Podcast: Let’s Talk About Aging With Dr. Brent Forester

On today’s episode, Trevor shares the new way that he incorporates exercise into his daily routine.

Then Dr. Brent Forester, chief of McLean’s Division of Geriatric Psychiatry (15:24), joins us to discuss the need to get people talking about the Alzheimer’s epidemic. He also talks about addressing behavioral complications in older adults. Brent shares a bit about his groundbreaking research project on the effects of ECT on people with dementia.

Episode Highlights

  • McLean Hospital is the leader in Alzheimer’s and dementia resources and research (22:26)
  • How music helps with memory retention (32:54)
  • McLean is using synthetic marijuana as one avenue of battling dementia (01:01:37)

Relevant Content

Episode Transcript

Trevor: Welcome to Mindful Things, Mindful Things on today’s episode. I’ll be interviewing Dr. Brent Forester, who is the chief of the Division of Geriatric Psychiatry here at McLean Hospital, and is the medical director for Behavioral Health in the center for Population Health Management at Mass General Brigham. We talk specifically about geriatric patients, Alzheimer’s and dementia. So I hope you all stick around for that. Welcome back, our regular listeners. Welcome, new listeners. I’m probably going to lose a bunch of you right here. Maybe not. We’ll see. So, as a person who suffers from depression, I want to talk about something that ... I’m not going to speak for all people who suffer from depression or a mental illness, but I know it’s something that is very controversial among those who suffer.

It’s a subject that offends us to our core. It’s a subject that is vile, dehumanizing, a subject that hurts so much and is so painful that a lot of us, including myself, just disregard it immediately when it’s brought up. I’m going to talk about exercise. Yeah, exercise sucks. It does. I see so many doctors get frustrated with us, but you don’t understand it or maybe you do understand. No, you don’t understand. You don’t understand. It hurts all day. I think that’s one thing that gets lost in this is that for a lot of us, there is a physical manifestation of our issues and it is painful. Like I have pressure in my head a lot and I know that it comes from stress and emotions, and not willing to or not having an avenue to let that pressure out. I know exercise, breathing exercises and meditation and all of that stuff helps, and I try to do it as much as I can.

I try and be mindful of all that, but the fact of the matter is, is I come home from work or I wake up in the morning for work and I’m already exhausted and just can’t move. It’s not laziness, and you’re welcome to think whatever you want. I know it’s not laziness. I know I’m not a lazy person, but depression just adds an extra couple 100 pounds to the weight that I already carry on my shoulders, and it’s just too much. Also, now this is me speaking for myself. About 2008, I joined a gym and I got in really, really good shape. Was lifting, was doing a lot of cardio, doing a lot of abs. I was in really good shape. About 2012, I had my breakdown and I had to come to McLean, but there was also a medical component to it as well. I went to see a doctor and he was like, “You really, you need to chill back on the exercise. You’ve really pushed your body way too far and now you’re having this emotional stuff and mental stuff.”

This is also when I developed or seemed to develop allergies, which doctor said was kicked off from stress. Allergies to food and whatnot. So now I associate exercise with sickness, so it’s even harder for me to get motivated. Now my physical shape isn’t bad. I’ve got a little bit of a tire, tiny one, but I mean I’m definitely out of shape. I huff and puff a couple floors on the stairway and that’ll do me an ... That said, I found an exercise routine that I’m kind of enjoying. Unfortunately it does require financial investment, but maybe not. Let me explain it to you. A lot of you are going to laugh and scream nerd alert and there’s really nothing I can do about it, but I’m telling you that I don’t think this is going to be a permanent exercise routine for me, but it’s gotten me back moving again and it does produce a decent amount of sweat. I’m definitely huffing and puffing, and I’m having fun.

About a month and a half ago, I invested in a Virtual Reality headset. I talked to a good friend of mine. He had convinced me not to invest. He said, “The tech just isn’t there.” He’s like, “It looks good right now. It really does. I’ll admit, but it’s just not there yet. It’ll be there soon.” He’s right. The tech isn’t there yet, but it works. I ended up not listening to him. I found a deal and decided to dive in, and I bought a Virtual Reality headset for my PlayStation and there are others. There’s Oculus and there’s VIVE. I think Samsung has a version that you can use with their phones that works okay, but the main ones from what I understand are the VIVE, Oculus and PlayStation. The PlayStation in terms of quality is the worst of the three. It’s also the cheapest. It also has the best games. So you weigh it. I figured I’ll just make the cheapest investment now, and see if this is something that I want to explore.

Well there’s a game I wanted to try called Beat Saber and it’s a rhythm game. What it is is you stand in the middle of this minimal but pretty cool like 3D sci-fi environment just made of panels and neon light. These 3D neon cubes come straight at you, and in each of your hands you’re holding on to controllers in your hand that a sensor picks up, in your hands are what I can only describe as light sabers, like just out of Star Wars. As the cube comes straight at you, you slice the cube in half, make a big arm motion and slice it. This is all set to songs and cubes are being thrown at you to the beat. If you like music and if you like rhythm games, it’s a lot of fun. It is a genuinely enjoyable game. For every song, I finally just check out at how crappy things are, and I’m enjoying the rhythm of the game. To get a little more exercise out of it, I also move my feet to the rhythms, so I’m just not standing there.

So I’m getting a little, little bit of cardio that way, but most of the cardio comes from, and it’s important to make big slashes. At the end of every song, I go right into another song. So there’s very little downtime. I have sweat pouring down my face. They recommend 30 minutes, keep it at 30 minute minimum so you don’t get too much eyestrain. By the end, I have a soaked tee shirt because I’m really moving and flailing around you. Once you set the game to the hard level of difficulty, you’re really moving and it’s a lot of fun. I decided after a couple of days of playing this, I’m like, “I think I’m getting an exercise out of this.” So I went on to Google and I did some searches, and I found a subreddit, which I know 99% of you just threw your arms up in the air. Trust me, I hear you. I try and stay away from Reddit.

There was a subreddit, a very detailed subreddit, how a man lost about 138 pounds playing Beat Saber. I was blown away. He took photos of himself over the course of days. He listed certain songs that got his heart moving the most, and it was really impressive. So, I’ve started doing the 30 minute Beat Saber workout, doing it every day. I’ve missed a day here or there, but the fact that I did it three days in a row is huge, and it doesn’t feel like a workout. It feels like I’m in a 3D world with a, I’m using light sabers, which are really just big drumsticks and I’m playing a huge virtual drum. What I read in the Reddit is that dance around a bit, move your feet and make big slashes. Thankfully, the game makes you stand up tall to get certain cubes coming at you and bend down. So, you’re definitely moving. Now Virtual Reality is expensive. I’d say that the PlayStation VR and first of all, I’m not a shill for any of these companies.

I’m not going to get anything if somebody goes out and buys this stuff, I’m not going to get anything from it. I’m just telling you I found something that worked for me, that has gotten me to get some exercise again. Hopefully this will move forward to maybe going out for a run every once in a while, or joining a gym again. I hope because it does help. Exercise is really important. The PlayStation VR I think is like 299, but you have to have a PlayStation too. So that’s another 300 bucks. There’s all different kinds of Oculus headsets. Most of them require that you have a personal computer, a PC that has a graphics card that is capable of running a Virtual Reality headset like Oculus or VIVE. So you’re talking potentially 15 to $2,000. I mean this is ridiculous. There is, however, a standalone headset Oculus just released it about a month ago called the Oculus Quest. No computer needed. You can play Beat Saber on it.

What’s really cool about playing the PC version is that there’s a whole modding community making their own tracks. So unfortunately with the PlayStation one, you just have options of the songs that come with the game, and then the songs that you can buy additionally in packs on their network. With the Beat Saber PC version that you can play on Oculus and VIVE endless options for music. So if you’re like me and music gets you moving, here’s something that works. Go on YouTube, watch some videos. Don’t have the money? Do you know a friend that might have it? Maybe give him or her $20 and be like, “Hey, buy this game for me. Can I borrow your headset or can I come over and try your headset? I want to see if this works, and then decide if it’s something worth investing in. I hate recommending something that requires such a financial investment.

That said, I found that it works for me and it might work for some of you. I mean, I know a lot of people that are suffering. Some of them, they go to the gym. They have to go to the gym, because if they don’t work out, they’re really going to fall down the hole. Some of us, it’s just too much. You come home, you’re wiped out. Let’s say you don’t even have to go anywhere. You’re still wiped out. Depression just wipes you out, and I know exercise will get you going, but how do you start exercising when you’ve got nothing, when you feel worse than completely depleted? Feels like well—Shut up. Okay? Just back off. Okay, you don’t know what it feels like to feel like you’re buried alive and that you have to dig out. You have to dig yourself out before you can even think about doing a single jumping jack. If you can’t respect that, I don’t know what to do.

The only reason I’m recommending this is that I go to do it, because I want to. I go to do it because playing the game is fun. I go to do it because I want to get better at the game, get a better score. If I end up breaking a huge sweat in the process, and I really do. Also, it’s funny to take the headset off and my cat’s just looking at me like, “Dude, I need to move out. You’re freaking me out.” That part is funny too, but all I’m saying is that the game is Beat Saber. I don’t get any percentage whatsoever, but this thing is the only thing in seven years that has gotten me to move again. I’m very, very thankful for it. It’s fun. It’s a legitimate exercise. You do some more Googling, you will find that there are doctors writing papers on it. It works for me. Again, I don’t think it’s the type of thing to build an entire, like once you start, you’re going to be like, “This is going to be the workout I’m doing for life.” No.

One thing that the subreddit pointed out is that you’re going to plateau after a while and at that point, you should consider moving on to a real exercise. Well, not a real exercise regimen, but a more traditional exercise regimen, but this will get you going. It’s fun. There’s music. I feel like I’m really developing even better hand-eye coordination than I had just operating a controller. You feel like a Jedi playing it. It’s cool. The music’s not bad. I mean it’s mostly electronic music. I like electronic music, but it gets me moving. Just try it. Again, I don’t get a penny. They do not, none of these companies, Sony, Oculus who is owned by Facebook, VIVE who I believe they’re owned by HTC. Then there’s another headset that’s run by Valve. I don’t work for any of them. They don’t know anything about this podcast. They don’t contribute anything. I’m just telling you, I found something.

A piece of technology, a VR headset and a game, Beat Saber and it’s gotten me to exercise again. I am grateful because I feel a little better, and anything that makes me feel better, I want to share with all of you. If you have any more questions, send an email and I’ll get back to you. Okay, here we go. My interview on dementia and Alzheimer’s with Dr. Brent Forester. I hope you enjoy.

Brent: The problem is in terms of even general medicine, but certainly in psychiatry, all the research that’s been done for treatment say for bipolar disorder and depression, especially bipolar disorder, 30 to 40 year-old healthy people. Then we extrapolate that information and say, “Well a 75 year-old, let’s just do what we did with a 35 year-old,” but they’re different. Their physiology is different. The way they metabolize medications is different. The brain is aging in different ways that may affect the way they respond to treatments. The good news is that, and this is why I love geriatric psychiatry, there’s so much we can do to help older people. There’s so much we can do. There’s a lot that ages and bias like, well I’d feel that way too. Basically generates what we call therapeutic nihilism, like why bother? Actually, the causes of depression in older people are very different than the causes in younger people. The symptoms are different.—

Trevor: Give me a few examples.

Brent: The criteria for depression that we think about a lot in younger adults, sleep disturbance, appetite changes, lack of motivation, lack of interest in usual activities, depressed mood.—

Trevor: I have all those.

Brent: Anxiety, all those things. As you get older, what’s often the case, first of all, most people think that as you get older, the rates of depression in the community go up. It turns out they go down.

Trevor: That’s what I’ve heard.

Brent: The reason they go down is that the population of patients where it does go up is in the medically unhealthy aging people. So if you’ve got bad heart disease or bad lung disease or cancer or diabetes or whatever, that’s where the rates are much higher than the general population. In healthy older people, much less. The other thing to remember is that as our brain ages, it changes in different ways. It responds to the environment differently. I’ll give you one example. Older adults who are depressed at the age of 70 may have been depressed on and off since they were in their 20s, or they may now just be for the first time experiencing the first episode of depression. Those are two different illnesses in many ways. The older onset illness is often associated with different symptoms. So there’s a lot of apathy or lack of motivation, lack of energy, less anxiety, more like blah apathy, lack of motivation and some cognitive changes. Not memory loss, but organization, planning, decision making, what we call executive functioning. It’s associated with small mini strokes in the brain, like areas of—

Trevor: Small mini strokes in the brain.—

Brent: Mini strokes in the brain like lack of blood flow or lack of oxygen that literally kill brain cells, and we see on MRI scans and other imaging modalities. The syndrome of lack of motivation, lack of energy and executive dysfunction associated with vascular changes in the brain. We call that vascular depression. Some people call it the depression executive dysfunction syndrome, but it’s a late onset type of depression that is often very challenging to treat. Families get very frustrated because they think that mom or dad were never like this, but they’re doing it on purpose. You know that kind of thing like, but they really aren’t doing it on purpose. This is a significant brain disorder. It’s just different depression than a younger person. You give them an antidepressant like a Prozac or Zoloft or something like that, they respond less well than they would if they had a healthier younger brain.

It takes longer to respond, and it may not be as complete a response. The good news is that psychotherapy works well for depression in late life. Very well. Cognitive behavioral type therapies, interpersonal therapy, short-term, very focused therapies, problem solving therapies. These are evidence based therapies that have been studied in dozens and dozens of trials.

Trevor: Do you think it’s because these therapies are generating movement or reactions from sections of the brain that they’ve reached a point in their life that the brain is not being used?

Brent: It’s engaging the brain.

Trevor: Yeah, it’s engaging the brain in the way that it normally doesn’t.

Brent: Right. So I think it does do that. It certainly makes people think, but I think that it’s also, these are practical tools that people can learn and use. I think younger or older adults really doesn’t matter, but some of these therapies are very, very practical. They’re problem solving approaches. They give people the tools to try to help them change the way they feel, and the way they behave that they can actually see a change and they don’t have to rely on as needed medication as much, or on somebody else that they don’t have to. They feel more confident in their ability to do things. I really feel like these practical problem solving approaches, which are being utilized now in all age ranges, frankly, but in older adults, they’re very well accepted and they’re very effective.

Trevor: Do you have stats of what percentage of the population over 65 are showing signs, or are having mental health problems?

Brent: If you just look at depression, and you walked into the waiting room of a primary care physician who saw only 65 and above patients, one in six of those people would have a clinically significant depression syndrome. That’s not full blown major depressive disorder with all the symptoms that you know, it may be a few of the symptoms, but it’s impacting their quality of life and their functioning. So in medical settings like I said, you start seeing rates one in six, that’s a pretty high rate. When you just looked in community settings like senior housing or people living independently in the community of any kind, that’s where the rates are much less. So that’s just depression.

Trevor: Let me ask you a quick question. With that number one in six, if the years are coming up where retirement and the baby boom population, you said it’s really going to explode, are you going to have the resources for this?

Brent: Well, I think the resources for depression, again, I think the places where we need to find the problems of depression are really in medical settings. So within embed clinical teams, within a primary care setting to provide what we call integrated or collaborative care so that we’re using not MDs to do all the work. We’re using social workers or we’re using folks with a bachelor’s degree, community health worker like people, we call them behavioral health supports specialists in our system that do basic techniques like behavioral activation, motivational interviewing, engaging people in treatment, focusing on what people can do, not what they can’t do. Very practical while guiding the primary care doctor on evidence-based medication management.

Those embedded collaborative care models were first studied in older adults with depression for exactly what you pointed out, which is that there are way too many people who are older with this problem, and there are not enough specialty physicians, clinicians, anyone to manage it. So, I think we are in the process here, partners of redesigning our healthcare system and providing what we call value based care. Part of that is focusing on psychiatry problems earlier and earlier in the course of illness.

Trevor: Have you seen any hospitals or institutions that have really stepped up with value based care, or are we really at the beginning here?

Brent: We’re at the beginning, I think Massachusetts, but our system in particular is way ahead of the curve. Way. When I go around the country and talk about this and I tell them what we’re investing in here, in terms of these integrated behavioral health models, they’re frankly blown away that we’re doing so much. University of Washington, very progressive in this area as well. Kaiser’s done a lot of work with integrated care. Mayo Clinic has done a lot of this work. Some people at Penn. There are definitely places, pockets around the country and there are now billing codes where you can actually get paid as a primary care physician’s office to provide this type of integrated care in the practice. So it’s not just you have to pay a full salary of a social worker and eat the costs. You can actually have them with the work that they’re providing, generate fee for service revenue.

Trevor: With the billing code.

Brent: With these collaborative care billing codes, yeah.

Trevor: That’s fantastic.

Brent: Yeah, it’s excellent. It’s a huge, and those just went into place in January of 2017. Unfortunately, it’s easier said than done, because—

Trevor: That’s for sure.

Brent: In order to qualify for billing, Medicare or private insurance for these codes, you have to see them a certain number of times, you have to collect certain data. What’s really interesting about the model is that it’s much more like a medical model of care than a traditional psychiatric model of care, and they use what we call measurement based treatment. So when you go to a primary care doctor with high blood pressure, they’re not going to give you a pill for a blood pressure based on, “How are you feeling today, Trevor. You look good. I can lower the dose or I need to increase the dose cause you’re feeling whatever.” They measure your blood pressure, and their objective criteria for when you use certain medications and the dosing and all of that. We have none of that in psychiatry, so the one measurement tool that’s become very widespread in many primary care settings is called the patient healthcare questionnaire.

Nine was the nine item form, and the PHQ-9 is the name of it. It’s all the depression symptoms with a severity rating. Based on that measure, we have an “objective” if you will in quotes. A measure of depression severity, and we can determine whether or not a medication or a psychotherapy or whatever intervention is having an impact on the severity of symptoms, and use that to guide therapy as opposed to just how you’re feeling today.

Trevor: Has there been any pushback by people or organizations that think that this PH-9 is not objective enough? Do they challenge its worthiness as whether you can objectively diagnose someone?

Brent: The PHQ-9 has been around for almost two decades, so there’s been a varying degree of receptivity. It really depends. I’ve seen psychiatrists who say, “We don’t need this tool. We’re the gold standard.” Frankly, most psychiatrists don’t use this tool. In primary care, nowadays most primary care doctors feel comfortable managing depression and anxiety, but when you really look at the data and they compare these integrated models with usual care, which is doing whatever the PCP wants to do or referring them out, the usual care does far worse than the integrated care. In fact, the outcomes in terms of remission of depression are dramatically different. Four years later, the cost savings are dramatically better with the integrated care, because you’re not saving money necessarily on days that they’re seeing a psychiatrist. You’re saving money on the cost of overall health care, because if you get their depression better, if you get someone’s depression and anxiety better, they take better care of themselves.

They sleep better, they eat better, they take care of their diabetes better, they have less visits to the emergency room, their heart health is better. All of those have been demonstrated. So the tool, the PHQ-9 is one way of assessing outcome. When you show clinicians, skeptical clinicians how this tool can help with regards to outcome measurement, you eventually get buy-in.

Trevor: That’s fantastic—

Brent: You still need to do a clinical assessment, but it helps, especially when you’re using less qualified clinicians, if you will.

Trevor: That’s fantastic. Last question before we move on to ECT and cannabis, were those things we wanted to talk about?

Brent: Yes. In terms of the behavioral symptoms of dementia, that’s some of the research we’re doing. Yeah.

Trevor: If the statistic is one in six, over 65. I’m sorry, this is a tough question. It’s a direct question. What’s the suicide rate?

Brent: One of the questions that people have is, so what is the real impact of depression in older adults, right? So what are the consequences of depression in older adults? So one of the consequences is overall healthcare outcomes are much worse. If you have a heart attack and you’ve got depression, your risk of dying in a year is much higher than if you don’t have depression, regardless of how bad the heart attack was. So there’s a direct interaction between depression and medical illness. The other really important consequence of depression is suicide in older adults. So the demographic, which is somewhat changing now with a lot of the information we’re hearing out of the VA and PTSD and younger adults with suicide rates going way up, and the opioid crisis contributing to that as well.

Up until recently, the demographic that had the highest suicide rate were older men, specifically Caucasian men over the age of 65. Older people tend to attempt suicide less, but are much more successful because they use more lethal means. So they often will use weapons as a means of harming themselves, or other violent means. It’s generally not cutting themselves with a razor blade on their wrist. They mean it, and they often don’t talk about—

Trevor: Oh my God, how do you know this? This is—

Brent: This data that people know.

Trevor: This is horrific—

Brent: This is unfortunately data that people collect.

Trevor: I’m sorry, that was a question more from my brain.

Brent: It’s a horrific image. I know, but it’s important to know because again, there’s so much we can do to help. There’s so many ways to prevent this as an outcome. This should never be the outcome of depression in any age group, especially in older adults where we have treatments that we know work.

Trevor: I wish the audience could see the face that I’m making at you right now, because my jaw is hanging half open and I’m totally locked in. Please continue.

Brent: Well, I think it’s interesting that you started this conversation with how you’ve realized that when you are being treated, you didn’t even think about older adults, but—

Trevor: Flat out ignorance and naivety maybe, but I just didn’t know. Didn’t think about it. I think you were right by saying ageism.

Brent: Well think about it, our society today and for good reasons, we’re all about the kids. We should be, but we can’t forget about the older adults, and we treat people who are older in this country vastly different than the rest of the world does -

Trevor: Absolutely.

Brent: We tend to ignore, we tend to think about, okay, patronize them, we try to take a paternalistic view. We try to ... In some ways we start treating our older adults like our kids. We worry about them. We’d start making decisions for them. We try to move them away as opposed to embracing what they have to offer, and helping develop communities where they can really thrive. What’s happened in the absence of really a movement in this way is a lot of for-profit companies have been developing these relatively wealthy retirement communities. It’s almost like building a college for older adults. In some cases, they actually locate these communities on the campuses of colleges and do intergenerational work. Those are great programs by the way, but there’s very little of this and they’re very costly.

That’s a whole nother topic for another day, which is what do you do as you age in terms of where you live, and who you interact with and how do you stay? We know that to stay healthy with aging emotionally and cognitively, we need to engage people in meaningful activities. Social activities, keeping their brains healthy with cognitive tasks and challenging their brains, nutrition and physical exercise. Those are really critical components of successful aging, and there are ways to provide that, but somebody living alone in a house, now widowed with family dispersed around the country is not a way to stay healthy with aging. That’s often the prototype of what happens.

Trevor: I can say personally that intergenerational education, is that—

Brent: Yes.

Trevor: When I went to film school, there were a couple students in their 40s and 50s in film school with us. They were looking to make a career change. I have to say that it made, especially the film theory classes, it made the discussion, the dialogue around cinema far more interesting. It really did. People that were a couple generations older than me really coming in knowing their French New Wave cinema, Orson Welles and Hitchcock, they knew it cold. We were coming in with our filmmakers from Hong Kong and Norway, and stuff like that. We’d fight, but we all learned from each other. I feel that I learned much, much more having that age gap where we came from completely different generations of filmmakers. I felt I learned a lot more, and because of that was able to appreciate Welles and the French New Wave more because of that. Because I could see the film makers that had such huge impact on me. Those filmmakers had such ... I recognized the passion. It made it so much more interesting in my opinion.

Brent: I’m glad you had that opportunity and that experience.

Trevor: It was great. So now we’re going to talk about Alzheimer’s. I wanted to share with the audience the story that I told you in our pre-interview. I was out shooting a documentary. It was about Alzheimer’s for NHK, the news organization out of Japan. Our director was from Japan. We had a translator, and we were shooting at the university of Arizona in Tucson. We were interviewing somebody with Alzheimer’s. His daughter was sitting next to him. Every 20 seconds he would forget who she was. She would remind, gosh, she was an angel. She really was. I mean, she didn’t lose her patience for a second, and she didn’t lose her composure for a second. It looked like she managed to find a balance between her sadness and her impatience, and is just ... If this is the ride that I’m going to have with my father, then I’m going to try and enjoy it as much as I can. It was really beautiful. The thing that blew my mind and I wanted to talk to you about is that after the discussion, he took out a civil war era violin and played.

Brent: Beautifully.

Trevor: It was stunning. It was stunning. Then when we shot interviews with specialists and doctors, they were saying that music was one of the last things to go with Alzheimer’s patients. Why?

Brent: Alzheimer’s disease is first of all, it’s one of many types of dementias. Dementia is a general term for a decline in memory, or other aspects of cognition along with an impairment in day to day functioning. When you get those two things together, memory loss and functional impairment, you have what we call the syndrome of dementia. There are many changes that occur in the brain that can cause that syndrome. Alzheimer’s disease discovered by Dr. Alzheimer in 1906, is the most common cause of dementia. It’s characterized by these sticky proteins called amyloid outside of the brain cells, and these deposits within cells called, of the protein tau. They develop these neurofibrillary tangles. So if you get amyloid plus tau, and a decline in memory and functioning, you get Alzheimer’s type dementia.

Two thirds of all dementias are the Alzheimer’s type. The person you were just describing, who is unable to remember what just happened or recall a familiar family members name, the symptoms of the illness when they first start are inability to learn new things. So, you tell them something that just happened or you have a conversation about a show you just watched, and they may ask the same question about, “What were we just talking about?” Or you may tell them that this is what you’re supposed to be doing this afternoon and five minutes later, “Where am I supposed to be right now?” So it’s the inability to learn new information. The part of the brain that gets attacked by these plaques and tangles early is called the hippocampus. It’s the memory storage part of the brain, and that’s why the symptoms we first see in Alzheimer’s are memory loss.

As the disease spreads and develops and engulfs the brain, and brain cells start to die throughout the brain, we start seeing other aspects of the illness, including some of these behavioral syndromes, if you will, like agitation, paranoia, depression, anxiety, et cetera.

Trevor: Paranoia?

Brent: Paranoia as well. What’s retained in the process of Alzheimer’s disease long past the inability to learn new things, is what happened to someone back when they were in a meaningful period of their life. Working, getting married, having kids, whatever it may be. The old memory stay longer. So from a pure memory standpoint, short-term memory happens first, preserve long term memory until years of the illness go by when people lose the ability to remember those things.

Trevor: I’m checking a shot in the dark, but are we talking to old memories or are we talking memories that have spikes in emotional weight?

Brent: Right, so that gets to your question about the music. So the memories that we retain for a long period of time are memories that we care about, that happened a long time ago. If you combine a thing that happened, a memory, with an emotion, you remember it. When I give you five words to remember that mean nothing like church, daisy, table, penny red, something like that, I’ll try to get you to remember it five minutes later, but it’s very hard to do that unless you’ve really paid attention and your ability to store new information is intact. If you create a story around those five words, and may be put characters in that story or put them in a place in your mind or you link it to something you’re familiar with and you do over and over again, you’ll do a better job at remembering.

When we connect emotion to a memory, we retain it for a long period of time. Music is one of those emotionally meaningful things that gets stored in a different part of the brain than the hippocampus, and is retained long into the illness. There are countless examples of people with dementia, even in the stages where they often can’t even speak, where they can still play the piano or sing. Even though they can’t speak, they can sing a familiar tune or hum a familiar tune. An artist who develop Alzheimer’s disease, who can still create beautiful new insightful art even into their illness, which is really fascinating.

Trevor: This sounds like something that, at least to me, and I don’t know if there’s a specific scientific term for it, but that sounds like muscle memory.

Brent: Yeah. In some ways it’s any behavior that you do over and over again that you’re good at. It’s like muscle memory. Like you don’t forget to ride a bike, because it’s muscle memory, et cetera. So, it’s definitely a different, it’s more of a routinized memory.

Trevor: Got you, and it can be different with every person depending on their routine, and their passion and yeah.

Brent: Yeah, exactly. That’s the other thing. If you’ve seen one person with Alzheimer’s, you’ve seen one person with Alzheimer’s. The disease presents very differently in people, depending on all sorts of factors including who they were when they were younger and what their passions were and interests, et cetera.

Trevor: What are you doing to, I assume you’re trying to counter these proteins?

Brent: Yeah, so up until the last decade, the method of treatment was based on biochemistry in the brain. Medications that would replace a chemical called acetylcholine that was being progressively drained out of the brain, if you will, because of the destruction of brain cells. So companies and the federal government and academia over the decades and decades developed a class of medications, with a fancy name called cholinesterase inhibitors. Essentially what they do is they prevent the breakdown of this chemical in the brain. The first medication came on the market in 1993 in the United States called Tacrine or Cognex. It wasn’t used very much, because it was four times a day, caused nausea and vomiting and liver dysfunction. Not a pretty sight for a drug that had a modest effect.

When Aricept or Donepezil came on the market in 1996, that became widely used, because it was safer, it was once a day and the effect was about the same in terms of the preservation of thinking and memory for a period of time. What those medications do, those cholinesterase inhibitors is they slow down decline. So the decline still happens, but instead of being steep, it’s more gradual. Drug placebo comparisons are only about six months in duration, because it’s not ethical to keep people on a drug that we know works at least a little bit beyond six months compared to ... In other words, we don’t want to keep people on placebo for more than six months if we know we’re preventing them from getting something that may help. So clinically, there’s some people who do really well, and they stabilize. Others who continue to decline, it’s very gradual. Either one of those are a success.

If people are responding not at all, then there may be no reason to continue it. However, how do you know who these people are going to be? We have no way of predicting who’s going to do a little bit better, or a little bit worse, and those who really won’t respond at all. So we treat pretty much anybody who has the symptoms of Alzheimer’s disease, and there are two medicines we use together. One of those drugs I just talked about, the cholinesterase inhibitors like Donepezil or Aricept, along with a medicine called Memantine or Namenda. This drug is a partial antagonist of a chemical in the brain called glutamate. Too much glutamate is problematic for the brain in terms of toxicity to brain cells, too little glutamate can actually make you paranoid and psychotic. So, this in the little sweet spot in between, it actually focuses and enhances attention, but it does so by reducing the toxicity of glutamate.

We combine the Aricepts of the world with Memantine or Namenda as the standard of care today, but we’re going after a problem in the brain that’s existed now for decades. We’re going after a chemical change. If you want to back up in time, if you’re now 70, and you’re starting to develop symptoms of Alzheimer’s disease, memory loss, et cetera, that means that these sticky amyloid plaques had been in your brain 20 years. 20 years. You were 50 when they started to develop.

Trevor: So what about the few examples where you hear somebody in their 20s, or 30s, or 40s having Alzheimer’s disease? That means, let’s say if they were 25, the proteins were starting to accumulate as a child?

Brent: The typical age of onset of Alzheimer’s disease is over the age of 65. That’s where the numbers just skyrocket. If you look at the United States prevalence rate is 65 and above in the United States. About 5% of the population of Alzheimer’s is 65 and above. By the time you get to 85, it’s 40 to 50%. When you start looking at some of those, and those people who develop Alzheimer’s later in life like I just said, there are genetics associated with risk. There’s gene that’s associated with a risk, but it’s not 100%. You may have a family member who was affected, but the ones you’re talking about who get it in their 20s, 30s and 40s have very rare genetic variants. We call those autosomal dominant genes.

There are three well known autosomal dominant genes that run in small clusters of families, or clusters of families, small numbers of these families. Most famous of which was portrayed in a 60 minutes story a few years ago to Columbia, South American cohort of 5,000 people, and they typically get symptoms in their 30s, or maybe early 40s. So, they’re doing a study right now that actually goes of a drug and antibody that gets infused into the brain, goes up into the arm, goes up into the brain and removes amyloid.

Trevor: If there is a not isolated, but if there’s a specific group in this specific area and they’re developing signs of Alzheimer’s in their 30s and 40s, then there must be something that has to do with their environment or what they’re doing that is causing these amyloids?—

Brent: Amyloid. They have a gene.

Trevor: It’s just gene. It has nothing to do with—

Brent: It may, but all those environmental factors which we can talk more about, accumulate over time and are associated with the later onset of the illness, but for these early onset folks, the genetic risk is 100%. If you have the gene, you get the disease. It’s like Huntington’s disease, but these are rare. Most people who develop Alzheimer’s first of all are older than 65, and even most of the people who develop it under 65 don’t have this one gene problem. They often have a series of genes, most of which we’ve not really identified yet. So for these folks that I just mentioned, like the Columbian cohort, there’s a single gene. It’s associated with the onset of the illness at a very young age, and by preventing amyloid build up in the brain or removing it once it’s there, the theory is again, you could have 20 years of amyloid with no symptoms or dementia.

By removing the amyloid early on before there are symptoms, you may prevent the symptoms from ever happening. It’s like give somebody a statin and at the age of 25 with high cholesterol and prevent a heart attack not tomorrow, but a heart attack when they’re in their 50s or 60s.

Trevor: So this prevention or pulling away, I’m sorry if this is a poor metaphor, but it sounds like how my dentists would talk about plaque. What’s the process of removing them? Just medication? I don’t mean just medication, but—

Brent: Yeah, so there are maybe a dozen compounds or so over the past decade or so that have been antibodies. Okay, these are molecules that get injected into your vein, go up into your brain, bind to the amyloid and essentially dissolve the amyloid. That’s one mechanism, but essentially these are medications that remove existing plaque from the brain by making them go from insoluble sticky plaques to soluble plaques that go away.

Trevor: That is amazing.

Brent: We know they definitely remove amyloid from animals with Alzheimer’s pathology in their brain. We also know that they definitely remove amyloid from humans. What we don’t know and what every single trial has failed to demonstrate, is that even though we can remove the amyloid from the brain, we see no effect on symptoms.

Trevor: What?

Brent: I know, what? So it makes you say, “Well, what is going on here?” In fact, the most recently failed trial March of 2019, spectacular failure. I mean sad, sad day for the whole world of Alzheimer’s disease, for the whole world was a drug called Aducanumab. An antibody like I just described that had been first studied in about 170 people in an early stage study. The report was published few years ago and in that study, they showed that not only did this compound, this amyloid antibody remove amyloid from the brain in people with Alzheimer’s disease, but their symptoms improved and there was a dose dependent effect. So the higher the dose the more amyloid came out, and the higher the dose, the better the symptoms got. When they decided, Biogen, the company that manufactured this compound, when they decided to do a very large scale trial to get the drug approved by the FDA for Alzheimer’s disease. I mean the last drug we had approved was Memantine 16 years ago.

The first what we call a disease modifying therapy this would be, they did this study in 3,000 people around the world. We were one of the sites here at McLean hospital. We had enrolled seven patients and caregivers into this study for years. A year and a half on drug or placebo and then open label, you definitely get the drug thereafter. They did an analysis of the data in the winter trying to determine is there a safety problem in this drug? If there is, we’re going to stop the study. Well there was no safety problem, but they also asked the question, how are the two groups doing? If the placebo group is doing as well as the drug group, and we’re now almost done with the study, we have about a year to go, then we’re not going to keep people in the study. It’s not worth it. When they did that interim analysis, what would they call a futility analysis, there was no evidence that even if you kept people on the drug and placebo for another year beyond the time they looked at the data, there would be no chance they would separate.

So Biogen announced to the world early in the morning of March 27th, I believe, that this futility analysis demonstrated there was no evidence of benefit, and they were stopping the study early. That morning I got on the phone with all participants and their family members who were devastated. Made the front page of the globe the next morning. The stock lost about $18 billion in four hours if you can imagine. So now we’re at the point where the field is saying to ourselves, “All right, we’ve been chasing amyloid now for a decade or more. It’s not working. We got to try something else. Let’s go after tau, and then let’s go after other things.” This is where we get to the prevention. Other things that are likely impacting the prevalence of Alzheimer’s disease beyond amyloid and tau.

Trevor: When something, God, I hate to use the word failure, because—

Brent: I know. I’m very optimistic too. So what do you want to say? Disappointment, this bump in the road.

Trevor: It’s funny, I’m the super negative person, but I don’t even want to say failure. Yeah, this bump in the road, but it sounds like a really huge bump. If I can bring the attention over to the doctors, the scientists, everybody who’s a part of this community at tackling this problem, what does that do for you, for all of you? Did some people just quit?

Brent: Interestingly enough, the passion of the Alzheimer’s community, which includes individuals with the illness, their caregivers, advocacy organizations like the Alzheimer’s Association, the pharmaceutical industry and the biotech industry and the physicians and the nurses, and everybody with a patient and their caregiver in the middle. Everyone is redoubling their efforts and the good news, the really good news here is that unlike, I used to see in earlier in my career with other psychiatric problems. The world, this community is collaborative. There are large scale trials going on right now that involve all these different partnerships around the world, and there is an increased effort from a funding perspective by the federal government of the United States. One of the few things our government has done together in the last decade, has been increasing funding for Alzheimer’s research.

We were way, way, underfunded. We still are. The demographics are scary as we talked about. We’re expecting the 5.8 million Americans today to grow to 14 million by the year 2050. $290 billion is the cost this year to be over $1 trillion. Seven years ago, we were spending $450 million only on Alzheimer’s research at the federal level. Today, seven years later, that 450 million is up to 2.3 billion. It’s about five times as high. It got a ways to go, will likely be close to 3 billion next year if all goes well in Congress. What that’s doing is that investment at the federal level is bringing in investigators that used to study other diseases, and they have different approaches. People who were studying schizophrenia, Huntington’s disease, all sorts of neuropsychiatric illnesses, bringing in other ideas. Well, you know what? We know about amyloid, we know about tau. What else should we be attacking?

We see inflammation in this disease. We see deficiency and dysfunction of this cellular organelle called mitochondria that produce energy. What are we going to do to preserve energy metabolism with aging? What are we going to do to reduce oxidative stress to the brain? What are we going to do to reduce inflammation, or what other pathways are there that might be causing? We know the genes, we have imaging. We can see amyloid and tau in the brain without a biopsy. We have a lot of tools. We have biomarkers. How are we going to find other pathways that we need to try to impact to try to alter the risk of this illness? That’s where the field is now. In two weeks, I’m leaving for Los Angeles. It’s the annual meeting of the International Alzheimer’s Association meeting, AAIC.

If you read the paper, third week of July you’re going to see a ton of stories about what’s going on. I imagine Biogen will be presenting for the first time what happened in that trial, because even though it stopped that day, we still haven’t seen from them any of the actual data. We only know that it was not safe to continue.

Trevor: I’m definitely going to keep an eye out for that. I want to read that.

Brent: We all do. We all really do. So to answer your question, despite the failures, no one has given up.

Trevor: That’s amazing.

Brent: The passion and the enthusiasm of this community is remarkable and frankly, we can’t give up. It is an epidemic of our time, it is going to bankrupt our government if we can’t figure out a way to reduce the prevalence of this illness, or slow down the decline. The reason why I’m interested in it as a psychiatrist is because I’m fascinated by the biology, but more than that, the impact on the people with the illness and especially their loved ones, because this is a disease that causes caregiver illness. People call it distress or stress, but what it really does is it causes depression in caregivers, and it increases their risk of death.

Trevor: I was going to ask, with all of these specifics and details, it also sounds like for the caregivers, for the scientists there, I would just think emotional investment would be unavoidable. I mean this sounds tough. I mean it’s all tough, but this sounds tough.

Brent: The caregivers that I’ve worked with over the course of my career are truly remarkable. I mean they dedicate and sacrifice their lives. What makes them exhausted, burned out, depressed, et cetera, are the moments of anger, irritability, agitation that their loved ones have, because that’s what the disease is ravaging their brains and they can no longer have control over their emotions. It’s that emotional distress, disinhibition, aggression, violence that really, really, really causes the distress in the caregiver. That’s what we can focus on and try to improve and reduce the burden on the caregiver. In 2019, despite the prevalence of these behavioral symptoms that drive all this burden and distress in caregivers and their loved ones with the illness, the FDA has never approved any treatment for the behavioral symptoms of dementia.

We use treatments all the time, they’re used off label. Well, I know, like, “What? How could that be?” So you know what we do? We take antipsychotic medications developed for 30 year olds with schizophrenia, or mania or treatment resistant depression. We give them to older adults with dementia, who are medically sick and have other issues and we expect that number one to work and to be safe. Why are we surprised that there are issues? The good news is that there is a lot of data. I mean back in the 1990s when the atypical antipsychotics like Risperidal and Olanzapine, Quetiapine, were all coming to market for schizophrenia and bipolar disorder. The companies knew that they had a gold mine of opportunity, literally a gold mine in treating agitation and dementia, because for decades the older drugs were being used not terribly successfully and with lots of downside, the Haloperidol, the Haldols of the world.

So these newer “safer drugs” would be great opportunity. The problem was is that when the first of those drugs, Risperidone manufactured by Jansen, Johnson and Johnson went to the FDA said, “We were seeking an approval for agitation and paranoia in people with dementia.” They looked at the data. There was definitely an effect in reducing those symptoms, but there was also side effects including when you pull all the data together from all the trials, about 17 of them that were done by companies to see are these drugs effective in reducing agitation and paranoia? There was in effect a clinical improvement, but there was also a high risk of death and a higher risk of strokes. So the death warning was established in April of 2005. We know that our medication treatments to reduce agitation are limited by side effects. Sleepiness, unsteadiness on your feet, worsening memory, falling, et cetera.

One of the roles that I’ve had here at McLean Hospital when I first arrived for my second stint back in 2002, I was medical director of our inpatient unit focused on these patients with Alzheimer’s disease and behavioral complications, or other dementias and behavioral complications. The first thing we did was we were noticing that there were some individuals who got better with nothing. Behavioral treatments, medication treatments, nothing. They were medically fine. One of my colleagues one day in caring for this woman who was in her early 60s, with about seven years into Alzheimer’s disease, early onset with severe aggression, violence towards her husband at home, and the same towards our staff here with no benefit from medicine and lots of toxicity actually said, “Well, why don’t we try ECT?” Electro Convulsive Therapy. I said, “Wait a minute, why would you try ECT on somebody already with such poor memory? She can barely speak, she can’t remember anything. We might actually make it worse. What do you think of that?”—

Trevor: A side effect of ECT is short-term memory loss.—

Brent: Short-term memory loss. So we said to the family, “There are a few cases in the literature where ECT has been helpful. We know it’s one of the most dramatic and successful treatments in all of psychiatry, especially for severe depression, but it may have a benefit in aggression. It may benefit somebody with dementia with aggression where nothing else is getting better.” So lo and behold, we treat this woman with ECT and after the third treatment, she starts to smile and she’s calm. After the eighth treatment, she goes home and she lives with her husband. Over the next 12 years, she comes back to McLean every month for ECT, and she passes away two years ago from cancer, totally unrelated to dementia, but having lived at home with her family, engaged in a meaningful life for 12 years. So, when we first started—

Trevor: ECT every month for 12 years.

Brent: When we first started treating people like this woman, we started seeing these incredible outcomes so we started to document them. We did a study where we looked at the charts of these people and published it. We did a prospective study and we published it, but we never had a control group. Like, well maybe it wasn’t the ECT. Maybe it was something else. We really need to do a definitive trial, and I tried for years. I collected a whole team of investigators across the country who are really passionate about this. I would be presenting this at meetings internationally and nationally, and we get a lot of people saying, “Oh my goodness, I’m so happy you’re doing this because we’ve wondered about doing this or we’ve done it a little bit, but we’re wondering is it safe.”

This year in the fall of 2018 after now our third attempt, the National Institute on Aging funded an $11.8 million study that we are running here at McLean. It’s a randomized trial of ECT versus a control group, which is getting something we’re calling simulated ECT over a period of nine treatments in three weeks while they’re in the hospital. 200 people, five sites around the country. Our goal is to show that there’s a reduction in agitation and aggression with a minimal amount of side effects. We’re certainly going to measure them very carefully. Confusion is a side effect or other medical side effects, et cetera. So, we’re really excited about that treatment.

Trevor: Where are the other four locations for our listeners?

Brent: The other four sites around the country, McLean is the coordinating site, so we’re one. The Mayo Clinic in Minnesota, Emory University in Atlanta. We have a site at Northwell Health, which is a very large healthcare system in Long Island in New York city. One of the flagship hospitals is Long Island Jewish Hospital. That’s where it is out on the Island. Then the fifth site colleagues of mine, who basically have a hospital like McLean out in Michigan called Pine Rest Christian Mental Health Services. They are a standalone like McLean Psychiatric Hospital affiliated with Michigan State University in Grand Rapids, Michigan. So we have those five sites, and we have biostatistician colleagues in South Carolina who are biostatistical core.

We’re on the phone with each other regularly. We have a data safety monitoring board. We are still awaiting approval from the IRB, the Institutional Review Board here at McLean, which will oversee all the other sites, and we’re waiting approval from the FDA that yes indeed you can use ECT, which we know works for depression. You are allowed to use it for people with dementia, and make sure you send us all your safety and your efficacy outcomes.

Trevor: You need FDA approval for ECT?

Brent: You need FDA approval to use the device for an off label indication and study it. So, they may say, “We exempt you from having to ...” They won’t exempt us from monitoring us, but they may exempt us from having to basically get what’s called an IDE or an investigational device. We’ll see, they will let us know probably by early next week. In either case, hopefully by the end of the summer we’ll begin recruitment. The other treatment, same unit, inpatient unit agitation, irritability, anxiety in people with dementia. Again, very common symptoms like 80 to 90% of people have them at some point. One of the other ideas that we came up with clinically many years ago was to try a synthetic version of marijuana called dronabinol or Marinol. It’s a synthetic THC chemical. It was approved years ago to treat nausea and vomiting in people getting chemotherapy, and for patients who had HIV related weight loss. Stimulates appetite, it also reduces anxiety and it may have one of these interesting biological effects on the brain. It reduces inflammation, and it reduces amyloid plaque buildup.

Trevor: I was going to ask if inflammation had any—

Brent: Yeah, inflammation probably plays a role in Alzheimer’s disease and the potential effect of the THC cannabinoid is really in reducing anxiety. At least that’s our, agitation and anxiety is our hope. So we’re doing a study funded by NIA of a randomized control design placebo versus drug in 80 inpatients, or in long term care, like assisted living in nursing home units with agitation. It’s a three week study of 10 milligrams of dronabinol, 10 milligrams of THC essentially versus placebo. We’ll see, we’re about three years into that study and it’s going to be about a six year study.

Trevor: Okay, Dr. Forester before we wrap up, why are you doing this?

Brent: Good question, Trevor. When I was in medical school, I loved medicine. I loved internal medicine, I loved solving complex problems. I loved having somebody come with a bunch of symptoms and figuring out what was the cause of those problems, and especially when it involved neurological symptoms that affected the brain, and even more when it affected the psyche. So I was always fascinated by how in my field that I’m in geriatric psychiatry, psychiatry medicine, and neurology all come together. What I really loved were two things. Number one is I really enjoyed people. I was more interested in their stories about their life, than I was about their pain in their abdomen. I mean, I cared about their pain in the abdomen, but I really cared about what was going on at home and what they were like earlier in life.

So I decided to go into psychiatry, but because I had this passion for medicine and neurology, I wound up doing a year of medicine internship at Mass General, and then trained here in psychiatry. The more I did my psychiatry work, the more I got drawn into this older population because in that population, I saw medicine, neurology and psychiatry coming together. I saw people with aging brains who were presenting with every manner of psychiatric problem. I saw an opportunity to follow people who had long term ongoing longitudinal needs, where in some ways I felt like I became their primary care doctor, who happened to specialize in their mental health. Then finally, I’ve always liked older people. I’ve liked stories in history and I’m fascinated by the fact that a lot of my patients lived through amazing times, and they were completely fine from a mental health perspective. They developed a lot of these disorders in later life, and they’re able to tell me about what life was like when they were younger.

They bring pictures in to see me, or I go do home visits. I’ve always liked that aspect of aging, is the history involved in these individuals’ lives. So I think the combination of passion for history and passion for the combination of medicine, neurology, psychiatry, and people who are aging and the ability to help families is why I liked this so much. I’m always amazed at the people who go into this field. People who care for individuals with dementia. The people who care for people who are aging with psychiatric illness are the best. I mean, they are great people. I have amazing colleagues and not just in medicine and nursing, social work. OT, PT, we are a team when we try to care for old adults. You can’t take care of folks in a vacuum. You’re a whole team taking care of these folks, and that’s what I really like.

Trevor: This hour was a whirlwind, and I heard countless details that need to be organized and double checked and played against each other. It sounds like a lot to manage.

Brent: Well, you know what? I was for years, I give these talks for the community a lot on the aging brain, on the risk of Alzheimer’s disease, on depression later in life. There are a lot of them that I’ve done over the years, and I’ve written about it. I’ve had blogs and things like that, but I’ve always felt like these messages about aging, how to prevent problems with aging, how to treat problems when they occur with aging, how to support your parents, there’s such an appetite for this information and I’m not sure how best to get it out there—

Trevor: There is. That is true.

Brent: If you have any ideas about that through different vehicles, let me know.

Trevor: Honestly, I got my first taste of that when a company from NHK, they’re a big huge international news market, where they’re contacting little me and they’re like, “We’re flying you out to Tucson to do this 40 minutes story on this subject.” That’s when I suspected that there was a, for lack of a better word, there is a market for this information.

Brent: Huge. I just, yeah, we’ve got to figure out a way to tap into it. Yeah, I agree. I think part of this is being driven not just by the people who are aging, but it’s their adult children who are seeing their parents age and those are the baby boomers.

Trevor: I’m not going to lie. I can’t tell you how many times and I cannot be the only one. How many times I’m on a group call with my two sisters and I’m like, “Are we seeing any signs?”

Brent: No. I know. I mean I’m in this field and I worry about this stuff with my parents all the time. All the time—

Trevor: It’s like, “How’s mom doing?” My younger sister is home so it’s like, “How are they doing? How’s mom and dad doing?” Look for the signs—

Brent: It’s a tough balance between, like I said this patronizing thing. I was like—

Trevor: Exactly.

Brent: Within the past few years, I was like, “Mom and dad, you need to leave this house. It’s not safe for you to be here, whatever.” At the end of the day, they’re competent people. They both still worked despite their age and their frailty. They’re physically frail—

Trevor: They both still work?

Brent: My dad’s a psychiatrist. He’s still seeing patients. My mom is a decorative arts historian in New York city at The New School, and she still teaches online classes.

Trevor: What? Your mom teaches at The New School?

Brent: Yeah. She’s been doing it for like 35 years. So, she can no longer now do physical tours of the Met, so she does online classes—

Trevor: Your mom used to do physical tours of the Met?

Brent: Yeah.

Trevor: I need to hang out with you.

Brent: Anyway, my parents are great examples of successful aging in their brains, but their bodies are falling apart. They know it and they don’t want to lose their independence, and they want to live where they want to live, but you know it’s an accident waiting to happen. It’s tough though how to negotiate that, but this happens all the time. I mean, people are struggling with this every single day and especially our generation. We’re in between, we’re raising families, we’ve got to worry about them, and I have aging parents. Got to worry about them. We’re the sandwich generation.

Trevor: Have you heard of a video game grandma?

Brent: No.

Trevor: Okay. Well, before we started the conversation, Dr. Forester and I were discussing the medium twitch. The streaming service for gamers and other things. There is a streamer, video game grandma, she’s in her 80s. She—

Brent: That’s awesome.

Trevor: I’m talking, she doesn’t just play video games. She plays the hardest games. I’m talking role playing games that require ... I’m a gamer, and there are some role playing games that require so much input. Keyboard, mouse, controller, hold down this button, and then this button does a secondary function.

Brent: It’s good for her brain—

Trevor: All this stuff you have to remember. Hitting this button alone has one function. Holding this button down, second function. Holding this button down, this one third function and she’s able to organize her weapons, her clothes. She’s playing fallout right now. She’s going around, she’s making sure all of her settlements are safe. It’s amazing. It’s amazing.

Brent: I also like game grandma. That’s great—

Trevor: She’s incredible. It’s great—

Brent: Thank so much. It’s been a pleasure—

Trevor: Dr. Forester, thank you so much. This was really great—

Brent: Great.

Trevor: All right, what did you think of that? I want to clarify something real quick, because I think you guys would actually enjoy looking her up. Her name isn’t video game grandma. She actually goes by two names. Grandma gamer or the gaming grandma and her real name is Shirley Curry, C-U-R-R-Y. Shirley, S-H-I-R-L-E-Y. She has a bunch of videos on YouTube and she’s an absolutely fabulous, fabulous, very funny person, and really smart and sharp. I think she’s inspiring, especially not just that she plays video games, but the video game community is very toxic and she is a very sweet, sincere, and gentle vegan in all of that mess. So yeah, check out. Shirley Curry, grandma gamer. She’s a lot of fun. I want to thank Dr. Forester for coming in and having that discussion with me.

Two weeks, two weeks, two weeks, two weeks, two weeks. I already have the episode recorded. So what’ it’s happening? It is on, so I will see you all in two weeks. I hope you’re doing well. I hope whatever pain or sadness you have, or battling right now that it will eventually be countered with love and relief. We could all use some relief. Okay, two weeks. Thank you for listening to Mindful Things. The official podcast of McLean Hospital. Please subscribe to us and rate us on iTunes or wherever you listen to podcasts. And don’t forget mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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