It is difficult to assess brain health status and risk of cognitive impairment, particularly at the initial evaluation. To address this, researchers have developed the Brain Health Platform to quantify brain health and identify Alzheimer’s disease and related disorders.
Dr. James Galvin - Director of the Boca Raton-based Comprehensive Center for Brain Health and a University of Miami neurologist.
Galvin is one of the foremost researchers in Alzheimer's disease, dementia, and Lewy body disease and leads some of the most innovative research and clinical care for patients, those at risk for Alzheimer's, caretakers, and multicultural communities. Among his latest work, he's developed new screening tools to better determine both the vulnerability risk for Alzheimer's and also resiliency to combat the disease.
Where: Newswise Live Event Zoom room (link will be given in email upon registering)
When: Wednesday, November 16, 2022, 11:00 AM - 12:00 PM ET
A video and transcript of the event will be sent to those that register shortly after the event takes place. Even if you can't make this live virtual event, we encourage you to register in order to get a copy of these materials.
Thom: Hello and welcome to this Newswise Live event. Today we are talking about Alzheimer’s Awareness month and a University of Miami Neurologist who is building a system to assess brain health and risk of Alzheimer’s Disease and related disorders as well by measuring vulnerability, resilience, and brain performance.
Dr. James Galvin is Director of the Boca Raton-based Comprehensive Center for Brain Health and he’s also a University of Miami Neurologist. Thank you so much for being with us, Dr. Galvin.
Would you tell us how doctors would be able to use this new system that you're creating, to categorize people according to the risk or their resilience, against developing Alzheimer’s?
Dr. James: Thank you for having me first of all.
So, we were very interested in asking a very important question – why do some people develop Alzheimer’s disease and other people do not? The Alzheimer Association estimates that roughly 4 out of 10 older adults will eventually develop Alzheimer’s disease, but we were interested in the rest – what about the other 6 out of 10 that do not, why don’t they develop the disease, and this got us to ask really important questions. What are some of the factors that increase the risk of developing the disease – their vulnerability? And what are some of the factors that decrease the risk of developing the disease – their resilience?
And there really were no good ways of doing this, doctors were really good at diagnosing disease, but how do you determine how someone’s brain health at the time that you see them – the first time they walk in the office, how can you determine how healthy their brain is and who is going to go on and develop a disease?
So we created a bunch of instruments – one was the resilience index, and this was a group of factors through our research that determined how healthy your brain was. This included a measure of your cognitive reserve – so how strong your connections and the strength of your brain were over the course of your life, and measures of your physical activity, your cognitive and mental activities, your social engagement, your mindfulness, and your diet and nutritional intake. And so, we created this resilience index. And then we created something called the vulnerability index, which allowed us to look at brain unwellness, or unhealthy, the risk of disease. And this included four nonmodifiable risk factors, so things that - basically, were about you - your age, your sex, your race, and ethnicity, and your education and then eight modifiable risk factors that told us a lot about the state of your body that may affect your brain health. Vascular risk factors, diabetes, stroke, heart disease, hypertension, cholesterol, and other factors like obesity, frailty, and depression. So that told us a lot about how vulnerable your brain was to developing the disease. And putting these two together, we can get a sense of your overall risk.
But that by itself wouldn't tell us enough. So, we all wanted to get a brief measure of performance. We created a test called the numbers symbol coding test, which allows us to look at executive function - your problem-solving, decision-making capacity because this underlies all the brain functioning, not just memory, which only changes late in brain disease, but something that really serves all of the brain functioning. We put these all together to create this brain health platform.
So, to really get to answer your question, the way the doctor would use this is someone then could, before they even show up at the office, fill out this platform and give an assessment of how strong their brain is, their resilience, how weak their brain is - their vulnerability, and how their brains performing, and the doctor will be able to then place them in a three-dimensional space and say, This is a brain that's healthy, and is likely to stay healthy.
This is a brain that's currently performing well but is at high risk for changing in the near future.
Or this is a brain that's starting to show signs of degeneration, and what could we do about it to make that person the best that they could be?
Thom: What can be done by identifying that middle case that you described in the currently healthy brain but with risk factors for developing Alzheimer's - and detecting this so much earlier than before? What can be done then at that stage?
Dr. James: Well, yeah, that's really the key - we wanted to focus on things that are actionable. Lots of people measure things that are not actionable. And that's great, but what are you going to do about it? We wanted to really focus on what we could change.
And so, it wasn't just that we wanted people to exercise, we really wanted to understand what activities people were doing, and how we could design things in a very personalized fashion. So, we took the principles of precision medicine, things that are used in cancer, for example. So, in cancer, we take a piece of the tumor, look for markers on that tumor, and we design a therapy based on the tumor markers. Well, we're not going to take a piece of the brain, obviously - so what we do is we carefully measure all the different factors about a person and then we can design an intervention based on that person. So, we looked at these factors about explaining brain health. We looked at physical activity, aerobic, anaerobic, and resistance training.
We looked at their diet, what they were eating, how much they were eating, and how often they were eating.
We looked at their cognitive activities, their arts, social engagement, and games, whether they're doing it by themselves, or whether they're doing it in groups, their mindfulness, what's their positive emotional regulation, and their negative emotional regulation. And we took all of these factors and looked at their vulnerability- their vascular. How much did they weigh? Were they frail or not? Were they managing their diabetes? So we take all these things that we can, we look at that as an individual, and we could say, how could we change that person? And that's going to be different from individual to individual. So, it becomes very, very personal.
So, if you aren't exercising, start exercising. If you're already exercising, how could we improve your regimen to make the maximal benefit for you as an individual?
Thom: If anyone has questions for Dr. Galvin, please chat them or you can use the raise hand function. Doctor, this sounds interesting in terms of a shift in the paradigm away from medicine being about avoiding or treating disease, and instead focusing more on how to sustain that vitality or that resilience and maintaining that quality of life, especially for those with the risk of developing one of these kinds of diseases. What does that mean to you about shifting this paradigm not waiting till the symptoms present and memory loss, and it's maybe more obvious, but trying harder to help those 6 and 10 people who don't necessarily get Alzheimer's to stay as healthy as they can throughout the rest of their life?
Dr. James: We as health providers really need to change the topic of our conversation. We spend way too much time talking about disease and disability and death, we really spend very little time talking about health and vitality and capabilities. We need to stop being reactive and be more proactive. Right?
Let's talk about prevention. Primary prevention, how can we stop the disease from ever appearing? Secondary prevention - maybe it's the beginning of the disease, but we can limit its appearance and emergence, and tertiary prevention - So even those people who are exhibiting signs of disease, how can we limit the effects of disease on that individual?
We could take a very tactical approach, we could look at risk reduction, we could look at healthful behavioral change, we could look at modification and tight management of comorbid medical conditions, right? And so we can make a big impact in a person's life. So instead of taking a one size fits all approach, everybody does the same thing, which really fits no one, we can then take it in a very one approach, treat each individual as an individual, but find out everything about that individual, and tailor that to that person so that we can get the maximal benefit for that person.
Thom: We have a couple of questions in the chat. First from freelancer, Robert Adler. How did you select and standardized the executive function tests that you're describing and could you describe them in more detail?
Dr. James: That's a great question. So, one of the things that we do as a part of our research is trying to develop standardized tests. One of the things we've been very interested in is multicultural approaches to figuring out what puts different people from different racial and ethnic groups at higher risk for developing the disease, and what's the best way to assess this.
One of the things we wanted to do is to take away the effects of language and education and assess brain function. So, we wanted a non-language-based test. And those are very hard to develop. The other thing was, we wanted to move it outside the concept of memory, because memory is affected very early in Alzheimer's disease, but not affected so early in other forms of brain disease. So in vascular forms of the disease, in Parkinson's, or Lewy body dementia, which is the second most common cause of memory problems. In head injury, in frontal lobe disease in multiple sclerosis, memory is not an early domain. So, we wanted to focus more on attention and executive function. This is basically the system of cognition that serves all forms of how people function.
What we chose was looking at a test, which will allow us to take a bunch of symbols, and a bunch of numbers. So it didn't matter whether you knew what the number was or what the symbol was. And at the top of the page, there's a code or a key. So, there are 10 numbers and 10 symbols. That's visible to you the entire time. And then we give a practice portion where you go from a number to a symbol, and then another practice test, where you go from a symbol to a number and then you get a 90-second time limit to go either from symbol to number or number two symbol.
So, the first 16 portions of the test are to go from number to symbol. So, you get used to doing that. Then all of a sudden, we start going from number to symbol or symbol to number and then switch back and forth. And that set switching is really where sort of the neurological stress test is. So just like a cardiac stress test, where you have someone walk on a treadmill that's flat, then you start to raise the treadmill and go a little faster - so it can bring out cardiac perfusion deficits. By adding that set switching component to this pencil and paper test, we start to bring out the neurological deficits. And so, we can pick up these very, very early changes in executive functioning. So, people who are at risk for having a cognitive impairment, we’re able to pick up these deficits, and it's not language based. So, it works very well across all racial and ethnic groups that we've tested it in, in African Americans, Afro-Caribbean, Hispanics, American Indians, Native Hawaiians, Pacific Islanders, it really doesn't matter who we're testing it in. It's performing well.
Thom: Okay, we have another question. This is from Joe Burns at WMFE in Orlando. Joe asks, how does this platform become a part of actual office care, especially for seniors?
Dr. James: That's also a great question. So, we originally developed it as a pencil and paper platform so that we could test it. And we've done it in office settings, as well as in research projects, we've now converted it to a digital platform, so we're now validating it as a digital platform. So, it could be done by the seniors on an iPad, in the waiting room, or at their own homes. And then it would give an output and that output could then be reviewed by the physician, and a plan of care could be developed from that output.
The back end of this is that all of these calculations can be done as part of this output. So, the senior would be able to do the input. The output could be used by the clinician to develop a personalized care plan, which would give them a primary or secondary, or tertiary prevention plan for that individual. It would allow actual in-office care, but the work could all be done outside of the actual physician's time.
Thom: Thank you, Dr. Galvin, any questions from our audience, just a reminder that we will have a video recording and a transcript that we’ll make available of this as soon as possible. And I've chatted into the chat, the links to some B roll and images of Dr. Galvin for use in any of your stories. And I believe that we will be able to share with you a press release or a link to a recent study by Dr. Galvin, and we can follow up with that by email after the event.
Another question here from Craig at next avenue.org. - What's the timeline for mainstreaming this?
Dr. James: Also, a good question. So, we're doing this in clinical practice right now. We've digitized all the tests. We're now trying to cross-validate it against the pencil and paper versions just to make sure that the cross-validity holds. We want to make sure that the tool works in other people's hands. We are testing this platform in remote locations. So, we're doing some testing of this platform on two Indian reservations in South Dakota, we're also testing this platform - or just starting to test this platform in American Samoa again, so we can do it very, very remotely outside of an academic medical center to show that it would work. And so, we hope to be able to offer this, again as an online tool for the everyday healthcare provider to be able to use in their clinical centers.
Thom: This follow-up from Robert, what evidence have you developed to link the personalized treatment plans you develop and longer-term outcomes?
Dr. James: Also, a great question - we are collecting this data as we go on in our project. What we've seen so far, is that by being able to tailor it to an individual, we can look at basically developing sort of one experiment, right? So instead of trying to apply group data to an individual, we can apply individual data to an individual and look and see changes what we've seen by applying this to an individual, we can stabilize cognitive performance or slow cognitive decline in individuals who have memory impairment. We can reduce depression symptoms, we can reduce inflammatory signals, can improve health-related quality of life. We improve nutritional outcomes, we increase physical activity, and we've shown some ability to reduce blood pressure - and that's largely by increasing their physical activity and improving their lipid profiles. So, we really are taking a healthy body, healthy mind, healthy spirit, and healthy brain approach. And this is again, by personalizing it, we can take a holistic approach to that individual by taking all of these inputs from the individual and tailoring the output to build a healthy brain as we get older.
Thom: Thank you, Dr. Galvin. Any other questions? I've chatted about that link to a PubMed link of Dr. Gavin's most recent study on this topic. As like I said earlier, we will provide a video and transcript shortly after the event.
Dr. Galvin, I think that's all the questions for today, I want to thank you very much for your time. And - we have one late coming question. How long have you been working on this?
Dr. James: I had hair when I started. I've been working on this project for 25 years to try and think about these important questions. My grandfather developed dementia when I was in high school, and I always wondered, why did my grandfather develop this disease and other people's granddads didn't - and it became a driving force that- why did this happen to my grandfather? And as I started developing this project, it really came down to - there were certain things that he probably did over the course of his life that other people didn't. But no one ever asked those questions of him. His doctor never asked what he ate, or what he did or how he exercised. And as I began to practice medicine, I realized that no one in medical school ever asks the students to ask these questions. And as we started practicing medicine and doing this, I realized that these are really important things that we don't ask our patients, and there's no standardized way to do it.
So, we wanted to standardize this. And so, we created the tools to standardize this. We collect information. And as we collected the information and started to look at it, we realized that if you're a healthy control and do these things, you do better than if you're a healthy control and don't do these things. So, this really gave us the information that this could really make an important difference in our patients' lives. In 1735, Benjamin Franklin said ‘An ounce of prevention is worth a pound of cure’ and he was right.
Thom: Thank you, Dr. Galvin, very much for your time, and best of luck with all this research. We'll make sure to share with everyone on the call the materials related and the contact for Dr. Galvin and Kaya at the University of Miami. Thank you again, Dr. Galvin, and thank you all for joining. Stay safe, stay healthy and good luck.