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Dr. Cherish Smith on Neurocognitive Dysfunction and Decline
4 Plays8 days ago
Music by Mical Teja
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Transcript
Introduction to Dr. Cheris Smith
00:01:04
Speaker
Welcome back to The Trauma Code. This is Dr. Simon Fisterra live and in the studio and we're going to cut right to an interview we did ah over the weekend with a good friend, Dr. Cheris Smith, an expert on ah cognitive ability, particularly in the elderly, getting back to our public health kind of roots, talking to specialists and sharing the information with you all out there. And now is as good a time as any. Go online, support WBAI at WBAI.org. Thanks for listening to The Trauma Code and stay tuned. Welcome to The Trauma Code. This is Dr. Simon Fitzgerald here in our home studio with my lovely co-host. Dr. Cassandra Afael. Happy Monday everyone.
Dr. Smith's Expertise and Background
00:01:44
Speaker
And we have on the line a good friend, a guest, a specialist to talk with us today about neurocognitive dysfunction and and decline, particularly in the elderly. Kind of a new topic for us. I'm happy ah to get into some new area. Cassandra, do you want to introduce our guest?
00:02:03
Speaker
Sure. Today's guest is Dr. Cherish Smith. Dr. Cherish Smith is a board certified psychiatrist and eligible neuropsychiatrist with years of experiencing, diagnosing, and treating a variety of psychiatric and neuropsychiatric conditions. Dr. Smith earned her doctor of medicine degree from Xavier University School of Medicine in Orangestad. She completed a fellowship in behavioral neurology and neuropsychiatry at the University of Florida in Gainesville. Her training includes expertise,
00:02:31
Speaker
in cognitive impairment, traumatic brain injuries, Parkinson's dementia, and pre-DBS psychiatric evaluations. That's pre-deep brain stimulation, psychiatric evaluations. At the Memory Care Center she works at, she evaluates diagnosis and manages an array of cognitive disorders. And her professional interests include working to uncover complex cognitive disorders and managing difficult psychotic and mood disorders as well.
Challenges Faced by the Elderly
00:02:58
Speaker
Please welcome to the trauma code,
00:03:01
Speaker
Dr. Cherish Smith. Hello. Hi, guys. Thanks for having me. Thanks for coming on, alas. We're so excited to have you on. And I know it's been a while, we've been talking about this for some time, right? Indeed we have been, but here we're materializing things in, twenty we're manifesting in 2020. We're making things happen, right? um So I'm excited to talk to you today because as Simon pointed out, we're broaching a topic that we don't often visit on the trauma code, but that we should never forget to do. We're going to talk today about largely the elderly. When Cherish and I spoke to prepare this conversation, we talked about how the elderly are, consider the elderly a marginalized group.
00:03:39
Speaker
Yeah, I mean so when you think of that term marginalized group, you know you think of group of people who have been underserved, not necessarily paid as much attention to, and with the patient population that I do see.
00:03:55
Speaker
ah The marginalization of this group is really highlighted when they do tend to have cognitive disorders and need to get certain resources that it's kind of difficult for them to get at their age. So, you know, it's a group that I think unfortunately has been forgotten for quite some time. And I like to see it as my my job to help bring them back into the fold for lack of a better term, just to give that support that they really truly need as people do live longer now. And getting that additional support is so, so important. Right, right. So oftentimes when we think about a marginalized group, ah we we kind of associate them with various assumptions that are made that kind of
00:04:44
Speaker
and omit the intersectionality of being a part of that group.
Elderly and Technology
00:04:48
Speaker
So what are some of the things that we say or assume about elderly folks that maybe don't really hold up the way that we assume they do? Yeah, there's so many things. I think the first thing is, and I think even it's so sad to see,
00:05:05
Speaker
that the elderly, they themselves marginalized themselves, right? Because it's what society has kind of allowed for it to happen. um They say things like, or we assume that because somebody is older, their cognition has dwindled. Or the expectation is, well, I'm forgetting because I'm older. When you can have a 97 year old patient who is as sharp as a tack, right? like And I think also in the advent of the technological advances. That's the way that we've been really kind of marginalizing our patients, especially in health care, because we have this electronic medical record now, this MyChart system, and I often have patients asking me when I send them for blood work, am I going to get a piece of paper? And, you know, it's like it's sent electronically, but
00:05:55
Speaker
You know, it's hard for them to really move as quickly as technology has been moving over the
Understanding Neuroplasticity and Cognition
00:06:01
Speaker
last decade. So that's the way that I feel like we kind of keep them out of the loop, which is not healthy. o Which actually brings me to something I'm i'm eager to, i very often eager to talk about is screens with young people, with middle-aged folks, elderly folks.
00:06:20
Speaker
um As much as we think that the elderly are kind of disengaged from the technological advances that ah that you know that we've been um kind of watching evolve over the past several years or a couple of decades, I also notice that there's often a lot of maybe people from the boomer generation who are very attached to their phones and trying to figure things out and getting onto social media.
00:06:51
Speaker
um Does that ever become a problem for the the elderly folks as I sort of see it for the younger people as a child psychiatrist? Oh, yeah, definitely. um It's been quite the conversation, I'd say, especially with couples. So I often would have a spouse complain about a patient constantly spending time on their iPad or their phone or, you know, in some of their cases, their desktop and things like that. And it kind of affects their dynamic and you can see it affecting their relationship as well too, because oftentimes the spouse is crying for more attention, more quality time, things like that. So I see that there are times that it could really interrupt the dynamic. But then there's times when it's really you know helpful, right? So a lot of times um I'd have patients who do a lot of these cognitive
00:07:47
Speaker
exercises indirectly, they are not realizing that it's cognitive exercises, but the word search puzzles and the crosswords and sudoku and all these things, which typically I advise to do, but I think like all of us are guilty of, there is this addiction and that dopamine feed that we get from constantly scrolling, right? And the elderly are not um exempt from that.
00:08:13
Speaker
Don't get me on my soapbox about screen addiction and the dopamine because I will go on and on. It'll be a whole different show. It's rough. It is rough. It is rough. But I'm happy to hear you mention crossword puzzles, word searches, Sudoku, and things like that because those are also things that I like to give to my own patients, you know, kids.
00:08:34
Speaker
to to kind of to to do, to kind of get what I like to call a slow dopamine. It's not so exciting, but you still get something done and you get to have a sense of accomplishment when it's finished. It lets you feel proud and to kind of lean more into like, I've been productive or I made something, I completed something and I'm proud. And that's the the kind of internal validation dopamine that I'm trying to encourage them to pursue. But I would imagine it also helps with neuroplasticity, maintaining it, right or or even, it well, when you got it, you got it, right? So right can you help the audience understand a little bit about what neuroplasticity is? Yeah. So neuroplasticity refers to the structural changes that occur within the brain, right? So when you think about it, it has a lot to do with these pathways that connect. And there's all these little proteins called neurotransmitters that are firing off.
00:09:33
Speaker
and allowing for the brain to function. So, you know, using that phrase, if you don't use it, you lose it type thing. um Neuroplasticity is kind of like that. Like if you're not really utilizing those really under accessed parts of your brain, it's kind of not going to function as well. So just there are certain cognitive of exercises that I do encourage.
00:09:56
Speaker
for my patients that could help with neuroplasticity and encouraging neuroplasticity. But there are also medications as well too, right?
Neurocognitive Dysfunction and Treatments
00:10:04
Speaker
That we know our psychotropic meds do also encourage neuroplasticity as well too, to a certain extent. Yes. um And I think what the concept of, you know, in my experience, particularly as a trauma surgeon, the idea of neuroplasticity is so different in young people and old people, right? And the same thing, learning languages and other things. Little kids can soak things up because their brain is designed to be building new connections. And it's certainly not the same in the elderly. right And I think, excuse me, when we're talking about this topic of neurocognitive dysfunction, particularly in the in the elderly, there's kind of two parts to it to me, right? Which we've been talking a little bit about
00:10:53
Speaker
you know, what makes the elderly a unique population, a marginalized population at times, and how can our prejudices or our assumptions, particularly in healthcare, care um be detrimental to their care. But the other part, which I think is worth taking a moment to better explain and understand, is just the the basic concept of cognition. Like we're actually talking about when we think about cognitive dysfunction, what is cognition when it works, you know, at its best?
00:11:23
Speaker
Right. I think it's it's really good to start off with just the definition of cognition, because that's so important. A lot of times when people hear cognition, the first thing they think about is memory, which is one of the domains of cognition, right? But there's so many other domains as well, too. And just by definition, cognition is the way that we think and our mental processing, right?
00:11:48
Speaker
And there are five main domains in cognition. So memory is one of them, but there's also language. So it's expressive language, how we speak and receptive language, how we receive and comprehend. Right. And then there's executive function, which is the area that's modulated by the front part of the brain and it's responsible for organization and planning and things like that. Then there's visual spatial skills. And then something that you know Cassandra and I are well familiar with, which is the perceptual part. right So perceptual disturbances is a part that's really key, especially in our patients with severe mental illness. Now, with respect to cognitive dysfunction, any kind of impairment in at least one of these domains
00:12:38
Speaker
would constitute cognitive impairments and dysfunction. So I hope that answers the ah question that you had. and Definitely. And so um you know what does neurocognitive dysfunction then mean to you? And why is this a topic that you wanted to prioritize in a conversation you know with ah the five boroughs and beyond?
00:13:03
Speaker
Because we're seeing it a lot more, right? So I think um if anything, across the televisions, we see these advertisements for something called Previgen, which um it's something that they've been promoting for cognitive health, right?
00:13:20
Speaker
And I think more often, we've been getting questions about these medications, our patient population, like we said before, they're living longer. So the longer you live, the more you would be around to see certain things happening, right? So the most common neurocognitive disorder is Alzheimer's disease. So I see that very often. And One of the reasons that it's so important is that we all at some point in time ah produce an excess of amyloid precursor protein, which is that protein that kind of like preludes or comes before Alzheimer's disease sets in. And then eventually, if we're not clearing it fast enough,
00:14:03
Speaker
You know, that's when the plaques start to form and the Alzheimer's disease kicks in. But just knowing that we have roughly about 4 million people right now with Alzheimer's disease is just one reason to bring and highlight and educate people on this very common neurocognitive disorder. There are things that can be done.
00:14:26
Speaker
And we've you know come leaps and bounds from like two decades ago, three decades ago when it comes to intervention. um I really like to educate people on you can have this neurocognitive disorder and still be at home.
00:14:42
Speaker
because people think I have dementia and I have to go into a nursing home. But there are things that can be done and there are a lot more supports that we do have available that can definitely be so instrumental in people aging with dignity, even with a neurocognitive disorder.
00:14:59
Speaker
Thank you for explaining that. So you you mentioned specifically Previgen and it's a new medication. So this the Previgen that we were I was talking about was the one that people ask about a lot that is not for any cognitive disorder. It's actually kind of of like a miss marketing of things. So, but the the one that is the newer medication is called Lacanumab. Oh, okay. Yeah. So is that, what's the um the brand name? Lacanby. Lacanby.
00:15:29
Speaker
Okay, yes is is it heavily advertised or marketed? Not as much as the other one, which is the Nanamap. And that one is um by Eli Lilly. And that one is branded as Kissanla. So that one is all over the internet ads and all over the TVs now. Okay. So it's pretty, it's pretty heavily marketed. Do you find that patients come in or patients, families come in with their, you know, loved one and say, Hey, what's up with, you know, yeah this new med that I heard about? ah How helpful is it? um And and what so what are the the pros and the cons of these medicines? Yeah, so really very common questions. um People get excited about it because you know, the way it's marketed is
00:16:15
Speaker
it it It restores hope, which is good. um And there are some pros to it and some cons, of course, right? So if we were to look at the mechanism of action and the way that it works is that early on, when I had mentioned that amyloid accumulates in the brain, right? And if we don't clear it, it forms these plaques. So those medications, the Lacambia and Casanla, they fall under a category of medications called monoclonal antibodies, right? So it's basically,
00:16:43
Speaker
the med coming in and removing the plaque, which is
Normal Aging vs. Dysfunction
00:16:47
Speaker
a good thing. And that's ah a one pro or, you know, positive um when it comes to the medicine. So removing the plaque, which is the underlying cause of Alzheimer's disease. And based on the trials, so Lacanumab or Lacanbi has gained approval based on this trial called the Clarity AD trial for anybody who wants to look it up on clinicaltrials.gov.
00:17:12
Speaker
And what they've shown is that with the removal of the plaque, it key it gives you about up to 20 months more of stability. Without medication, people tend to decline over a 10 to 15 year span. And if we were to give you a cognitive test today while you have Alzheimer's disease, and we retest you a year from today,
00:17:39
Speaker
you will most likely, based on the average, decline by one to two points on the cognitive test. So based on the Clarity-AD trial, what they're saying is that you take this medication and you're supposed to kind of stay where you are,
00:17:55
Speaker
for an additional 20 months, right? Now granted, this is clinical trials. It's a more controlled setting. So right now we're kind of like seeing how things look in real time, um but as the pros come, so do the cons, right? So the negative part would be like with every medication, there's side effects, right? So I like to liken the amyloid plaque to a scab.
00:18:22
Speaker
If you pick that scab, there's two things that can happen. There can be some swelling, i irritation, and then there can be some bleeding, right? So the main side effects that we see that are scary or concerning would be something called ARIA-E and ARIA-H. So ARIA stands for amyloid related imaging abnormality.
00:18:46
Speaker
And that basically means on the MRI, we're going to see abnormality concerning where the amyloid was, right? Information. I'm sorry? Information, is that what you're saying? Exactly, yeah. And then E stands for edema, and then H stands for hemorrhage.
00:19:03
Speaker
So the edema would be the swelling and the hemorrhage would be the bleeding, right? So you pick that scab, it swells or it bleeds. Based on the Clarity 80 trial again, based on your genetic makeup, that is where we could tell whether or not you're at increased risk for having ARIA, E or H. So there is a gene
Risk Factors and Prevention
00:19:24
Speaker
called the ApoE gene.
00:19:26
Speaker
and people who have copies of ApoE4, if you're heterozygous or homozygous, meaning having one copy or two copies for this, then the risk increases for having the ARIA E and H with the medication. So there's a whole like like criteria that must be met, an algorithm that should be followed, which is also kind of a con as well, too, because Our patients are tired, they're forgetting, you know, they're a little bit dysregulated emotionally and to go through all of this could be a bit daunting at times. um But like I said, and it's it's instilling some hope. um And it's a small percentage of patients who end up having ARIA. And the the benefits I wanna highlight is very modest. So it's nothing that's extremely drastic, but it gives hope and it does slow things down a bit.
00:20:20
Speaker
and And you've been talking about how the marketing of that medication has um brought attention onto neurocognitive dysfunction and bringing people forth with questions. But I wanted to back up a little bit. I don't know if we've actually talked about, like, what does that neurocognitive dysfunction look like, particularly in the elderly? And I don't know if it's worth talking about, you know, is, you know, compared to what neurocognitive dysfunction might look like in younger patients.
00:20:49
Speaker
Okay, so I think let's tackle it this way, talk about the older people ah and talk about what normal aging looks like first. So ah when we get older, you know, our brain shrinks, so we lose that volume and everything just kind of like starts to slow down, right, as we're preparing for death.
00:21:08
Speaker
and ah And I know not to be morbid, but that's just how it is. You know, we're all gonna die. So, you know, things slow down. Oh, cool, old age and with peace in your heart. Oh, yes. And dignity. And dignity, yes. Most importantly, which is what I'm promoting, right? So, you know, things slow down and processing speed is the first thing that slows down and mental flexibility, right?
00:21:36
Speaker
So what is going on is that you know you'd see patients coming in and they'd say things like, you know, I went into one room and I forgot what I went for, but eventually it came back, right? It's supposed to come back eventually, right? Now, when it starts to not come back, that's when we start to kind of have some concerns, right? um The way that we typically see neurocognitive dysfunction in the elderly is short-term memory problems, ah repetition of self. So they start to have issues with delayed recall and immediate recall. So they're starting to ask the same question within like five, 10 minutes of, us you know, that that time span or whatever it is.
00:22:27
Speaker
Now, when you think of neurocognitive disorders in children versus in the elderly, with the elderly, they continue to decline, right?
Impact of Mental Health on Cognition
00:22:37
Speaker
It's because that degeneration is happening. It's just continually moving along in a negative direction, unfortunately. With children, the neurocognitive dysfunction, we see would typically be in neurodevelopmental disorders, right? So we're talking about the ASD's, the ADHD, things like that, Rett's disorder. I don't even think they use the term Rett's anymore, pervasive developmental disorder, all these things that we've learned about. um So that looks a little bit different because of the one, the prognosis, and then the the way that things look um like a ah graph, right? So like we look at it from,
00:23:19
Speaker
On a graph, we look at it over time for the elderly, they continue to go down. With neurocognitive disorders in kids, they usually improve with intervention. but right So so it it definitely looks different if we were to map things out on a graph. So as somebody who works with a lot of children who are diagnosed and living with ADHD, one of the domains of cognition that particularly suffer is that of executive functioning.
00:23:48
Speaker
that's like great oftentimes the overlooked bit of ADHD, like if you ask any you know anyone on the street, what's it like? or what what do you How would you know if somebody had ADHD? They would be like, well, they don't sit still. right and And that's probably the chief thing that they would name, but there are many other things that are included. So when we're talking about cognition and ADHD, particularly we're talking about struggles with executive functioning, which means being aware of ah time passage and being able to be organized and to plan things. And ah one big, big thing of executive function that is often overlooked in many kids who are diagnosed with ADHD is the emotional dysregulation or the emotional regulation bit, which um
00:24:39
Speaker
they they They have a bit of a hard time modulating their emotional responses. If they're happy, they're very happy. And if they're angry, even though it may seem like a very small infraction, but they're very angry, right? Yeah. and That's my experience in working with with children. In your experience working with the the elderly, how do executive dysfunction difficulties present it or is it similar? Funny enough, it presents almost exactly the same.
00:25:09
Speaker
Right, almost exactly the same, um I think, initially, especially in the beginning stages. So we see a lot of executive dysfunction in frontally mediated neurocognitive disorders. So things like frontal temporal dementia, even frontal or thyroid behavioral variants, Alzheimer's disease, which is like a type of Alzheimer's disease where it's like more so executive function affected than memory.
00:25:36
Speaker
We tend to see that in the beginning, they start to have little bits and pieces here of like organizational skills, falling through the cracks, and then it starts to affect like their complex or instrumental activities of daily living.
00:25:52
Speaker
Because at this point, you know I mean, you're grown. So you're you're doing your finances, you're driving, paying your bills, all these different things. So now we're starting to get into accidents because we're not paying attention anymore. And you know we're not averaging well when we're making that turn. We're turning too wide. So that's how we start to see it in the and the elderly. And then obviously, as time goes by, the executive function starts to bleed into the recall and memory part of things.
00:26:22
Speaker
Well, this is all very interesting. I know that, I don't know if we'll say this on the air or not, but, you know, you've heard some people say, oh, well, you know, the elderly at some point should maybe reconsider whether they can drive or, I mean, like there should be a test when they get to a certain age or whatever. Right. It's safe for them to be outside. Do you know anything about that, Cher?
00:26:45
Speaker
Oh gosh. So I think once again, just waving my flag of dignity, that's really important for as one of my elderly folks. Driving is something that does require a lot of attention and strength in these front of the mediated domains, right?
00:27:05
Speaker
so Age should not be a determining factor on whether someone should or should not drive. but Their cognitive ability and their physical ability is the most important thing. So you can have 95-year-old Gertrude who is with it and has all her faculties and is healthy and She's able to turn her head to the side perfectly. There's no stiffness in her neck. Leave her alone. She's fine to drive. Leave her keys where they are. Put her keys back. Yes, give her her keys. But then you have you know someone else who may have like a significant medical history. For instance, if we say something like Parkinson's disease, where we know people start to get significant rigidity, you can't move your neck around
00:27:55
Speaker
You know, so it's it's kind of hard for you to move fast enough to see if somebody's coming out of the side, you know, your peripheral vision's affected, your hands are shaking because you're tremulous, you know, like that definitely would be an indication. But I think that is also one way that we marginalize the elderly by assuming that they shouldn't be driving because they're 103.
00:28:19
Speaker
But no. ah right But you know what I mean, as long as you're physically and cognitively capable.
Socialization and Cognitive Health
00:28:29
Speaker
Now, like I said, mental flexibility, processing speed, all these things do kind of slow down a bit as we get older.
00:28:34
Speaker
um I always encourage the adult children of my patients to at least ride along with mom or dad maybe once every few months just to make sure that the mechanics are in gear and they're driving at the speed limit. A very common complaint um I get is mom or dad is really really cautious and they're actually driving below the speed limits and they think that because they're driving slow it's good but it's just as bad as driving too fast because if you're on the highway and you're driving at 35 miles per hour then you know that is really not good.
00:29:15
Speaker
And, you know, we talked a little bit about, you know, the the hope and and the modest benefit of the medication. And I want to get into some alternatives, you know, um either behavioral or other interventions or ways of preventing. But I wanted to even step back a little bit, you know, what puts somebody at risk as the age of having, um you know, neurocognitive decline or dementia or other dysfunction? ah What are the risk factors that people can control when they're a little bit younger?
00:29:45
Speaker
Right, so those would be modifiable, right? So the generic things that all three of us have said so many times in our career, which is diet and exercise, and all doctors have said this, all clinicians, right? But the emphasis is just, it's necessary. And there's a diet that we promote now Disclaimer, it's not going to cure or reverse anything that's cognitive um cognitively impaired but it's important that we do follow a really good diet and the Mediterranean diet is significantly Considered the best because it is one that's rich in fruits nuts vegetables poultry and very little red meat and the reason for the
00:30:30
Speaker
encouragement for this diet is because it does help to promote a really good vascular system. And I think it would be remiss of me if I didn't mention that most of my patients will have vascular disease when we do an um MRI. And if you take a picture of our brains, you we will see some degree of some changes as well too, right? Because, you know, we all eat Uh, little unhealthy from time to time. Med school is just the number one cortisol producing, you know. Right. Right. And then residency would do it and fellowship even worse. So it's like, you know, these, it's it's a lifestyle thing, right? But the diet is really, really helpful and studies have shown. that it is you know something that could really help prevent adding insult to injury, right? So that's one piece. Then the exercising is another piece. It's really important, um especially for our patients who have neurocognitive disorders with a setting of movement disorders. So for instance, Parkinson's disease, people tend to, 50 to 70% of patients who have Parkinson's disease tend to have cognitive dysfunction eventually.
00:31:43
Speaker
and There are a lot of like um boxing classes for Parkinson's and, you know, um they call a big and loud program, all these different types of like therapeutic interventions that can be really helpful, not just for physical, but also for cognitive. So this is like the modifiable things that I had an exercise.
00:32:03
Speaker
and And what I would add to that, because I agree that vascular disease, the same things that will lead to heart attacks and strokes can also lead to vascular dementia. Right. So in addition, a little more granular, but ah poorly controlled diabetes, blood sugar yes is important in long term.
00:32:20
Speaker
Also smoking increases inflammation in the vessels and can increase vascular disease and vascular dementia. So the same things you think about to prevent a heart attack also will probably prevent um similar problems in the vasculature leading
Support for Neurocognitive Decline
00:32:35
Speaker
to the brain. and and Definitely. and And even just to tap into the psychiatry part of things as well too, there have been some recent articles that spoke about vascular cognitive impairments and this bi-directional relationship with depression. And what they found is that depression is now a risk factor for vascular cognitive impairment. So I think
00:32:59
Speaker
in you know this era where people are actually more aware of their mental health and they feel more comfortable seeking out psychiatric treatment. I think this is also a way to encourage people to get their depression treated, whether it be by non-pharmacological interventions like psychotherapy and or you know medications as well too.
00:33:25
Speaker
It may be a relatively small subset of people, but I think in the same idea, as a trauma surgeon, repeated traumas can cause chronic inflammation, repeated hedge trauma. And there's probably other things that we don't understand as well about what can cause inflammation in the brain. I don't know if you have any other comment on that. Are there viruses or other things that can have a cognitive dysfunction?
00:33:52
Speaker
Definitely. So a lot of times um people would have like some kind of like encephalitis. um Most times it's due to HSV, which is the herpi herpes simplex virus. So what we found is that
Cognitive Impact of Illness and Surgery
00:34:06
Speaker
in a quite substantial percentage of people who have had HSV encephalitis as like a sequelae later on, they do tend to develop um some cognitive dysfunction.
00:34:20
Speaker
And I've had a few patients like that. So I think um in cases like that, just really encouraging if you do have any kind of like HSV outbreaks to really seek treatment, getting that taken care of, whether it be prophylactically treating it, you know, with your provider of course, because having it untreated could have some consequences um when it comes to cognition as well.
00:34:46
Speaker
I have um two questions related to what you just mentioned. Might you be able to speak a little bit about long COVID? COVID, I knew it was coming. No, I was coming with this. ah Yeah, because so many people say, oh, you know, I have it. And um not unusually, yeah I hear that there are, again, memory lapses and things like that involved. So by what mechanism does that happen?
00:35:13
Speaker
Yeah. So, you know, I actually had a ah really interesting conversation with one of my colleagues who is an infectious disease specialist. And um I think for a while because, you know, I have trust issues. I was like, I don't believe in this long COVID thing. Like, what do you mean long COVID? Like, this makes no sense. And he has a cited a few articles that basically highlights at the pro-inflammatory states that COVID puts people in. And then I attended Harvard's neuropsychiatry comprehensive course last year, and they spoke about how systemic COVID is. And, you know, the means by which it causes all these symptoms is still being studied, but it's thought to be pro-inflammatory. It's also thought to be um a systemic illness that causes like this hypercoagulable state
00:36:07
Speaker
So when you think about that, it it still affects the vasculature of the brain, right? And when I speak to like my neuropsychology colleagues and how long COVID presents on cognitive testing, it actually presents very similarly to vascular disease. So it's like a front, so it's a cortical process, which is what we describe it as. Wow, that's very, it's interesting and also kind of alarming because you you know you watch the numbers going up and down and up and down. and Yeah.
00:36:38
Speaker
people are trying to get rid of this masking business so hard. And most of us probably don't do the masks too much anymore. Yeah, but I mean, yeah, people kind of have kind of like phased that out a bit. And it is what it is, right? I mean, I'm pretty sure the majority of us have at least contracted COVID once, you know. Yep, please, please.
Financial Aspects of Elderly Care
00:37:01
Speaker
Not me, not me.
00:37:04
Speaker
knock on whatever would, you know, might even try to say this on the air somebody you know, I know, but i am but I mean, we definitely can't we can't prevent. Um, by means I mean, we we get vaccinated. I mean, like you know, what else do we do, right? You try to wash your hands and you know, stay killer of people who are sick, be responsible. And if you're sick, wear a mask, because that's the best way to utilize the mask, right? um I think people don't think about when you'll rain the mask to protect yourself, what about your eyes? Like, but if somebody's wearing a mask, like, and they're sick, when they cough, you know, it's kind of contained, right? So
00:37:46
Speaker
I think in the very, what you're saying reminds me of the very early days of COVID, I was working outpatient as a resident. And it was, I think, still in the very early days because they hadn't decided that we couldn't come in yet. Yeah. and It was just kind of new on the streets and maybe not even that, you know, aggressive in New York yet. One of my patients actually who, who suffered a traumatic brain injury that gave him some, you know, cognitive decline, but he came in wearing gloves,
00:38:16
Speaker
and a mask and goggles. He was not playing with this. like yeah like And I remember thinking, well, this is eccentric. Yeah, yeah. Little did you know. Little did I know. think Exactly. He was the sharpest guy in the room. Exactly. He was, right, right. Doctor. He was an early adopter, we should say.
00:38:39
Speaker
I mean, you know, the show being the trauma code, we we often do find systemic inequalities and yeah um and the like that give people risk factors or that put certain people at a disadvantage of us, you know, in a situation that we're discussing or in ah in a state that we're discussing. So previously, when we were preparing, ah you know, to have this conversation, you mentioned that education has been studied as something that or education level, I should say. yeah It's been studied as something that can contribute to ah one's prognosis in terms of preserving neurocognition.
00:39:16
Speaker
um We did talk about how just kind of continue if you if you don't use it, you lose it. right so Perhaps akin to achieving a certain education level is just how much you're using your your mind. How much are you exercising this organ?
00:39:35
Speaker
and and and that is significant in preserving brain health, right? Yeah, no, definitely it does you know add to cognitive reserve, right? So you think of it as a tank. If you fill it all the way up, ah when you know you poke a hole in it, you know it's it's things are gonna come out, but not as fast as if you only had this much in it, right? So definitely education is protective um and supportive of cognitive health. And you also mentioned um
00:40:09
Speaker
air pollution, even, right, can have some pro-inflammatory effects ah in the body and of course, then the brain that can lead you to neurocognitive decline in the long term.
00:40:23
Speaker
Yeah, no, definitely. I mean, um you know, it's very rare that we, I have cases like this, but I had one patient who had like where I am now where I live and I was in Connecticut and we have ah like these wells, right? So people have wells, um you can have public water or you can have a well system. And one of my patients actually had arsenic in her well water. And there's been, I think,
00:40:48
Speaker
A few papers out there, you know nothing too substantial, but some link that these they think might they might be between arsenic and Alzheimer's disease. That doesn't mean that there's a true you know correlation, but a few articles. But it just goes to show that you know one socioeconomic status can affect you know your cognitive health as well, too, because where you live, your education system, all these things influence what is available to you and then subsequently affects your cognitive
Cultural Reflections and Closing
00:41:20
Speaker
health. So it's just really unfortunate when we have um school systems that fail
00:41:28
Speaker
our children, because ultimately it's affecting, it's going to affect their health. you chocolate It is a part of your health. Right. Even in the very long term, right? Even in the very long term. If somebody feels like they, you know, school is not the right place for them, for reasons that the school could change, but maybe not change.
00:41:46
Speaker
um So that, and then also diet, right? So we we spoke a lot about that, but what's available to different people in different communities, yeah you know, might then make it or increase the risk so for certain groups of people. Yeah, yeah, which is really unfortunate. So I think it just it really goes to show how much could be and should be done systemically to allow for a healthier society. Right.
00:42:15
Speaker
so you know In understanding the risk factors, I think we understand prevention a little bit, right? Don't smoke, eat a healthy diet, exercise, control your blood sugar, um minimize brain trauma and other causes of inflammation such as COVID. um But for someone who's starting to notice neurocognitive decline or dysfunction, what are some non-pharmacological behavioral, technological treatments? What are the other options when people come to you talking about these medications?
00:42:45
Speaker
Yeah, so I mean, when there is dysfunction, when there is impairment, the first thing obviously is to get diagnostic clarification, right? We need to understand what's going on before we even come up with any kind of treatment plan. So if it is something degenerative, you know, if somebody is in this state of what we call mild cognitive impairment, meaning that they're in the beginning stages, but they're still able to do things independently, like drive their finances, those things aren't being affected. Before this new medication came out, which is the Blacanumab and Denanumab, there was nothing that could be done ah pharmacologically, right? So we would typically say um cognitive rehabilitation, which is basically run by neuropsychologists. It's kind of like physical therapy, but for your brain basically. And they come up with like this really rigid kind of like,
00:43:44
Speaker
program for you to meet your needs and, you know, really just kind of help cater to the areas of challenges that you're having and um encouraging that neuroplasticity, right?
00:43:57
Speaker
Now, if people have kind of gone on from mild cognitive impairment into this domain domain of dementia, which is where now you can't drive anymore, you can't do finances, we do the meds, but the non-pharmacological interventions are based on what we call BPSD, which is the Behavioral and psychiatric or Psychological Symptoms of Dementia. So people might have sleep-wake disturbances, so they're getting up at like 1am in the morning and you know opening doors and trying to leave. ah They may have hypermorality, eating a lot.
00:44:35
Speaker
extremely agitated, aggressive, they might have calf-grass syndrome, or what we call in neuropsychiatry, prosopagnosia, so they can't recognize their loved ones, right? So how do we kind of intervene to help temper things down a bit? so ah There are some studies going on with blue light therapy and that really does, it differs from UV light in that though I think the wavelength is like shorter, but light is light, right? But blue light is found to be less ah harmful than UV light. And basically the thought process behind it is that
00:45:14
Speaker
we kind of promote normalizing that circadian rhythm because the state of wakefulness and sleep is run by our brain. And if that's degenerating, then it's going to be impacted. So I always recommend when it's to the daytime, have your patients up or your loved one up, make sure that they have a routine that they're following. Routine is going to be key.
00:45:40
Speaker
and then make sure that they're going to bed at the same time every night, make sure the room is well lit, right? And then using little compensatory strategies like a whiteboard, write the date on it, you know, making a list, you know, it it sounds really simple, but can be so effective. and And I realized maybe I skipped, you gave us some good advice for people who are starting to demonstrate some neurocognitive dysfunction, but for, you know, people who are aging,
00:46:08
Speaker
in a healthy way and getting elderly. Are there recommendations you make for maintaining neurocognitive health and staying sharp? Oh, yeah, definitely. So, ah you know, as we get older, our social circles get smaller, right? And then you're not socializing as much and the key is really keeping that socialization going. So even though you've retired, you know, you're not going to a nine to five every day, just really ah getting into some kind of volunteer work or
00:46:41
Speaker
you know, being active in, if you go to some kind of like religious affiliations, you know, something, and just making sure you're around people, staying engaged, those things are really helpful. Doing things that you like and that bring you joy. Because you you don't want to tell somebody who hates to read read a book. So, you know, you I like to ask my patients, like, what do you like to do? I have patients who like to paint, who play the piano, you know, some more artsy.
00:47:11
Speaker
I have people who love to garden. So, you know, just even the simple acts of gardening every day is so helpful and so instrumental. Right, because it's, ah well, it it gives you exposure to the outside and getting that fresh air is is great. And then right um it's exercise, it is physical activity. ah One thing that you didn't mention specifically, but that I am excited because my my two young children have recently become a little bit,
00:47:40
Speaker
ah a little bit better able to participate in na games. So it's very exciting for me, where you know, they've learned to play dominoes or go fish. And, you know, in terms of it kind of like addresses two things, the the the thinking and the the cognition part and the engagement. Yes. And then also the socialization part. Right. Yes. Yeah. So yeah it's a little bit a multifaceted approach to also maintaining good brain health, I would imagine. Yeah, no, definitely. um So when my patients come and they talk about things like cribbage and things that I have no idea about, thats probably culturally like, that' why i should look it up properly yeah, just should but not people say it, you should, yeah, maybe even get a board or whatever it is in here to keep in your office.
00:48:35
Speaker
Yeah, they talk about some really cool things. I learned so much from my patients. And that's one of the things, too, that um I encourage patients to do as well, too. Like, you know, share your stories, share your life experiences. Like, it's it's so good to just feel like, you know, wanted or needed. And like, you're making a difference in somebody's life and, you know, the Alzheimer's Association.
00:49:00
Speaker
they do have a annual walk every year. And they they also do have like these support groups, right? And a few of my patients actually do go and they give like a talk and you know, it's it really is rewarding for them. And as as we know as psychiatrists, you know, there is this like, um almost like, it's like a defense, right? Where ah you kind of like use what's painful for you.
00:49:29
Speaker
and kind of like use it to support others. And it's a way to kind of like redirect the significant sadness and anxiety and all these things that come with such a life-changing disease process. So there's so many organizations here that they can get and people can get involved in. That is wonderful.
00:49:51
Speaker
Thank you for for reminding us and introducing some of us to those opportunities to get involved and be supportive of folks who are struggling with neurocognitive decline. um And also it's worth mentioning um when they get a little bit further down the line and they they their functionality is decreasing significantly and they can do less and engage less. And like you said, maybe don't recognize their loved ones. um The people who take care of them,
00:50:20
Speaker
or who help take care of them either at home or in a nursing home or, I mean, big shout out to them. And and I'll say that my mom is somebody who has worked in ah nursing homes and long-term care facilities up for as long as I can remember. she She was a nurse in those settings and now does education about working with such patients. It is hard work, rewarding work.
00:50:46
Speaker
right And I would say, I actually got this from a cousin of mine, and I'm not sure if I'm describing it the right way, but ah when her mom passed with neurocognitive disease, she was saying, you know, when you think about the person, you remember them in different phases, right? You remember them at different points of their decline, I guess, yeah right? And, you know, the more functional and as things started to change and
00:51:18
Speaker
It's also a very, it can be a taxing process for the folks who, who take care of them, especially when we're talking about your own, your own relatives, your own loved ones. I would imagine, are there probably, you know, are there, are there support groups also for? Oh, definitely. Definitely there are support groups. And, you know, I always encourage Most memory care centers, so at my clinic, we do have a social worker. So most memory care centers typically would have a social worker that can help connect care partners to support groups. And then if you are not able to have that support through your own clinic,
00:51:59
Speaker
The Alzheimer's Association definitely um has resources online. So all you have to do is just Google Alzheimer's Association and get onto their webpage. And it's it's usually easy to find a support group in whatever state, whatever city you're in.
00:52:17
Speaker
And, you know, I wanted to ask a question again from my experience, um you know, and it comes back to this idea of neuroplasticity about how traumatic injury or major surgery or critical illness can affect cognitive function and cognitive decline. You know, I've seen really, you know,
00:52:36
Speaker
yeah young adults who had really devastating brain injuries, especially only on one side who have managed to learn how to walk again, learn how to communicate and have meaningful roles and in their children's lives and things, whereas that's much less likely in the elderly who have significant injury like that. And then that's an extreme example, but particularly with elderly people who go to surgery or were hospitalized, especially in the ICU,
00:53:03
Speaker
What do you notice about neurocognitive function and decline after such a major illness and anything that can be done to maintain cognitive health in that situation? Yes. So um when it comes to traumatic injury,
00:53:18
Speaker
And even if it is iatrogenic, right? So even if we're the ones that are inducing the the injury by doing surgery. um So for instance, if somebody has extra fluid on the brain and the neurosurgeon's going in and putting in a shunt or whatever it is, and the self is causing some injury as well too, right? um The bounce back, of course, for the elderly is a lot more challenging and would not be and and shouldn't be, and it's not comparable to you know a young 18-year-old who you know has had something similar happen to them. So it will be the same thing when it comes to rehabilitation recommendations.
00:54:02
Speaker
which would be whether it be PT, OT, if they have any kind of like apraxia or like any kind of like physical or occupational challenges, speech, all these different things, cognitive rehabilitation, I can't stress enough. oh But also it just kind of like allows me to segue into the effects of general anesthesia on the elderly, which is a big thing. And very often I have patients come into my clinic And they'd be like, you know, mom or dad, or, you know, my wife or husband, they were fine up until that surgery in summer of 2023. And I think it's the anesthesia that did it. And, you know, I typically have to explain to them, unfortunately, it's most likely that something was brewing for a while and the anesthesia just kind of allowed for the unmasking of what's been going on. But, you know, it it does kind of help us at least identify that
00:54:58
Speaker
there is something going on. And if and should this person need surgery again, maybe another means of um anesthesia might be necessary, whether it be like a little cold or whatever the case might be. and And I don't know if it'll be helpful. My theory or understanding of that has to do, and it's a little bit technical, but just has to do with when younger people are able to regulate blood flow to the brain much better than older people.
00:55:25
Speaker
In anesthesia, especially on top of critical illness or major injury, um it's it's a fine dance, a fine line to try to maintain a steady blood pressure, steady oxygenation, and those fluctuations between high pressure, low pressure.
00:55:43
Speaker
that a young person might tolerate an old people might be very injurious. And yeah that's just something, I don't know if there's ways to recover from it. Certainly people should be aware of trying to get the best situation and the healthiest situation to go into surgery and also have a fine eye attuned to the possibility that they may have changed after surgery or illness and having attention paid to it. Yeah, no, definitely. And um I know where I did my fellowship uh, at University of Florida in Gainesville, they have a clinic there where they actually do a pre-operative search of like intervention where they kind of like do cognitive testing to see what your risk could potentially be. for possibly having this decline. um you know And it looks at obviously things like your past medical history. So obviously somebody who has like CHF or their cardiovascular system is already compromised. like you eat We know that that's most likely not gonna be um someone who is gonna recover as well. Well, we're getting close to the end of the hour. Anything else that you wanna...
00:56:53
Speaker
Make sure you share with our audience or otherwise summarize or on this topic of neurocognitive function and decline, particularly in the elderly. Yeah, I think, um you know, definitely one thing I want to encourage people to do and to think about, and for even for us at this age, long-term care insurance is going to go a long way.
00:57:18
Speaker
And I say this because none of us, we don't even know how long we're going to live. But if we do happen to get to that place um where we're in, you know, well into our 70s, 80s, 90s, and something does happen, just having that in place is so helpful for getting the support that you may potentially need. And I just really want to encourage um people to to look into that because unfortunately I've seen so many of my patients who did not have long-term care insurance and they needed to get assistance. They don't have children. They don't have you know someone to care for them in their home. And then it's kind of like we're kind of fighting to get grants to get them support that they need. So I think that's one one big piece. And I just wanted to really highlight the importance of patients just really talking to their providers and asking their providers to refer them to a memory care specialist if they do feel as though they are having memory problems.
00:58:18
Speaker
Well, whenever we have a guest on and when we have time, we like to take a moment to acknowledge our other cultural interests and give you a chance to shine a light on something and share with our audience that they may not have seen, read, heard, or listened to otherwise. So you have any music, movie, book, art, performance, any other cultural recommendation you want to share with us? Oh, yes. So, you know, I am Trini. I am from Trinidad and Tobago, and we are known for the best carnival.
00:58:45
Speaker
out of all the entire universe. So nobody says we did it first. So I um ah really, really touching song and really, it has a lot of vibes and it means a lot to me, especially as an immigrant. so um A song by Mikhail Tayshia called DNE. Really, really great song. um Love it. And I think it's pretty self-explanatory.
00:59:13
Speaker
So we'll maybe close out the show with DNA by Who Share? Mecarlatasia. And there you go. Thank you again for coming and hanging out with us and and talking to us and ah sharing some very insightful thoughts and with our audience. Before we close out, is there any other, you mentioned it earlier, but any other resources or anything else that people can follow up on that you haven't mentioned already? I think that the Alzheimer's Association is the biggest one.
00:59:43
Speaker
Excellent. Well, definitely thank you for joining us. Dr. Cheris Smith, our expert on neurocognitive function and decline, neuropsychiatry and behavioral neurology. There you go. Thank you for doing that. Thanks for having me.
01:00:35
Speaker
Let we dance now. Take a chance now. Win, win, win, win, win, win, win, win, win.
01:00:50
Speaker
And the previous program was Trauma Code Heard Mondays at 2 p.m. here on WBAI New York at 99.4.