Avenidas Videos: Watch & Learn

Avenidas Care Partners presents a panel discussion with Dr. Mehrdad Ayati, Director of the Geriatric Center and Dr. Logan Schneider, Co-Director and Staff Neurologist for the Stanford VA Alzheimer’s Center.

Dr. Ayati begins the session with an update on Covid-19. Each speaker will then introduce the services provided at their clinics to help clients understand cognitive health, signs and symptoms of impairments and testing protocols.

Includes extensive Q&A with attendees.

Transcript

Katherine King  0:05  

Good morning. Thank you all so much for being here. We are so glad that you could be here with us. A couple of things I wanted to share, before we get started: I wanted to reiterate that we will be recording this town hall today, and will be uploading it to our website later this week. So you can share it, rewatch it, whatever you would like. As you may have noticed, we have you muted this morning, and you will not be allowed to unmute for the sake of order. But the chat line is open. It’s on the bottom toolbar if you’re a Windows user, and I think it’s on the top if you’re a Mac user, but you can find the little chat bubble, and click that and you should be able to talk. So please feel free to ask any questions or put in any comments you have, we will be taking those I believe throughout. And after both Dr. Ayati and Dr. Schneider have spoken. Thank you both for joining us. And I’m going to hand things off to Paul Wolfson, manager of Avenidas Care Partners, who will be helping me moderate today’s session.

Paula Wolfson  1:12  

Good morning, everybody. I’m sitting in my office, downtown Palo Alto and the building is closed. But I do come in. And right now I’m sitting here with this book called Dementia Reimagined by Tia Powell MD, I don’t know if our doctors have read this or not. But here at Avenidas we try to reimagine everything, and see what we can do to help enhance the quality of lives of all of our people. And so this town hall, we decided to do quite a while ago, and then of course, COVID, and the vaccines and all of this is now in the news. And I just want everybody listening right now to know that the January town hall will be about COVID and the vaccines and we’re going to have experts from Stanford on at that time. But if you have questions about this today, think of them in relation to our topic of COVID and dementia, and and how that may play out in terms of having a person with dementia vaccinated or what your questions might be about that. We want to try and stick to our topic today. But Dr. Ayati, will start things off in a second regarding a little bit of an update on COVID. 

But let me tell you about our two speakers. So, many of you know Dr. Ayati, because he’s been with us many, many times. He’s the director of the geriatric Center in Los Altos. He’s testified before Congress and legislatures in Sacramento, on challenges of aging. I say, I will say this, I should wear a T shirt that says he’s got the State of the Union address on caregiving and aging in America. And I keep wanting to give him that platform and one of these town halls one day to do that, maybe January 21st. We’ll have him on doing a state of the union address on aging. 

And then I recently met Dr. Schneider, because I was brought in on a session where he was giving testing results to a 92 year old gentleman. And it was an amazing process to watch. So Dr. Logan Schneider is a neurologist on staff at,  on staff at Stanford, and the assistant director of the VA Alzheimers testing center, and I’m gonna let him explain more about that. But he’s also an internationally recognized expert on sleep and cognitive issues with a special interest in big data approaches from genetics to machine learning. And I’ll let him talk a little bit about that too, because that helps him to understand brain health. And part of what we want to talk about today is brain health, and sustaining cognitive health. So I’m going to start now by turning it over to Dr. Ayati. I’m going to go off screen and kind of help manage the chat line. So Dr. Ayati, the ball’s yours.

Dr. Mehrdad Ayati  3:56  

Thank you so much. Again, I appreciate it again for Avenidas for inviting me. Glad back again to the town hall is such a wonderful group to discuss and I’m again so it’s a pleasure to be with Dr. Schneider today. 

Before I want to go about our topic of the brain and aging and also regarding dementia. Just the one topic because a lot of people ask and Paula asked me as well. Sadly, we’re not doing well in as far as like the Coronavirus has spread this days. The last two weeks has been a big disaster in Santa Clara County, we have many new cases, more death, more hospitalization. The new virus behavior is extremely airborne means that we have to be extremely careful especially every every everybody. All the facilities that I go right now everyone has an outbreak right now. It’s a really big disaster right now in the community. The other things that a lot of people may do this is a discussion for the next topic, but regarding the vaccination. And as you probably know all people age 65 years older and people with pre existing condition in the category of one B is after the healthcare worker in a skilled nursing home residents, and there will be the second phase of the vaccination. However, vaccination is a true dose of vaccination. It takes almost weeks after vaccination that we see immunity even after that, it takes six to nine months that we see effective vaccination in a community. That what does it mean with, is even we do the vaccination next week or next two weeks? It doesn’t mean anything, we still have to be smart, be safe, be careful, especially with the new behavior of this virus as well. Because it’s a it’s again, it’s very contagious right now, and many people actually infected. And we have to be very careful about that. 

With that introduction, I just wanted to again, because today we don’t have our presentation, I’m going to ask Dr. Schneider to talk more. And I see some of the questions in the chat. One thing, I’m a geriatrician, I’ve been in this area for a long time. I’ve been teaching geriatric and internal medicine at Stanford as well. And I’m continuing my adjunct faculty position with Stanford and part of the geriatric group. And I also having a clinic in Los Altos, which I provide geriatric consultation for people in community. I’m not acting as a primary care, but I do, seeing the people for the geriatric syndromes. One of the biggest challenge that I can share with you, and I’m sure Dr. Schneider is gonna continue that, it’s really the biggest challenge for many of us, is diagnosis of dementia, early diagnosis of dementia is especially very, very important. And many of people they actually don’t like to have early diagnosis of cognitive impairment because they say, Well, I don’t want it to be labeled with that. But the other things that I’m sure we will be happy to talk about it, there are many risk factors that add, or many reversible cause of cognitive impairment, that we can identify in earlier stages. That’s why we love to have more comprehensive evaluation about memory, and mental health in all aging population. And not only focusing on some of the lab results, only checking your cholesterol or checking your blood pressure, it is very important that all the providers in the community to focus on neurological examination, which we encourage them to do. Because many of neurodegenerative disease many of other big umbrella because dementia is just a name, is a big umbrella has many diseases under this big umbrella, how we can diagnose them, how we can confirm the diagnosis. When it comes to the testing, as Dr. Schneider is going to explain more, we can actually find what exactly wrong or what part of the brain is wrong. And what should we do as far as I can manage. Now, as far as a geriatrician, I do manage many of the complexity related to dementia, a majority of them behavioral disturbances related to dementia as well, which is that one of the main reasons that is caused a lot of caregiver burden as well. And, and managing these symptoms can be extremely difficult for family members for when you see the loved one has this this issues. And this is why I believe if we’re able to diagnose dementia in their in much earlier stages, we educate the family members about what’s what we going to see in the future. What are the expectation, what are the symptoms that may happen? Like for example, I see somebody in the chat with about the frontal temporal dementia, we have a lot of behavioral symptoms related to Lewy body dementia, or even Alzheimer dementia as well. Or even vascular dementia is sleep disturbances related to change of the what we call brain circadian– Brain circadian disorder as well. These are the things that we wanted to make sure that people and family they’re very well educated because then that can help you to manage better the symptoms of your loved one. Now, I’m going to ask Dr. Schneider to have starting to have this conversation. We continue then I will be happy to answer any questions you have regarding this and also regarding the COVID situation right now.

Dr. Logan Schneider  9:27  

Great, yeah, thank you, Dr. Ayati. I think that’s a very excellent introduction. And obviously, two main themes coming out of that one obviously being the impact that this pandemic is having on all of our lives. And obviously the relevance to very select populations, including those who are at risk for dementia tend to be older and therefore higher risk. And so these are the people that obviously we want to target to keep them healthy, and having as good a quality of life as possible as long as possible.

But the other vein that you struck upon really is talking about the nature of diagnosis. And I think a couple of the points that you brought up that I jotted down and want to re-emphasize are one is that early diagnosis is key, right. And so this is not something that necessarily we want to diagnose somebody early with dementia, in fact we want to try and capture people early, prior to their onset of dementia. In fact, because most cases of dementia, we actually don’t have any treatments that stop or reverse the disease, but really only have the option to what we call risk factor modify. So find out the things that are contributing to the existing cognitive problems, and then stop them so that they no longer progress or no longer cause progression, even though you know, generally, none of us are in our 20s anymore, we all feel that. And so progression over our lifetime is obviously going to eventually end in us going to the afterlife. But in the meantime, obviously the the course of that progression is something that we hope to change, right. And that’s really the essence of early diagnostics. And one of the problems that we face in medicine in general, but certainly in the dementia world, is people tend to not present to us until there’s a problem. And so as a as a researcher and and clinician, it’s always hard to know, well, where did you go? Where’d you come from? And where are you going? Right? We don’t actually understand where that trajectory is, if we catch everybody at this point, your trajectory could be like that, or it could be a little bit more flat. And so one of the things that is very challenging is people don’t get what we call the baseline, right? We don’t tend to follow them over their entire lifetime. We tend to see them once there’s an issue. And that’s, you know, for example, if you had a brain tumor, well, how long has that brain tumor been there, nobody’s getting their yearly MRI, for example. That’s actually just to put in a plug for the Stanford VA Alzheimer’s Center, which is freely open to anybody in the community who wants to be seen. It is not a clinical center per se, even though we do a clinical evaluation, that is incorporating of neuropsychiatric or neuro psychology testing, which is one of the components of a diagnosis of dementia, and other cognitive problems like mild cognitive impairment. It’s one of those things that where we add that to your clinical care, you can take it to whoever’s managing your primary care, but it’s a free resource to anybody, VA veterans, anybody within the California Community, because it’s part of this California state funded by your taxes, Alzheimer monitoring cohort that’s been going on since the 1980s. So that’s one of the components of diagnosing dementia. And it’s important because people can come in without any problems whatsoever we have, we have 40 year olds come in, we have veterans who’ve had traumatic brain injuries come in who have just cognitive concerns. So we have all vareties of people. And this is valuable, because it allows us to then track a baseline and then monitor things over time and see how they progress to give us a better understanding for you, whoever comes in and has interest, to be able to see where things might be going. Right. So you know, a single point doesn’t tell you much just like a Polaroid wouldn’t tell you much of a movie plot. But really, those points over time can give us a trajectory and understanding of how you’re progressing. While at the same time, you’re contributing to our understanding as a as a clinical field as to how do people progress normally and not. Right. And as mentioned, this is the second point that I thought was excellent. Lee brought up by Dr. Ayati, is that way, the ways in which we diagnose and this is to the the point of the Frontotemporal dementia is that we don’t actually have diagnostic certainty while people are living. And that’s hard, right? Medicine, people look at it from the outside and think, oh, you come in, you get your tests, and you get your answer. And medicine is not that concrete. Even in some of the more classic diseases, right? We often deal with what we call the differential diagnosis, a list of possibilities, and we slowly try and winnow that down to what we believe are the most likely answers. And it comes through pattern recognition, integrating information from multiple different domains. We’ll take the testing, what areas of thinking are you having problem problems in? Are you having functional impairments in your life, and we integrate that into sometimes adding appropriate diagnostics, imaging of the brain is good to often rule out or you know, get off the table considerations that are not playing a role. Like we don’t want to see a tumor causing people to have seizures that make it look like they’re having a dementia, for example. But sometimes it can provide useful information, patterns of shrinkage of the brain that look like very specific disease states. Evidence of strokes that may be hiding in there. Sometimes people don’t know that they’re having small strokes over their lifetime, or even just blood vessel damage. Just like heart disease builds up in the brain just like it does in the heart, even if you don’t have a heart attack. So those types of things can be helpful. Sometimes additional diagnostics, of course, including risk factors, like if your thyroid is low, and your brain just doesn’t seem to be running on all six cylinders anymore, that could be a thing. So we want to rule out other things that obviously can mimic dementias or thinking problems, but that are not neurodegenerative, meaning that the brain is slowly accumulating damage over its lifetime and declining, right. That’s the those are the things we want to get off the table, fix those things up, and then see where we stand. And then of course, there’re some of the more research intensive type of modalities where we can take a sample of the fluid that floats around your brain, look at levels of toxic proteins, normal proteins, but in excess they become damaging to the brain. Some imaging, like brain images, that, that include things like PET, which they use a little radioactive tracer, not more than you would experience by flying on airplanes five times a year. And it just gives you that we want to see how your brain is metabolizing. Is it working in different areas? Is it not working in different areas, those types of patterns and stories then add to the overall picture. But once again, the only way that we can definitively diagnose and even sometimes it’s hard then, any dementia is obviously having the symptoms of dementia. But then after you pass away, being able to look at the brain under a microscope and really see what does the damage look like? Is that damage caused by the classic proteins of Alzheimer? in classic spaces of Alzheimer things like beta amyloid? How? Is it happening, that it’s mostly stroke type damage? Is it something else is it maybe a different type of toxic protein accumulation like alpha synuclein, like you see in Parkinson disease. And so that adds to the diagnostic certainty. But normally in life when we’re talking to people, even with a lot of the advances in science so far, we often are stuck in the kind of probable possible space right? Oh, this sniffs like this. And the odds are pretty good, you know, 60 to 85% of people with a dementia have Alzheimer, at least as a part of it. Particularly in the United States, we have mixed dementias where blood vessel disease, like heart disease is also brain disease of the blood vessels. And so we tend to see a lot of mixed pictures in the United States. But for the most part, our job is to gather all of this information, history that you provide, the pattern of decline, how long it takes, is it fluctuating as we might expect in certain dementias and not others w– how– what do those fluctuations look like? Have we diligently gone through the list of other possibilities and gotten them off the table, assimilated all of the additional diagnostic tests, and sometimes brain electrophysiology, like EEG– electrical activity study, sometimes brain imaging studies, sometimes blood markers, sometimes genetic information, particularly if you’re presenting in an odd way, like super young, with an– with an Alzheimer type dementia, well, then that says like, well, there might be a genetic component that’s strongly causing this. And then we put all that information together and say, This is the pattern that we’re looking at. And at our center, we’re just one critical piece of that puzzle, because the way that dementias manifest is by their symptoms, symptoms of memory problems. And so we help nail that down by defining areas of thinking that have problems. And a presence of a functional impairment, where you may not be able to shop for yourself for, or your financial management is now becoming a problem. And so you put all that together, and we’re just one piece of that big puzzle, to be able to decide on what we think is going on and what appropriate interventions to do. And sometimes those interventions help answer things, right, certain medications work for a type of dementia and not for others. And when we’re on the fence, maybe a response to medication that we expect, leans us more toward saying, “Yeah, well, this is that, right, that type of dementia, particularly the Alzheimer type dementia with classic acetylcholine esterase inhibitors, or mantiene.” Right. So those medications shouldn’t be working very effectively in other dementia types. And so if it works, we’re like, okay, maybe that’s even part of our understanding of the disease. So in your case, right, one, each individual’s case. So it’s a long story about how we do that, as mentioned again, but the key is catching it early so that we can alter that course, and, and even it out and do the best we can to prevent.

Dr. Mehrdad Ayati  18:41  

Thank you so much. And I really appreciate that. I wanted to add to Dr. Schneider again, the fact about the diagnosis of dementia. It’s a very complex. And and again, first of all, I think one of the people asked about imaging, is it going to be helpful for for diagnosis. One thing we know that is still we don’t know many things about brain and again, finding the brain map. I remember that was something people and during Obama, Pres. Obama, there was been this giving $100 million for a budget for more diagnosis related to dementia. $100 million is nothing for for for really brain research, because it’s a very, very complex organ. And we still need a lot of the, again, expanding of all the research centers and all this stuff, the spending a lot of money for and resources to just really find what’s in the back of this mysterious curtain of brain. Because many things affects the brain and, and for the very good point that actually Dr. Schneider brought it up because I’m, a lot of time, people– I see the people in the skilled nursing or memory care and they have a symptoms of behavioral disturbances related to dementia. And that was a really good point about medications may you may may be useful for some kind of dementia is not useful for other kinds of dementia. When I go see the people, they only diagnosed with cognitive impairment or dementia, and their problem is not the type of dementia. And then because of the behavioral problem, we try some anti psychotic medication, which sometime in some sort of dementia can have paradoxical adverse effect, especially like Lewy body dementia, which, using an anti psychotic medication, it actually makes the agitation and many of the behavioral symptoms worse. Now, if we really don’t know about type of dementia, if you really don’t have a very experienced neurologist to kind of evaluate the patient, find what kind of dementia this person has. And we just have a very, like a way name of dementia, and the use the medication, sometimes we actually going to see more adverse outcome in patient. Now many time again, which I’ve been very blessed with the collaboration with the with, with my colleagues at Stanford, we able to kind of identify what kind of dementia this person has. And based on that even choose medication that they can they can use. And the other thing about that Dr. Schneider brought up, which is very important, it’s about why it is important to have this diagnosis on board, even like earliest stages, or even if we have it, it is important to to know about it. Because many medications that we use for other purposes, like for example, many people use medications for the urine incontinence that we call it anticholinergic side effects. And that anticholinergic side effect it makes the actually the cognition to be worse. The adverse effects of many medications, even cardiovascular medications or any other medication that we use, it is very, very important that we be aware of is there any pathology going on in the brain? And if we want it to treat other diseases that is not related to the brain with any medication, then we be aware of that side effects of these medications on the brain health as well. This is these are the things that again, we really like the people have a better comprehensive evaluation. And both side by neurologists and also geriatrician to go over together. Managing of dementia is a teamwork, it’s not a single physicians can actually manage dementia, isn’t it’s not only physicians only, it’s going to be the entire team, including social worker, nurses, physicians, it’s like a big team work a specialty team work, that we can manage a person with dementia and give them quality of life. I just wanted to mention about another question is that, “Do we have any specific magic image?” Dr. Schneider answered very well, we don’t have any specific magic image like MRI that we after this MRI, we can say definitely the person has Alzheimer’s or Lewy Body dementia. The answer is no. But definitely image can help us a lot to find many other finding, as Dr. Schneider pointed out, if somebody has tumor, we see the shrinkage in some part of the brain. There are other part of the brain we call hypo campo area, which is the Center for short term memory and learning. We can see shrinkage in that area, we can see some abnormality in some functional MRI, more and more specialized MRI that we can find what’s wrong with the person or even like a Frontotemporal dementia. As somebody asked about the Frontotemporal dementia, I’m going to ask Dr. Schneider to to talk more about Frontotemporal dementia. But it’s a it’s a very challenging type of dementia, as far as, like, the management, especially because of behavioral symptoms is more prominent in these people. It happens in more younger, it’s also genetic background is also very important. And again, Dr. Schneider if there’s anything about frontotemporal I think one person is asked about Frontotemporal dementia. But I’m gonna ask you to a little bit talk more about Frontotemporal dementia as well.

Dr. Logan Schneider  23:56  

Sure, yeah. Thanks. So that’s, that’s a layered question that you may not be aware of. But Frontotemporal dementia is similar to the nature of other dementias that we diagnose. And I have to, you know, start by saying, you know, our understanding of dementia is, is evolving. And so the way, you have to think back to how we started all of this. The way that it all started was, well before we actually had all of these advanced diagnostic imaging studies. And so physicians and the medical community relied upon pattern recognition, that’s often what neurologists like to do, but also medicine is a degree of just pattern recognition. And so the way we would do it, is we would start by looking at people who had symptoms during lifetime and say, oh, what was the symptom that this person had? And then from a neurologist perspective, we’d love to say, well, localization, meaning where does it sit in the brain. And then look at people after they passed away, and then notice the patterns there. And so with the frontotemporal dementias, what was prominent there, as opposed to other types of dementias, was that there was shrinkage, or what we call atrophy of parts of the brain specifically the frontal lobes, the part of the brain sitting right at the front above your eyeballs, and the temporal lobe, sitting right near your temple. Right. And so that’s hence the names that we have for all of our body parts. And so the the pattern of atrophy was– or shrinkage of the brain– was very commonly seen among certain people who often would have certain symptoms, right. So these people would have often behavioral disinhibitions. They would, you know, pick their nose or suddenly get a, you know, in public when that wasn’t their normal character walk around in their underwear, start using crass language, be more impulsive, certainly a lot of them tend to have a sweet tooth, where before they weren’t eating a lot of sweets, and now suddenly they are and also the age of presentation, right? Alzheimer generally tends to be a late age onset in most individuals, classic stage Alzheimer, classic type of Alzheimer tends to present on in your role, certainly well, after your 60s and this type of dementia would present ten percent earlier and progress more rapidly. And so we look at these patterns. And we said, Oh, these types of people look like this. And then after they pass away, their brains look like this on the large scale. And so that’s how we started clustering these things. We would have, oh, people who look kind of like Parkinson, and then people with some additional features. So those are the Parkinson’s plus syndromes. And then we would have the Alzheimer type people who are more characteristic. And then we would have these Frontotemporal dementia. And back in the day, we used to just give them the names of the people who originally described it, like Pick Disease, not as useful because it doesn’t describe as much. And then as slowly, as the field has progressed, we started to learn that there is some degree of overlap between these conditions in the sense that, you know, one person may look like something, symptomatically, and then after they pass away, their brain may look like something else, even if we took a scan of it. And and then we started to get molecular diagnoses, where we could actually see what are the proteins that are causing this, what are the genetics that are causing this. And we started to take these large groups, these clumped groups and kind of start to differentiate them, identifying that there are subtleties different varieties of frontotemporal dementias. And these frontotemporal dementias spread out both on their underlying genetic and protein based causes. So you might see some people who have this very classic association of Frontotemporal dementia, these behavioral inhibitions and dementia in association with Lou Gehrig’s disease or anti lateral sclerosis, right. So and so in these individuals, you’ll see a pattern of muscle weakness that looks kind of like what Stephen Hawking had, in addition to the dementia component, and these people tend to have very clear genetic associations, as opposed to other groups that may have a different genetic underpinning and a different protein and it’s causing toxic accumulation. So we’re starting to spread these out. And as we start to get a better understanding of the underlying causes of the genetics and the proteins that accumulate, we can then backtrack and start to figure out what are the subtle differences between these groups. And so that really takes a much more in depth look at it, right? So obviously, you want to get the presence of a dementia and then kind of differentiate that among the symptom patterns, and then help us help guide us. If it’s not looking like a typical Oh, this seems like a straightforward Alzheimer, well, then we may need to dig, dig a bit deeper, and see if there’s something underlying that that we can understand. And then hopefully, that can guide us on appropriate treatments, right, like, as mentioned, in those individuals with Lewy body dementia, who have these fluctuations in cognition, and then they become combative, if you use certain medication types. And those people, they’re very sensitive to those and you want to make sure to prioritize, oh, I’m not going to go there in this individual. And so this is one of those things where it’s really important to get the feel of what that pattern is. Dig deeper, if it’s not sniffing to be a standard kind of run of the mill 60-85% of people with a Alzheimer type dementia, and with a mix possibly of blood vessel damage to the brain. And then once you’ve identified those, then it helps you narrow down treatments, Unfortunately, most of the treatments that we have for almost all of the dementias now, like I said, nothing that stops or reverses the disease are treating the symptoms of dementia. And we need to make sure that we’re choosing the right ones based on what’s happening to the brain what what systems are working well and which ones are not and how sensitive people might be to different types of medications in those cases, so that we’re not doing more harm than good. And obviously, the fallback in all of these instances is you know– which is very challenging, right– it’s it’s the caregiver aspect, right. In which we do behavioral modifications, we try and manage people’s schedules, give them cues, make sure their environment is safe, transition them to the safest next level of care at an appropriate time so that the caregiver doesn’t burn out, but also educating the individual while while they’re still able to know what’s going on about the process that’s going on, so they’re not as frightened, but also educating the caregiver to respond appropriately, but also keep the individual safe and living the happiest possible life that they can. So so it’s a long winded answer to we’re still learning about these conditions, and what’s causing what’s causing the brain damage. And then, and how that brain damage translates into what we see on an individual to individual basis, because even everybody with the same genetic cause, and the same pattern of damage doesn’t react the same way. And so it takes a very personalized approach once you get to that level.

Thank you so much. I think we have some of the questions here on the chat, I’m trying to say, one of them, somebody asked us about that. When is going to be the time I should have a baseline test about memory? The answer is that Alzheimer’s Association had a survey in 2019. And they found that actually, unfortunately, the primary care physician more they emphasize on managing blood pressure, or shedding the cholesterol and all this stuff, they forget a very, very important part of the examination, which is going to be neurological examination. And part of that, it will be a very simple cognitive test for everyone 65 years or older, no matter if they are in good shape or not. I think it’s important, we are trying to educate all the physicians to be sensitive to baseline it whenever it becomes sensitive, like finding by your primary care physician, or you may subjectively, or people around you objectively notice that there are some issues like for example, short term memory loss, forgetting the things of this orientation, or very, very interesting, which we see, behavioral change. A lot of times depression, anxiety can be an early sign of the cognitive impairment that is important to be addressed. And we have the right referral to the right person evaluated that can be the call early sign of cognitive impairment, which we call it is a big umbrella of dementia, and then we can, through the expert person that we can categorize what kind of the problem that we are dealing, what are the risk factor as we discuss, we can reduce it. That’s why again, there’s really not certain age for baseline, it’s something that we encourage everyone to be evaluated. What part of your Medicare annual care, when you go see your doctor, we always encourage to all our physicians to definitely focus on neurological exam. Many parties, many neural neurodegenerative disease can be found in earlier stages as well, we really like to have this ability for all the people to have this evaluation. And not only or Medicare annual exam, only emphasize to do some blood tests and just checking the blood pressure. These are important, but also neurological evaluation, it is very, very important. One of the other things that we like that we do is actually especially now the discussions about neurology is gait evaluation, or balance evaluation, is one of the major factors for people which is going to be different topic. 

Dr. Mehrdad Ayati  32:41  

Somebody asked us about sundowning syndrome and why this is happening. I just want to say a very simple example. This is a very complex physiology I saw and Dr. Schneider is also like about a sleep pattern. But as we know this is a different topic. This is going to be a absolutely have different sessions to just talk about brain and asleep and sleep circadian. But one thing we know that when we look at the babies, every time they started to cry is exactly at 6pm. When the when the parents wants to start getting dinner, they started to have sundowning at that time, that’s the way the brain is actually act in babies. Sundowning is the same brain circadian pattern as exactly in evening time, there’s a lot of complexity related to melatonin related to brain circadian. And this is why evening time, it’s a time many of people with advanced dementia starting to become more agitated. And this is going to be one of the biggest problem and complexity for the caregivers as well. What are the protocols we need to do? Again, this is going to be a different topic. But we do have more non pharmacological and sometimes we use pharmacological. We always prefer non pharmacological, some of the strategies to help to redirect the loved one or persons with dementia in the evening time, most of the time is helpful. And in this some certain cases, we offer some sort of pharmacological, which is a different category, which comes to the next question in the chat. 

Somebody asked about what should we do with the person with dementia who is agitated? Who is heating who is who has this behavioral disturbances? I want just want to tell you one tip, there is no magic pill that you can give to someone with dementia and then all the symptoms with behavioral problems going to be disappeared. First of all, expectation. Always we try to educate people that they have expectation. But for example, when I see the patients, I always use the question. And this question is which we use neuro psych questionnaires or I’ll use Coin Mansfield inventory question, that questioner I asked if, for example, even if I prescribe a medication from this week to next week, if that person is kicking seven times a week, if next week that person is only kicked a caregiver for three times, that means this is a successful in the treatment, that it doesn’t mean that person should be next week extremely sweet call and all the symptoms going to be disappear. This never happened. So that’s why it is very important that we know, even with non pharmacologic and pharmacologic, there’s still going to be some sort of the symptoms. But as far as this symptoms doesn’t cause caregiver burden and caregiver things that they can manage, and also it doesn’t cause anxiety and agitation, then we use different category of medication, that’s going to be different we use all sort of antidepressant or anti convulsive or even anti psychotic medication. But there are there is this, there is a strategy. We wanted to first of all, most of demented patients they are geriatric, they’re extremely sensitive, as Dr. Schneider said, to medication. We have to be mindful about adverse effects of this medication, we also have to start always low dose go up is slow. But go, it means that we should have a therapeutic plan. Always start with the pediatric dose, which we always encourage, encourage geriatric is like pediatric, we can– start a pediatric dose, monitor the side effect, closely follow up with the patients and family, and then go up on the dose. And there’s really depends on what kind of dementia that we’re talking as Dr. Schneider and I were trying to say. And then we go to different category of this medication. Given this reality that not all these medications are safe, they have some adverse effects. But as far as physician and family and caregiver part, if they have the side effect, and they can report to each other and communicate with each other very well, then be able to manage many of the symptoms. And again, and again, based on that, that expectation is reducing symptoms, not completely zero. We don’t want to sedate the person, I always make a joke in my lecture, if you wanted to you if you really wanted to utilize a good physician for managing behavioral disturbance and dementia, we need anesthesiologists because they can quickly sedate the person. But this is not our goal. We wanted to still be able to engage but quality of life for both patients and also family members as well. 

One question also here and I’m going to ask Dr. Schneider, too, there are some questions, and maybe Dr. Schneider can also help us with this question, is about using alcohol with people with dementia. It’s a big controversial discussion. I mean, first of all, let me just say alcohol is bad or good. Alcohol is act like another medication. When somebody with dementia, which I’m sure many of the people with dementia, they’re already taking a blood pressure medication, they’re already taking some sort of the medication for their accordionist raise inhibitor, maybe like mantiene, maybe some antidepressant medication, we have to put, in fact, these are drugs can affect the central nervous system, or different type of part of the body. And you wanted to add alcohol routinely to it. Does it have interaction between alcohol and these medications? These are very important questions that we need to answer that. Is that if giving alcohol to someone that taking all this medication at the same time, does it cause any adverse effects at the same time or not, is that this is always come to my discussion. And in many times when I have a patient that taking many medications, I will say well, maybe better to not giving them alcohol on the top of it, and also make them also dehydrated as well. And then this is one of the biggest problem that is happening. But I wanted to ask Dr. Schneider to add any comments about using alcohol or maybe routinely for people with dementia as well as previous experience as well.

Dr. Logan Schneider  38:41  

Thanks. Yeah, I think that question is a challenging one, because it comes to the place of where people are living versus what medicine recommends. But just to get a few facts on the table, obviously, in addition to the interactions of alcohol with all the other possible medications in a regimen, you know, point in fact, alcohol is a poison, right? It’s toxic to our bodies. Despite what evidence has shown in the past about maybe one to two drinks a night being healthy for individuals, more recent research has demonstrated that no amount of alcohol is healthy, particularly for the brain, in the sense that any alcohol exacerbates the risk of dementia, as well as the rate of progression. Probably because it’s a it’s a toxin. And, you know, there there are some therapeutic applications for alcohol, but normally those are very selective and applied in like emergency rooms, you know, to make sure that other toxic alcohols that might be ingested inappropriately, don’t actually get turned into things that can make you blind, for example. So you know, alcohol is not a treatment for any symptoms. In fact, there are medications that if appropriate, can be used in lieu of alcohol that may mimic the effects of alcohol but have safer durations. Don’t risk as mentioned, like the the potential for dehydration and what have you, but even then, those are not first line agents. Those agents called benzodiazepines, which are basically like pill form of alcohol, have in the same way as alcohol shown increased risk of people developing dementia and also worse outcomes in people with dementia because the consequences of alcohol are that it, you know, when a police officer makes you walk a line, that’s because alcohol is causing your cerebellum to not work. And so there’s a risk of falls in addition to, so just the risk of harm and death in addition to the brain consequences of alcohol. So so never is alcohol an appropriate treatment for anything in medicine other than maybe cleaning a wound externally type of thing. And it has to be very high proof as you saw for Coronavirus, right. If you were just turning Tito’s vodka into a hand sanitizer, it wasn’t doing the job. So, in essence, just to put that on the table, alcohol doesn’t provide any help. Now, that being said, you know, part of what might be going on is that, in addition to the fact that alcohol is short-acting, gets metabolized very quickly, you can have then rebound symptoms once a person is off of it. But also, over time, alcohol loses its effect. And so then you need more alcohol to do the same thing. And so you get this tolerance building or withdrawal syndrome, all sorts of complications come out of that, that you don’t want. So even though it’s harder, obviously, stage one is behavioral modifications, and then even looking to the root of what the problem is like, what’s causing this person to be behaving like this where I feel like alcohol is something that’s needed? Is it some aspect of routine? Is it some aspect of pain? Or is it some aspect of anxiety? All of these things that maybe we can address either through behavioral and environmental modification, some people just find that, you know, and most of the answers I get from this are not universal answers for everybody. They’re things that come from individual patients and their caregivers that tell me what to tell the next person and it’s like, oh, we found that once we put a sign up on the wall for Fernanda that said, “Hey, by the way, you know, the cat’s okay, blah, blah, blah,” and just like laid out the things that she was always anxious or agitated about, suddenly, that reduced the amount of stress just because she was always getting a regular reminder. And that’s not everybody’s solution, because that’s not the underlying problem for most people. But you have to be inventive and creative to really do the safest thing, which is often not incorporating another medication. As Dr. Ayati was alluding to, but wasn’t explicitly stating is that one of the big things, hurdles that we face in older populations is they built up a lifetime of medications. And those medications interact, those medications affect our brain through their side effects, even though they’re doing something good for our cholesterol level, they can actually cause us to have a little bit of a thinking problem, and so we often want to decrease this amount of what we call polypharmacy, too many meds, to get them down to the bare essentials of what really keeps them healthy. Because the more you do, the more likely you are to cause side effects and problems. And so adding another thing into the mix is certainly not a good solution, in my mind, yeah. So so we often try behavioral modifications, in certain circumstances, certain medications can be used when the benefits of reducing potential harm to the individual or harm to others. Maybe they’re wandering risk or something like that is out by producing that that benefit is outweighed, is outweighing the risk of potential side effects of these medications that can cause their own problems, right, everything is kind of a personalized one on one case by case discussion to try and figure out the best way to do that. But I always encourage people as much as their energy can handle, because it is a lot of energy for a caregiver, a spouse, a child, anybody who’s trying to care for somebody who is having thinking problems is very challenging, particularly at certain times of the day. And sometimes that modification is not something you want to do then, just like we were talking about with sundowning, most significant contributors to sundowning, particularly when you’re in a foreign situation, what we call the delirium in the hospital, generally, is the mismanagement of the overall day. So people are looking at the behavior when it’s happening, and like, how can I stop this from happening, but part of the problem is, well, maybe the cataracts are causing visual impairment that are in enhancing potential for hallucination. Maybe the lack of wearing the hearing aids is one thing that’s contributing to that kind of being isolated in the brain kind of drifting off into other spaces. Sometimes it’s just the dysregulation of sleep-wake states. If you took a nap during the day, well, then you’re going to be more activated at night, because you don’t have that drive to sleep. So these are a lot of factors that weigh into it, where it really takes management of the whole day, the whole environment and really caring for all aspects of somebody’s life to actually make sure that things are being managed. Because we’re often reactive, we see the symptom, we got to treat the symptom, when in fact, it’s like, both we’ve been proactive and didn’t allow for a 12 hour sleep opportunity, then insomnia wouldn’t be there and the person wouldn’t be so drowsy– wouldn’t be so alert the next time they need to sleep because they overslept every night. So a lot of factors that weigh into and really takes a personal discussion where we help you hopefully identify some of the more common causes but then also allow you to be empowered to say, “Well, what might be at the root of this and how can we address it behaviorally, environmentally, before we go to medications?”

Dr. Mehrdad Ayati  44:55  

Yeah, absolutely. And thank you so much. I really appreciate, and the other points that Dr. Schneider brought up is about benzodiazepine as well, and long term use of benzodiazepine. Unfortunately, we see, a lot of people use the benzodiazepine like Lorazepam and many of this medication for anxiety control. And the chronic use of that it shows significantly science that has effect on the brain health and also cognitive impairment in the long term increased risk of falls. Many of the sleep aids that also we used, we have to look at the long term effect on the brain as well. And same same category as we discussed with alcohol as well in the long term, and especially the balance and fall as well. Which again, you guys have been in my town hall meetings many times, in all the diseases like if somebody’s telling me that I have a geriatric person, I have diabetes, I have cancer, I have this, but I have frequent falls. I will say my nightmare is always falls for my patient, because this has always caused more frailty, more decline in function, balance in fall, is balance impairment and fall, it’s a very, very important thing. And again, alcohol definitely can contribute to more problems in balance as well and increased risk of falls as well. I think couple of questions here, doctor Schneider, if you wanted to address I think somebody asked about routine PETs, PET CT scan, I believe, I forgot that, if you wanted to point–

Dr. Logan Schneider  46:26  

Sure

Dr. Mehrdad Ayati  46:27  

Yeah.

Dr. Logan Schneider  46:28  

So you know, the choice of imaging modality, meaning do you choose a CT scan, which is an X ray based imaging study of the brain, or do you choose an MRI, which is kind of like taking that 1950s television set and coming into HD? The question is, which do you do? And I think part of that answer is well, it’s what’s available to some degree and what you’re looking for. Generally, head CTs are adequate to be able to do a first screen pass and say, Hey, we’re looking for any big causes that might be contributing to memory problems or thinking problems that are not actually dementia. So you’re looking for tumors, strokes, particularly in elderly individuals, bleeding inside the brain can– some are just even on the outside of the brain pushing the brain down a little bit can cause it, or unusual changes that you might be able to see there are useful. Sometimes when you’re looking for a more specific diagnosis, want to get more detail, particularly being able to get, you know, where a brain is encased in bone and bone blocks X rays. So if you need to get a more detailed image, sometimes then you want to go to the MRI and say hey, is there shrinkage, specifically, as Dr. Ayati had alluded to, and hippocampus, the special memory centers of the brain, if you want to do look for that underlying blood vessel damage, if something just doesn’t, doesn’t look perfectly clean on the CT scan, you might go to the MRI next. In older populations, generally, we’re not as concerned about the lifetime accumulation of radiation that we would if, let’s say we were giving somebody a CT scan at age six. It’s like well, that’s, you know, there’s a lot of, you know, long term cancer risk in those people. But, you know, it’s the lifetime accumulation of radiation doses that that most people are concerned about, and they have very low dose, radiation CT scans these days, that can still give a very good image. And so in those circumstances, we’re more likely to try the very fast, very cost effective, very low risk imaging modality of a CT scan versus an MRI at the outset. So, you know, any any sort of screening imaging modality, but for the most part, once again, these are not nailing down a diagnosis, they’re often looking for other things that should be taken out of the equation, before we can then make a diagnosis of well, this is a dementia, most likely neurodegenerative, not because there’s some sort of tumor in the pushing on part of the brain that’s causing that part of the brain to dysfunction, for example. So that’s really where imaging modalities do sometimes they add, like I said, patterns of shrinkage, certain patterns of like blood vessel damage or something like that can lend weight to certain diagnoses. And that might be where you go for the more you know, more expensive magnetic resonance imaging that doesn’t use x rays to get a very detailed image. But yeah, for the most part, it’s, it’s a person by person basis, and also circumstances.

Dr. Mehrdad Ayati  49:21  

Thank you so much. And again, the two questions here. The first question that somebody asked, “I don’t have any cognitive impairment but what should I do to prevent it?” It is very important we talk about it. Number one is finding any risk factors can may increase your chance to have more card– as we discussed– any cardiovascular disease. If somebody has high blood pressure, diabetes, high cholesterol, we always recommend to have anything set like that to be addressed by a physician if needs to be controlled. It is important to be controlled. If somebody has some sort of heart arrhythmia we call atrial fibrillation, it is important to diagnosis, it is important to find it, because that can contribute to some vascular damage later to the brain as well. I mean, these are the things we like to screen, evaluate. Doctor Schneider talked about some sort of metabolism problem, somebody has thyroid problem, we need to address that more– and again, minimize the risk factor. Not every risk factor is medical. Somebody has hearing problem, and hearing loss in the long term can cause cognitive impairment as well, if somebody has if have a bad hearing, definitely we make sure hearing is one of the most sensitive sensation for brain when it doesn’t work very well, brain doesn’t like it. And it’s actually it’s using more of your memory cells to compensate your hearing as well. It is very important to have, if you have hearing problems that definitely address that. Exercise, we have, this is a different discussion, a lot of things is produced by exercise not only helped with the cardiovascular, not only helps with the brain gets better perfusion of the blood, it’s also helps to release some other factors. We know some of them like BDNF, brain derived neurotrophic factors, and many other things that can help the neurons to be more stabalized. As social engagement, I mean, unfortunately, because of COVID, we haven’t had it but it is very important even in this kind of virtual discussion, as we have we have more social connection, I always make an example live like Italian people talk and talk and be engaged and be happy. And just more social engagement, that can help a lot with, this is a best speech therapy for brain that you can get it free and with no cost. But you need to go talk to be to friends have a social interaction with people. These are the things can be very, very important for brain. And is there anything else Dr. Schneider you wanted to add as well, wh- what is a healthy person should do for reducing the risk factors for brain as well?

Dr. Logan Schneider  51:50  

Yeah, so I think that one of the things you brought up was incredibly powerful, and we don’t really understand the association for why social engagement, it’s the richness of your social network. And I often have to tell the younger people that that doesn’t mean how many people you have on your Facebook profile is your friend, but not so relevant to people who may not be as on on social media. But we don’t understand why. But it seems to be really associated with lower risk of Alzheimer, or other dementias as well as lowering the risk or lowering the rate of progression, which is fantastic. You know, we are social creatures, to engage with people socially, you have to utilize all of the brains functioning areas. So essentially, you know, to talk to people, you have to remember facts about them both immediately, as well as long term history that you’ve had with them. You have to use the language centers to interpret everything they’re saying, and then respond in kind. The frontal centers where you, you know, don’t lash out when you disagree over politics, for example, but then actually discuss things. So all of the aspects of the brain are being, you know, taken through basically the full, you know, like the gymnastics of the Olympics, or you do all of the different types of competitions, instead of just focusing on one task, which can often cause you get really good at that task, but doesn’t actually help the overall brain. It’s like cross training, right? If you want to run a marathon, you do a little bit of swimming, a little bit of biking, and then certainly emphasize the running. But other factors that are key to prevention, right, so the standard pillars of health are those same pillars that we use for the prevention of dementias in general, but certainly Alzheimer. You have diet, right, so there are two diets that have been studied in great depth, but you don’t have to use those absolutely. There’s the mind diet and M-I-N-D, as well as the Mediterranean diet that you may have heard a lot about. And if those work for you, great. Follow them, if they don’t, look at them for just general guidance. And I, the general guidance I give the rule of thumb to people is if it’s heavily processed, you probably shouldn’t be eating it right? If you can look at the label, and can’t recognize the ingredients in the actual food product that are written on the label. Or if you can’t recognize the names, probably processed, highly refined sugars, not healthy for your brain. Sugar, like alternatives like even sucralose, what have you not healthy for your metabolism. And if you just wanted to shop around the edges of the grocery store where all the fresh ingredients are, that’s probably a healthy rule of thumb, right? And it’s not about dieting, it’s about sticking to a new lifestyle. That’s really what it is. So whatever you’re gonna do, that’s the thing that’s going to be successful. Another one is exercise. So the American Heart Association, American College of Cardiology, and then countless studies supporting exercise support that you should do this. And so the AHA, AGC, recommend 30 minutes of exercise at least five days a week at the moderate to strenuous level. And that’s different for every person that could be, you know, walking, could be water aerobics, could be running a marathon, you’ve got to define that for yourself. I generally say if we can have a conversation like this and not be short of breath, then you’re probably not at the moderate level of strenuousness. So, but once again, keeping yourself safe, knowing your limits, and, you know, working up to whatever is working for you. But getting moving and active at least 30 minutes a day is recommended at least five days a week. And then, oh sleep, right. My old subspecialty. You need to make sure that you’re getting enough sleep at night to wake feeling rested and non drowsy throughout the day. And that amount of sleep is different from person to person. For some people that can be six and a half hours. For some people, that’s eight and a half hours. Obviously, as we age, the amount of sleep that our brain tends to take at night declines. But the key is you want to keep it consolidated at night, stay active during the day, and consolidate your sleep at night. Critical for maintaining your body’s biological rhythms, what we call circadian rhythms, but also making sure that you’re getting adequate sleep to do the job of clearing out all those normal proteins that if they stick around, become toxic proteins and clump up and cause problems gunking up the works. So it’s not just about the quantity, though, it’s quality. So if you have an underlying sleep disorder, you slept eight hours and you’re still drowsy during the day, you just don’t, you’re yawning all the time, you need caffeine to counteract the effects of sleepiness, maybe you have an underlying sleep disorder. That’s the point at which you kind of go and get evaluated, maybe take a look at your sleep at night and see if there’s something interrupting it, you know, the the likelihood of having obstructive sleep apnea once we’ve passed 60 is on the order of like 20-25% of the population. So it gets really high. And so you need to make sure that you’re treating any underlying disorders that could decrease decrease the quality despite enough quantity. And those are the four main areas right to mental exercise. You know, actual physical exercise, diet and sleep.

Dr. Mehrdad Ayati  56:18  

Thank you so much, I appreciate. I think the next question is comes to you, Dr. Schneider, is asking about a testing, a neuropsych testing for either financial and healthcare decision making. I mean, oh, this neuropsych testing can actually help to people to know about this. 

Dr. Logan Schneider  56:36  

Yeah. That’s great. That’s a great question. I think it interweaves with something I do want to touch back on about what you had already talked about. But I’ll get to this question as well. The question was, well, should I get a baseline evaluation? And in medicine, we always have to wonder, well, what is the value of screening somebody? And what are we going to do with the results of that screen? If they’re not symptomatic? Right? So the nice part about the Stanford VA Alzheimer’s center is it’s not a healthcare, you know, process, right? It’s not requiring pre authorization, it doesn’t go through your insurance. It’s just something that we’re doing as a research study. And so we give back to you the data that we get out of this. So even if you have no symptoms, we offer this free service, so we’re happy to give you that information. And so the earlier you screen things, the better. And the reason being is that, granted, if you if you if you have a negative test, and you have no symptoms, that’s great. If you discover something that’s like starting to verge on the preclinical domain, something that maybe you can just track over time and respond to earlier if you need to. Because when we start to have symptoms, it’s often too late, right? So when you actually are when, “Oh, yeah, we think back, this started like five years ago with grandma.” Well, in those circumstances, it actually might be that that was then and also 10, 20 years before that is when the damage started happening. And we see that in Parkinson disease: by the time you start having parkinsonian symptoms, you’ve had 80 to 90% of the cells that are already dead. And so we see the similar thing, the way the the pathology, the damage spreads they tend to spread from like the primitive parts of the brain and then starts getting into the higher order parts of the brain. And so we often want to look early. And the nice part about these study, these tests is that even though you may perform well, in general, we compare you to people like you. So we would compare a 40 year old to a 40 year old, we compare a six year old to a six year old. And so when we track you over time, we can see, is your performance going faster down than somebody like you as they progress through age. And so from our center standpoint, not from the general clinical standpoint, because it’s not, you know, the AAHRQ and other groups that have looked at this have not said hey, you should be screening everybody, just because, it may be on a every five to 10 year cadence when younger individuals without symptoms, that’s a reasonable amount of change that you might expect over that timeframe to be able to start separating those lines out of trajectories. But from our center standpoint, because it’s a free service, it’s something that we’d be happy to see you like on every five year basis, kind of sets the bench benchmark that you and your that you yourself have to track over time. Then to the other question, how neuropsych testing fits into this picture. Well, the, as we said, you know, the primary mainstay of defining a diagnosis is symptoms, where you actually notice something in yourself that’s going on, that we can then confirm, well, how should you be performing? This is what we call a clinical sign, right? It’s an objective measure of your performance, to be able to say how you’re doing. And the diagnosis of dementia, the overarching umbrella of all these different disorders of memory or thinking problems relies upon two main features. One is a functional impairment, meaning you are not able to do something in your life that you normally ought to be able to do, that is essential to functioning. And then two areas of thinking, most often one of which is memory, that are then also impaired, right. And so we have to do neuropsychological testing to get objective quantification. How bad is each– are each of these areas relative to how well you should be performing, to get an idea of that. And even then you can step back now that we’ve done a lot of research in this area to even say well, even if it’s not causing a functional impairment, there may be one area, maybe two, but most often just one, that is already showing evidence of problems that you may not be aware of, but we’ve caught it. So that then that gives us a pre diagnosis where it’s what we call mild cognitive impairment, it doesn’t meet the diagnosis of dementia to areas of thinking problems with the functional impairment, but it’s early enough that we’re like, something looks like it might be wrong, let’s track instead of every five years, every year, and see how things are changing over time. And so that’s really the value of neuropsychological testing, is it gives us a measure of how well you’re performing relative to how well you should perform, that we can then track over time that gives us insight into what your trajectory looks like, as well as helps us figure out a pattern of well, is this a pattern of long term slow progression, Alzheimer? Is this a rapidly progressive dementia that we need to investigate more quickly, do a little bit more genetic testing or other unusual testing, to be able to sort it out? So that’s the value of neuro psych testing.

Dr. Mehrdad Ayati  1:00:54  

Thank you so much, Paula. I mean, at any other point, Dr. Schneider, or any other question, I believe, I think we address all the questions in the chat.

Paula Wolfson  1:01:07  

Yeah, thank you both. I did want to talk a little bit about the role of the caregiver in all of this, especially with when to take over decision making, because that does come up a lot in my caregiver groups. And one of the big thing that comes up is, when to stop driving. How do we test for that? Where should we go for that kind of test? Should it be an occupational therapist, the geriatrician, the neurologist, can they get tested, Dr. Logan, at your clinic for driving abilities? And then specific testing, I think people are confused about, is there a different test for financial decision making, a different test for healthcare decision making, and what parts of the brain are tested. Th- everybody in my caregiver groups throws around the phrase executive functions, and I’m not always sure that everybody knows what they mean by that? 

Dr. Logan Schneider  1:01:56  

Sure, sure. So yeah, so. So to start with, the timing of drive– of driving ability, when we decide what you’re not eligible for driving is basically dictated by state law. So it depends where you are. In California, once you have a diagnosis of mild dementia, that’s the point at which we have to report that to the Division of Motor Vehicles, and they would require that you retest driving and written test to make sure that you can maintain driving privileges. Which if you pass, then you can maintain those driving privileges. You have to then decide from your personal standpoint, as well as that of the caregivers and people who love you and want to keep you safe, whether or not that’s the safest decision in general. So at the mild level, generally, you may be able to retain driving privileges. As it progresses, obviously, we update that. Once you get to a moderate level of dementia, obviously, then your license is taken away, because your level of functional and cognitive impairment is so high, that it’s just not safe. And no- and it doesn’t matter if you happen to pass the test. It’s unlikely but even if you do we- it’s not acceptable. So really, that’s the kind of decision point, is once you have it, we have to report it and then you have to go to DMV for that. Then from the standpoint of financial and healthcare decisions. So executive function is, as you mentioned, one of the many areas of thinking. Generally we look at memory, various varieties of memory, is it short term memory, is it long term memory, is it the flavor of memory, what we call semantic memory, working memory, the ability to process things kind of in the mind actively like turning numbers around in your head, for example. So it’s memory, that’s obviously an important area of memory problems, like dementias, then we have other areas executive functioning. As I mentioned, these are the things that really make humans human. So it’s your ability to inhibit impulses, right. So instead of punching somebody when you disagree with them, you calm down and you discuss it, right? Just look at a child, they haven’t myelinated the front of their brain, and so they’re more impulsive, right? Once you get the adults aspects, then you are able to restrain that. And so everything that you see in a child is lack of executive function. Everything in an adult is is is that executive function, if you wanted to make a strict comparison. Then you can look at other domains, things like visual spatial function. So I liken this in Alzheimer patients who tend to lose this early to Hansel and Gretel, right. So they walk out, and they can’t create that mental map anymore, and they can’t find their way back home, and so that’s how they tend to get lost. But that translates into many different areas where the ability to interpret that worlds in three dimensions starts to break down. And so that can be a difficulty there. You have– what other domains do we have– processing speed and attention. So this is not as much a problem for people with Alzheimer, but certainly is evidence of the brain not being able to– it’s kind of like a computer slowing down when you have too many programs running. Or if you have an older computer and even just one program running, it could still slow down that computer and that’s really what we start to see in certain people. And then, let’s see, what is the last one that we generally test. For spatial memory. Please forgive my memory problems.

And… Oh, and then language, right. So all of these dimensions of language, so it’s your ability to understand what somebody says, grammatically, take the emotional content attached to that and put it in, reference it against your lexicon, or basically your dictionary and your brain, formulate a thought, then translate and transmit that thought out, obviously, reading is a part of this loop as well. And writing is a part of this loop. And so all of this information can be tested to see what parts of memory degrade over time– what parts of this thinking degrade over time. So, you take all of those, and then you can demonstrate that there’s a functional impairment, and a level of neurocognitive impairment that is so severe, that you’re falling below about 93% of people like you in multiple domains, right. So those two domains, you have to have 93% of people outperforming you for us to be considering it clinically relevant, function– cognitive impairment. And once you get to that point, then it’s an ad hoc process for each of those questions, financial and healthcare decision making. So hopefully, before you reach that point, we’ve all had– sat down and had these discussions to outline who will who will take control to have my voice be heard when I am no longer able to understand and effectively communicate? And the question comes to capacity versus competence. So as a clinician, I can’t determine competence, that is something determined by courts. And if somebody believes that their family member has become incompetent, they need to take that before a judge and have the judge, look at the evidence and say, Okay, this person is no longer going to be able to make these decisions on their own, we will then put your guardianship and your decision making capacity completely into somebody else. And there are a whole bunch of legal aspects about that. From a capacity standpoint, though, capacity is a somewhat case by case problem. And so, you, from moment to moment could make different decisions. We’ve all seen the day to day fluctuations in people’s thinking abilities. It’s a good day, it’s a bad day, we all have them, but they’re more evident in dementias. But even then, like the decision to say, Oh, we don’t, like, should we eat a grapefruit, or should we eat an orange for breakfast is an easy decision, you have the capacity to make that decision. But the the capacity to make a decision like well, should I get a G tube for feeding or not, is one that becomes much more complex. And that is determined on an ad hoc basis, right. So sometimes the healthcare decision making will obviously come into play, particularly if you don’t have advanced directives, you haven’t discussed this with family members who are acting to bring your voice to the table, not their impressions, but your voice to the table when you can’t. But the decision making complexity might decide what’s going on. And the way that medicine decides that is, we assess on a case by case basis, we’ve discussed the situation with you, have you understood that information, communicated to us that you understood it, and then made an informed decision based on your value structure. For example, if a Jehovah’s Witness said I don’t want blood products, they could, they could say that at 15. They could say that at 20. They could say that when they’re demented at 80. And their decision still stands, because that’s something that’s completely consistent with their with their belief structure, where somebody else is like, Oh, I don’t want blood products. And it’s like, well, why not? Because blood products contain, you know, contain government microchips. And it’s like, well, that’s not a valid reason to not want a blood product. And we know that you in the past would have had transfusions and have had no problems. So that would be an instance where we would say it seems that this person doesn’t understand the situation here. And in incon– it’s consistent, that this person would actually want that. So they don’t have capacity for making that decision at that moment, based on the complexity and lack of understanding. And so this really becomes an ad hoc thing where you can be capacitated and not capacitated in the same moment for two different decisions just based on your understanding and interpretation of that. And that requires the physician to discuss this with you, discuss the decision making process, outline that, bring in external input from family members, when capacity is not there to help inform the decision as if you were sitting at the table making that decision yourself. So that that’s certainly from the healthcare standpoint. From a financial standpoint. You know, sometimes it’s– hopefully this has been outlined early– but once you just enact a power of attorney, a durable power of attorney for finances, oftentimes most financial decisions are quite complex. And so anything that’s relevant, where they would reference a durable power of attorney generally just stands uniformly. And hopefully you have pre drafted documents like wills and what have you to help outline what what your wishes are, but healthcare is so vague and complex that really requires a decision by decision determination there, but at every point, the person whose capacity is in question shouldn’t be at the table. And we should talk to them make sure that we that we are feeling that they don’t have the capacity and then try and make the best decision that they would have made if they were able to speak but otherwise, they s– they may still maintain capacity for certain decisions. And I think that’s, you know, it’s a very ad hoc thing. Just make sure that you know who the person is, the durable power of attorney for healthcare decisions is, in case there isn’t a capacity in case the determination is that you don’t have capacity.

Paula Wolfson  1:09:58  

Thank you for that. I just want to say to everybody that Dr. Ayati needs to leave us. But Dr. Schneider, if you can stay on for a little bit longer, we can go to 12:30 if you have the time to do that. 

Dr. Logan Schneider  1:10:09  

Yeah, I’ve got time.

Paula Wolfson  1:10:10  

Okay, so Dr. Ayati, thank you so, so much.

Dr. Mehrdad Ayati  1:10:13  

Appreciate it.

Paula Wolfson  1:10:13  

And I just want to know, is your clinic, Dr. Ayati, open? People can–

Dr. Mehrdad Ayati  1:10:19  

We try to just doing majority of the visits through telemedicine for people who needs to be exam they can come in? Yes, absolutely one patient at a time. And, but again, we try to minimize that. I wanted to also, again, really appreciate Dr. Schneider as well, I wanted to again, re emphasize on this point that is so important. Not everybody does. Somebody doesn’t have financial capacity or legal capacity, but not necessarily they’re losing their medical capacity decision. And that’s very, very important that we differentiate that. And again, that’s why individual individual is very different. Not everybody with moderate or mild dementia doesn’t have capacity to make medical decision, they still can make medical decision, but it’s important that if there is a complex medical decision, we always encourage somebody help them. Not they say Yes, exactly. Doctor Schneider say somebody’s surgeon comes with the consent and say, Okay, I want to take you to operation room, they’re going to say, okay, yes, but they really don’t understand what the procedure is going to be. It is very important to the care of family members to be involved to explain what’s going on, what’s the consequence. But again, they losing their medical capacity much later in the stages of the dementia. And this is why it is so important to clarify for that. It’s such a pleasure. Again, thank you for inviting me again to town hall. Happy Holidays to everyone and everybody stay safe. And thank you, doctor Schneider it is such a pleasure to be with you today.

Dr. Logan Schneider  1:11:45  

Yeah. Likewise, it was a great tag team. Appreciate your time.

Paula Wolfson  1:11:48  

Thank you, Dr. Ayati. So Dr. Schneider, just one more bit about the decision making. So if a person with dementia ends up in the emergency room, and doesn’t have their person with them, for some reason, I know sometimes the police get involved and bring somebody in who’s wandering, confused, an older person. I don’t know if you’ve been in the emergency room recently or during your course of training. How is that person evaluated in an emergency room? If they’ve walked in, they’re older, frail, they appear confused?

Dr. Logan Schneider  1:12:24  

Sure. That’s a that’s a conv– obviously a convoluted question. Is all healthcare situation seem to be from an ethical standpoint? All physicians have to rotate through an emergency department during their training? And you know, as a neurologist, obviously, you continue to see strokes and what have you in emergency room settings, where decisions are sometimes very difficult because people can’t suddenly can’t talk, for example. But the the question about people coming into emergency departments, so there are levels of the requirement for physicians to obtain informed consent. Informed Consent is really that decision making process request from a patient, are we– are you accepting of our intervention. Obviously, we do everything we can to seek out understanding from the patient, to make sure that we have– that they have grasped what we’re asking to do. And obviously, the higher the invasiveness, the higher the risks, the higher that bar. And we use a reasonable person standard, if you were sitting, if another physician was sitting there, or if another person was sitting there and this situation is going on, would you believe that the interaction was appropriate, and hopefully, it’s been documented accordingly, to be able to ascertain, does this person understand? If they don’t understand, obviously, it’s our– it’s incumbent upon the healthcare system to do the best that we can to then seek out guidance on a timeframe that is safe, right, where we obviously try and reach out to family members, any surrogates, any bit of information that we can gather. If we have records, like advanced directives, we call around, we try and get whatever we can to kind of frame and understand. But obviously, we’re talking about the emergency room. And so some things are actually emergencies. And the risk benefit certainly is an ad hoc thing. If I’m going to administer fluids to fix your dehydration is different than if I need to do a lumbar puncture to make sure that you’re not having a meningitis, right. And so the urgency and requirement of that need versus the the risk that it poses to you and and whether or not that’s going to impose upon, you know, transgress upon your autonomy. But sometimes we don’t have that luxury. Particularly in emergency room, we see this even with people who don’t have dementia, but who just have what we call delirium, right? So it’s a transient state where they’re just out of sorts. And so in those circumstances, and particularly for emergencies, that obviously any reasonable physician would believe is an appropriate emergency, sometimes we don’t even have to seek your consent. Those are circumstances where it might be life threatening. And sometimes the better answer is, put the tube in your throat. Start you on a ventilator and then we’ll have to find out the answer that you would have wanted if we don’t have an answer. And oftentimes, very often, physicians are dealing with incomplete information despite our best efforts. But emergencies are emergencies for that reason, otherwise you wouldn’t have come in there. And so those are circumstances where we do our best to gather information and help make the safest decision possible to ensure the greatest degree of autonomy for any individual. But if they cannot evidence, understanding that we can document that they are capacitated, to refuse an emergent intervention, we often then are, by law, unable to proceed with that intervention, recognizing that once we gather that information on a matter that is not going to pose a risk to life and limb in that individual, then we will be able to reverse that decision. Obviously, sometimes, it’s harder to reverse things than others, you know, taking a tube out and extubating somebody so that they pass away rather than do not intubate to begin with is often a more challenging and ethical consideration. We see that all the time in strokes and what have you. But, you know, we deal the best we can with very incomplete information in times. But again, every physician is enabled to be able to assess capacity. And through accurate documentation, verify that they’ve done the best that they can and make appropriate decisions balancing that risk and benefit particularly in the setting of an acute emergency where it’s always often appropriate to make sure that you stabilize and make the person safe and then and then get the answers if it was unable to be ascertained immediately.

Paula Wolfson  1:16:16  

Okay. Stewart has been asking us a few different questions throughout the chat about the use of puzzles and games for brain health. But more importantly, his last question, and I think we can work towards ending with this question is– So for your clinic, Dr. Schneider, can you just tell us about a typical family dynamic, caregiver, a person may be showing some signs who would come to you and take us through the process and that you also do follow up because I think what’s not clear is your follow up and your work with the family. We know you do testing, but kind of how– what’s the trajectory of how long you work with somebody. And then I’ll talk about Dr. Ayati’s clinic, because they’re asking the difference between your two clinics. And I and I work a lot with Dr. Ayati and his folks. So if you could clarify why somebody would come to you, that’d be great.

Dr. Logan Schneider  1:17:07  

Sure, yeah. So just to clarify, we’re not a clinic. We’re a center. We’re a research center. And so I wanted to disambiguate that because clinic implies that we are your caregiver, and we are not your caregiver. We cannot order tests on you. We cannot provi– prescribe you medications, we cannot do any of that. We are a research study, in essence, however, I am a physician, a board certified neurologist, all of my colleagues who see patients are all board certified neurologists. We have board certified psychiatrists on our staff, we have board certified neuropsychologists who are the test specialists. But from the standpoint of what we do is we don’t manage your care. We will see you, we will add to your to your care plan, particularly if it’s difficult to get neuropsych testing. And so that’s the value that we bring, is you get a full neurologic exam, history, and physical, as well as a full battery of neuropsychological testing to help identify if there is a thinking problem objectively. That can then be integrated into the overall plan of care where then your primary care doctor be it a, you know, internal medicine doctor, PA, RN, a… It could be a geriatrician, like Dr. Ayati, it could be a neurologist, hopefully, if you’re talking about memory disorders. And any of those individuals can help manage the care because they are, as Dr. Ayati mentioned, you have to have somebody who centralizes all event management and care. And so we provide, just like if you, if they send out for an MRI, to get an image of your brain, that information would come back to the doctor and they would integrate that into the overall story of what next steps would be and the discussion with you about what to do. And we’re just one of those diagnostic evaluations: you get a full neurologic evaluation, as if you would see me in clinic as a as a standard cognitive neurologist, along with that full neuro psych testing, which is often, you know, it’s two hours visit at our center. Some neuropsych batteries can run longer or shorter hours as sufficient. And then you get to take that with you as part of the diagnostic workup. Like I said, it’s a pattern of putting things together to define the overall diagnosis. We also make recommendations about what to do, that you’re then physician can follow. These are notes that you can integrate into your clinical care if you so if you so wish we give them to you for your for your, you know, records, but we make recommendations on imaging studies, lab testing that could be performed or should be performed with an eye of Oh, this is what is possible to do in the clinical domain as opposed to what what is ideal to do in the research domain. Right, things are sometimes not, have not been approved for the actual management of patients but are part of that. That being said, we have a lot of studies circling around in the Stanford community, in the VA community, that may be appropriate for you based on the type of diagnosis we make as a group in which you know, you might be eligible to participate in for example, a drug trial like this and aducanumab, you could have been a participant in that for example. So it does give you access to those other types of maybe even experimental opportunities for therapy. But once again, we don’t, we are not the person to contact long term about your care, because we are just a research study. And so we’re not, we’re not under the overarching premise of protected health information, for example, even though we keep everything HIPAA secure within the VA, so it’s like hyper secure, as you might hope.

And, but then we do do follow ups. So every visit, be it an initial evaluation, or even a yearly or every five year check, which we are– will follow, we it’s a longitudinal study, as I said, since the 1980s, we’ve followed people for decades. So we’re happy to see people as often as is appropriate, particularly if there’s an abrupt change, we now have a comparison to be able to track that. And that provides you, then, information to take back to your primary care doctor, on, on what to do about that type of change. And so we will see people, not infrequently, we’ll see people many, many times over many, many years. And often we guide you on suggesting when that should happen, and we keep it on our books to reach out to you and you can keep it on your books to reach out to us. But every visit, be it the initial evaluation or subsequent evaluation is paired with a short term follow up where we actually will then, once we had a chance as a team, among the neurologists, psychiatrists and psychologists to discuss your case, then we’ll then meet with you and or caregivers, if it’s relevant, to be able to provide the diagnosis that we believe as well as any recommendations that we have for going forward. So that’s the general gist, those are generally about a half hour to hour follow up where we discuss the case, the diagnosis, recommendations, and then any questions or concerns that you have. And of course, we’re not, we don’t just send you out and never see you again, until the next visit. Of course, you know, questions obviously arise in the interim, we’ve had people who are trying to sort out, you know, example, somebody needed support for making a– for claiming incompetence of their family member who is being not, you know, maybe verbally abused, as well as financially abused by somebody who claimed to care for them. And we had to make sure that they were deemed incompetent and were able to be, you know, taken into a safer setting, that wouldn’t cause financial ruin, and then distress for their life. So we can obviously provide documentation to assist those types of things as part of that thing, but obviously, most of the care coordination beyond our piece of that puzzle is managed by your primary physician team, we’re not that we’re not that replacement.

Paula Wolfson  1:22:24  

Okay, that’s a that is a big question I get all the time as a community social worker, that there is abuse, or there is a need for the documentation that somebody, after being tested, does lack the decision making. So what you just said that in certain ad hoc cases, if somebody does need the documentation regarding the testing results, if there’s been some sort of financial scam or abuse or confusion going on that has shown that they’re they are not making wise decisions, and they are in danger, then you would make– you are able to provide that documentation?

Dr. Logan Schneider  1:22:56  

Right, right. So if it’s, if it’s coming to the point of getting the courts involved to actually make a more blanket and almost irreversible designation of in, incompetence, right, different than capacity and competence. When we see that there is somebody who is sufficiently impaired, we think we can make a comment, like, oh, it seems that based on the degree of impairment here, and the pattern of behaviors and functional impairments that this person has, that it’s unlikely that this person at any point would be able to grasp the necessary understanding of financial decision making that would allow them to safely, you know, comport their own lives. And in this context, where x, y or z is happening to this individual, it seems unlikely that that is a safe situation that is being respecting of that individual’s normal decision patterns, or that the decisions are being made in, in their best interest. And so that’s something that then has to be litigated, right. That means lawyers have to present that evidence, judges have to give–

Paula Wolfson  1:23:55  

Right.

Dr. Logan Schneider  1:23:55  

–decisions on that evidence. That’s not something we can claim. Like, we can’t say, every situation, we have a we have, like I said, we have our own Polaroid of their life circumstances. And we can only aggregate the information that we have. And in those complex situations that as Dr. Ayati alluded to, like not being able to make health, financial decisions blanketly does not mean that you can’t make ad hoc decisions healthcare wise, right. So we look at the world differently. We can just add information that helps people who make those more blanket decisions, make those decisions, after gathering enough information from all sides that are involved. so we we can just provide you our perspective, from the vantage point that we’re looking at and sometimes that can help people narrow that down, right. So that’s that certainly…

Paula Wolfson  1:24:43  

Jean has asked if they do need scans, MRI, that kind of imaging, that is not done at your place, but you recommend that and then they go back to their primaries to get referred to wherever they’re, they get those done. 

Dr. Logan Schneider  1:24:56  

Correct. 

Paula Wolfson  1:24:56  

Is that correct?

Dr. Logan Schneider  1:24:57  

Yes, yeah. So once again, we’re a free service. So we’re completely outside of your insurance. And in fact, if you’re worried about your memory, and you don’t want it to appear on life insurance or what have you, this is something that you can tuck away in your pocket, it doesn’t have to go into your medical record. But yes, we are not able to order testing on you, unless you’re a veteran within the VA system, and we are seeing you there, because we are we are effectively employed by the the Veterans Administration hospital. Those individuals, we can actually place orders and then we just notify for co signature on the primary care provider within the VA system. But most people who come in from the community, we we cannot and do not do that because we are not healthcare providers in the sense, we are researchers, in a clinical research study. We just make the recommendations to your your primary physician, and then they can act on that. Just like any lab study that they would order, like, Oh, I ordered this thing, your sodium is a little high, should I give you sodium tablets, right. That’s a decision that has to be taken into the context. We try and consider all those factors when we make our recommendations to your primary care team. Once again, we do not do the ordering because we do not do the follow up on that. We are a research study. If you do get it done, though, we are happy to add that information into your research notes that then we can track over time, and that adds valuable data to our understanding of your story that we can then summarize again, for your team. It’s kind of like this expert consult anytime you get an expert consult. Yeah.

Paula Wolfson  1:26:14  

Thank you. I know I hear a lot from my clients who are with PAMF and other providers services that when they want testing, there’s now a delay with the pandemic and COVID to get testing done. So if somebody just called your center today and wanted to start arranging a series of testing, do you know what the delay time would be? Or what the average wait time is to come in?

Dr. Logan Schneider  1:26:40  

Sure. Yeah. So coincidentally, right now for the next three weeks, because Stanford is on a winter break, you know I’m saying we’re not a cli– we’re not a clinic, which runs… 

Paula Wolfson  1:26:50  

You’re not a clinic!

Dr. Logan Schneider  1:26:51  

… because Stanford is on holiday break, and we’re a research body at Stanford. So we, all of our staff are on that holiday break. 

Paula Wolfson  1:26:57  

Oh. 

Dr. Logan Schneider  1:26:57  

But, generally, because of the our demographic, our patient population being at higher risk, because they’re generally older, we have seen a decrease. We normally would see six to eight people a week for the research protocols, but almost always have openings. I mean, this week, I only have one person on Thursday. So if you want to get this testing done, we can probably schedule– we schedule Monday mornings, all day Tuesday, all day Thursday. And hopefully, depending upon changes in staffing, we might even just open up to every day of the week, Monday mornings, and then Tuesday through Friday. But I mean, the openings, it’s incredibly easy. If you want to get booked and you you match with our schedule, we can, we can see people, like, this week, for example, or even next week. So we have we are not booked booked out because we’re doing all virtual visits now. But even when we were in person, the tend– the delay would tend to be about a month. 

Paula Wolfson  1:27:51  

That’s amazing. So I think folks, we just heard the holiday miracle for the next few days. If you want testing, I imagine you’re going to your clinic, your center is going to get some calls now. 

Dr. Logan Schneider  1:28:02  

Yeah, great. And we’re happy to see anybody, even even people who don’t have memory problems. Somebody was mentioning that their mom is the one that they’re caring for, but they’re interested in themselves. Which is always a question. We have lots of people who are caring for their parents see us as well. And so we’re happy to see anybody.

Paula Wolfson  1:28:16  

Okay. All right. So we’re at 12:28. I want to thank you so much, Dr. Schneider, for joining us today and for joining us here at Avenidas. And I think we’ll have you back at some point…

Dr. Logan Schneider  1:28:26  

Sure.

Paula Wolfson  1:28:26  

I think there’s probably going to be a whole many other topics we can delve into more deeply whether it is sleep. 

Dr. Logan Schneider  1:28:33  

Mhmm.

Paula Wolfson  1:28:34  

And I’m sure I’m going to get a lot of feedback from everybody today. So everybody, thank you so much. I will– we will be sending out surveys to you for feedback on this. And I and if you have questions about Dr. Ayati’s Clinic, so it’s a second opinion clinic. He’s not– he will work with your primary, too. But he actually does second opinions, and he does take insurance in some cases, some cases not. It’s always worth calling his office. He has a geri-psychiatrist onboard, social workers. So it is in Los Altos, it’s a geriatric center. And he’s one of the few geriatricians I know, he’s opened up basically a second opinion clinic because things are so complicated as we age in these days. And Kaiser has certain ways of doing things, the Medical Foundation, PAMF, Stanford, that many, many times people want a second opinion outside of their provider. And he does offer that. So I’m going to turn this back to Kat who’s going to, I think, close us for the time. So thank you so much. 

Dr. Logan Schneider  1:29:41  

Take care.

Katherine King  1:29:43  

Thank you everyone so much. Just to say, just here to say thank you. And we are so glad that you could be joining us. Next month, we have another town hall. And that will be… Paula, it’s January 21? 

Paula Wolfson  1:30:01  

Yeah, I think, is that the day of the State of the Union? No, it’s going to be in January, and it’s going to be Dr. Martin. She is the section chief of the Stanford geriatric–

Katherine King  1:30:10  

January 20th.

Paula Wolfson  1:30:11  

–which is… I’m sorry, what, Kat? 

Katherine King  1:30:13  

January 20. So it’s inauguration. 

Paula Wolfson  1:30:16  

It’s a it’s that that Wednesday, same time 11. And we’re going to dive deep at that point into COVID and the vaccination situation. So she’s going to come on, she’s a section chief of geriatric medicine at Stanford, she used to be the director of the Senior Care Clinic, she works in a lot of the area’s skilled facilities, she’s part of the Avenidas operation PPE, where we’re distributing personal protection equipment to a lot of the memory care units and assisted care facilities that did not get them. And we’re very involved with that. She’s a close community partner of, of Avenidas, and she’s going to bring an expert on, we don’t know who that is yet to really help us understand about the vaccinations, the protocols, priority testing. And by then we’ll know much more about that. But I do want to let all of you who are still on know that this Saturday, the city of Palo Alto is gathering about 100 of us to be ambassadors, and they’re going to start to educate us on this process and what’s going to be involved with it. And I’m going to join them in that training for this Saturday, so that I can work with our community on on what’s going to be happening for us, but you can always call your doctors. You know, we’re telling everybody to call your doctors, ask them questions about what will be available and when for patients or clients. But remember, everything right now is going to frontline workers in hospitals, emergency rooms, paramedics, to make sure that they are vaccinated at the frontline. If you have questions for me, you can call me anytime, I’m at 650-289-5438. That’s my direct line. It’s confidential, Avenidas care partners, I am answering that phone line and checking it Saturdays, Sundays, up until eight o’clock at night, holidays. We are in a pandemic, a lot of you are experiencing difficulties, crisis. So you can call and if I can help you, I will if I can help you find another resource. I will do that. But that is one number you can call and I will call you back within a day or 24 hours, Avenidas Care Partners. All right. Thank you so much, Kat. Once again, thanks, everybody. And let’s stay in touch. 

Katherine King  1:32:28  

Yeah, hopefully we’ll see you all next month. Happy holidays. 

Paula Wolfson  1:32:32  

Happy Holidays.