Scott Webb: Though dementia typically affects older adults, it's not a normal part of aging. In other words, most people will not develop dementia in their lifetime. But for those that do, diagnosis and treatment has come a long way. And though there's no cure, there's reason for optimism if you or someone you know is living with dementia.

And joining me today to discuss dementia, the signs and symptoms and treatment options is Dr. Olga Noskin. She's a vascular neurologist with Valley Health System.

Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. I'm Scott Webb.

Doctor, thanks so much for your time today. We're going to talk about, Alzheimer's dementia, but broadly speaking, cognitive impairment in general today. So as we get rolling here, what are the symptoms of cognitive impairment?

Dr. Olga Noskin: So cognitive impairment has many different domains. And basically, it's the different domains of cognitive function, which have to do with memory, learning, motor abilities such as walking, even language abilities, communication as well as attention. And ultimately, these affect our daily activities. And depending on the degree to which they're affected, we talk about mild cognitive impairment or possibly moderate or severe cognitive impairment, which can also be known as dementia.

Scott Webb: Yeah. And before we get too far into our conversation today, maybe just to kind of define things, what is the difference between Alzheimer's disease and dementia?

Dr. Olga Noskin: That's actually a very commonly asked question, Scott. And the answer is there is really no difference because dementia is a very large umbrella under which multiple diseases may live, including Alzheimer's disease. Alzheimer's is simply one type of dementia. We have many more. Alzheimer's is the most commonly known and commonly seen type of dementia.

Scott Webb: Yeah, I think you're right. Whether it's media, social media, we're all pretty familiar with Alzheimer's disease. How do you diagnose or evaluate cognitive impairment?

Dr. Olga Noskin: A lot of times these patients get brought into their primary doctor, geriatrician or neurologist, and the same types of questions arise from the family. Why is my loved one repeating the same question over and over, can't recall certain things and so on? Why are they acting differently and their personality's changing? So, we go through each one of these situations and we test their memory with some standardized testing, such as neuropsychological testing or cognitive evaluations. And we have multiple iterations of those. We certainly go through some blood work analyses looking for reversible causes of cognitive impairment, and we actually have some of those. We do imaging studies such as CAT scans and MRIs, and sometimes PET scans of the brain because, obviously, the brain is the organ system, which ultimately is involved in dementia. We also do sometimes genetic testing and even some invasive testing such as spinal taps, depending on the patient's situation. So, we certainly have a protocol to go through before we finally diagnose somebody with dementia and the type of dementia they have and offer them treatment.

Scott Webb: Yeah. And before we get to treatments, you mentioned there some of the elements or signs or symptoms may be reversible. So, one of the questions I had was, is dementia permanent or are some at least elements of it reversible?

Dr. Olga Noskin: There are some types of dementias which are fully reversible, almost fully reversible, potentially 100% if caught early and if the reversible aspects are found out. For example, the two most commonly reversible causes are vitamin B12 deficiency, which we always test for in any case of cognitive impairment. And B12 deficiency can be reversed as well as the symptoms of B12 deficiency. Another commonly sometimes forgotten, unfortunately, but commonly seen reversible cause of cognitive impairment is something called normal pressure hydrocephalus. It is a diagnosis which is both clinical and radiological on imaging, but the dementia that's associated with this condition can be reversed at least partly with a surgical procedure.

Scott Webb: You know, one of the things, doctor, that occurs to me, I worked with somebody once who when he would forget something, he'd say, "Oh, sorry, I'm having a senior moment." But I'm wondering, isn't forgetfulness just a normal part of aging or are we chalking too much up to the aging process?

Dr. Olga Noskin: Yes and no. Certain types of forgetfulness, we certainly have pretty much from our 20s, 30s and 40s as soon we start getting enough distractions in our lives, such as children coming in or other activities that we need to attend to or five different activities that we need to attend to. Our ability to multitask certainly decreases, declines with age. So that kind of forgetfulness and inattentiveness can be normal. However, the degree to which it occurs, such as being unable to recognize your loved ones or being unable to find your way home or feeling paranoid about normal activities inside your household, these types of things are certainly out of the norm. They're out of range for normal aging, and that's when we start getting concerned and we start looking for other causes such as dementia.

Scott Webb: Yeah. And you talked about some of the types of dementia that possibly can be completely reversed, which is amazing. And I'm sure reason for optimism, and I'm sure there's lots of work going on to try to make everything reversible. But in the meantime, when we think about dementia or possibly Alzheimer's disease, let's talk about family history and genetics and what role they may play in cognitive impairment.

Dr. Olga Noskin: We always talk about the family history with our patients. There are certain types of cognitive impairments and dementias which are often genetically predisposed or provoked by genetic factors. However, just because a family member has had an Alzheimer's type dementia, for instance, even though it does have a high genetic component, it does not 100% automatically mean that your family members or your children, progeny will necessarily contract the same disease. It does not get transferred 100%.

There are some other types of dementia. For example, there's a condition which is very rare, but also is associated with dementia, such as Huntington's disease, which has a very high genetic transfer from generation to generation; patients with Parkinson's disease who get dementia oftentimes if this condition runs in families. But then, there are others that are completely sporadic, spontaneous, and have no genetic predisposition.

I think regardless, it certainly helps to know especially in patients who have vascular risk factors, so stroke risk factors or heart problems. Patients with vascular changes in their brain such as strokes, oftentimes have dementias. And that is important to know from generation to generation. Yes, family history plays a big role.

Scott Webb: So, you mentioned earlier about treatment. Let's talk about the latest and greatest in treatment for dementia, Alzheimer's, cognitive impairment, what's good, what's got you excited, what's working for patients and so on.

Dr. Olga Noskin: So, you know, up until a few years ago, the only treatments that have been available aside from the reversible treatments that we've talked about, maybe vitamin deficiency treatment, thyroid treatments, maybe even surgery depending on the condition. In Alzheimer's disease specifically, we've really only had two drugs or two classes of drugs available which have been treating this condition but not curing it unfortunately. And those medications may be very well known by their brand name. I will just mention the generic names, which is donepezil, galantamine and rivastigmine. These medications are both oral and patch form. They have been around for many years. They do have some side effects associated with them, which I always talk to patients about. And in some rare cases, these do actually offer a benefit of improvement of cognition which is relatively short lived. But the ultimate goal of this medication, as well as memantine, which is the second class of medication which has been around, the goal of these medicines is to slow down the progression of the dementia. It is not offered for every type of dementia except Alzheimers, but I have really found this combination to be very helpful for a number of patients. I believe that it slows down their progression.

And then, over the course of the past several years, a lot of your listeners probably heard that there's a couple of companies which are really working hard in developing a medication, which tries to target the actual underlying cause or what we believe to be the cause of Alzheimer's disease. And these are what are called really immunotherapies, which is the hot stuff of medicine and pharmacology these days. And these medications are yet to come on the scene as definitely effective and for sure not unsafe. So we're still learning about them. One such medication was in fact approved a year and a half ago. But we, as a community of neurologists and dementia specialists, we have not been entirely. Happy with some of the data that has come out about this particular medication. Therefore, we are actually awaiting the second iteration of a similar medication that's about to come out soon. We are all very hopeful. We want this to work. We all have patients who are potentially going to benefit.

Scott Webb: So, let's talk a little bit about whether or not folks with dementia can take care of themselves. And if we find ourselves taking care of a friend or a loved one, or a parent, whomever, how do we comport ourselves with them? Should we tell them or remind them that they have dementia? Should we tell them the truth about topics? From your perspective, from your expertise, how do we handle all of that?

Dr. Olga Noskin: Well, this type of question actually usually takes me a good hour with my patients and families. In fact, right before we started talking, I had scheduled an hour discussion with one of my family members of a patient who has dementia, new diagnosis of dementia, to discuss these very questions. It is not a simple answer.

I think what I would offer as an answer primarily is to say, use your family member's lead to discuss what they can accept and comprehend and what doesn't give them any kind of an emotional distress. And if you think about it, I think this will apply to pretty much all of your questions.

The three avenues or the three kind of big topics that I discuss with my families are the patient's safety, their ability to deal with medications and nutrition. And under the safety umbrella, we do talk about what can we discuss with the patient, so that they don't get scared, they don't get paranoid, they don't think that the whole world is against them and they're trying to put them away.

Some patients at the beginning of their journey are able to comprehend and accept the diagnosis of dementia, but they may not hold onto it. What they may, however, hold onto is the emotional content of that discussion, which may be very negative and it make them very depressed. So, I think you have to be very careful about being judgemental or accusatory or labeling the patient as having dementia because that discussion really carries no weight other than it makes the patient depressed. What you do want to do is be supportive, find ways to supervise the patient in their daily life.

If you think that they're in trouble, if they have more trouble remembering to dress themselves every morning or to brush their teeth or, you know, remembering how to make breakfast, help them out. Make it a fun activity together. Try not to push them or pressure them into it. If they forget that their brother or sister or mother or father have passed away, you do not have to remind them about it every single day because guess what? The next day they will forget again, and they will have to relive that trauma every single day.

I think little white lies are okay to tell to some patients with dementia as long as they feel comfortable about it and it'll put them at ease. You can say that their loved ones are not here right now, but they're okay and we can talk about something else. You can go through old pictures instead, but you don't have to necessarily open up some emotional conversations again because they really serve no purpose.

I think that as neurologists and psychologists and there are some dementia counselors out there who are social workers and wonderful nurses who can guide the families through these times, we spend extra time and discuss all of these little innuendos and scenarios with our families if we have time and if they're willing to, and we guide them through it because it certainly is very traumatic. And I think it's also very important that family members of these patients take good care of themselves, both health-wise and in terms of their emotional health because this is a very trying time for any family to see their loved one going through this journey.

Scott Webb: Yeah, it really is, and I appreciate that, normally, you know, that whole thing may have taken you an hour or longer, I appreciate you cutting it down to three or four minutes. So, well done, doctor. Just a few more questions for you here. Is dementia in and of itself terminal? I mean, we're all facing, you know, an expiration date, if you will, but is dementia itself terminal?

Dr. Olga Noskin: Again, it's a complicated question because it depends on the type of dementia, but let's maybe concentrate on Alzheimer's dementia. With Alzheimer's dementia, there is sufficient and often rapid progression of atrophy and internal damage and deterioration, degradation of brain structures. And our brain ultimately is responsible for many of our vital functions, such as swallowing and drinking, and even breathing and walking as well, you know, our bowel and bladder control, if you will. As our brain functions get worse and the brain actually atrophies, a lot of these functions deteriorate. So you can imagine that, for instance, the swallowing ability unfortunately starts falling apart and patients first of all are unable to swallow safely. They can choke and they can develop pneumonias, which certainly is terminal potentially if it happens repeatedly.

And also, they forget to take care of themselves. They also lose their interest in food and their appetite decreases and they're unable to walk anymore. They're now bedbound. And when they're bedbound, depending on the care that they are provided and they're nutrition, they may run into some bed sore situation and infection. So indirectly, dementia does, unfortunately, lead to terminal prognosis in these cases. But again, with good supervision and nutritional care and family support, this does not need to happen very rapidly. There are certain types of dementias that have very indolent, very slow course, and patients do not necessarily die from it.

Scott Webb: It's very interesting stuff today. I know that we could speak all afternoon, but neither of us has that kind of time. So I'm going to give you one last question here, Doctor, and I really do appreciate your expertise. You're giving me a lot of food for thought. What advice do you have for patients who are concerned either about themselves or loved ones, family, friends, grandparents, whomever, about cognitive impairment?

Dr. Olga Noskin: The advice that I would have is don't be surprised if there are many other people around you in your community who have had similar experiences and similar thoughts that you can actually turn to without embarrassment. And I'm not talking about the medical community, I'm talking about just your immediate community. You can talk to people and you can ask their advice because a lot of them have been through this journey with their loved ones and they can help out in terms of resources. And I'm just jumping ahead in case you are already diagnosed or you have someone diagnosed.

But do not feel embarrassed or shy to bring these questions along to your physicians. We listen, we know our families and a lot of times three, four generations of families in our practice, and we need to know your worries. And in fact, anytime you go to the doctor, you want to come out with your worries addressed. So if you have a concern, please bring it up. We may or may not be able to give you the answer that you're looking for, but we will at least give you the pros and the cons of getting that answer now or in the future or we may give you some advice on how to ward off certain dementia symptoms, in fact, because there are certain things that people can do in terms of their lifestyle and health control and nutrition. So there's a lot that you can gain if you're worried. Talk about it. Open up.

Scott Webb: Yeah, you're so right. There is so much support typically in respective communities. Obviously, we have medical care providers and specialists and so on. And unfortunately, doctor, most of our lives have been touched by some of these things, whether it's dementia, Alzheimer's, cancer, but the good thing is that there's lots of work being done and lots of things on the horizon, lots of support, medical experts like yourself, your expertise, your compassion. So, this was really great today. Thank you so much. You stay well.

Dr. Olga Noskin: Thank you very much.

Scott Webb: And for more information about today's topic, please email valleypodcast@valleyhealth.com. And if you found this podcast helpful, please do share it on your social media and maybe with some family and friends. And thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. I'm Scott Webb. Stay well.