Risk Factors for Cognitive Decline

Sarah Lyon

00:00:00Unfortunately, the world is heading towards a dementia crisis. The number of people living with dementia is projected to nearly triple by 2050. But there is real hope for changing this trajectory, and that is prevention. A Lancet Commission estimates that nearly half of dementia cases could be prevented or delayed by addressing 14 modifiable risk factors, including hearing loss, hypertension, physical activity, and social isolation.

00:00:31And our guest research points to another incredibly important piece of this prevention puzzle, the role of environmental risk factors. It is estimated that nearly half of individual differences in Alzheimer's risk may be attributable to environmental influences, like access to green space and light pollution.

00:00:51In today's course, we will talk with Ganesh Babulal about addressing those risk factors, recognizing cognitive decline early, and whether early intervention can slow, or in some cases, even reverse decline. We will close with a vision for a team approach to care, where public data on environmental risk is synced into the EMR system and physicians can recognize risk earlier, and a therapy referral can help mitigate that risk before problems arise.

00:01:19We have so much to cover today, so let's dive in.

00:01:26Welcome to the OT Potential Podcast. I'm your host, Sarah Lyon, OTR/L, and I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform, but to gain CEU credit, you will need to be a member of the OT Potential Club, our OT continuing education platform.

00:01:49You can go to otpotential.com to learn more. Okay, here we go.

00:01:56As I mentioned at the top, joining us today is Ganesh Babulal, PhD, OTD, MSCI, MOT, OTR/L, FAOTA. Ganesh is a professor in the departments of neurology and quantitative health sciences at the Mayo Clinic and director of two laboratories, the DRIVES project and ARCHES. He is also a research associate at the University of Johannesburg in South Africa.

00:02:25Ganesh's research seeks to understand the relationship between cognition and mental health and its impact on instrumental activities of daily living, such as driving, in healthy older adults and those with chronic neurological diseases. His research intentionally focuses on healthy aging, protective factors that support brain health, and risk factors for dementia.

00:02:47The overarching research program among older adults has investigated and connected biomarkers and complex functional outcomes like driving, mental health, and health disparities as risk factors for Alzheimer's disease and related dementia, while also identifying points of intervention, especially for minoritized populations.

00:03:07Ganesh holds dual bachelor's degrees in biology and English, dual master's degrees in occupational therapy and clinical investigation, and dual doctorate degrees in OTD and a PhD in health sciences. Okay, without further ado, we will patch Ganesh into our live studio Welcome, Ganesh. It's so great to have you today.

Ganesh Babulal

00:03:27Good afternoon, Sarah. It's a pleasure to be back. Thank you for having me again, and welcome to everyone else.

Sarah Lyon

00:03:33Oh, thank you so much for being here today. I want to start us off with almost a warning to people. Like this research that we are talking today, I feel like once you learn about it, it's like you can't unsee it.

00:03:45Like it has just been sitting in my mind all week. It just makes you think about... for me, it makes me think about, one, just protecting ourselves from some of the downsides of modern life. Like this comes up when we talk about cancer or when we talk about heart conditions and then again looking at dementia.

00:04:05Like there is just this common thread there of things that we can do, to be protecting ourselves. And two, how do we shift more of our healthcare system to addressing things earlier? Like I think we have so much capacity and potential as therapists to really shift our focus earlier, and this is just another conversation that's gonna really get our wheels turning about that.

00:04:29Before we get to these like big picture thoughts though, I would love to just open again with your story and how you came to this place where you are researching cognitive decline.

Ganesh Babulal

00:04:43thank you so much, Sarah. I think it's, been quite a journey, and it's been one that I've been very fortunate to have shared with a lot of other people that have helped me along the way.

00:04:53and ultimately, I think it started back many moons ago when I was a director of rehab and the interim director of memory care in Colorado, in actually rural Colorado, the western slopes, which is, absolutely amazing, country. And, I saw a lot of patients that had their overall deconditions and older adults as well.

00:05:13overall deconditioned did my share of, ortho, hips, knees. but then, I started to notice that there was a lot of cognitive impairment and would use, screens like the MMSE and the SLUMS to assess their cognitive function to better understand, where are they? Can they follow the directions or the recommendations?

00:05:32And then when I, started managing the, the memory care, this was a locked memory care. I saw patients, or, and clients in there that just had a significant array of different responses, how they were active, whether it was the evenings or the mornings, whether or not they recalled you, how quickly they forgot you.

00:05:54And the heterogeneity really always stuck with me, and it ultimately led me to going back for more schooling and being a broke student for another ten years. And so when I went to Wash U, for my first doctorate, I actually, I did a lot of research in stroke, specifically s- first stroke survivors.

00:06:13And we really wanted to understand how did the environment influence recovery, both short-term and long-term? And I was fortunate enough to be able to create and validate an, measurements called Measure of the Stroke Environment to look at patients that had aphasia and to understand how did aphasia itself was impacted by their environment, how they're able to feel supported or not feel supported to be able to do their activities.

00:06:37And then once I finished that work for my postdoc, I eventually transitioned into driving and, in the context of Alzheimer's disease, and I'll talk about this a little, bit later in terms of the complexities associated with that disease. And it really, as an IADL, struck an, internal and very important chord for me as an OT.

00:06:58And then we really started to focus on how did the subtle breakdowns in that, specific IADLs could that potentially influence and help us understand the disease trajectory and decline. And eventually, as a junior faculty into more tenured faculty, I worked on establishing my own research cohorts to bet- better understand how did the environment exert influences to support cognitive function, a construct called cognitive reserve and cognitive resilience, and essentially to understand why do some folks age better in place and others don't, and why do some folks get dementia versus others.

00:07:37And, so it really was this menagerie, of, so many different complex diagnoses, the conditions that were influenced by the environment, and conversely, how did they in, interact with the environment. And ultimately, I think it led me into just really focusing more on IADLs. And as an OT core to my internal identity, we really wanted to understand early detection and could we potentially use that as a marker to identify those who are at the highest risk and then intervene well before they actually progressed and saw, somebody in the clinic.

Sarah Lyon

00:08:14I love your story because I think we can all relate to being in practice and having those kind of questions like, why was this person susceptible to this condition? were there factors that could have prevented this? And you took all those questions, and you got to follow it into a career, and you're still following it, and it's such a fascinating part of research.

00:08:39I wanna start, I think, with just some foundational knowledge, getting oriented to the different stages of cognitive decline. I can totally relate to what you were saying, like being the therapist on the floor, doing the SLUMS. I would do the Allen's cognitive level. I was really pecked as like the cognitive person in every setting I was in, the SNF, in the hospital, in the psychiatric setting.

00:09:06And I remember getting the scores, but I would love for-- to hear from you now, like what I wanna call it the buckets or the stages- That is good ... of cognitive decline, and starting with w-what healthy looks like. Where's healthy, and then what are the stages from there? What are the words now that you would use to describe those?

Ganesh Babulal

00:09:29happy to elaborate. And, like you, I did many of those measures as well, and I would have never, in a million years imagined myself being here, Yeah ... to continue to pursue this. So I think the, the most important thing to communicate is that, things-- A, a lot of folks have heard the words like Alzheimer's disease and dementia.

00:09:49and so I'll set the stage. Those are what we call non-normative parts of aging. And so the consensus is that, nor-normal aging, we might experience slower, processes that might tend to, attenuate as, we're not able to respond as quickly as we used to.

00:10:09Occasionally forgetting things. you're at a party, you're meeting a lot of people. You may not remember everyone's names or all their stories. You might have, struggles finding your keys, like me most, most days. But the, the key aspect of it is that new learning still occurs without any issues.

00:10:28Now, when it becomes a problem is when that process becomes disrupted, and the g- we start to hear words like Alzheimer's or dementia. And so I wanna start off really quickly that dementia itself is this umbrella construct, or term that subsumes all types of different dementias. So just like cancer, is an umbrella, dementia is an umbrella.

00:10:52And Alzheimer's disease just happens to be the most prominent, form of, dementia. Specifically, it impacts roughly about sixty to eighty percent of the population. Then we have other forms like vascular dementia. Typically, if you have cardiovascular issues like a heart attack or a stroke, you're at a much higher risk where the vascular infrastructure of your body is compromised and, blood is of course pumped to the brain, and takes nutrients in addition to removing waste products as well.

00:11:20And then there's other etiologies like frontotemporal dementia, that's, currently impacting, a, a significant portion of the population, but not as big as Alzheimer's disease, dementia with Lewy body. And then you can also have mixed dementia pathology. because Alzheimer's is such a prominent piece of the pie, I'll focus on that for a little bit.

00:11:41And, for my research, what we've done over the past decade is actually looking at a s- a specific phase of it. It's called the pre-clinical stage of the disease. This is where the individual is cognitively normal, but the proteins, the two key proteins, beta amyloid and tau, that aggregates within the brain itself, specifically some that aggregate within the neurons and those outside of the neurons, they start to break down the cerebral architecture of the brain.

00:12:09And what happens is that you start to-- The activities that you do on a daily basis, they, are no longer, you're not efficient. they may take a little bit longer to do. And that stage is massive. It can take anywhere from fifteen to twenty years So for example, if a person's diagnosed at age 65, the disease itself maybe has started in their late 40s or early 50s, and that's where a lot of the energy and the resources are being poured into is to better understand what can we do right now?

00:12:37How can we intervene to stop the disease from progressing to the latter stages? So the next stage after, pre-clinical AD is a term that we've all heard, which is mild cognitive impairment, and this is measurable. Particularly, there's two forms, amnestic and non-amnestic. Amnestic is just what it sounds like.

00:12:55there's challenges with memory and thinking. and non-amnestic is struggles in other cognitive areas. But basic ADLs are intact usually, but IADLs typically take a hit, so managing your checkbook, driving to familiar places or to new places may not be as efficient as, as we would expect, and that's n- normally where, a client or a patient might see a neurologist or neuropsychologist or go to their PCP and say, "Hey, really struggling."

00:13:22But usually it's their family members that see those signals earlier on. And then the rest of the stages really is the mild, moderate, and the severe stage. the mild stage is roughly about two years that an individual might spend there, and this is where they need a lot, moderate to significant assistance with their IADLs, and then they can do most of their ADLs.

00:13:43It's roughly intact. Moderate dementia, about two to four years. This is where ADLs are significantly impacted, and it becomes the focus of the, of the treatment and therapy. And the severe stage, unfortunately, is roughly about one to two years. This is when they're in a locked memory care unit often, and that they're end stage where maximum assistance is needed for ADLs and IADLs.

00:14:05Now, the causes may vary, and what I wanna, also make note of is that you can have a lot of different diseases that might influence the risk of different forms of dementia. But that's a few of those buckets that you alluded to and of, where we're doing a lot of the research and focused on right now.

Sarah Lyon

00:14:24That's super helpful. I have them written down on my paper. I wasn't expecting to ask this, but I wanna sneak this in. I-- because I heard you say cognitive reserve towards the beginning.

00:14:36And as a therapist, we're usually working with someone in an acute situation, and it feels like we're not really seeing their baseline usually.

00:14:47It's usually, especially thinking of the hospital setting, their cognition, you can tell it's just off, like that they're in a dip. How would you talk about that dip in an acute situation, and how can we understand this on this, re- these stages that I just wrote out

Ganesh Babulal

00:15:08Certainly, yeah. So cognitive reserve and resilience really, encapsulates sort of the hardware of your brain.

00:15:15how much, neurons do you have? do you have s- different, conditions, for example, like white matter hypertensities, a stroke that might impact the hardware itself? And then resilience is the, the neuronal connection, how they, how does the prefrontal cortex communicate with the amygdala or the parietal lobe, and how resilient are they?

00:15:38So typically, what we do know is that education is a great, supporter of reserve and resilience because it helps to h- hone and strengthen the communication between different brain regions, and also it can withstand the damage to, for example, like a traumatic brain injury or seizures or a stroke.

00:15:57You're able to bounce back quicker. And in an acute setting, you're, and you're spot on correct. a lot of folks don't wanna be there. They're not sure why they're there because you're taking them out of their natural elements, their environment. But if they have chronic conditions, or we're starting to see a change in terms of their status, cognitive function can take a, hit, and that's typically one of the reasons why you'll do, a test of orientation to time, date, place to make sure that they know where they are.

00:16:25But, reaction time, how quickly they're able to respond to competing tasks can be impacted, and especially within that acute stage. So you kinda wanna assess, do a baseline assessment, but then also multiple assessments to see how they improve and if they get back to where they were pre-hospitalization or admission into, any kind of institutional care.

Sarah Lyon

00:16:50Which leads me to My next question about this, and that is just capturing those changes that we're suspecting with some kind of data. Knowing what you know now, what's your advice to us as therapists on the floor? Like, how would you be capturing if we suspect something's off, how would you be capturing those changes?

Ganesh Babulal

00:17:18Yeah. That's a, phenomenal question, and I get that quite often, too, from not just therapists, but also, other healthcare practitioners. I'm sure-- So I've got to fly out later on this afternoon, for a meeting, and, when you go to the TSA, it says "If you see something, say something," right?

00:17:35Yeah. So it's, corny as it is, but I, like that adage because it's the same thing. As, as therapists, we're really trained to truly be scientists and the experts in behavior, and specifically ADLs and IADLs. So if you see, change that seems to not necessarily follow a trajectory, really comment about it or make a note and connect with others to say, "Hey, are you observing the same thing?"

00:18:01Whether it's another therapist or it could be nursing or c- or, could be a PCP. Where I'd like to start is that I always ask about IADLs first, and the reason why is I think it's the canary in the coal mine. You start to see subtle shifts there, and that usually is indicative of something larger coming down the pipeline.

00:18:21And, the reason why IADLs is because these are highly over-learned, activities that we do, but they're also very complex. So any perturbations, anything that impacts it, you'll see the ripple effects occur within that first. And, what I study is driving, but you certainly can see this in medication management, preparing a meal, cooking, just managing finances if folks still do manage a checkbook or balance a checkbook these days.

00:18:49And the reason I say that is because, as you mentioned, things like, the ACL, the MoCA, or the SLUMS, those are screens. They're not meant to be a comprehensive assessment of function, and I wanna delineate that because they're paper and pencil measures, for the most part of how are they functioning right at that time.

00:19:07It doesn't tell you what they were beforehand or, the variation or the fluctuations over time. And, what we look at, Sarah, is in terms of driving as a window within the brain, what we've shown is that we can actually predict and differentiate individuals who are in that preclinical stage just based on the proteins that are starting to build up.

00:19:30We start to see subtle changes in their driving behavior, and this is many years before they ever see a neuropsychologist or a neurologist that can evaluate them and say, "Aha, you've got this." So IADLs really help to provide that, and we can able to flag that with anywhere from an 80 to 90% accuracy. Now granted, this is in the research end of things within our own cohort, but the, our goal and what we're working actively right now is to take this into the clinic.

00:19:59And so the other thing though is you also wanna, look at subtle shifts or changes within their behavior. So I'll, stick, with the driving, for, right now, maintaining that lane. What we, do know is when there are ch- significant changes, like they may not drive in the night versus a year ago they used to drive in the night, or they no longer drive on the highway when they didn't have any issues whatsoever with that, or they might prefer to go in non-rush hour times because it's so challenging to navigate multiple stimuli.

00:20:32too many things occurring. We're taking a different route than they normally take. All of those might be, telling you that, all right, this self-regulation or this modification, something is happening there. But there's also other signals too, I would note, in terms of sensory motor changes, other things in terms of, their daily function that could signal and, this domino effect is starting to topple.

00:20:57And the other thing I would tell therapists is that monitor, actively monitor everything because you never know when that one observation might be that first pull of that thread that'll unravel, a condition that, healthcare is not even prepared to detect right now.

Sarah Lyon

00:21:16Let me repeat back and put together some of the things I think I'm hearing, and you can tell me if it's accurate.

00:21:24I mentioned at the top that, as OTs we tend to get pegged with cognition. I'm putting together for the first time based on what you're saying that because we're a- typically doing something functional with the patient, I wonder if we're catching the changes more so than our colleagues who are just having short conversations.

00:21:48Is that accurate? Yes. Yeah. That, that- That changes tend to show up in function first. Yeah.

Ganesh Babulal

00:21:53Oh, yeah. Ha- hands down, Sarah, tenfold. and simply, the ethnographic act of observing how they're doing a simple meal prep like cracking an egg or something- Yeah ... or, trying to figure out, hey, what...

00:22:07This is the weather situation that you're given, how would you prepare to dress for it, right? Going back to all the things we learned in OT school and also have seen in practice. You can, see how they sequence through a task- and where that potential breakdown is. So that's absolutely massive data that's so precious that, your conventional paper and pencil tests are not capturing, and this is not a knock to, A lot of my colleagues are neuropsychologists, and the conversations we're having is that very static paper and pencil measure that you're doing, that's been validated since the 1970s may not be capturing the complexities associated with the change, and because you're only typically measuring one single domain of typical cognitive function.

00:22:55You're not measuring how the different brain regions are communicating with each other and where that breakdown might occur because it's, that's that complexity that I'm, that, I keep alluding to that I think we're, truly the experts and to be able to say, "We're seeing this. How does that transfer into other aspects of their daily life?"

00:23:16And then should we be concerned about their ability to age in place, their independence, to be able to conduct their activities, that they're selecting, in a meaningful way?

Sarah Lyon

00:23:27I'm thinking about literally just to, what to write in my notes. I'm imagining someone who, during my intake, I was suspecting changes in cognition.

00:23:37I asked about driving. They said the hallmarks of what you said, like they've stopped driving at night- they've stopped driving on the interstate. As I'm seeing the sequence, them sequence during ADLs, I'm seeing difficulty there. What's the sentence I write in my notes? does c- I'm not diagnosing anything.

00:23:57I'm not saying anything definitive, but I see these red flags. Yeah. what's the- what's the right wording to capture that- Yeah ... that's clinically accurate?

Ganesh Babulal

00:24:06That's a fantastic question. and so what I would say is if they've never done the activity before, or, or whatever it might be, then obviously it's, not clinically significant or noteworthy.

00:24:17What we w- we're, interested in is that intra-individual change over time. So if a year ago they didn't have any issues whatsoever, but then they've self-reported, or perhaps it's a collateral source like a loved one, a spouse, a caregiver, a, an adult child, whatever it might be, self-reported like, "Yeah, they're doing this, we're seeing this," that's critical.

00:24:39And you would say, whether it's the client or the caregiver self-reports a significant change from baseline due to s- it's either secondary to X, Y, and Z, but here's the resulting change, and this may signal potential impairments in other domains that require further evaluation. So, again, I think it's a, an initial marker to say, "We're observing this.

00:25:08This requires further investigation. It requires additional testing that needs to be done for a, a more comprehensive evaluation," whether that's sending them out for a full neuropsych evaluation that's, two to three hours, something, you know, like the road test to ensure that they're still safe on the road, or it very well could be, maybe they have, yeah, thinking about potentially a tumor, doesn't have to be dementia, that's influencing or impacting one potential region of the brain that requires a scan to detect it.

00:25:39So I think, you might observe it and think, "Eh, it's nothing really, important. It's trivial." But I think documenting it is really important. As we know, if it's not documented, it didn't happen, right? And so that itself could be the very, very earliest signs of something occurring, some departure from baseline that might then portend additional change in their, daily activities.

Sarah Lyon

00:26:04The one other foundational question that I wanted to be sure to ask is when we see this early cognitive decline, and maybe it's in an acute care and we don't even know if it's a long-term thing or if we're just seeing, a big dip. When we see it Is there hope of slowing that decline? Can it be reversed?

00:26:28Is it going to progress through these four stages no matter what we do? What does that mean for the future?

Ganesh Babulal

00:26:35Yeah. It's, a phenomenal question, Sarah. So I'll start w- with the, quick epi shot right now. my focus is, older adults geriatrics. By the year 2050, so literally in 24 years, we are gonna have roughly about 88 million older adults.

00:26:49That's age 65 and older. And, spoiler alert, I will be joining that strata of the population, by that time. So I, I'm, acutely aware of that. There are not enough neurologists, neuropsychologists, therapists, practitioners to be able to screen populations, right? And worldwide, it's, it's even more stark, and I can throw numbers out that, that you initially started with to show that, these issues are gonna become much bigger if we don't start addressing them right now.

00:27:19And so I think slowing things down or progression is a significant focus from both public health. What I wanna potentially clarify for everyone listening right now is that it's not a sentence. If you're starting to see these changes occurring, it could be, a plethora of other conditions that are influencing or mimicking it.

00:27:39And so that's what, we need further evaluation for. And having a, for example, diagnosis of a MCI or, Alzheimer's disease, it's not destiny. it's not fixed or written. if you've got a genetic marker, it's, not fixed. It's a combination of that nature versus nurture. And what I wanna say is that MCI doesn't always progress into dementia.

00:27:59A person can be there for the entirety of, their, life or, if they're older. So what I tend to look at from a therapy standpoint, inclusive of all allied health, is what are the potential things that could, are reversible? And an immediate one of those is depression. So long life depression, late life depression, dysthymia, bipolar disorder.

00:28:23you slice and dice it any way, mental health is a massive, area, and depression specifically because it can mimic the symptoms of both cognitive decline and also mild cognitive impairment and even dementia. Now, what makes it more complicated is depression is also a risk factor for Alzheimer's disease and other forms of dementia, and conversely, when you're diagnosed with it, your risk of depression also goes up.

00:28:46So it's this chicken and the egg thing, like which one comes first and how are they all, coalescing? And so doing quick screens that are free, like the PHQ-9 or even the PHQ-2 in your therapy session, very easy to see, hey, are they endorsing symptoms of depression? Do they have something going on in their life that's impacting?

00:29:04'Cause you can see cognitive slowing. You can see breakdowns in executive function, or the, ability to recall is not as sharp as it should be The other thing is sleep. Sleep is immense. It is massive. Really quickly, when we sleep, actually the brain's glymphatic system turns on, and it starts to remove the toxic proteins that build up over the course of the day.

00:29:28So sleep deprivation that leads into chronic conditions like sleep apnea or obstructive sleep apnea, more specifically insomnia, RBD, these are important things that are actively treatable. But because you're not able to sleep, it can influence your d- your daily behavior. As a matter of fact, we had a study that was, published in the Journal of Sleep that patients with, obstructive sleep apnea for every eight-point increase on the apnea-hypoxic index, we saw a roughly twenty-seven percent increase in hard braking, sudden acceleration, and speeding behavior.

00:30:05And again, they're all cognitively normal. No dementia whatsoever, no- not even any preclinical Alzheimer's disease. But because they're not getting that restorative, component to be able to reset, it's impacting their ADLs and IADLs. Medications are another one. opioids, for example, are massive.

00:30:22They've been known on, to in-influence your ability to think. So looking, and of course, polypharmacy is really a, a big thing right now in not just medicine, but also for the field of pharmacy right now. So there's a lot of w- work being done on des- deprescribing to make sure that you don't have drug-drug interaction that is impacting their ability to age in place, but also just to do their daily activities.

00:30:43And other chronic conditions, neurological conditions like traumatic brain injury and seizures can also, again, mimic, forms of cognitive impairment. Again, are all treatable that can, be intervenable as well. There's been a lot of work, in the field thus far, in biomarkers. that's one of the hot topics right now, especially in preclinical Alzheimer's disease.

00:31:06We can detect these rogue proteins that are rapidly acc- accumulating within the body. And then the question is, how do we address that? What do we do to ensure that, they're not gonna continue to transition into, dementia? And so a lot of, though, is they're really mainly being used for monitoring the disease progression and to also eliminating other pathologies so that we can get closer into precision medicine.

00:31:35And where I hope the field goes to one of these days is precision rehabilitation, so we can identify patients and clients that are at the highest risk and intervene well before that point. And the last thing I kinda wanna touch on right now, for individuals that are either working in long-term care or, in geriatrics, or you have maybe your family members there that have a diagnosis, is that for the first time in probably about thirty plus years, we actually have treatments that are available.

00:32:03I'm not advocating for any of these. I'm just sharing more what's available Anti-amyloid treatments, lecanemab and donanemab, which has been shown to essentially, clear out beta amyloid, one of the toxic proteins within the brain. And what it does is it effectively pauses the disease treatment for Alzheimer's or e- the progress specifically for Alzheimer's disease so that, they're not starting to decline further.

00:32:28Now, you do have to have a diagnosis of MCI, and it, does have to have confirmation that your beta amyloid level is high enough to be able to be prescribed the treatment. But it gives hope for millions that are suffering for this disease. Now, it doesn't fix it. There's no cure, I wanna be very clear.

00:32:44There's no cure for the disease, and it doesn't fix the damage that's already been done. So the neurons that have died, the deregulation between the communications between regions of the brain, that damage is already there. But what it does is it does pause it and, folks do have to stay on it for the rest of their life, but the hope is that we have more treatments that come on board to help folks that are in that e- that prodromal stage of the disease.

00:33:11But what we're focusing on right now is that preclinical stage, what can we do now? And, I'll end my answer really quickly. All the things that your mom told you when you were growing up, get lots of sleep, do your homework, go to school, work on, mental cognition, eat healthy as well.

00:33:28I know we didn't get into that right now, but eating healthy is also a, a significant part of it, and get exercise as well. Those are things that you can continue to do throughout the life. It's free to help preserve your ability to age in place and support brain health.

Sarah Lyon

00:33:42I'm hearing you say That it's not a sentence and there's, sounds like there's a lot that we can do so it is worth having the conversation when we start to notice a change or like the changes, hopefully early.

00:33:59I had someone in the comments ask about how we can bring it up in a compassionate way with our patients, with our families. I'm going to say just try a pass at it out loud, to hopefully lead you into the next question. It sounds like we might want to say something like, "Hey, we've not- we've noticed a change that's been going on in the dai- in your, or your loved one's daily routine that makes me concerned that there might be a cognitive change going on under that.

00:34:33But there's a lot of things that we can do at this early stage. I'd like to focus some of our therapy on those protective factors." Is that like an okay... Is

Ganesh Babulal

00:34:44that accurate-

00:34:45Sarah,

Sarah Lyon

00:34:45I think

Ganesh Babulal

00:34:45that's brilliant ... in

Sarah Lyon

00:34:45a transition?

Ganesh Babulal

00:34:46That's brilliant.

Sarah Lyon

00:34:46Okay.

Ganesh Babulal

00:34:46Yeah. No, I wish I had you m- for, there's many a conversations that I've had to have, that have been challenging.

00:34:51Okay. Both with clients, patients, and their family members where "Hey, this, we're seeing this happen. do you see this hap-" And, it, is a very sensitive area and, Yeah ... and it's, also very scary for a lot of folks, not just, the patients themselves, but also their family members, their larger support network.

00:35:07So a lo- I, love the way that you framed it in terms of, this altruistic but very positive way that, hey, we're noticing this. Can we focus on other things to help support that are salutatory to good health? It's definitely a great way to do it, and then that continuous monitoring as well I think is, helpful.

00:35:24Making them, being transparent about it, making them a partner within that conversation I think is absolutely critical.

Sarah Lyon

00:35:32We're going to talk about two layers of risk factors that we could address at this stage, ones in our environment and ones, like, in our person. I think we tend to think about the personal risk factors the most.

00:35:46Could you just spend a couple minutes saying what those personal level risk factors are? And then I definitely wanna g- to get to environmental 'cause those actually feel pretty- Some of those feel easier to modify to me.

Ganesh Babulal

00:35:57Exactly. Yes. Yes. Yeah. So, for folks that are attending, this is such a big, topic of interest.

00:36:02So the Lancet convened a special commission, in two thousand sixteen, and every four years they put out a new updated sort of, what are the big risk factors that we need to be aware of? And it's, really transformed over the past ten years now. So what they've shown is that in early life, the more education you get protects your ability to age in place and helps to withstand the, the impact of cognitive decline.

00:36:25In midlife, there's a lot of things that come online, unfortunately, and I'll quickly go through them, in terms of risk factors. So hearing loss, high cholesterol or hyperlipidemia, depression as a-another risk factor, traumatic brain injury, physical inactivity, so inability to exercise, diabetes, smoking, hypertension, obesity, pun intended, is, a significant global health problem that we're all intending to focus on, and then excessive alcohol intake or alcohol use.

00:36:56Those are, the really the crux to focus on in midlife to addressing and ameliorating them to preserve good brain health. And then in later life or older age, social isolation, air pollution, which is one of the only environmental pieces that they've added in there, and vision loss are all-- all of those fourteen, account for roughly about forty-five percent of the risk of dementia encompassing all of them.

00:37:21And so a lot of the research that we've done in our lab, along with other colleagues as well, has really shown that hearing, depression, traumatic brain injury, and we've published on these, inc., are all associated with a faster progression from being cognitively normal and/or cognitively intact, more appropriately, to a mild cognitive impairment stage to then a prodromal or a, you definitely got the disease, this is the point of no return.

00:37:48And, honestly, to segue into that, a lot of these individual or personal risk factors that you touched on, Sarah, are also being influenced by the environment. So for example, if you can't get out and go exercise because you live in a rural area and maybe there is no, gym or recreational activities, and you've got to drive an hour, you may...

00:38:10That's not conducive. Or you live in the inner city and, there again, is not a, a available areas for you to recreate. That's gonna influence your ability to, try to get exercise so that you can age in place and be healthy. So there's a lot of the environment, these upstream factors that are feeding into these individual personal factors.

Sarah Lyon

00:38:34I'm picturing after a therapist has had that tough conversation, I'm gonna have a handout with those 14 things from The Lancet. I can picture a conversation with a patient to be like, "We've noticed these changes, cognitive changes, not a life sentence. There's things that we can do. Here's the 14 risk factors.

00:38:55Is there one that stands out to you that you feel like we could address? And let's spend time talking about your hearing, why are there any barriers to getting that hearing testing that I can help you with as a therapist?" There's those, personal risk factors as you've started to allude to interlink with the, our environmental risk factors.

00:39:18You have this awesome article called The Association of Environmental Exposome and Cognitive Function Among Older Adults With and Without Preclinical Alzheimer's Disease. This was a great read. I definitely recommend it to people. what have you learned about environmental risk factors, and can you define exposome for me?

Ganesh Babulal

00:39:40Yes. Yes. So for all the OTs listening, believe it or not, our work is getting out, but it's not under the guise of the OT banner. So really the exposome is the environment. It's the totality of what we've been exposed to since birth, pretty much up until death, and there's a significant focus on the environment.

00:39:58So think about, the P-E-O-P or the Kawa model or any of the theoretical, frameworks that we've used. It always has the individual The environment and then either occupation or performance or participation, right? So what I call, behavior. Again, I'm an OT in neurology, and so I've gotta adopt the language mo- the, language tables that they use.

00:40:19So, there's actually, there's like a renaissance right now, this, this massive explosion of work being done to quantify the exposome. And so to, to give a quick example, it's like the physical environment. So think about the air that you breathe, the noise that you hear, the light that's afforded to you, the green space that you're in, the neighborhood that you live in, the social environment that you're a part of.

00:40:42and the social envi- environment is very, dynamic and complex. It can include poverty, isolation, discrimination, all of those softer pieces that are oftentimes challenging to, to, measure. And, it's also the body's response to the environment. So it's really the fusion of both of those in terms of trying to understand how does the genes, what you have, what you bring to the table, interact with the environment and to really, predispose you to good health or to, certain diseases and risk factors.

00:41:17And, really quickly before I dive into that article, one of the things that we've known, that's been well-established in the field itself is that air pollution, specifically particulate matter 2.5, it's the finest grain that we can measure at least right now, and nitrous oxide, these two things, if you're, in inter- in certain cities and you're exposed to a higher concentration, they can actually cross the bro- the brod- blood-brain barrier, alliteration there, say that 10 times real fast, and actually, catalyze buildup of s- toxic proteins within the brain, inflammation that leads to, a higher risk of cognitive impairment and eventual risks of dementia.

00:41:55We also know that chronic stress, being exposed to environments like war, for example, drives up the risk factors for, neuroinflammation within the body and a plethora of different neurological disorders. Getting less sleep at night because you're in a city that's just got a lot of bright lights and, there's, leakage into your bedroom and you can't sleep, that's gonna disrupt your circadian rhythm and the ability of the pineal gland to reset so that you can get that restorative sleep that you need.

00:42:25And of obviously noise, if you're Living in higher construction environments or just a lot of background noise, it's gonna impact your ability to also just shut down and get the restorative rest that you need. So there is an, a significant influence of these risk factors on your ability to age in place.

00:42:42And what our studies showed that you were alluding to, Sarah, is that walkability, if individuals resided in areas that had more walkable, routes and environments, it was associated with a higher, better cognitive function. Individuals that resided in places that had more green spaces, a higher dense, more green, tree canopies, also they were able to, had faster reaction time, better cognition, ability to recall things much faster.

00:43:11The same thing with light pollution. So if they lived in areas that had greater light pollution, we saw poorer cognitive function compared to those that reside in areas that didn't have as much light pollution. And then what we saw, interestingly enough, 'cause I know I talked about the pre-clinical stage of disease, these biomarkers that we're measuring, used to be via pet, pet MRIs, cerebrospinal fluid, and now blood, did not play a role, at least in our study.

00:43:38So what it was saying is that the environment seems to exert a much higher risk, and maybe that biomarker signal comes down much later down the line. So the one thing that I wanna note, Sarah, about the, the study is that it was a cross-sectional study, so we're looking at associations. We couldn't look at causations.

00:43:55However, there are a lot of longitudinal epidemiological studies that are currently being done right now across the world to establish the risk factors within the environments that we live in. And actually, I saw The Lancet just put out a separate call to arms, so to speak, for all populations, globally.

00:44:14Air pollution was definitely up there. War and conflict was also up there, and some of the research that we won't get to talk about now, I do research in LMICs, in particular in conflict and fragile states, and we do show that individuals that live in, environments that have high conflict, high war rates, climate change as well, there is a much higher risk of dementia and cognitive impairment.

Sarah Lyon

00:44:42I might me- be taking too much of a leap here in how to use this information, but because I feel like we get this information 'cause we're looking at big groups of people and we're making associations. Like you said, it's not causation. But I'm wondering as a therapist how to use this, and I'm wondering if we're at the stage where I can start treating them as protective factors, where I'm like, "Okay, I can-- I-- From what we're seeing, it looks like you're in ear- we're seeing some early cognitive decline.

00:45:17Based on what I know in the research currently, I would love to spend some time looking at your sleep, getting you into green space, and looking at your air quality." Like if I was-- Can I take these risk factors and use them as protective factors? Do you feel like we're at that stage? Is that clinically appropriate?

00:45:37Or is how that you-- is that how you would use this data if you were a therapist?

Ganesh Babulal

00:45:41I certainly would and, treating clients, that's exactly what I would do is make a report card and, to show that, hey, these-- this is where things are because they're risk factors and protective factors at the same time, right?

00:45:53it's, really a spectrum, and it's just depending on where they are on that spectrum, it transfers from risk to, protection or protection to risk itself. And, what I would say too is, we do a lot of home health evaluations within, therapy. instead of just assessing the home itself to ensure that it's safe, do you have throw rugs?

00:46:14are there trip ha- other trip hazards? how accessible is the home? Evaluate the neighborhood as well. ask the client like, "Hey, how often do you go for walks? Do you feel safe in the neighborhood that you live in? How close is, the park or a green space relative to where you are?

00:46:31And do you have adequate transportation perhaps to, to go from point A to point B?" But then you could also measure, just using like a, a smartphone nowadays. They all have these, noise, meters built into it. You can measure how high is the decibel, and even smartwatches too.

00:46:48My Apple Watch is able to measure decibels, like what's the ambient background noise look like and is that potentially disrupting their ability to rest? So there's a lot of tools that we can use that are already in our toolkit and our ar- arsenal to be able to quantify and measure how much is the environment impacting their ability to age in place.

00:47:07And, the, I wanna make something, as a caveat. when I was in OT school, aging in place was this very positive things like we want our clients to age in place 'cause, they're not going into, long-term care, to where we know it-- things inevitably decline. But for some populations, they're stuck in place.

00:47:26They don't have the ability to leave, and their environments that are not conducive to good health. And so figuring out what can we modify about the environment to support their ability to still age in place in a positive way. And, I would, think about treating sort of these external environments as all part of their treatment plan.

00:47:46getting good sleep, modifying, noise and light so that they are able to sleep more peacefully and get that restoration that they need. Addressing things like hearing as well within the home, I think is, really useful. Granted, we're not audiologists, but you can confer with your audiology colleagues or speech language ther- pathologists to say, "Hey, I'm seeing this."

00:48:07"Do we need to get hear- hearing, aids on board?" And I will-- This is generalizable. men are w- the worst about this. They are the last to get hearing aids because they're vain about it. and it's well-established in the literature. It's, we, have data to back this up.

00:48:23And so addressing it, having that conversation is really, important. But the other piece too, thinking about building social participation and support within the community, a lot of studies and some of our work has shown is that you can be in what I call a environment that's not necessarily conducive to, good health.

00:48:39But if you have social support to create a buffer, collaboration, support, friends, social network, that can help to really allow them to really age in place without, having to deal with the overall day-to-day onslaught for, contending with poor health because of the air that they're breathing or the sound that they're, hearing.

00:49:00There's so-- There's a lot of things that can be done within the environment itself.

Sarah Lyon

00:49:06Yeah, and I love thinking about addressing the environment. Honestly, it just feels easier sometimes than to change behavior to think about changing the bedroom. Like it's, I don't know- Feels less threatening, I think, to the individual to talk about the environment first.

00:49:25It almost feels like the low-hanging fruit to pick off. and I love the visual of, turning something from a risk factor to a protective factor and having this scale, and I can picture people, marking where they're at on the scale. I really quick wanna link this to some other content that we've had on the podcast.

00:49:45We've talked about life's essential eight, which is a similar list. We've talked about-

Ganesh Babulal

00:49:50Oh, see,

Sarah Lyon

00:49:50yeah ... the list of risk factors for cancers, which is another similar list. As I'm saying this, I wish there was just one list that we could work off 'cause they're all very similar. Yes. But that feels like a shared concept of, like- Yeah

00:50:04taking the risk factor and turning it into a protective factor and like you said, making it like a report card. I had one question in the comments that might be too hard, but I'm going to ask it.

Ganesh Babulal

00:50:18Sure.

Sarah Lyon

00:50:18there was a question about water quality and forever chemicals related to dementia. We've talked about that with related to cancer here on the podcast.

00:50:28Off the top of your head, does anything jump to your mind with that question?

Ganesh Babulal

00:50:32it's a fantastic question, and what I can say is I'm not familiar of any research or any work being done right now to investigate that linkage. I anticipate, though, that to really s- come on really more heavily just because, So I'm from f- a third-world country, and back in the, 1970s when DDT, which worked brilliantly in the United States, when it was problematic and they found out led to all these neurodevelopmental disorders and, birth defects, they shipped it to third-world countries. My country was one of those, and my father was a rice farmer, and he used it heavily.

00:51:02I'm like, "Ugh, so my concentration is much higher than the rest of the population." I think we're s- gonna start to see a lot of research, specifically in the, endocrine disruption area, where we know it impacts it, biological health and endocrinology, but we're not really sure how, what that long-term impacts or that dosage looks like.

00:51:23But I think it's a, a critical and important area for us to start paying attention to because where we live is, it's a closed loop. everything that goes out to the environment comes back and impacts us, and there's a concept called biological magnification, and this is where a lot of that research and the literature started to take, place from, is all the toxins, the pesticides, the herbicides that we're using, it's going out there, but guess what?

00:51:47We're consuming it, and the animals that are all being exposed to it as well, we're consuming those as well. And so strongly to pay attention to that, I think is really important, so I really appreciate the question, and I wish, I had more data, or, research on it, but I, just don't.

Sarah Lyon

00:52:03Yeah, I think it's a really interesting question, and I wanna link it to something that you taught me about, which was that there are large data sets out there and resources related to things like light pollution, to sound levels, and I know that there's starting to be more public data sets about water quality.

00:52:24So like address by address, you can look at the exposure to that. Now that I know that exists, I see a reality where that public data is mapped into our EMR People's addresses are flagged if they're in one of those risk factor areas, and they get a, offered a therapy referral to come out and maybe we can't- Yeah

00:52:44change the whole- lighting on the street, but we can change their bedroom.

Ganesh Babulal

00:52:49Exactly.

Sarah Lyon

00:52:50Is that the direction you think-

Ganesh Babulal

00:52:52Yeah ...

Sarah Lyon

00:52:53we need to go? Is that the best solution?

Ganesh Babulal

00:52:55I, th- I think there's a lot of folks... Actually, there, there's a big movement that's, moving towards that direction, which is using the, geo-coded locations of our clients and our patients, their home address, to better understand what they have access to in their home environment.

00:53:10so there's something called the Area Deprivation Index. This is free of charge to use. A- Dr. Amy Kind and Barbara Bedlam, are, two actually epi researchers and, physicians as well, that created it. And, what you can do is you can look at typing in, an address, and you can find what your Area Deprivation Index is.

00:53:28Within the state, it goes, I wanna say, zero to 10, where the higher, the more deprived of an environment you live in. And then nationally, so you can compare individuals across states, goes from zero to 100. And so researchers use it immensely to quantify, what does that home environment look like where our patients and, clients live?

00:53:47And, I think that's starting to be pulled into a lot of EMRs right now so that you can understand where they live, what they're exposed to, how deprived, their environment might be or perhaps not conducive, to health. And where I can see this playing a significant role, and this is where, as therapists, we need to start advocating for, "Hey, we can help with X, Y, and Z.

00:54:06We can, help to start thinking about how to, bring more therapy within the community itself, or address the impact of the external environment onto the client's house to ensure that it is a, perhaps a protective pocket. And, the adverse effects of these, ex- environmental teratogens and, risk factors are mitigated to a certain degree."

00:54:30A- and, really because these all influence function. They influence ADLs and IADLs and the ability to engage within them, and that's where we're starting to see if there are shifts occurring, we wanna figure out what's, influencing. Is there perhaps a new development coming into town that's causing a lot more ni- n- noise pollution and light pollution that needs to be addressed, at City Hall?

00:54:53th- these are areas in which I think are brand new and so exciting and novel for us to start thinking about expanding, our toolkit into and truly having a significant impact on the environment itself.

Sarah Lyon

00:55:06And I love this environmental l- or this environment level lane, lens because it feels like it takes, the personal blame off the patient.

00:55:17And not as therapists that we're ever trying to, like- Give the impression that we're blaming someone, but when you're talking about sleep and eating and weight, like those just feel personal. Yeah. Yes. and it feels really different to talk about "You live in a food desert, so this- is really hard," versus like- Exactly

00:55:37making it feel more personal than that. I think this is all so helpful. This has been such a wide-ranging conversation from just having the foundational knowledge, what to do when we walk in and we see changes, to really- zooming out and thinking at the society level. We've touched on so many things today.

00:55:58I could go into all of them in more detail with... But what's like the final thing that you wanna leave us with today?

Ganesh Babulal

00:56:05Certainly. And I know there's been a lot of questions that I- we didn't get a chance to touch on, so feel free to email me. I'm happy to follow up with you in, individually via email. I think, the main takeaway is, for all the therapists listening, to this, is that function itself, in my opinion, is the first...

00:56:20and I'm gonna say biomarker, but I'm gonna a- annotate that and say it's a neurobehavioral marker. In all of my, studies that I put out, that's how I've been quantifying it. So ADLs and IADLs are function. It is neurobehavioral marker, and it's one of the first things that we can see changing in the environment, in the actual before they see a clinic, before they, they go into a hospital, before they go into a SNF, an ALF, any of these institutional cares to get treatment.

00:56:47The changes actually start at home, and they start in their community itself. And we are trained to measure, to observe, to un- quantify and understand what might be occurring. And so that is immense. That is so valuable. It, to a certain degree, trumps any biomarker, any test, any quantification or any exams.

00:57:08so don't let that go. Continue to measure that. Continue to document it. and I can preach on and on about this. a task analysis, a, any formal testing, whether, it's assessment on the road or doing a home evaluation itself, we're measuring all of that right now. And then we can actually follow up on that and treat, create treatment plans that are detailed, that are inclusive of beyond the client, but their family members and their community itself.

00:57:37But then also getting that function into EMR, I think is so critical. And as a researcher, as a former clinician, still a clinician at heart, but I can't act, since I'm not actively treating, my mandate, what I'm gonna be doing, the d- the, hill that I'm gonna die on is getting function into EMR.

00:57:53Getting function outside- of OT, PT, SLP into neurology, neuropsychology, into all the massive associations that are starting to see the light in my, mind. and so I think, if I... Before I do the closing soundbite, I think focus on fu- function would be the key area.

Sarah Lyon

00:58:14Oh. Ganesh, this-- I wasn't expecting this topic to come back to, the heart of what we're doing, to come back to function, the importance of observing it, the importance of capturing the changes that are going on, and then to really use it as protective factors.

00:58:34it truly is our through line here. I'm so thankful for you to help us understand this topic in this way and just for the research that you're doing and the advocacy that you're doing to elevate this super important marker, and really concrete thing for us to work on. So thank you so much for this conversation and for all you're doing on this front.

00:58:56I just appreciate it so much.

Ganesh Babulal

00:58:59You're very welcome. Thank you so much for having me, Sarah. It's always a pleasure.

Sarah Lyon

00:59:06Thank you for joining us on the OT Potential podcast. To earn one hour of AOTA-approved continuing education for your time today, you will need to sign in or sign up at otpotential.com. Once you're in the OT Potential Club, you will find a five-question post-course quiz connected to this episode. When you pass the quiz with a score of 75% or higher, you will be able to download a PDF certificate that certifies your completion of this course.

00:59:35Okay. I wanna thank you for joining us today, and we'll see you next time.