BrainStorm
When Memory Fades: The Case for Early Alzheimer's Detection
When Memory Fades: The Case for Early Alzheimer's Detection
What if knowing sooner could change everything? In this episode of BrainStorm, host Meryl Comer sits down with Dr. Nathaniel Chin — geriatrician, Alzheimer's researcher, and author of When Memory Fades: What to Expect at Every Stage, from Early Signs to Full Support for Alzheimer's and Dementia, to explore why early diagnosis of Alzheimer's and dementia is more empowering than it is frightening.
Dr. Chin opens up about the fear, stigma, and denial that keep patients and families from seeking answers, and why those hesitations have a real cost. Drawing on his own experience watching his father's cognitive decline, he walks through the subtle early signs of memory change, the difference between normal aging and something more serious, and how new biomarker tests are reshaping the diagnostic conversation.
From navigating family denial to balancing hope, Dr. Chin offers a rare combination of clinical expertise and deeply personal insight of the journey. He reminds us that behind every diagnosis is a family with their thoughts on what matters most.
Meryl Comer (00:00):
This is BrainStorm and I’m Meryl Comer. For decades, Alzheimer's disease has been treated as something to fear. So aren't we prepared for a future where Alzheimer's is identified before symptoms become obvious? Is early diagnosis a gift, a burden, or perhaps both? Joining us is Dr. Nathaniel Chin, director of Medical Services at the Wisconsin Alzheimer's Disease Research Center and wrap the Wisconsin Registry for Alzheimer's Prevention Studies. Dr. Chin, thank you so much for joining us.
Dr. Nathaniel Chin (00:39):
Thank you for having me.
Meryl Comer (00:41):
In your new book, When Memory Fades, you map out why delay in diagnosis has a cost. Why should early diagnosis be more empowering than frightening in today's treatment landscape?
Dr. Nathaniel Chin (00:56):
Wonderful question, Marilyn. And I think it really gets at this idea that we have advanced in our understanding of thinking change in general, not just Alzheimer's disease, and that we've learned there are many things that we can do, many interventions, both lifestyle and medication based, that can be helpful to a brain that is vulnerable in going through change. And so when a person receives an earlier diagnosis, it opens that opportunity not only for themselves to, to learn more and to potentially intervene, but then for their families to be involved and to have these meaningful conversations and, and talk about planning. And planning can be both scary but also really empowering. And so I think this earlier approach, this earlier diagnosis, leads to more fruitful and productive outcomes.
Meryl Comer (01:49):
What are the most common reasons that stop people from seeking that early Alzheimer's testing
Dr. Nathaniel Chin (01:57):
Denial's the first word that comes up as you, as you ask that question. There's so much fear and stigma around thinking changes, whether it's Alzheimer's or not, but certainly the word Alzheimer's brings up a lot of fear or Parkinson's disease or Lewy body disease as you get further into it. And people don't want to hear that. They don't want to be labeled with that diagnosis. And so it might be easier to simply not address the things in front of them and, and hope that it's not that, and that they can move on to something else. I also think it's access. It's not easy to get a full and proper evaluation. And so even when people do bring up having thinking changes, sometimes it is either ignored or minimized. And sometimes people have the best of intentions and they still don't get to the underlying cause of whatever they're experiencing. And so I see both a community self healthcare stigma as well as a system, system related issue within healthcare.
Meryl Comer (03:04):
It strikes me that as you move earlier in diagnosis, people are younger. So is it stigma at work? Is it social isolation, losing independence? Is it all of the above that is so fearful?
Dr. Nathaniel Chin (03:20):
I think it's all of the above. And for every age demographic, there's probably some different stigmas or different fears. And, and certainly at a certain age, a younger age, it might be about the future that they think that they want and have whether it's having children or, or having grandchildren or, or working a long life work itself. But even after a person retires, there's other fears that, that they have, again, related to their future and, and sort of this anticipated grief of what things they feel like should have happened. So I do think it spans the whole spectrum of age. And, and while there are similarities, I do think every age demographic thinks about things a little bit differently.
Meryl Comer (04:06):
So as a clinician, how do you help families make decisions when certainty doesn't equal control?
Dr. Nathaniel Chin (04:16):
You know, a a lot of it is, is really letting the patient and family drive that conversation and get, because we need to know who they are, who is the patient, what is their life, what is, what do, what do they want for the future? How does that relate to the family? Because the family might have their own desires and hopes as well. And we have to recognize that since it, it isn't just one person, I do ground these conversations not only in what matters most to them, which is a geriatric principle but also their what is the diagnosis? What is actually happening in the brain, what, what stage of thinking change are they in? And then as a geriatrician, what I think people value most is their function. Where are they in the, their functional ability that is their independence, their quality of life. That is what makes us more unique as, as a, as a species. And so I try to figure out not only where are you, but what things look like in the future and is that acceptable to you or, or should we be doing things to try to modify that, that potential future.
Meryl Comer (05:22):
Your book is so informative but also very touching. And the question you lead off with is one, you say that you're often asked in the memory clinic, and that's what would you do if this was your father? Share those insights as a geriatrician, but also why did you decide it was important to weave in your personal Alzheimer's journey with your father throughout the book?
Dr. Nathaniel Chin (05:47):
So that's, those are two great questions. I think I might ask you to repeat the second one for me, Meryl, but the, the first one, you know, as a geriatrician, I do get asked the question a lot of, well, this is great, you're talking to me as the supposed expert or someone who's in this doing this regularly, but this is very personal for me as a patient or family member, what would you do? And I think that's a very reasonable question to ask of a provider, especially if there is a, a, a major age difference between your clinician your physician and, and the patient, which I tend to see in my patient panel. And so I've, I had that question asked pretty regularly. And, and I had no problem sharing my own personal experience. People, my patients tend to know why I'm in this field.
Dr. Nathaniel Chin (06:32):
I that I never thought this was going to be my career, but it allows for me to also say things that I don't think other providers might feel comfortable saying, because I know what it's like to sit not in my patient seat, but in the seat next to them. And, and so I think it was, it has been valuable to, to share, well, this is what I did, and that doesn't mean that that was right or or wrong, but this was my experience. And certainly this is the experience of other patients and other families because this is still a quite a unique experience despite how many people are affected by it. And so I think it's helpful. I will also say I'm a, I view my role as, as being a consultant. I am here to share with you what I believe is happening and what the potential options are and what the risks and benefits of those options are. But it is the patient's decision and the family's deci decision together on what they want to do. And I will be with them in beginning to end, no matter what they choose. But I think it, so it's, it's helpful for me as a consultant to say, okay, this is what you can do, but is this really what you want to do? And therefore, I can then offer my, my guidance as, as someone who's gone through that experience too.
Meryl Comer (07:46):
So let me ask you the, as the second part of the question. Did you consult with your mother or the family before you included your story? Because it's all about protecting a loved one's dignity at the same time.
Dr. Nathaniel Chin (08:02):
So I, you know, I'm really glad you asked that because Absolutely. Yes. throughout the writing of the book, I reached out to my mother to talk about, well, I would like to say this. And more often than not, she was okay with it. But there were times where she was not particularly happy with how I would phrase something. Now, granted, my experience was different than hers as the primary caregiver but I always wanted to make sure that what I was saying was accurate or, and, and appropriate. I I did the same with my sister, who was a a distant secondary caregiver because she lived across the country. We had wanted to write this, a story involving my father prior to this book. And so I knew I had their support as family in telling parts of the story. But it is so true, Meryl, that, you know, this is very personal, and it was, it was hard to write some of those sections because of how personal it was. But I always wanted to make sure I, I told it the proper way.
Meryl Comer (09:02):
I was very attached at the back of your book in the acknowledgements, when you really talk about your experience as a young intern in the hospital. It was not related to your family, but it was that personal moment. And hospitals are always such a difficult environment for people with dementia.
Dr. Nathaniel Chin (09:22):
The story itself was when I was an intern, so I'm merely in training. I'm months from finishing medical school. And so for those that that know this, you know, you think you know so much and then you're thrown into the real world and you realize how little you actually know. And that was my experience, my, my intern year. And to come across and, and engage with a patient in the hospital with dementia was really not what I was anticipating when I thought of my medicine training. And so I actually came at it with what I am embarrassed to say. It was just not the proper approach of that person-centered, human-centered way that I think now. But I really disregarded it. I, I didn't think it was interesting. I didn't think it was meaningful. I guess the one silver lining was that I held true to my belief in, in being present for the patients. I was sitting with this man with dementia holding his hand and listening. And that's Marielle as you know, from reading it. That's all I did. And I didn't think much of that moment until only after my dad was diagnosed and I recognized, well, wow, that could have been him. And I certainly hope if I wasn't present that the next doctor would've had, you know, a, a better belief than I had at the time. But certainly, at least the, a similar approach to simply being another human caring for a person.
Meryl Comer (10:47):
I'd love to go through the chapters of your book because it really takes you from early stages. And I'm going to start with chapter one. What's happening in my mind, which is everyone's concern. You know, what are some of the most frequently observed early symptoms of cognitive decline?
Dr. Nathaniel Chin (11:06):
This is something I give a lot of presentations about in the community because this is so important for people. It, you know, I want to destigmatize cognitive aging, and because I think that is that barrier, one of the barriers to an evaluation. But change happens, and I think we have to recognize that as we get older, an 80-year-old brain is not the same as a 20-year-old brain. And so I think recognizing there are normal changes that can happen. And so I talk about this idea of walking into a room and not knowing why you went there or the tip of the tongue moments where you're trying to figure out a word in the midst of a conversation. And it doesn't come back until minutes later when that conversation is over. Or another one, which I experience frequently is coming across someone who you don't see every day, but what, what is their name? Again, this can be normal aging, but unfortunately can also be the earliest changes in, in something that is pathological. And so I describe, we call it episodic memory, the things that have just happened to us. And so I describe that as well as some of the other parts of our brain that can be affected, like our attention and problem solving. And that is why, because you cannot differentiate normal aging from early pathologic change just by a story. You really need to go in and be evaluated.
Meryl Comer (12:24):
So for chapter two, I didn't see it coming. That's the name of a number of books, by the way, on that very topic, whether it was Lewy Bodies, dementia. So even with signs of memory changes, your instinct as a family member, you hesitate, you hope it's stress, you hope it's a misdiagnosis, you hope it is anything but Alzheimer's or another dementia.
Dr. Nathaniel Chin (12:51):
This was the first chapter I wrote in the book, and it was the most meaningful to me. It was the most personal, because it was how our family handled it. It was really about how my mom handled it, because she, as the, the spouse, but the primary care partner had observed changes earlier than anyone else. They were subtle, they were inconsistent, but they were there. And so I really interviewed her for that chapter to get a sense of what did you go through? And it was months of what I imagine was very emotionally draining and stressful experiences in, in writing these things down so that she could feel certain in what she's doing. And so I argue in the book, this is a approach, but I certainly thought it was very helpful because eventually she had to share this with her two kids who are equally as stubborn, who were arrogant in thinking, I'm a physician, I know better than you and who we're both wrong.
Dr. Nathaniel Chin (13:50):
And so she had this family meeting, and so I described this family meeting and the principles I've learned from this family meeting and how we handled it, and like you said, I denied it stress. He's a, my father is a busy physician, so it's all stress, it's all this. And I described this moment where my sister and I wrongly, and I, I state this in the book, tested him with a Sudoku game, and he did not do well. And it was something that I'm embarrassed that I did, but certainly was clear to my sister and I that something was wrong in this man. And so yeah, I really, I will say I'm, I'm probably one of the most proud of, of that chapter. But I also think it's so important for those that read it like that is the moment that it's those that type of experience that really sets you up for what you do going forward.
Meryl Comer (14:44):
Spouses, and I was one of them really try to shield a loved one and keep moving to find a different answer than the one that they may have been given. My husband was misdiagnosed for five years, too young, too smart, didn't fit the profile. What are the subtle signs that the spouse is not telling the truth about what's going on?
Dr. Nathaniel Chin (15:09):
Wow, that's a great question. You know, I have the luxury in my memory clinic to have people go through what is about an hour long cognitive testing battery. And, and so I do have this experience where people will test poorly. They will show these impairments objectively, and the family or the spouse will say, oh, no, they, they're able to do this. And I look at the testing and I, and I show them this picture and I say, is this hard for me to believe what you're telling me given the changes that I see in this testing? So that's easier for me than other people. I will say, just as you alluded to, having other observers is really powerful when a care partner is telling a story and you ask sort of a deeper question and they pause, and it's, I think it's that internal struggle of, well, now I'm being faced. I have to face something that I have not wanted to deal with. And you're, they're deciding whether or not they want to go down that path or continue the denial and whether or not their answer is truthful or not. As a clinician, if you see it enough, you see that pause and you recognize there's something here and, and then you have to push, and that's, that's uncomfortable at times.
Meryl Comer (16:22):
You admit in the book that upon your father's diagnosis, you, like all the rest of us became a bit obsessed about your own health, your own future. Does that weigh into the delay in getting a parent there as well? Sometimes?
Dr. Nathaniel Chin (16:39):
I certainly think so. I mean, this, that mine was a, was this obsession with trying to find a reversible cause, trying to find something that the doctor was wrong about. I at least embraced at that point the diagnosis, but I certainly think we just don't want it to be this incurable progressive brain disease. And, and so we will do whatever we can to protect the fragility of that moment of my, I don't want to see this future of this person. I love being so different. And, and I will say I, whenever my patients' families are experiencing denial or they propose, you know, these non-evidence based thoughts, I never judge because I was there. I recognized that moment. I had those exact thoughts. And so I'm able to say, okay, we can, we can discuss this. I, I know it personally but I'll also explain to you why it's probably not the case.
Meryl Comer (17:36):
What are the most common reversible factors that can cause the memory loss? I think that's important that we flag for people as well.
Dr. Nathaniel Chin (17:46):
Oh, it's so important. And I honestly lead with that because I think it helps people talk more about just optimizing their brain, their function, their wellbeing. Even in the setting of Alzheimer's or Lewy body or frontotemporal, there are usually other factors that we can address. And so I tend to see a lot in my clinic obstructive sleep apnea or insomnia or just poor sleep in general. As a geriatrician, I think a lot about medications and interactions with each other as well as interactions with supplements. So medication side effects, mental health has a huge impact and how we function in the world. And so depression, anxiety, just excessive worry, that tends to be very common. But then there are things that we can check on a blood test, which most providers do check looking at your thyroid or, or vitamin deficiencies. Those can have real impacts on thinking ability too. And the, our, I will say our healthcare knows them. I mean, they know the reversible factors. They tend to look for them once they're pushed and prompted to do so. And so just takes that initial getting over that inertia of please evaluate further for all of these potential factors.
Meryl Comer (18:58):
So how do the new biomarker tests change the conversation between the patients, the caregivers, the doctors, and what is the clinician's responsibility in that space?
Dr. Nathaniel Chin (19:11):
I think the biomarkers have helped de-stigmatize the evaluation process. Maybe it hasn't changed de-stigmatize the disease itself, but people are coming into their provider, their primary care or memory specialist with the specific question of, well, what about the biomarker testing? Can I get the testing? Can I identify this disease because maybe there's that new disease modifying therapy for it. And so I think that's been a really positive thing. I, I worry at times that it distracts us from those reversible factors we just talked about since not all memory and thinking change is due to Alzheimer's. And, and frankly we only have the biomarkers for Alzheimer's. We're still missing the other brain diseases. So I do think there's great potential and I'm very excited about them. We use them in our specialty clinic for clinicians in general, you know, I certainly think there's a place and they need to be used after we really get an understanding of what's happening. And I think that's the key is Meryl that I don't see this as mass screening. I don't see getting these blood tests, right when a person says, my memory's not the same. I think we still need to do our due diligence in talking to patients, getting a history, looking for those reversible factors and coming to an understanding of what's actually happening before we get them. But now we can quickly get them, get results back and go to the next steps.
Meryl Comer (20:35):
Is that how you as a clinician balance hope in the new treatments with honesty about what they cannot do yet?
Dr. Nathaniel Chin (20:45):
Absolutely. You know, shared decision making is the phrase that is very popular. And it, it's because it's true. We really need to make sure that our patients and their families have all the information. How do we get to this point? What are our options? What are the risks and the benefits of each of those options? And then does this decision that you want aligned with that? And key to that is the limitation piece of this, because there's so much excitement, and I'm, I'm grateful for that. There's so much excitement for understanding the biology, the biomarker, and then potentially going on these new therapies, but we also have to understand the limitations of it, the consequences of it, so that people really walk into this process with all the information and feeling comfortable with the decision they make. So I actually spend more time talking about the, my, the limitations or my, my concerns so that people really are, are given all the information, and that when they make that decision to go forward with therapy, I know that they're truly ready for it.
Meryl Comer (21:47):
Our guest has been Dr. Nathaniel Chin, his new book When Memory Fades, what to Expect at every stage from Early Signs to Full Support for Alzheimer's and Dementia. Dr. Chin, thank you for the seminal book. We're also very grateful to Dr. Chin for his guidance on the Expert Advisory Council for us against Alzheimer's Brain Health Journey map. That's it for this edition. I'm Meryl Comer. Thank you for brainstorming with us.
Speaker 3 (22:20):
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About This Episode
What if knowing sooner could change everything? In this episode of BrainStorm, host Meryl Comer sits down with Dr. Nathaniel Chin — geriatrician, Alzheimer's researcher, and author of When Memory Fades: What to Expect at Every Stage, from Early Signs to Full Support for Alzheimer's and Dementia, to explore why early diagnosis of Alzheimer's and dementia is more empowering than it is frightening.
Dr. Chin opens up about the fear, stigma, and denial that keep patients and families from seeking answers, and why those hesitations have a real cost. Drawing on his own experience watching his father's cognitive decline, he walks through the subtle early signs of memory change, the difference between normal aging and something more serious, and how new biomarker tests are reshaping the diagnostic conversation.
From navigating family denial to balancing hope, Dr. Chin offers a rare combination of clinical expertise and deeply personal insight of the journey. He reminds us that behind every diagnosis is a family with their thoughts on what matters most.
Transcript
Meryl Comer (00:00):
This is BrainStorm and I’m Meryl Comer. For decades, Alzheimer's disease has been treated as something to fear. So aren't we prepared for a future where Alzheimer's is identified before symptoms become obvious? Is early diagnosis a gift, a burden, or perhaps both? Joining us is Dr. Nathaniel Chin, director of Medical Services at the Wisconsin Alzheimer's Disease Research Center and wrap the Wisconsin Registry for Alzheimer's Prevention Studies. Dr. Chin, thank you so much for joining us.
Dr. Nathaniel Chin (00:39):
Thank you for having me.
Meryl Comer (00:41):
In your new book, When Memory Fades, you map out why delay in diagnosis has a cost. Why should early diagnosis be more empowering than frightening in today's treatment landscape?
Dr. Nathaniel Chin (00:56):
Wonderful question, Marilyn. And I think it really gets at this idea that we have advanced in our understanding of thinking change in general, not just Alzheimer's disease, and that we've learned there are many things that we can do, many interventions, both lifestyle and medication based, that can be helpful to a brain that is vulnerable in going through change. And so when a person receives an earlier diagnosis, it opens that opportunity not only for themselves to, to learn more and to potentially intervene, but then for their families to be involved and to have these meaningful conversations and, and talk about planning. And planning can be both scary but also really empowering. And so I think this earlier approach, this earlier diagnosis, leads to more fruitful and productive outcomes.
Meryl Comer (01:49):
What are the most common reasons that stop people from seeking that early Alzheimer's testing
Dr. Nathaniel Chin (01:57):
Denial's the first word that comes up as you, as you ask that question. There's so much fear and stigma around thinking changes, whether it's Alzheimer's or not, but certainly the word Alzheimer's brings up a lot of fear or Parkinson's disease or Lewy body disease as you get further into it. And people don't want to hear that. They don't want to be labeled with that diagnosis. And so it might be easier to simply not address the things in front of them and, and hope that it's not that, and that they can move on to something else. I also think it's access. It's not easy to get a full and proper evaluation. And so even when people do bring up having thinking changes, sometimes it is either ignored or minimized. And sometimes people have the best of intentions and they still don't get to the underlying cause of whatever they're experiencing. And so I see both a community self healthcare stigma as well as a system, system related issue within healthcare.
Meryl Comer (03:04):
It strikes me that as you move earlier in diagnosis, people are younger. So is it stigma at work? Is it social isolation, losing independence? Is it all of the above that is so fearful?
Dr. Nathaniel Chin (03:20):
I think it's all of the above. And for every age demographic, there's probably some different stigmas or different fears. And, and certainly at a certain age, a younger age, it might be about the future that they think that they want and have whether it's having children or, or having grandchildren or, or working a long life work itself. But even after a person retires, there's other fears that, that they have, again, related to their future and, and sort of this anticipated grief of what things they feel like should have happened. So I do think it spans the whole spectrum of age. And, and while there are similarities, I do think every age demographic thinks about things a little bit differently.
Meryl Comer (04:06):
So as a clinician, how do you help families make decisions when certainty doesn't equal control?
Dr. Nathaniel Chin (04:16):
You know, a a lot of it is, is really letting the patient and family drive that conversation and get, because we need to know who they are, who is the patient, what is their life, what is, what do, what do they want for the future? How does that relate to the family? Because the family might have their own desires and hopes as well. And we have to recognize that since it, it isn't just one person, I do ground these conversations not only in what matters most to them, which is a geriatric principle but also their what is the diagnosis? What is actually happening in the brain, what, what stage of thinking change are they in? And then as a geriatrician, what I think people value most is their function. Where are they in the, their functional ability that is their independence, their quality of life. That is what makes us more unique as, as a, as a species. And so I try to figure out not only where are you, but what things look like in the future and is that acceptable to you or, or should we be doing things to try to modify that, that potential future.
Meryl Comer (05:22):
Your book is so informative but also very touching. And the question you lead off with is one, you say that you're often asked in the memory clinic, and that's what would you do if this was your father? Share those insights as a geriatrician, but also why did you decide it was important to weave in your personal Alzheimer's journey with your father throughout the book?
Dr. Nathaniel Chin (05:47):
So that's, those are two great questions. I think I might ask you to repeat the second one for me, Meryl, but the, the first one, you know, as a geriatrician, I do get asked the question a lot of, well, this is great, you're talking to me as the supposed expert or someone who's in this doing this regularly, but this is very personal for me as a patient or family member, what would you do? And I think that's a very reasonable question to ask of a provider, especially if there is a, a, a major age difference between your clinician your physician and, and the patient, which I tend to see in my patient panel. And so I've, I had that question asked pretty regularly. And, and I had no problem sharing my own personal experience. People, my patients tend to know why I'm in this field.
Dr. Nathaniel Chin (06:32):
I that I never thought this was going to be my career, but it allows for me to also say things that I don't think other providers might feel comfortable saying, because I know what it's like to sit not in my patient seat, but in the seat next to them. And, and so I think it was, it has been valuable to, to share, well, this is what I did, and that doesn't mean that that was right or or wrong, but this was my experience. And certainly this is the experience of other patients and other families because this is still a quite a unique experience despite how many people are affected by it. And so I think it's helpful. I will also say I'm a, I view my role as, as being a consultant. I am here to share with you what I believe is happening and what the potential options are and what the risks and benefits of those options are. But it is the patient's decision and the family's deci decision together on what they want to do. And I will be with them in beginning to end, no matter what they choose. But I think it, so it's, it's helpful for me as a consultant to say, okay, this is what you can do, but is this really what you want to do? And therefore, I can then offer my, my guidance as, as someone who's gone through that experience too.
Meryl Comer (07:46):
So let me ask you the, as the second part of the question. Did you consult with your mother or the family before you included your story? Because it's all about protecting a loved one's dignity at the same time.
Dr. Nathaniel Chin (08:02):
So I, you know, I'm really glad you asked that because Absolutely. Yes. throughout the writing of the book, I reached out to my mother to talk about, well, I would like to say this. And more often than not, she was okay with it. But there were times where she was not particularly happy with how I would phrase something. Now, granted, my experience was different than hers as the primary caregiver but I always wanted to make sure that what I was saying was accurate or, and, and appropriate. I I did the same with my sister, who was a a distant secondary caregiver because she lived across the country. We had wanted to write this, a story involving my father prior to this book. And so I knew I had their support as family in telling parts of the story. But it is so true, Meryl, that, you know, this is very personal, and it was, it was hard to write some of those sections because of how personal it was. But I always wanted to make sure I, I told it the proper way.
Meryl Comer (09:02):
I was very attached at the back of your book in the acknowledgements, when you really talk about your experience as a young intern in the hospital. It was not related to your family, but it was that personal moment. And hospitals are always such a difficult environment for people with dementia.
Dr. Nathaniel Chin (09:22):
The story itself was when I was an intern, so I'm merely in training. I'm months from finishing medical school. And so for those that that know this, you know, you think you know so much and then you're thrown into the real world and you realize how little you actually know. And that was my experience, my, my intern year. And to come across and, and engage with a patient in the hospital with dementia was really not what I was anticipating when I thought of my medicine training. And so I actually came at it with what I am embarrassed to say. It was just not the proper approach of that person-centered, human-centered way that I think now. But I really disregarded it. I, I didn't think it was interesting. I didn't think it was meaningful. I guess the one silver lining was that I held true to my belief in, in being present for the patients. I was sitting with this man with dementia holding his hand and listening. And that's Marielle as you know, from reading it. That's all I did. And I didn't think much of that moment until only after my dad was diagnosed and I recognized, well, wow, that could have been him. And I certainly hope if I wasn't present that the next doctor would've had, you know, a, a better belief than I had at the time. But certainly, at least the, a similar approach to simply being another human caring for a person.
Meryl Comer (10:47):
I'd love to go through the chapters of your book because it really takes you from early stages. And I'm going to start with chapter one. What's happening in my mind, which is everyone's concern. You know, what are some of the most frequently observed early symptoms of cognitive decline?
Dr. Nathaniel Chin (11:06):
This is something I give a lot of presentations about in the community because this is so important for people. It, you know, I want to destigmatize cognitive aging, and because I think that is that barrier, one of the barriers to an evaluation. But change happens, and I think we have to recognize that as we get older, an 80-year-old brain is not the same as a 20-year-old brain. And so I think recognizing there are normal changes that can happen. And so I talk about this idea of walking into a room and not knowing why you went there or the tip of the tongue moments where you're trying to figure out a word in the midst of a conversation. And it doesn't come back until minutes later when that conversation is over. Or another one, which I experience frequently is coming across someone who you don't see every day, but what, what is their name? Again, this can be normal aging, but unfortunately can also be the earliest changes in, in something that is pathological. And so I describe, we call it episodic memory, the things that have just happened to us. And so I describe that as well as some of the other parts of our brain that can be affected, like our attention and problem solving. And that is why, because you cannot differentiate normal aging from early pathologic change just by a story. You really need to go in and be evaluated.
Meryl Comer (12:24):
So for chapter two, I didn't see it coming. That's the name of a number of books, by the way, on that very topic, whether it was Lewy Bodies, dementia. So even with signs of memory changes, your instinct as a family member, you hesitate, you hope it's stress, you hope it's a misdiagnosis, you hope it is anything but Alzheimer's or another dementia.
Dr. Nathaniel Chin (12:51):
This was the first chapter I wrote in the book, and it was the most meaningful to me. It was the most personal, because it was how our family handled it. It was really about how my mom handled it, because she, as the, the spouse, but the primary care partner had observed changes earlier than anyone else. They were subtle, they were inconsistent, but they were there. And so I really interviewed her for that chapter to get a sense of what did you go through? And it was months of what I imagine was very emotionally draining and stressful experiences in, in writing these things down so that she could feel certain in what she's doing. And so I argue in the book, this is a approach, but I certainly thought it was very helpful because eventually she had to share this with her two kids who are equally as stubborn, who were arrogant in thinking, I'm a physician, I know better than you and who we're both wrong.
Dr. Nathaniel Chin (13:50):
And so she had this family meeting, and so I described this family meeting and the principles I've learned from this family meeting and how we handled it, and like you said, I denied it stress. He's a, my father is a busy physician, so it's all stress, it's all this. And I described this moment where my sister and I wrongly, and I, I state this in the book, tested him with a Sudoku game, and he did not do well. And it was something that I'm embarrassed that I did, but certainly was clear to my sister and I that something was wrong in this man. And so yeah, I really, I will say I'm, I'm probably one of the most proud of, of that chapter. But I also think it's so important for those that read it like that is the moment that it's those that type of experience that really sets you up for what you do going forward.
Meryl Comer (14:44):
Spouses, and I was one of them really try to shield a loved one and keep moving to find a different answer than the one that they may have been given. My husband was misdiagnosed for five years, too young, too smart, didn't fit the profile. What are the subtle signs that the spouse is not telling the truth about what's going on?
Dr. Nathaniel Chin (15:09):
Wow, that's a great question. You know, I have the luxury in my memory clinic to have people go through what is about an hour long cognitive testing battery. And, and so I do have this experience where people will test poorly. They will show these impairments objectively, and the family or the spouse will say, oh, no, they, they're able to do this. And I look at the testing and I, and I show them this picture and I say, is this hard for me to believe what you're telling me given the changes that I see in this testing? So that's easier for me than other people. I will say, just as you alluded to, having other observers is really powerful when a care partner is telling a story and you ask sort of a deeper question and they pause, and it's, I think it's that internal struggle of, well, now I'm being faced. I have to face something that I have not wanted to deal with. And you're, they're deciding whether or not they want to go down that path or continue the denial and whether or not their answer is truthful or not. As a clinician, if you see it enough, you see that pause and you recognize there's something here and, and then you have to push, and that's, that's uncomfortable at times.
Meryl Comer (16:22):
You admit in the book that upon your father's diagnosis, you, like all the rest of us became a bit obsessed about your own health, your own future. Does that weigh into the delay in getting a parent there as well? Sometimes?
Dr. Nathaniel Chin (16:39):
I certainly think so. I mean, this, that mine was a, was this obsession with trying to find a reversible cause, trying to find something that the doctor was wrong about. I at least embraced at that point the diagnosis, but I certainly think we just don't want it to be this incurable progressive brain disease. And, and so we will do whatever we can to protect the fragility of that moment of my, I don't want to see this future of this person. I love being so different. And, and I will say I, whenever my patients' families are experiencing denial or they propose, you know, these non-evidence based thoughts, I never judge because I was there. I recognized that moment. I had those exact thoughts. And so I'm able to say, okay, we can, we can discuss this. I, I know it personally but I'll also explain to you why it's probably not the case.
Meryl Comer (17:36):
What are the most common reversible factors that can cause the memory loss? I think that's important that we flag for people as well.
Dr. Nathaniel Chin (17:46):
Oh, it's so important. And I honestly lead with that because I think it helps people talk more about just optimizing their brain, their function, their wellbeing. Even in the setting of Alzheimer's or Lewy body or frontotemporal, there are usually other factors that we can address. And so I tend to see a lot in my clinic obstructive sleep apnea or insomnia or just poor sleep in general. As a geriatrician, I think a lot about medications and interactions with each other as well as interactions with supplements. So medication side effects, mental health has a huge impact and how we function in the world. And so depression, anxiety, just excessive worry, that tends to be very common. But then there are things that we can check on a blood test, which most providers do check looking at your thyroid or, or vitamin deficiencies. Those can have real impacts on thinking ability too. And the, our, I will say our healthcare knows them. I mean, they know the reversible factors. They tend to look for them once they're pushed and prompted to do so. And so just takes that initial getting over that inertia of please evaluate further for all of these potential factors.
Meryl Comer (18:58):
So how do the new biomarker tests change the conversation between the patients, the caregivers, the doctors, and what is the clinician's responsibility in that space?
Dr. Nathaniel Chin (19:11):
I think the biomarkers have helped de-stigmatize the evaluation process. Maybe it hasn't changed de-stigmatize the disease itself, but people are coming into their provider, their primary care or memory specialist with the specific question of, well, what about the biomarker testing? Can I get the testing? Can I identify this disease because maybe there's that new disease modifying therapy for it. And so I think that's been a really positive thing. I, I worry at times that it distracts us from those reversible factors we just talked about since not all memory and thinking change is due to Alzheimer's. And, and frankly we only have the biomarkers for Alzheimer's. We're still missing the other brain diseases. So I do think there's great potential and I'm very excited about them. We use them in our specialty clinic for clinicians in general, you know, I certainly think there's a place and they need to be used after we really get an understanding of what's happening. And I think that's the key is Meryl that I don't see this as mass screening. I don't see getting these blood tests, right when a person says, my memory's not the same. I think we still need to do our due diligence in talking to patients, getting a history, looking for those reversible factors and coming to an understanding of what's actually happening before we get them. But now we can quickly get them, get results back and go to the next steps.
Meryl Comer (20:35):
Is that how you as a clinician balance hope in the new treatments with honesty about what they cannot do yet?
Dr. Nathaniel Chin (20:45):
Absolutely. You know, shared decision making is the phrase that is very popular. And it, it's because it's true. We really need to make sure that our patients and their families have all the information. How do we get to this point? What are our options? What are the risks and the benefits of each of those options? And then does this decision that you want aligned with that? And key to that is the limitation piece of this, because there's so much excitement, and I'm, I'm grateful for that. There's so much excitement for understanding the biology, the biomarker, and then potentially going on these new therapies, but we also have to understand the limitations of it, the consequences of it, so that people really walk into this process with all the information and feeling comfortable with the decision they make. So I actually spend more time talking about the, my, the limitations or my, my concerns so that people really are, are given all the information, and that when they make that decision to go forward with therapy, I know that they're truly ready for it.
Meryl Comer (21:47):
Our guest has been Dr. Nathaniel Chin, his new book When Memory Fades, what to Expect at every stage from Early Signs to Full Support for Alzheimer's and Dementia. Dr. Chin, thank you for the seminal book. We're also very grateful to Dr. Chin for his guidance on the Expert Advisory Council for us against Alzheimer's Brain Health Journey map. That's it for this edition. I'm Meryl Comer. Thank you for brainstorming with us.
Speaker 3 (22:20):
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