Our team had a zoom interview with Dr. Kentaro Nishino, M.D., the Geriatric Medicine Doctor at Overlake Medical Center – Senior Health Clinic in Bellevue, Washington to learn about care for Alzheimer’s patients. The summary of our interview is below.
Tara: How often have you encountered patients with Alzheimer’s?
Dr. Nishino: I’m a geriatrician so I’m a doctor that specializes in seniors. It seems like every other patient has dementia. it’s so prevalent as we’re living longer. The statistics that we often quote are that 5% of people at 65 years old have Alzheimer’s disease and it doubles every 10 years, like 10% of people at 75 years old. Such a number is pretty high and looks to be common among the elderly.
Tara: What stage are they usually in for your patients?
Dr. Nishino: There is a whole range from super early to the end of the stage. A lot of patients have a hard time coming in. Those patients usually stay at home care.
Tara: How do you run tests for Alzheimer’s diagnosis?
Dr. Nishino: It’s actually not that complicated, but it just takes a lot of time. You don’t necessarily have to be a specialist to diagnose Alzheimer’s disease. Basically it’s a lot of talking, because the core of the diagnostic criteria is cognitive impairment to the point that it’s affecting that person’s function. So it really has to get to know about the patient’s cognition and ability to perform functions by having a lot of conversations with them and their families. After that, we’ll do some memory testing in the office and a neurological exam. You can also check to rule out other factors that could cause the memory loss such as stroke, Parkinson’s Disease, or B12 deficiency.
Tara: What treatment do you usually recommend for Alzheimer’s patients? Or what lifestyle changes would you typically recommend?
Dr. Nishino: I think it’s a little bit of lifestyle and maybe other factors such as genetics. There’s a really interesting study called the “Nun” study. Apparently, when young women were going into the convent to be a nun, they had to write an essay about why they wanted to become a nun. And over the years they would have a copy of the essay that the young ladies wrote when they first went in, and then at the end of their life when they’re really elderly, a lot of nuns decided to donate their brains to science. And then when they looked at this, they could make a correlation between the prevalence of Alzheimer’s and how complex the essays were grammatically. So if somebody had a very basic education and used very simple sentence structure, that seemed to correlate more with Alzheimer’s disease. It was different from somebody who had very fluid writing intricately using an analogy or metaphor.
Lifestyle has a high risk for a type of fast food dementia. It’s about what people eat, how much exercise, or smoking that can definitely correlate with vascular diseases like stroke or high blood pressures, high cholesterol, or diabetes.
Tara: During Covid time, how much have your patients’ lifestyles affect them? For example, they might not have good access to medicine.
Dr. Nishino: A lot of what we saw with regards to the Alzheimer’s patients was that the social isolation was really hard and affected a lot of people in a really bad way. A lot of people became depressed. Depression can make your memory worse just by itself.People not taking care of themselves as well.
Tara: Does telemedicine work a lot of the time?
Dr. Nishino: TeleMed was really nice. We had asked for the telemedicine for a long time but Medicare hadn’t covered it. It was just not something that Medicare covered actually within a month or two of the pandemic. It was huge for us as we’ve never done it before. Of course, we weren’t sure what program was to use, or the logistics involved with patients, privacy and all security issues that involved the software and equipment. However, over the past three years we’ve all kind of gotten used to doing it right. It really helped to be able to see them through zoom. So it’s been a nice development.
Hana: I have some questions about music and Alzheimer’s now. When we played music for the residents, they began to request different songs and clap along and sing along.
How does listening to music affect the brains of people with Alzheimer’s?
Dr. Nishino: This really seems to jog some memories. Yeah, I’ve seen that too. During training, for geriatrics, we do a lot of work in a nursing home too, and seeing nursing home patients and I’d get to be in the back of the room sometimes when they do the music.
And you’re right, I think I saw somebody writing about this on the website, people look like they probably don’t talk at all or rarely talk, they’ll be just like, bumping around, and I think it seems like it really stimulates a part of the brain that’s probably been shut off for a long time.
So I think it’s a wonderful thing that you all are doing to do that, to bring some joy to the patients that probably hadn’t felt like that in a long time.
Hana: Do you think by stimulating those memories of remembering different lyrics or different songs, they’re able to remember other memories as well that kind of correlate with those memories from before?
Like in the past, let’s say, where they were in their childhood where they heard those songs or different memories that weren’t just those lyrics.
Dr. Nishino: Yep. I think so. I’m not sure you know specifically about studies that have been done on that. There probably are, but I would think so. A lot of memories seem to be attached to each other.
So same for us, right? When we hear a familiar song, we think back to when that was popular and the things that we knew back then so I think there is that kind of component. I think that’s a nice thing that you’re doing. One of the disciplines in rehab medicine will be like a recreational therapist, which are a lot of the people that work at the nursing homes and things like that. I think that’s what they try to do with a lot of the activities, including the music, to jog some of those memories.
Hana: Would you recommend listening to music as part of the treatment for patients with Alzheimer’s?
Dr. Nishino: I think that can be a really wonderful part of the treatment.
I guess this conversation makes me think more about maybe suggesting that more to our patients. I think a lot of times for music, just as for everyday practice, some of the Alzheimer’s patients get really agitated and it’s not their fault.
It’s just that their brain is going through a lot of issues. And some people, you might have seen, when you go into a nursing home, some of them may be yelling out or getting agitated. And then music can really help with that part. So especially, if families are having trouble at home with their loved one that has agitation, especially in the early evening, this time of day is actually the hardest time of day for a lot of Alzheimer’s patients. It’s called sundowning, but this is that time of day. Having some soothing music or something that’s familiar can be a really good way to treat that.
Elisa: I know you mentioned lifestyle, education, and genetics all influence the likelihood of dementia. Is there one specific factor that “flips the switch” to start the cell death or is each case unique?
Dr. Nishino: As we all get older, a lot of the things that happen to us. What we call multi-factorial ideas. That’s usually a little bit of this, a little bit of that combined together to cause one big issue in this case, the memory. A common recommendation that we try to suggest to people to delay the condition is to stay active both mentally and physically. They may play some games like Sudoku or learn new instruments, actively exercise, and very importantly be socially active.
Elisa: What specific parts of the brain, besides the hippocampus, are affected by Alzheimer’s?
Dr. Nishino: Basically it affects everything, not just the memory. The hippocampus would be, of course, really important for retrieving memories, but what we have to deal with every day is emotions, which are controlled by our brain too. So one of the first signs is that the patients are not themselves as before, like becoming angry easily. We have our frontal lobe, which is kind of our filter. So, when the frontal lobe deteriorates, people can behave differently from what they used to be. Another one is called the executive functioning which is really not just remembering certain things, but the problem solving of simple tasks in daily life that we don’t really think about. That is the part that the patients lose too.
Elisa: Have there been any inspiring breakthroughs in your patients? Such as a new treatment that a patient responded well to or a cognitive exercise that brought back some memories?
Dr. Nishino: There have not been much really. There’s a one that was just approved this year but somewhat controversial. This is like an antibody treatment for getting rid of certain proteins deposited in the brain with Alzheimer’s. So these are antibodies that you inject to attach onto those proteins, and try to rip them out. It’s controversial because the experts who gave FDA recommendations were against it but it received the FDA approval anyway.
They’re basically four medicines that we typically use for Alzheimer’s and all of them are just trying to slow down the rate of decline. None of them really improve the memory at all.
Elisa: As a geriatrician, what are some treatments or therapies to make a patient most comfortable as they’re mentally declining?
Dr. Nishino: It’s about figuring out the logistics of their care. There came to a point when all patients were required basically around the clock 24/7 care. Before we get to that stage, a lot of it’s really the planning about themselves. It’s trying to empower them to make a lot of the decisions for themselves for the future while they still can because after a certain point, they’re not going to be able to make their own decision. And then it is just basically taking care of their welfare. There’s a lot of challenges wherever the care is if it’s at home or finding a care facility for them.
Ellen: Have you heard about dementia villages? Do you think there are any ways we can improve patient care?
Dr. Nishino: I’m not familiar with dementia villages. There’s one facility that they try to make it really nice. It has a town square in the middle of their facility, and they have a shop there and try to give them some independence there. About the care, it’s hard because it’s expensive and a lot of people can’t afford them. A very nice home care can easily require nine thousand ten thousand dollars a month which is very expensive. There are still some less expensive home cares that could provide individualized care. It can be heart-wrenching sometimes as everybody wants their loved ones, or their mom and dad, to get into the best place.
Ellen: If they recall something, can they forget them?
Dr. Nishino: Surely they can. They may remember in the moment, but they certainly could forget it especially with a short-term memory. Short-term memory is the one that they usually forget at the beginning.
Ellen: So how do you treat patients? Medicine, therapy?
Dr. Nishino: As we talked about before, the medications just try to slow down the rate of decline. The care is really complex, it’s not like just giving them the prescription. There are so many layers to it as all medicine has potential side effects. We also have to think about where they are going to live. Do they live by themselves? Are they safe to live alone? It’s a lot about the patient’s social situation too. It’s a progressive neurological disease and we can’t really stop it. It’s going to get keep getting worse
Ellen: Why is it so hard to find a cure for dementia/alzheimers?
Dr. Nishino: The human brain is a very complicated organ. There’s a lot of theories about what causes Alzheimer’s and still even a lot of arguments about that. So we just don’t have a very good understanding of what’s causing this. If you’re all in neuroscience, this will be your potential future. We rely on smart people like you to figure out the cause.
Ellen: Any advice you give people who have relatives/friends with Alzheimer’s?
Dr. Nishino: Support them and try to help in whatever way you can. I think a key is to spend time with them. Giving a gift of time and whether they remember it tomorrow or not, it will still be a very meaningful thing to do. You all have very special things to share with them with the exciting music.
Hana: Thank you very much, we really appreciate your time talking to us today.
Dr. Nishino: You’re welcome. You all have really good questions. What you are doing with your project is really exciting and very meaningful. So good luck to you on that and to your future careers.