Dementia

Dr. Art Walaszek (00:04):

Being in locked down in isolation is difficult for anyone's psyche, let alone if they have dementia, if they have a process that's affecting their judgment, their decision making, their memory, it's really challenging. So it poses a challenge for all of us as healthcare professionals and as kind of people thinking about systems, about what are other ways that we can do to support older adults, their caregivers, and the professional staff working around them.

Dr. Laura Roberts (00:40):

Hi. I'm Dr. Laura Roberts, editor-in-chief for the Books Portfolio to the American Psychiatric Association. And welcome to the APA Books Podcast. Well, welcome to Unbound. We're so excited today. We have a wonderful guest lined up, Art Walaszek. Art is a professor, vice chair for education and faculty development, and he is the residency training director, the program director in the Department of Psychiatry at the University of Wisconsin's Department of Psychiatry. In addition to these many hats, he also is the co-leader of outreach, recruitment, and education, a core at the Wisconsin Alzheimer's Disease Research Center, and a public health pillar leader in the Wisconsin Alzheimer's Institute. That's also at the University of Wisconsin School of Medicine and Public Health. So he's a busy guy, lots of jobs, beloved colleague in medical education and in geriatric psychiatry.

Dr. Laura Roberts (01:37):

And he has put together a beautiful book called Behavioral and Psychological Symptoms of Dementia, which I think is really going to be a critical kind of essential book for not only geriatric psychiatrists and psychologists, but primary care providers who have a large group of elders that they take care of, certainly everyone in training. And I think general psychiatrists will find this particular book extremely helpful. We're delighted. It's great to have you here, Art. Thank you so much for joining us. Tell us a little bit about why this book was the book that needed to be written.

Dr. Art Walaszek (02:21):

Laura, first of all, thank you very much for inviting me to the podcast. Thank you for your leadership at APA publishing and for agreeing to take a chance on a first time single author book, so I really appreciate it.

Dr. Laura Roberts (02:44):

Well, we're going to get back to that in a minute.

Dr. Art Walaszek (02:48):

Well, so I really feel like there are kind of two ways in which I can be helpful to others. One is through educating our next generation of psychiatrists, and the other is through the care of older adults, especially those with dementia. And this book brings those two things together. I really enjoy teaching and writing, and I've given many talks over the years about how to manage multiple aspects of dementia, including behavioral and psychological symptoms of dementia. And the book just seemed to be a great way to pull all that together and have a wider audience at the same time. And the need is really, it's critical.

Dr. Art Walaszek (03:38):

We have an aging population. The rates of dementia due to Alzheimer's disease are predicted to go up pretty dramatically unless we can find a cure or a preventative measure. And along with that will come behavioral and psychological symptoms because they're very common. Almost everyone with dementia will experience some sort of behavioral or psychological symptoms. And we're not well equipped as a system or a society to take care of all that and to help patients and their family members. So my hope is that the book will play at least a small part in helping that out.

Dr. Laura Roberts (04:19):

One of the things that's really lovely about the book is it helps the reader differentiate among different types of dementia and to define different strategies to help in the context of early and later dementia. Can you comment just a little bit on those clinical issues?

Dr. Art Walaszek (04:35):

Absolutely. So I didn't want to make any assumptions about where readers were at with respect to their understanding of dementia. And a lot has changed in the last few years, the terminology has changed, so even in the DSM, though dementia is still a totally acceptable term, it's major neuro cognitive disorder. And there's a distinction between that and mild neuro cognitive disorder. And there's also a rethinking about all the causes of dementia, so Alzheimer's disease, for example, is the underlying process that eventually leads to dementia. But before that, can have more subtle changes, or even be completely undetectable clinically, so it's really an illness that progresses over time. And the dementia part is really the end stage of that illness.

Dr. Art Walaszek (05:29):

So even just that re conceptualization, that's something that's a fairly recent advance. And then Alzheimer's and dementia are not synonymous, so there are many other causes of dementia including Parkinson's, alcohol, medication, stroke, and so on. And these aren't just kind of academic nuances. They're important in terms of understanding a person's prognosis, how we educate patients and family members about the illness, how they can plan ahead, and then how clinicians can help treat them. So that's why really, I wanted to start the book with just a real primer on: What is dementia? What are the different causes and so on? Before launching into the more specifics around behavioral and psychological symptoms.

Dr. Laura Roberts (06:19):

Right. And so just who do you think would benefit from this book? I'm just trying to think about our listeners and who might want to actually pick up this book.

Dr. Art Walaszek (06:31):

Yeah. Absolutely. I mean, I think any general psychiatrist would benefit. Certainly, our patients are aging, and so they're going to head into this territory. And one of the questions might be: Is this dementia versus their preexisting psychiatric condition that's causing the symptoms that they're experiencing right now, for example? So I think any generalist psychiatrist who has a late middle life or older population would benefit from this. I think even if they're treating younger patients, those younger patients may be the primary caregivers for people with dementia and behavioral disturbance. And so helping, say, the adult child of someone with dementia better understand what might be going on, I think a psychiatrist would benefit from that.

Dr. Art Walaszek (07:24):

I think it'd be a great tool for any primary care providers who are taking care of older adults. Hopefully, it'll be a good teaching tool as well for residents, fellows, medical students, and so on. And then I think other healthcare professionals involved in the care of older adults, you mentioned psychologists at the outset, so I think they would benefit from this. The most effective interventions for behavioral and psychological symptoms of dementia are typically not medications. There are other non pharmacological or psychosocial interventions, so I think psychologists, social workers, others say in social services, who work with folks with dementia and their caregivers might benefit from it as well.

Dr. Laura Roberts (08:10):

I think another thing that's special about this book is it's very holistic. You really try to understand the full life and full clinical implications of this condition in the patients. And you recommend assessments that are more comprehensive and take into consideration social strengths and resilience and other kinds of I guess pieces that a clinician can try to connect with to try and bring better care to that patient. Do you want to talk a little bit, not only about the approach, but how you arrived at that?

Dr. Art Walaszek (08:49):

Yeah. Absolutely. I think part of it stems from just the general background we have in geriatrics around kind of thinking about the whole picture of the patient, and not just focusing on symptom management. Or, okay, a symptom arose, let's stamp it out. But thinking about the big picture of: What is this person's quality of life? What is their ability to live in their current situation? And what resources might they need to help them stay longer in their situation? What's the impact of what's going on, on their family members, and on other caregivers, and on their neighbors, and sort of people more distal to them?

Dr. Art Walaszek (09:32):

So that's sort of a general orientation of geriatrics anyway. It's around quality of life, functioning, respecting people's wishes and values and trying to support them in that regard. So I think that's the foundation. I think the next level up is it is tempting to say a person with dementia now is hallucinating, or is agitated, to simply just go to the medicine tool kit and pull something out of there and try to eliminate the symptom that way. But that runs the risk of not only not getting it right in terms of what's the right treatment approach, but potentially worsening the situation. So by not addressing the various factors that could be contributing to the symptoms, and maybe even exacerbating those underlying factors through the medications themselves or their side effects, we could actually be doing the patient harm in that way.

Dr. Art Walaszek (10:34):

So that's why even if these things look like crises that need to be responded to immediately, I think there is benefit in stepping back and trying to get a broader understanding of what's are going on here. And then that actually opens up all kinds of possibilities in terms of: What are our treatment options beyond just medications?

Dr. Laura Roberts (10:55):

So let's go back to your earlier point, which was taking on a sole, single authored book as ... Well, a little bird told me that it actually isn't your first book, that you actually I think wrote a novel when you were in college. So I think you have hidden depths, first of all. And I'm wondering what nom de plumes you've written under in the past. But you clearly are a writer, you're a gifted writer. But it's still ambitious to take on writing a whole book. So what was that like, and how did you tackle that? And what did you learn from that process itself?

Dr. Art Walaszek (11:36):

Yeah. Thank you for asking. So in college, I was an English major, and then within that, there was a creative writing program, and so I was enrolled in that program. And my colleagues and I, I think there were about eight or nine of us all together, spent a year, each one of us, working on a novella. And I think the goal was to get to about 100 pages or so. So it was five pages a week, we'd all get together once a week and critique each other's work and so on. And perhaps ironically, it was about a guy who was aging and became a hoarder, so perhaps that was before I knew I was interested in geriatrics. So it's a young man and his dad, and kind of watching his dad become a hoarder over time.

Dr. Art Walaszek (12:29):

And then I had written several short stories as well in undergrad and one in medical school, so that kind of went away, and I honed my skills writing policies and procedures and goals and objectives and so on, but didn't quite scratch that itch of wanting to tell a story. And I think that's what this is about, that's what kind of writing a compelling book, whether it's a novel or an academic text, is about a story. And of course, it's evidence based and there are facts and so on. But we learn through narratives, and we have a shared culture through these stories that we tell each other. And I think that's what any good book is about, is sharing a story about our humanity with each other. And I hope that's sort of what happened in the book.

Dr. Art Walaszek (13:22):

So in terms of what that was like, it was a lot of work, and it just required a lot of discipline around, okay, Saturday and Sunday, these are my writing days. I'm just going to get to work on the book. Or I went to a conference, I'm going to add an extra day or two and just spend ... That was advice from a colleague of mine about spend an extra day or two at a conference and write there. That's how the book started in New Mexico at a conference I attended there a few years back, so yeah, it was a lot of work. But it was incredibly fulfilling. And at the end of it, I really felt like, oh, I think I know this subject area pretty well, and so it helped kind of inform some of my other teaching in this area as well.

Dr. Laura Roberts (14:13):

It's interesting you say that. I feel like I do ... I mean, I read all the time, obviously, but I read a lot when I write. I bet you read a lot when you wrote this book.

Dr. Art Walaszek (14:26):

Absolutely. And I recall that was sort of my process in college as well of just sort of reading, reading, reading, reading, reading. And at some point, there seems to be some gelling or some phenomenon that takes places that's like, okay, I feel like I'm ready to put this to paper right now. So yeah, absolutely. And that was, for the book, it was necessary just in terms of the literature search and kind of making sure that I have the most up to date information as well. There's a balance because of course, it's almost infinite, the amount of research out there. And so at some point, you have to draw the line about how much reading versus writing one's doing.

Dr. Laura Roberts (15:09):

I think you're working on another book for us right now. Tell us a little bit about that.

Dr. Art Walaszek (15:15):

Absolutely. So while dementia is a significant problem in our older adult population, there are other major categories of illness, including other psychotic disorders, substance use disorders, and then the topic of the upcoming book is late life depression and anxiety. So anxiety disorders and depressive disorders are both quite common in older adults. And there are some ways in which they're similar to depression and anxiety in younger adults, but some really important ways that they're different in terms of pathophysiology, in terms of presentation, in terms of some of the psychosocial issues that are going on with older adults, and then in terms of treatment as well.

Dr. Art Walaszek (16:10):

So I'm very fortunate to have a number of wonderful collaborators on this book, so I'm editing the book and writing one of the chapters. And then I have a variety of co-authors who are working on the other chapters as well, so it's been a very fun process as a team writing a book, versus as a solo author, so I've really, really enjoyed that.

Dr. Laura Roberts (16:33):

I want to make a personal comment. First of all, I've treasured our friendship over many, many years, and it's been so fun to see your work develop and to see you have so much influence in American psychiatry. And I'm so grateful for that. The personal piece of it though is my mom has now, she's 85, and she has been kind of sheltering in place and effectively quarantined for months now. And I just watch and see how important it is to stay connected and how helpless she feels, and discouraged about the world. When you've had a long life and have seen so much, and then you see the world in such pain right now, as we are with coronavirus and the pandemic. Psychiatry, we had the suicide epidemic. We have the opioid epidemic. And now we've got a coronavirus pandemic. And on top of all of that is the disproportionate burden that vulnerable populations and certain populations carry with these conditions, and then the division in our country around race and community that's just so profound.

Dr. Laura Roberts (17:51):

And to see the impact on my mom, it's just been devastating. And she's doing okay, and we're all connected. And we go and drive and wave to her on her porch, and see her a lot. But it makes me so appreciative of what the millions of elders are experiencing in our country. And I just wonder if you have some reflections or guidance for all of us who are so concerned about our loved ones and elders.

Dr. Art Walaszek (18:22):

Thank you very much for raising that point and sharing that about your mother. I think you've hit the nail on the head. Our older adults, and especially older adults who are persons of color or in other disadvantaged communities really, really are feeling the burden of, especially the pandemic, but of course, all the social issues that we've been experiencing recently as well. So with the pandemic, I think one of our go-to plans for helping older adults with depression, or anxiety, or dementia related behaviors involves interpersonal connection, activities, structure, getting together in groups, going outside, or going to the museum. We have a whole playbook of various strategies that we use. And many of those plays are either unavailable to us now, or have to be modified in some way, done virtually, for example.

Dr. Art Walaszek (19:30):

Or as you said, the drive by on the porch, and it's just not the same. And so there's tremendous burden on our older adult patients, on their caregivers as well, who again, our advice to the caregivers are, well, let's not throw a bunch of medications. Let's get them outside for a walk each day. And let's play crossword puzzle, et cetera, et cetera. And when there's fewer of those options, it gets much trickier for the caregivers as well. And on top of that, the paid professional caregivers, so like in assisted living, or nursing homes, they already have very, very difficult jobs to begin with. And then to layer on top of that, that they have to worry about wearing protective equipment and ensuring that the residents don't get exposed to the virus and so on. I mean, it's asking a lot of a lot of different people who are already strained quite a bit.

Dr. Art Walaszek (20:30):

So clinically how that's showing up is more depression, more anxiety, more sense of loneliness. I would also kind of focus a little bit on kind of meaning and purpose. So older adults find that in a variety of different ways. One is through their work with others, so being a grandparent, or volunteering, or having their weekly coffee get together with their friends, or whatever, is giving you some sense of: Why am I here? What purpose do I serve, and so on? And that too has gotten a lot more challenging as we've had fewer, less ability to have those interpersonal connections.

Dr. Art Walaszek (21:18):

We're also seeing it with dementia related behaviors. So being locked down in isolation is difficult for anyone's psyche, let alone if they have dementia, if they have a process that's affecting their judgment, their decision making, their memory. It's really challenging, so it is, it poses a challenge for all of us as healthcare professionals and as kind of people thinking about systems, about what are other ways that we can do to support older adults, their caregivers, and the professional staff working around them.

Dr. Laura Roberts (21:55):

You've touched on the sort of implications of what you said relate to this. But the other thing I observe in my role is ... Well, let's put it differently. Psychiatry itself is an aging profession, and so one of the things I've seen with the coronavirus is that practicing psychiatrists have had to adapt certainly to provide care, let's say through telehealth, but also have pulled themselves out of usual clinical activities because they're vulnerable to becoming sick. And I've seen a number of our colleagues who are thinking about early retirement, who are thinking about, and their financial situation has been affected, and so that feels like another threat and very difficult.

Dr. Laura Roberts (22:47):

So the only other question I would ask is: What thoughts do you have about members of our professional and the health professions more broadly who, we are ourselves aging every day? And kind of how to think about these same lessons as we apply them to our own lives.

Dr. Art Walaszek (23:07):

Thank you. The conversation has taken a turn that I wasn't anticipating, but you're spot on. I mean, I think especially as we think about wellness of healthcare professionals, and workforce development issues. And how do we ensure that we have psychiatrists in the future? And we're unsure of the situation as it is, and there's potentially risk of more of that. I think without sounding like a Pollyanna, I think one positive that could come out of this is the finally widespread adoption of telehealth alternatives to in person visits. So I think that solves multiple problems at the same time, one, addressing issues around contagion and risk and safety. Two, so many of our patients have had challenges, whether it's with transportation, or work obligations, or whatever in terms of getting into appointments regularly.

Dr. Art Walaszek (24:15):

It's possible that telehealth could really foster those kinds of interactions more, and maybe even change the nature of the field a little bit from once a month in the appointment, or in the office for 20 minutes, or 50 minutes, or whatever, to a much more fluid patient centered approach. The downside of that is that requires significant adaptation for all of us. We had a routine and a pattern and we're comfortable with it. And then all of a sudden, it's learn these three new streaming platforms, and help your patients troubleshoot if they're having trouble with the connection and so on. So I think the transition could be difficult, but it's possible that on the other side of this, we actually have a much more flexible approach to taking care of patients both from a patient perspective and from a practitioner perspective as well.

Dr. Laura Roberts (25:16):

Yeah. I totally, totally agree. In fact, psychiatrists, we have the longest careers of all of physicians if you look at the data from the AMA. We're able to sustain a fulfilling career, confident and fulfilling career in ways that other fields, it's just much more difficult. And so I look to the future as actually lengthening the careers of clinicians, and have been urging my colleagues, who have been thinking about early retirement, as I mentioned before, to hold steady and to let's see where this goes. And I do think that the innovators and adapters will survive well. But to me, it represents an opportunity for longer careers and different kinds of collaborations and true partnerships and patient centered care practices that are different than in the past. So I welcome the reflection and disruption, if not the cause of this new thinking about our field.

Dr. Art Walaszek (26:22):

If I may add one other point as we think about professionals who are aging themselves is, and linking back to kind of prior discussion around meaning and purpose, I can't say this definitively, but I would suspect that longer time in practice, longer time exercising the brain as it were may be beneficial from the perspective of preserving cognition, and perhaps preventing onset or recurrence of depression or anxiety. So I think there's tremendous value in maintaining professional work longer from a healthy aging perspective as well.

Dr. Laura Roberts (27:10):

Yeah, I'm sure it has this neuroprotective kind of effects. And lucky us, to be in a field where the center of it is purpose and meaning. Right? And understanding what's important in our human experience, so lucky, lucky us. And lucky, lucky us for having your beautiful book, and you did such a great job. And now you're doing more for us, so delighted that you're working with us and APA Publishing. I'm so grateful for your effort and beautiful work on these books, so thank you so much, Art.

Dr. Art Walaszek (27:49):

Thank you very much. Thanks for the opportunity, and thanks for all of your leadership.

Speaker 3 (27:55):

Our original music is by Willa Roberts. Our executive producer, Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing. John McDuffie, publisher. To purchase copies of this book or other books by our guests or host, please visit www.appi.org. That's A-P-P-I.org. We hope you enjoyed this podcast and thank you for listening.