Can Alzheimer's Prevention Work via Telemedicine?

Richard S. Isaacson, MD; Hollie B. Hristov, MSN, FNP-C


August 05, 2020

This transcript has been edited for clarity.

Richard S. Isaacson, MD: I'm Dr Richard Isaacson, director of the Alzheimer's Prevention Clinic at Weill Cornell Medicine and NewYork-Presbyterian.

Hollie B. Hristov, MSN, FNP-C: I'm Hollie Hristov, the family nurse practitioner at the Alzheimer's Prevention Clinic.

Isaacson: Today we're going to be talking about how to practice risk reduction or prevention for Alzheimer's disease in the age of COVID-19.

Back in March, when everything changed in New York City and really globally, our practice had to learn to become very nimble and switch as much as we could. A lot of practices throughout the country have had immense trouble doing so. We are fortunate that we've been able to see patients for telemedicine. We're not a heavily procedure-based clinic. But initially we had no ability to do cognitive testing, and our billing came down by about 70%. I have a lot of empathy and compassion for practitioners out there, whether in private practice, more structured settings, or academia, because it's been really tough. We've really struggled, but we're trying to tread water and keep it up.

Normally at the Alzheimer's Prevention Clinic, a new patient comes in, we get to know them, and talk to them for about an hour and a half. To determine what their risk factors are, we begin by having them fill out some surveys. We check their body fat, muscle mass, anthropometrics. We look at their blood for lipids, cholesterol panels, nutrition markers, metabolism markers, inflammation, and some genetics. And then, of course, we do the cognitive assessment and give them a targeted plan based on personalized multidomain interventions.

Hollie, what's it been like managing patients for risk reduction when we just don't have the majority of that information?

Hristov: For new patients, it's been pretty good so far. We don't have those biometrics, labs, or the cognitive testing, but we're getting used to that. The first visit with us is about providing a really long, detailed history. Being able to see the patient and talk over Zoom, or whatever platform, hasn't been so much of a challenge, because it's similar to how we do it in the office. Internet connection and computer issues have been a major obstacle, but other than that the new patient visits have gone well.

In terms of seeing follow-up patients, not having those new labs, the cognitive testing, and the biometrics has made it a bit trickier. We're instead making recommendations based on old things. But we do the best we can. Some patients have had labs with their primaries that we can use, and now some labs are starting to reopen, which is a good thing. We can send patients to get some blood work done and follow-up. It's been a little bit tricky, but not too bad.

Isaacson: I think most people are unaware of the specific approach to risk reduction for Alzheimer's disease. As you mentioned, we take a very detailed history. I learned in neurology residency that a neurologic diagnosis should be made based on the history alone, at least 80%-90% of the time. I would say maybe 70%-80% of our targeted risk reduction interventions can at least be crafted initially by taking a detailed history.

We look at early life, midlife, and late-life risk factors for Alzheimer's. We try to understand a person's cognitive trajectory, how much educational attainment they had. We account for their dietary patterns and exercise patterns. We note whether they have any vascular risk factors, high cholesterol, diabetes, blood pressure. A lot of people have borderline blood pressure that goes unaddressed for a while, which we now know can really have a detrimental effect on the brain. We can perform sleep histories to find out how much sleep they get, how much total sleep using a wrist tracker, whether it's deep sleep or REM sleep.

We can give focused recommendations based on the types of exercise they do, which we can then personalize. We can learn about what stress reduction techniques they are doing. Maybe they're not doing anything there and perhaps don't realize the detrimental impact of stress on brain health. We can at least educate them on the tools that they can use now while we wait until things open up again.

When it comes to the cognitive testing, we've kind of switched gears a little bit. Over the past month, we've been able to start performing our cognitive testing online, which is really cool. I think our patients have enjoyed it. We use a software called TeamViewer to control our computers in the office, and then Zoom to have a conversation with the patient.

For most people, neuropsychological testing has traditionally been done in an in-person, one-on-one fashion. But adopting computer-based testing has really worked for us. We use the NIH Toolbox. We incorporate a face-name associative memory test, which is basically a PowerPoint slide we show patients. We do traditional tests like the Mini-Mental, which we can perform online for the most part. We can ask about animal naming, the Functional Assessment Staging Test, different word tests. We can also do a memory recall, where we give a list of 15 words and grade delayed memory. For practitioners out there who want to do cognitive assessments online, I do think it's possible.

How do you think things have been going with these tests?

Hristov: I think it's gone really well. Patients may not enjoy cognitive testing, but I think that they're okay with it and really appreciate being able to get an assessment at home. We have to be pretty flexible at this time, so I think patients really appreciate getting some information and data on themselves and us being able to follow up with them.

Isaacson: For the viewers out there who are following along with the video, I wanted to share my screen for a moment. Pictured here is the paradigm that we follow in the clinic, which call the "ABCs of Alzheimer's Prevention Management." We published several papers on this paradigm, most recently in in Alzheimer's & Dementia, as well as in an instruction manual to Alzheimer's prevention.

Some of the steps in this paradigm can't be done from home through telemedicine, but a lot can. The "A" in the ABCs stands for "anthropometrics." A lot of people actually have the means to measure body fat and muscle mass at home. You can get a relatively inexpensive scale online for around $100 to $150. They may not be perfect in terms of monitoring someone's anthropometrics, but at least they are consistent internally when that person uses it over and over.

The "B" stands for "blood-based biomarkers." We use a specific panel that is mostly used for preventative cardiologists. We partner with Boston Heart Diagnostics (I have no commercial relationship or relevant disclosures with this company), which has been helpful because it really packages the information in a fairly easy-to-digest way. Most neurologists watching may not be super-aware of apolipoprotein B (ApoB) or low-density lipoprotein particle (LDL-P), but these are really important metrics when it comes to cardiovascular risk factor modification. Most people focus on low-density lipoprotein (LDL) and high-density lipoprotein (HDL), but I think it goes much deeper than that.

There's also a host of inflammatory markers. We can look at diabetes or metabolism tests, such as the homeostasis model assessment of insulin resistance (HOMA-IR). We look at fasting blood sugar and fasting insulin, which calculates the HOMA-IR. We also look at the hemoglobin A1c. People with diabetes are twice as likely to get Alzheimer's disease, and if we can intervene here we can protect memory loss and protect the brain.

Some of the other tests that we order include homocysteine levels, which are really important. The VITACOG studies have shown that when people can get their homocysteine better controlled using B complex vitamins (B6, B12) and folic acid, that can actually slow overall brain shrinkage over time. Watching and reducing homocysteine levels is really important.

Vitamin D is also an important marker. Most people maybe aren't aware that cystatin C is a really important marker. If someone has mild cognitive impairment due to Alzheimer's disease, if the cystatin C is high, the person is more likely to convert to dementia due to Alzheimer's in the next 3 years. When that is low, that person is not as likely to convert to dementia. We look at omega-3 levels, which is complicated because it tends to be more protective in people with the ApoE4 gene. And we also look at some genetics.

These are the types of labs we usually get and, unfortunately, we can't get those right now.

Hollie, if there's someone watching who wants to practice Alzheimer's prevention, which are the labs that you think are most important for risk reduction management?

Hristov: I think that the particle sizes are super-important. I know that it can be very tricky to get insurance to cover that. But if I had my own practice and was able to make up a panel, I think that would be probably my number one thing.

Also, the metabolic numbers — insulin, glucose, hemoglobin A1c. You can even calculate your own HOMA-IR, so although you don't need that included, I think it's relatively cheap. For the inflammatory markers, you can probably just go with C-reactive protein if you need to be basic. Homocysteine is definitely important. And then vitamin D and B12 are also helpful.

If I only had limited markers to choose, those would be the ones I'd select.

Isaacson: I agree. For those watching or reading who want to help patients reduce their risk for Alzheimer's, these labs are helpful, even if it's just having the HDL or the LDL.

As Hollie mentioned, particle size is an important consideration. LDL can have different inflammatory particles. They can be large and fluffy, which may not cause as much damage; or small and dense, which pings against the blood vessel wall and really fast-forwards atherosclerosis. The LDL-P is a marker of that. And more specifically, the ApoB is really, really important.

HDL is a little more confusing. Higher is probably better, but it's a little more confusing. One of the subparticles that was mentioned is the APOA-I. In some papers, the higher the APOA-I, the lower the Alzheimer's risk, but only if you have the ApoE4 gene. So one of the keys here is that we do test for the ApoE4 gene in all of our patients and we really personalize implementations due to pharmacogenomic and nutrigenomic considerations.

This stuff is a little complicated, but we have published several papers on this, including a nice review paper in The Journal of Prevention of Alzheimer's Disease from Dr Carol Berkowitz and colleagues.

And finally, the "C" in our ABCs stands for "cognition." We don't need to perform fancy tests. We can at least do some sort of screening. We really like the NIH Toolbox, and other computer-based tests out there are also relatively good. Odor identification tests are also helpful. That's been very limiting when we're not in person with someone. But we've actually been mailing the smell cards to people, which is one way to do it.

To wrap things up, Hollie, I'd like to ask you for your thoughts. Can we be Alzheimer's prevention specialists remotely? Do you think we have to be in-person or do you think we may not need to have a clinic anymore? You can work from Wisconsin and I can work from Long Island, or something like that.

Hristov: Yes, I think it's possible. But do I want that to be the reality? I'm not sure. Yes, Zoom is great. I do miss connecting with patients in person. But I think this is great because it can reach so many more people. The most important thing that we're finding is simply that it can be done, which is great.

Isaacson: We published 18-month study results showing that these types of multimodal interventions (we recommend, on average, 21 different interventions per person) actually lead to cognitive improvements if they follow these instructions. That's pretty uncommon. There's no drug or intervention that has really shown cognitive improvements at 18 months, but at best perhaps a little bit of a delay in decline.

But I guess what I'm realizing is that telemedicine can reach so many more people. We've had a waiting list for so long and it's been great to begin going down that list. We're meeting people from all over the country and it's fun, because people are generally healthy or maybe have just mild complaints, and we can really make a big impact if we start early.

Hollie, thanks so much. And for our viewers, thanks for taking the time with us today.

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