Richard S. Isaacson, M.D., serves as Director of the Alzheimer’s Prevention Clinic, Weill Cornell Memory Disorders Program, and Director of the Neurology Residency Training Program at Weill Cornell Medicine/NewYork-Presbyterian Hospital.
Dr. Isaacson specializes in Alzheimer’s disease (AD) risk reduction and treatment, mild cognitive impairment due to AD and pre-clinical AD. His research focuses on nutrition and the implementation of dietary and lifestyle interventions for AD management.
This is part three of three of our interview with Dr. Richard Isaacson.
Click here to read part one.
Click here to read part two.
Jed A. Levine (JL): Acknowledging that it will take time to know if you’re truly preventing Alzheimer’s, can you expand upon the name of the Alzheimer’s Prevention Clinic?
Dr. Richard Isaacson (RI): While I go back and forth on this, I still feel comfortable with calling it the Alzheimer’s Prevention Clinic because we enroll people in trials and care for their family members with Alzheimer’s. It’s a holistic approach. By seeing families together, you can see a mom has Alzheimer’s and find manifestations in the daughter’s profile. The son may be more like the father. We’re learning an immense amount about the science, but also a lot about the psycho-social aspect of Alzheimer’s prevention.
As an example, we’re finishing our first study examining the first 100 patients of the Alzheimer’s Prevention Clinic. We asked them to do a comprehensive survey of where they were when they arrived and where they are now. We learn about their attitudes towards being a patient in an Alzheimer’s prevention clinic and learning about their genetic profiles. These are 30 to 70-year-old people from all walks of life. And what we’re finding is absolutely fascinating.
At some point we’re going to find a drug to either prevent or cure Alzheimer’s disease, and when that blockbuster drug comes out, we will be treating patients for primary and secondary Alzheimer’s prevention. There will be psycho-social and behavioral elements that are going to need to be understood. The good news about our practice is that we’re actually learning about this now.
JL: You’re studying it already?
RI: We are attracted to the science and fascinated by the psychology. We are confirming that when someone learns that they have an APOE-4 gene, their compliance goes up.
The REVEAL study taught us that when people first learn they have the gene, they are anxious. But after a year, that goes away. Even if they understand that having the gene doesn’t mean they will definitively get Alzheimer’s, knowing that they have the gene improves compliance with the recommendations. So, we’re learning about how to give this message.
The name of the clinic is the Alzheimer’s Prevention Clinic, but throughout our brochures and flyers, you don’t see the words “Alzheimer’s” and “Prevention” next to each other. We have a FAQ where we respond to the question, “Can we truly prevent Alzheimer’s?” The answer is no; we cannot definitively prevent Alzheimer’s and we are a long way from being able to do so. In the interim, our philosophy is to educate a person to take a clinically precise approach towards their own health, follow them, learn from them and, we believe, have a positive impact on their brain and body health.
This message is tough to deliver, so to get the right language, we did market testing, had focus groups, used internet messaging, and operated a Facebook page. I got yelled at when I used the words Alzheimer’s and prevention together. I hear things like, “My mom did everything right and she still got Alzheimer’s.” I’ve heard this over and over.
The problem is most people can do everything right and still get Alzheimer’s. But in my opinion, and based on the best available evidence, there is a subset of people who may be able to either delay Alzheimer’s long enough to be candidates for an effective therapy or simply outlive the onset. These people effectively prevent their Alzheimer’s.
That’s the reason to empower people to use a scientifically based, yet honest approach towards brain health. That’s why I’m still okay with the language. Today, although I still get tomatoes thrown at me, it’s much better than it used to be.
JL: Initially, I had a strong reaction. I asked “Who is this guy? Who does he think he is?”
RI: We’re very cautious about what we say, but today there is more information. In 2015, there was a study about exercise improving some cognitive function for some people in the early stages of the disease. Another group studied healthy people aged 65 and over who exercised different amounts each day, ranging from 25 to 55 minutes. The amount of time made only a modest difference, but everybody had some improvement in cognitive function or on their cognitive tests.
This goes back to your first question, “Why am I doing Alzheimer’s prevention?” I have four family members with Alzheimer’s disease. I’m completely biased. I want to prevent this disease like everyone else, but I’m also living it too.
JL: I’ve heard Dr. Reisa A. Sperling say similar things.
RI: She’s a trailblazer! You know, I am so appreciative for CaringKind’s willingness to have an open conversation about this. I want to be responsible in the message and communicate it the right way. The evidence is starting to show up, but we still have a long way to go. People don’t even know that there are Alzheimer’s prevention trials going on. Some people think of Alzheimer’s prevention as enrolling in clinical trials. But just the fact that someone can come to a place and learn about ongoing Alzheimer’s prevention trials is reason enough to have a clinic like this.
JL: How do people find the clinic and apply? Are you looking for more subjects or are you overwhelmed with subjects?
RI: In three years, we’ve grown from one to 12 staff members. We have two neurologists that see Alzheimer’s prevention patients, more than any other similar facility, but there are still only two of us. The clinic completely exploded. My colleague and I have a six-to-eight-month waiting list. We’re doing the best we can, but we need to hire more people.
When the A4 trial got going and people were unsure if they should enter, we saw a lot more patients. Now, because we are in the “big city,” we have a stream of patients and an influx of calls every time a brochure, new study, or news report comes out. As an example, we hosted two neuropsychologists from Puerto Rico. We shared our entire approach with them so they can build and implement the model. In Puerto Rico, the patient will most likely access the service through primary care, which makes a lot of sense.
JL: That’s where people should be getting their primary healthcare, through their primary care physician.
RI: Primary care is where the five vital signs, like pain, are examined. Cognitive health is a vital sign too. It should be the sixth vital sign. Primary care physicians are better suited to this work than neurologists. When that blockbuster drug finally arrives and we have to decide who gets it, maybe neurologists should be the prescribers, but for risk assessment and intervention, we need a variety of healthcare practitioners to handle the work.
I hope that this field takes off within a few years. Hopefully, we are laying the groundwork and can accelerate the timeline. Even if we can accelerate it a little bit, I’ll be satisfied.
JL: Some studies show that there is a relationship between sleep, duration of sleep, quality of sleep and development of Alzheimer’s disease. For example, there was a study about sleeping on your side. I’m a side sleeper.
RI: I’m a side sleeper too. The study was for mice, but it appears that sleeping on your side opens up the glymphatic system so amyloid can be more easily flushed out.
Sleep is really important. The analogy that I use for my patients is not perfectly scientific, but it’s a good way to explain it.
You can exercise, which is the only thing that we have in 2016 to definitively break down amyloid. Exercise busts amyloid. But, how do you get the amyloid out of the brain? Through sleep. Amyloid is basically taken out to the curb as we sleep through the glymphatic system.
There’s also findings about melatonin and research on variances between people who remember their dreams versus people who don’t. I see these kinds of things in my clinical practice, but I don’t understand the patterns yet.
This is an example of the biological principle of synergy; a combination of factors makes a difference. Nutrition plus exercise plus sleep. Then you add stress reduction. Then you add vascular risk factor modification. When you add all these things that have shown evidence to make a difference and are low risk, that’s the biological principle of synergy.
Last year, there was an article in The Lancet that said one in three cases of Alzheimer’s is preventable. That’s a big statement. If we can delay a stroke or a heart attack by six months, a year, two years, and can use the term prevention, I think there’s also encouragement to use the term for patients worried about cognitive decline. That’s the key.
JL: Thank you so much for sharing your thought on this very complicated subject. I know our readers, like me, have learned a lot.