Mental Health and Memory: The Connections between Chronic Mental Illness and Dementia

Accreditation Statement

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In support of improving patient care, the University of Wisconsin–Madison ICEP is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

Credit Designation Statements

For more information about continuing education credit for this episode, visit the ICEP online learning portal at ce.icep.wisc.edu/dementiamatters/chronicmentalillness.

The accreditation for this course expires 9/18/2024. After this date, you will no longer be able to access the course or claim credit.

References for this Episode

Walaszek, A. (Ed.) (2022). Late-Life Depression and Anxiety. American Psychiatric Publishing Inc; 1st edition

Transcript

Intro: I'm Dr. Nathaniel Chin, and you're listening to Dementia Matters, a podcast about Alzheimer's disease. Dementia Matters is a production of the Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners on the latest news in Alzheimer's disease research and caregiver strategies. Thanks for joining us. 

Prerecorded Dr. Nathaniel Chin: This episode is approved for continuing education credits for physicians, physician assistants, nurses, and other members of the healthcare team through the Interprofessional Continuing Education Partnership at UW-Madison. At the time of this recording, Dr. Art Walaszek has no relevant financial relationships with ineligible companies to disclose.  Information on how to claim credit will be shared at the end of this episode. Additional continuing education information is provided in the show notes. 

Dr. Nathaniel Chin: Welcome back to Dementia Matters. Today, I'm joined by Wisconsin Alzheimer Institute's public health leader, Dr. Art Walaszek. Dr. Walaszek is a board-certified geriatric psychiatrist and professor of psychiatry at the University of Wisconsin-Madison, whose research focuses on public health approaches for improving the care of people living with dementia. Last year, in February 2022, he published his book, Late-Life Depression and Anxiety, which serves as a guide for healthcare providers to better diagnose and treat older adults with depression and anxiety. He joins the podcast today to discuss the connections between chronic mental illness in older adults and dementia. Art, welcome back to Dementia Matters. It is great to have you on the show again. 

Dr. Art Walaszek: Thank you very much. I really appreciate being invited back, and Nate, thank you for all you do with respect to the podcast and all the dementia related work that you do. 

Chin: Well, thanks, Art, and I will say that I carry your other book, Behavioral and Psychological Symptoms of Dementia, with me when I go to the memory clinic or to the nursing home, but we are not here today to talk about your first book. We're here to talk about your second one. Nonetheless, I'm very excited for our conversation today because the topic of chronic mental illness and its relationship to dementia is an important one, but it's also a common one. When I give talks to the community, as I know you do, this topic inevitably comes up. So to begin, let's talk a bit about chronic mental illness so that we're all on the same page. What conditions fall within this category? Can you speak to how common they are in the population? 

Walaszek: Yeah, thank you for your interest in this. I agree. I mean, this has become a very popular speaking request to talk about this issue, and I think it has to do with, you know, with the aging population, the growing number of people over 65, the growing number of folks at risk of dementia. There are also more people who have lived with chronic mental illness for many years and there are lots of questions about that related to what's the risk of dementia and how do I know if someone's developed dementia and how do I treat that and so on. So I really appreciate your interest. I would put in this category of severe chronic mental illness three conditions. Schizophrenia, bipolar disorder and major depression. I'll define them a little bit later, but for starters, just in terms of how common are these conditions. In general, around 1% of people have schizophrenia, and interestingly, that's a worldwide number, so lots of types of mental illness. It really varies a lot where you are in the world, but Schizophrenia is fairly universal. Roughly 1% of the worldwide population has schizophrenia. Bipolar disorder, that's a little bit higher. That's probably closer to 2%, and actually of the three, depression, major depression or clinical depression is by far the most common. In the US, that's probably roughly about 15% altogether. The numbers are a little bit different when you look at older adults, but just in general, that's kind of where those are at. 

Chin: And of course, you and I are both geriatricians, so we tend to see people who are older. But in my population, in the people that I look at and care for, you could have depression in the middle of your life and that carries over and you could have new symptoms or a recurrence of it. But you can also develop later life depression or bipolar or schizophrenia, and I'm asking that as a question, so you do see these later life onsets where people develop it and they never had it before. 

Walaszek: Oh, absolutely. Although it's interesting and I think there's a lot of question about what are those conditions and are those really the same as the earlier onset conditions or do they reflect something else? For example, in the case of depression. Most people with depression have their first depressive episode probably in their teens, 20s or 30s, somewhere in there. If you have your first episode of major depression 65 or later, which can certainly happen, those folks are at really high risk of developing dementia. In other words, about half of them within five years will have dementia, so it suggests that that depression is different than the depression of earlier in life, that in fact, it may be an early sign that something is going wrong with the brain, and it's first showing up as depression, and it's later gonna show up as dementia. More broadly, any time we see a later in life onset of any of these things, we really do want to think very carefully about, “Well, are there medical causes here?” “Could something be off about someone's thyroid or electrolytes?” Or “is it the medications they're taking?” So we do a pretty deep dive to look at potential causes since later life onset, though not uncommon, is a little bit atypical. 

Chin: Okay. I think that's, I mean, you're speaking to me now as the clinician that I know you are, and I will say, you know, people lose loved ones. They lose their colleagues or friends as they get older and they can have a hard time adjusting to that, so that is slightly different than what you're describing too with depression. 

Walaszek: Absolutely. Well, that's such a great point, and that goes back to Freud, who wrote a book called “Mourning and Melancholia”. So melancholia is an old term for severe depression and mourning as in the mourning of someone you love that you've lost. Those two can look kind of similar, but the key difference is that mourning is part of the human condition. We lose people we love and then we grieve for them. That's normal, so we don't want to pathologize that, and some of the, you know, some parts of grieving and mourning can look like depression, but really there are two different things with the fundamental thing being that grieving is normal. We expect that to happen, and severe depression, we don't expect to have. That's a condition that we want to try to address. 

Chin: So let's talk about bipolar disorder and depression, and I'm going to ask you to define those conditions because they can get confusing with mourning and grieving. I want you to provide for our listeners, some of which are clinicians and researchers, but some are out in the community and part of the general population. What do you look at when you diagnose someone as a clinician? And then after that, can you talk about its relationship to dementia? 

Walaszek: Absolutely. It's kind of similar to the grief versus depression question. There's sadness and then there's depression. So we all feel sad, right? That's just a fundamental human emotion. Something bad happens or we lose something or someone, we feel sad afterwards, so that's normal. Again, we don't want to pathologize that. If someone is sad most every day and or has lost interest in joy and activities and has kind of a combination of other things like poor sleep, loss of appetite, feeling hopeless, feeling guilty, feeling worthless and in some cases, even feeling like they don't want to go on living or having suicidal thoughts. I would just say, if that is the case, folks should just call 988, the new national one-stop shopping phone number for folks who are undergoing a mental health crisis. If you've got that cluster of symptoms for two weeks or more, and for most people it's much longer than two weeks, but that's just the definition, that's major depression. That's a major depressive episode, and if you have one or more of those, then you meet criteria for major depressive disorder. Now, bipolar disorder also has depressive episodes, same ones, and also has a different kind of mood episode called hypomania or mania. In mania, it's a period of at least a week of high energy, lots of ideas, thoughts going real fast. You don't need to sleep at night, and a little bit of that might help productivity, but most people don't have a little bit of it. It's full bore and it can cause really severe problems. Huge spending, gambling, doing things out of character, destroying relationships, really can cause some pretty significant damage, and in very severe forms, people can get psychotic, meaning they lose touch with reality. If you have those sorts of episodes, manic episodes alternating with depressive episodes, that is bipolar disorder. In terms of risk of cognitive impairment, unfortunately, both of those are associated with higher risk of cognitive impairment. With bipolar disorder, it's probably two to three times increased risk of dementia compared to someone who doesn't have bipolar disorder. With depression, kind of the usual earlier onset, that's kind of roughly a doubling of the risk of dementia. 

Chin: I'm going to ask you questions in a few minutes about why we see that increased risk, but I do want to pause here, just for our listeners, we're talking to right now with Dr. Art Walaszek, geriatric psychiatrist, but he is not giving medical advice at this moment, and he is not diagnosing anyone who's asking themselves, “Oh, I have these symptoms.” I just want to make that clear for our listeners. This is for informational purposes only. With that caveat out of the way, Art, I appreciate you explaining all of that. One of the ways I try to internalize that as a person is experiencing some pretty severe or significant symptoms and it is impacting how they engage in the world and how they're living their life, and when you have both of those components, that's when we should start really asking why I should go and talk to someone and potentially be diagnosed. 

Walaszek: That's absolutely right, and that's pretty much universal across our understanding of psychiatric disorders, that it's some combination of symptoms or experiences the person is having with impairment. Sometimes it's distress. You don't necessarily have to have impairment. It may be very distressing to have these experiences, but for most everybody, there'll be some impairment, meaning problems in relationship or work or doing day-to-day functions. So yeah, you're absolutely right. 

Chin: Now, schizophrenia, you mentioned earlier, and this is my understanding is it's less common in older adults and more often will affect younger individuals. I'm wondering, by having a chronic mental illness for a longer period of time, does that lead to an increased risk for cognitive decline later in life for these particular individuals? 

Walaszek: Yeah, I'll say a little more about schizophrenia now. Schizophrenia is quite a different disorder from bipolar disorder and major depression, although they can overlap, but schizophrenia, really, the fundamental parts of it are that people have psychosis, and psychosis includes two things: hallucinations, delusions. A hallucination is perceiving something or someone that isn't there, and that could be visual – you see something that isn't there. Auditory – you hear something that isn't there. Could be other sensations too, like smell and taste, but it's most commonly hearing and seeing things. That's hallucinations. Delusions are fixed beliefs that don't change despite lots of evidence to the contrary, so common delusions that someone's schizophrenia might have is that they're being persecuted. Someone's trying to kill them. The TV is sending messages to them, etc. So that's the classic kind of description of schizophrenia. Those are also called positive symptoms because those are things that are there that ought not to be there. More impairing for people with schizophrenia are the negative symptoms. So those are things that should be there but aren't there, like motivation, interest in participating in activities, social skills so that one can hold down a job and have relationships and so on, the will to make decisions and so on. So those negative symptoms are less visible, but much more impairing. There's a third category, which is relevant to what we're talking about today, and those are the cognitive symptoms. So people with schizophrenia can have significant problems with what we call executive function, which is making a decision, planning, doing things in the right sequence, inhibiting actions when you need to inhibit them and so on. All that stuff that allows us to kind of navigate the world smoothly can be impacted in people with schizophrenia, and those cognitive symptoms are there from the get-go. In fact, sometimes we might see a kid in high school who is starting to struggle academically. They had done okay before that. They start to struggle academically first, and then kind of the other psychotic symptoms show up. So many people with schizophrenia, they basically are taking kind of a cognitive hit very early on in life, in their teens or in their 20s, and then their cognition is stable, but it's at a lower level than it would have been without schizophrenia, so they may be at higher risk as they age, as other medical issues for developing dementia, because they have less cognitive reserves, sort of less in the bank in terms of their cognitive functioning. So people with schizophrenia, of the three conditions I've mentioned, have the highest risk. It's about a three times higher risk of developing dementia. 

Chin: Something you said I think is important for us to pay note to, which is that these are separate processes. Depression is separate from the dementia and the schizophrenia is separate from the dementia. But these are pretty impressive statistics that you're sharing with us as far as this risk. I know that a very common question I'm sure you must be asked is, why do people with chronic mental illness have this higher risk for developing dementia? 

Walaszek: Yeah, that's a great question, and there isn't one clear answer for everybody, so I'll give kind of a range of answers, and I'll start with schizophrenia since it has the highest risk. One issue is smoking. 90% of people with schizophrenia smoke. Much, much, much higher than the general population numbers, and people with schizophrenia who smoke tend to smoke a very significant amount. Of course, you know, tobacco is not good for all kinds of things, including for brain function, so that in and of itself will increase risk. Across most condition, mental health conditions, there's an increased risk of alcohol use and other substances. We'll talk about alcohol a little bit later, but in general, those are also associated with increased risk of dementia, so those would be some biological causes. Our treatments can be problematic. For schizophrenia, there's a wide range of treatments out there. Medication is just one part of it. There's a lot else out there, including focusing on housing and jobs and interpersonal skills and so on and medications, and unfortunately, many of the most commonly used medications can cause weight gain, increase cholesterol, increase the risk of diabetes, and all those then are in turn risk for developing dementia. Three, a lot of folks with mental illness, especially severe mental illness, remain very stigmatized. We've done a great job as a society raising awareness of mental illness, de-stigmatizing. However, there's still a long way to go. Many unhoused people have very severe mental illness and there's tremendous stigma against unhoused people. Many incarcerated people, in fact, the largest provider of mental health services in the United States is the LA County Jail. Lots of people with severe mental illness end up in the carceral system. Again, another very highly stigmatized population. Stigma leads to discrimination, including lack of access to good health care. If you don't get good kind of preventive health care over the years or access to health care when you have a problem, that's going to increase all sorts of medical risks, including the risk of developing dementia. And associated socioeconomic things as well, like poverty and lack of access to high quality food and jobs and so on and so forth. So wide range of kind of things that we would think about in the social determinants of health sort of domain of reasons why there might be a link between severe mental illness and dementia. There are other theories as well. There's kind of a neuroinflammatory theory that some people say with depression or bipolar disorder that there's actually some neural inflammation going on, and that in turn increases the risk of dementia. I think there's less evidence for that, but that's kind of an interesting thought. There's a construct called neuroplasticity, which is the ability of our brain to change, so when we learn, it's because we're able to make new connections, so there's a lot of evidence that people with severe mental illness, in particular depression, lose a lot of that neuroplasticity. Maybe that, in turn, then increases some risk of dementia. 

Chin: Well, thanks for explaining that, Art, because that really does showcase the complexity in this, in this intersection of our biology and the social determinants of health, possibly inflammation and these other mechanisms, and you did mention alcohol and I do want to move on to that. I know we could spend the entire show talking about alcohol and its relationship to dementia, but we are not going to do that here today. Instead, can you describe for us, first of all, how common alcohol use is in older adults? And then what exactly is that risk for developing dementia? Not necessarily specific disease causing dementia, but just dementia itself. 

Walaszek: Yeah, so it's a very complicated story. I bet you could ask 10 different folks in this area and get 10 different responses. I'll start with the things that I think we can all agree upon. So alcohol use is increasing in older adults, and this is not sort of fully understood why. It's possible that in general, not a big fan of generation generalizations, but in general, folks in the baby boom generation perhaps have different attitudes about alcohol and other drug use than prior generations, maybe even more positive attitudes about alcohol use. Bring with them, as they're becoming older adults, greater use of alcohol, and use that might be okay if you're in your 40s or 50s, but then puts you at risk if you're 70s or 80s and you're falling and you have memory issues and you're on a bunch of other medications and so on. So just total alcohol use is going up in older adults. At-risk alcohol use is going up. Then there's a subset of people who develop alcohol use disorder, where the alcohol use is clearly causing problems. There's impairment, people might become dependent on it, meaning they withdraw in the morning because they haven't had any alcohol for several hours, etc. So alcohol use disorders are unfortunately, we've been tracking this for 20 years, they've been generally going up over time. I think everybody can agree on that. I think the other thing everybody can agree on is too much alcohol is not good for the brain and is not good for cognition. After that, it gets more complicated, like how much is too much, for example, not entirely clear, although I'll give some suggestions in a moment. The other more controversial part, and I've seen sort of good evidence on both sides of this, “Is there some protective effect?” In other words, “Is there a safe amount you could drink in midlife that would reduce your risk of developing dementia later on down the line?” Again, I think some studies say yes, but I think there are other studies that really point out that essentially any alcohol use is less safe than no alcohol use in terms of developing dementia. If there is a sweet spot, and I don't know if there is, it's also not clear what that sweet spot is. Is it a drink a day? Is it a drink a week? Is it some other number? It's not really clear. There are national guidelines about this. So the NIAAA, which is the National Institute that has to do with alcohol use, recommends that for people 65 and over, they should have no more than seven drinks in a week, and I'll define drink in a minute, or three drinks in a setting. I personally think that three drinks in a setting is a bit much, and I generally recommend for folks who are over 65, who don't have memory impairment, who are not falling, who are not depressed or anxious, who are not taking medications that could interact with alcohol, that a drink a day is probably a reasonable amount. Not necessarily for any protective effect, but really just like if you enjoy a drink a day, that's probably okay unless you have one of this list of other issues. A drink is defined as 12 ounces of regular strength beer, 4-5% beer, 1.5 ounces of liquor, so 80 proof or 40% alcohol by volume, or 5 ounces of wine. Bear in mind, lots of beers are much more than 4-5% right now, including 9, 10, 12%, so the math changes accordingly. But that's how a drink is defined. My advice, if someone is worried about their memory, they should not be drinking. Or if they're having memory complaints or memory problems or certainly falling, they really shouldn't be drinking. I mean, alcohol is a nerve toxin. We know it kills brain cells. We want to hang on to as many of those brain cells as possible, so taking something that accelerates that process, if the goal is maintain cognition as long as possible, not fall, stay physically healthy, probably as close to abstinence as you can get is probably for the best. Now, there are other benefits. There are social benefits. People get together and have a drink. We've been talking a lot in the last couple of years about isolation and loneliness, so I don't want to underestimate the social value and even the meaning of the ritual of you and your best friend or you and your partner have a drink at dinner or whatever. There's value in that and it has to be balanced against the risk that I mentioned. 

Chin: Well, that was a very complete answer, Art. I thank you for that, and for my patients that are listening, I'm going to be directing them to this part of the podcast because I think you encapsulated everything that I have learned as well, especially this idea of a standard drink. Because we have a lot of home pourers, we have a lot of very powerful beers and wines that just have a lot more alcohol than when those standards were actually put together and shared publicly. We just have to be mindful and I appreciate the way you explain that. I do want to move on though, because I don't want to focus exclusively on alcohol, and I want to talk about the challenges in diagnosing someone with dementia who also has a chronic mental illness. So in my memory clinic, I find this to be quite challenging because it's difficult to know if the symptoms this person is experiencing is due to the mental illness or the medications being used, as you mentioned, to treat and manage the mental illness, or if this is a new process reflecting dementia. So what challenges do you see in your geriatric psychiatry practice and how do you know when to pursue a dementia specific evaluation? 

Walaszek: Well, you're exactly right about that being the challenge, and part of that is that we know that depression, anxiety, insomnia all affect cognition. That's true at any age. If a 25-year-old is really depressed, their memory is not going to be great. Their attention is not going to be great. Their executive function is not going to be great. You know, the mood disorders clearly also have cognitive effects. Similarly, if someone has schizophrenia or chronic psychotic illness. If you're hearing voices all the time, your attention is not going to be good. You're going to have cognitive issues in addition to the ones that I mentioned earlier. So there's this two-way street that takes place where psychiatric symptoms can result in cognitive impairment. Going the other way, we know that if you develop dementia, that also puts you at risk for depression, anxiety, hallucinations, insomnia, kind of a whole range of psychiatric issues. It can be difficult to disentangle that. The way I would think about that is, is there a change from before? And either that covers cognition and it covers functioning. It's possible that a person with bipolar or major depression or schizophrenia has had memory concerns for many years. The question is, “Is this different now?” In the last six months, year, two years, have you noticed a change in memory, language, decision making, etc. And the same goes for functioning. When you're really depressed, your functioning isn't good. When you're manic, your functioning isn't good. If you're actively psychotic, your functioning isn't good. But at baseline, is that functioning changing? Is someone now starting to have trouble with driving, with money management, with cooking, other activities of daily living, even though their psychiatric disorder is under pretty good control. If that's going on, then that would raise some red flags about, “Aha, maybe there is a new cognitive process going on,” and we need to evaluate that just like we would in a person without severe mental illness. 

Chin: We're not going to cover the dementia evaluation itself today, but I'm wondering if there are any additional aspects to the evaluation that are unique to people with chronic mental illness. 

Walaszek: Yeah. So, you know, the medications are a big component of it. We think about that anyway in our standard dementia evaluation. Are there medications that could be contributing to the cognitive impairment? And often the answer is yes. So then we would try to reduce or stop those. It's a little more complicated in people with chronic mental illness. Especially bipolar disorder and schizophrenia, people can end up on an awful lot of psychiatric medications at the same time, and those medications can have cognitive effects in and of themselves. They may be sedating. They may cause people to be kind of dulled out during the day, etc. And those medications may cause side effects that are in turn treated with other medications that then have their own cognitive side effects. So it wouldn't be uncommon for someone with severe mental illness to age and be on three to five psychotropic medications, psychiatric medications, not not to mention blood pressure, diabetes, cholesterol, all the rest of it. In that case, it isn't as easy as saying, “Oh, well, let's just get rid of the medication because that medication may be fundamental for keeping their mental illness in check and keeping them functioning, and their quality of life good,” and so on. So it's part of the evaluation. It's also part of the treatment challenge of it'd be good to reduce doses or maybe stop some of them, but which ones? I kind of think of it a little bit as a Jenga tower, which I pull out these blocks very, very slowly, and I can breathe a sigh of relief when one is out and the tower is standing. But I don't know that if I pull the wrong one out, is this person's severe illness going to decompensate then? With the aging process, people may not need as much of the psychotropic medication. Liver function, kidney function changes, the brain is shrinking. So psychiatric medications work by targeting receptors in the brain. If your brain is shrinking, there are fewer receptors, which means effectively you're getting more medication, it might make good sense to begin to trim some of those medications. With some psychiatric medications, we can follow blood levels, so we can see that. With most, we can't, so it is a tricky puzzle of trying to figure out which, if any, medication to recommend reducing. One other essential thing to think about in this context is about the risk of suicide. We talked about that a little bit earlier. It's one of the things that can arise in people with depression. It happens in bipolar disorder. Actually, bipolar disorder is our most lethal psychiatric condition with respect to suicide risk, and people with schizophrenia are at higher risk of developing suicidal thoughts and then dying by suicide as well. So you've got that in the background and now the person has developed cognitive impairment and maybe even being given a diagnosis of Alzheimer's disease or another dementia. What we know is that there is a slight uptick in suicide risk in the three to six months after being given a diagnosis of dementia. and then it declines after that. It suggests that a person, really anybody, but especially a person with a history of severe mental illness in particular, if they've had suicide attempts before or other risk factors, that that's gonna be a really critical period to give the person a lot of support, make sure you're available to answer questions, bump up their mental health treatment, etc, during that period around the time and immediately after the evaluation of dementia and potentially the dementia diagnosis. 

Chin: You've hinted to this already, so I'm wondering, once you have this diagnosis of dementia and chronic mental illness, what do you focus on when you think of treatment? I'm not asking for specific medications, but how do you approach this whole thing holistically, knowing you have two very serious conditions, two stigmatizing conditions? What should clinicians at this point be thinking about? 

Walaszek: Absolutely. Well, I would go back to the person with dementia themselves. What are their values? What are their goals? What's important for them? And then that should really drive the treatment planning. The general interventions would be things we would do with dementia anyway, which is look at substance use, alcohol, cannabis, other substances and reduce or eliminate those. Promote healthy habits around exercise, diet, regular social activities, regular exercise. Watch for any worsening of depression or other psychiatric symptoms and get those addressed. That can get tricky too. So you mentioned my first book, Behavioral and Psychological Symptoms of Dementia. So dementia can cause depression, anxiety, psychosis and so on. When someone has had those things before and now they have them again, Is it part of the dementia, or is it a recurrence of their old illness, or is it a combination of the two? That can be very difficult to tease out, and treatment gets complicated too, because some of the treatments we would use become more problematic in people with dementia, including warnings around risk of death and various other side effects. 

Chin: Along that thought, My next question relates to this, and we know how important and beneficial it is for people to have support, and in particular, professional counseling. So are changes needed if a person has both dementia and chronic mental illness, knowing that that executive function, perhaps the attention, even the memory could be impacted? Is there a change in how we approach this? 

Walaszek: Absolutely. This is an opportunity for me to share. While I've been talking about medications a lot, that's only part of the treatment of people with mental illness. I alluded to this when we're talking about schizophrenia. There's a model called assertive community treatment that was developed here in Madison, Wisconsin in the 1970s as a way of helping people with severe mental illness do well in the community and stay out of the hospital. That's mostly about case management, transportation, helping with job skills and so on. I alluded to that earlier. For depression, for mild to moderate depression, psychotherapy is evidence-based treatment. With mild depression and psychotherapy, with moderate, it's the combination of therapy and medications. For severe, psychotherapy gets a little trickier to do, and it's kind of more medication-focused. Anxiety disorders, actually therapy, a particular kind of therapy called cognitive behavioral therapy, that's the gold standard. That's what we recommend for anybody with an anxiety disorder. Psychotherapy is a very effective tool and it's effective all across the age range. All those same things have been studied in people over 65 and though there's less data. Those interventions work, too. They may just need modifications, and the simplest way to think about this is psychotherapy helps you learn. You learn new coping skills. You learn new ways of seeing the world. You learn new perspectives. It's about learning. Dementia is a disorder of learning. It's harder to learn new things. It doesn't mean you can't learn new things. It just means it's going to take more trials to learn something new. That means when we would do psychotherapy in someone with cognitive impairment, we've got to slow it down, more repetitions, try not to cover as much material in each therapy session, so it can still work, but may require some modifications to be effective. 

Chin: So Art, any last thoughts you'd like to share with our audience today? Anything else that you've covered in your presentations that you think would be important for us to know? 

Walaszek: Well, again, Nate, thank you so much for your interest in this topic. I think we're going to see a lot more discussion about this just in general as part of the aging population. I want to just talk for a moment, we touched on this a little bit, but about the stigma side of things. Folks who are aging, who have severe mental illness, who then develop cognitive impairment, are getting stigmatized from all different directions.  The term for that is intersectionality. But I tend to think of it as like layering on of stigma. A lot of stigma still regarding people with severe mental illness. Ageism remains rampant. Every day I sort of go to my favorite news sites and there's something that upsets me about, you know, some ageist comment being made about public figures, for example, that remains really rampant. And then you add on other things that people with severe mental illness may experience. Poverty and all the stigma associated with that. Lack of access to resources. Being from an underrepresented population like a sexual or gender minority or ethnic or racial minority. You've got kind of these multiple layers of stigma that people can then face, so I think what you're doing here helps get at that, you know, that people with mental illness are at higher risk of dementia, and we can detect that, and we can help them out. 

Chin: Well, thank you, Art. Something can be done, and hopefully those that are listening know this. As always, it's been wonderful to have you on Dementia Matters today, and I appreciate your wisdom and your advice here. Dr. Art Walaszek, geriatric psychiatrist from UW, I'm certainly going to have you on again. 

Walaszek: Thank you so much, Nate, and thank you for this wonderful podcast. 

Pre-recorded Dr. Nathaniel Chin: As a reminder, continuing education credit is available for this episode through the Interprofessional Continuing Education Partnership at University of Wisconsin-Madison. To claim credit, text this code: LULTOL at this number 608-260-7097. Again the number is 608-260-7097 and the text code: LULTOL. Your feedback is important to us. To complete an evaluation form for this episode, see the show notes.

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