From left: Dr. James Pacala, past president of the American Geriatrics Society (AGS), fellow AGS member Dr. David Reuben of UCLA, and AGS President Dr. Debra Saliba at the AGS 2017 Annual Scientific Meeting in May in San Antonio, TX, where Dr. Pacala and Dr. Reuben were recognized for their work on the 75th anniversary commemoration of the Society. Credit: © 2017, American Geriatrics Society
BY NOAH GLENN
In this wide-ranging interview, James Pacala, MD, MS, AGSF, past president of the American Geriatrics Society, talks about important advancements in our understanding of the aging brain and related neurologic disorders. He also shares valuable advice for caregivers.
How has the understanding of Alzheimer's disease changed over the course of your career?
One of the biggest changes is increased awareness of Alzheimer's disease and related dementias. And while meaningful treatments to alter the course of the illness have been stubbornly unresponsive, I do think there has been a big change in the number and quality of support systems for caregivers, as well as interventions that allow people to stay in their homes rather than be institutionalized, or to delay institutionalization. Everybody's still holding out hope for some type of biologic or pharmacologic treatment that will fundamentally alter the course of the disease; that just hasn't happened yet.
How has the impact of stroke changed over the years?
The decline in stroke over my 30 years of practice has been precipitous and profound, and has really changed the landscape. Stroke is still a huge problem and still devastating, but it is not as prominent in full-scope adult practice as it was 30 years ago.
Why do you think that is?
It's a real credit to preventive medicine and paying attention to vascular risk factors, and in some cases, earlier and better treatment of acute stroke. There have also been great advances in rehabilitation and the treatment of stroke survivors, but it's been the decline in the occurrence of stroke that has really changed. You just don't see as many older people who've had prior strokes as you used to.
What other changes have you seen?
In Parkinson's disease, new treatments, both pharmacologic and surgical, have emerged or been developed over the past 30 years. There is also a greater understanding of the accompanying health problems associated with the disease and how those can be treated and managed.
What are some significant advancements you foresee in relation to brain health?
I'm guardedly optimistic about genomics and genetic personalized medicine. When scientists decoded the human genome more than 10 years ago, there was great optimism that finding these genetic markers would dramatically individualize and change treatments. That has really only been borne out in a significant way in the treatment of cancer. In all other areas of medicine, that potential has not yet been realized. We've found out that markers are much more complicated than we thought. Even with the ones we understand, the genetic makeup explains only a small amount of the variation between individuals and populations. Of course, that can only get better. I think with supercomputers, computer algorithms, and artificial intelligence, sorting out really complex genetic markers and other types of personal characteristics will incrementally move us toward individualized treatment and risk assessment, but I think we're a fairly long way off. [For more about precision medicine, go to bit.ly/NN-PrecisionMedicine.]
Are there any specific mental or physical activities that you recommend to address age-related mental decline?
Everybody's doing Sudoku and crossword puzzles and stuff like that, and the data on that—I'm not an expert—but the evidence I have seen on that is pretty mixed. I think the pattern that emerges is you need to stay active mentally, physically, and socially. And as you get older, you need to become more proactive in ensuring that you engage in all three of those areas.
How can people be more proactive with exercise?
As you get older, you may get arthritis and your muscle mass may not be what it used to be, and you begin to slow down. Then you have to take a more proactive approach. It doesn't mean you have to go out and run marathons, but you have to actually schedule physical activity. You can't just rely on going out and exercising when you feel like it.
How about socially?
We all can get set in our ways. You have your group of friends, you get your routine down, and after a while you're staying at home more. You're not going out and meeting new people or exploring new social avenues. I think that can be limiting. So you have to be aware of that, and you have to push yourself to say: "I should go and learn a new thing. I should explore a new hobby or meet new people."
What other factors should people keep in mind as they age?
You want to pay attention to your health. It's beginning to emerge that paying attention to and controlling your blood pressure, for example, is probably even more important than we thought. We're understanding that uncontrolled high blood pressure may be as significant a risk factor for developing Alzheimer's disease or related dementias as some of the other traditional risk factors. You've got to try to keep yourself as finely tuned as you can.
How can diet help maintain brain health?
Heart-healthy diets or diets that help control high blood pressure are good examples of eating plans that can help you. For any other diets people are trying, just make sure your health care provider knows about them and says they're okay before you start making any changes. [For more about brain-healthy diets, go to bit.ly/NN-BrainDiets.]
What signs of dementia should people look for as they age?
That's a good question, because everybody experiences a mild diminution and slowing of some cognitive processes as they age—that's normal. And the fact that we don't have any effective treatments for pre-symptomatic cognitive disorders makes it a little bit more difficult. I would say that you need to be aware of your own functioning and when that's declining. Then you need to be in touch often with the people around you—your family members, your spouse, and friends. If they see a decline, if they're doing things for you that you used to do yourself, that's a sign that might point to the need for a broader conversation with your health care provider.
What advice do you have for the caregivers of people with Alzheimer's disease or similar illnesses?
I think it's one of the hardest jobs on the planet. Caregivers do amazingly difficult and challenging work. They probably already know this, but they have to recognize that things are going to change constantly. In the course of an illness that impacts mental health, impairment can fluctuate markedly day to day, week to week. And there can be periods when people do relatively well and periods when they really struggle or when new problems seem to crop up every day. That's hard, and that makes it qualitatively different from most other illnesses where there's a more expected trajectory. In Alzheimer's disease and related dementias, it's a jagged, variable course. Sometimes I see caregivers getting frustrated by that. And I tell them that's what they need to expect but it doesn't mean they're doing anything wrong. Simply pay attention to it and try not to get frustrated by it.
What else should caregivers be mindful of?
If you're a caregiver, you need to take care of yourself. Caregiving is a risk factor for all kinds of problems, and it is very easy to lose yourself and forget about your own needs. Caregivers need to be proactive about staying physically fit and socially active. That can be very difficult with the burdens of caring for somebody. But it's also extremely important, and resources are available to help people do that. To determine how well you're taking care of yourself, go to bit.ly/HealthInAging-Assessment.
To learn more about keeping your brain healthy throughout your life, go to bit.ly/NN-BrainHealthforLife, and listen to our podcast at bit.ly/NN-BrainHealthPodcast.