#399 ‒ The evolution of Alzheimer's disease and dementia care: how early detection, personalized treatment, new therapies, and a multimodal approach are changing the landscape | Gayatri Devi, M.D.

View the Show Notes Page for This Episode https://peterattiamd.com/gayatridevi/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=260713-pod-gayatridevi&utm_content=260713-pod-gayatridevi-podfeed Become a Member to Receive Exclusive Content https://peterattiamd.com/subscribe/?utm_source=podcast-feed&gayatridevi%20=referral&utm_campaign=260713-pod-gayatridevi&utm_content=260713-pod-gayatridevi-podfeed Sign Up to Receive Peter's Weekly Newsletter https://peterattiamd.com/newsletter/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=260713-pod-gayatridevi&utm_content=260713-pod-gayatridevi-podfeed Gayatri Devi is a nationally recognized neurologist specializing in memory disorders, including Alzheimer's disease and related dementias. In this episode, Gayatri explains how to think about dementia as a spectrum—including Alzheimer's disease, vascular dementia, Lewy body dementia, and mixed presentations—while exploring the evolving biology of amyloid, tau, and neuroinflammation and why brain pathology does not always correlate with symptoms. She discusses her approach to detecting subtle cognitive decline in high-functioning individuals, the role of biomarkers and APOE4 testing in asymptomatic patients, the benefits and risks of anti-amyloid therapies such as lecanemab and donanemab, and strategies for minimizing treatment-related complications. Gayatri also examines why some patients may stabilize or even improve with individualized care, the overlap among different dementia syndromes, and the relationship between menopause, estrogen, and cognition—including her concept of menopause-related cognitive impairment. Finally, she discusses how advances in early detection, AI-assisted monitoring, targeted therapies, and precision medicine are reshaping the future of dementia care. We discuss: Gayatri's training and clinical focus, why dementia is a spectrum disease, and how personalized treatment is changing Alzheimer's care [3:45]; How Alzheimer's disease fits within the broader spectrum of dementia: diagnosis, biomarkers, and early pathophysiology [7:15]; The emerging role of neuroinflammation and viral infections in Alzheimer's disease [13:30]; Gayatri's comprehensive approach to evaluating cognitive decline in high-functioning patients [17:45]; Why forgetting names is usually normal and when word-finding problems become concerning [29:00]; Why women are at higher risk for Alzheimer's disease and how menopause influences cognition [33:45]; The promise and limitations of blood-based biomarkers for diagnosing Alzheimer's disease [40:15]; When preclinical Alzheimer's screening is appropriate and how to interpret positive biomarker results [45:00]; Case study: early Alzheimer's prevention in a highly-functional woman in her 50s with two copies of APOE4 [47:15]; Anti-amyloid therapies: balancing clinical benefit with ARIA risk using slow titration [51:45]; The aducanumab controversy, why it was discontinued, and why Gayatri would still choose it [1:00:00]; How anti-amyloid therapies cause ARIA, strategies for detecting and managing these complications, and how future therapies may improve safety and accessibility [1:03:30]; Two patient examples of exceptional responses to anti-amyloid therapy [1:12:30]; A multimodal approach to Alzheimer's treatment: combination therapy, MRI-guided TMS, GLP-1 receptor agonists, and more [1:15:00]; Vascular dementia, Lewy body dementia, and the overlap with Alzheimer's disease [1:21:00]; Lewy body dementia and Parkinson's disease: distinguishing two alpha-synuclein disorders [1:26:45]; Risk factors for Lewy body dementia and what remains unknown [1:36:15]; Treating menopause-related cognitive impairment: hormone therapy, brain rehabilitation, and balancing breast cancer risk [1:38:45]; How biomarkers changed Gayatri's perspective on the potential for Alzheimer's patients to improve [1:47:15]; The future of Alzheimer's care: AI, precision medicine, and personalized treatment [1:49:30]; and More. Connect With Peter on Twitter https://twitter.com/PeterAttiaMD, Instagram https://www.instagram.com/peterattiamd/, Facebook https://www.facebook.com/peterattiamd/ and YouTube https://www.youtube.com/channel/UC8kGsMa0LygSX9nkBcBH1Sg

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:11Dr. Peter Attia?

  Hey, everyone. Welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive, member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription.

• 0:54Dr. Peter Attia?

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• 1:04Dr. Peter Attia?

  My guest this week is Dr. Gaye Devi. Dr. Devi is a neurologist and psychiatrist specializing in memory disorders, cognitive neurology, and women's brain health. She is the founder of New York Memory and Healthy Aging Services and a clinical professor of neurology at Zucker Hofstra Northwell School of Medicine. Her practice spans the full spectrum of Alzheimer's disease, from asymptomatic high-risk individuals through advanced dementia, and she is known for a personalized multimodal approach that integrates biomarker-guided diagnostics, anti-amloid therapy, hormonal factors, and lifestyle interventions. I've wanted to have Dr. Devi on the podcast for a while now because the field of dementia is changing

• 1:49Dr. Peter Attia?

  rapidly. For a long time, Alzheimer's disease was viewed as really kind of a one-way decline, diagnosis with very little room for nuanced intervention. But she takes a very different approach, one that is highly individualized, focused on early detection, careful risk stratification, and matching the right combination of treatments to the right patient. In this episode, we talk about how to think about dementia as a spectrum, including Alzheimer's disease, but also vascular dementia, Lewy body dementia, and many other mixed presentations in between, as opposed to discrete diseases. The evolving biology of Alzheimer's disease, including amyloid tau neuroinflammation, and why pathology does not always map neatly

• 2:29Dr. Peter Attia?

  onto symptoms. How she evaluates high-functioning patients with very subtle cognitive changes, and how she thinks about biomarkers, APOE4 risks specifically, and testing asymptomatic people. We talk about anti-amloid therapies, which have become very controversial, although slightly less so today than when they were initially released, including lecanumab and dicanumab, their risks and benefits, and her approach to reducing side effects, including the most devastating side effects, which we talk about. Why some patients with Alzheimer's disease may stabilize or even improve with a personalized multimodal treatment strategy. The overlap between Alzheimer's disease, vascular dementia, and Lewy body dementia,

• 3:13Dr. Peter Attia?

  including why Lewy body disease is often confused with Parkinson's disease. The relationship between menopause estrogen and cognition, including her specific concept of menopause-related cognitive impairment. And finally, how early detection, AI-assisted monitoring, neuroinflammation, targeted therapies, and more personalized treatment may reshape the future of our dementia care. So, without further delay, please enjoy my conversation with Dr. Devi.

• 3:49Dr. Peter Attia?

  Gaye, so great to be with you today. Very excited to talk about this. It's a topic that we've discussed a number of times on the podcast, but unfortunately, there's always a lot to talk about here. And I think you're a physician that, of course, is near and dear to our heart in the practice. We co-manage a number of high-risk patients, and you know, I've just always been impressed by the way that you have taken a very personalized approach to managing this condition. But I just want to let folks get to know you a little bit better. So, you're both a neurologist and a psychiatrist, is that correct?

• 4:28Speaker 01

  That's correct. I mean, I'm boarded in multiple specialties: neurology, psychiatry, brain injury medicine, pain medicine, and behavioral neurology. But my subspecialty is really memory disorders, primarily from a neurological perspective. But all these other areas allow me to better handle people with cognitive impairment.

• 4:50Dr. Peter Attia?

  I'm just kind of curious, as you think about the evolution of your career, when you started, which is obviously not that many years ago, you're still quite young, to where you are today, what has been kind of the biggest shift in your understanding of the dementing conditions that we're going to talk about today?

• 5:13Speaker 01

  I think two things, Peter. One, that over the years of my practice, I've come to realize that pretty much all dementing conditions, and particularly Alzheimer's disease, can present variably, depending on the person who has the condition, and also depending on comorbidities. So, there really is a spectrum aspect to Alzheimer's and dementia, which people don't recognize. They think of it as an all-or-nothing disease, and that's not true. Much like autism, it really can span the spectrum from very mild

• 5:55Speaker 01

  impairment that doesn't get worse to severe impairment that kind of deteriorates rapidly. That's number one, that dementias are really a spectrum disorder. And number two, that what's really exciting to me is I feel like I'm in the field now, almost as if I was an infectious disease doctor who is practicing medicine before and after penicillin was invented, you know, or discovered, sorry. So, basically, that there are now so many different ways that we can treat dementias. We can personalize our treatment. We can give each person the

• 6:36Speaker 01

  right cocktail, if you will, of medications that would best benefit them. And we now have drugs that can alter the course of the disease, which is absolutely, to my mind, fantastic. We still have a ways to go, but I feel like we're on the threshold of something really grand.

• 6:56Dr. Peter Attia?

  Well, that's probably the thing I want to talk most about today, but I think there's some groundwork I'd love to lay, to bring the listeners along with us, before we get into both the treatments, but also the way in which you personally kind of manage some of the risks. So, we're going to talk about some of these risks, and then the various treatments around them. But before we do that, let's go back to kind of what you opened with, which is that we're not dealing with binary diseases. It's not like you have vascular dementia or you don't, or you have Lewy body dementia or Alzheimer's disease or you don't. Can you go a little deeper into this idea of what the spectrum of these diseases look like? And maybe, for the purpose of this first question, let's limit it just to Alzheimer's

• 7:40Dr. Peter Attia?

  disease. So, maybe define Alzheimer's disease within the broader context of dementia. I think there's probably still some people who use those terms synonymously, even though they're not. And then, within Alzheimer's, again, walk us through the different subtypes, if you will, and maybe how a clinician is able to arrive at that diagnosis.

• 8:00Speaker 01

  Right. So, dementia is the umbrella term. So, a dementation of the brain, and that means that there is loss of connectivity between the brain cells that results in a loss of function, and it's a progressive condition. That's dementia. And there are several different types of dementia, Alzheimer's being the most common. And what Alzheimer's is defined as is a loss of synaptic connections, synaptic connectivity, that results in a

• 8:38Speaker 01

  loss of function that is driven by the presence of extra neuronal amyloid plaques, intraneural or intracellular tangles, neurofibrillary tangles, and increasingly, what we now know to be inflammation in the supporting microglial cells and other glial cells of the brain substrate that cause cognitive impairment that progresses. So, the question is, how do you make this diagnosis in a person? And, you know, that's really difficult because you have to really

• 9:21Speaker 01

  be, have a high index of suspicion, particularly with people who are very intelligent, people who are very functional, people who are able to compensate very well, so that you can have someone who has moderate pathology and even severe pathology, and they can still perform very well in many areas because they have good brain reserve. They have a resilience in their brain that prevents the kind of cognitive and functional deterioration that someone who has less reserve and less brain resilience doesn't have. And there are many

• 10:01Speaker 01

  different subtypes of Alzheimer's disease, depending on the part of the brain that's affected. So, you have, you can have an Alzheimer's disease that primarily affects memory versus Alzheimer's that can affect more the visual-spatial system. So, it depends of the, on the area of the brain where the pathology tends to predominate. And it also depends on secondary conditions, comorbid brain conditions that are present, such as Lewy body disease, TDP43 pathology, or gerophilic brain disease, all of which can inform how the person presents. So, when you're looking at Alzheimer's disease, you want to look

• 10:46Speaker 01

  at, first of all, you want to establish that the person has these plaques and tangles. And that's something we can get into later, because there are two groups of thought on that. There are people who say, well, you can just have biological indices that say that a person, you can diagnose Alzheimer's just based on biological biomarkers alone, versus another group that says, well, no, you need biomarkers plus clinical symptoms. You need biomarkers plus functional deficit to make the diagnosis. But the biomarkers are really amyloid tau and increasingly neuroinflammation.

• 11:27Dr. Peter Attia?

  Okay, a few things I'd like to unpack there. But maybe I actually want to start with a more basic question, which is, we will get to obviously talk about APOE, the genotype, which is probably one of the most common genetic predisposing factors, although not the strongest. And maybe we can even spend a minute talking about the other genetic conditions that are more dispositive in their prediction of a person developing Alzheimer's disease. But pathophysiologically, what is the order of operations? Stated another way, what starts this process? Does it start with the inflammation? Does it start with the deposition of amyloid?

• 12:11Dr. Peter Attia?

  Does it start with the tangles? Is it different in every person? Is it different by location in the brain? Maybe talk us through that a little bit.

• 12:20Speaker 01

  So generally speaking, it used to be thought that really amyloid was the first abnormality that begins in the brain up to two to three decades even before the onset of clinical symptoms. But now we're beginning to understand that changes in the inflammatory pathways may predate amyloid deposition by quite some time. So it may be that first neuroimmunological changes, then amyloid, and then eventually down the road tau. And that ultimately causes synaptic dysfunction, where the synapses, the connections between the nerve cells,

• 13:04Speaker 01

  start to go awry and the person then develops cognitive changes. And that process takes decades. So the whole point, I think, with Alzheimer's and other dementias is if you can intervene early enough, even as early as your 30s into your 40s, by incorporating anti-inflammatory methodology, anti-inflammatory activities into your lifestyle, then perhaps you can prevent the whole cascade from being triggered.

• 13:37Dr. Peter Attia?

  On that topic, one of the things we've become much more aggressive in our practice around is managing two viruses in particular, herpes simplex virus and varicella zoster. Now, the data appear much, I think the data appear stronger for the management of varicella zoster through the use of a shingles vaccine in individuals who have been previously infected, which of course, at this point, by the time you're 50, is virtually everybody. And so presumably, the observations that we see that there's a significant reduction in the risk of dementia and Alzheimer's disease in people who have been vaccinated for shingles

• 14:21Dr. Peter Attia?

  and people who have HSV treated suppressively versus those who don't. You know, the thinking is that this works through an inflammatory pathway. What can you say about any of that?

• 14:33Speaker 01

  Yeah, I really think there's something to be said. I think neuroinflammation is going to be the new frontier in terms of how we're going to deal with and even prevent entirely Alzheimer's disease. I have, for example, like two patients in my practice where the sibling is riddled with Alzheimer's, but these two patients have severe neuroimmunological disease that they've been treated with aggressively for decades. And neither of them have a lick of Alzheimer's pathology. It's quite impressive. So I think there's, there's something to be said for, you know, this kind of treatment with an exposure to various viruses that have a predilection for the brain

• 15:18Speaker 01

  and the central nervous system, like the herpes zoster virus, for example, that causes shingles.

• 15:24Dr. Peter Attia?

  Sorry, just to clarify the case you presented there. Are you saying you have three siblings that are genetically comparable? I mean, meaning like they would all have the same APOE phenotypes across them? They're three fours or four fours or whatever. One of them has disease. The two that do not have a deficiency of their immune system that renders them less susceptible to mountain immune response?

• 15:47Speaker 01

  So I have two pairs of siblings.

• 15:50Dr. Peter Attia?

  Ah, okay.

• 15:51Speaker 01

  So in each of which, one sibling has significant Alzheimer's and the other sibling doesn't, which is particularly remarkable in one case because that person has two copies of the APOE4 allele, which puts them at higher risk. In fact, definite risk for developing Alzheimer's. And that person doesn't even have any amyloid, not even a touch of amyloid in their 70s. So it gives you pause. It makes you think, well, what is it about this person that protects them?

• 16:24Dr. Peter Attia?

  And are you saying that they have a known immunologic condition that is reducing inflammation? Or are you saying that's the hypothesis potentially?

• 16:33Speaker 01

  That's the hypothesis. The hypothesis is, and the fact that they've been treated with various drugs that somehow modulate the immune system may have had maybe factors here. Again, it's speculative, but it's certainly worth thinking about.

• 16:50Dr. Peter Attia?

  Yeah. The other thing that I would say that lends some credibility to this argument, and again, unfortunately, we're largely stuck relying on epidemiologic data as opposed to clinical trials, although there are trial data on some of the vaccines, is the relationship between gingival health and dementia, which again, points to this idea that you have an area that is in very close proximity to the brain. And, you know, as anybody knows who's listened to our podcasts on dental health, when the gums are inflamed, it wreaks havoc on the body through an inflammatory pathway. And so the brain would obviously be highly susceptible to that. So again, I think all of this makes sense.

• 17:31Speaker 01

  Yeah, I totally agree. And to your point, even the entire gastrointestinal system, you know, the internal lining gets replaced, what, every two weeks? The entire lining does? So you've got to think what happens in that process and how that drives, you know, that changes with different immunological conditions.

• 17:51Dr. Peter Attia?

  So talk to me about how you evaluate a patient. Let's maybe take a step back and talk about your practice. So are patients coming to you more commonly being referred by another physician? Are patients coming to you directly because they find out about your center? And they say, look, I, you know, me or a loved one are concerned about some evolving symptoms. But basically, how are patients finding their way to you? And what is your process of evaluation?

• 18:17Speaker 01

  We have, I've been in my practice on the Upper East Side for 26 years. So over this time, there's a large referral base of physicians who refer to me. I also have kind of developed a niche in terms of the evaluation and treatment of physicians and other professionals. So they seek me out. They read an article in a journal or something along those lines. And then, of course, referrals through families and friends. The one thing I will say about our practice is most of our patients are highly functional. They're still working, many of them, and they want to stay working. And my great joy in my, in these years

• 19:01Speaker 01

  is that I've been able to help them achieve that goal, to be able to stay functional and useful to the society and also have a sense of agency for themselves. So the thing, the challenge with all these patients, especially the high functioning ones, is that they are extraordinarily, their brains are extraordinarily smart at compensating. So a lot of the testing that we do has to be fairly rigorous in order to uncover the problems that such patients might have. So if you did like what people routinely know, which is the minimetal status exam or the Milka exam,

• 19:45Speaker 01

  many of these patients score a 30 or a 29 or a 28, well along into their condition, even 10, 15 years into their condition, because they are so adept. They have such great cognitive reserves. Right, what do I mean by cognitive reserve? The ability of the brain to make, to maintain a large number of connections and to be resilient to disease such as Alzheimer's. So once we put them through, so first of all, we do a very meticulous general history, including history about immunological conditions, past exposure to shingles, things like that, a family history. And then after that, decide on the kind of testing we want to do,

• 20:30Speaker 01

  which often involves a cognitive testing, which takes several hours. We often will look at the electrophysiology of the brain to see if there's any evidence of early slowing. Look at brain blood flow using transcranial Doppler to see how much blood flows through different areas of the brain. We will do specialized exams, imaging exams such as MRIs, using special techniques so that we can evaluate the different brain regions, such as the hippocampus, the parietal lobes. So we can see if there's differential changes there, early changes. And oftentimes, especially here in New York, we're, we're able to do amyloid scans and people that we're worried about,

• 21:15Speaker 01

  and tau scans, which measure brain levels of tau, which is the other abnormal protein that's associating Alzheimer's. And sometimes we will also do what are called DAT scans, which are scans looking at dopamine levels in the brain, which also help us to differentiate if there's another process going on. So it's a fairly rigorous series of tests that's tailored to each individual person. And of course, laboratory testing, looking at APOA, APO little b, inflammatory markers, and obviously the APOE genotype. And certain patients where there's a history, family history of early onset Alzheimer's, we do do early onset genetic screening

• 22:00Speaker 01

  to see if there's a particular gene that's abnormal.

• 22:03Dr. Peter Attia?

  How routine is the use of a lumbar puncture? Is that something you would do in everybody? Or have the, has the robustness of the current blood-based biomarkers for AB40, 42, and PTOW displaced a lot of the need for lumbar puncture?

• 22:19Speaker 01

  So I am kind of, I think I'm old school with the blood-based biomarkers. I definitely think they are the future, but I'm not sure they are already the future. I don't, I feel that they are standardized against amyloid, for the most part, amyloid scans. And I'm of the opinion that they would probably need to be standardized against both amyloid and TOW, because so many of us in our 70s and 80s have amyloid and will never develop Alzheimer's. So I tend to, pretty much in anyone that I'm concerned about with Alzheimer's,

• 23:01Speaker 01

  I will do either TOW and amyloid scan or a spinal tap. The advantage to the spinal tap is it's less expensive, and you also are able to detect very early changes in TOW, whereas the TOW PET scans traditionally don't really pick up early changes in TOW. The disadvantage, of course, is no one wants to get a spinal tap. Although, may I just say that all the women who've had epidurals to have children have effectively had reverse spinal taps. You know, they've had anesthesia injected into their spinal cavity.

• 23:40Dr. Peter Attia?

  That workup sounds incredibly extensive. On average, since you're managing this as patients who are outpatient, you can't do everything you just said on a day, I'm imagining. So is that, for a motivated patient, is that a week, two weeks' worth of interventions?

• 23:57Speaker 01

  So we have patients come in from around the world or from different parts of the country, and they're just here for testing and an evaluation. And we're able to pretty much schedule everything over a two- to three-day period.

• 24:12Dr. Peter Attia?

  Okay, that is an exhaustive list of tests. I'd love to kind of walk through the contours of how you piece together results and start to come up with what the archetypes are. So in other words, once you have all of those tests back, how do you start to say, this is the pathology? So let's call it by disease. So I think you're on an Alzheimer's pathway. I think you're this far along on the pathway, and I think it's of this variety. Does what you see in one snapshot give you a sense of velocity? Or can that only be determined over a time course, where you repeat the evaluation a year later, look at the change,

• 24:57Dr. Peter Attia?

  and say, this is a slowly progressing versus a rapidly progressing condition? And basically, how do you take that information and then create a treatment plan?

• 25:08Speaker 01

  That's such a great question. You have to marry the symptoms that the patient has, the time period over which the symptoms have occurred, how old the person is, their comorbidities, whether it's high blood pressure, obesity, cholesterol, high cholesterol, and other brain comorbidities. For example, how many strokes they've had, where these strokes are located in the brain, which occurs in quite a large percentage of patients with Alzheimer's as they have concomitant cerebrovascular disease. And then you look at the test results.

• 25:52Speaker 01

  How many copies of the APoE4 allele do they have? Or do they have a pre-sinalon 1 mutation, which is 100% associated with Alzheimer's, usually early onset Alzheimer's disease? You also want to look at their cognitive scores to see, is this person has an overall intelligence at the 99th percentile, but their language scores, their ability to come up with words, is at the 10th percentile? This is somebody I'd worry about, because it means that they're progressively losing their language skills, and they're having trouble communicating. And let's say they're working in a job as a lawyer, then it may affect how well they're going to be able to function.

• 26:35Speaker 01

  And that's one of the ways I assess, in a single time point, how much of a change has occurred. So someone who's overall ability at the 99th percentile, visual spatial skills at the 10th percentile, language skills at 10th percentile. I worry that this person's declined quite a bit, but they're compensating overall. And maybe the next, the following, the ensuing year, might be a year where they're losing quite a bit of function. So this might be someone where you want to be more aggressive about treatment. You have a patient who's having problems with language, and they have, just in that area, their blood flow is much reduced, or they have some slowing in their EEG,

• 27:18Speaker 01

  which is worrisome, even though they look clinically fine. All those things go into, all those different facets of their evaluation, go into my final determination of how much of each condition. Often, it's very rare that the person just has primary Alzheimer's alone. They'll usually have Alzheimer's plus, Alzheimer's plus a little bit of stroke, Alzheimer's plus a little bit of hydrocephalus, Alzheimer's plus a little bit of TDP43 pathology. So you want to kind of put that all together and see how much each area is being affected. Interestingly, if it's only memory that's being affected,

• 28:00Speaker 01

  that's actually a better prognosis for patients than if it's primarily language that's being affected, because we have data to show that the trajectories, the rate of progression, varies across, depending on where the pathology is. And then I'm not, I'm one of those people, I think, who is very, very, very averse to staging Alzheimer's. I am not, people often will say to me, well, what stage is this person in? And I usually say, listen, this person is at stage zero as far as their ability to communicate. But maybe in memory, they're at a stage three or four. And maybe in language, they are in a different stage.

• 28:45Speaker 01

  So you really want to look at the person in all their different functional domains and stage them on their different domains. That helps you better than just giving an overarching stage, which I find to be very reductionist, simplistic, and does a disservice to both the patient and the family.

• 29:06Dr. Peter Attia?

  I want to ask you a question that I am positive you get asked every time you go out and someone finds out what you do for a living, which is, what explains the fact that I might be seemingly in perfect neurological health, and yet I find it very difficult to remember names of people who I know? And I don't mean like know very well, like my wife or my kids. But like, a person who I've met 30 times, I might see them for the 31st time, and it might take me a full minute to remember their name. So people ask me this all the time, because they experience it. And truthfully, I observe it in myself a number of times. And it's not just the name of an individual.

• 29:51Dr. Peter Attia?

  It could be, I don't know, like the name of a city or something like that. It just happened to me the other day. I couldn't remember Ibiza. I was like, what is that place in Spain again where everybody goes to party? And it literally took me, it felt like an hour. It was probably 15 seconds, but it was an eternity to come up with Ibiza. Like, I don't know how I could forget something like that. So again, I don't believe that I have Alzheimer's pathology, but what explains this phenomenon of occasional delays in acquisition of names?

• 30:31Speaker 01

  This is, you're right, one of the most common questions that I get asked, and one of the most common requests. Will this treatment help me remember better? Particularly names. And I always say, get used to calling people darling and dear. Become more southern, you know? Because the truth is, names are inorganic bites of information. Our brain is trained to remember things organically. So a name is really a neologism. It's a made-up thing. It doesn't have very much meaning. And we're now, particularly in modern times, obviously inundated with names. Whereas 100 years ago, there were very few names that one had to remember.

• 31:16Speaker 01

  There are certain people who have a proclivity for remembering names. Politicians, for example, someone you might know who never forgets a name. But the vast majority of us, our brains are not meant to remember an endless amount of names. We really maybe, I mean, some people speculate that maybe we're only supposed to remember 150 names, which is a very small amount. I would say that the majority of us have access to most names, and it will, it's not, to me, a viable thing to try to recover as we get older, because it's an, it's an effort that I think is doomed to failure. The other issue, which I think is more problematic,

• 32:01Speaker 01

  is the ability to recall common nouns. To remember to call something a chair, to say, well, that's a book. I want to know the five different ways you can say green. You know, chartreuse, tau, tau, hunter green, et cetera. Those kinds of things, if you're beginning to have trouble coming up with finding words for that, finding words is supposed to trouble finding names. That becomes more of a problem, because that kind of memory... Is much more housed in the part of the brain which deals with facts as opposed to names, which I think unless they're well rehearsed, like the names of your family

• 32:45Speaker 01

  members are much more episodic, their names, their names are more like episodes, triable, things that happen that have a specific time and place. What did I have for breakfast? What did I eat yesterday? What color was the jacket of the person I saw two days ago? None of those things matter. Our brains are designed to forget most of the things we're exposed to most of the time because that's how our brains function. And all these episodes, all these times where we have little micro memories on a daily basis, millions of micro memories, if we kept them in our brain, we wouldn't be able to function. So

• 33:27Speaker 01

  evolutionarily, we're designed really to forget most names and most episodes.

• 33:33Dr. Peter Attia?

  That is very reassuring to hear because even though that has been my intuition and that is how I have generally counseled patients when asked this question, there's always a tiny part of me that gets worried when I can't remember one of these names. Let's talk a little bit about now the evolution of treatment. Actually, no, no, there's one question I want to ask you about before we get there. We haven't alluded to it yet on this podcast, but it's been discussed on other podcasts and we've written about it. And I think many people listening may be familiar with this fact, but there is a significant difference in the prevalence of Alzheimer's disease between men and women.

• 34:15Dr. Peter Attia?

  There are lots of speculations as to what those are. I have my own thoughts. I'd like to hear you sort of provide your views on maybe what could be driving that and anything else that is different beyond just, you know, the top level prevalence, right? There must be some biological or nuanced differences in presentation and things of that nature as well.

• 34:36Speaker 01

  Right. So, um, you know, let's not forget that compared to 150 years ago to now, our life expectancy has nearly doubled. You know, we've gone from an average life expectancy of 50 plus, 50, 52 years to now 70, late 70s, early 80s. And women 150 years ago generally were dead by the time they reached menopause, which is a time period when we stopped making estrogen. And we now know that estrogen receptors co-localize in the brain, particularly in different parts of the brain that deal with memory, like

• 35:15Speaker 01

  the hippocampus. And estrogen, the presence of estrogen drives and keep drives synaptic sprouting in the hippocampus. Dominique Turan-Alarand at Columbia did some of the early work in this. And Barbara Shirin at McGill did quite a bit of work in terms of what happens to women who go through surgical menopause, who've had, you know, who suddenly stopped making estrogen and their deficits and memory deficits, they start to have trouble with short-term memory, they have trouble with executive function, they have trouble with recall, with word finding. This looks identical to the early stages of Alzheimer's disease.

• 35:59Speaker 01

  So imagine someone in their 40s who may not realize that they're going through menopause or perimenopause because it's a very gradual process and they start to notice these changes than they can. And I've actually had this, I have patients in my practice who've been misdiagnosed with Alzheimer's disease and other dementias, who really only turned out to have menopause-related cognitive impairment where they have findings that are identical to what you see in early Alzheimer's disease that are objectively seen and that can be treated with hormone replacement. And if that's not possible, with various other interventions.

• 36:42Speaker 01

  Now, why is it, is it because of this lack of estrogen for the pretty much half their lives or a third of their lives that women are at higher risk? That's possibly one reason. It could also be because men die quicker from cardiovascular disease than women do. Women tend to survive more after cardiovascular insults. And therefore, whenever you have any kind of risk factor for cardiovascular disease, that also puts you at higher risk for Alzheimer's disease. The two conditions are so intertwined that years and years ago, in 2002, there was a paper that said, is Alzheimer's stroke, published in the

• 37:26Speaker 01

  journal Circulation, because if you look at the risk factors for Alzheimer's, every single one is also a risk factor for stroke and cerebrovascular disease. So women surviving past a time period where men die may also put them at higher risk for Alzheimer's. There's certainly a huge difference in immunological susceptibility to illnesses between men and women. There's a big difference in multiple sclerosis risk between men and women. There's a big difference in various other rheumatological conditions between men and women as lupus, erythematosis. So there may be immunological factors that we don't yet know that are, that are driving the higher risk in women. Reason being, and of course, people always

• 38:10Speaker 01

  say, well, women live longer, maybe that's why they're at higher risk. But we do know that even when you adjust for that increased, you know, life expectancy of women, they still are at higher risk. And the other interesting thing about women who present with Alzheimer's who have con is that they present differently. Women often will present with depression. They present with withdrawal. They often have more language difficulty problems than men do. Men present more often aggression with agitation. And so the presentation is different as well.

• 38:47Dr. Peter Attia?

  And what about the pathologic findings when you get right down to the assessment? If you took a man and a woman who would ultimately turn out to both have Alzheimer's disease, are you going to see differences in the patterns of amyloid versus tau versus any of the other markers that you're looking at as sort of standard markers?

• 39:10Speaker 01

  Generally speaking, not, Peter. Generally speaking, it's very hard to differentiate between the sexes based on the biomarkers or based on the differences in testing. But certainly, I mean, in terms of their presentation, I would say very strongly that women are far more likely to present with depression. And also, women who present with Alzheimer's tend to generally have gone through earlier menopause, tend to generally not have been on hormone replacement.

• 39:42Dr. Peter Attia?

  Yeah. And unfortunately, as we sit here recording this in 2026, we're still sort of dealing with that problem because you again have that generation of women I refer to as that lost generation that were with, you know, denied HRT following the WHOI in 2002. And so these are probably the women that are coming fully into the consequences of that at a higher rate because these are women that would now be in their 70s, having never had hormone replacement therapy, which again is, I'll get off my soapbox before I even get on it on that topic. We didn't actually, maybe just for the sake of completeness, finish the swing fully.

• 40:26Dr. Peter Attia?

  My bad, I took us away from it. On some of the top level biomarkers. So we mentioned them, but maybe give folks a sense of what you're looking for. So I think people nowadays, meaning patients themselves, are even requesting, hey, you know, doc, can you look at my AB 4240? Can you look at my P tau 217? Can you talk about the most common commercially available validated assays and what the levels mean? And, and also I'd like you to, after that, give us your point of view on the utility or futility of testing asymptomatic people.

• 41:04Speaker 01

  May I talk a little bit about the differences in diagnostic approach here?

• 41:08Dr. Peter Attia?

  Absolutely.

• 41:09Speaker 01

  Okay, so I actually tell you a story. I I saw a patient in the early part of last year who just had, you know, is a high functioning man who had in his seventies, kind of vaguely wasn't feeling well, ended up seeing a neurologist who I really respect at an academic center here in the city and got tested for, he actually happened to get the Quest testing for AD detect test to see, and it turned out he had abnormal levels of A beta forty-two and therefore was diagnosed with Alzheimer's by this neurologist and he came to me for a second opinion.

• 41:54Speaker 01

  My feeling was, you know, after talking to him, I wasn't really convinced that he had really cognitive impairment. I thought he felt a little slow, a little sluggish, maybe there were physical issues. But be that as it may, we did amyloid scan and the scan was negative. So for about three weeks, he had thought he had Alzheimer's. He didn't have Alzheimer's, just based on the scan alone. So I'm saying this as a cautionary tale to say that you want to be careful making a diagnosis of Alzheimer's with just the blood tests alone. I mean, there are certain blood tests, the the Lumi pulse blood test, the percividy

• 42:33Speaker 01

  blood test, the Quest AD blood test, the C two N assays, but all these are generally, all the blood tests are standardized against, for the most part, I think there are a couple that aren't, but the ones I mentioned are all standardized against amyloid beta pathology on PET scan.

• 42:55Speaker 01

  So because amyloid is present, so if you take all all people in their seventies, community dwelling people, and you image them, about twenty-five percent of us will have amyloid in our brain. If you take people in their eighties and you image them, about thirty-plus percentage of us will have amyloid. And by the time you get to ninety, about forty-four percent of us will have amyloid without symptoms, living in the community. So if you're going to standardize a blood test and say, this blood test is sensitive for picking up Alzheimer's and it's specific for Alzheimer's, in other words, when it's

• 43:37Speaker 01

  positive, it means it really is Alzheimer's and not another condition, but you're validating it against an amyloid PET test, PET scan, you see my problem there is that because amyloid is positive in so many people as we get older, many of us without any clinical symptoms, what does this really mean? And so this is now a critical juncture, I think, in terms of how we diagnose Alzheimer's because there are two groups that have different approaches to diagnosing Alzheimer's. That is the Alzheimer's Association Criteria for Diagnosing Alzheimer's, which diagnoses

• 44:17Speaker 01

  Alzheimer's primarily based on the presence of amyloid, whether it's in the blood, whether it's in the brain. And there's the International Working Group, which is mostly European, but international, you know, member of the National Institute of Aging is a part of it, a few American major centers are a part of it as well. That group feels that there are too many people who have amyloid so that when you make a diagnosis, you really want to be sure that you have amyloid and tau and symptoms. So it's a clinical biological condition rather than a primarily biological condition.

• 45:00Speaker 01

  So I'm I'm careful about testing people who are asymptomatic unless they have a family history. So for example, I have a young physician in her fifties, both her parents had Alzheimer's, confirmed Alzheimer's, and she has two copies of the four. She's somebody where you really want to do testing, even though she has no symptoms, right? So and she turned out to have amyloid in her brain and she's being treated to clear the amyloid. So there is, I think, a role for preclinical testing in people who are at high risk, but the vast majority of people, we should be careful. And if the blood tests are positive and it's surprising, you may really want to get further

• 45:43Speaker 01

  testing to confirm the diagnosis because otherwise, as the International Working Group very eloquently put it, you have a large population of, quote, patients in waiting, unquote, people waiting to become patients, but maybe in the process, changing their whole approach to living. You've got to be careful.

• 46:03Dr. Peter Attia?

  Yeah, this is, to me, what separates this type of screening from cancer screening. Obviously, I'm very vocal about my view on early and aggressive cancer screening, and I certainly take a lot of criticism for it, but I find it very easy to defend the position, and I won't do it now. However, I think the type of screening you're describing is fundamentally different, not only because of the pre-test probability, but because of the implications of what to do about it. And so I think your approach makes a lot of sense. And unfortunately, yeah, go ahead.

• 46:39Speaker 01

  Just to go back to your cancer analogy, when PSA screening first came out, you know, a while back, the incidence of patients being diagnosed with prostate cancer just rose dramatically. And it was only a few years later that we were able to approach it in a more nuanced way and understand that PSA levels rose as we get older. So you really want to plug all the factors and rather than just knee jerk, oh, high PSA equals prostate cancer, you got to figure out age, et cetera. And similarly, I think we will probably arrive at a more nuanced approach to the presence of amyloid and equating that with a diagnosis of Alzheimer's disease.

• 47:24Dr. Peter Attia?

  So let's talk about the patient you just mentioned, only in the sense that it's a it's a great foray into maybe something that is is not the standard way we would treat. So so the example you gave is a highly functional woman in her fifties who carries two copies of the E four gene. And again, I I think just maybe for the sake of ensuring everybody is familiar with what the statistics are, if you're carrying two copies of the APO E three three gene, so if you're the wild type, you're, and you don't have a particularly noteworthy family history, what is your lifetime incidence as a male and a female for developing Alzheimer's disease?

• 48:07Speaker 01

  I'm going to let you come up with those numbers.

• 48:10Dr. Peter Attia?

  Okay.

• 48:13Dr. Peter Attia?

  No, I I mean, I think I think I think for, you know, it's in the ballpark of, gosh, I I don't even know anymore. I would, I was going to say it's probably about six percent for a man, ten to twelve percent for a woman, if you're a three, three.

• 48:26Speaker 01

  Yeah.

• 48:26Dr. Peter Attia?

  But it could be a little less than that.

• 48:28Speaker 01

  Yeah, yeah.

• 48:29Dr. Peter Attia?

  Now, that said.

• 48:30Speaker 01

  For me, yeah. The way I think about it is I say, if you have two copies of the four, four, that kind of is akin to you having BRCA, the BRCA gene for breast cancer. So it increases your risk by sixty percent as opposed to the wild type.

• 48:45Dr. Peter Attia?

  So so so this woman has two copies of the E four gene, which again is not deterministic the way the P C N one, P C N two, or A P P genes that you loosely referred to earlier may be closer to deterministic. But again, it is a heavy, heavy risk modifier. And she's totally fine, but she's saying, look, I I don't want to wait until I'm not fine. So is there something we can do? And of course, everything is predicated on the belief that the answer to that question is yes. If the answer is no, then why would we do anything about this, right? But the answer is yes. So she comes in, did you go straight to the amyloid brain scan? Or was that just the first thing that came up positive in the suite of testing that you did?

• 49:28Speaker 01

  That was the first thing that came up positive in the in the test. Actually, she was a person where we did a spinal tap. So the level of amyloid in the brain was determined by the presence of low amyloid because most of it is getting deposited so that there's very little in the spinal fluid amyloid. And she also had tau that was kind of borderline and she had two copies of the four. And, you know, this is very important, actually. People will come to me all almost every day who is a new patient and says, oh, you know, I have a family member with Alzheimer's. And I always ask them, how was that Alzheimer's diagnosed? Was it diagnosed by autopsy? And the answer is almost never, yes.

• 50:13Speaker 01

  And up until two thousand and seven or eight, when we had the spinal tap, we really had no way of diagnosing people antemortem before death. So whenever people say they have Alzheimer's, I actually, in my family history, write down that the person has a family history of dementia, but we don't know what type it is because most often they may not have had Alzheimer's. But in this physician's case, because I also happen to take care of her father, I know that he really did have Alzheimer's because we've done all the tests, the amyloid and the PET scan. And the mother, who had died, did not have an autopsy, but most likely had Alzheimer's as well, based on her presentation.

• 50:54Speaker 01

  So in her case, even though she did very well overall, she may have had a couple of areas that I was not quite happy with on the cognitive scores, you know, things that gave me pause, her language wasn't quite as fluent, maybe there were a couple of areas where her memory could have been better for a physician compared to her overall ability, which was quite high. And therefore, we opted to start her on a whole slew of preventive treatments to help her reduce weight. She was, she went on GLP one, but she also went on a monoclon antibody to remove the amyloid that was beginning to build up in her brain.

• 51:35Speaker 01

  And I think that was something that I was very excited to do with her, that she was very excited to embrace because now there was a possibility that we could change her destiny, you know? And and that's really the kind of thing I find wonderful.

• 51:52Dr. Peter Attia?

  Okay, so let's let's talk about these anti amyloid therapies because they're a little bit of a mixed bag. In fact, I don't know the order, but was aducenumab the first one that was approved?

• 52:05Speaker 01

  Yes.

• 52:06Dr. Peter Attia?

  Okay. And gosh, it's it's hard to believe how fast time has flown, but I want to say it's been, was this pre, this is probably about six or seven years ago?

• 52:16Speaker 01

  So aducenumab, I can tell you exactly when. Aducenumab was approved in July of twenty twenty-one.

• 52:24Dr. Peter Attia?

  Oh, wow. It was post COVID. For some reason, I thought it was pre COVID, but but it was a very controversial approval in the scheme of things because. There was an advisory board to the FDA that recommended against approval. I'll let you explain why. The FDA decided against, entirely within the purview of the FDA, to go against its advisory board, but it's just not often the case. But in this case, it did, and it went ahead and approved the drug. So walk us through the controversy there. Why did the advisory board say one thing and the FDA another?

• 52:56Speaker 01

  The advisory board was not, so the aducanumab, which is a drug that clears amyloid plaque in the brain, so it's a monoclonal antibody against amyloid, as are the two other drugs subsequently approved, lecanumab, lecan, lecanemab, and donanimab, kissinla. All these three drugs reduce and eventually eliminate brain levels of tau, so that when you, the person's been on the medication for some time, there's no longer any plaque in the brain. The problem is that it's not necessarily associated with clinical benefit.

• 53:37Speaker 01

  And that's really the crux of the problem that the advisory board had, was that even though the drug was effective in clearing plaque, it was, it didn't necessarily translate into significant clinical benefit for the patient. And it was associated with serious side effects, including brain bleeding and brain swelling. And it was not insignificant in cost. When it was first approved, I think it was somewhere in the mid $50,000 range per year for treatment. So for those reasons, there was a department, and I think several members left the advisory, there was a lot of buhaha around it.

• 54:18Speaker 01

  But it was approved, and I actually was one of the first adopters of aducanumab, because I thought that despite the controversy, I felt that if we could move the needle a little bit for patients with Alzheimer's, it was worth trying. So I started using it, and because the drug had a greater than 40% incidence of abnormal brain bleeding and brain swelling as a result of the use of the drug, I developed a very, very slow titration protocol. My reasoning with this protocol was, well, the amyloid's been developing over decades in these patients.

• 55:02Speaker 01

  There's no reason to go in and quickly accelerate the dosage. We could go, go at it slowly. So, so what if it takes two years to clear the plaque as opposed to a year and a half? And another big problem with it, with these drugs as a group, all three drugs, is that they are not generally used for patients who have two copies of the ABOE4 allele. The feeling being that these patients who have two copies of the 4 allele are much more likely to have significant ARIA, which is amyloid-related imaging abnormalities, edema and hemorrhage in the brain. But the problem is, the patients who have two copies of the 4, like my physician patient,

• 55:45Speaker 01

  are the ones who are most likely to progress, and also the ones most likely to need this drug. So I've developed a protocol where we start and titrate patients up very slowly. And in fact, recently, for the drug donanimab, which is a third drug in this group, they have, the FDA has approved a slightly slower titration protocol than initially used, because they too have noticed that a slower protocol is helpful in drastically reducing risk of side effects. The one thing I will say that is that if you look at the amount of change, what's called

• 56:24Speaker 01

  the CDR, sum of boxes change, between patients on drug versus patients on placebo, on all these three groups. Lecanumab, which is a second drug. Aducanumab is no longer on the market. It was taken off the market. So we're really only talking about lecanumab and donanimab. Lecanumab is a once every two week drug intravenously. Donanimab is a once a month drug. If you look at the changes on the CDR sum of boxes scores, which is, you know, changes in memory, ability, et cetera, the changes are small. It's point, point three or point four points out of 18 points on the CDR sum of boxes score. This is a very small change.

• 57:09Speaker 01

  And in fact, in the early data on donanimab, there was really no change on the CDR sum of box scores between patients on drug versus patients not on drug. But I do believe that many of these patients had moderate to severe disease. So if you treat patients early on, before there's a lot of tau pathology, before there's too much synaptic loss, then you are able to, I think, have greater benefit, and that's been shown to be the case. And then, of course, there's the question of what if you treat people before they ever get the symptoms? What if they have the amyloid, they're at high risk, like my physician patient, are you even able to prevent the disease?

• 57:53Speaker 01

  So these are questions that we don't know. But certainly in, in my patients, even the, you know, what I would say to your listeners is if they have two copies of the 4.4, they may benefit from a very, very slow titration protocol. And we've published on it, and our data is, we find about a 4% risk for amyloid-related imaging abnormalities in such patients.

• 58:15Dr. Peter Attia?

  Can you tell me, what is the sort of boilerplate incidence of ARIA, these abnormality, these amyloid-related imaging abnormalities in 4.4s, to contrast with the 4% you're seeing in your series?

• 58:28Speaker 01

  So generally, the, what happens in patients who have two copies of the 4.4 is they have a lot more cerebral amyloid angiopathy to distinguish it. So amyloid deposited in the blood vessels of the brain. And this amyloid can sometimes cause a break in the continuity of the blood vessels going into the brain and cause small micro hemorrhages when there's bleeding, or can cause white matter changes.

• 59:05Speaker 01

  It seems as though people who have two copies of the 4.4 have higher prevalence, more severe cerebral amyloid angiopathy, and are more prone to developing ARIA E and ARIA H, amyloid-related imaging abnormalities with edema or with hemorrhage, and are also more severe. So they're more, much more likely to have larger bleeds, more edema, and more problematic. This is also one reason people often get confused. They say, well, why is it that people on placebo develop microbleeds, as did people on drug? That's because microbleeds can happen in people who have cerebral amyloid angiopathy, regardless of anything.

• 59:50Speaker 01

  So the fact that you get the monoclonal antibody, it increases your risk, but you may have a baseline risk anyway, because you're, you have two copies of the 4 allele, or even a copy.

• 1:00:03Dr. Peter Attia?

  Okay, so let's, let's go back to the very beginning on that. So, so aducanumab is approved. The controversy is basically, it improves the biomarker, it doesn't improve the disease. You know, the way, the example I would give here is, it's a drug that lowers LDL cholesterol, but doesn't prevent heart attacks. You decided, and I don't want to sort of paraphrase or misrepresent, but I think what I've heard is, look, you said, there's an alternative explanation here. A, we could be looking at too short a period of time. B, we could be looking too late in the history of the disease. If we intervene earlier, give ourselves more time, and mitigate the side effects by ramping the drug up slower, we are, after all, removing amyloid, and amyloid is playing a role in the disease.

• 1:00:48Dr. Peter Attia?

  Is that a fair assessment of the nuance that you sort of applied to the first drug, which is no longer there, but the logic still applies to the second and third?

• 1:00:57Speaker 01

  That's correct, yeah. Exactly right. And the other thing, Peter, I always ask myself, anytime a new drug comes out, is, would I want this drug? If I had Alzheimer's now, knowing everything I know about this drug, would I want to be on this drug? And I felt that with aducanumab, my answer was yes. So that's why I started giving it to my patients.

• 1:01:18Dr. Peter Attia?

  Now, was it ultimately pulled off the market because of ARIA? Or was it pulled off the market because of lack of efficacy?

• 1:01:27Speaker 01

  It was pulled off of the market because they required post-monitoring of the drug because of the controversy and that became financially for the company, I think, unfeasible.

• 1:01:40Dr. Peter Attia?

  Got it. What is the annual cost of lecanumab and dicanumab?

• 1:01:45Speaker 01

  They cost, the drugs themselves cost about $26,000. But then there's the administration fees, which can range, you know, sometimes in institutional settings, they can be as high as $10,000 just to infuse the drug. Versus you go into a infusion center, it could be $400. So there's always that spread per infusion.

• 1:02:07Dr. Peter Attia?

  Wow.

• 1:02:07Speaker 01

  And then there's a cost associated with the MRIs that the patients might need, uh, which they need, and then they need amyloid imaging. And one of the things that I unfortunately have discovered is the insurance companies, especially with lecanumab, which starts at 10-milligram dosing, right away, 10-milligram per kilogram. Uh, they, they will not reimburse patients if we start them at a lower dose and titrate them up.

• 1:02:33Dr. Peter Attia?

  So in other words, your efforts to protect the patients from area-related imaging abnormalities is something the insurance companies are saying, hey, we don't have a protocol for this. We're not gonna, so the patient's gonna have to pay out of pocket if they want a safer protocol?

• 1:02:49Speaker 01

  That's correct, yeah.

• 1:02:51Dr. Peter Attia?

  That sounds about right.

• 1:02:51Speaker 01

  We haven't run into, yeah, it's very unfortunate. We haven't run into that with the donanumab so much because donanumab does have a 350 to 700 to 1050 to 1400-milligram titration schedule. And so we've been able to like keep people at the 350 for like four or five infusions without anybody noticing. But unfortunately, we haven't been able to do that with lecanumab because it just starts at 10-milligram per kilogram. And we've had patients, Peter, who are 4-4 patients, who've had severe aria on just 3-milligrams of lecanumab. 3-milligrams per kilogram as opposed to the 10s. Can you imagine what their side effects would be on 10-milligrams per kilogram?

• 1:03:36Dr. Peter Attia?

  And, and the reason for this is simply the higher initial risk. Uh, in other words, it's, it's that the APO, if you're a 3-4 and then ultimately a 4-4, with each of those steps, you're moving towards a higher susceptibility for the edema and/or the hemorrhage in response to the drug. Can you say a little bit more about what it is the, and I know you kind of alluded to this already, but, but what is it that the drug is doing in the process of clearing amyloid or tau that is resulting in edema and hemorrhage?

• 1:04:10Speaker 01

  So the ant monoclonal antibody, whichever one it is, the drug goes into the brain and it starts to clear amyloid in the substrate of the brain. But it also removes amyloid from the tunica media or the middle coat of the small arteries in the brain. Uh, that's where amyloid is. So what that does then is it disrupts the lining of the arteries and it causes leakage of initially fluid. And that's called edema, aria E. And then eventually there's extravasation of actual blood

• 1:04:52Speaker 01

  because there's a rupture of the lining, there's a tear in the lining of the blood vessels, if you will. And that then causes aria H or hemorrhage. And if it's a large enough disruption, then you can actually have a massive brain bleed and there are cases of depth in such patients, particularly if they're on a blood thinner. You know, we have patients who could be on a blood thinner for atrial fibrillation or something like that. Alternatively, also, you know, for example, the young, one of my younger patients who's on it for prevention, she's 51 or 2 and she's developed significant aria E on both sides of her brain on 3-milligrams per kilogram of lecanumab.

• 1:05:35Speaker 01

  And she's been on this dose now for six doses, which is almost, you know, it's three months. And she still has aria E in different areas because her brain is, you know, there, there's little tears in the fabric of the blood vessels as the monoclonal antibody removes amyloid from the lining of the blood vessels.

• 1:05:57Dr. Peter Attia?

  Now, is she having any symptoms? Or is this something you're only able to know because you're doing the, you know, concomitant MRIs along the way to monitor progression? Is this something you never want to wait until it shows up symptomatically? You want to know that it's there radiographically and pull back in response to that?

• 1:06:15Speaker 01

  That's a great question and the answer is absolutely. So we have a very, you know, rigorous monitoring protocol with imaging. And I will say, I've been using monoclonal antibodies since 2021, so it's been over five years. And I would say I cannot remember, perhaps in one 4-4 patient who was in her early 60s with Alzheimer's, she had some visual findings, but everybody else, we only discovered the brain bleeding and the brain swelling on MRI.

• 1:06:50Dr. Peter Attia?

  Sorry, you're saying that in the five years of your very liberal use of monoclonal antibodies, your incidence of aria is 4%, but symptomatic aria has only been one case?

• 1:07:04Speaker 01

  Symptomatic aria has been one case. I did have one case, which was a dr- and all the patients have stayed on the monoclonal antibody, including one patient who had significant aria where he had, aria is defined in multiple places, some of them rather large aria E. And he had absolutely no symptoms. And this was one of, he was on aducanumab. He was a 4-4 patient. He was in his early 60s and he had been on aducanumab, a slow titration, and he had gone up to 8-milligrams per kilogram. And at month 19 or 18,

• 1:07:47Speaker 01

  he developed on MRI significant aria E. We're talking fairly significant with some micro hemorrhages, without any symptoms, including on a careful neurologic exam.

• 1:08:00Dr. Peter Attia?

  And how far do you pull back the drug when you see that?

• 1:08:04Speaker 01

  So that patient was actually quite scary. I mean, that was my first real, I mean, that was maybe 2024 or so before the other drugs had really come out and early 2024. And, uh, he, what we did was we realized that the aria had happened a few weeks before because of the characteristics on the MRI, it wasn't acute. And he actually happened to, wanted to go to Europe the following week. His exam was normal, so he went to Europe. And then he came back and we, I think we cut down to a lower dose. We went down to 6-milligrams and then went back up again.

• 1:08:46Speaker 01

  So it was a scary moment. What I do do now, what I've learned to do is when you have patients who have, people with CAA cerebral amyloid angiopathy can have aria without, as I said, without any impetus. They can just have spontaneous aria E, aria A and E. And generally, the way you treat it is you treat it with steroids. So what I do in my patients who have, who have, like, for example, this young woman who's got 4-4 and 3-lecanumab, uh, 3-milligrams of lecanumab, who has aria E, which seems fairly refractory.

• 1:09:27Speaker 01

  I treat her with steroids as you would somebody who has cerebral amyloid angiopathy with the inflammation. And we just pre-medicate with steroids and that seems to control it.

• 1:09:40Dr. Peter Attia?

  Uh, pre-medicate. So in other words, you're saying you prophylactically manage with a small dose of a steroid before each subsequent dose, once you've made the diagnosis of aria?

• 1:09:49Speaker 01

  Yes, yeah.

• 1:09:51Dr. Peter Attia?

  So are there any clinical trials that are going on to take this protocol of yours and do it in a randomized fashion? Because obviously you're doing it in what we would call open label, meaning everybody is being treated this way. Nobody's getting either a placebo or a standard approach. To me, an elegant trial, quite frankly, although I think it would be cost prohibitive and that's probably why it's not going to be done, would be taking your low and slow approach, you, you, what I would call the low, slow, early approach, right? So we take these high-risk patients that are in their 50s or 60s who are probably 10 years away from clinical disease or five years away from the first symptom.

• 1:10:33Dr. Peter Attia?

  We treat them in a way that is very low, very slow, very safe. And we ask the question, are we bending the course of their disease? Because to me, that's the interesting question, right? I think what these drugs have demonstrated is if you take a person who is in florid dementia and you slam them with these monoclonal antibodies, you are not bending the arc of their life. And in fact, if they are E4-4, you are introducing a staggering amount of risk. In fact, I, I assume many neurologists would not even treat an E4-4 late enough in the game with a high enough dose because the risk and reward isn't there. So it's a shame that, that-

• 1:11:16Dr. Peter Attia?

  You know, the companies that make these drugs wouldn't subsidize the cost in a way that would allow a more longitudinal study in the, what I think is the appropriate patient population. But, you know, I'm not gonna, you know, I'm not gonna diminish the cost of monoclonal antibodies. They're certainly more expensive than your typical small molecule, but they're probably not the sticker price. And I think there's more people to be helped if we could do the right study and, and again, kind of replicate what I think you're doing clinically. Because again, the approach makes sense. If you think about most chronic diseases, time and area under the curve is the issue, right? We know this with atherosclerosis. If I, if I take a person for primary prevention, I'm not going to move the needle treating them for a year.

• 1:12:00Dr. Peter Attia?

  It's just not enough. I have to treat them for years to move the needle. So, anyway, I think that's, it's hard to imagine. So, so tell me, what's on the horizon as far as the monoclonal antibodies? Like, where do you see, you know, with every drug, whether it be GLP-1s or statins or any drug, they always get better with subsequent generations. So, so where do you see them going next?

• 1:12:23Speaker 01

  I think we're gonna have drugs that are monoclonals that are able to, like, ameliorate this risk of, you know, edema and hemorrhage, drugs that can be taken as pills, drugs that can be given at home. And I do want to say, the most exciting thing that happened to me, I have a woman in her 70s, who came to me with, you should've seen a, you know, a television show in which we were discussing Alzheimer's, and so she came to the office, and she turned out to have Alzheimer's. And she's very, very, very functional. Not particularly, I mean, I think her overall ability was at the 70th percentile, so not,

• 1:13:08Speaker 01

  you know, one of these uber high-achieving people. And we started her on medication after a spinal tap showed evidence of amyloid and tau. And she was on the canapam. She eventually cleared the amyloid. I decided to do a tau scan. She no longer had tau. And, you know, there is downstream reduction in tau in all these different, with all these monoclonal antibodies, because even though they target amyloid, they also clear some tau. But she actually had no tau on our tau scan. So now we're waiting on her spinal tap, because I refuse to believe that we've, we've basically erased, removed her pathology.

• 1:13:53Speaker 01

  Clinically, she's done remarkably well. So that, again, speaking to the spectrum of Alzheimer's, there are some patients who respond dramatically. And who knows, maybe her immune system is just different from someone else. I have a pair of identical twins, and I take care of one of the two. And the one she just, you know, she was on a monoclonal antibody, initially on aducanumab, and then on donanimab. And she did much better than her identical twin, who was in a facility. And my patient actually also had heart disease. She had rheumatological heart disease, which destroyed her valve, and she had an artificial

• 1:14:33Speaker 01

  heart, and she was on Coumadin, and we still decided to put her on a monoclonal and watch her like a hawk. She never developed side effects, and she cleared her amyloid. So, I'm just saying that I think it's an exciting time. I really do. And I think early diagnosis really does make a difference now in terms of changing the trajectory of someone's cognitive health.

• 1:14:56Dr. Peter Attia?

  So, you've been in practice for 25, 26 years, and these drugs have only been available for five years. So, prior to the approval of the first monoclonal antibody, what were you doing for this type of a patient? And what were you doing for the later-stage patients? And how much of those things are you still doing today?

• 1:15:17Speaker 01

  So, I've always, you know, I actually trained in the era of HIV and AIDS. So, I, and, you know, we, all my early patients who died, died from HIV, you'd see them one day, they were dead the next week. And I, for the first time, a few weeks ago, saw a patient who actually had not just HIV, wasn't just HIV-positive, but actually had clinical, had had clinical AIDS with PCP and capulsi sarcoma, who had survived going on immunotherapy and IVIG and all of this, and now is in his 70s and concerned about his memory. So, I mean, it was the first time that I'd ever encountered that. And the way I've approached Alzheimer's disease is the same way.

• 1:16:02Speaker 01

  We don't have a cure yet, but we can give each person a cocktail of medications, just like they do with patients with HIV. And in this particular patient, he was on IVIG, you know, so God knows what it did to his immune system. And therefore, you can keep the person alive, so, and functional, not just alive, but actually functional, and that's important.

• 1:16:24Dr. Peter Attia?

  Yep.

• 1:16:25Speaker 01

  So, before the advent of these monoclonal antibodies, and to this day, I still have patients on a combination of a cholinestriose inhibitor, such as donapazole, galantamine, et cetera, memantine, which is a NMD receptor antagonist, that basically, I just say, reduces signal-to-noise ratio in terms of brain neurotransmission, and it also may prevent apoptosis or cell death in patients. Depending on the patient, we may have them on something like valacyclavir. Some patients benefit from other immune-modifying treatments when needed, and better control of their comorbidities.

• 1:17:09Speaker 01

  Many patients have, may benefit from interventions like ventricle-peritoneal shunt for hydrocephalus. And the other area that I feel is important is maintaining a person's neuronal connectivity. And by that, I mean, how well the networks function. And for that, in 2008, I started using transcranial magnetic stimulation, targeted TMS, to help maintain function. And TMS works by stimulating the brain using magnetic stimulation that then creates a small area of current just under the area of the coil.

• 1:17:54Speaker 01

  So, an area about 1 centimeter squared of the cortex gets stimulated. And then that creates a stimulation in the circuitry to which that area of the cortex is attached, and the hope, connected. And the hope is that by that method, you're able to keep those circuits alive, regardless of the pathology, regardless of whether the pathology and the cognitive impairment is from stroke, from menopause, from Alzheimer's. And over time, we've kind of refined this process. And so I continue to use TMS in patients, and I find it particularly helps people with language problems, for example.

• 1:18:34Dr. Peter Attia?

  Are you using TMS with EEG guidance? I know that that's something that's becoming a little more popular with psychiatric disorders, such as recalcitrant depression and things of that nature, but not, not sure about your application.

• 1:18:49Speaker 01

  I really always use TMS using neuronavigation guidance, guidance of anatomical structures. So, we actually have kind of a, we plug in the patient's MRI, and we kind of create a GPS of that person's brain, and then we mark those areas that we think need to be stimulated. And I usually stimulate the dorsolateral prefrontal cortex, Broca's area, the precuneus for parietal and visuospatial skills. And some patients, we also stimulate the auditory, Wernicke's area. And again, this is off-label, because TMS is only approved in the United States for treating depression and for certain electrodiagnostic purposes.

• 1:19:33Speaker 01

  But we've been using it off-label since 2008 for treating our patients with dementia.

• 1:19:39Dr. Peter Attia?

  How optimistic are you on the causal nature of the relationship between GLP-1 agonist use, dementia? Obviously, the observational data appear favorable. The challenge with data of this nature is it's a little difficult to establish perfect causality. You have, obviously, the healthy user bias of people who can afford and use and comply with these drugs. But of course, you have the bigger issue, which is, any drug that is resulting in weight loss and an improvement in metabolic health is going to improve risk, and that might alone be a reason to use it.

• 1:20:19Dr. Peter Attia?

  But the real question is, do these drugs offer a benefit in risk reduction through an inflammatory pathway, or a pathway that is not so directly tied to, to weight loss of insulin resistance?

• 1:20:33Speaker 01

  I believe so. I think the GLP-1s offer an advantage. And even the older drugs like metformin, you know, may offer benefit in this area. And so I do use it in my patients where I think it's necessary. And you know, the other thing too is obesity is finally coming down in the United States. You know, thanks to GLP-1s. And I'd be very curious to see what happens as a result of that with so many diseases associated with the brain, many of which are driven by obesity and cardiovascular disease, which is a direct consequence, diabetes.

• 1:21:11Dr. Peter Attia?

  We've talked a lot about Alzheimer's disease. I do want to just give a little bit of time to discuss vascular dementia and Lewy body dementia. And I'm assuming you see quite a bit of those in your practice as well. Can you walk us through, A, how those diseases present and B, how you diagnose them?

• 1:21:29Speaker 01

  It's very rare. Alzheimer's almost never presents in isolation. So they've done autopsy studies in patients and find that between 98% to 99% of patients with Alzheimer's have some kind of concomitant primary brain pathology. And the most common is vascular disease, vascular brain disease. But in terms of the primary vascular dementia, I find that rarer than you might think because so many, so many of us, as we get older, will have some vascular disease in our brain. You know, what I call white matter schmutz in the brain.

• 1:22:13Speaker 01

  And used to be thought of as rather benign, but now we know that it is not benign, that it interrupts the connectome of the brain. And it's progressive and causes problems that perhaps interfere with the resilience of the brain to pathology and therefore needs to be addressed specifically. So I'm fairly rigorous about treating patients with vascular dementia, often with concomitant other conditions as well. And one of the things that I do do in my patients who say have multiple strokes in their brain that I believe are the primary cause of their cognitive impairment is, you know, aside from putting them on statins and all of that, is that they do have atrial

• 1:22:58Speaker 01

  fibrillation or some kind of a heart problem that is the cause of the strokes. I recommend a Watchman so that they can then go off the, the anticoagulant medication, Eliquis, Zeralto, et cetera. Because many of these patients are at higher risk for falls just from their vascular pathology, they are, they have dementia. So it just prevents an added problem down the road. Along those lines, in patients who are on blood thinners for atrial fibrillation or another condition, who then have Alzheimer's disease and therefore are precluded from

• 1:23:39Speaker 01

  going on a monoclonal antibody because of the blood thinner, I recommend them getting a procedure like a Watchman. So then they can go off the anticoagulant and then get on the monoclonal. So I've done that with a few patients. Lewy body disease, you know, if you look at patients with Alzheimer's, about 40% of them eventually will have some level of Lewy body pathology. If you look at patients with Lewy body, about 30 to 40% of them have Alzheimer's pathology. And some people think even a higher number. So the two conditions coexist quite a bit. What I find the most troubling in my practice is the number of patients with Lewy body

• 1:24:24Speaker 01

  who get diagnosed as having Parkinson's. And therefore are treated with Parkinsonian medications, levodopa and carbidopa, the dopamine agonists like Mirapex, et cetera. And that actually worsens their Lewy body. They get, they get more confused. It doesn't really help with their symptoms. And I have quite a few of those patients. But in terms of a diagnosis, for me, again, the big, it's not as straightforward as you might think it is. I do almost, in all my patients in Lewy body, I do work them up also for Alzheimer's because of the vast comorbidity overlap between the two.

• 1:25:07Speaker 01

  And if they don't have any of the Alzheimer's biomarkers and they have only Lewy body biomarkers, which is primarily, we do dopamine scans. We can also do skin biopsies to see if they have alpha synuclein pathology. Can also do a spinal tap, send the fluid off for alpha synuclein. You make the diagnosis. The one thing I will tell people is there is, I think, a fairly prevalent misconception that Lewy body disease is rapidly progressive and causes death in five to six years. And I'm here to say that that is absolutely not true. Patients with Lewy body, in fact, respond fairly well to treatment and sometimes better than patients with Alzheimer's.

• 1:25:52Speaker 01

  Some patients actually get dramatically better. And as far as I'm concerned, in my practice, the life expectancy is not that different from patients with Alzheimer's.

• 1:26:03Dr. Peter Attia?

  Can we talk a little bit more about the pathology? So how much is Lewy body dementia impacted by ApoE4, first of all?

• 1:26:10Speaker 01

  Everything's important impacted by ApoE4, unfortunately. And I think it has to do, so much of what happens in the brain has to do with robust clearance of pathogens. And whenever you have E4 pathology, it interferes with that. So I think there is a slight increase. I mean, obviously, it's not as, as dramatic as for Alzheimer's pathology, but does increase risk.

• 1:26:41Dr. Peter Attia?

  So tell me, or tell us, the, the role of alpha synuclein in the pathology progression? Is it a target of therapy? Does it play a role similar to amyloid? Obviously, I mean, maybe start with the easiest case, which might not be that realized, but a pure case of Lewy body dementia without a significant overlap of Alzheimer's disease. So what's happening, what's the order of events in pathology?

• 1:27:07Speaker 01

  So, you know, the, the problem is that Lewy body disease and Parkinson's disease same, share the same pathology, which is abnormality in the alpha synuclein protein. And the difference is sadly, a difference of time. So if you have motor symptoms for less than a year, during which time you then develop cognitive symptoms, then it's Lewy body's disease. Whereas if you have motor symptoms and then after a period of time of over a year, and some people say two years, then you have Lewy body disease. It's kind of an arbitrary distinction. In addition, with Parkinson's disease, the pathology, it's alpha synuclein pathology

• 1:27:52Speaker 01

  is primarily confined to the area of the basal ganglia, whereas in Lewy body disease, it's more widespread. But any disease will eventually, and then Parkinson's, what, how do you differentiate Parkinson's disease related dementia? Which is, so people now, I think, more and more people are, again, going back to the spectrum concept, think of the alpha synuclein spectrum disorders of which Lewy body and Parkinson's disease, all of them are on that same spectrum and the presentation may be different. One way I distinguish between Parkinson's Lewy body, because sometimes it's very hard to tell exactly when somebody begins to have cognitive changes, as we've discussed, the

• 1:28:36Speaker 01

  smarter the person, the easier it is for them to compensate, is to look for a rest tremor. I have in fact, never seen a patient with Lewy body present with, initially with a rest tremor. So that classic pill rolling tremor of Parkinson's disease, I've never seen in a Lewy body patient, ever. And we're talking.

• 1:29:00Dr. Peter Attia?

  So does that mean that by definition Lewy body, while the alpha synuclein is diffuse, it's sparing the basal ganglion?

• 1:29:11Speaker 01

  No, because in Lewy body disease, by definition, you've got to have motor symptoms.

• 1:29:16Dr. Peter Attia?

  So why do you think they don't pill roll?

• 1:29:19Speaker 01

  And that I don't know, Peter. This is one of the mysteries of neurology that I haven't figured out yet. But that's what I've noticed and that's what I use to make my distinction. Obviously, when you do a DAT scan, there are classic patterns that you see in Lewy body that you don't see in Parkinson's disease. But again, that is not quite as rigorous and as distinctive as you'd like. But it's important from a clinical perspective, because if you have Parkinson's disease, you would want to treat with drugs that increase brain levels of dopamine. Whereas if you have Lewy body disease, adding dopamine can cause

• 1:30:02Speaker 01

  serious negative side effects, including psychosis, worsening the psychosis in patients with Lewy body. So Lewy body disease clinically is diagnosed by the presence of motor disorder, Parkinsonian features, fluctuating consciousness, cognitive impairment, and often visual hallucinations. And these can be quite dramatic. And the one thing also about the visual hallucinations of Lewy body disease is patients have insight into them. So for example, I was talking to the mother of a physician who is my patient, who has Lewy body disease, and she's a wonderful woman, she's in Florida now. And I was talking to her on the phone and she said, yeah, you know, I don't understand.

• 1:30:44Speaker 01

  I was very, very clear that I was not in my house. And everyone else told me I was in my house. And I kind of knew I should feel like I was in my house, but I really didn't think I was in my house. Now, Alzheimer's patients rarely ever say that. They don't have that insight, usually. Patients with Alzheimer's can also have those kinds of hallucinations and delusions, but their insight is not as crisp. Or else I'll have a patient say, you know, I called the cops because I saw these people on the street. And I knew, because I've done this before, that they were not real,

• 1:31:26Speaker 01

  but they absolutely looked real to me. And even though my wife told me not to call the cops, I called them.

• 1:31:33Dr. Peter Attia?

  I mean, that has to be beyond terrifying. I mean, that's almost like, even though it's a completely different disease, I mean, that that almost feels like schizophrenia minus the voices.

• 1:31:44Speaker 01

  Yeah, yeah. Yeah, it's rare to have auditory hallucinations. In fact, I've never, ever had a patient with that in my practice.

• 1:31:53Dr. Peter Attia?

  So what are the differences, once you have the diagnosis made? What are the differences in your playbook of treatment? And are you catching these Lewy body patients later in the disease? Do you have fewer tools to identify early alpha synuclein relative to amyloid beta?

• 1:32:11Speaker 01

  We have fewer widespread tools, right? So we don't, I mean, skin biopsies now are great, easy to do.

• 1:32:19Dr. Peter Attia?

  And pardon my ignorance, that is news to me. I didn't realize you were biopsying the skin for alpha synuclein. I thought you were getting it out of CSF. So why does this same protein that is involved in neuronal geography making its way into the skin? And how does that, how do you link what you're seeing in the skin to what's happening in the brain?

• 1:32:41Speaker 01

  So, you know, they travel along the neural pathways. So because your skin is full of neural, of nerves. So you're really, when you're doing a skin biopsy, you're really not looking-

• 1:32:52Dr. Peter Attia?

  You're doing a nerve biopsy.

• 1:32:53Speaker 01

  You're doing a nerve biopsy, but you're doing a biopsy of the small cutaneous nerves in your skin. So you do punch biopsies on your neck, further down in your knee, and then further down. So you kind of see how much synuclein there is at each level. And the more synuclein you see further from the nervous system, the more likely it is to be widespread disease. But you know, there are so many conditions that can mimic motor disorders that are not caused by synuclein. So what the skin biopsies do is that they distinguish between them.

• 1:33:29Dr. Peter Attia?

  But that's only giving you information above sensory nerves, correct?

• 1:33:33Speaker 01

  Yes, it gives you information about, yeah.

• 1:33:36Dr. Peter Attia?

  So that's, you know, relatively speaking, in the grand scheme of the cortex, that's relatively small real estate. So the other stuff you're doing clinically, so you'll, you would infer based on visual hallucinations that the occipital lobe is involved and things like that?

• 1:33:50Speaker 01

  Right. No, so we, so for dementia with Lewy bodies, again, as I say, I work patients up, even if they have Lewy body dementia, I always work them up for Alzheimer's because I know that there's such a comorbidity between the two. But the thing that I often will do is I will do a DAT scan. So when you have a dopamine uptake scan, you can tell if there is abnormalities in the basal ganglia that would be consistent with alpha, could be consistent with Lewy body disease. But then you can't really be absolutely sure until you do the biopsy to verify that it's alpha synuclein that's driving the pathology.

• 1:34:30Speaker 01

  In terms of treatment, one of the most important things that I do is get them off their Parkinson's medications. And that can be very difficult because patients, I found, love the high of the Parkinson's medication. I saw a patient yesterday, actually, a new patient, who was in her seventies, had been having a, what's called an essential tremor, which is a fine tremor that many of us have, but that can also be present. There's a comorbidity between essential tremor and the tremor of Parkinson's disease. But she never had a rest tremor.

• 1:35:11Speaker 01

  She had, despite a negative DAT scan, she'd been put on levodopa carbidopa, three, three tablets, three times a day of 25100 at an academic institution for treating presumal Parkinson's disease, despite her negative DAT scan. And the thing she told me is, you know, she says, listen, these pills really helped me because right before I'm ready to take the next set of pills, I start to feel a little bit down. So you have an internal kind of low and the pills kind of reset you because of the dopamine high.

• 1:35:55Speaker 01

  So patients are often averse to going off the pills. So one of my tasks with her, because she's been on these nine pills a day for the last year, is trying to get her off those pills. And she really didn't have, the tremor that she had was in the central tremor and not the tremor of Parkinson's.

• 1:36:15Dr. Peter Attia?

  So what are the predisposing factors for Lewy body dementia, where it's the dominant form of dementia? So yes, there may be some overlapping vascular and/or Alzheimer's dementia. But I assume family history poses a risk? What are some other known risks for Lewy body?

• 1:36:33Speaker 01

  So family history, family history poses a risk, but the problem is-

• 1:36:38Dr. Peter Attia?

  Yeah, I mean, let's assume it's diagnosed correctly. I know that that's, that's its own problem with diagnosis, yeah.

• 1:36:44Speaker 01

  Right. No, the problem is that with, yeah, if it's diagnosed correctly, what are the risk factors? I mean, Lewy body usually occurs in patients a little bit younger. Again, vast risk factors, increased risk for Lewy body disease. Alzheimer's disease increases risk for Lewy body disease. Parkinson's disease increases risk for Lewy body disease. And actually, essential tremors also will increase risk because they are on that spectrum of possibly kind of morphing into-

• 1:37:15Dr. Peter Attia?

  But do we think that those things are increasing risk? Or their presence is a demonstration of other factors that are underlying the risk? In other words, whatever it is that's causing everything you just said happens to increase the risk of Lewy body, but what are those other things? In other words, does metabolic dysfunction, just as we believe metabolic dysfunction is truly causally related to the risk of Alzheimer's disease? Do we think it is, and by the way, the important point there is, therefore it is treatable, right? Therefore, we target aggressively hypertension, dyslipidemia, and insulin resistance. Because those three things, we have such conviction, are causally driving Alzheimer's disease. Do we have the same level of conviction around Lewy body dementia?

• 1:38:01Speaker 01

  I, I feel anything that's good for the heart is absolutely good for the brain, regardless of the pathology in the brain. And having said that, I feel like we don't yet have enough knowledge about Lewy body disease because we've just, we don't have the-

• 1:38:22Dr. Peter Attia?

  We just don't have the data yet. We don't have a robust enough data set.

• 1:38:25Speaker 01

  Yeah, yeah.

• 1:38:28Dr. Peter Attia?

  By the way, female, male difference in Lewy body? Is it, is it, is it one to one, two to one? How does it compare to Alzheimer's?

• 1:38:36Speaker 01

  I think there's again a slight, there's more, there's more men with Lewy body disease. But

• 1:38:44Dr. Peter Attia?

  But that's also because we've got more men with Parkinson's and we might be capturing, yeah, we might be doing this thing incorrectly. Got it. Let's go back to females with menopause. You, you coined a term, I'm blanking on it, like mercy, menopause-related cognitive impairment. Is that, did I get that right?

• 1:39:00Speaker 01

  You did. I'm very impressed. How did you remember that?

• 1:39:03Dr. Peter Attia?

  I have a great team of analysts that remind me of these things.

• 1:39:08Dr. Peter Attia?

  So is it, I mean, is there ever an indication where, is there ever a scenario where you, you have a woman who's come to you, she's got a history of breast cancer and you're, you're just saying it's not worth the risk? Or she's, she's too afraid of the risk. You, you may or may not be familiar with my views on the relationship between estrogen and breast cancer. But, but let's just say, let's take an extreme case, right? Which is she is actively undergoing treatment for breast cancer, in which case, if it's estrogen sensitive, you clearly wouldn't give her estrogen. But outside of an extreme situation like that, do you consider estrogen, and then by extension progesterone, if needed to oppose it, sort of mainstays of maintenance therapy for women in either prevention or even the, the treatment of disease?

• 1:39:49Speaker 01

  Yeah, I mean, I think those, those, you know, in patients who are not, where there's no contraindication, we do give, recommend estrogen. Another thing that really works better for women like this, for menopause-related cognitive impairment, is just targeted brain exercises. You know, the brain is fantastic at the concept of learned non-use. So that you could have a stroke and suddenly not be able to move your right hand. And this could go on for 10 years. But let's say I, and I restrict my right hand, I put it in a sling. I'm sorry, I restrict my left hand, I put it in a string, and all of a sudden, I don't have my healthy left hand to help.

• 1:40:29Speaker 01

  All of a sudden, 10 years later, your right hand starts to move. You know, that's the whole concept behind constraint-induced movement therapy for stroke. And I find that the same can happen in menopausal women. So the same problem happens in menopausal women where if they start to have trouble with coming up with words, it's a very common problem, or they're having trouble multitasking. They just stop doing it as they, they, there is some disuse, dysfunction. And so when you actually force them to use those areas, when you do targeted brain exercises,

• 1:41:11Speaker 01

  even just as little as once a week, forcing them to use those areas, they recover function quite dramatically. You can also, in such women, use drugs like cholinestrice inhibitors, because the underlying mechanism of cognitive impairment is ultimately loss of acetylcholine in the nucleus basalis and areas of the brain in these perimenopausal women. And so those drugs can work. We actually, years and years ago, did a double-blind placebo-controlled trial of donapril versus placebo in women going through menopause with cognitive impairment, and found a trend in 21 patients, 21 on drug, 21 placebo,

• 1:41:54Speaker 01

  for improvement in, in cognitive function in the donapril group. So I think those, and then brain stimulation, transcranial magnetic stimulation, seems to help women in this situation as well. So there are multiple different ways that we can help. On the other side of the coin, I have patients who are on an anti-estrogen for treating breast cancer, or ovarian cancer, you know, anastrozole, tamoxifen, et cetera, who are coming in with severe cognitive impairment because of that, who actually want to go off of the drug regardless of personal risk,

• 1:42:36Speaker 01

  because they just can't stand how their brain's functioning.

• 1:42:41Dr. Peter Attia?

  Yeah, this, I think, you know, this is one of the, the real pleasures of being a clinician, is your, your patients teach you a bunch of stories. And I think back to one of the first women that taught me that lesson in 2014 or 2015. This was a woman who also came to see me, status post mastectomies, bufolectomies, hysterectomy for, I think, primary breast cancer, but, but bad genetics. Anyway, she was taken off all of her hormone replacement therapy, and the course of chemotherapy in her life turned out to be devastating. So she was, she was really far down that spectrum of mercy in the sense that basically functionally debilitated.

• 1:43:25Dr. Peter Attia?

  And she was a young woman, right? She was in her 50s. So went from being completely normal to, you know, couch-ridden effectively, due to brain fog and just inability to do anything. And she came to me with the suspicion that I think this is due to the loss of hormones. I think this is due to the, the hormone withdrawal. And, you know, after many, many discussions, not only with her, but with some other physicians, we decided to, to take the risk and, and take her, and put her back on her, her hormones. And the, the recovery was remarkable. I mean, it wasn't subtle, right? So it was, it was very quick that she regained her cognitive faculties.

• 1:44:07Dr. Peter Attia?

  And so what I take away for me was both the physiology, but also the choice, which is, for some people, it, and I would probably put myself in that situation, I'd rather deal with the risk of cancer than cognitive decline.

• 1:44:23Speaker 01

  Yeah.

• 1:44:24Dr. Peter Attia?

  But, but again, it's, the bigger question is, it should be a choice. And, and, and, and I also have a little bit of an issue with how aggressively aromatase inhibitors are used for things like DCIS, which I think is, I don't think, I don't think patients fully understand just how small the risk is that they're mitigating with an aromatase inhibitor for five years in the context of a precancerous lesion. And so I think there are these edge cases where we're doing a lot of harm without a very clear benefit.

• 1:44:58Speaker 01

  I, I can't agree more. And I totally, I, I can't tell you, I mean, patients that I've worked with who are also being seen by folks at Sloan-Kettering, for example, in New York, and have decided with me, to your point about choice, that they would rather risk the possibility of recurring cancer than risk the ongoing ineptitude and inability to function in their lives. And, you know, again, I saw a young girl, this, this can happen, you know, the lack of estrogen driving brain fog. A 20, 21-year-old girl that I see for migraines, who's in college,

• 1:45:40Speaker 01

  and she spoke to me earlier this week, and she said, for the last six months, she's been in a complete fog, complete brain fog. She can't function. She's in a good university. And, and I had her go see her gynecologist, you know, she hasn't had her period. And so the estrogen level for her came back at 22, you know, picograms per deci, it's very low. As you know, menopausal women, it's less than 30 or 35. So hers was extraordinarily low, and we don't really know why that is.

• 1:46:15Dr. Peter Attia?

  And was her, was her FSH or LH elevated as significantly?

• 1:46:18Speaker 01

  They were not. So it was very interesting. Her FSH and LH were normal, but it was almost like primary ovarian failure of some sort, you know? But in the meantime, she's not able to function. She can't, she cannot work at school. And this is not some, and so I told, you know, I told her, I said, she may benefit from some kind of low-dose oral contraceptive, while they're trying to figure out what they should do, because she needs to be able to, you know, finish, finish school.

• 1:46:48Dr. Peter Attia?

  And in the cases where you're managing the hormone, do you prefer a transdermal estrogen to an oral one, given the other changes with the, you know, increase in SHBG and binding capacity and things like that?

• 1:47:03Speaker 01

  Yeah, I mean, I actually prefer transdermal, you know, either a gel or a patch, because yeah, you, you have lower risk. In my, in my, for me, the big consideration is lower risk of strokes and venous clots.

• 1:47:18Dr. Peter Attia?

  So you've been on this really incredible journey. You're, you're at the forefront of what can only be described as a very, very personalized nuanced approach to the early treatment of dementias across the board.

• 1:47:35Dr. Peter Attia?

  What do you believe today that you absolutely flat out didn't believe 10 years ago? Like, what have you actually changed your mind on?

• 1:47:45Speaker 01

  I never thought that patients with Alzheimer's could get better.

• 1:47:50Dr. Peter Attia?

  And you really, you really believe that that is the case?

• 1:47:54Speaker 01

  Oh, 100 and 20%.

• 1:47:55Dr. Peter Attia?

  That is just not conventional wisdom, right?

• 1:47:57Speaker 01

  Yeah, no, I never, never thought. And even before, even before we had the Mark Knaus, I had patients who got better with treatment, which just didn't make sense. And I used to think, before we had the biomarkers, before we had the spinal taps in 2007, I used to think, maybe I made a misdiagnosis. Maybe this person didn't really have Alzheimer's. Because, you know, the teaching is that every person with Alzheimer's inexorably declines. And we also know that 30% of patients in drug trials, where with the drug trials for Alzheimer's, didn't actually have Alzheimer's by pathology, right? They were misdiagnosed clinically. So I used to think that.

• 1:48:39Speaker 01

  And then I realized, when I had the biomarker ability, that actually, patients with Alzheimer's could get better. And that was, it took me, I think, I, I've been in the field specializing in this area since 1994, Peter, and I think for the first six, seven years, I was just learning about it. And then I started seeing patients where we'd get better with treatment. Sometimes something as simple as just brain exercises, which didn't make sense. And I always thought we misdiagnosed them. And then when 2007 came along and we had the drug, the actual ability to diagnose pre-antimortem, I realized that patients could get better. Then it took me another five, eight years before I truly believed it.

• 1:49:25Speaker 01

  Truly believed it because it's so ingrained, was so ingrained that that was not, that was not even a possibility. And now I, now I really do believe it.

• 1:49:36Dr. Peter Attia?

  When you think about the next 10 years of your career, what do you think is going to have the biggest impact on your ability to reverse Alzheimer's disease or prevent Alzheimer's disease?

• 1:49:53Speaker 01

  I think for preventing Alzheimer's disease, what's going to have the biggest impact is AI for early detection of changes in our patterns of thinking. In addition to a cocktail of medications designed to ameliorate first inflammation and then pathology in the high-risk group of patients. And in terms of treatment, I actually think targeted neuromodulation will be important in addition to drugs to reduce pathology.

• 1:50:26Dr. Peter Attia?

  Do you know if there are any drugs specifically in the pipeline for neuroinflammation? Obviously, the field of immune modulators is a popular field, though it's often around autoimmune diseases and oncology. But do you, do you know if there are people specifically targeting neuronal inflammation?

• 1:50:48Speaker 01

  I mean, there's, I actually can't, I can't, I know there are, but I can't think of any right now.

• 1:50:54Dr. Peter Attia?

  But, but you, there are, there are drugs in pipeline?

• 1:50:57Speaker 01

  Yeah, yeah.

• 1:50:57Dr. Peter Attia?

  Yeah, okay.

• 1:50:58Speaker 01

  And I will tell you, years ago, Norm Relkens' group at Cornell had the IVIG, which is pooled autoimmunity infused into patients who had Alzheimer's disease. And I actually used IVIG in a whole group of my patients with Alzheimer's, diagnosed by spinal tap analysis. And two of my patients became plaque negative. And one of them stayed stable for 17 years, and the other one is still stable. So they, they, eventually, the feeling was that IVIG had no place in treating Alzheimer's disease.

• 1:51:42Speaker 01

  But if you looked at the analysis, people who had the EPOE4 allele were far more likely to benefit from the drug than people who didn't. So that was an early.

• 1:51:54Dr. Peter Attia?

  Which is really not surprising. I mean, we see this over and over again. I know you and I have spoken about obacetropib and the profound impact it's having, at least in a pilot study, when you look at the biomarkers. But the, the, the impact is most profound the more severe your risk is. So the four fours actually have reversal, the three fours have a dramatic blunting. So again, I, I think, what I hope comes out of this, and where I hope the world is in five years, I don't even want to wait for 10 years, is I hope that more people are taking an approach like you are through clinical trials, where we're doing better identification and stratification of risk and tailoring treatments.

• 1:52:39Dr. Peter Attia?

  Because as you said, the biggest risk of the current landscape of these treatments is that we are trying to take a very, very, very heterogeneous group of genetic predispositions, other comorbidities, disease manifestations, and we treat them with one hammer. We hit everybody with the exact same hammer and we blunt all of the potential responses. Now, I think that's true, unfortunately, in most clinical trials for most diseases. It's true in the way we manage diabetes and heart disease and cancers. Although with cancer, at least, you now see gene targeting and drive, you know, mutation drivers and things like that.

• 1:53:21Dr. Peter Attia?

  So my hope is that that's, that's where the field goes and that we start saying, we're not treating Alzheimer's disease, we're treating this subtype of Alzheimer's disease in this subset of patient. Just as we don't treat breast cancer, you know, it's, are you triple negative? Are you ER positive? Are you HER2 new positive or negative? Those are completely different diseases for all intents and purposes. So I, I think the work you're doing is important because I think it's helping people start to hopefully align towards that path of both diagnosis and treatment.

• 1:53:54Speaker 01

  Yeah, I think, I think you're 100% right. There is no more heterogeneous disease I can think of. No more than Alzheimer's disease. Because it's each person with Alzheimer's disease has their own private version of Alzheimer's disease. That is different from everyone else who has the disease because that person has their own individual brain. So that, you know, what's really startling, you know, is you take two patients, identical twins with Alzheimer's, and you find, there are studies, publications, that the risk

• 1:54:34Speaker 01

  for Alzheimer's is dramatically different in identical twins who are raised in the same environment. Sometimes one of a pair of twins doesn't get the illness for 10 to 15 years after the other one. How does that happen? Because their brains, although as identical as they are, are still different. And that is really what drives the illness, as well as inflammation, epigenetics, so many things. And you absolutely need a nuanced approach.

• 1:55:11Dr. Peter Attia?

  Well, Dr. Debbie, this has been a fantastic discussion and I learned a lot. But more importantly, I think everybody listening did as well. So thanks for taking time away from your clinic to join us. And I'll look forward to many more discussions with you on these topics.

• 1:55:27Speaker 01

  Well, thank you very much for having me, Peter. That was great.

• 1:55:30Dr. Peter Attia?

  Thank you for listening to this week's episode of The Drive. Head over to peterattiamd.com/shownotes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram and Twitter, all with the handle Peter Atia MD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical

• 1:56:15Dr. Peter Attia?

  advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterattiamd.com/about, where I keep an up-to-date and active list of all disclosures.