AAIC Special Series Part 3:
Mild cognitive impairment (MCI) is an early stage of memory loss and cognitive impairment that can develop into dementia. While physicians have medications they can prescribe to manage the condition, many researchers and doctors are focusing on lifestyle interventions that could support a person’s cognition and address behavioral changes. Dr. Linda Lam joins the podcast to discuss her work studying mild cognitive impairment and preview her upcoming AAIC plenary talk on non-pharmacological treatments for MCI and dementia.
Guest: Linda Lam, MBChB, MD, professor, Chinese University of Hong Kong
AAIC is the world’s largest forum for the dementia research community. Register for the plenary events, which are free to the public with registration, at the AAIC website.
Learn more about Dr. Linda Lam on the Chinese University of Hong Kong website.
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Dr. Linda Lam Excerpt: I believe that non-pharmacological care could be and should be the integral part of a whole person's management for dementia.
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.
Dr. Nathaniel Chin: Welcome back to Dementia Matters special Alzheimer's Association International Conference series where we're previewing the plenary talks to learn more about the conference speakers and their work. I’m joined today by Dr. Linda Lam, professor of psychiatry at the Chinese University of Hong Kong and the Founding President of the Chinese Dementia Research Association. Her research focuses on the early detection and intervention for mild cognitive impairment and dementia, as well as biomarker evaluations and determinants of healthy aging. Her AAIC plenary talk focusing on non-pharmacological care, behavioral change, and MCI, will take place on Thursday, August 4th. Dr. Lam, welcome to Dementia Matters.
Dr. Linda Lam: Hi, Dr. Chin. It's my honor to join you at Dementia Matters today.
Chin: We're very excited to talk to you today. To begin, I'd like to know what got you interested in dementia research and the specific area of early detection and intervention.
Lam: I have always been interested in elderly medical care since my early career days. When I started psychiatric training years ago, dementia was not a popular diagnosis in the sense that there's nothing we can do. For example, we were taught, at that time, that Alzheimer's disease was diagnosed by excluding known brain diseases – is diagnosis by exclusion – which is unthinkable nowadays. So, especially for patients with dementia and behavioral problems, they were a big headache to most conditions regardless of what specialty they were in. Being a psychiatrist myself and training at that time, I naturally got interested into how to tackle these mental and behavioral symptoms associated with dementia. They look so difficult to treat but they are common problems. Even years back, but nobody take any interest in that. Gradually when I go more into psychiatric training and see more patients with dementia, it’s increasingly obvious that the person changes, the personality and the behavior changes a long time before obvious cognitive impairment. The behavior changes. I ask myself should they assess in early diagnosis and intervention, and I think so too. That got me interested in the assessment of behavioral symptoms and how it assists in early diagnosis. It remains a big question to most neurologists and psychiatrists that, if we could intervene behavior earlier would it make a difference in the disease prognosis for dementia as a whole.
Chin: That's an astute clinical observation that you had years ago in your training and in your career. I say that because only now am I seeing more and more discussion of behavioral symptoms as part of possibly the earliest symptoms of a dementia process, the changes in the brain. We even use terms now – mild behavioral impairment – I know that's more common in research. You were seeing this in patients and starting to see this trend. That's incredible. Do any symptoms jump out at you when you think about the earliest emotional or behavioral change?
Lam: Anxiety and apathy. We learn a lot about depression and how depression in mid-life is a risk factors for dementia, but more and more we got to see patients who were labeled as very well. Their cognitive function, especially the most highly educated one, remains to be a top scorer but then they are very anxious. A few years later you find that they got more cognitively impaired. And of course apathy, especially in those with mild neurocognitive disorder. This could be quite disturbing. The person knows that they lost interest but they just do not know why they lose interest in the usual activity and that was quite distressing, especially in the contact that you still could be very functional.
Chin: Well one of the themes of your plenary talk is non-pharmacological care. So within this category of therapy – non-medication care – what do you find to be the most compelling, as far as interventions go?
Lam: Indeed. I think non-pharmacological care would be the main theme of my talk. I believe that non-pharmacological care could be and should be the integral part of a whole person's management for dementia. This is not because we still do not have the creative drugs that would revert the cognitive function and neural degeneration, but also that the whole person lived a life not only for the cognition. Those feelings stay, where the person is joyful and how they function in the context of the community. So we need to think about strategies that both improve cognition, or even if it does not improve cognition a lot, it would improve a person's life from a different perspective. That's why we think non-pharmacological care should be a group part of dementia care. From a clinical perspective, from the conditions point of view, I think this type of care could range from structured lifestyle intervention, such as a leisure activity interventions and doing more physical exercise or changing your diet and sleep, to the more laboratory-based paradigm that specifically enhances cognition. It's a wide range of things. As there are many modalities, I am more into the lifestyle intervention such as physical activity as well as the non-physical cognitive function. It is hard to say which one is best, but I think that the primary consideration should be whether a person loves to do it or not. If he or she enjoys activity or training so much that he would carry it on month after month, year after year, this is the only reason that it would benefit the person. Even if a small cognitive gain or a person feels happy that they continue that for a long time, that should be considered as a useful intervention. I would like to give an example. I have an elderly lady – she is now with severe Alzheimer's disease. Years before that, many years ago, her son told me that she got interested in jigsaw puzzles and initially she could do the 500 jigsaw puzzles when she's suffering from mild Alzheimer's disease. Now she's suffering from severe Alzheimer's disease. Her son told me that she still plays jigsaw puzzles every day except that she does not fit the pieces well, but she's happy doing it almost two hours in the morning. So I think that's already a good cognitive intervention for her. Enjoyment should be the prime driver. (laughs)
Chin: I really appreciate that, and that's something I think people forget about because you don't want this to be a chore or something that you have to cross off your list. You want to enjoy this activity which inherently then benefits your brain and also the enjoyment benefits you, your overall well-being.
Chin: I wonder, in the list of modalities that you talked about, you know where does dance therapy or language – learning another language – fit. The reason I mention these is because you've done some research in those two categories. I think that's fascinating. If you could share with us, what you found or what you think of those two things?
Lam: Dance is a movement-based physical exercise from my perspective. Taking the physical part of dancing is balance-training and you have to move quickly so that you have to attain a sense of balance, and it’s muscle training because most of the movements require muscle strength and they strengthen the joints and the muscles. It’s quite aerobic, if you do the strain, dancing is a kind of aerobic activity. More importantly from the cognitive aspect, you have to coordinate the body movements with the music. It's a kind of cognitive training, especially for attention-training. One thing I think is very interesting in dance therapy is that a person, especially when they dance with partners, you have to anticipate and think about what the other partners are doing. It's a kind of empathy training. You have to think from the other's perspective, otherwise we get into chaos. This is also a fun tool for function training. Of course those who persist in dance therapy are those who love dancing. You can't hate dancing and do it for a long time. So this is a joyful activity. It's cognitive stimulation. It’s a physical exercise, so it’s the multimodality lifestyle interventions that we could think of. For the language – learning a foreign language is interesting. I once heard about a presentation about research on Indian elders because they have many different kinds of language in India. Those who speak three or four different Indian languages have years gained in terms of delaying outside of dementia. In our place in Hong Kong, the elders… most of them do not have a chance to learn English when they are young but they treasure this chance very much when we try to embark on English learning as a kind of cognitive training for dementia prevention. So it's very user-friendly. They think that they can take this chance to learn English which they think is right for their case of their life. I think the motivation and the positive experience that one could gain through this kind of cognitive stimulating activity definitely play a role in terms of its efficacy.
Chin: Another aspect of your research is early detection of cognitive impairment. What do you see are key barriers to early detection and what are some potential solutions that are being investigated?
Lam: I think it's increasingly difficult to detect early cognitive impairment, especially in the community. It’s not because the cognitive screening tools are failing but because the education level of the community dwelling elders have been increasing significantly. With high education attainment, conventional screening tools may fail to detect early and subtle cognitive changes. I guess this would be one of the important barriers to early detection especially in the next decades to come when most young ones actually have high educations. Our brains develop good compensatory strategies to cover up some mild cognitive changes in the face of early neurodegeneration. What are the potential solutions that we can think about? It’s perhaps to have more serial assessment of the healthy older adults and they can join in as healthy older adults to have serial changes. They may start off with a hundred percent score but the next year with a five percent drop – they’re still a top scorer – but the next year is a ten percent drop. This annual new change in the top performers would indeed ring a bell for further investigation.
Chin: Can you share for us some of the key themes in your plenary presentation?
Lam: One point I want to share is to bring out a discussion about the outcome measures for treatment for mild cognitive impairment or, even earlier, the subjective cognitive decline. We have very standard and reliable measures for dementia, interventions with dementia, like the cognitive function tests, behavioral tests. How well these clinical outcomes or cognitive outcomes would apply for those with mild cognitive impairment or even those with subjective cognitive impairment remain questions which are not easy to answer because these cognitive changes are still subtle in the early phase. It's very hard to detect any cognitive change that is functionally important for a person in interventions with my cognitive impairment. So we think about the other aspects such as behavioral improvement after some non-pharmacological intervention or even mental health measures. I mean the positive mental health measure after intervention because, after all, if you want a person to have persistent, sustained lifestyle intervention for cognition and functioning the mental health aspects should be considered. One has to like the intervention – like in the sense that so much so that they would continue this kind of intervention for months and years to come. So I would like to talk about mental health outcomes as part of the measurement outcomes for early intervention. The other aspect I would like to share with you is – which I'm very excited about as well – because I am soliciting the help of clinical dementia researchers all over Asia. These are my friends' networks and I invite them to share with me one slide about their non-drug interventions for mild cognitive impairment. Now I got feedback from Japan, Korea, Thailand, mainland China, India, and Indonesia. I think this is a great opportunity that I could summarize – I would not say that I could digest but I could summarize their work which is interesting and culturally friendly. I hope the rest of the world will like this Asia tour for non-pharmacological intervention.
Chin: Oh that's very exciting. We’ll have to tune in to hear that part of your presentation. I guess to end, what presentations or topics are you excited to listen to in this year's 2022 AAIC?
Lam: As mentioned before, I really like to learn more about apathy and there is a plenary talk on apathy and dementia. Apathy is so common and is so subtle but is so distressing both to the functioning elders and their caregivers. Even for those with moderate to severe dementia, apathy indeed is something that caregivers feel very stressful, especially when you want to motivate your family members to do something that they are happy with but they just are not interested. I'm looking forward to the talks on apathy and what insights that we can get to derive some interventions that can tackle apathy.
Chin: Well with that thank you, Dr. Linda Lam, for being on Dementia Matters for the special series with the Alzheimer's Association International Conference. I'm looking forward to hearing your presentation as well as the scientific session that you're leading.
Lam: Thank you. Thank you very much.
Outro: Thanks for listening to Dementia Matters. Be sure to follow us on Apple Podcasts, Spotify, Google Podcasts, or wherever you get your podcasts to be notified about upcoming episodes. You can also listen to our show by asking your smart speaker to play the Dementia Matters podcast. And please rate us on your favorite podcast app -- it helps other people find our show and lets us know how we are doing. Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health and the Geriatric Research Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private university, state, and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers. This episode of Dementia Matters was produced by Rebecca Wasieleski and edited by Caoilfhinn Rauwerdink. Our musical jingle is "Cases to Rest" by Blue Dot Sessions. To learn more about the Wisconsin Alzheimer's Disease Research Center and Dementia Matters, check out our website at adrc.wisc.edu. You can also follow our Facebook page at Wisconsin Alzheimer’s Disease Research Center and our Twitter @wisconsinadrc. If you have any questions or comments, email us at firstname.lastname@example.org. Thanks for listening.