Q4 2021 Bulletin: Brain Health: Strategies for Healthy Aging and Reducing Risks by SCCMA

Official Magazine of the Santa Clara County Medical Association

Vol. 27 | No.4 Fourth Quarter 2021

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2021 SCC MA AW CEREMO ARDS NY

This issue:

BRAIN HEALTH: STRATEGIES FOR HEALTHY AGING AND REDUCING RISKS

SCCMA/CMA Sponsored Insurance Programs

Your Membership Offers Additional Savings of 5%* on Already Low Rates! Preferred Employers Insurance workers’ compensation rates have the potential for savings to physicians. Santa Clara County Medical Association/CMA members are eligible to save an additional 5%* because of their membership! SCCMA and CMA partner with Mercer Health & Benefits Insurance Services LLC and Preferred Employers Insurance to provide best-in-class Workers’ Compensation insurance that includes safety and risk management advice along with outstanding customer service and an easy to navigate website in the event of a claim. This program is already serving the needs of hundreds of California physicians. Have you considered the Safety, Service, Stability, and Savings, offered by Preferred?

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* Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Program Administered by Mercer Health & Benefits Insurance Services LLC

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In this issue SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.

Feature Articles 09 Santa Clara County Healthy Brain Initiative Ethan Giang, MPH, TTS

SCCMA Staff Chief Executive Officer | April Becerra, CAE Deputy Director | Erin Henke Physician Engagement Associate | Angelica Cereno Facility Manager | Paul Moore

SCCMA COUNCILORS El Camino Hospital of Los Gatos | Shahram S. Gholami, MD El Camino Hospital | Anlin Xu, MD Good Samaritan Hospital | Krikor Barsoumian, MD Kaiser Foundation Hospital - San Jose | OPEN Kaiser Permanente Hospital | Joshua Markowitz, MD O’Connor Hospital | David Cahn, MD Regional Medical Center | OPEN Saint Louise Regional Hospital | Scott Benninghoven, MD Santa Clara Valley Medical Center | Harry Morrison, MD Stanford Health Care/Children’s Health | Sam Wald, MD Managing Editor | Erin Henke Production Editor | Prime42 - Design | Market | Host Opinions expressed by authors are their own, and not necessarily those of The Bulletin or SCCMA. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Erin Henke, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850 Fax: 408/289-1064 erin @sccma.org

16 Lifestyle Intervention Can Profoundly Reduce The Burden of Alzheimer’s Disease Dean Sherzai, MD, PhD, MPH, MAS and Ayesha Z. Sherzai MD, MAS

20 Lewy Body Dementia - Hidden in Plain Sight Robin Shepherd

24 Longitudinal Association of Total Tau Concentrations and Physical Activity Prankaja Desai et.al.

25 Association of Social Support With Brain Volume and Cognition Joel Salinas et. al.

26 To Cry or Not to Cry? That’s the Question Norman T. Reynolds, MD

Monthly Columns 05 Membership Insider 06 President’s Message Cindy L. Russell, MD

Community News 04 2021 Year in Review 28 In Memorium 30 Highlights from the 2021 SCCMA Awards Ceremony

New and Noteworthy 32 Upcoming Events 34 Advertiser Index

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The Bulletin | Fourth Quarter 2021 | 3

2021 YEAR IN REVIEW The California Medical Association (CMA) was once again at the center of key state health care policy decisions and action. With CMA’s help, California helped set an example for the nation in vaccinating residents, even as we coped with the rise of the delta variant. In addition to our work on COVID-19, CMA won key victories for physicians in the state budget, helped increase funding for public health and continues to build our physician workforce to help deal with chronic shortages across the state.

COVID-19 Vaccines: CMA worked closely with the Newsom Administration to ensure all Californians had access to vaccines, providing mapping data and physician feedback to help the state build a distribution network that allowed community-based physicians to obtain vaccines for their patients. CalVaxGrant: CMA helped establish and administer the CalVaxGrant program, which provided $40 million to physician practices to help offset the costs of obtaining, storing and administering COVID vaccines.

Justice, Equality, Diversity and Inclusion: CMA created new Standards for Cultural Linguistic Competency and Implicit Bias in continuing medical education.

Telehealth: CMA sponsored AB 457 (Santiago), which ensures patients can access telehealth services from their selected health care providers, rather than a third-party corporate telehealth provider.

Billing Disputes: CMA’s Center for Economic Services recouped more than $1 million from payors on behalf of physician members.

COVID-19 Payments: CMA sponsored SB 510 (Pan), which requires health insurers to cover the cost of COVID-19 tests and vaccine administration.

Vaping Tax: CMA helped pass an increase in the tax on e-cigarettes and vaping products to more closely mirror the taxes on other tobacco products. The bill also ensures future funding for physician workforce programs, such as the physician loan repayment program.

Physician Workforce: CMA successfully advocated to make permanent a portion of Prop. 56 tobacco funds to pay for physician loan repayment and graduate medical education.

State Budget: In the budget process, CMA helped ensure state policy conformed to federal tax law with regard to Paycheck Protection Program loans for physician practices and made permanent the Prop. 56 supplemental payments for Medi-Cal providers.

Visit cmadocs.org for more information.

Membership Insider JOIN OR RENEW TODAY As a member of the Santa Clara County Medical Association (SCCMA) and California Medical Association (CMA), you join more than 4,500 members in Santa Clara County and 50,000 members throughout California of all specialties and practice settings who are actively protecting the practice of medicine and defending public health. We cannot do this alone. Your support through SCCMA/CMA membership is critical to the success of our efforts on behalf of the profession of medicine. Please join or renew your membership today! NEW MEMBERS – Join SCCMA/CMA online today at https://www.cmadocs.org/join. CURRENT MEMBERS – Hurry – renew online at https://www.cmadocs.org/renew before your membership is dropped on March 1. MONTHLY PAYMENT OPTION AVAILABLE – new and renewing members have the option of paying dues with a credit card on a monthly basis. Simply select the monthly dues option when joining or renewing online.

Next CalHealthCares Loan Repayment Program Application Cycle Opens The next CalHealthCares’ application cycle begins January 24, 2022. CalHealthCares provides loan repayment on educational debt for California physicians and dentists who provide care to Medi-Cal patients. Eligible physicians can apply for a loan repayment award of up to $300,000 in exchange for a fiveyear service obligation. Eligible dentists can apply for a loan repayment award of up to $300,000 in exchange for a fiveyear service obligation or a Practice Support Grant of up to $300,000 in exchange for a 10-year service obligation. The program is funded by Proposition 56 (2016) voter-approved, state tax revenues. The FY 2021-2022 (Cohort 4) CalHealthCares application cycle closes February 25, 2022, at 11:59 p.m. Read more at www.phcdocs.org/Programs/CalHealthCares. CMA Launches Free Online CME on Health Equity and Diabetes Prevention The CMA and the California Department of Public Health are proud to present “Break the Bias: Health Equity and the Importance of Screening and Referring for Diabetes Prevention” as a free, online continuing medical education (CME) opportunity for physicians in California. California experienced a large percentage increase in deaths from 2019 to 2020, including from diabetes (17.7%), with differences in death rates within each race/ethnic group increased for all race/ethnic groups, and disparities in rates between groups increased (Data Brief: 2020 Increases in Deaths in California). This one hour and 50-minute virtual CME features experts sharing how screening patients for prediabetes, referring them to the National Diabetes Prevention Program, and identifying and overcoming barriers to screening and referral can advance health equity. The program is available on-demand at cmadocs.org/webinars.

effect on January 1, 2022. The federal No Surprises Act (NSA) prohibits out-of-network health care providers and facilities from balance billing commercially insured patients, in certain circumstances. The NSA and its implementing regulations set a method for determining the patient cost-sharing for these outof-network situations, and when state law does not establish a provider payment methodology, the NSA establishes an independent dispute resolution (IDR) arbitration system to establish provider payment. This toolkit focuses on three operational challenges that physicians will need to address immediately in order to be compliant with the new requirements. The AMA will update the toolkit as additional guidance is available. View the toolkit at https://www.ama-assn.org/system/files/ama-nsa-toolkit.pdf. COVID-Related Stress and Work Intentions in a Sample of U.S. Health Care Workers A new Mayo Clinic Proceedings article led by the AMA explores the relationship between COVID-related stress and work intentions of U.S. health care workers. The article found that physicians, nurses, and advanced practice providers are at the highest risk of reducing clinical work hours or leaving their practice, with one in five physicians and two in five nurses intending to leave their practice altogether. Factors associated with a greater intention to reduce work hours or leave a practice include higher levels of burnout, stress, workload, fear of infection, anxiety or depression due to COVID-19, and the number of years in practice. The article concluded that organizations should implement measures to enhance health care workers’ sense of value, create supportive environments, and reduce work overload through better teamwork to reduce stress and prevent turnover. View the article at https://bit. ly/3EWQRQm.

AMA Releases No Surprises Act Tool Kit The American Medical Association (AMA) has released an initial toolkit for physicians on the implementation of the No Surprises Act (NSA). Many of the provisions of the NSA take www.sccma.org

The Bulletin | Fourth Quarter 2021 | 5

A Message from the President

Here We Go Again by Cindy L. Russell, MD

SCCMA President

The super spreading delta variant of the COVID-19 virus is brazenly mutating to provide us with yet another surge of cases this winter of 2021, with effects significantly more dangerous in unvaccinated people. Omicron, a new South African variant of concern, has more than 30

in four states – Illinois, Michigan, New York and Pennsylvania – although the deer exhibit no symptoms and in general the disease is milder in animals. Mink are one species that appear to spread the virus and pass it back to humans. These animals

There have been a total of 777,000 COVID-19 deaths so far reported in the U.S. since beginning of the pandemic January 2020. variations of the spike protein that could not only increase the transmissibility but also evade the immune system, even in vaccinated individuals. A domino of lockdowns and travel restrictions are now being implemented, once again in many countries, while manufacturers are testing the current vaccines and boosters against Omicron. The Omicron variant has not yet been identified in the U.S. but scientists think it is only a matter of time. Uncertainty continues.

could serve as a reservoir for mutants which may impact efforts to check the virus. Sewer systems, which have identified and monitored COVID worldwide, may also prove to be reservoirs of newer viral mutants that can be transmitted to animals. “Not to sound any alarms, but everything we don’t want to see with this virus seems to happen,” said Arinjay Banerjee, coronavirus researcher at McMaster University in Hamilton, Canada.

Cats with Covid

Healthcare Workers Need a Break

There have been a total of 777,000 COVID-19 deaths so far reported in the U.S. since beginning of the pandemic January 2020. COVID-19 is reaching endemic levels, continuing to spread and mutate. The virus has now been found in dogs and cats whose owners had COVID-19, however, there is no evidence to date that pets can transmit the disease. Surprisingly, COVID-19 from humans has also been found in 40% of white-tailed deer

As we know, the pandemic has stressed the medical profession with a fresh and painful loss of healthcare workers. A Morning Consult report states that almost 1 in in 5 healthcare workers have quit their jobs during the pandemic, citing poor pay and burnout as the primary reasons.

6 | The Bulletin | Fourth Quarter 2021

Wellness and Mindfulness

Although physician burnout was described www.sccma.org

decades ago, physician wellness has become a central focus for healthcare systems and individual practices in this challenging time. The SCCMA has a new Resilient MD program which combines mindfulness practices with peer discussions and support. Thich Nhat Hanh, a Vietnamese monk and the Father of Mindfulness, reminds us of the interrelated nature of all living things and how to deepen our physical connection with the earth. One of his lessons…“We have to walk in a way that we only print peace and serenity on the Earth. Walk as if you are kissing the Earth with your feet.”

postponing cost-effective measures to prevent environmental degradation” (UNEP 1992). It means that once we find there is a reasonable amount of evidence that something is harmful to the environment, and indirectly to us, then we step away from it, study it more and look for safer alternatives. We might think about extending this principle to adequately pretest manufactured products before they are placed on the market, adding a carbon footprint to the data. We may consider shifting from the economic model of the GDP (Gross Domestic Product) to what Rethinking Progress calls the GPI (Genuine

Human innovation and creativity have helped our species develop very convenient tools to advance our society. Reflections: Science, Innovation, Precaution

Human innovation and creativity have helped our species develop very convenient tools to advance our society. The invention of the wheel, which allowed us to more easily connect with each other, evolved into the invention of the cell phone that allows us to connect with almost anyone in the world anytime. Despite the supreme usefulness of these novel wireless gadgets, we are identifying troubling issues which have developed as a result of this technology, with the realization that there are privacy issues, data mining violations, surveillance questions, psychological addiction and dysregulation in children with a “disconnect” among adults and kids who overuse the technology, as well as an exponential increase in energy consumption due to a technology which we now depend upon to the navigate our modern world. We need to be thoughtful about the indirect consequences of innovation. Industry Accountability

Like tobacco, asbestos, Teflon, lead in gasoline, pesticides, factory farming, clear cutting, the internal combustion engine, nuclear power, to name just a few, we have not thought clearly about the long-term or indirect effects such as the erosion of human health, loss of biodiversity and climate change when we develop a new product. We have also now learned that in some cases corporations knew about the harmful effects but hid them from the public (Tobacco Papers, Monsanto Papers, Teflon Papers, Petroleum Papers).

Progress Indicators), which goes beyond just the exchange of money to measure economic success, instead calculating education, health, environment and equity in a circular economy equation without waste…an economy of forethought and prevention. COP 26 Glasglow Conference 2021

Leaders at the Glasgow, Scotland COP 26 revisited pledges from the Paris Agreement of 2015. Greta Thunberg, the now 18-year-old internationally known climate activist, spoke at the COP 26 summit on climate change. She, along with the IPCC scientists, give us 9 years to change our habits to reduce the chance we will land above 1.5 degrees Celsius, when irreversible feedback mechanisms will operate to rapidly warm the planet. Some people think we are already there. CO2 lasts 100-1000 years in the atmosphere, so each individual’s (yours and my) carbon footprint long outlasts themselves and their grandchildren. The CO2 levels in 2021 have reached 419 ppm in our atmosphere when the upper limit should be 350 (350. org). Greta has called the COP 26 climate summit a “failure” and a “PR exercise.” Others call it a COP OUT. Greta, who is not known to be shy about her views on climate change previously said, “We don’t just need goals for just 2030 or 2050. We, above all, need them for 2020 and every following month and year to come.” U.S. Healthcare’s Role in Addressing Climate Change The U.S. healthcare system is responsible for about 10% of our country’s

We have a duty to follow the Hippocratic Oath to, “First do no harm.” This will mean focusing on sustainability as other businesses have done. The Precautionary Principle and Unintended Consequences

Our society works on the principle of invent now, increase profits and study harmful effects later. Europe still operates that way but has incorporated the Precautionary Principle in its deliberations. The Precautionary Principle states, “Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for 8 | The Bulletin | Fourth Quarter 2021

total carbon emissions and about 25% of all global healthcare emissions. We have a duty to follow the Hippocratic Oath to, “First do no harm.” This will mean focusing on sustainability as other businesses have done. Practice Green Health along with Healthcare Without Harm are already establishing best practices for large healthcare systems so they can remain high performing and sustainable for the long run. www.sccma.org

The Lancet Climate Countdown paper (Romanello, 2021) carefully summaries the interwoven issues and healthcare’s future needs to create changes in the underlying social and environmental determinants of health as well. Obstetricians and Gynecologists also now recognize their role in climate change within “the context of women’s reproductive health as a public health issue, a social justice issue, a human rights issue, an economic issue, a political issue, and a gender issue.” (Giudice, 2021) The Perils of Ignoring History

Considering the state of the environment, with species loss, habitat degradation, extreme weather events and burgeoning epidemics of modern disease (especially in children), we need to rethink our strategy as humans on this planet in order to survive. We are now becoming experts in the law of unintended consequences. Widely adopting a meaningful version of the Precautionary Principle while including human rights, could fundamentally change our economy for the benefit of the environment and indirectly help all of the nine billion humans inhabiting our fragile earth. We can otherwise continue to collectively or individually decide to deny, delay and dismiss the problems. (“The Science for Profit Model”, 2021)

Medicine is Still an Honorable Calling

A unique bond of trust and caring is formed with each doctor patient interaction. To heal and see a life improve is immensely satisfying for both involved. This is a result of a long history of rigorous MD training along with a dedication to the profession of medicine and human kind. Pursuing medicine is a selfless act, but one that now only 10% of physicians recommend to their children. The “Business of Medicine” has now overtaken the “Joy of Medicine”, with crushing administrative burdens that are most obvious to private practitioners. Medicine is still an honorable and rewarding calling. Let’s reform the profession, so we can still “enjoy the journey” as Dr. Abraham Vergese wisely advises. The SCCMA like our sister organization, the CMA, will continue to pursue its mission “to promote the science and art of medicine, protection of public health and the betterment of the medical profession.” Join us in this endeavor. “I think we learn from medicine everywhere that it is, at its heart, a human endeavor, requiring good science but also a limitless curiosity and interest in your fellow human being, and that the physician-patient relationship is key; all else follows from it.” ~ Dr. Abraham Vergese, Stanford Professor and author of Cutting for Stone

REFERENCES: The search for animals harbouring coronavirus — and why it matters. Scientists are monitoring pets, livestock and wildlife to work out where SARSCoV-2 could hide, and whether it could resurge. March 2, 2021. https://www.nature.com/articles/d41586-021-00531-z COP26: What was agreed at the Glasgow climate conference? Nov 15, 2021. BBC News. https://www.bbc.com/news/science-environment-56901261 Nearly 1 in 5 Healthcare Workers Have Quit Their Jobs During the Pandemic Medical workers cited COVID-19, poor pay and burnout as reasons for layoffs, resignations. Oct 4, 2021. Morning Consult. https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/ What we know about the Omicron variant. CNN. Nov 27, 2021. https://www.cnn.com/2021/11/26/health/omicron-variant-what-we-know/index.html The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? Milbank Q. 2009 Mar; 87(1): 259–294. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879177/ The Monsanto Papers: Poisoning the scientific well.Int J Risk Saf Med. 2018;29(3-4):193-205. https://pubmed.ncbi.nlm.nih.gov/29843257/ For Decades, Polluters Knew PFAS Chemicals Were Dangerous but Hid Risks from Public. Environmental Working Group. Teflon Documents https://www.ewg.org/pfastimeline/ Exxon Knew about Climate Change almost 40 years ago. Scientific American. Oct 26, 2015. https://www.scientificamerican.com/article/exxon-knew-about-climate-change-almost-40-years-ago/ The Science for Profit Model—How and why corporations influence science and the use of science in policy and practice. Legg et al. . PLOS One. June 23, 2021. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253272 Wingspread Conference on the Precautionary principle: http://www.sehn.org/wing.html The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. The Lancet. Vol 398, issue 10311. Oct 20, 2021. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01787-6/fulltext Climate change, women’s health, and the role of obstetricians and gynecologists in leadership. International Journal of Gynecology and Obstetrics. Giudice LC et al. Oct 25, 2021. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.13958

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The Bulletin | Fourth Quarter 2021 | 9

Santa Clara County Healthy Brain Initiative (SCCHBI) By Ethan Giang, MPH, TTS

Healthy Brain Initiative Lead, Healthy Communities Branch Santa Clara County Public Health Department

Funded by the California Department of Public Health Alzheimer’s Disease Program, Santa Clara County Public Health Department (SCCPHD) is one of six local health jurisdictions in California to be awarded the Healthy Brain Initiative. It is a 2-year project that aims to build and raise awareness of brain health, Alzheimer’s Disease and Related Dementias (ADRD), and cognitive decline risk reduction, education and messaging. Our department goal is to integrate cognitive health as a key component of public health’s prevention framework to prevent chronic diseases and injuries of our aging population. At SCCPHD, we envision all adults thrive in healthy, equitable, and supportive communities that ensure optimal health and promote aging in place.

In Santa Clara County, the older adult population is growing rapidly. About 1 in 4 residents is over the age of 55. By 2050, it is projected that about 1 in 4 will be over age 65. The racial and ethnic demographic distribution of the older adult population is also anticipated to shift from predominately White to increasingly Asian/Pacific Islander and Hispanic/Latinx, while the African American population will remain relatively the same. It is estimated that over 35,300 county residents living with Alzheimer’s disease or a related dementia. By 2040, that number will grow to over 82,300. In 2019, Alzheimer’s disease was the 5th leading cause of death among all residents in the county. Based on the 5-year rate (2015-2019), the age-adjusted death rate due to the disease is 16.4 deaths per 100,000 residents. The death rate of Alzheimer’s disease among female is 17.7 deaths per 100,000 residents compared to 14.2 deaths per 100,000 10 | The Bulletin | Fourth Quarter 2021

residents for their male counterparts. There are some health disparities when looking at Alzheimer’s disease among the African American population. The death rate due to the disease is higher among African Americans (24.7 deaths per 100,000 residents) than White (17.6), Latinx (16.8), and Asian/Pacific Islander (13.1) residents. In addition, 1 in 10 county residents regularly provides care or assistance to someone who has a long-term illness or disability. Residents ages 55-64 comprised the greatest percentage (16%) of caregivers. Caregiving was most frequently provided to a parent. Among caregivers, nearly half (48%) have an annual household income of less than $50,000. Also, paid and unpaid caregivers are more likely to be women ages 50 or older. Caregiving does take a toll on the health and wellness of caregivers in which the emotional stress of providing care is high or very high, www.sccma.org

leading to higher rates of depression, physical illness, and social isolation. Caregivers also named stress (30%) and financial burden (26%) as the two greatest difficulties of their caregiving role. Overall, the data represents a small portion of the burden and the impact among families and caregivers of people living with dementia. From this evidence, the Santa Clara County Healthy Brain Initiative (SCCHBI) takes a deliberate approach to eliminating health disparities within priority populations by: 1) Meaningfully engaging communities with the greatest disparities in cognitive health and caregiving; 2) leveraging partnerships with multisector agencies serving these communities; 3) embedding culturally and linguistically appropriate activities into the SCCHBI work plan; 4) and designing countywide health approaches to uplift all communities. This approach is carried out through an array of resources and services such as in-person and online Brain Health Series workshops (Brain Health & Aging, Dementia Friends, and MIND Diet) at Santa Clara County Senior Nutrition Program sites, distribution of cognitive health education resources and materials, virtual learning/training opportunities on ADRD and caregiver resources for health and service providers, and health education campaigns to raise awareness of brain health and cognitive decline risk reduction education in multiple languages. The challenge of addressing cognitive health and caregiving is complex, and the public health agencies face many demands for their expertise and support that often exceed available resources. Much of the SCCHBI workplan spans the entire populous of Santa Clara County (focusing on adults and older adults) but there are priority populations with which funded partners (Alzheimer’s Association Northern California and Nevada & Roots Community Health Center, South Bay) promote brain health and provide cognitive decline risk reduction education. As an emerging issue, brain health is an integral component of public health because our department’s goal is to protect and improve the overall health and wellness of our community within a racial and health equity framework. The vision of the SCCHBI is to advance cognitive health through community education, participation, and partnerships. The intent is to bring our core essential services (data-driven approach, outreach and education, partnership engagement, and policy development) and risk reduction focused framework into the field of dementia with our internal and external partners by strengthening our data systems of cognitive decline and caregiving among aging population. Another component of the SCCHBI is the opportunity to leverage the current work at SCCPHD Healthy Communities Branch and in the community regarding cognitive health and risk factor reduction: diabetes prevention, proper nutrition, physical activity, and tobacco avoidance. To promote optimal health, we integrate cognitive decline risk reduction education and messaging across all PHD programs via

the informational infographic Stay Sharp – A Healthy Brain at Any Age—a health fact sheet of brain health risk and protective factors and healthy habits to reduce the risk of cognitive health decline with tailored messages for general and priority populations. This infographic also contains chronic disease and injury prevention tips. Stay Sharp – A Healthy Brain at Any Age is available in English, Spanish, Vietnamese, and Chinese. Over the two-year period, the SCCHBI collaborating agencies have been engaged the public to join the movement of becoming a Dementia Friend in partnership with the County of Santa Clara Social Services Agency’s Seniors Agenda. More than 200 people from a diverse group of community members, partners, and stakeholders are part of the Dementia Friends USA. To strengthen our partnership with the Health & Hospital System (hospitals, behavioral health services, social services agencies), the SCCHBI has been successful in hosting several symposiums and webinars to deliver healthcare and service providers education on brain health, cognitive health assessment screening, and ADRD diagnosis, and opportunities to improve care for those they serve through these annual presentations. On the policy level, we will collaborate with the County Senior Care Commission, County Board of Supervisors, and the County Executive Office to establish a County Dementia Plan and Caregiver Resource Hub. Both of which are emerging needs in public policy. Through these collaborations, the SCCHBI strives to educate policymakers about cognitive health and impairment, the impact of dementia on caregivers and communities, and the role of public health in addressing this priority work. By June 30, 2022, the SCCHBI hopes to transform the county to be an age- and dementia-friendly environment where community members, policymakers, and stakeholders recognize risk factors and signs of ADRD, promote cognitive health, and engage in adopting a healthy lifestyle, system and policy changes to reduce behavior, social and environment risk factors associated with ADRD. We aim to manifest strong support of public engagement in chronic disease and injury prevention, brain health, and commitment to a sustainable healthy lifestyle. Healthcare providers and staff will have integrated culturally tailored education on brain health and screening of ADRD to improve care of patients. Most importantly, impacted communities, family members, caregivers, and people living with ADRD will have equitable access to high-quality chronic disease and injury prevention resources, including brain health and cognitive decline risk reduction and health and wellness services.

By Jocelyn Dubin, MS, RD Lead Public Health Nutritionist, Healthy Communities Branch Santa Clara County Public Health Department

Can Nutrition Reduce Alzheimer’s Disease Risk? An Exploration of the MIND Diet

14 Photo | TheCredit: Bulletin | Fourth Quarter 2021 https://penntoday.upenn.edu/news/dietary-adherence-and-fight-against-obesity

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For decades, researchers and medical professionals concluded that the etiological underpinnings of Alzheimer’s disease were wholly genetic. Given this consensus, lifestyle medicine to prevent Alzheimer’s disease was neither widely researched nor advocated. In the past decade, new data elucidates that lifestyle medicine can play a significant role in decreasing the risk of Alzheimer’s disease. Among the most prevalent and universal lifestyle factors contributing to Alzheimer’s disease risk and etiology is nutrition. A 2019 JAMA manuscript entitled “What is Dementia?” states that “Other recommendations for good brain health include keeping mentally, physically, and socially active, eating nutritionally-balanced meals and drinking alcohol only in moderation (not more than one alcoholic drink a day), and getting enough high-quality sleep.“ However, very few patients have an understanding of what constitutes “nutritionallybalanced meals.” In 2015, nutritional epidemiologist Martha Clare Morris and her research team published the results of the nine-year Mediterranean-Dietary Approach to Systolic Hypertension (DASH) diet intervention for neurodegenerative delay, commonly referred to as The MIND Diet. This prospective study, funded by NIH’s National Institute of Aging, showed strong correlations between the consumption of specific foods and beverages and neurodegenerative delay. Those foods are dark leafy greens, colorful vegetables, whole grains, nuts, beans, poultry, berries, fish, and extra virgin olive oil. While these may appear to be familiar constituents of a generally healthy diet, the MIND diet enumerates the frequency with which the aforementioned foods should be included in one’s diet in order to reduce the risk of Alzheimer’s disease. The basis of these frequencies is (1) data on subjects’ vitals that the researchers began collecting in 1997, (2) responses on an annual Harvard semiquantitative food frequency questionnaire which began in 2004, (3) the study subjects’ performance on nine annual clinical evaluations (involving a battery of cognitive tests), (4) statistical control of confounding variables, (5) and extensive review of validated studies related to diet and brain function. All subjects also provided consent for a brain autopsy upon death.

cheese, pastries and other processed sweets, fast food, and fried foods. Given how ubiquitous these “brain unhealthy foods” are in our society, the MIND diet explicates the number of servings per week of these foods that the healthiest cohort included in their diets rather than oversimplifying the results to reflect complete abstinence of these foods in the subjects’ diets. Given that people eat in the real world, it is unrealistic to expect that our patients will strictly adhere to any one dietary prescription or program. The results of the MIND diet study showed promising results for these “real world” eaters. The Mediterranean diet reduces the risk of Alzheimer’s disease if followed strictly. The DASH diet has also been shown to reduce the risk of Alzheimer’s disease with strict adherence. However, neither the Mediterranean nor the DASH diet has been shown to substantially decrease the risk of Alzheimer’s disease if followed loosely. Conversely, the MIND diet reduces the risk of Alzheimer’s disease by up to 53% if followed steadfastly. What’s encouraging is that even those who follow the MIND Diet loosely can reduce their risk of Alzheimer’s disease by up to 35%. In follow up studies, Dhana et al found that the strong correlations between MIND diet adherence and reduced risk of Alzheimer’s disease persisted even for subjects who were carriers of the APOE e4 allele. As scientific advances in Alzheimer’s disease research occur, it is important for us to remember that while we cannot control our own or our patients’ genetic profiles, we can confidently implement and share that what we eat has a profound impact on our brain health. In addition to the many other tools in our clinical toolkits, may we all use food as medicine and our forks as our shields.

The resulting MIND Diet prescribes the following foods and food frequencies: • • • • • • • • • •

1/2 cup cooked or 1 cup raw Dark Leafy Greens per day ½ cup cooked or 1 cup raw Colorful Vegetables per day 1 ½ cups cooked Whole Grains per day 1 oz. Nuts 5 days per week ½ cup cooked Beans 3 days per week 3 oz. cooked Poultry 2 days per week 1 cup Berries 2 days per week 3 oz. cooked Fish per week Extra Virgin Olive Oil as the primary oil used 1 (optional/maximum) 5 oz. glass of Wine per day

In addition to denoting foods to include on a daily and weekly basis, the MIND Diet details foods to limit or exclude from the diet to reduce the risk of Alzheimer’s disease. The foods to minimize or exclude are red meats, butter and stick margarine, www.sccma.org

1. 2.

4. 5.

Arvanitakis, Zoe, and David A Bennett. “What Is Dementia?.” JAMA vol. 322,17 (2019): 1728. doi:10.1001/ jama.2019.11653 Morris, Martha Clare et al. “MIND diet slows cognitive decline with aging.” Alzheimer’s & dementia : the journal of the Alzheimer’s Association vol. 11,9 (2015): 1015-22. doi:10.1016/j. jalz.2015.04.011 van den Brink, Annelien C et al. “The Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and MediterraneanDASH Intervention for Neurodegenerative Delay (MIND) Diets Are Associated with Less Cognitive Decline and a Lower Risk of Alzheimer’s Disease-A Review.” Advances in nutrition (Bethesda, Md.) vol. 10,6 (2019): 1040-1065. doi:10.1093/advances/nmz054 https://www.rush.edu/news/new-mind-diet-may-significantlyprotect-against-alzheimers-disease Dhana, Klodian et al. “Healthy lifestyle and the risk of Alzheimer dementia: Findings from 2 longitudinal studies.” Neurology vol. 95,4 (2020): e374-e383. doi:10.1212/WNL.0000000000009816

The Bulletin | Fourth Quarter 2021 | 15

By Dean Sherzai, MD, PhD, MPH, MAS and Ayesha Z. Sherzai MD, MAS

Lifestyle Intervention Can Profoundly

Reduce the Burden of Alzheimer’s Disease

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The fastest growing epidemic in the United States and most of the world has been dementia, and the most prevalent type of dementia – Alzheimer’s dementia (AD) – represents 60% to 70% of all dementias.

Today, there are more than 50 million individuals worldwide diagnosed with AD, and in the United States alone, there are more than 6.2 million, with one person being diagnosed with Alzheimer’s every 64 seconds. AD is the fastest growing epidemic in the Western world. In the United States, this number is projected to increase to 152 million worldwide by 2050, rising among low-income to middle-income communities. The emotional cost of the disease to those that experience it, and to their families, is overwhelming, and the financial cost is also staggering. Comparing the cost of Alzheimer’s to the second costliest disease – heart disease – is astonishing. Heart disease costs the healthcare system around $120 billion, but Alzheimer’s is significantly costlier at $305 billion in direct costs and another $245 billion in indirect costs. The cost is expected to grow to more than $1.1 trillion in the next 20 years, which will absolutely devastate our healthcare system. Women, African Americans, and Hispanics appear to be at much greater risk. One in six women are diagnosed with dementia in their lifetime compared with 1 in 11 men. Compared with Caucasians, African Americans have a two to three-time greater risk of developing AD, and Hispanics have a two-time greater risk. It is in this environment that we have been chasing amyloid plaques and neurofibrillary tangles for the past 30 years. To that end, researchers have created many cellular and animal models of the disease on which they have tested thousands of molecules. They create the proverbial “lesion” and find a molecular “plug” to fix it. In this way, they have been able to cure or at least curtail the disease in dozens of scenarios. But when translated to human trials, these methods have failed to provide the desired outcome in every instance. To date, AD has been described in many ways and by some, as type 3 diabetes. Others have described it as a garbage disposal disease and yet others as an inflammatory/immune regulation disease. The reality is that one can approach the disease from different paths. There are patients who have a history of chronic insulin resistance or diabetes, and in these cases, insulin resistance primarily drives the disease, and yet

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chronic inflammation may be the main driving force behind the inception and propagation of the disease in other cases such as chronic traumatic encephalitis. Lipid dysregulation, as driven by Apo e4 or other pathways, can serve as a driver of neurovascular and neurodegenerative disease as well. And finally, oxidative stress can be a major driver of neurodegeneration as a result of free radical formation, damaging neural architecture and vasculature1. We also know that chronic, low-grade systemic inflammation is common in insulin-resistant states, which are seen consistently in many of the pathways toward the disease. These four processes are involved in the neurovascular and neurodegenerative processes. The only factor that changes is the dominant driver of the underlying pathology. Reviewing the literature, we have found that there are five fundamental factors that can significantly influence the four pathways leading to AD described above. These factors are related to Nutrition, Exercise, Stress management, Restorative sleep, and Mental and social optimization. To make it convenient to remember the concepts and incorporate them as needed we have come up with the acronym “NEURO” to help healthcare professionals and the general public. “N” is for Nutrition, “E” Exercise, “U” for Unwind (stress management), “R” for Restorative Sleep, and “O” for Optimize. Nutrition

With regards to Nutrition, despite a great deal of confusion in social media, in the scientific realm there is no question that there is plenty of evidence that a plant-centered diet low in saturated fat, processed sugar, and salt can significantly reduce one’s chance of developing dementia. Whether one looks at the studies coming from the Adventist health study (vegetarian diet), the Framingham study, the California teacher’s study (Mediterranean diet), or the Chicago healthy aging project (MIND diet), the common denominator consistently has been a diet high in greens, beans, cruciferous vegetables, nuts, foods high in omega 3s, herbs and spices, and water as the main source of liquid consumption.

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Exercise

Exercise is more important for the brain than any other organ. A Harvard study demonstrated that a 25-minute brisk walk every day reduced one’s chance of developing dementia by as much as 45%. Though we have always known that exercise is good for us, we didn’t know that it would have such a profound effect on our risk of dementia, stroke, and even psychological diseases like depression and anxiety. Another remarkable fact is that leg strength is correlated with bigger brains and better brain health. Given that exercises provide us the quickest and most effective response, we always start a lifestyle change program with a simple exercise regiment, like a brisk morning walk. Unwind (Stress Management)

The third element of NEURO – U for Unwind – speaks to managing stress by specifically addressing the bad stress in our life and increasing the good stressors. Bad stress is the kind of stress that is not driven by our purpose, doesn’t have clear objectives and successes, whereas good stressors are those activities that serve our purpose, have clear successes and timelines, such as learning to play a musical instrument, learning to dance, learning a new language, taking a class one always wanted, leading a book club, and other similar activities. Restorative Sleep

The fourth element of NEURO speaks to sleep – but not just going unconscious. Rather, going through the four phases of sleep at least four to five times per night. To achieve this

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Restorative sleep, one needs to use sleep hygiene techniques, such as keeping a consistent pattern of sleep (consistently going to bed at the same time and waking up seven to eight hours later). Other sleep hygiene techniques include managing bedroom light and sound, not using electronic devices or watching the television a half an hour before sleep, not eating at least two hours before sleep, and keeping the room temperature slightly on the cooler side. And if despite these techniques, running thoughts are affecting sleep, then cognitive behavioral therapy should be applied. Optimize Mental and Social Activity

Lastly, but not least, is the O for Optimizing mental and social activity. In a recent study, it was shown that the most powerful factor protecting the brain is cognitive reserve, which is achieved through challenging, purpose-driven activities. As demonstrated by two famous studies (the nun study and the taxi driver study), challenging mental activity can increase cognitive reserve more than anything else and can profoundly delay the onset of dementia. As we discussed previously, Optimizing mental activity is the similar to the effects of good stress and can build capacity at any age. Some of the other factors that appear to affect risk are diminished hearing, smoking cigarettes, drinking more than one glass of wine per day, and head trauma. It is now universally accepted that as much as 60 % of AD can be prevented, but these numbers come to us from suboptimal lifestyle interventions. We believe that as much as 90% of AD

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can potentially be prevented or delayed past normal age (80 yrs.) if started earlier and through more optimal interventions. But irrespective of the numbers, 60 or 90%, for a disease that is expected to overwhelm our healthcare system, and one that has no disease-altering treatments, we think it is critical

that physicians start speaking about and applying the abovementioned interventions to those most at risk as even a 20% reduction in risk and prevalence of AD would significantly reduce the financial and social burden to our communities.

About the Authors:

Dr. Dean Sherzai is a behavioral neurologist / neuroscientist whose entire life has been dedicated to behavioral change models at the community and population level. Dr. Sherzai finished his medical and neurology residencies at Georgetown University with a subsequent fellowship in neurodegenerative diseases at the National Institutes of Health, followed by a second fellowship in Dementia and Geriatrics at the University of California, San Diego. He also holds two master’s degrees in Advanced Sciences at UCSD and in Epidemiology from Loma Linda University. He has received a PhD in Healthcare leadership focused on community empowerment from Loma Linda/Andrews University. Finally, he completed the executive leadership program at Harvard Business School. His vision has always been to revolutionize healthcare by empowering communities to take control of their own health. Dr. Ayesha Z. Sherzai is a vascular neurologist and a research scientist. After completing her residency, she completed a fellowship in vascular neurology and Epidemiology at Columbia University Neurological Institute of New York. Dr. Sherzai is at the tail end of a master’s degree in public health in lifestyle epidemiology from Loma Linda University. Knowing the importance of empowering her patients, and their communities, she completed an extensive culinary training program in New York and now teaches large populations how to make tasty, easy, and healthy meals for their brain health. They are the authors of two best-selling books, The Alzheimer's Solution (2017, HarperCollins) and The 30 day Alzheimer's Solution (2021, HarperCollins). They are currently leading the largest community-based brain health initiative in the country.

Preventing Alzheimer’s: Our Most Urgent Health Care Priority, Dean Sherzai, MD, MPH, PhD(c) and Ayesha Sherzai, MD, Am J Lifestyle Med. 2019 Sep-Oct; 13(5): 451–461. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732875/#bibr37-1559827619843465

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The Bulletin | Fourth Quarter 2021 | 19

By Robin Shepherd Executive Director and Co-Founder, The Sue’s Story Project

Lewy Body Dementia Hidden in Plain Sight

What is LBD?

How does LBD fit into the dementia syndrome?

Lewy body dementia (LBD) is a complex and challenging brain disorder that affects thinking, movement, behavior and mood. It has been “hidden in plain sight” for decades despite the fact that it is a leading cause of dementia, along with Alzheimer’s and vascular diseases.

Lewy body disease is associated with two possible outcomes of progressive dementia: dementia with Lewy bodies (DLB) or Parkinson's disease dementia (PDD). Because DLB shares some symptoms with Parkinson’s, Alzheimer’s, and psychiatric disorders, it can be difficult to diagnose or be misdiagnosed. It is not unusual for patients to consult with multiple physicians over a period of three or more years before receiving an LBD or DLB diagnosis. Today, the term Alzheimer’s Disease and Related Dementias (ADRD) is used by the National Institutes of Health (NIH) and other organizations to collectively refer to neurodegenerative causes of dementia. To further clarify, ADRD is defined to include Lewy body dementia (LBD) as well as frontotemporal degeneration (FTD), vascular contributions to cognitive impairment/dementia (VCID), and mixed etiology dementias (MED).

This historic lack of awareness, education, training and research focused on Lewy body dementia created a domino effect that has hindered progress toward a cure and thwarted efforts to care for people living with LBD today. More attention and resources must be focused on LBD to fully understand the cause, develop tests for a definitive diagnosis, and pursue clinical trials to find a cure. Until there’s a cure, improvements are needed in healthcare approaches and options for people with LBD and their caregivers.

20 | The Bulletin | Fourth Quarter 2021

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Lewy body dementia (LBD) is characterized by abnormal deposits of the protein alpha-synuclein in the brain. The pathology was first described by a German neurologist named Dr. Friedrich H. Lewy in his studies of Parkinson’s disease (1912-13). His findings were confirmed by Dr. Konstantin Tretiakoff, a Russian neuropathologist, who coined the term “Lewy bodies” (1919, 1921). A half-century later, dementia with Lewy bodies (DLB) was first described by Dr. Kenji Kosaka, a Japanese psychiatrist (1976). The build-up of Lewy bodies interferes with neurotransmitters (chemical messengers) in the brain, and causes neurons to die.

What symptoms are associated with LBD?

All LBD patients present with dementia: progressive cognitive decline to the extent that it interferes with normal activities of daily living. Not all patients present with the same set of symptoms, and these may change with disease progression. • Fluctuating cognition, periods of confusion, lack of focus or attention • Trouble with executive function: thinking, judgment and decision-making • Recurrent visual hallucinations • Parkinsonism (bradykinesia, rest tremor, rigidity, balance issues) • REM sleep behavior disorder, hypersomnia, hyposomnia • Visuo-spatial deficits • Memory impairment • Difficulty with language, word-finding, conversation

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• Postural instability, repeated falls, syncope • Anxiety, apathy, agitation, depression • Autonomic dysfunction (for example, incontinence, constipation) • Severe sensitivity to certain medications (anti-psychotics, opioids)

The Bulletin | Fourth Quarter 2021 | 21

LBD patients need an advocate. Even in early stages of the disease, people may have difficulty organizing and expressing thoughts, needs and feelings. They may exhibit “showtime” behavior, masking the fact that they are confused by test results or discharge instructions. They may be unable to say if a medication is working or describe pain or other problems. Healthcare professionals need to bring the family caregiver into the conversation in healthcare settings from clinic to hospital.

What steps are taken to form a diagnosis?

Depending upon the health system, the physician(s) and the patient, evaluation and testing may include a combination of the following: • Evaluation of patient’s medical history/physical examination • Neurological examination for Parkinsonism • Cognitive Screening (MoCA/MMSE/Mini-Cog), Neuropsychological Testing • Brain Imaging—MRI, CT, PET, EEG • Bloodwork, cerebrospinal fluid testing • Functional Activities/ADLs (Activities of Daily Living) • Sleep Study When LBD is suspected, researchers and physicians often use the “one-year rule” for diagnosis: onset of dementia within one year of parkinsonism qualifies as dementia with Lewy bodies (DLB), and onset of dementia more than one year after parkinsonism qualifies as Parkinson's disease dementia (PDD). Diagnosis can be challenging for a number of reasons beyond the current lack of a definitive test for LBD. People may not recognize, understand or accept symptoms they are experiencing, or they may rationalize their symptoms as part of normal aging. People in these cases are less likely to discuss symptoms with their doctor or family members. Doctors with no training or experience with DLB patients may not recognize symptoms in their patients, particularly during medical visits of 22 | The Bulletin | Fourth Quarter 2021

short duration. A physician may refer a patient presenting with LBD symptoms to a specialist for a second opinion. For example, a neurologist specializing in movement disorders may refer a patient to a geriatric psychiatrist for additional evaluation and testing. Given that LBD involves a combination of cognitive, motor and behavioral symptoms, a second opinion can provide important insights in forming a differential diagnosis. What are the stages of LBD progression, the prognosis?

The stages of progression are often described as early, middle and late stage dementia. While symptoms and progression vary among people with any type of dementia, during the early stage people may still be able to function independently but may experience problems with planning, decision making and other activities. In the middle stage, cognitive decline continues while behavior changes and physical symptoms may become more pronounced and the need for caregiver support increases. In late-stage dementia people typically require full-time care and support that may involve transition to a memory care facility. LBD typically occurs in people aged 50 or older, with 67 being the average age of symptom onset and 76.3 the average age of formal diagnosis. Life expectancy for people with LBD is about 5 to 8 years from time of diagnosis, but survival can vary on both sides of this range.

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How is LBD treated, and what are key challenges to treatment?

Currently there is no cure for Lewy body dementia, and as yet, no drug has been approved by the FDA for treatment of the disease. Drugs such as donepezil or rivastigmine (acetylcholinesterase inhibitors) are used primarily to treat a patient’s cognitive symptoms. People with LBD tend to be highly sensitive to certain medications including antipsychotics or sedatives used to treat behavioral symptoms. Thus, physicians may avoid or exercise caution in prescribing them to avoid risk of worsening some LBD symptoms or other potential harms. Advances in healthcare include increased use of palliative care and management of behavioral symptoms with non-medication alternatives such as improved caregiver training and support, creative activities involving music and art, and innovative solutions for lighting, housing design and other environmental elements of daily living.

Science tells us that diseases associated with dementia may begin to impact the brain long before symptoms appear. Increasingly, physicians are encouraging patients to adopt brain healthy lifestyle choices—good nutrition, regular exercise, lifelong learning, social engagement, sufficient sleep of good quality, avoidance of substance abuse, treatment for depression—early in life, to help reduce or avoid risk of dementia in our later years. Disclaimer

The information in this article is for informational purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Mention of drugs or medications or their manufacturers does not constitute an endorsement, recommendation, prescription or directive of any kind.

What types of research studies/trials are underway?

As of this writing, the clinicaltrials.gov database lists a small number of clinical trials related to LBD. Among these, 41 are recruiting, 12 are not yet recruiting, 7 are recruiting by invitation, 6 are active, 52 are completed and 5 were terminated. In November 2021, phase 2 clinical trial results were published for an investigational drug, neflamapimod, demonstrating disease-modifying potential for dementia with Lewy bodies (EIP Pharmaceutical). This type of news is encouraging given the many challenges to LBD research, from trial design and patient recruitment to diagnostic criteria, use of biomarkers, and demands on patients participating in clinical trials.

About the Author

Robin Shepherd is the Executive Director and co-founder of The Sue’s Story Project (thesuesstoryproject.com), an initiative that seeks to increase awareness, caregiver resources, and research funding to find a cure for Lewy body dementia, a fatal neurodegenerative disease. Robin can be reached at shepherdrobin7@gmail.com or (408) 458-6102.

What are the key risk factors – keys to prevention?

With more research, scientists will continue to learn more about risk factors for LBD. Some of the known risk factors for LBD include: • • • •

Age REM sleep behavior disorder Parkinson’s disease Family history of LBD (variants in APOE, SNCA and GBA genes may indicate risk)

RESOURCES https://www.ninds.nih.gov/Disorders/All-Disorders/Dementia-Lewy-Bodies-Information-Page https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496518/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782269/ https://pubmed.ncbi.nlm.nih.gov/28592453/ https://www.nia.nih.gov/health/diagnosing-lewy-body-dementia-professionals https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181810/ https://medlineplus.gov/genetics/condition/dementia-with-lewy-bodies/#causes

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The Bulletin | Fourth Quarter 2021 | 23

Longitudinal Association of Total Tau Concentrations and Physical Activity With Cognitive Decline in a Population Sample By Pankaja Desai, PhD; Denis Evans, MD; Klodian Dhana, MD, PhD; Neelum T. Aggarwal, MD; Robert S. Wilson, PhD; Elizabeth McAninch, MD; Kumar B. Rajan, PhD Importance

Main Outcomes and Measures

Tau is a brain protein located in neurons and develops abnormally in individuals with Alzheimer disease. New technology is convenient for measuring blood total tau concentrations and provides a unique and increased opportunity for early intervention to slow cognitive decline.

The main outcome for this study is global cognitive function, measured through a battery of cognitive tests. The study hypothesis was developed after data were collected.

Objective

To evaluate the association of physical activity and total tau concentrations with cognitive decline at baseline and over time. Design, Setting, and Participants

The Chicago Health and Aging Project is a populationbased cohort study conducted in 4 Chicago communities. Data collection occurred in 3-year cycles between 1993 and 2012. Participants completed in-home interviews. Clinical evaluations, which included blood samples, were performed with a stratified random sample of 1159 participants. Statistical analyses were conducted from October 30, 2020, to May 25, 2021. Exposures

Physical activity and total serum tau concentrations. Data on physical activity were obtained through self-report items, and a sum of minutes per week was calculated. Little physical activity was defined as no participation in a minimum of 4 of the items on the physical activity measure. Medium activity was defined as participating in less than 150 minutes of physical activity per week, and high activity was defined as participating in 150 minutes or more of physical activityper week.

Results

Of the 1159 participants in the study, 728 were women (63%), and 696 were African American (60%); the mean (SD) age was 77.4 (6.0) years, and the mean (SD) educational level was 12.6 (3.5) years. Participants with high total tau concentrations with medium physical activity had a 58% slower rate of cognitive decline (estimate, –0.028 standard deviation unit [SDU] per year [95% CI, –0.057 to 0.002 SDU per year]; difference, 0.038 SDU per year [95%CI, 0.011-0.065 SDU per year]), and those with high physical activity had a 41% slower rate of cognitive decline (estimate, –0.038 SDU per year [95%CI, –0.068 to –0.009 SDU per year]; difference, 0.027 SDU per year [95%CI, –0.002 to 0.056 SDU per year]), compared with those with little physical activity. Among participants with low total tau concentrations, medium physical activity was associated with a 2% slower rate of cognitive decline (estimate, –0.050 SDU per year [95%CI, –0.069 to –0.031 SDU per year]; difference, 0.001 SDU per year [95%CI, –0.019 to 0.021 SDU per year]), and high physical activity was associated with a 27%slower rate of cognitive decline (estimate, –0.037 SDU per year [95%CI, –0.055 to –0.019 SDU per year]; difference, 0.014 SDU per year [95%CI, –0.007 to 0.034 SDU per year]), compared with little physical activity. Individual tests of cognitive function showed similar results. Conclusions and Relevance

KEY POINTS Question Is physical activity associated with slower cognitive decline in people with higher total tau concentrations? Findings In this population-based cohort study comprising 1159 participants, medium physical activity was associated with a 58% slower rate of cognitive decline, and high physical activity was associated with a 41% slower rate of cognitive decline compared with little physical activity among those with high total tau concentrations. For participants with low total tau concentrations, medium physical activity was associated with a 2% slower rate of cognitive decline, and high physical activity was associated with a 27% slower rate of cognitive decline compared with little physical activity. Meaning This study suggests that measurement of blood biomarkers may offer an opportunity for early intervention of physical activity to reduce the rate of cognitive decline.

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This study suggests that, among participants with both high and low total tau concentrations, physical activity was associated with slower cognitive decline. Results support the potential utility of blood biomarkers in measuring the benefits associated with health behaviors and may contribute to specifying target populations or informing interventions for trials that focus on improving physical activity behavior. Future work should examine the association of total tau concentrations with other health behaviors and physical activity types. Article Citation: Desai P, Evans D, Dhana K, et al. Longitudinal Association of Total Tau Concentrations and Physical Activity With Cognitive Decline in a Population Sample. JAMA Netw Open. 2021;4(8):e2120398. doi:10.1001/jamanetworkopen.2021.20398 Read the full article at https://bit.ly/3pRO1b8

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Association of Social Support With Brain Volume and Cognition By Joel Salinas, MD, MBA, MSc; Adrienne O’Donnell, BA; Daniel J. Kojis, BA; Matthew P. Pase, PhD; Charles DeCarli, MD; Dorene M. Rentz, PhD; Lisa F. Berkman, PhD; Alexa Beiser, PhD; Sudha Seshadri, MD Importance

Cognitive resilience refers to the general capacity of cognitive processes to be less susceptible to differences in brain structure from age- and disease-related changes. Studies suggest that supportive social networks reduce Alzheimer disease and related disorder (ADRD) risk by enhancing cognitive resilience, but data on specific social support mechanisms are sparse. Objective

To examine the association of individual forms of social support with a global neuroanatomical measure of early ADRD vulnerability and cognition. Design, Setting, and Participants

This retrospective cross-sectional analysis used prospectively collected data from Framingham Study participants without dementia, stroke, or other neurological conditions who underwent brain magnetic resonance imaging and neuropsychological testing at the same visit. Data from this large, population-based, longitudinal cohort were collected from June 6, 1997, to December 13, 1999 (original cohort), and from September 11, 1998, to October 26, 2001 (offspring cohort). Data were analyzed from May 22, 2017, to June 1, 2021. Exposures

Total cerebral volume and, as a modifying exposure variable, self-reported availability of 5 types of social support measured by the Berkman-Syme Social Network Index. Main Outcomes and Measures

The primary outcome was a global measure of cognitive function. Cognitive resilience was defined as the modification

of total cerebral volume’s association with cognition, such that smaller β estimates (presented in SD units) indicate greater cognitive resilience (ie, better cognitive performance than estimated by lower total cerebral volume. Results

The study included 2171 adults (164 in the original cohort and 2007 in the offspring cohort; mean [SD] age, 63 [10] years; 1183 [54%] female). High listener availability was associated with greater cognitive resilience (β = 0.08, P < .001) compared with low listener availability (β = 0.20, P = .002). Overall findings persisted after adjustment for potential confounders. Other forms of social support were not significant modifiers (advice: β = −0.04; P = .40 for interaction; love-affection: β = −0.07, P = .28 for interaction; emotional support: β = −0.02, P = .73 for interaction; and sufficient contact: β = −0.08; P = .11 for interaction). Conclusions and Relevance

The results of this cross-sectional cohort study suggest that social support in the form of supportive listening is associated with greater cognitive resilience, independently modifying the association between lower total cerebral volume and poorer cognitive function that would otherwise indicate increased ADRD vulnerability at the preclinical stage. A refined understanding of social support mechanisms has the potential to inform strategies to reduce ADRD risk and enhance cognitive resilience. Article Citation: Salinas J, O’Donnell A, Kojis DJ, et al. Association of Social Support With Brain Volume and Cognition. JAMA Netw Open. 2021;4(8):e2121122. doi:10.1001/jamanetworkopen.2021.21122 Read the full article at https://bit.ly/3eOekZm

KEY POINTS Question What is the association of different forms of social support with an early neuroanatomical marker of Alzheimer disease vulnerability and cognitive function? Findings In this cross-sectional study, high (vs low) availability of supportive listening was associated with cognitive resilience, which indicated better global cognitive function than expected for lower cerebral volume. This association was absent for other forms of social support. Meaning In psychosocial interventions and related public health strategies to promote neurocognitive health, precise targeting of specific forms of social support, such as supportive listening, may be warranted.

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The Bulletin | Fourth Quarter 2021 | 25

To Cry or Not to Cry? That is the Question

“Those who do not weep, do not see.” ~ Victor Hugo, Les Misérables

I entered medical school at age 20, and now I am over 70 years old. In that span of over half a century, I have never, ever seen a doctor cry. I have never heard a doctor talk about feeling like crying. It never occurred to me to ask, “How I should handle such feelings?” Instead, I wanted to hide my feelings and pretend I did not have them. I was ashamed. I thought there was something wrong with me that I had such feelings in my role as a professional. I saw myself as less than, as inferior, defective for even having such feelings. As an intern assigned to pediatrics, I attended children who had terminal illnesses. I recall watching the life drain out of a boy undergoing treatment for leukemia. On nights that I was not on call, I would get down on my knees before getting into bed and pray (something that I did not routinely do, or more accurately rarely did). I pleaded to God to let the boy die that night when I was not on call. Why? I was afraid. If he died on my watch and I had to pronounce him dead and interact with his parents, I knew I would tear up, perhaps lose my voice, or even breakdown and cry. Well, thank God, he did die on a night that I was off. However, thereafter, I was still in a quandary. What was I to do to acknowledge his passing? I knew I could not talk in person to his parents because, again, I might cry. I decided to write his parents a letter of condolence. In the wake of his death, none of my coworkers (including me) talked about him or how to express ourselves to the family. There was no discussion of our feelings of sadness and loss and how to respond. Could we do things that ordinary human beings do, like go to his funeral service, or send a card, or send flowers? The boy passed, his room was cleaned, and we were onto our next patient—business as usual. In saying this, I don’t want to imply that he was not treated by the physicians and staff in a caring way because they did. But, discussion of feelings was an unspoken taboo. Physician feelings of sadness, grief, and 26 | The Bulletin | Fourth Quarter 2021

morning were taboo topics, as if such feelings didn’t exist. How did this experience affect me? Previously, I had considered pediatrics as a field of specialization. I like children. However, given my emotional make up, I decided that I could not become a pediatrician. I did not fit into the culture of my colleagues. Obviously, I was not emotionally strong enough. Over subsequent years, on my own, I developed a different perspective. About a year after entering practice as a veterinarian, my daughter called me on the phone one night and said: “Dad, I am in trouble. I might lose my job.” She had been the vet for a family whose pet dog eventually had to be euthanized. At a final gathering, the two young children were overcome with grief. In response, she hugged them, and then she teared up. She told me that as students, she and her classmates had been explicitly told not to show such emotions. I responded: “People know instinctively when you are crying for yourself and when you are crying for them. If your colleagues can’t see that, they don’t deserve to have you.” The comforting words of a father were not enough to erase the fear. Of course, neither the family nor the support staff registered a complaint against her. On the contrary, a month later, a large bouquet of flowers arrived at the clinic with a card addressed to her thanking her for “caring” and requesting that, when they were ready to adopt a new pet, they wanted her to help them in the selection. The staff placed the bouquet with the card on the office reception counter for all to see. Yes, as professionals, we have to exercise some restraint over our emotions. But, our patients know the difference between crying for them and self-indulgence on our part. Sometimes, especially when there is nothing else we can offer, they just need our compassion. Think about it: “To cry or not to cry? What kind of doctor do you want to be?” www.sccma.org

By Norman T. Reynolds, MD Distinguished Life Fellow of the American Psychiatric Association

“Do not apologize for crying. Without this emotion, we are only robots.” ~ Elizabeth Gilbert, Eat, Pray, Love

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The Bulletin | Fourth Quarter 2021 | 27

In Memoriam

The Santa Clara County Medical Association pays tribute to our members who have recently passed away. May their shared memories and many contributions be celebrated by all.

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DR. MARK LILLO

DR. CHARULATA RAMAPRASAD

DR. TAMEROU ASRAT

DR. BARRY BRUMMER

DR. SAHEJ SIDHU

DR. MARTY FENSTERHEIB

DR. CLIFFORD WANG

30 | The Bulletin | Fourth Quarter 2021

www.sccma.org

Highlights from the 2021 SCCMA Awards Ceremony The Santa Clara County Medical Association celebrated the 43rd Awards Gala on Thursday, December 2, 2021. The virtual meeting gathered physicians for an evening celebrating the work of the SCCMA, hearing from renowned speakers, and recognizing those making a difference in medicine and in their communities. The SCCMA thanked our outgoing president, Cindy Russell, MD and introduced our incoming president, Clifford Wang, MD. We were joined by special guest speaker, Dr. James Doty, TedTalks speaker and New York Times bestselling author of

"Into the Magic Shop: A Neurosurgeon's Quest to Discover the Mysteries of the Brain and the Secrets of the Heart" and "Lessons from the Magic Shop" to talk about stress management and how compassion can be a cure for chronic stress. We also received an update from California Medical Association President-elect, Donaldo Hernandez, MD. You can view a recording of the 2021 Annual Awards Gala at https://bit.ly/3sY7j0u.

Congratulations to all the 2021 SCCMA Award Recipients! William C. Parrish, Jr. Leadership in Healthcare Award Dr. Mark Lillo, Kaiser Permanente Santa Clara This award is named after the beloved long-time executive director of the Santa Clara County Medical Association and recognizes an individual whose leadership, innovation, and dedication have resulted in profound improvement to healthcare in Santa Clara and has left a lasting impact on the physicians and patients of the County. William Parrish is the first recipient of this award (established in 2018).

Benjamin J. Cory Award Dr. Clifford Wang, Santa Clara Valley Medica Center For a physician member of the Medical Association who has displayed forward-looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.

Outstanding Contribution in Community Service Award Dr. Marty Fenstersheib, Santa Clara County Health Office For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.

Outstanding Achievement in Medicine Award Dr. Charulata Ramaprasad, Kaiser Permanente San Jose Medical Center For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.

Outstanding Contribution to Medical Education Dr. Tamerou Asrat, Kaiser Permanente Santa Clara For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.

Citizen’s Award Sahej Sidhu, Oakwood High School For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a non-physician, although physicians are not categorically excluded.)

Outstanding Contribution to the Medical Association Award Dr. Barry Brummer, PAMF San Jose, Chair of Bioethics Committee For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large. www.sccma.org

The Bulletin | Fourth Quarter 2021 | 31

Upcoming Events Resilient MD Series - Battling Healthcare Burnout and Restoring Resilience Tuesday, January 18, 2022, 6:30-7:30pm | Webinar Register at https://bit.ly/3ERw7JD Join the SCCMA and the Physician Wellness Committee for the second session of our solution-oriented wellness series, Resilient MD. This one-hour session will be led by physician for the NFL Players Association and author, Dr. Thom Mayer. Dr. Mayer believes it didn’t take a worldwide pandemic to make leaders realize that the stresses from working daily at the edge of high performance, coupled with the difficulties of daily living, have produced a crisis of burnout. When job stressors exceed the personal and organizational resilience / adaptive capacity to deal with them, the result is the three cardinal symptoms of burnout: emotional exhaustion, cynicism, and loss of meaning at work. As one of health care’s most respected leaders, Dr. Mayer leads from the front, with passion and purpose, which has led him to develop a pragmatic set of solutions to the burnout crisis for leaders in all businesses. Far from a “touchy, feely” talk, this session resonates with stories from the NFL, businesses, national leaders, and others – all in service of developing personal and organizational resilience. The session also includes a wellness exercise so participants may be fully present and experience a moment of self-care, along with a wellness booster - an action-oriented takeaway you can use personally, with colleagues, and within your practice setting to find joy and meaning in medicine. Registration is free. No Surprises Act - The New Federal Law and Its Impact on California Physicians Wednesday, January 19, 2022, 12:15-1:15pm | Webinar Register at https://bit.ly/3EWAmDV This webinar will introduce the “No Surprises Act,” the federal surprise billing law enacted as part of the 2020 Consolidated Appropriations Act. It will address the impact of the No Surprises Act on physicians in California, including the interplay with AB 72 and other California-level surprise/balance billing protections. We will focus on compliance “essentials,” including when balance billing is and is not permissible; what new notices must be provided to patients; and the new requirement that physicians provide uninsured patients with a “good faith estimate” of the charges for scheduled care. Finally, we will highlight the evolving considerations around the independent dispute resolution process and the notice and consent procedure for obtaining a patient’s agreement to be balance billed. For CMA member's staff: To receive a promo code for free registration, email Becky Paplanus at events@cmadocs.org with your physician's California medical license number.

32 | The Bulletin | Fourth Quarter 2021

CalHealthCares Informational Webinars for Loan Repayment Program Applicants January 20, 2022, 3:00pm (general application) February 1, 2022, 12:00pm (general application) February 18, 2022, 12:00pm (general application) February 3, 2022, 12:00pm (practice support grant application) Register at https://bit.ly/3t2ynLQ CalHealthCares will be hosting informational webinars to assist applicants with the loan repayment program application process. The webinars will provide an overview of the application, important timelines, common errors and the scoring system. The webinars will conclude with a live question and answer session and information on scheduling one-on-one sessions for prospective applicants. Policy and Practice Updates from CMS Wednesday, January 26, 2022, 12:15-1:15pm | Webinar Register at https://bit.ly/3mTswED CMS Regional Chief Medical Officer, Dr. Ashby Wolfe, will provide an overview of current CMS policy as outlined in the 2022 Physician Fee Schedule. She will focus on key updates related to telemedicine, evaluation and management services, and the agency COVID-19 response. AMA National Advocacy Conference February 14-16, 2022 | Washington, D.C. Register at https://bit.ly/3EX9hjI The National Advocacy Conference gives attendees the opportunity to connect with industry experts, political insiders and members of Congress about current federal efforts to improve health care, as well as advocate on crucial health care issues affecting attendees and their patients.

www.sccma.org

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Q4 2021 Bulletin: Brain Health: Strategies for Healthy Aging and Reducing Risks

Articles inside

Highlights from the 2021 SCCMA Awards Ceremony

Upcoming Events

To Cry or Not to Cry? That’s the Question

In Memorium

Association of Social Support With Brain Volume and

Santa Clara County Healthy Brain Initiative

Lifestyle Intervention Can Profoundly Reduce The Burden of Alzheimer’s Disease

2021 Year in Review

Can Nutrition Reduce Alzheimer’s Disease Risk?

Longitudinal Association of Total Tau Concentrations and Physical Activity

Membership Insider

President’s Message

Lewy Body Dementia - Hidden in Plain Sight