Thank you for watching this program tonight with the best physicians of the region.

My name is Dr. Luis Munoz.

I'm the president of El Paso County Medical Society.

It is our hope that you will find this program informative and interesting.

We, at the El Paso County Medical Society invest in community education with our programs.

I hope you'll find this program very informative, with great medical advice and great medical information.

Thank you again for watching this program tonight.

And have a great night.

With the advancements in medicine and simply taking care of ourselves a little bit better, we are all living just a bit longer.

And isn't that great news?

There are, however, some fiscal complications with aging and sometimes mental complications, which all can be a bit emotional and difficult to talk about.

This program this evening is called Mind Matters, a conversation about dementia and the mental health of our aging family members.

We'll talk about the first stages of dementia, a diagnosis and treatment options that exist here in El Paso.

This program is underwritten by the University Medical Center, the geriatrics department, And a big thank you to the El Paso County Medical Society for bringing the show to you each month.

I'm Kathrin Berg and you're watching the El Paso Physician.

Thanks again for joining us.

We're talking this evening about mind matters, a conversation about dementia.

And it's not just about misplacing your keys or putting something in the refrigerator that you need to take out the door.

This is real issues with people who are aging.

We have two geriatricians with us this evening.

We have Dr. Jose Luis Aguirre, who is with us this evening.

And thank you for being here again, you're geriatrician will talk about what that specialty is in a moment.

And then we have Emmanuel Enriquez, who is also a geriatrician.

So when I say that, obviously the word geriatrics means geriatrics of older age, and maybe we can define too what older age is.

I think that today's 60 was yesterday's 40.

Today's 90 was yesterday's 65, I'm not sure.

But in general, if you're going to explain what the discipline of a geriatrician is, Dr. Aguirre, how would you explain what that is?

The easiest way to think about it is, everybody knows pediatrics, right?

Pediatrics is a care of children, children and teenagers up to the age of 18.

Geriatrics is not that new.

It has been around for at least 50 years.

And geriatrics really is the care of older adults.

It's defined arbitrarily with the age of 65.

I think, as you pointed out, many people think that the 60 is the new 40 and perhaps 80 is the new 60.

And that to a certain extent may be true with the advancements and advancements in medicine.

And what we better understand about how to take better care of ourselves.

And so at least here in El Paso, where we're still trying to establish a geriatric medicine culture, 65 and up is really the population that we that that we take care of and the types of topics that we try to do.

It's confusing because doctors say you're geriatrician.

What does that mean?

Then we have our patients.

Oh, they told me you're you're a geriatric doctor.

Well, what is that?

Right.

So we're kind of a hybrid specialty in the sense that we are a primary care physician for older adults arbitrarily, 65 and up, but we're also specialists to other primary care physicians for a host of different issues.

So many times we may co-manage a patient with their primary care provider where we're doing a review of medications, we're doing maybe having sensitive talks that we have more experience doing, like advance care planning in terms of having your advanced directives, your medical power of attorney do not resuscitate forms, these types of difficult conversations, but that should be done early.

We also help in figuring out why people are falling fall assessments.

Polypharmacy Are they on the right medications or are they on medications that may potentially cause them harm?

And so in that sense, we are both PCP, primary care physicians and specialists.

And so we are able to help the population in that sense.

There are only about a little over 7000 geriatricians in the entire country, in the city of El Paso, board certified Fellowship trained.

There's only ten of us with Dr. Enriquez recently joined us.

UMC has three.

And so there's not enough of us certainly to take care of the entire geriatric population.

But because of our expertise in our specialty, we're able to provide additional help or support to the primary care physicians in our city.

Well, I think that we're all inching more and more to that area.

So I'm glad that this is something that is expanding, especially here in El Paso.

Dr. Enriquez, so Dr. Aguirre kind of explained what geriatricians do.

What is it if you can kind of explain like your routine all day, every day as a geriatrician, how does it differ from other doctors?

Like do you have rounds that you do every day?

Do you have appointments that come in every day?

In general?

How does a normal day for you go?

Well, I got the clinic.

I mean, it's pretty similar to like a sort of like a regular PCP visit.

But it depends, obviously, on what sort of aspects can be covered.

You're doing just like your primary care, you know, visit, which is like pretty much the same time allotted.

But if you are doing like annual exam or you're doing like a memory assessment, then things are a little more different than what you might do at just a PCP and then like there's like other aspects to consider as well.

Like in the intake, when the patients come in, like things you ask about, like the fall risk, the depression risk, that all these issues that are very specific to to the to the geriatric population, I mean, I'm pretty sure everybody does it.

Well, I agree.

I try to be very you know, like the medication is, you know, review by both the the MA and the and the provider.

So like we kind of like are our looks a little different kind of like more focus on what the geriatric population or elderly population might be needing.

And I with that in mind like maybe the index a little different, you know, the things that we look for are a little different.

But yeah, and it depends.

I was just, I kind of like your follow up is that it's pretty similar with that kind of like mindset of taking care of different aspects that affect our elderly population.

And other visits are a little more like, you know, there more time like the memory assessment and other things that you do as a as a provider for which area.

And so that that is a great transition into what we really are here for this evening is dementia.

And I feel that through the media and through movies and television shows, the word dementia is just kind of thrown around like, Oh, well, they've got dementia, oh, they've got Alzheimer's.

Oh, it's early this age, early that.

So I'd kind of like to set the record straight if we could.

This evening in Dr. Aguirre.

If there is a true definition of dementia, when people use the word as a medical professional, what is the word mean?

It is interesting.

They come up with the word dementia specifically because I was not in tune with this before.

And so I became a geriatrician and started treating people from all different types of backgrounds.

I think I've become a little more culturally sensitive to it.

The word dementia really means loss of the mind or out of their mind.

Oh inches in some cultures saying that your dementia means that you have lost your mind.

Yeah.

And that's I'm so glad that you said that, because I feel that some people say, oh, they're demented, which has a whole different connotation.

You know, there's the definition of it.

So I think but there's a culturally used word.

And so I think the word itself does mean like losing one's mind, that that is the literal definition of it.

However, the way that we use it is when there is a loss of memory beyond what is considered normal.

Okay, I like that.

The loss of memory beyond what is considered normal for any given age.

We say, okay, great.

So if you're looking at it that way and Dr. Enriquez, if I can bring this on to you and feel free to both kind of throw it in there.

So when we say dementia or loss of memory beyond what is normal, there are different types, right?

I mean, I think we all think about Alzheimer's.

We all think about sometimes Parkinson's with it's part of what happens with Parkinson's.

But in general, what are the different types of dementia that you deal with?

So, yeah, like Dr. Aguirre was saying like that the dementia component is like kind of like the loss of, of like that cognitive abilities of a person that's not normal, right?

So like I used to have a, well I had at one of my professors that described the dementia as well as like a brain failure.

Right.

The brain's not working as it's supposed to be and there's a host of issues that could be causing that.

Right.

So that's how we kind of like classify different types of dementia.

The most common ones, Alzheimer's, dementia, that the one that's more prevalent, the most population that have it.

Um, we also have things called vascular dementia.

We also have Lewy body dementia.

Go back, did you say Vascular Dementia?

Yes, yes.

Interesting.

And that just okay, there's vascular.

There's something also called Lewy body, something called frontotemporal dementia.

Okay.

And I think I mean, that's kind of like the most common ones.

But then again, it's kind of like the dementia diagnosis is like what's causing this sort of like like deficit.

Why is this person having issues with their memory?

And then we've when advances like they're functioning overall and like so yeah, there's all kind of different types.

They have the different kind of like physiology or like causes or each type of dementia, for example, for Alzheimer's is related to how it's caused by like building, building up of the proteins in the brain, specific proteins we call Tau protein and Amyloid protein.

But like that's kind of like that's kind of a specific sort of thing that they're looking for.

But with the different type of dementia you think about like the onset of, of the issue, like in what characteristics the patient has, if it's like a progressive sort of loss of, of memory or issues with memory, we usually think about Alzheimer's and like let's have for example, like vascular dementia is very common with people with vascular problems, which means like issues with like the blood vessels, like people with high cholesterol, diabetes.

People have strokes that sort of blocks.

Loss of oxygen type of a dementia.

That.

Yeah, exactly.

So yeah.

So when you have like what you call insults to the brain definitely has to affect the functioning.

Right.

And then the way that this dementia is kind of like presenting itself is like a stepwise process.

Like each time it becomes a little worse, right?

Um, but it's spaced so mostly because of the range of blood vessel issues like heart, like issues with, like, you know, artery disease, right?

And then like, for example, Lewy body dementia.

I mean, each one has its own little characteristics, but this one has there's hallucinations early on with this type of dementia and also like what we call Parkinsonism symptom symptoms similar to somebody that would have Parkinson's disorder.

And I prefer the temporal like either I mean, it's at a younger onset and then usually related to also some sort of protein build up in the brain.

But yeah, yeah.

So we have some kind of like categories, kind of like based on the symptom presentation on the onset, on the progression of the disease and then and kind of like in certain characteristics, but of all the dementia types that we look at, the Alzheimer's, kind of like the one that's most prevalent in our population.

So I feel like with Alzheimer's, there's been so many leaps and bounds with the research in the last decade.

You know, we I said last 20 years or so, but over the last decades and I we've been doing this show now for 27 years.

And I remember when we were doing a program on dementia specifically on Alzheimer's way back in the beginning, I remember one of the doctors saying that it was so hard to diagnose true Alzheimer's, because a lot of times when someone passes away, then you can afterwards go into the brain and find all the proteins that were there.

I would love to take us from that time, Dr. Aguirre, to now of how we in our society are starting to diagnose different types of dementia, different types of loss of brain, like you said.

But, but memory issues, again, there's Alzheimer's is a lot of the ones that we were talking about.

But in general, how is the diagnosis done in if we can take a couple of steps backwards to we all kind of joke about, oh, I'm having a senior moment or you going through menopause, Oh, I'm having a menopausal moment, or you're just I'm just stressed out or having a stressed out moment.

So how do you differentiate the casual man?

I can't find my phone.

Where's my phone?

Is anybody know My phone is to true stage hours of when somebody should be worried.

Right.

And so right before I get into that, I wanted to clarify one thing.

So I've had family members come in before and say, oh, she has dementia, but she doesn't have Alzheimer's.

And so I want to clarify that dementia is and is an umbrella term as Dr. Enriquez already elucidated, we have different types of dementia.

So Alzheimer's disease, Lewy body, vascular frontal, temporal, there are all types of dementia.

Dementia is just that, the umbrella term.

And really to figure out what the best treatment for the patient is, is really figuring out what type of dementia you have.

Okay.

Because the treatment may vary a bit depending on which one.

And then another interesting tidbit, the frontotemporal dementia, which tends to be of a younger onset in the news a lot lately.

Bruce Willis, that's the type of frontal type of dementia he has.

Okay.

So I guess if you always want to remember what type of dementia hits younger patients, that one does come today.

Because you'll hear about it here and there and when it hits you, it's like, okay, that's the one.

And of course, a lot of people think to Michael J.

Fox, we know he's been dealing with Parkinson's for a very long time, and Parkinson's related dementia is also within that category.

There's also a whole subset of dementias that don't really fall into those categories, and that's because they're secondary to psychiatric illness or end stage or certain psychiatric illnesses, which has schizophrenia.

There's also from alcohol induced or drug induced from long term drug abuse or alcohol abuse.

And that we know that can and ultimately in dementia as well.

And so the treatment for dementia, it always gets so casually thrown around.

Let's find out the diagnosis.

I think that's really where a someone who's specialized in diagnosis, such as a geriatrician, a neurologist or a psychiatrist, really is important because these are the type of complaints that we get on a day to day basis of I'm forgetting my phone every day so I must have dementia.

And you can't just say, Oh, here's a pill, this will make your memory better.

I think we really need to figure out is this memory loss within the normal realm or is it not?

And so the the old way, which is still the current way for most doctors of doing dementia, is, number one, looking for reversible causes of memory loss.

Reversible.

So reversible causes include like severe anemia, uncontrolled diabetes, vitamin deficiencies such as vitamin B12 or folic acid deficiencies, and then, of course, having brain tumors, prior strokes underlying arrhythmias that lead to strokes, cardiovascular heart disease that's affecting blood perfusion to the brain.

And so we have to really do a comprehensive of evaluation of what could be causing these changes in memory in a person's there's even pseudo dementia.

So the dementia is someone who presents as a classic dementia.

But then in reality there's some type of uncontrolled mood disorder, depression, anxiety, other psychiatric illness that's not well controlled.

And once the patient is placed on adequate treatment for these for these type of issues, then the memory actually goes back to normal.

And so pseudo dementia also categorizes into that reversible causes of dementia.

And so in my practice and it kind of mirrors the practice that we've had for a while now, first we look for the reversible causes.

We run blood tests, the blood tests that we typically would run would be a complete blood count looking for that anemia, a vitamin B12 level, a folic acid level, a thyroid stimulating hormone level, because uncontrolled thyroid disease can also cause it.

And then we would do a brain MRI and then we would do some type of memory screening test.

The most widely used one is one that's called the mini cog.

It has you remember three words draw clock and then you have to they tell you what time should be on the clock and you have to put it out even.

Five for an insurance.

And I had to take this test.

And I think it took me nuts.

And I felt like a knucklehead as.

A as a as a, you know, during residency and fellowship.

I told people, you do.

You are aware that we're going to have to come up with a new screening because people don't look at watches anymore.

Everybody looks at their phone and they look at digital.

And even in day to day practice, I can say that that is a truth.

Even if my of my oldest olds, even my nine year olds don't look at clocks anymore, they look at digital things on their wall, maybe a big digital clock with big numbers or they're their phones as well.

So more and more I'm getting a lot more false positives that they test positive for potential cognitive impairment, but it's just that they don't look at clocks anymore once we see if there's something reversible or not.

If let's say your thyroid is not well controlled, okay, you do have depression or anxiety, then what we try to do is we try to correct those abnormalities first, or at least I do before, even though moving on to the next test, because I know the past, the probability of you failing that extended testing that we do just goes up.

So I rather correct as much as I can so that not just the patient but also the families feel like it wasn't a rushed diagnosis.

Right.

I'm going to ask something really quick to interject thyroid issues, because as people get older, that's when the thyroid starts going a little bit crazy.

I am hypothyroid have been since I was pregnant with my daughter at the age of 30, but when the thyroid I would like just to take a moment of what the thyroid controls in this area of memory.

Obviously there's you know, my gosh, what am I looking for?

Energy, a little bit of energy, weight gain, weight loss.

But in general, the thyroid, I think that it's an under rated issue unless you know about the thyroid, this sense.

So you're right, like typically under the age of 60, we wouldn't really screen anybody for thyroid issues.

And as they were having some type of symptoms, once you're over the age of 60, I think we do try and screen everybody at least once a year to make sure that there are no thyroid issues because we know it does it it is a it is involved in a lot of metabolic processes in the body.

And so the the symptoms that are involved with the thyroid can be so wide ranging.

I know that's the frightening loss of memory or feeling like you're sluggish to feeling like you're anxious with palpitations to weight gain, to weight loss, depending on what spectrum of hypo or hyper thyroid that you're on, you're constipated, you're not constipated.

Proximal muscle weakness, not being able to get up from your chair or even raise your arms above, above your head.

The thyroid has a lot of implications throughout the body, not just a memory, but certainly in the memory.

It's something that we look for in the memory as well.

I'm glad you talked about that because I feel like that's something we never talk about.

And since you brought it up, I thought that was a perfect thing to do.

So as you're talking about a diagnosis, unless you have something to add to that.

Yeah.

So perfect.

So that was okay.

That's really just like the initial that's day one.

We show up, we take a comprehensive, like, history from you.

Is that your short term?

That's a short term memory is the fact that is that your long term memory is affected.

Do you feel like you get more confused as the day goes on and the evening hours approach?

Are you anxious?

Are you depressed?

We do include the depression and anxiety screening as part of your of your memory assessment.

Are you having any psychosis?

And that can mean are you hallucinating?

Are you hearing things?

Are you seeing things?

Are you in danger of hurting yourself or hurting others?

Are you wandering away from the house?

Did grandpa or mom or dad get on a bus and end up in another city at some point?

And it happens all the time.

And one gentleman that the second he got the keys, he was heading over to Mexico just like he did when he was young.

And so they are we were always the family was always worried that they were did he go to Mexico?

And so a lot of this is the wandering is a big one.

And that's the one that really sets our families.

They can disappear for days at a time.

And when they come back home, it's usually escorted by a police officer or sent or in the case of one gentleman that I take took care of recently, the Mexican police called them and say, please pick up your loved one.

He was living on the streets in Juarez, completely lost and.

They found idea on him, thank goodness.

Thank goodness he found an ID and they were able to contact them.

But he was living homeless on the streets of Juarez doing God knows what because his memory wasn't working the right way.

Right.

And so this history is important to see.

Okay, is this sound more like a psychiatric illness?

Does it sound like maybe potentially as memory loss?

But before we can say someone has dementia, we have to do the screening and the reversible workup to make triggers and nothing that we can actually correct.

So many people show up with a dementia diagnosis and they end up not having dementia.

It's something completely different.

And that's the part that interests me.

And so I'm going to go with Doctor Enriquez for a moment and ask about risk factors, if there are any that you can tell and if there are some that you can tell prior to being 30 or 40 or 40 years old.

I'm not sure if there are.

But in general, when people ask you for risk factors or my mother really had an issue with dementia, am I going to have that?

Maybe she had Alzheimer's, maybe Parkinson's, maybe she had, as you were talking about, Lewy Body, which I don't know yet what that is.

Vascular dementia makes perfect sense to me.

Any time you have some blood constriction or oxygen constriction to the brain, frontal to temporal, I can see that being younger, like my son, who's 22, keeps saying, Mom, all the mistakes I make, it's okay.

Because I'm not frontally temporally developed until I'm 25.

My frontal brain is fine.

Yeah, exactly.

It's just it's not.

It's not develop.

You are right.

Yeah, right.

He has not an excuse.

It's an excuse.

But in general, what, what could be risk factors.

I know that you were kind of covering some of that in there, but when somebody comes to you, family members come to you and ask you what risk factors there are, what are your answers to that?

I mean, like first of all, Lewy Body, real quick, it's all lies.

And so that was the one I didn't get started.

By some sort of a genetic issue.

Your body starts building this protein inside the cells.

Okay.

This kind of like, messes up with the cell function in your brain and sort of like it causes the symptoms on a person like which include that person has to start having hallucinations and then eventually having memory issues.

And as well as effects on their mobility, they start having like things and Parkinson's symptoms.

But it's usually like a disease or some factor, some genetic thing that causes this protein called alpha synuclein.

That's like the time they're going to wake up.

Like a doctor.

You know.

It just the scarier protein that is making the amazing brain, right, is kind of like altering the function of the brain.

And it benefits good with some sort of like, like clinical presentation.

It's actually being like more common than before.

It's kind of like a more relevant thing already.

Like the dementia umbrella.

Right?

So going back to the risk factors, genetics is one of the main ones, like having family history of somebody having some sort of dementia cognitive thing in your family in the past.

Right age is a very big factor, especially for Alzheimer's, because so sorry at 65, I think like the percentages, if I can correct me, I guess the kind of 8% of the population up within like 65 has some for like 8%.

That's a pretty big percentage moving.

And once you get to like the eighties, it kind of goes to the 40%.

So like so it's like the age is kind of like, I mean, that makes sense.

And then like the processes of like, you know, this genetics having some sort of protein alteration in your brain starts very early.

We still haven't kind of like figured out like the best way to identify.

So we know how to identify like specific genes for like maybe you might be at risk of having like Alzheimer's, but it's not really like you're going to have it, but you're at high risk, right?

But like, the risk factors go to age genetics, right?

Trauma to your head.

People that have incidents and traumatic brain injuries might be a higher risk of having of dementia or having cognitive issues later in life.

Like Dr. Aguirre was mentioning.

Alcohol, Drug use also, I mean, affects some brain functioning which could have effects in the future.

And I use also like, you know, take care of your diabetes and hypertension when you're with your patients, right?

Yeah, because in the past, okay, you have diabetes, hypertension, cholesterol problems.

You had a stroke, you're going to get a heart attack.

But now also as well, you have the genetic makeup.

You may be also speeding out for some sort of dementia.

Right.

So having control of diabetes, uncontrolled hypertension, not taking care of your cholesterol may also affect and the risks like you're you're affecting the the vessels in your body, the vessels in your brain.

So the the blood flow that's important.

And over time, it's been shown that like this can cause the protein buildup as well.

I was also looking at some stuff, like or so social interaction like.

All in it talked about.

Quite a bit about.

Geriatrics in general loneliness.

Exactly the.

Better shape.

So you already have that like the, you know, the the genetic predisposition and you're like you have some sort of problem with loneliness, You're isolated from, from like socially or you don't have those connections.

That might also be a risk factor for you to develop dementia or speed up the process.

Right?

And yeah, that's kind of sort of those things that kind of like have the sort of the risk factors, you know, not doing exercising, eating healthy.

and like the cognition too, like not stimulating your brain like and then I think I was doing like the cognition training, which means like learning new stuff like the fortunately that degree of education is also one of the risk factors that's consider because apparently the more education that you might have, kind of like the less of a factor, but and like the genetic sort of makeup's kind of like the baseline, right?

And then all these factors can just like contribute to it accelerated.

And we just have to be mindful of those and kind of like that's what we try to do, right?

Change the things that we can while we're trying to determine or kind of like figure out ways to detect earlier and even to which we talk about .

Or a lot of things like, you know, do puzzles, you know, the words that are out there and this and that and other that all of that is good.

Just try to it.

And actually like the like learning things like actually in our language or like a new process right now, like just simple memorize them.

Kind of like making your brain like process a little more and things.

As I hate to be the bearer of bad news, but crossword puzzles , word finding puzzles are not are not going to stay off dementia.

I there's so many patients patients families that should we buy them a crossword puzzle?

What does your family member like to do?

Why do they like to learn?

Do they like to bake?

Okay, let's bake a cake.

What do you need to have them learn new things?

Have them repeat them to?

Certainly.

We're also learning more processed foods.

Our Western diet doesn't do much to help us with staving off dementia either.

If you've seen that that documentary on on the blue zones.

So these are did how fascinating all.

Some of these areas had certain types of types of foods that have antioxidants that also prevent the buildup of these beta tau the beta amyloid proteins.

And so our diet is starting to become a big factor.

There's lots of things that we still don't know that we're learning now that in these blue zones they're actually eating more of and it seems to be beneficial to to prevent onset of dementia and the accumulation of these proteins... sleep.

It's something that we do every day we spend a third of our life doing, hopefully.

So how far we're learning that to a certain degree while we're asleep, there are some brain processes where it's like you're sticking your your brain in the dishwasher and it's cleaning out these these protein, these toxins that we're supposed to wash out.

So if we're not sleeping and we're not brushing out these things that are causing these proteins to accumulate.

And so sleep has become a new area of interest, we're like, oh, well, maybe the people that don't sleep, they get more dementia.

So yeah, we are seeing some of it.

Here's the difficult question on that.

I'm not a good sleeper and I've never been it.

Goodness I know it's one of those things, but I think that for the most part, it's understood that sleep is good for you.

And I'm saying this too, in connection with anxiety, depression, some of the things that you were talking about that manifests in different ways of presenting, Right.

So those with anxiety and depression have more and more sleep issues.

Sometimes they can get to sleep, can't stay asleep or sleep for a couple of hours.

Not, oh, this is a tough question.

When does the role of medication come in for sleeping?

I know there's the whole sleep hygiene situation.

You go through your routine.

I feel like I've done.

We could spend the entire first show just working on a medicine.

And at the end of the day, just as like a brief answer to that.

If you look at the American Association of Sleep Medicine guidelines, like none of them are effective and none of them are recommended and none of them are recommended if you do use them for long term use.

Not no, no good answers to how we can help people get better sleep in terms of from medications.

So again, you're looking at the routine and hopefully sleep hygiene.

So there's a lot of that.

Sure.

Yeah.

There's a lot of things that people like could do.

And like like the simple fact of I know it's sleep hygiene and maybe just like kind of like not overrated, but I could repeat it so many times.

But like, you've been having, like the phone, like next to your bed or having television, like, a lot of people don't think that in the bad light.

Yeah, Yeah.

And like, even, like the the temperature of the room, like there's a lot of little things that are very, very helpful saying like a schedule, trying to sleep a little later, if possible, or, you know, having some sort of like, like a routine.

Right.

But yeah, like the medications may not be always the best answer.

So I always try to encourage like please.

So and so touching on that.

Yeah, I think the best thing you can do is really follow your own schedule.

Exactly.

Which unfortunately the way we're dictated 8 to 5.

Yeah, I got to go to sleep now because then I'm not going to wake up for work.

Yeah, but the best thing would be if you could follow your natural circadian rhythm that you, your natural sleep cycle.

Not everybody wants to go to sleep at 9 p.m..

Some people may prefer to go to sleep at 12 and wake up at nine.

Now it sounds like right there at me too, but that doesn't really fit.

Yeah, those are societal norms and and our regular business hours, right?

Yeah.

So I think that's maybe a major contributor.

And of course there in modern times we have all these lights that tell our brain that it's daytime and we're awake and yeah, that, that has insinuation also.

You wake up go outdside and just not stare at the sun but kind of stare at the sun, you know try to get that that circadian rhythm to whatever your clock is.

And I just naturally, for the most part, wake up with the sun no matter what time I go to bed, good or bad, I don't know, but I just can't stay asleep at night.

So I would like to touch base little bit because again, in the older population and to your point, so poignant social connection, sleep, movement, depression, loneliness.

So when we're looking at all this is points of dementia and it all makes sense, right?

It's the health of the brain and how you get that going.

Is there also way to diagnose within the population and let's say 65, but I feel like that's so young, like 75, 85.

How does one diagnosed depression?

I mean?

That sometimes is very clinical.

It's a kind of a clinical.

It's not like you can, you know, get a blue blood test and say, Oh, you're depressed.

How do you deal with that?

And then in combination with dealing with treating dementia and I know that's that's it's a two tiered thing and feel free to both kind of say, but Dr. Aguirre will start.

We have we.

Have validated surveys that help us determine who may have issues with depression and anxiety.

When we was called the PHQ-9.

and which we tend to use in younger and younger patients.

And then once you're over 65, we tend to use that screening tool that's called the geriatric depression screening the GDS.

And then for anxiety for both populations, we tend to use what's called the G 87.

And these are Q&A type tests.

We our Q&A kind of ask you, do you feel do you feel like you're sad or down?

And then you say, Never, rarely.

Sometimes more than half of the week, more almost every day.

And so we have cutoffs for that.

And then once we have that, of course, the next question is to ask the patient, Well, you answered in this way.

We think you might be having some issues with depression.

What do you think?

And usually some people will be like, Oh, no, I'm fine.

Are you sure?

Because you had the.

Way they.

Were, you answered.

They don't know any different.

Well, some of them.

Truly might have not really understood the question.

Or maybe there's something that happened recently that has them feeling that way, but it hasn't really been anything persistent.

And but many times when it is positive, they'll start crying, where they'll start sharing, why they're sad, and then we can make a determination, unfortunately, subjectively, of whether this patient truly is having issues with depression and and then there comes a discussion of what do we want to do about it?

Do we want to try medication that there are medications that we can use and we can use safely in the geriatric population, very different from the ones that we use in a younger patient to to help them with these symptoms.

And then, of course, counseling and counseling services, support groups, maybe enrolling them in an adult day care where they have more of that social interaction and activities to stave off that that loneliness that they're feeling.

So if I'm understanding, right, this is all something that in your discipline at UMC, you all help out it.

So that I'd like to talk about that for a minute.

So people who may be listening or watching, it's like, okay, either I myself feel this way, my parents, my uncle, whatever.

Talk a little bit about what you all provide as your specialty and what happens with UMC in the geriatric.

Like we are doing like depression, anxiety, so like we are.

In social interaction.

I think that right there is such a Oh, you're a big example, you know, somewhere where there's other people.

Oh yeah, sure.

Like I guess our main sort of like support for that sort of like resources we have like very common and social workers have, you know, knowledge of what's out there in that community sometimes like we go through of like our work and there's areas that we don't really like, you know those are people that might be knowledgeable with things that are out there, their communities are experienced.

I think social works are really good helping kind of like guiding us, guiding the patient, especially the caregivers, which will probably be quite rare right now in the moment.

Yes.

Yeah.

Yes.

That's like though, I guess one of the most vital parts in the treatment and management of dementia patients.

Right?

And so, yeah, like we have behavioral health specialists as well.

We have a tools to diagnose, to count and we also are trained to like star treatments and then help people with whatever they might need regarding depression, social interaction, like, like Dr. Aguirre was saying, being aware of the adult centers are out there for, for, for patients and like yeah social workers are lifesavers in my experience and they can give us both the family and us as providers like a lot of the resources that might be needed to help this patients say like get started, something they didn't even like.

know these things exist, right?

And by the time like when we go to a social work again, these are your options are we can start like getting the ball rolling and kind of seeing what's out there and available.

And I regard like the depression part sometimes like when you have like dementia patients sort of like they might not be able to kind of like go through the questionnaire.

Right.

So this is what like very important, like rely on those caregivers because they might change some of like behavior change, like they're not doing the things that they.

Should be aware themselves.

or like maybe with the questionnaire a little more alter their like behaviors a little more different than what previously was.

So that's kind of like also some of the signs that we can see as providers is would you mentioned we have to be creative.

I guess a lot of times we are not able to because the patient is not able to kind of like give you that information, right?

So that's what's going to aspect.

You have that contact with the caregiver and like we're going back to that.

What UMC has, like there's plenty of competent people like social worker.

We have our help people, providers that are like very knowledgeable of resources so we can have for the families and help them with that.

So shortly before Dr. Enriquez joined us.

So we talked a little bit before the show about how UMC is trying to improve and expand upon their geriatric services.

Part of that is the creation of of a formal geriatric service department for the outpatient clinics.

Dr. Ismael Rodriguez, which isn't here with us today, myself and Dr. Enriquez are the beginnings of that.

And so part of that creation came the certification of our outpatient clinic, says geriatric friendly clinics.

This is a national certification where we have to show that we're implementing the four M's of geriatric medicine, the four M's are mind, which is what we're discussing today, right?

Mobility medications and what matters most.

And so part of that integration of that into our clinics is we have to implement assessments, evaluations and next steps to help our geriatric population in those specific sector segments of their lives.

So in the mind aspects, certainly depression and anxiety screenings are a must for every new patient.

Oh, good.

On every visit, every patient is briefly screened with two questions to you, two to see if they might have an issue with depression or anxiety during that day or and the G 82.

And if they are, then they are given a full screening.

And then also on their annual exams, we do the screenings as well.

So depression, anxiety, something that we are very aware of, something that we do have a lot in our geriatric population and it's something that we're constantly screening for that we talked about like part one of my journey of my diagnosis.

We didn't get to the part two And the part one, the mini cog, that first screening that is part of your annual exam and it is part of everybody's first visit with us in the geriatrics department and of course, if there if the family or the patient, even if it's not within our typical schedule and there is a concern about memory loss, then you're going to be screened automatically for cognitive impairment.

So here's a question to either one of you.

So I'm thinking to myself, if if you're of 65, 70 years of age, if you don't have to your point, a caregiver, someone who is with you, a family member, etc., and you simply don't know that you're having these issues going forward, what you see in your practice, do you see that a very large percentage and I'm thinking like 85, 90% are the caregivers bringing their elderly friends, family members over?

Are the elderly coming on their own?

Is it a mixture of the two?

Explain how I think.

I certainly see that.

I think this may actually vary depending on what side of the city you are in.

And I would say on in the West Clinic, I would say probably of our elderly above age, 65, probably the older they are probably above 80, maybe 70% of them come with a caretaker, maybe as high as 75%.

And then it is somebody hired.

Usually it could be a provider that they're getting through Medicaid, okay?

It could be a family member or sometimes it could be even an extended family member, like a niece.

Okay.

A niece or a friend or I even seen friends of the family that bring in people with concerns for for memory loss.

And then in our on our younger geriatric population 65 to 80, probably 40% of them come with a caregiver.

So they'll go on their own and say, I'm having some kind of issue.

I need to go check this out.

Okay.

That's that's one for here.

Yeah.

We've had a couple visits where we've gotten to know them better and we see repeated stories repeated complaints, maybe diagnostic tests that we ordered weren't done, medications that we ordered or not aware of.

So then we start seeing the pattern that, you know what?

Maybe we are You okay if we call your son, your daughter, your husband, your wife to come with you on the next appointment, okay?

Just so that we can verify what what we're seeing and maybe get to that next step of figuring out what's going wrong with the memory.

Makes sense.

So let's move over to and I know this is like, oh my goodness, it's almost a can of worms.

This is treatment now, right?

There are so many different treatments.

And understandably, the types of dementia that we were talking about have obviously different treatments.

So let's first talk about vascular dementia.

I can see a lot of that is getting the vascular issues under control.

Lewy bodies, sometimes that is like you said, it is something that you can't it's inherited, so to speak.

That's a whole different something that may not be something to, you know, share on the show for the next four or 5 minutes because it's too big to go into frontal temporal same thing.

But in general, not that there is just like the geriatric depression, anxiety, dementia, but let's pretend that there is that.

What are some of the common treatments that you all do with geriatric dementia?

I know it's loaded, you know, I get it.

But you know where I'm going with on this.

Dr. Enriquez, would you like to start with that?

So, yes.

So I guess we have to be kind of like clear on the sort of like what this is, I guess, about like what the treatment entails.

And at this moment, those are like definitive treatment, like to like a curative treatment for dementia.

And like what the options that we have are usually to kind of like slow the progression of, of the disease, because there are many patients that kind of like go and they're like, okay, we're having this problems with dementia.

What's the medication that we are going to use to?

It's kind of like the rest of it.

Or help our family member go to baseline to buy in.

Like, well, fortunately the cases that of the options that we have, most of them just kind of like help kind of like with the progression but at this point is at something.

Like this a magic pill.

Exactly like this is where will most likely progressed to to whatever it has to progress.

And we have a couple of options that can help us sort of slow that progression.

And they're having tested more specifically for Alzheimer's disease with people with mild to moderate like cognitive like memory issues.

Um, we have a colony stress inhibitors and we have three medications that are kind of like the like to go to based on the experience and the research.

And these are medications that help slow down the progression is, yeah.

Okay, help.

Sometimes they might be successful, sometimes say may not and once called the galantamine and rivastigmine.

And then we have also what we call NMDA antagonists, and it's a drug called memantine.

So we kind of recommend this when you have like moderate sort of Alzheimer's disease, it might be helpful also with the Lewy Body, kind of like issues with memory, but it's very limited or what they can do.

And it's also like having a conversation with the family that, you know, watch in my walk in might not most likely you might not have a significant effect.

And you have to take into account that these medications may have significant side effects, especially GI side effects, nausea, vomiting, diarrhea.

So you have to kind of I put it in a balance, like if and then you have to reassess after you start to use medications 3 to 6 months after you start, like progressively you increase them.

Right.

But you have to kind of like pros and cons, right?

It is medication you seen that is not helping at all.

The memory deficits getting worse and then just the symptoms are not tolerable then it's not worth continuing the medication.

But if you see that it has some sort of like the fact some sort of like benefit, at least you're noticing that there's some stalling and in the progression of the disease then you it's it's fair to to continue right.

And it's kind of like I mean it would be hard for me like I personally I my father has Alzheimer's and I know I understand.

Like, I wish you would go back to the way he was.

I wish that the medications were like a magic pill.

But you have to understand and we have to do counseling.

Explain to our patients that it's a hit or miss, but it's also all has to do with the progression because unfortunately, it's not it's not something curative at this point.

So it's kind of like the the main to go there's like people are trying, researching, trying to come up with new things.

And Dr. Aguirre and I, he was like, enlighten me about like monoclonal antibodies and I'll let him explain that There's like new sort of medications again that might be helpful or not with they everything carries like a risk and benefit, but.

yeah I was going to say this at this point the program because we got a whopping 7 minutes left.

But this is just you I think.

Okay, this is what we have now.

What do you see in the next five ish years?

And I just wanted to go to so the medications the doctor Enriquez has mentioned, they are the ones that we typically do use.

Honestly, from the research that I've seen I don't think it actually the it doesn't really slow down the progression.

And all I think is the way I expand the families is you're still going to get from point A to point B regardless if your memory is going to go in one, five or ten years.

It's going to happen with or without the medication.

But you have to land that plane somehow.

So it can either be a crash landing, turbulent landing for everybody, or it can be kind of smoothed out.

And like where I are, it's nice.

I had a reference like you're talking about when attending stuff that you used to say, like you're going 80 miles per hour.

You But it does make it's probably just bring you down 70 miles per hour.

Right.

But it's still going to go like that.

It's still going to progress.

As we know, most patients do better when they're at home, in their environment, with their surroundings, with their belongings, with their family, with their sights, with their sounds.

And the moment you take them out and you put them into a foster home or nursing home, everybody is shocked with how fast it starts getting worse so that the intention with the medications is if we see that there might be some benefit, if there are a lot of behavioral issues associated with the the better that we can smooth that right out for everybody, the better that the patient is going to do in their in their home environment, that the newer medications, I think everybody tends to oversell them.

At this point.

We're not sure the monoclonal antibodies are the newest, greatest thing in the last few years.

They're now a few of them, a couple of them that have been released officially on the market.

They are showing promise of slowing down the progression.

The dementia, 25 to 30%.

Oh, my.

That's a big percentage.

However, And here's a big here's a big caveat.

Here's a big caveat.

So we talk about the accumulation of beta tau and the amyloid protein, and they're very, very effective at removing up to 90, 95% of these plaques in the brain in before and after imaging.

And so what we're wondering now, does that mean does your memory stay in the place where they are right now?

Is that what we're talking about?

Like it's not going to get worse?

Yes.

Or like regenerate or are we talking about, oh, suddenly we removed the protein, You're going to go 25% better than where you were before, right?

We're not sure.

Yeah, we're not sure.

And then in initial trials, the side effects were not benign.

There were significant amounts of anywhere varying from 10 to 15% of brain edema.

So swelling in the brain and maybe some degree of brain hemorrhages, small brain hemorrhages.

So as we get to use these on more people, are we going to see more of this?

Is it going to be so bad that we're going to have to take the medications off the or are they not going to be so bad?

And are we going to see the benefits that we're all hoping that we're going to get?

We don't know.

Right.

The point is, in El Paso, I don't know of anybody who's actually getting this type of treatment.

I referred a couple of patients already to outside neurologic centers, but really the cost is prohibitive.

I think a lot of the insurance companies are not willing to approve it because of the cost.

One year treatment is about $26,000.

This is from data that I that I was privy to last year.

And this year around.

For how long?

Five years?

Well, when they started with the development that we started talking more about it.

But as of like on the market, let's start giving people to it really last year.

Oh, wow.

So this is brand new?

It is and have a complete different discussion.

Next year.

We have the V.A.

last year approved it for widespread use within the VA.

Okay.

So I think we will get more data from them because, you know, they don't have that limitations of insurance approval or patients ability to purchase these types of medications.

And hopefully from there, we get more.

If we get good results, then the insurances will start hopping on and approving these medications as well.

But I just want to give this big caveat.

It is not curative.

Like Dr. Enriquez said, we're hoping on these monoclonal antibodies that it reduces the progression for the current medications that we use on a day to day practice.

I don't see any any improvement in the progression on the tests that we do.

Most of them are in the 30 point scale.

It improves your testing score by 2 to 4 points.

Oh, well, I don't want to give out a huge shout out to caregivers.

I know we talked a little bit about that earlier, but with dementia that is so vital and especially those that, you know, family members, sometimes extended family and it's just thank goodness we live in a community where there are a lot of really good people.

And so shout out there.

I know we're we're running out of time.

So I do want to say once again, thank you so much to Dr. Aguirre and Doctor Erinquez.

Both of you are geriatricians with the University Medical Center.

This is with the geriatrics department.

But thank you again so much for being here.

Thank you to UMC and appreciate you all listening and watching.

I'm Kathrin Berg and this has been the El Paso Physician.

Hello, I'm Kathrin Berg.

Today, we like to pay tribute to a man, a man to whom this very program would not exist if it weren't for him a great man, a visionary inspiration, and a masterful doctor who helped take away the pain for so many people.

As a rheumatologist, he was a true advocate, public service and of education.

Dr. Raj Marwah passed away unexpectedly on November 27th.

The physician members and officers and staff of the El Paso County Medical Society express their sincere condolences to Dr. Marwah's family and also would like to pay homage to him for his dedication and service, not only to the El Paso County Medical Society, but to the community as a whole.

He was a true renaissance man.

His Duty to his community and his patients was his life's work.

This program, the El Paso physician, was the brainchild of Dr. Marwah.

He, along with the executive committee of the El Paso County Medical Society, planted the seeds, watered and fertilized this production and watched to grow into an award winning medical education program.

It is the only running program that has been going for 27 years in this entire country, and we have not been able to find in the world a long running program such as this.

Thank you again, Dr. Marwah.

For 27 years now, it airs every single month on PBS El Paso.

And in recent years it's been available nationally and internationally through various online platforms.

You can always find episodes on the El Paso County Medical Society website at PBS El Paso and on YouTube.

And again, it's the only running program of this type anywhere that you can find for the amount of time that it's been going each year.

Dr. Marwah would host a thank you gathering for everyone that was involved in this production of the El Paso Physician.

Just two weeks ago, just two weeks ago.

Dr. Marwah address all of us in his humble way and with his quiet yet strong voice.

And as usual, he was giving credit to everyone in the room and not even thinking himself nor would he.

That's not what he would do.

One of the doctors in the room could not have said it any better when he said, Dr. Marwah, it is on the shoulders of giants that we stand, so true.

Dr. Marwah, Thank you.

From everyone who is involved with the production of this program.

And thank you from all the people in the community who may have learned just a little bit something by watching this program.

None of this would be possible without you.

Farewell, dear friend.