: Mm-hmm.
Dr Alessi: Right. And I think the statistics regarding memory loss and dementia are outstanding.
Can you talk a little bit about that? It’s tremendous growth.
Dr. Zdanys: That’s very true. So, the number one risk factor for developing dementia is age. So, the older you get, the higher your risk of developing dementia. And I should also clarify what we mean by the term dementia,
Dr Alessi: Please.
Dr. Zdanys: So, dementia is a cluster of different illnesses that presents with memory problems that interfere with somebody being able to do what they need to do day to day.
And in most cases, those dementias are progressive. So just like there’s the term cancer, we know there’s all different kinds of cancers. There’s the term dementia, which means there’s all different kinds of disorders that can cause memory problems. So, in the United States, Alzheimer’s is the most common.
It probably makes up about three quarters of our patients who present with memory problems, and that makes up about 7.2 million people in the United States who are currently living with Alzheimer’s disease.
Dr Alessi: The projections are something like, what 30 million people by 2050 or something of that nature?
Dr. Zdanys: Yeah, I don’t think it’s quite that high, but probably around 14 million by 2050, 2060, so
Dr Alessi: Wow.
Dr. Zdanys: Yeah, and the problem is without a cure, we don’t really have the infrastructure in our society to take care of these patients. Right? So most of the care burden is falling on family members who are often juggling jobs and their own children and trying to navigate the difficult course of the disease.
Dr Alessi: Kristina, what’s your practice look like when someone comes to see you? Are there tests you do? Is it mostly talking to them? Kind of walk me through what a typical visit would be for one of our listeners.
Dr. Zdanys: Sure. So as a geriatric psychiatrist specifically, my primary job is to listen, right? So, I want to hear what’s going on with somebody in their life, what’s important to them, and what is the reason they’re coming to see me in the first place?
So, we might say broadly as our chief complaint, “oh, somebody is coming in because they have problems with their memory.” But what does that mean for them? Is it that they are now relying on their family for transportation because they’ve been getting lost when they’ve been driving? Or does it mean that their hypertension is poorly controlled because they keep forgetting to take their medication? So, I want to hear what the patient’s experience is, first of all, so I can understand how it’s impacting their life. And I think that might be a way in which a geriatric psychiatry approach might be a little bit different than some other specialties.
But, at the same time, we do perform the same type of blood work that we would do for somebody coming into an internal medicine office or a neurology office. We typically do recommend head imaging. Brain imaging has come a long way in the past decade that I’ve been here at UConn Health. Previously, we were only able, typically to get an MRI.
Now we have special MRIs called NeuroQuant analysis where you can actually measure out the size of different parts of the brain, and that helps us get a better idea of what the patient might be suffering from that’s causing their memory problems. We do more advanced scans, like PET scans that can actually show us whether or not somebody has amyloid in their brain, which is the protein that we see in people who have Alzheimer’s.
So, when I started here, we were making general clinical impressions. To make our best guess about what might be causing somebody’s memory problems. But now we’re using specific biomarkers to have very specific diagnoses available for our patients and inform our treatment plans going forward.
Dr Alessi: How big a factor do you find genetics to play in dementia?
I mean, old people are always asking me that in respect to their father and mother who may have Alzheimer’s disease. How big a factor do you find genetics and the APOE4 studies and things like that?
Dr. Zdanys: Yeah, that’s a really good question. So there’s different types of Alzheimer’s too, and I won’t get into too much of the details about that, but there’s earlier onset Alzheimer’s that tends to have more of a familial component where people have something called an autosomal dominant inheritance, where if they have a parent who has an early onset Alzheimer’s, they may have a 50% chance of developing it themselves.
That’s a very small portion of our population, probably under 5%, if not under 1% of our population. The gene you mentioned, the APOE4 gene. This gene is a risk factor for developing Alzheimer’s disease, but doesn’t mean necessarily that people are going to get Alzheimer’s. So it wasn’t necessarily something that we would typically test for prior to the advent of these new treatments that we have available now.
But what’s interesting about the APOE gene is that based on the version of the gene that somebody has, we can actually predict their risk factor for side effects from some of our new medications. So now we are routinely screening for the APOE gene as opposed to even five years ago when we were maybe considering it, but it wasn’t standard of practice.
Dr Alessi: It’s interesting ‘cause with my practice in sports, there was a period of time where people were advocating to test for the APOE gene in boxers before they got into the sport. And obviously that met with tremendous resistance on the part of promoters and athletes.
And as you describe it, I don’t know that it would’ve been very predictable from that standpoint. Let’s talk a little, let’s get into the drugs, right? I think this has been one of the exciting fields in memory disorders and dementia is the new drugs to kind of clean up the brain. Can you describe a little bit about them and what they do?
Dr. Zdanys: Sure. So, since 2021, we have had a new class of medications available for the treatment of Alzheimer’s disease. This is not a pill that you take. These are actually infusion medications. So our patients are coming into our infusion center once every two weeks and getting the medication through an IV.
What these medications do as a class, they’re called monoclonal antibodies, and essentially what they’re doing is what you described. They’re vacuuming up the amyloid plaque that I mentioned earlier and really exquisitely clearing it out of the brain so that the brains of people with Alzheimer’s no longer have this burden.
Now, the tricky part is that doesn’t mean it’s a cure for Alzheimer’s disease because there’s multiple different factors that play into a person’s development and progression of Alzheimer’s. So, they very well slow down the progression of the disease. They help improve people’s independence, so they’re able to stay more independent longer, in terms of those activities of daily living that they need to do, whether it’s driving, or managing their medications, or doing their finances, or doing their shopping.
But there’s other factors that the medications don’t address. So, one of those is another protein in the brain called tau, which we see in something called the development of tangles in Alzheimer’s disease, which is a marker of neural degeneration. And then also there’s an inflammatory process that happens in the brain of people with Alzheimer’s disease.
And these monoclonal antibodies don’t address that either. So, what I tell patients is it’s not a cure, but it’s really currently the best tool we have for slowing down the progression. But I will say that not every individual who has Alzheimer’s disease is necessarily a candidate for these medications, and there are other medications that have been around for decades that we continue to use for all our patients to slow the progression.
Dr Alessi: Let’s switch gears a little bit in terms of treatment. What should people do? ‘Cause what a lot of people are thinking who are listening to this is, “I don’t have dementia, but I want to avoid it.”
Dr. Zdanys: Mm-hmm.
Dr Alessi: What should people be doing in order to avoid, and there are so many studies about this and people have mid-forties, this is what you should start doing, and a variety of things. Can you talk about what you recommend to patients?
Dr. Zdanys: Absolutely. So I think the general theme that encompasses all those recommendations is that your heart health is your brain health.
So, what keeps your heart healthy is going to keep the blood vessels in your brain healthy, and is going to keep your memory working better longer. Now, just because you have a perfect adherence to all of those recommendations doesn’t mean that you will prevent the development of Alzheimer’s disease, but we know that you can potentially stave off the onset by doing a few things. So, one is cardiovascular exercise and the recommendation for cardiovascular exercise is a half hour of moderate cardio. You don’t have to be running, you can be doing a brisk walk. Half an hour, five days a week is shown to reduce risk of development of Alzheimer’s disease.
Dietary modifications. You don’t have to do a crazy diet, but we generally recommend something called the Mind Diet, which is a combination of a traditional Mediterranean diet, lean protein, fish, chicken, leafy greens, nuts, olive oil, those sorts of things in combination with a low sodium diet called the Dash Diet. So that’s going to help keep your blood vessels healthy, keep your cholesterol in check, keep your blood pressure in check.
I also want to emphasize blood pressure maintenance is really critical. There was a study called the Sprint Mine Study, where folks who kept their systolic blood pressures below 120 during the duration of this monitoring period actually reduced their risk of developing Alzheimer’s by about 20%.
So, blood pressure maintenance is important, not smoking - critical, and also moderation of alcohol use is important as well.
Dr Alessi: So everybody wants a magic pill, right?
Dr. Zdanys: Yes, of course.
Dr Alessi: And their supplements and things like that, most commonly, Prevagen.
Dr. Zdanys: Mm-hmm.
Dr Alessi: Does it work?
Dr. Zdanys: No.
Dr Alessi: Okay.
Dr. Zdanys: So, the FDA is actually after them for misleading advertising.
Dr Alessi: Okay. Because if you follow the ads and it’s all out there. Let me ask you a question. How hard is it for you, and I know it’s hard in my practice to tell people they can’t drive anymore?
Dr. Zdanys: Mm-hmm.
Dr Alessi: You must have to do that a lot.
Dr. Zdanys: Yeah, so, and it’s tricky because I’m not sitting in the car as a passenger with them.
So, I don’t know each individual kind of where they are and what they’re doing. But what I know is that when people have forms of dementia, like Alzheimer’s disease, one of the most majorly impacted aspects of their cognition is actually, it’s not just memory, but also their reaction time. And what I tell people is, listen, if you’re driving down the street, and a kid or a dog runs in front of your car, if you can hit the brake in half a second, that kid might be okay. But if you hit that brake in a second and a half, then we could have a completely terrible outcome. So looking at it from that perspective of safety of an individual, I think can sometimes be very compelling for folks to actually go and get a professional driving assessment where things like reaction time can be measured.
So it’s not a, you know, punitive measure. And I know symbolically taking away someone’s license is horrible in terms of their kind of self-concept and their independence.
Dr Alessi: Only because we don’t have good public transportation.
Dr. Zdanys: Well, this is a whole nother category that we could talk about.
Dr Alessi: I mean, if you lived in a city with public transportation, it’d be fine.
Dr. Zdanys: That’d be totally different.
Dr Alessi: But I think that’s it.
Dr. Zdanys: Yeah, no, here, you know, if you’re living in Farmington or Avon or somewhere, you may feel extremely isolated.
Dr Alessi: Yeah. So along that lines, when you’re thinking of in your field, what’s something our listeners need to know?
What are some of the things that are happening in your field that folks need to know about?
Dr. Zdanys: Yeah, so I think historically talking about mental health and cognitive health has been taboo, especially in the generation of adults who are older now, but number one, we do have effective treatments for many of our mental health conditions like depression and anxiety, and for folks who are experiencing memory changes, it’s worth mentioning to your doctor as soon as you are concerned.
Because the treatments that we have are most effective in the very earliest stages of our disease. Once the Alzheimer’s progresses to a more moderate stage, somebody might no longer be a candidate for things like our infusion medications. So, I think the earlier you can bring it up with your doctor and start that process of working it up, the better. And if your result is, “hey, you don’t have Alzheimer’s”, then wonderful, you know that. But if it is, “hey, yeah, it looks like your brain has the changes consistent with Alzheimer’s disease”, well, let’s talk about that and what we can do to get started on treatment as soon as possible.
Dr Alessi: Kristina, thank you.
Thank you for your time today. Thank you for everything you do for our patients here at the University of Connecticut.
Dr. Zdanys: It’s my pleasure. Thank you for doing this.
Dr Alessi: Many thanks to our guest today, Dr. Kristina Zdanys. If you have any questions or ideas for future programming, you can reach out at healthyrounds@uchc.edu.
Jennifer Walker is executive producer of the Healthy Rounds podcast. Chris DeFrancesco is the studio producer of the Healthy Rounds podcast. This is Dr. Anthony Alessi. Until next time, please stay healthy.
