Alzheimer's May Not Be Exactly What We Thought...


Many of the early years of my career was spent conducting clinical trials on Alzheimer's disease therapies. The medications we were studying were thought to potentially slow the progression of the disease. I enrolled countless patients and caregivers into these trials with one common thread between all of them: hope that their participation would make a difference in the course of Alzheimer's research; if not for them, then for future generations. I'm thankful for the many clinical research participants and caregivers who have volunteered to participate in research for Alzheimer's because their participation has mattered greatly in the development of our knowledge about this devastating disease. We have learned so much about the disease in the last two decades, all of which is guiding our path forward on lessening the impact of Alzheimer's. The potential impact of the disease in the coming years is significant, but thankfully, our hope in lessening the burden of the disease is even greater. 

Alzheimer's disease currently impacts 5.2 million Americans, two-thirds of which are women. It is the sixth leading cause of death in the United States. We now know that 45 million Americans hold a gene called ApoE4, which can increase your risk of developing Alzheimer's disease anywhere between 30-90%. The disease is projected to affect between 13.8 to 16 million people in the U.S. by 2050. Pretty concerning. 

And sadly, even after decades of research on new therapies, we are no closer to either a cure or even an modestly, effective treatment. In fact, of the six medications that have been FDA-approved (one of which was discontinued for safety issues) for Alzheimer's disease, each of them only temporarily reduces the symptoms of the disease for a period of 6-12 months. A new Alzheimer's drug has not been approved since 2003. Alzheimer's is the ONLY one of the nation's 10 most common causes of death for which there is no effective treatment. Yes, there are many new drugs in the pipeline for Alzheimer's disease research as well, but interestingly, each only targets one specific mechanism in the body that we think contributes to Alzheimer's. 

Emerging research is demonstrating that cognitive decline (including Alzheimer's disease) may not actually be caused by one specific mechanism, as once thought. Rather, it seems that cognitive decline can develop based on any combination of 36 different mechanisms. So, while taking a drug that targets one or two of these mechanisms can make a difference, according to Dale Bredesen, MD, whose team has discovered and documented these mechanisms, "it's like trying to plug a roof with 36 different holes." Dr. Bredesen's work is focused on not only what drugs can make an impact on as many of these different mechanisms as possible, but also what lifestyle factors can make a difference in Alzheimer's disease as well. His work is exciting and more research is ongoing. You can learn more about Dr. Bredesen's work in his book entitled "The End of Alzheimer's." 

We know that in individuals with Alzheimer's disease, there is an accumulation of amyloid-beta in the brain. Amyloid-beta is a protein fragment that forms sticky plaques which build up in the spaces between nerve cells. The disease also features neurofibrillary tangles made from another protein called tau that builds up inside of cells. Additionally, neuroinflammation (inflammation in the brain) seems to be the key trigger that causes someone to exhibit symptoms of cognitive decline. In fact, brains of the elderly without cognitive decline were examined after their death and were found to also contain plaques and tangles, but without neuroinflammation, symptoms of cognitive decline were not displayed. 

According to Dr. Bredesen's research, they are finding that production of amyloid beta is actually a normal defense mechanism of the brain to injury, infection or some other type of assault. These assaults can be from inflammation, lack of nutrients or even toxic exposures. Also, the disease process starts decades before someone starts to show symptoms of cognitive decline. In fact, this process can start as early as age 40 in someone with high genetic susceptibility to the disease (those with the ApoE gene, for instance). So early intervention is key in reducing the likelihood of developing the disease. 

So what can we do about Alzheimer's disease? I'm glad you asked because the one thing we can do is focus on the things that we can control. We may not be able to control the time it takes to research new therapies. We also may not be able to control our genetic risk for the disease. But we can begin to impact our approach to Alzheimer's disease by changing our mindset and therefore our approach to risk. First, our genes don't have to necessarily be our destiny. We know that our genes are influenced greatly by our environment, so even if your mother had Alzheimer's disease, steps you take now could impact your ability to prevent the disease. Additionally, we have learned that our brains can change and grow throughout our lifetime, so new behaviors you take on can grow your brain and the networks within it. 

So what do experts recommend that we do to prevent Alzheimer's disease? Change your lifestyle through simple steps that can make a big difference. Ensure 8 hours of quality sleep each night with consistent sleep and wake times. Handle stress in your life- better yet, embrace any stress in your life because it's a reaction to something that you care about deeply. Be engaged with others in community- do all that you can to avoid feeling isolated. Move your body. Our bodies were designed to chase animals for food and walk miles and miles each day foraging. Continue learning new things- read books, learn a new language, hobby, etc. And finally, eat real food. The Mediterranean diet has shown great promise in reducing the risk of cognitive decline, and even improving memory in aging populations. Plus, it's a great way to eat with a focus on fresh, local food around family and friends and with a nice glass of red wine every now and then. 

Interested in leaning more about how you can reduce your risk of cognitive decline? Stepwise Health is offering a new program starting in Spring of 2018 that will guide you through each step of the risk reduction process. You will learn the latest science on how to prevent cognitive decline, learn how our brains are capable of changing and growing throughout our lives and build new habits that will contribute to optimal brain health, energy and longevity. For more information, please contact us directly. We are planning to offer individual and group programs in the local Winston-Salem community. If you live outside of Winston-Salem, we also have a Telehealth option so you can engage in the program from the comfort of home. 


The Evolution of Primary Care


In the next five years, expect your primary care visits to look very different than they do now. Your primary care experience will likely involve more time and attention from your healthcare team. In today's healthcare climate, that seems to be wishful thinking, but there are several drivers that I believe will contribute to this unexpected trend. Several key areas are fueling the need for a much more robust and meaningful primary care experience:

The Rise of Chronic Disease

We have seen volume in our healthcare system increase exponentially over the years because of the rise of more and more chronic disease in our society. "Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems. As of 2012, about half of all adults—117 million people—had one or more chronic health conditions", according to the Centers for Disease Control (CDC). Health risk behaviors are behaviors that contribute to disease that you can change. Four of these health risk behaviors—lack of exercise or physical activity, poor nutrition, tobacco use, and drinking too much alcohol—cause much of the illness, suffering, and early death related to chronic diseases and conditions, per the CDC. In fact, they note that eighty-six percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions. The current model of treating chronic disease is too costly and too little time is available in primary care visits to address the lifestyle factors that are driving disease. Telling patients what they need to do is not enough. Sharing the consequences of not changing lifestyle is demotivating and demoralizing to many patients. Change is extremely hard without adequate support.

Patient-Centered Care

Intuitively, everyone in healthcare knows that patients are the most important part of the equation of care. But, as patients, do we always feel that our wellbeing is a focal point of our care? I greatly value and appreciate the time I spend with my healthcare providers. I'm thankful for their expertise, their insight and their compassion. I appreciate that my provider takes a personal interest in what's wrong with me. And as expected, generally, my visits focus around just that- what's wrong with me. And I'm thankful that when something is wrong, I can reach out to my provider for their help. But who can help me ensure that I'm doing the right things for my health day-to-day? That I'm doing the things that minimize my health risk. Clearly, there is a missing link with what actually happens on the many days, weeks and months between primary care visits. Many of those decisions fall within my own sphere of influence, not my provider's. And honestly, I don't think those should fall within my provider's sphere of influence because he or she needs to attend to other patients who have things wrong that need to be fixed immediately. 

Time Constraints and Healthcare Provider Burnout

Which leads me to my next point- a provider's time is much more limited now. So much has changed in terms of administrative, management and leadership responsibilities for providers in the last 10 years. This challenge became especially apparent with the inception of the electronic health record (EHR). For providers, this adds an administrative layer to their responsibilities that is not only time-consuming, but also has providers scratching their heads as to how to get it all done. Do they park their computer between them and their patient to collect the EHR on the spot and risk the ever-present physical barrier to patient care? Or, do they spend 10+ additional hours a week at home catching up on patient records, when they really want to be with their families? I, for one, don't prefer either scenario. I want a provider who is thriving. When he or she thrives in their life, their patients will thrive too. I want a provider who is present during my visit, but also one who is present for the things that matter to them when they're away from their work. Current estimates show that burnout affects over 60% of primary care physicians according to the American Medical Association.  Healthcare provider burnout is a growing problem that affects the quality, safety and efficiency of patient care. Providers need greater support in the clinical setting to accomplish the excellent care of the patient. 

A New Breed of Healthcare Professional

There is a new type of healthcare professional that is evolving and rising up to help meet the chronic disease challenge. Meet the professional Health and Wellness Coach- the new face you will begin to see as part of your healthcare team within the next five years. According to the International Consortium for Health and Wellness Coaches (ICHWC), Health and Wellness Coaches partner with clients seeking self-directed, lasting changes, aligned with their values, which promote health and wellness and, thereby, enhance well-being. In the course of their work, Health and Wellness Coaches display unconditional positive regard for their clients and a belief in their capacity for change, and honoring that each client is an expert on his or her life, while ensuring that all interactions are respectful and non-judgmental. ICHWC is ensuring a new standard of professionalism and competency with professional Health and Wellness Coaches through a new credentialing process that now recognizes a coach as a National Board Certified Health and Wellness Coach.

When you reach out to see a primary care doctor in the future, you will most likely be connected early on in that process to a professional Health and Wellness Coach who will work with you to, first and foremost, co-create your health and wellness goals based on your unique vision for health. They may even conduct much of the new patient intake process at the practice. You will most likely see your Health and Wellness Coach at each of your primary care appointments, and even stay connected with them even between your visits through phone, video chat or instant messaging. Your Coach will have the time to support you in changing your lifestyle, because that is their primary purpose. They will celebrate your accomplishments with you and inspire you to use your strengths to reach your full vision for health. Your Coach will connect you with the resources you might need to make the changes you desire. Your Coach will focus on what's right with you, while your doctor focuses his/her expertise on fixing what might be wrong when those times come. 

And from a cost standpoint, the entire healthcare system wins because Coaches are a much more affordable option for contributing to the overall management of chronic disease. Coaches support a primary care practice in many ways that can reduce burden on other providers- from scheduling, new patient intake, medical records, education and follow up. And finally, because chronic disease is fueled by lifestyle factors which require sustained behavior change, Health and Wellness Coaches represent one missing link in the chronic disease care equation. They are the experts who have the skill, time and knowledge to support this behavior change process. Research also shows that Health and Wellness Coaches, as part of the healthcare team facilitate greater trust between patients and their providers. 

Early outcomes for research on integrating Health and Wellness Coaches in primary care models are promising, demonstrating the value of health coaching in terms of improved clinical outcomes, which persisted one year after the completion of the health coaching intervention. The study's author encourages primary care clinics to hire Health and Wellness Coaches to equip and encourage patients to self-manage their chronic diseases. 

So, prepare to meet your new Health and Wellness Coach during a future visit to your primary care provider and get ready to create your very best health yet! 

We need to talk about burnout...


I have been burned out at work. And it took it's toll on my life and my health. It detracted from strong relationships that I had built over many years. It affected my family life. It affected my health. I can recall many times waking up in the middle of the night; heart racing, in a cold sweat, with the fear of having to face it all again the next day. Yes, I had stress with my job like everyone, and there were high expectations at my place of employment, but that wasn't it. I can rise to those types of challenges. It was actually a misalignment in my calling and my daily work. At one time, my work in my field served great meaning and purpose in my life, but I changed over time, and so did my interests, values and passion. I had evolved to need something different to fuel my meaning and purpose. What I interpreted as burnout, was actually just friction between my daily work and my calling. And that was for me to figure out, not my employer. And I did. I don't have everything in my life worked out yet, but I know I'm on a path that serves incredible meaning and purpose for me and for what I have been entrusted to give to others. Not all cases of burnout require taking a new direction; some just simply require reconnecting with our original path.

Burnout is a type of stress that occurs when something you care about is at stake. In my case, what was at stake was my personal value to align my calling with my daily work. Today, one of my passions is helping people cultivate their personal resources to build resilience. It's helping people connect to what brings meaning and purpose to their lives. So if you feel as though you're experiencing burnout, take heart. You're experiencing it because you care greatly about something and your heart is trying to get your attention to find, once again, your source of meaning and purpose. It's never lost, it might just be buried under years of thoughts, emotions, images and replays. 

My pastor once told me, "we are human beings, not humans doing". Sometimes, we need to put down our phone or our computer or walk outside of our office and just be. Be alone, be with others, create safe spaces for ourselves where we can recharge and then later, re-engage with our very important world.

So, actually, we need to talk about the opposite of burnout. We need to talk about resilience. Why? Because resilience is the antidote to burnout. But guess what? We generally aren't taught how to be resilient. Even still, resilience can be built. 

Resilience can be built through a few specific areas. Keep in mind though that you already have everything you need within you. It's just a matter of bringing it into the light and consistently using it and sharing it. So, you are ready. 

Mindset and Mindfulness: In particular, positive mindsets: I'm not talking about the kind of positive mindset that thinks that everything is sunshine and lollipops and there are no bad things ever. No, I'm talking about a mindfully-positive mindset that accepts, in a non-judgmental and compassionate way, what is; while acknowledging that with all bad comes some type of good. Maybe not right away, maybe not even for a while, but holding onto the hope that it will be there. Looking for the good in situations always. Looking at the silver lining of your stress. You don't stress about things that don't matter to you, because what you do matters. Meaning comes from a mindset focused on what matters most. 

Knowing Your Strengths: Your strengths are core to who you are. These are the virtues that come naturally to you. You may not know what your strengths are, and that's OK. I knew some of mine, but certainly not all of them. You can find out by taking a free survey online called the VIA survey here and you'll receive a ranking of your strengths. Your top five strengths are called your signature strengths, but you have every strength on the list within you. You may only call them forward only at times when you really need them, or they may be in the background in use without your awareness of them. You can use your strengths to cultivate greater mindfulness in your life. And, you can use mindfulness to become aware of how you leverage your strengths and build strengths. It's a virtuous cycle. And it matters. They should teach this stuff in schools. 

Caring for Others: Research has shown that for each stressful event in one's lifetime, the risk of dying increased by 30%, but with one major exception. For those who routinely spent time helping and caring for other people in their communities, there was actually no increase in risk of death whatsoever, even if they experienced more significant stressful events in their lives. Helping and caring for others also creates resilience. 

We are individuals. What creates meaning and purpose for you will fuel your resilience; but, there is no cookie-cutter approach to building resilience. It is as individual as you are. The approaches I mentioned above are foundations to resilience, but this is a gift for you to discover. What matters most to you? 

A Stepwise approach to building resilience can help, if you are concerned about burnout. Make sure to contact us to get started.