Caitlin Whyte (Host): Well, Doctor, certainly an interesting topic that we're getting into today. To start off, can you give us a definition? What is dementia and are there different types?

Shilpa Srinivasan, MD: Thank you for having me, Caitlin. So, Dementia is really an umbrella term that's really used to describe a condition which causes symptoms such as memory loss, difficulty with what we call executive functioning, which are higher order cognitive processes that we use every single day to problem solve and plan, and these symptoms of memory disturbance and difficulty with functioning significantly interfere or impair daily life. And in clinical care, dementia really falls under the category of what we call neurocognitive disorders. But as I said, dementia is really an overarching umbrella term.

Host: And what are the earliest signs of dementia? Is it beneficial to catch these signs early?

Shilpa Srinivasan, MD: Absolutely. So there are a lot of different types of dementia. I will just add that Alzheimer's dementia is one of the most common types, and oftentimes we kind of associate that with dementia at large. But it is just one type of dementia, and there are several others. But in terms of early warning signs, there can be a lot of variability in how dementia presents and among the more common types such as Alzheimer's dementia, some early signs can include difficulty with first and foremost memory.

Sometimes the memory impairment affects what we call short-term memory, or it can cause confusion with keeping track of time and place, which is memory for more recent events. For example, a person may not be able to keep track of what they did recently or recall a recent conversation, and that can lead to some repetitiveness in questioning or even repetitiveness in conversations.

Other early signs can include difficulty remembering recently learned information. Again, can lead to repetitive questions, difficulty with those executive functioning tasks that I talked about a little bit earlier, which is the ability to plan, to sequence, to organize. Some examples of how difficulties with executive functioning can show up as an early sign would be a person forgetting how to maybe follow a well-known recipe, something that they've made and prepared time and time again or difficulty with remembering directions or getting lost along familiar routes or even balancing one's checkbook or managing finances or paying bills. Sometimes we see behavioral or even mood, anxiety or personality changes as early signs, along with difficulty in holding and following conversations, which can sometimes cause withdrawal from social activities or work.

 It is definitely important to identify these changes to determine and differentiate what normal age-related change in memory is from something more concerning and early detection can then help with early identification, early diagnosis, and early treatment interventions when clinically appropriate.

Host: How does dementia change over time? What are the different stages?

Shilpa Srinivasan, MD: So with Alzheimer's dementia, clinically, we used to refer to stages as mild, moderate, and severe based on an individual symptoms and the loss of their daily functioning abilities, such as their loss of ability to manage complex tasks, what we refer to as instrumental activities of daily living, like balancing a checkbook, driving, preparing a meal, shopping, managing medications.

These typically get impacted in the earlier or milder stages, and then progress through moderate and severe when even simple day-to-day tasks and activities like swallowing or walking, what we would consider basic activities of daily living, are impaired. So the disease really continues along a continuum.

It is important, however, to understand the distinction between Alzheimer's dementia and Alzheimer's disease. What I mean by that is Alzheimer's disease refers to the actual brain changes that occur due to the degeneration, which is the loss of brain cells, which shows up as brain atrophy, shrinkage, or other neurobiological changes. And to detect these, we actually use biomarkers like special brain imaging scans, or more emerging aspects of biomarkers in the clinical realm, which are blood-based biomarker tests to detect these brain changes. Therefore, with the advent of the clinical use of such biomarkers, we think about the stages of dementia now along a conceptualized continuum of Alzheimer's disease from clinical stages one through six, reflecting severity, really ranging from no detectable biomarkers, but perhaps there are some genetic markers for change, and the person is entirely symptom free, to the opposite end of that clinical staging spectrum where they have the full signs and symptoms of the severe disease or dementia. So this is how we think about this condition along stages.

What we do know is dementia is a progressive neurodegenerative condition, and, does progress at varying speeds and at varying rates, depending on the type of dementia, but progressive, nevertheless.

Host: Well, Doctor who then is at risk for dementia?

Shilpa Srinivasan, MD: So again, depending on the type of dementia, in general, we know that age is the most prominent risk factor, for example, for Alzheimer's dementia, the most common type. And the majority of individuals who develop Alzheimer's dementia, for example, are over the age of 65. We know from 2025 data that there are over 7 million Americans over the age of 65 who are living with dementia. And of those 7 million, 74% are over the age of 75 years. But it's important to remember age is not a cause of dementia, rather it is a risk factor. So the risk of developing dementia increases with age. So age is what we would call a non-modifiable factor.

Something that we cannot change or do something about. Other non-modifiable factors would be genetics or family history, but it's important to remember that there are also modifiable risk factors for dementia, things that we can do something about. Those modifiable risk factors are things such as maintaining heart health, brain health, or what we know a risk factor is a strong correlation with brain and heart health and conditions that adversely impact one puts an individual at risk for the other.

So, for example, certain health conditions like longstanding, poorly controlled hypertension or high blood pressure, or diabetes; conditions that for example, affect healthy circulation, can really put individuals at risk at higher risk for developing dementia than someone who's got well controlled blood pressure or diabetes. In addition, in terms of women, almost two thirds of Americans with Alzheimer's disease are women. We have to keep in mind that data shows that women live longer than men, so this may be a survival difference that contributes to what we call a higher prevalence of Alzheimer's and other dementias in women than in men.

Host: Well, you mentioned genetics in that last answer, and I'd love to dive into that for a second. Is there a genetic test for Alzheimer's, and when is that usually recommended?

Shilpa Srinivasan, MD: Yeah, that's a really good question. And it is also a very common question, and it's something that's on a lot of people's minds. So we hear this a lot. First, we should be aware that there are two major categories of genes that are considered when we think about genetics related to Alzheimer's disease.

One category is what we call risk genes, and the other category is what we refer to as deterministic genes. So what's the difference between the two? Risk genes increase the likelihood of developing a disease, but they do not guarantee that the disease will happen. In contrast, deterministic genes directly cause a disease.

So we have to keep that in mind. Now we know that there are certain risk genes that are very prominent. So the risk gene, again, this is one that can be, can increase the likelihood, but it does not directly cause or guarantee. But the risk gene with the largest known impact on Alzheimer's disease, and particularly in European descended white populations, is something called the APOE gene.

Which encodes for a protein in the brain called apo lipoprotein E. And there are four types of this APOE gene, 1, 2, 3, and 4. And people can have one or two copies of any of those four or a combination. What we know is that people with one copy of the APOE4 gene have a threefold greater risk of developing Alzheimer's disease than people with other forms of the APOE gene.

And people with two copies of the APOE4 gene have an even higher risk. So we talked a little bit about deterministic genes as well. Now, those deterministic genes, which directly cause the disease in Alzheimer's disease are actually in a very, very small minority of cases compared to all cases.

Usually these genes code for younger onset Alzheimer's disease, and these are sometimes referred to as dominantly inherited or autosomal dominant Alzheimer's disease. So someone with these genetic mutations have a higher likelihood of developing Alzheimer's disease. But again, I want to emphasize these are very rare cases and typically only account for less than 0.05% of Alzheimer's cases worldwide.

In terms of genetic testing in the clinical arena, in general, we do not advise routine genetic testing of healthy individuals for risk of Alzheimer's or other dementia until they've really received genetic counseling and truly understand the information necessary to make an informed decision. Because there are lots of social, economic, and ethical factors that come into play that could be impacted by having this genetic information. It is really important to remember genes are only one factor implicated in risk, and currently genetic tests that determine Alzheimer's or other dementias are primarily of value in research settings for clinical trials, for example, that investigate the role of genes in disease onset or for progression.

 It's also, helpful and we do encourage that anyone who's significantly concerned about their dementia risk or the risk of a loved one based on their family history or symptoms, they should really consider adopting healthier lifestyle habits regardless of their genetic status. Because those are shown to reduce the risk of dementia or cognitive decline.

Host: Now, how is hearing loss connected to Alzheimer's disease?

Shilpa Srinivasan, MD: Sensory impairment is a real concern. And while we definitely need more research to enhance our understanding of how sensory loss like hearing loss impacts Alzheimer's, we do know that age related hearing loss has also been associated with faster rates of cognitive decline and dementia in general.

Some of the reasons that are being explored is that hearing loss may place a higher burden on our brain processing pathways, so there's more brain effort directed towards auditory or sound processing than towards memory processing and consolidation. Another possible explanation that is being looked at is that hearing loss leads to, behavioral and environmental changes like social isolation and social withdrawal, which has actually been linked to an increased risk of dementia.

 And then more recently, studies are also investigating whether hearing loss is possibly an early manifestation of the underlying brain changes that cause the various forms of dementia. So there's a lot more research that needs to be done to look at a definitely common and concerning issue.

Host: One of these types of dementia that we've mentioned is vascular dementia. Can you tell us about that and how it's different from a lot of the other types of dementia?

Shilpa Srinivasan, MD: Absolutely. So vascular dementia is a condition that develops when the blood vessels in the brain are damaged, or when brain tissue is injured from either not receiving enough blood, not receiving enough oxygen or nutrients, and people with these conditions who develop dementia symptoms are considered to have vascular dementia.

It can often be seen in combination with brain changes of Alzheimer's disease as well. So in which case, this is a combination of vascular and Alzheimer's and is referred to as mixed dementia. Clinically, vascular dementia can present with more of a stepwise progression. For example, someone has a vascular insult to the brain, whether this be a stroke or aTIA or some other condition that adversely affects blood flow to the brain.

And subsequent to that vascular insult, they exhibit changes in their memory, but typically, that change is not progressive. They reach a new baseline, if you will, and they stay at that plateau until the next vascular insult occurs, and then cognition drops again, and then it plateaus and so on and so forth, which is why it's referred to as somewhat of a stepwise clinical progression rather, or in contrast to, let's say, Alzheimer's dementia, where the progression is slow yet insidious. So that's one way it can differ clinically.

Host: And when we're talking about risk, do certain medications increase the risk of dementia? What would you do if you take any of these medications currently?

Shilpa Srinivasan, MD: That's a great question as well, and certainly something that people always wonder, you know, am I on medications that can help me or harm me? So there are certain medications that the long-term use of these medications can adversely impact cognition or slow brain processing. And with some medications, long-term use can put individuals at risk for worsening cognitive impairment and risk for dementia. These include medications known as CNS or central nervous system depressants and some medications in this category include medications called benzodiazepines.Others are medications that are highly anticholinergic.

For example, medications that are often taken over the counter for sleep that contain diphenhydramine are anticholinergic agents. Now it's the long term c ontinuous use of these medications, or even sometimes narcotic pain medications used at high doses over long periods of time can adversely impact an individual's risk for dementia.

That certainly does not mean that one should abruptly stop these medications because abruptly stopping any medication can disrupt other health conditions and can certainly have a deleterious effect on quality of life. Rather, if someone's taking such categories of medications or are concerned about the impact of their medication regimen on their long-term cognition, they should certainly discuss their treatment plans with their healthcare providers and make an informed decision in that way.

Host: Well, in that case, how can you lower your risk of dementia overall?

Shilpa Srinivasan, MD: Yeah, so although there currently are no proven methods for preventing dementia or Alzheimer's disease, there are things that we can do today that can, that may lower our risk. First and foremost, we have to remember heart health is closely tied to brain health. So things like controlling high blood pressure, maintaining healthy blood pressures, talking to healthcare providers about medications and healthy lifestyle and related behavior changes that may help maintain optimal blood pressure control is one ready component. Maintaining a healthy weight. If a person has problems with diabetes or blood sugar regulation, managing their blood sugars and learning to reduce risk of diabetes or better managing diabetes through both healthy lifestyle as well as treatment interventions is important.

Smoking cessation, if someone smokes. Smoking cessation can significantly help because again, what's good for the heart is good for the brain. Getting enough sleep and getting restful sleep is also very, very important for brain health. So if someone has an underlying sleep apnea or has another condition that adversely impacts their quality or quantity of sleep, seeking treatment for that, talking to their healthcare providers about it.

Maintaining a healthy diet is also found to be helpful, and particularly a diet that emphasizes fruits, vegetables, whole grains, nuts, healthy fats like olive oil, healthy protein while limiting saturated fats and processed sugar, goes quite a long way. In fact, the Mediterranean diet has been linked to heart and brain health.

Another thing that we can do is stay physically active. It's good for the heart. It's good for the brain, and it's never too late to start a regimen of physical activity. In addition to maintaining physical health, it's also important to maintain and address mental health and seek treatment if there are any concerns about physical or mental wellbeing.

Another really important area is staying socially active and socially connected. Whether this be meeting with friends or family, volunteering, doing activities that one enjoys, supporting organizations, joining a book club or a walking club. But staying socially connected is very, very important for healthy cognitive processing, as is staying mentally active.

And the way we can do that is by challenging our mind, by learning a new skill, maybe taking classes to learn a new language. Anything that challenges the brain to perhaps think and do things in ways that it does not already do over and over again can be very, very helpful.

Learning new things and, and keeping up with things via the use of podcasts or blogs is another way to, again, stay mentally active. Protecting our hearing and treating hearing problems. Using a hearing aid if needed is also helpful because again, the links between sensory components and memory. And last but not least, there are linkages tobrain health, cognition and head trauma. So using the appropriate safeguards to ensure that we minimize our risk for head trauma, at any age, are some of the things that we can do to lower our risk for dementia.

Host: Now for those of us who may be caretakers to individuals with dementia, how can you protect someone with dementia who is prone to wandering?

Shilpa Srinivasan, MD: Wandering is an example of a behavioral disturbance in dementia. It can be seen as the disease advances, and sadly, it is not uncommon. It can certainly pose a risk to safety from the standpoint of falls or other harm and can cause significant distress. So some safeguards to ensure that the person with dementia who is exhibiting wandering behavior, is that they have adequate support and supervision in the home environment, securing the home exits, particularly at night or during times when there's less supervision. One way to do this is to perhaps install a deadbolt or a latch on the top of the door, or a section of the door that if the person with dementia cannot readily reach, utilizing a safety gate.

Reducing clutter at home to ensure that if the person who is wandering is not going to be at risk for falls by tripping or stumbling. Keeping the person with dementia engaged in activities, especially during times when they are more prone to wander, because sometimes wandering can be a function of boredom.

Considering daily supervised walks and using assistive technologies like an ID bracelet to ensure that if a person does wander, that they have some form of identification on them to be able to inform their safe return. Or even using a GPS enabled device, like a Wander Guard can be helpful.

Host: And why do people with dementia have worse symptoms at night? Is there anything that can be done about that?

Shilpa Srinivasan, MD: So this condition or this notion of persons with dementia having more behavioral issues or agitation or confusion at night is commonly refer to as sundowning, which is actually a nonclinical term, but it is used to refer to those symptoms that are associated with a state of confusion in persons with dementia that may occur later in the day and may last into the night.

 People with dementia are more susceptible to this state of confusion, particularly as the disease advances. There's really no single cause, but some factors that can contribute to this confusion include things like fatigue, boredom, low ambient lighting in the environment, disruption of the body's internal time clock, pain, depression, hunger, et cetera.

And there are some strategies that can be helpful. One important thing is to try to keep to a routine and avoid disruptions, so keep a predictable routine for bedtime, for waking, for meals and activities, and avoid changes or disruptions in that routine as much as possible. It's also helpful to plan for activities and exposure to light during the daytime.

Again, to address some of that internal clock time clock disruption, so more light exposure during the day to provide more of a readiness for the slowing down of activity that supports nighttime relaxation. In as much as possible, try to limit daytime napping, for the person with dementia who's exhibiting this type of sundowning.

That can be challenging, but trying to limit it by having activity and minimizing boredom can be helpful. Similarly, limiting caffeine and sugar to morning hours so that some of the nighttime activity isn't necessarily increased or worsened because of the urge to go to the bathroom, which can happen with a lot of caffeine and sugar consumption.

At night, turning on a nightlight to reduce agitation can be helpful, particularly when surroundings are dark or not familiar. Also, in the evening, trying to reduce background noise or stimulating activities. So for example, if watching TV and programming leads to more stimulation or even perhaps even some concerns, then that can be upsetting.

So minimizing that activity can be helpful. If the person with dementia happens to be in an environment that is not familiar to them, let's say they're traveling out of state, been taken to another person's house, et cetera. Then bringing some familiar items, like a favorite blanket or a photograph can create a more relaxed setting.

And in the evening, trying to wind down by playing familiar or even gentle music like soothing sounds, sound of waves or nature, et cetera, can be strategies to try. Medications can sometimes be helpful, like low dose over the counter melatonin, but we have to remember that medications can also sometimes worsen confusion, like over the counter sleep aids that have anticholinergic agents like diphenhydramine, which really should be avoided in persons with dementia.

Sometimes a medical condition, like an underlying infection, like a urinary tract infection, may be the cause of new onset of these behaviors. Untreated pain, depression, or other factors may be contributing. So if a caregiver or a family member notices such sudden changes or confusion states in their loved one with dementia, they should really reach out to their healthcare provider about these observations and concerns.

Host: And to close us out Doctor, any other tips that you have for caregivers of loved ones with dementia?

Shilpa Srinivasan, MD: Absolutely. Thank you for that question, because this is really, really important. Dementia is a condition that doesn't just affect the person diagnosed with it, but it has a profound impact on caregivers. So it's really critical that caregivers attend to their own care needs and wellbeing as well. This can be challenging when a caregiver spends so much time and energy focused on the care of their loved one with dementia that they put themselves on the back burner, which can in turn adversely affect the caregiver's own physical and mental health.

It can be helpful for caregivers to reach out to family and friends to for support, to provide a break in caregiving whenever possible. And for caregivers to know that there are resources in the community to provide such support so caregivers can feel heard, they can feel respected, and feel empowered and understood.

Also, caregivers may need to navigate their loved one's future healthcare and financial needs or resources that, involve accessing information for legal aspects such as surrogate decision making or powers of attorney. So there are community resources that can be really helpful. One such resource is the South Carolina Chapter of the Alzheimer's Association.

It provides caregiver support groups and programming as well as resources for respite care for persons with dementia. Here at PRISMA Health, we have memory health programs that offer caregivers access to caregiver resource libraries that contain educational resources on caregiver stress, proper care, and relevant topics.

There are also quarterly caregiver education sessions designed to improve caregiver understanding on how to properly care for someone with a memory disorder. So in summary, for caregivers, dealing with dementia and having a loved one with a diagnosis of dementia; it's not just about the diagnosis, it's really about the journey.

And for us in healthcare, we try to walk alongside, our patients and their families along this journey, and we recognize that caregiver health and caregiver wellbeing is directly tied into the health and the trajectory of persons with dementia as well.