E124 - How can we Prevent and Treat Dementia? (w/ Dr. Ben Underwood)

Dr Ben Underwood is Assistant Professor in Applied and Translational Old Age Psychiatry at the University of Cambridge and an Honorary Consultant Old Age Psychiatrist. His interests are in translational medicine in dementia, where he has been principal investigator (PI) for academic and pharma led clinical trials.

Today we discuss:

Trajectories of Common Mental Health Problems into Older Age, how mental health issues such as depression or psychosis evolve as people age.

Dementia and Its Different Types, including Alzheimer's disease, vascular dementia, Lewy body dementia, and frontotemporal dementia.

Dementia Prevention,  strategies for reducing risk and managing symptoms, including lifestyle interventions and early detection.

How Dementia is Treated, including pharmacological and non-pharmacological approaches. 

The Advent of AI in Psychiatric Research, exploring how artificial intelligence is transforming diagnosis, treatment prediction, and mental health monitoring.

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

Welcome back. Today for the first time on the podcast, we're discussing old age psychiatry, and in particular the problem of dementia. And with us to have this conversation is Dr. Ben Underwood. Dr. Underwood completed his psychiatric training in Cambridge, where he also undertook a PhD in molecular genetics.

He is assistant professor in applied and translational old age psychiatry at the University of Cambridge, and a consultant old age psychiatrist. His interests lie in translational medicine and in dementia where he is been a principal investigator for academic and pharma led clinical trials. He's clinical director of the Windsor Research Unit, a facility dedicated to joining NHS patients with clinical research, and he's the dementia lead for the East of England National Institute for Health and Care Research.

So naturally, he was the best person we could have this conversation with. Today we discuss a bit about old age [00:01:00] psychiatry, some of the common trajectories of mental health conditions like depression, psychosis, bipolar disorder. As people get older, the problem of loneliness specifically with older adults.

And then we dive into dementia, talking about the different kinds of dementia, how dementia could potentially be prevented. Looking at things like nutrition, exercise, and alcohol, current treatments for Alzheimer's dementia, and how newer dementia drugs work and the promise they show in potentially slowing down the symptoms of Alzheimer's dementia.

And we also discussed the advent of AI and how AI could potentially accelerate clinical research. Both when it comes to dementia and more broadly in psychiatry in general. This is The Thinking Mind, a podcast all about psychiatry, psychology, psychotherapy, and self-development. If you like it, do share it to the friend.

Give us a rating, leave a review wherever you watch or listen. If you're interested in supporting the show further, you can check out [00:02:00] some of the links to the description. Thank you for listening, and now here's today's conversation with Dr. Ben Underwood. Thank you so much for joining me. Uh, thank you very much, Alex.

It's a real pleasure. I'm really happy to be able to make an episode about Old Age Psychiatry. We really haven't gone into this territory yet. And to introduce listeners to this, maybe you could tell us a little bit about Old Age Psychiatry and how is it importantly different from, say, general adult psychiatry or neurology.

Yeah, sure. So I am an old age psychiatrist. Uh, that's what I, uh, that's how I would primarily see myself. It's, uh, a, a wonderful specialty and it's something that has developed really in the United Kingdom back to the early 1970s. I. Where it was felt, I think that, uh, older people didn't always get a fair crack of the whip in psychiatric services.

So a lot of resource might be diverted away from them and they were kind of left out. And, uh, and there are some other [00:03:00] things about older people that are different. Uh, uh, physiology changes as we get older. The sort of conditions that we might suffer from change as we get older. Most notably, uh, a big increase in the risk of, of dementia.

Um, and so, uh, uh, it, in, I think it was 1973, the faculty, uh, of old age psychiatry under a slightly different name, but first appeared in the Royal College of Psychiatrists with an attempt to try and create a separate specialty to make sure that older people, I. Got the, uh, attention that they deserved. So we still look after all of the things that an adult psychiatrist would look after.

Um, but on top of that, we also have a lot of work, uh, dealing with dementia. So it is still the case, uh, that more than 98% of people who get a diagnosis of dementia get that diagnosis from an old age psychiatrist. So whilst there is some overlap with cognitive neurology, it's still a relatively minor sport for the neurologist, whereas the bread and butter of the old age psychiatrists.

[00:04:00] What, uh, in, in terms of mental health, outside of dementia. What are the unique things that an old age psychiatrist needs to be aware of that perhaps a general adult psychiatrist doesn't? Um, well, we probably all need to be aware of all of it, but I think where we sort of slightly differ is that, uh, we are used to dealing people with, dealing with people with a lot of physical comorbidity.

So. I think this is a part of the sort of definition of old age psychiatry, really we deal with the frail, multi morbid elderly patients. So you may see people in their seventies who are completely fit and well, and actually they may be better looked after in, in adult psychiatric services, but as people age, they tend to collect more, uh, more conditions and more comorbidities.

Uh, and so we're used to dealing with people who. Are often physically unwell, who are often on many different medications, and for whom the side effects of treatments may be more significant as well, uh, due to their, the, [00:05:00] the, the frailty that they experience. So all of those things are things that old age psychiatrists really, really keep in mind when we're treating people and when it comes to common mental health conditions, by which I mean things like say depression, anxiety.

Even bipolar disorder, psychosis. What are the common trajectories of those conditions across the lifespan? So for example, with depression, is it the case that depression tends to. Resolve, you know, if someone has a few episodes of depression in earlier adulthood, is the trajectory for most people that it tends to get better, or does it actually tend to worsen as people get older?

Are older people more vulnerable to things like depression or other mental health conditions? Uh, well, if you look at happiness, uh, there's a sort of view shaped, uh, curve where middle age is the least happy time, and then things improve as, as you get older, and there's a certain round of truth, uh, in that, in depression as well.

So, I, I take heart from the fact that I'm probably [00:06:00] maximally miserable just now in my early fifties. Uh, but the, um. But that there is still a significant comorbidity, uh, of affective disorders in later life. And certainly people who've experienced a number of depressive episodes during their adult life are highly likely to continue to experience those episodes into old age.

Mm-hmm. And my understanding is when it comes to things like psychosis, you have an initial peak of onset of psychosis when people are, say, uh, 19, 20, 21. Uh, my understanding is there's then a second peak in someone's say, uh, late fifties, early sixties. I, is that the case actually? And if so, what? What are the possible reasons for this?

Well, that's a, that, so you're absolutely right. Uh, I think, uh, for the medics listening, they remember at medical school they're taught that schizophrenia starts in your late adolescence, early twenties. [00:07:00] Um, but, but you're right. There is a second peak, which has been long recognized. So it used to be called Renia Now, uh, very late onset schizophrenia.

Uh, it is a little bit different to, uh, to the. In his presentation, uh, to that, uh, in earlier life. Uh, so it's more common in women who live alone. The psychopathology is often around partition delusions and things coming through the wall, uh, and associated with sensory deprivation. But what we do know thanks to a, a trial called Atlas by Professor Rob Howard in London, is that these people, uh, these patients do respond to antipsychotics, in fact.

You might even say they have a better response than younger patients, uh, and at lower doses. So, uh, that was a very difficult trial to do, but it, it has shown, you know, that the evidence is that people who. You know, experience these, uh, conditions later in life do at least respond to the same treatment. So [00:08:00] there's, there's quite a lot of overlap, but there's also some intriguing differences.

Uh, but it is also striking that there is that second group of people I. And you know, if you develop a psychotic episode, age 20, you're very likely in the United Kingdom to fall into a a specialist early onset, uh, or first episode psychosis service, which are absolutely rightly well-funded and very specialist and offer great care if you are 80 and that happens.

Uh, you may well not get that service and you may be in a, in a general old age, uh, service. Now, whether that's right or wrong, uh, that is something that does, uh, that it's a striking difference in service depending on your age. And you mentioned living alone, and it strikes me that loneliness must be a huge factor when it comes to the worsening mental health of the older population.

And, you know, the UK. The Western world more broadly seems to have this problem that as a result of a more atomized [00:09:00] society, where all the people are often less integrated into the community than, for example, other pop, other cultures that say a culture like India comes to mind, or other Asian cultures or more Mediterranean cultures.

Is this something you see in your clinical experience that loneliness? I, I is an important risk factor for the development of a, of a mental health condition in an older person. So a absolutely, uh, loneliness is a really interesting concept. So you can be somebody who goes to work with lots and lots of people all day, uh, sees people in the evenings, but you can still feel quite lonely.

I. Uh, so there is a sort of difference I think, between loneliness and isolation. And there are certainly people who are very isolated and quite happy like that, and they don't feel lonely, uh, either. But I think one of the striking things for me working through the Covid pandemic and subsequently, is that of course a lot of people, um.

Which were, were isolating during the pandemic, understandably, uh, for their own health reasons. But then they've never got quite out of the house again after the [00:10:00] pandemic. And that, uh, that loneliness and that isolation, I think more than loneliness is something that has been, uh, pernicious to, to mental health.

Certainly we've seen a, a large and sustained increase in referrals and people experiencing difficulties post pandemic. I was just one more comment on that is that I was very struck by the BMJ uh, article recently on depression in older people, and I was delighted to see that the authors started by saying, what can you do to help this person in terms of isolation and activity?

I think that is a great place to start rather than starting maybe with medication or, or other things. Yeah. But just trying to, it seemed very human. Yeah. And I think, I think it's obviously important a across all the age groups, but especially in the older population. And the other thing I think about is meaningful engagements with life.

Like you said, you might be able to be with people, but I wonder if in the West we have this unconscious attitude that we know once you're older. Your kind of role in society and the [00:11:00] community has elapsed and you don't need to have sort of a meaningful role. And I think that's a, that's a huge problem as well.

And it really speaks to the fact that, you know, mental health isn't always best treated necessarily in a medical paradigm, although sometimes it should be. But we also have to be thinking about importance of sort of society and societal and cultural questions and how do we treat people? What helps people feel?

Included or or left out. 'cause of course that's gonna have like an enormous impact. On someone's mental health. Uh, yes. So I think you're, you're right in all of those things, of course, this is why psychiatry is such a fabulous specialty. You have to think about society. You have to think about people as human beings and their background and their life.

And old age psychiatry is a joy because all of the people you see are old and they've had quite a lot of life, and they've almost always got something really interesting to, to tell you that they, they, they've learned in that time. Uh, and you sort of touch on almost, um. Existential, uh, psychotherapy ideas there of role and meaning.

Um, and I [00:12:00] think that's true and important for people all of their life. Uh, one of the things that strikes me as an old age psychiatrist is that we never talk about the difficulties of retirement. I. People see retirement as this sort of halian state that they can't wait to get to and then they won't have to go to work.

And uh, you know, they plan their retirement, they look forward to their retirement. You congratulate people on your retirement, but actually it's a huge life change. Just like becoming a doctor or getting married or having a baby or going to work and actually cha losing. Your working role is very interesting.

It changes a lot. It changes your income, but often it change, it changes the people you see and your social connections. It changes your status often. Uh, I think sometimes people, uh, you know, almost define themselves through work and it totally changes your relationship because instead of being out most of the time, you're now at home most of the time.

That can be, uh, uh, can be challenging in its own way as well. Uh, the, the last thing I would say on, on role is I think it's gonna be very [00:13:00] interesting, uh, go looking forwards because our society in, in the UK and, and pretty much the rest of the world is aging. There will be more and more old people. And in this country, there was a large baby boom, uh, during the 1970s.

So those people are now, uh, reaching. Uh, sorry, during the 1960s. So those people this year will become 65 and the number of old people will increase dramatically now over the next 10 or 20 years. Uh, and so this idea that you stop working when you are 60 or 65, or it may be that actually as society changes, um, and I see a lot of older people in my clinic who to have lots and lots of meaningful roles, and the, one of the advantages they do have is that they are.

Sometimes financially well off after a lifetime of working, but most importantly, they are time rich so they actually have the time to do things. Yeah, and I think you're right. The role of [00:14:00] the oldest strata of society could really radically change because of the aging population, as you say, which just means the older segments of the population are just in all likelihood, going to have to be a lot more productive and to have to contribute to generating wealth.

Participating more actively in society, which, you know, a lot of people at the extreme end, some people are worried that this could cause like real societal insta instability. But the optimistic side of this, I suppose, is it could incentivize people really to optimize for longevity as much as possible.

And this concept of health span rather than lifespan. Like how do you live the healthiest possible life for the longest? Amount of time as opposed to optimizing for lifespan, which is just how do you live for as long as possible in whatever state that you can manage. Um, there seems to be more of a trend of trying to think about delaying aging or, you know, [00:15:00] slow aging.

Um, a lot of interesting documentaries about this. I know you've done, uh, a PhD in molecular genetics linking to things like autophagy. How, how possible do you think it is? To start to slow the aging process. Is this something you're optimistic about as a, uh, as part of the scientific endeavor? I, I will cover that question j just to c cover the previous point that you made about older people.

I think we can look at them as a resource, uh, rather than a burden. And, uh, it's true that your sort of memory and thinking your cognition in, by most measures, peaks in your mid twenties, uh, which is kind of bad news for me. But what is true is that as you get older, you can still accumulate more and more knowledge.

So this idea of old people being wise is, in fact, I. Uh, you know, true. And, uh, so tho that that population isn't something that, uh, we should ignore or, or diminish, but there are people with, with huge resource. And you mentioned other cultures in different parts of the world, and I think that's how older people are, are seen there.[00:16:00] 

Can we, can we delay it though? Can we stave it off and, uh, do things to improve our health? Well. I don't know. Uh, I'm not an expert on, uh, delaying aging. I do know that there's a lot of people very interested in that. There's a lot of investment in that. Um, and, you know, uh, I think we'd all like, like a bit of it, uh, uh, you know, there's, uh, many parts of aging that perhaps aren't, uh, aren't to be welcomed.

And uh, if you could stave that off, that would be great. I think what's much more. There are some things. So we, there are some things, for example, that we know are risk factors for dementia and it seems likely that you might be able to do something to ameliorate that, uh, and therefore decrease the number of cases of, of dementia.

So, uh, there are lots of examples. I mean, a great big example in the United Kingdom is to. Decrease in the number of people smoking. You know, that's something that will help your health span, uh, very considerably, um, and will also de decrease, uh, in all likelihood your risk of dementia. But there are many other things, uh, some of which are a bit [00:17:00] counterintuitive.

So I think we probably all have, uh, thought about drinking and smoking, but. Two that really strike me is, uh, one of them is the amount of education that somebody has, uh, earlier in life. So there is something positive about education beyond all of the good things about education anyway, it may, uh, increase your cognitive reserve.

And the other thing that has been really interesting over the last few years is seeing how deafness is a risk factor for dementia. And deafness is something that, um, can be checked and treated with, with hearing aids. Completely know whether restoring people's hearing may, you know, takes that risk away.

But these are, uh, things which, you know, I think almost lend themselves well to public health campaigns. So we're treating one of his three, uh, you know, uh, sort of three point plan is, uh, from treatment to prevention. Uh, well, let's, let's, you know, do that. Um, some of this stuff is, is so irresistible, it's surprising we're not doing it.

Treating blood pressure in [00:18:00] midlife will decrease your risk of dementia well, but also decrease your risk of heart attack and stroke and many other things. Are we really doing that as well as we could do? Um, so there are some things that are, are fairly basic before we start getting, uh, excited about, um, you know, drugs that will make us live forever.

Yeah, there's definitely a lot of common sense strategies that should be the foundation, I think. And even when I have looked into. Certain social media influencers who are talking about this day too, will talk about the common sense strategies first, not drinking, not smoking, good nutrition. There's a few different bits I'd like to pick up on.

You mentioned education. W would it be fair to say in your view that you know, the longer you keep your mind engaged in pro problem solving and problem solving activities? The better you'll, you, you will be able to be at problem solving for a longer period of time. Is that a fair statement? I, I appreciate that might be part of your intuition, clinical experience part backed by science, but what's your view on that?

Well, I, I [00:19:00] think for, for many of these things, I think well intervening is, is good in itself. So why would you not want to help someone who can't hear. Here, you know what, what, whatever its impact on, on dementia, that seems to be a good thing. Ditto blood pressure, stopping smoking. Um, and so education has, has something that's positive about it.

It it anyway. Um, but it's definitely true that, uh, keeping yourself active in your mind is, is positive in many ways. Uh. The, the difference between seeing correlation between a risk factor and dementia and then causation and then whether treating that cause then can take away that risk are actually quite separate questions, uh, that are, that are actually quite, I.

Often very difficult to tease out, you know, how could you do a randomized controlled trial of, of education? So really you're left with, you know, large epidemiological studies and associations. Um, but you know, we always recommend to our, our patients, they keep themselves active in [00:20:00] their, their mind and body.

Uh, and, uh, if you look at the overall pattern of the science, I would say that it supports that being beneficial. Okay. So even if you look at those larger, uh, epidemiological studies, they will show an association between. Engagement with education and prolonged, uh, cognitive performance, appreciating that correlation does not equal causation.

But that's what the studies show that they're correlated. Yes. So you can do that fairly straightforwardly by looking at people's highest level of education and their risk of developing dementia later in life. Uh, and it does seem that, uh, you know, education is something that, that might be protective. Um, zoning in on alcohol for a moment.

I. Recently released an episode about how and why I went sober and stopped drinking alcohol. And part of my reasons are longevity reasons. You know, I kind of see the mind as a supercomputer that we're gifted with through which, you know, your, your mind is your problem solving machine as also the lens through which you can appreciate some of [00:21:00] life's most sublime, beautiful moments.

The thing that allows you to have fun as well. And so I, I made an argument. To stop drinking alcohol. Based on that and some other arguments as well, in your view, is there like a reasonable amount of alcohol to drink? Is there a quote unquote safe amount of alcohol to drink throughout life or would your approach more be, you know, the less the better for in terms of brain health?

Purely? So that's a great question and I think that it's, the answer is, uh, it's complicated. So let me try to explain that. Uh, the person who's done a lot of work on this is, is, uh, an old age psychiatrist in London called Tony Rao, who would be a great, a great guest for you, I think. And one of the things he shows is that there's a real change in, uh, drinking patterns by generation.

And the real villains for drinking are my generation. So people in their fifties and sixties. Uh, if you [00:22:00] look at people in their twenties, actually, they're drinking less now than people in their twenties did in the 19 1980s. So there is a cohort of people who really, uh, that drinking heavily has become, you know, quite, quite commonplace and has continued throughout their life.

Now, I think in answer to your question, what about, uh, you know, what is the sort of safe level of consumption? Uh, I suspect that, uh, the amount of alcohol one could drink in your. Twenties is very different to that in your eighties. And yet sometimes I see people who've got ingrained patterns of drinking, you know, a couple who have a bottle of wine every night, and they've been doing that for the 50 or 60 years of their marriage.

Well, when they were 20 and newly married, that maybe one thing, but when they're in their eighties and they've now started to fall and they've got cognitive impairments there on lots of medicines and their physiology's changed, that might be something quite different. Of course the government guideline is 14 units of alcohol, but 14 units of alcohol in a [00:23:00] 20-year-old versus an 80-year-old are wildly different thing.

So I, I actually think that there is a real problem because that cohort that I told you about born in the 1960s is also the cohort for whom habitual alcohol drinking is, is more common, and they're the people who are now aging. So we are about to find out, I think, whether, uh, what, you know, just how damaging that might be.

And I guess you would be seeing other addiction issues as well. 'cause my intuition would be, you know, addiction probably you would see a lot less commonly in older people, you say 10 or 20 years ago. But as drugs have become more of a thing, recreational drug use, I can imagine now you're starting to see people getting older but still laboring with certain drug problems like.

I don't know, use of heroin or cocaine or things like that. Is that the, is that something you're seeing clinically at all? Uh, actually, um, uh, less so than other conditions that are more, more sort of commonly thought of as adult conditions. So, for example, I've just [00:24:00] started to see the first people coming into clinic with, you know, have I got a DHD, but they're in their, you know, seventies, um.

People with eating disorders such as anorexia, uh, people with various forms of personality disorder, people on Clozapine. Uh, so it's a very, uh, it, it's a very mixed bag. I see less people primarily with, with heroin addiction. I'd see, I see a lot of alcohol. I see a lot of benzodiazepines. People have been prescribed benzodiazapines for a long period of time, and sometimes you find so addiction is everywhere.

Uh, and sometimes you find it in surprising places. I can remember sitting on a sofa in somebody's house and, uh, sitting on a. On a bottle and I pulled the bottle out and it was cough mixture, but of course it was a codeine tus. And, uh, you know, um, that was something that the person had got very used to, to taking over a long period of time.

So sometimes the addiction shifts, but I think for the people vulnerable to addiction, [00:25:00] uh, there's, there's, it's still there. And zooming in on nutrition. I've seen some stuff online about dementia, and I think specifically Alzheimer's dementia being increasingly thought to have a metabolic component relating to food, perhaps too much sugar in the diet, or too much refined carbohydrates in the diet.

I've heard of Alzheimer's being referred to as type, so-called Type three diabetes. What's your view on this? Is there a lot of science to back this up, that there's a metabolic component to to, to something like Alzheimer's? And if so, does nutrition also form an impor important part of a prevention strategy?

So, teasing out diet is, is, uh, super difficult in terms of association and causation. Um. Because of course, people's diets very messy and complicated, and they, uh, you know, evolve and they change over very long periods of time. Uh, so it is, it is hard to to, to do that with any sort of [00:26:00] degree of certainty.

Um, what we do know is that extremes of BMI. Are associated with different risks of dementia, um, both high, very high BMI in in in midlife and, and low BMI, uh, in later life. So actually what's an optimal BMI, um, might change a little bit as you age as well. So much of what we say and we think is all based on younger adult populations, um, rather than older adult.

Uh, populations. So I think maintaining a sort of healthy body weight, um, is something that's important. Whether that is mediated through another factor, for example, you know, your glycemic control or your blood pressure or so on, uh, it's, it's, you know, harder to, to discern. Um, but I think in terms of specific diets, uh, very hard to, to be really certain about anything.

Is there a, is there a metabolic component to Alzheimer's disease? Well, Alzheimer's disease is such a complex. Whole body disease is primarily a brain disease, but it [00:27:00] has many, uh, many effects and many parts to it. And I think, you know, we would be, we would make a mistake to be too simplistic about it. So certain, almost certainly there is a significant inflammatory, uh, element to this.

There's protein misfolding and deposition. Um. There's synaptic loss, there's vascular components that are often, uh, I think have been perhaps overlooked. So, uh, it, yeah, it, it's, it's a very complex condition and the idea that there might be some metabolic components to that, it, it's, I think, quite likely.

Great. And then zooming in on exercise. Is exercise important for L longevity and and maintaining long-term brain health? I appreciate the answer might be similar. That might be difficult to establish those associations, but. What do you think it? Well, so the only way you can really look at causation is through, uh, randomized control trials.

So there is a famous trial called finger, uh, which was a multi-component, [00:28:00] uh, uh, intervention, if I remember rightly, which, which included exercise, um, which was, uh, you know, which was encouraging in terms of potential benefits cognitively. But again. It's something where there's a lot of literature, uh, there's nothing very, uh, it, it's, it's quite difficult to be absolutely certain about.

Um, but again, I think keeping yourself active in your body has got to, you know, will bring you many benefits, will bring you benefits in all likelihood in terms of strength and balance and, um. Uh, and simply just keeping yourself alert and engaged. So I think it's hard to say, yes, this trial has shown that you should be doing, you know, this, this amount of exercise in this way, and this will change your risk by X amount.

Uh, I don't think we're in that place, but, uh, uh, I do think it's something that, that we can consider. Yeah. And even if exercise had zero impact on dementia and cognitive performance, it's super important to do as you age because we know [00:29:00] it's gonna increase your, or preserve your muscle mass. Your bone density.

You know, one of the most common ways for, uh, elderly people to deteriorate is to break a bone, which it can be done more easily. If there isn't enough bone density or muscle mass, then a person can then end up in hospital and then can, there can be all sorts of serious consequences. From that, the mobility that I can produce.

So definitely exercise is gonna be a hugely important strategy for longevity, even if, even if it's not an important strategy for brain health, per se. Um, moving on to sort of dementia more broadly. Obviously we've talked a little bit about Alzheimer's. I think dementia is often spoken of as kind of one condition, and a lot of people aren't necessarily aware that dementia is actually a group of conditions.

We've talked about Alzheimer's. Is Alzheimer's the most common form of dementia? Yeah, so dementia just, it's an umbrella term which describes a syndrome where your memory and other cognitive [00:30:00] functions decline over time. And this is beginning to, uh, interfere with you being able to live your life. Uh, and the causes of that are, are manifold.

There's well over a hundred different, uh, causes of dementia, but by far the most common is Alzheimer's disease, perhaps two thirds of, uh, of cases, uh, or perhaps even a little bit more, uh. The other big secret about dementia is that if you look at people who are very old, so people in their eighties and nineties who are the age group most likely to suffer from dementia, and uh, Carol Brain in Cambridge has done much of this work looking at those, uh, brains.

Um, at postmortem, what you actually find is that it isn't one nice, neat diagnosis as the textbook suggest, is actually a mixture of all sorts of different things happening on happening at the same time. They may have common. Cause, um, but in older old people, uh, it's, it's often a mix rather than just a single pathology.

And, and what are the other kinds of like really common kinds of [00:31:00] dementia besides Alzheimer's? So after Alzheimer's disease, you, uh, you have probably vascular dementia. That's a concept where actually vascular vascular damage often goes hands in hands with Alzheimer's pathology as well. Um, but certainly you see people with multiple strokes.

I, I know I. Some people here, like Professor Hugh Marcus in Cambridge is, uh, doing a lot of work with, uh, vascular dementia and particularly small vessel disease, which I think is something that we've perhaps, uh, not given as much attention as we might have done. Uh, you also have, uh, conditions, uh, such as Parkinson's disease, dementia, and related to that, uh, Lewy body or leafy body, uh, disease, um, you.

Perhaps slightly more common In younger people you have, uh, frontotemporal dementia or frontotemporal lo degeneration. Uh, and then beyond that, you start getting into, um, you know, things become progressively rarer, but you get, so some genetic conditions, for example, like, uh, Huntington's Disease, [00:32:00] um, or indeed some other diseases of the nervous system can sometimes lead to dementia, like multiple sclerosis.

And when it comes to Alzheimer's. I'm aware there is a genetic component, so having certain genes, I'm thinking of the A POE allele, um, will make having something like Alzheimer's more likely. Do you think that it's worth testing for those kinds of genes even when you're young and therefore, you know if you get positive results?

Those gene, having those results might inform. Your strategies that you might take an extra, more cautious approach, say with your brain health? Is that something worth thinking about? Oh gosh. That's a, that's a, a tricky question. So, um, you are right. Uh, there are genes which will increase your risk of dementia, but I think we've got to, uh, understand from the.

Get go. That dementia's extremely common if you live long enough. So perhaps a third of people in midlife now will develop dementia [00:33:00] because they will live a, a, a long life. So that's an incredibly high risk to start with. So everybody should be doing it, I think, rather than just those at high risk. But my, one of my students here has just finished, uh, writing a review.

In which actually with disclosing people's risk, uh, does seem to have some impact on their behavior, or at least people say it will, uh, change their, their behavior. How well that is sustained, uh, uh, is, is a different kettle of fish. But I think you've also gotta be very careful because even, uh, uh, you know.

APOE genotypes that in most increase your risk of dementia. Don't mean to say that definitely you're going to get it. And having a, a more favorable genotype doesn't mean to say you definitely won't get dementia. And they only relate to Alzheimer's disease, which as we've already discussed, only accounts for about two thirds of the cases anyway.

So, um, uh. I, as I understand it, there are co companies now where you can have your genotyping done through the internet. So if you really [00:34:00] want to know your AE status, as I understand it, you, you could, you could do that. Um, uh, but whether it would really change things, I dunno, I think individuals would have their own view on that.

And most people, you know, when they think of dementia, they think of memory problems. Primarily, but if you're living with an older person or perhaps regularly taking care of an older person. What are some common early signs of dementia that therapist, more subtle perhaps, that someone might, that it might be helpful for someone to know?

Well, the, the more subtle signs sometimes are in terms of mood, uh, and, and behavior and sort of some personality changes. But, you know, uh, it's very hard to untangle those. One of the. The problems is that just now, right now, we don't have very many, uh, definitive tests for dementia other than looking at the brain under the microscope, which obviously, uh, we don't, we don't offer as a diagnostic test.

Um, certainly very, very rarely would we do [00:35:00] that. Uh, I think things will change, uh, substantially as we, we start moving into blood tests that can help us make these diagnoses. Um, and that will be a be a change. But right now we, it is very hard to be. Sure. And therefore subtle signs, you know, you can't really make a diagnosis at that time, but certainly that sometimes you see early changes in mood or in personality.

Um, the hallmarks really of Alzheimer's disease are short-term memory loss and forgetfulness, and that's often manifest by people asking the same question. So people find their relative is repetitive, but so are they because they're both saying the same thing. What time are we going to the doctor's? 10 o'clock.

Two minutes later, what? So, and, and so on. And the other thing of course is that because it's a disorder of the, uh, interal cortex, uh, initially in the medial temporal lobe, this is your seat of spatial memory. This is how you find your way around. Um, how does that manifest itself? Well, I often see people in clinic where, uh, when they're washing up, they always, uh, the, the person who's doing the drying starts putting things back in the wrong cupboards.

They've lost a [00:36:00] spatial awareness around their kitchen, um, or. Perhaps a little bit more worryingly with driving. Other dementias have very different, uh, initial presentations, so there are certain for so frontotemporal dementia often, uh, or usually presents with changes in either speech or behavior and personality.

Uh, and, uh, dementias associated with Parkinson's disease can often actually present with psychiatric symptoms or problems with vit geospatial skills. So, uh, it's actually quite a broad church. The other thing that's really important is, uh, to pick up on when. It's causing people difficulty, uh, with practical tasks.

So things that people used to be able to do but they can't do now. And with Alzheimer's, my understanding is, uh, problems with facial recognition is a, is an issue. Does that tend to be. An earlier sign or perhaps something that's much later when the disease is set in quite a lot. So I think it can be, it can be both.

Uh, I mean, this is stuff that, uh, involves your fusiform gyrus, which we know is [00:37:00] another area that can be affected by Alzheimer's pathology. Um, I, it's, it's something that I do see in clinic, but it's not as common as, uh, of the, as the other symptoms of spatial awareness and, uh, and short term memory. Uh, and, uh, if I'm honest, I think overall it's more commonly a late symptom where particularly when people are struggling to recognize people, very well known to them like family members, that is something that is, uh, I would say I see more commonly in later disease.

Yes. And again, for, for carers of older people, do you think the way they should think about it, the principles should be, you know, the sooner, the better If they're worried, if they're seeing these changes. Taking them to the GP to perhaps get a referral to something like a memory clinic. Do you think the principle should be like the sooner, the better rather than waiting?

'cause presumably this is something you want to get a handle on as early as possible. So I think, uh, I think if anyone is worried. And that's got [00:38:00] and is concerned, seeing their doctor is, is a good idea. Uh, the worst that can happen is that the doctor reassures you. And that's all part of doctoring and actually it's got a nice thing for the doctor to do.

It's good to give some good news, uh, rather than, uh, more difficult news. Um, at the moment there are no drugs which really slow down the progression of. Most forms of dementia. There are some drugs that have been recently licensed in some parts of the world, including the uk. They're not approved by NICE for Alzheimer's disease.

Um, but they even, they are not, uh, you know, they're not wonder drugs. And, uh, therefore the question of diagnosing it early, what are the, what are the benefits of diagnosing it early and actually. If you are encouraging a lot of people to come at the first possible opportunity, actually for a lot of that, it's gonna be very hard to make the diagnosis before we have more diagnostic tools.

On the other hand, ignoring things until they've got to a very advanced state, uh, is an isn't helpful either. So I think the worry [00:39:00] is a, is an excellent barometer of when you should go after the doctor if you are worried about your wife that you've been married to for 50 years. You'll, you'll know, you'll know because no one will know your wife better than you or your husband, uh, or your, your parents.

You've known each other all of your life. Um, and so if you are worried, then there probably is a good reason to go to the doctor. So you kind of alluded to that with what you just said. But I feel like every, every, so when I hear the news, I see a headline about a very new, exciting. Drug for, to treat something like Alzheimer's or another form of dementia.

I know there was an issue some years ago of some case of scientific fraud where they thought they had produced a drug or found the drug, uh, markedly more effective, but that, that, that turned out to be fraudulent in science, as far as I know. Are, are there any treatments on the horizon which you're excited about that might be able to improve dementia symptoms Significantly.[00:40:00] 

Oh, so firstly, I should be clear that we do have treat, uh, drugs, effective drugs that are available on the NHS, which treat symptoms. So definitely we can do, and, and the drugs are only one part of many things that we can do to help. So, uh, I wouldn't be, uh, two despondent. Uh, but of course we always want better treatments.

Uh, I think it is an absolute, uh, you know, it's, it's almost, uh. Uh, an unbelievable moment in some ways that actually there are drugs now which can pretty convincingly be shown to slow down the progression of Alzheimer's. That was something that some people thought may not be possible, and it is possible.

Uh, so that is great. Of course, now you want drugs that do that better, and probably you want drugs that do that in different ways so that you can take a variety of drugs, uh, that. Perhaps together might be more effective. So the good news is that, that such drugs are absolutely on the horizon. So, uh, every year, uh, a man, uh, an academic in the United States, Jeff Cummings [00:41:00] publishes a map of this and it looks a bit like the solar system.

Uh, and every year there were more planets on the solar system and there were more moving into the center, uh, which suggests that. There are drugs. I know this year there are several drugs that will, um, complete what are called pivotal trials, uh, which, uh, which are kind of the final step if you like. Uh, and they, they're not all, uh, targeting the same thing.

They're not all trying to work in the same way. They actually work in quite different ways. Uh, and that's really, really encouraging 'cause it makes you think that, you know, you. That, uh, they're perhaps a little bit more likely to work if they're trying different things. And the fact that there is stuff that is coming through and can clearly be seen to be coming through, uh, is, is really, really exciting.

Especially given there has been, uh, you know, the success of the first drugs that have been licensed, uh, as disease modifying drugs in Alzheimer's disease. So a little bit of success, I'm hoping Will, will, will lead to more What, what, uh, how do these drugs work on a molecular level, the ones which have been demonstrated to slow down the progression of [00:42:00] Alzheimer's.

So Alex, I think I should, uh, be, be really clear that, uh, in over the years I've been at times have involved in paid advisory boards for some of the companies to make these drugs. I think it's important for your listeners to know, 'cause it may, uh, may cause them to consider what, what I say with, with perhaps, I dunno, a bit more skepticism.

Uh, but the, the drugs that have been approved, uh. For use, uh, all, uh, there's only two. There's Lecan and Umab. And what they both do, they're monoclonal antibodies and they bind to beta amyloid. One of the two proteins that's deposited in the brain, predominantly in Alzheimer's disease. Uh, they bind to the, uh, to the amyloid.

Your body then recognizes it a foreign and destroys that, uh, that protein. And in that way, you can take away most of that protein from your brain. Uh. Perhaps disappointingly only leads to small benefits, so you can take away a lot of, you know, the protein that that many people consider to be at the heart of the disease, but it doesn't really solve the problem.

It just [00:43:00] helps things a bit. So hence the, the rationale for, let's find better drugs, perhaps different mechanisms of action. That might be able to do the job better. Yes, I think so. But I, I, so that, can you improve those existing drugs? Can you, uh, make them work better and have more impact with less side effects?

I think there's a lot of interest in that. There's also a lot of reasons to believe that Alzheimer's disease is more complicated than just perhaps the deposition of proteins, as is often shown in the textbooks. I don't doubt for a second that's important, but there are lots of other things, uh, that are important as well.

Uh, you know, we've talked about inflammation already. Um. Uh, that, that's one example. Can, uh, can drugs targeting other mechanisms, uh, also have a positive effect? Um, so we, uh, we will see, uh, certainly I think, uh, this year and in the next few years, we'll see a number of drugs that have got to really late stages of testing.

Uh, and we'll, we'll, we'll get the answers to those questions. And then, besides medication, what are the other [00:44:00] important treatment considerations when you have a patient with Alzheimer's? Or another form of dementia. What are the different things you take into account in, in someone's management plan? So, uh, I, I think this is really important because it's very easy for doctors to get into conversations about drugs, and they may only be a small part of what you can do to help.

We talked a bit, uh, uh, earlier about people going to the doctor, uh, to, well, what's the point in that? Uh, you might say, well, one of them is that of course there are lots of conditions that might mimic. Dementia. So for example, uh, you know, disorders of your thyroid gland or if your blood glucose is very out of whack.

So one of the things that will happen is that you get a sort of MOT to try and exclude those other things that might be leading to confusion. It's always really good to look at somebody's list of medicines, uh, because we know that some medicines can cause confusions, and as we've discussed, older people seem to collect.

Uh, medicines as they get older, I've started to collect one or two and that C carries on. And so revising those medicines to see if people really need [00:45:00] them and they're doing more good than harm is, is important. Um. We've talked about the importance of activity. So there is, uh, a lot that can be done. It's often at a very local level, but there are things that people can go and enjoy and take part in.

Some of these are organized through, uh, national charities, so there are ideas like singing for the brains. There are sort of dementia choirs that people can join. And uh, the early sort of feedback from that is. They look like they're, they're very positive for people. Um, there, uh, the, the diagnosis of dementia has implications for driving.

Uh, uh, so it's something that you have to inform the DVLA about, and that's about keeping people safe, keeping the driver safe and other people safe too. Um, it might make a change in benefits. Uh, we talk about legal things that might be useful, like power of attorney. I. We, uh, introduce people to things like the carers trust or if you're lucky enough to have some in your area of the country, Admiral Nursing, to focus on carers and plans.

You [00:46:00] know, what happens if your wife breaks their legs, Murray, who's gonna look after you? Then, um, uh, and also how you can support the carers so they can continue to support the individual. Uh, and we always like to. Uh, well, I dunno if it's just because we're in Cambridge, but wherever we are, we should be doing this.

And that's giving people the opportunity to take part in research. That's something that people find really empowering, that they're no longer just, you know, the disease is doing it to them, but they're actually doing something, uh, in the opposite direction and something which, you know, to. To be honest, people often really enjoy and can really get involved in.

Uh, so there's, I mean, I, I would no doubt that there would be lots of things that I've forgotten there. Uh, but there's, uh, that there's a, a rich variety. I mean, the other thing that we should talk about is actual practical care as well. If, does somebody need some help with their meals or getting up washing and dressing?

What about medication? We've talked about that. Well, actually, if you're on lots of pills, that's very hard to deal with. What are the compliance aids and things that might be useful? There is, [00:47:00] as in my own local area, there's a big assistive technology team so they can do things, uh, which such as, you know, mats so that you know when people are going out or some more unusual things.

So they've got some sort of bionic cats that can sit on people's laps and, uh, be petted and the cat purrs if you keep stroking it. And this is something that can bring people comfort and distraction. So there's, uh, you know, there is a myriad of of things. It's not a case of just getting a diagnosis and, and giving people some pills.

Yeah, and I'm hearing, you know, not just interventions guided at improving symptoms, but actually meaningfully improving someone's quality of life, which is. The ultimate goal at the end of the day. Yes. I think there's a lot of interest in this. So, you know, uh, a lot of our tests over the years or drugs are trialed about, you know, how well you can do on a particular cognitive test.

But I've never had a patient come to me and say, I'm, I'm worried, doctor. I can no longer draw a clock or name the Prime Minister or take seven away from 100, uh, time after time. Uh, so it [00:48:00] really, I think, you know, as doctors, this is our job. It's about improving people's quality of life. Um, and that is the key outcome that I think we should always keep in mind.

And trying to achieve that in a broad way as possible is really the essence of, of good dementia care. I think we're almost out of time, but the last thing I wanted to ask you is, you know, you've been involved in the research world for a long time. What do you think about the advent of artificial intelligence and its potential use in helping us to accelerate?

Clinical research for, you know, psychiatric conditions in general, but also dementia. Do you think AI is gonna play a big role in the coming decades? Yes, I do. I certainly hope so. Uh, it's something that is, you know, the pa that there's is huge power. Let's harness that power for good. Uh, and that can, that there at every single step through, you're talking about the development of new treatments and so on, but actually there are.

Other things that, that might be really [00:49:00] useful, that are much more proximal. So, uh, you know, doctors and nurses spend a lot of time typing into computers. Uh, somebody I think once said that if an alien came to earth, they would think that nurses looked after computers, not patients. Uh, and all of that information is going in, well, can we use that?

Clinical information to, uh, to enhance our care. 'cause at the moment we tend to treat people with dementia. For example, we've talked a lot about dementia. It's important to remember there are other mental health conditions that older people suffer from as well. But just in the dementia world, we treat everyone.

Often the the same, they get the same service, but. It's highly unlikely to be an optimal service, in my view. How can we stratify patients using AI for, as just one example, to make sure that they get the best care for them? So I, I think there is absolutely huge potential and I, I'm very encouraged that the health minister also has that in his sites as, uh, from analog to digital.

I think that is something that could bring a lot of benefits. Uh, and going along similar lines here, the role of genetics and perhaps [00:50:00] using AI to better understand someone's genetics. Tailoring treatments to someone's genetic profile. Do you, do you predict that that's going to be a big thing of the future?

Well, it's been a big thing in cancer for sure, but really the genetics is just one way of stratifying patients. So I think genetics, um, you know, lots of omic technologies, proteomics, metabolomics, imaging, there's a lot of data that is, is held in every single scan and there are. Projects trying to extrapolate that.

Uh, for example, Tim Whitman's cumin project running across the country. Um, there's lots of stuff in the clinical record, so, uh, and there's lots of stuff that you can harness about people that's perhaps not been harnessed before. I know there's lots of research groups interested in. The data that can be extracted from people's smartphones?

Are they moving around as much? Are they sleeping as much? Um, you know, the, the smartphone sort of, uh, uh, is our finger moving as smoothly across the front of the glass as it used to? So the smartphone is sort of capturing loads and loads of information about us. Is [00:51:00] that all also stuff that we can use? So rather than thinking about one thing like genetics or clinic, I think really it's an enormous data soup and that I'm, I'm not an AI expert, but my understanding is that's really where.

AI can help is spotting patterns in very large data sets. That would be impossible I think, for a person. Yes. And separating the, the signal from the noise. Yeah, that makes a lot of sense to me, Ben, under it, it's been a pleasure speaking with you. I feel like I learned a lot and I hope our, my, our listeners did as well.

I'm sure they did. Thank you very much for spending some time with me today. Well, thank you very much indeed for the invite. I really enjoyed talking to you. As I said, it was my first podcast, so, uh, I feel I've now got that out of the way and, uh, I, I, I would say. Um, not only thank you, but it's great to have the opportunity to talk about old age psychiatry.

I don't think people think about it as a specialty that often. It's not something that in the public consciousness, but not only is it. A wonderful job for the doctors like me that are lucky enough to do it. [00:52:00] Uh, but one of its pleasures is there is so much that you can do to really help people. Uh, and seeing people get better is, is a really rewarding part of the job.

So it's always a pleasure to come on and talk about that. Excellent. So training psychiatrists that are listening, perhaps old age psychiatry might be the specialty for you. Thank you again, Ben. Alright. Thank you Alex. Lovely to see you. Take care.