McGill Cares: Understanding Vascular Dementia

hello everyone and welcome to McGill cares webcast series supporting family and informal caregivers I'm Claire Webster a former caregiver certified dementia care consultant and founder of McGill University's dementia education program I work with a dynamic team of leading Healthcare professionals to oversee the program who include Dr Jose mare from the division of geriatric medicine and Dr salj Gautier professor emeritus formerly of the McGill University Research Center for studies and aging McGill cares is supported by the Amelia Saputo community outreach for dementia care today's topic is understanding vascular dementia it has been one of the most requested topics so I'm thrilled to to have this webcast today and my guest today is Dr Sandra black she is an internationally known cognitive and stroke neurologist she is Professor of medicine in the division of Neurology at the University of Toronto she was the inaugural executive director of the Toronto dementia research Alliance from 2012 to 2020 and in April 2020 she became scientific director of the Dr Sandra black center for brain resilience and Recovery her research Bridges dementia and stroke using standardized quantitative neural Imaging cognitive functional functional and Neuropsychiatric measures genetics and neural pathology to study brain Behavior relationships and dementia Dr Black was appointed member of the order of Ontario in 2011 and officer of the Order of Canada in 2015 for her contributions to Alzheimer's disease stroke and vascular dementia Dr Black will be discussing vascular dementia who is most at risk and how it differs from other forms of dementia welcome to McGill care as Dr Black my pleasure and thank you for the opportunity so it's my pleasure today to talk about one of my favorite topics which is vascular um dementia and when we say vascular cognitive impairment we mean a person has a problem in their cognitive abilities but they're still functioning independently whereas dementia means that the cognitive impairments usually involving a couple of different areas like maybe memory and language means that they need help in their day-to-day activities that's what we mean by dementia as opposed to uh just impairment impairment implies you have problems but you're still able to function on a day-to-day basis so I have no conflicts um of of interest and I haven't really put my objectives in front of you because it's going to be obvious that what I'm trying to do is help people to understand uh what we mean by vascular brain disease that can lead to cognitive impairment and to dementia and I'm just going to do a little flow diagram here because the most important thing for the audience to know is that cardiovascular risk factors that is risk factors that have to do with your heart health also have to do with your brain health your Kidney Health your body's Health in general and there are some very very important risk factors that fortunately now we have under control better in the current ERA because of medications so high blood pressure very important it's very injurious to the brain you need to have your blood pressure under good control and in recent years we think the upper number which is what we call the systolic blood pressure should be 120 and Below we used to think 140 so it's come down now in the utilization that as people are living longer you need their blood pressure to be under control for every decade of their life diabetes is another major risk factor and there are new medications that are making diabetes under better control but also your body weight and your kind of desire for sugary Foods has to be combated and it's very important also that you exercise and you try to keep keep your body weight appropriate genetics is something we can't do anything about but um sometimes uh in the future it may be that the genetics will allow you to know you're at risk and measures can be taken even even earlier to prevent the development diseases for example even in Alzheimer's disease that might be become a possibility high cholesterol likewise is very treatable needs to be recognized there are even people at a young age that can have high cholesterol it's a family diet it's a genetic form and they have to be on cholesterol-growing Agents from their teens on so be aware of this and then heart disease if you have problems with your heart especially the rhythm of the heart you may cause little strokes in the brain if your heart is failing you don't profuse you don't get blood flow to the brain in the same sort of way so this is just to make a point that a healthy lifestyle exercise like a Mediterranean diet having proper sleep sleep apnea is also something very important to be treated and social engagement these all protect against dementia of any sort and particularly vascular dementia so damage to the cerebral blood vessels that's what vasculature means vessels in the brain cerebral means brain this is what these risk factors lead to over time and just aging starts to do that in the brain and there are many different ways that you can develop vascular dementia the one that most people would think of is when you have what we call a large vessel stroke you have a stroke you block an artery in the brain that supplies a particular area of the brain that's important let's say for language and you can't talk um so that uh that's what we all understand is a stroke or you become paralyzed on one side of your body um or your face and and so that's a stroke for your blood vessel in the brain blocks doesn't get the that area doesn't get the blood supply and and it no longer functions but if there are small Strokes that also can be related to vascular dimension in particular I'm going to point them out uh later on and also what happens if you accumulate multiple small Strokes then you're more likely to have what we call dementia because more areas of cognitive function are being affected and that's what can lead you to need need help in day-to-day life if you just have a stroke that affects your walking even though you may be more dependent so maybe you can't drive a car you can't get around the way you used to so you are dependent but that's usually not what we mean by dementia you have a physical disability that makes you dementia makes you dependent whereas with dementia we're talking about a cognitive a combination of cognitive problems that lead you to be dependent so there's there are large vessels but also there's small vessels that can be affected in um in the brain and I'll show examples of those without going into some fancy uh terminology you can also have a bleeding type of stroke you know if you get uh an accident where you hit your head you can get um blood between the the brain and the skull and that's called a subdural and that can lead to significant problems it can be it can be removed and uh you know you can return to normal if it's discovered it's often associated with a head injury you can have bleeding from an aneurysm that's called a subarachnoid hemorrhage but the one that's most feared um is just a cerebral hemorrhage by itself where instead of a blockage to the brain you have bleeding from a blood vessel the blockage to a vessel you have bleeding from a blood vessel and that can uh that can if that's big enough that can be fatal um just one one large hemorrhage and then the other thing is if you have a cardiac arrest or you know with your blood flow to the brain because of blood pressure problems if you're too low you can also have what we call hypoperfusion you're not perfusing you're not getting blood to the brain properly and that can cause more General damage so the bottom line is it what this does is it causes damage to cortical structures like the brain itself the cortex part of the brain or the connections between those areas those are on the on the other side it's called Interruption of the subcortical circuits and projections also it can affect um a very important part of the brain that has to do with focused attention it's called the collagic system and this all leads to uh what we call vascular cognitive impairments or um vascular dementia so let's just quickly now with that back we're going to go through and just show a bunch of um examples of what it looks like because sometimes a picture a picture is worth a thousand words and let's start off with what we call multiple faces of small vessel disease and I'm showing you in the upper left area just a picture of the brain um it's on an MRI it's a special sequence that shows you the what we call the white matter hyperintensities uh which show up as you sort of see little fluffy white spots and areas around the dark deep structures in the brain which are called the ventricles that's where the spinal fluid is produced and then it circulates around the brain so the brain is cushioned in spinal fluid around it you can see sort of a block area around the brain and the ventricles in the middle and the um there is a tendency is people age in particular to begin to see these fluffy white areas around the ventricles which I'm going to explain later has to do with some Harding of the veins in the brain so these are the different types of small vessel disease that have been defined by agreements amongst all the specialists in the world interested in vascular causes of dementia on the left side you see a little white spot which is actually a recent blockage that shows up as white but then eventually it becomes a whole and that would be that would turn into what we call a lacunar infarctica it means a small hole in the brain the white matter hypertensities is showing us that's wnh that's what I just showed you in the picture above this would be an example of a Lacuna a little hole that's near The ventricle there's also there's also some changes that we can see you can see these little linear structures these are the perivascular spaces of the veins that are you know that are draining toward the ventricles and they can sometimes be enlarged I'm not going to talk too much about that but that has now been recognized as also something that can be related to vascular injury there's something called microbeads where you have a little micro bleeding around the vessels I'm going to show you examples of that and you can sometimes have even little tiny infarcts that are so small that we didn't even see them until we had higher higher resolution MRI scans even though we don't really have time to talk about that but those can be so tiny that you can hardly see them but they may contribute to cognitive impairment if you get enough of them over time and sometimes those are related to uh heart problems when you have for example an irregular Rhythm called atrial fibrillation so they that can be associated with little emblem little little clots that go to the brain that can cause these tiny Strokes so with respect to the swipe matter disease you know we've known for quite a few years now a couple of decades that this is very common and um back when they started realizing this in the 1890s early 2000s they showed that um almost almost a quarter of people over 65 this is based on a very large survey when they started doing MRI scans they had these little silent Strokes which meant there were more than three millimeters in size um and that was shown similarly another big study in in sorry in the Netherlands the rottenham study and they showed that these silent lacunes as they recall because they were small enough that people didn't even know they had them um they were nevertheless Not Innocent if you had these you were more likely to show cognitive decline towards vascular cognitive impairment if not dementia eventually over four years and a long over a longer period had twice the risk of developing dementia which again means you've got multiple domains that make you not be independent in your day-to-day functioning it increased the risk of a stroke like a proper cortical stroke my body about five times because it was reflecting you know vascular risk factors and even if you corrected for vascular risk factors it still meant it increased your risk of having a typical stroke where you have a sudden onset of a phase a loss of language or your arm goes limp and you can't walk or you can't use your hand so this they were a sign of what we call small vessel disease that could tell you that the vessels are in trouble in a bigger sense so then there are these micro bleeds um and they're shown here where you can see these like the dark blotches and little dark spots um those are actually reflecting um Iron deposits in the brain the iron deposits can sometimes just accumulate over time as you can see in this kind of patch of them deep in what we call the basal gangly deep in the brain but you see all these other little black spots that are around here and this is this is in a part of the brain that's called the basal ganglia where we have uh it's the old old brain it's the brain part of the brain that's in all mammals and the cortex is a big area around that is what kind of evolved in human evolution towards from mammals to primates eventually to the human species and what you can see is if you have high blood pressure uh or diabetes and so on you might have a tendency to injure the blood vessels deep in the brain here and that can lead to these micro bleeds where red blood cells are escaping out of a damaged vessel they can be silent but they're not a good thing to have and they can eventually lead to a hemorrhage so that's sort of shown there and then there are microbeads that occur out in the cortical regions shown here this is a very exaggerated example that this person has multiple microbeads and you worry about this um turning into a bleed I'm going to show you in a moment what that looks like an actual bleeding event in the brain and this represents amyloid along the blood vessels amyloid is the protein that is associated with Alzheimer's disease and so one of the messages of the talk today is an amyloid which is the protein that you see in the plaques of Alzheimer's disease also is seen around the blood vessels because when you're in deep Sleep your brain is getting rid of the days the accumulated garbage as it was as it were including amyloid which is produced on a daily basis and it has to exit from the brain along those deep penetrating vessels I'm going to show you what they look like in a moment to get out of the brain and if you have sleep apnea for example or other kinds of fragmented sleep you don't do as good a job of getting rid of it and so you can accumulate more injury to the to the brain because of that fact so that's why sleep the start of sleep and treating sleep apnea is such an important thing to be aware of and to have treated so you see that you you see the the Deep area that's spared in this kind of thing it's called amyloid angiopathy and it's actually in the cortex now the white matter hypertensities which I showed you an example of is shown here in a way that gives you a feel for how severe it can be and it's actually something that we've shown what looks like when you quantify when you actually see how many cubic millimeters or cubic centimeters of the white matter hypertensities do you see we have little scales that reflect the different uh amounts of this and so um up at the top you can see a very mild amount five cubic centimeters you know most people by the time they're in there on 70s and 80s will have some of this I'll explain why in a moment but some people have more and it's left at around 10 cubic centimeters is when this starts to have a little bit of effect on your speed of processing and and maybe sometimes even a little bit of balance problems you can see that's what 10 cubic centimeters looks like it's thought to be sort of a threshold from where you might start to have some problems not so much dementia but just kind of cognitive impairment based on some what we call um speed of of processing and decision making and abstraction those sorts of things and then you see at 25 cubic centimeters what it looks like and there you're starting to have more of this and at 50 cubic centimeters people who have that amount of white matter disease around the brain often they have problems with balance they definitely feel like they're slower um they they they're not as quick as um you know change is like switching attention or doing dual tasking when you do two things at once um those sorts of things like walking and talking at the same time is actually a dual task because your brain has to do two things it has to keep your balance and it has to help you talk and so people start to have more trouble with those kinds of what we call dual tasks now here's what's underlying it it's actually you can see that there are these little linear structures in red here and at the right you can see this actually mapped out by my colleague Dr GAO who lovingly did this in a 65 year old man and what he was mapping out here is the the venous system in the brain that drains blood from the cortex showing here in towards venous sinuses at the base of the brain so that you have um you have arteries draining into veins and the surface of the brain and they they have their own circulation but also their arterioles that penetrate in toward the ventricles become venules and the venules are draining the uh the uh the the blood in in towards this area and what happens is over time when they start to harden a little bit it's called they they deposit collagen which is a scarring which is the same thing you can see in the arterials because this is actually happening in the venules and so this white matter kind of confluent patchy white matter disease is actually leakage around these deep venule the Deep benue system now in longitudinal studies look at white matter hypertintensities this is not innocent and I mentioned that it can actually cause slowing of thinking and and problems with balance but having this uh these this degree of white matter disease as it gets into the tendon you know in in 20 and 50 cubic centimeters that increases your risk of Stroke by about three times risk of becoming demented meaning becoming dependent because of cognitive problems about twice and also it's associated with deaths and is twice the risk of death now what you see if you do uh somebody does a brain donation and you look at this area and you look in the brain at what we call pathology because we learn so much when people are kind enough to donate their brains to help us understand even that's how we understood Alzheimer's disease that was in 1906 when the brain donated by a patient who was 49 years old that Alzheimer was looking after because he was uh he was actually a sort of a neuropsychiatrist or the way a neurologist that's how he discovered the plaques and Tangles of Alzheimer's disease so brain donation is really important and it's something we're still learning from all the time because we as we understand the molecular underpinnings of some of these conditions the postmortem is really an important way for us to even understand better what's going on in the brain and also to verify the diagnosis so when you look at this area here and you do a special kind of staining in the brain around those vessels you see this kind of blue area which is essentially scarring that keeps the vein open so it still can drain but it doesn't make the veins be as responsive because normally the veins can get bigger or smaller depending on whether you're you've got too much fluid in the brain or not enough fluid so you lose that sort of ability to be responsive to the fluid status of the person for example and it also means that you have resistance to the inflow which makes it even harder to produce that part of the brain and around the vedicles of you know the brain doesn't get as much blood supply in the area around the ventricles as it does in the cortex so that is just showing that when you do a pathology study then this is what you see and this is something that we just we discovered and published about several years ago and some other studies now have replicated this binding so having said that now what about this overlap you're getting the sense that there is an overlap between Alzheimer's disease and vascular dementia where you just have a stroke and you may not have any Alzheimer's disease that can happen but more common as people get older they may have a little bit of both and also when you think about Alzheimer's disease I've mentioned that you can have amyloid around the vessels so Alzheimer's disease is also a disease that affects vessels because the amyloid as it's is it's trying to get out of the brain can actually injure the injure the blood vessels so um there's this kind of Continuum between what's mainly Alzheimer's disease and what's vascular dementia but in fact Alzheimer's disease um there really is no such thing as pure ulcers disease without the vessels being involved and injured so that's the that's the tricky part and when they do postmortem series that is brain donation and they look at people's pathologies Alzheimer's pathology itself which is a plaque entangles explains only a small percentage of the actual findings and the most common finding in pathology at uh you know when people use you know pass away in their later years is actually changes in the blood vessels hardening of the arteries um this AMOLED angiopathy those are the things that really are seen and Alzheimer's Disease by itself only just for the plaques and Tangles is actually quite rare often seen in younger people and that is Maybe ten percent so it's really a mixed bag and so vascular pathology is actually uh very much part of the Alzheimer's story whereas if you have a stroke sometimes you may not have any Alzheimer's disease because if it's you're at a younger age you can have a pure stroke that doesn't involve AMOLED angiopathy so moving on to the next slide this is just showing that the genetic factors there's also the tangles that are involved and then you have stroke and then all the vascubus factors contribute to it so I'm just going to give you some quick examples of this now um and sometimes it's actually very frightening to realize that you can have stroke in a specific part of the brain it's really it's like a hub for a whole bunch of connectings it means that one minute you're fine and the next minute you have dementia that means you have three at least two to three areas of cognitive impairment that means you can no longer function without help and this is an example of that just to show you how small the stroke can be if it's in a strategic area of the brain and this is a this is a hub if you can see on the left there you can see this little black hole here deep in the brain I'm pointing to and this was a gentleman who had a sudden onset of confusion he was 72 years old he had I think he had a little bit of hypertension and high cholesterol that he was being treated um and all of a sudden he became confused now the CT scan didn't show this to start with and you have to understand that sometimes the CT is not sensitive to the very acute phase of stroke specially small ones but you can see it you know a few days later in his case um they just thought he was confused and they sent him home um but he never really recovered and this shows you that shows you the whole this shows you that in a sequence of the brain shown here you can see it sort of as hyper intense because there's some inflammation around it and you can see it here on the right these are two different sequences and he went home and he was never the same he had problems remembering things he couldn't find words he couldn't sort of understand more kind of abstract ideas or he wasn't able to function at the highest a higher level than he used to and that is because this area connects to the frontal lobes which is has to do on the left side with your ability to have abstract thought generalize from things and understand and problem solved it went to the area of the brain that has to do with the ability to speak words to say words it's called Broca's area where you produce words even though you know what words mean you can't produce them properly so we have word fighting difficulty and more importantly this connects to a through a connection that I again can't show with the time limit today that connects to the part of the ring that has to do with memory it's called the hippocampus the short-term memory area of the brain so he lost his short-term memory and he never recovered so this is an example of pure vascular dementia and even we've seen cases where at postmortem there's no hint of Alzheimer's disease in what we call a strategic location so this would be pure vascular dimension here's the example of a gentleman who's a lawyer and he was a high functioning business lawyer and he became kind of confused um and his his the people in the office that maybe he'd been drinking too much or something because he was he was kind of bumping into things and he looked like like odd So eventually they called it an ambulance he came to the hospital and when they did the CT scan here you could see something you can see this big white blotch which is a hemorrhage it's a cerebral hemorrhage the left side of the brain is on the right side of the picture because we're looking from the feet up but you can see this big blotch and and you can see it on different levels just on a CT scan that is a cerebral hemorrhage and when you see that in somebody who doesn't have he didn't have a hint of hypertension you worry about AMOLED along the bustles that can lead to a hemorrhage and sometimes I could be epidemio along the vessels and not really have too much evidence of Alzheimer's disease it's called congophilic AMOLED angiopathy and their hereditary forms of it and sometimes people don't develop Alzheimer's disease but most time most times they do and then this gentleman at that time he couldn't speak properly he he couldn't carry out actions because he had what we call apraxia and he he couldn't actually he couldn't read uh he had a whole bunch of difficulties because of this left side location being very important for processing of language so a few weeks later we did the special kind of scan that we have now that we can do on an MRI and what happens is over time that that blood just turns into iron because there's hemoglobin that is in the blood cells when it gets outside of the vessels it turns into hemociderin which is iron because you know there's iron in your blood cells which is very important um it's very important part of how the blood cells are you know delivering important uh how the blood cells are very important in delivering iron in hemoglobin to oxidates brain and sort of make you function properly so what's what's showing here is that a few weeks later you're just seeing the iron in the brain the the scar became smaller but you can see the iron deposits where he had the Hemorrhage and you can also see that he's got a whole bunch of little black dots all over the place which means that he had amyloid he has amyloid along the vessels um in in more than just where he blend and so the thought was that he had cognitive gamma and angiopathy but we had the chance to follow this gentleman over time he made a recovery he couldn't go back to being a lawyer um he was well off enough that he could be you know cared for he was never really independent again um and then eventually he came back to us a few years later where he was having more and more difficulty and in his case the long story short is that he was developing signs more typical of Alzheimer's disease and when he did pass away we did the brain donation autopsy he had both Alzheimer's disease and the amyloid along the vessels and really it's because ability along the vessels um can be seen in Alzheimer's disease but it doesn't always cause this degree of damage um I'm not going to have time to go into this just that if you have that white matter hypertintensity like I showed with the severity of you know the 25 the 10 cubic centimeters and 25 and 50. you can have um a syndrome is called subcortical because it's below the cortex ischemia means you're not getting your blood supply properly and that you know so it's vascular Dimension is called subclitical ischemic basket Dimensions actually got a whole kind of syndrome that presents where the person may have problems with a gate and they're off balance they can sometimes have urinary frequency you have to go to the bathroom a lot they might have a little trouble saying words properly or swallowing they can sometimes laugh inappropriately or cry inappropriately it's called emotional incontinence it can sometimes look a bit parkinsonian and they can have depression and mood changes so it's a syndrome in individuals who have that you know severity of the period been created what we call a perimetricular white matter disease that we recognize now as we have gotten better in our ability at least in developed countries to be treating high blood pressure high quality you know high cholesterol or more aware of sleep apnea and diabetes were treating much better we're seeing less and less of this than we used to but it's a well-developed syndrome that we've recognized in years past and you have problems with what we call Executive phonics dysfunction have trouble with colliding ahead and initiating and people get a bit apathetic and they can't plan and organize um and they just can't kind of you know change from one idea to another or kind of switch attention and they can have trouble with recall that they're not really you don't have a primary memory loss it's just that they have trouble recalling things but they'll recognize it when you mention it so they're not like Alzheimer's disease per se um they they have their own syndrome so it's just to let you know that this can exist as a form of what we call vascular dementia from small vessel disease without acute without big Strokes or strategic Strokes that just relate to this white matter disease I'm going to skip this it's just to show you that one I'm not going to go into just some details just to show you that some of the tests we use are very informative when you get a person to draw a clock and you can see um how they're having trouble they're supposed to draw a clock and put the hands at 10 after 11 it shows you that people start to have trouble with and you can see it in Alzheimer's but you can see it also from vascular dementia and it's something that can be very you know helpful in uh kind of doing quick tests to see how people are able to do things by the way I think in some provinces in in Canada they now do when people turn 80 you know in Ontario they have to draw a clock and if they can't do it properly they have to do a driver's test so it's used for driver evaluation in Ontario all right so this is just showing a lady we followed for a number of years and you can see how her white matter disease was increasing over time she was getting leakier and leakier around those vessels and eventually you know when she died she had both Alzheimer's disease and she had the white matter disease so I just want to end by saying that you know in Canada now we do have some consensus criteria for the diagnosis and treatment of vascular cognitive repairment vascular dementia and we have recommendations about doing CT scans or MRI scans um trying to optimize treatment of the vascular risk factors um and trying now to grow even lower than we used to and really really drive at the you know the vascular risk factors and you know lifestyle choices are extremely important for for all of us if you can walk on a daily basis even like physical activity maybe three four kilometers if you're able to do that it's around seven thousand steps that helps to protect your brain the Mediterranean diet with fruits and vegetables fish and poultry not too much red meat especially beef seems to have a special tendency to injure some of the vessels some of the proteins that are involved in beef uh extraversion olive oil one study suggests a couple tablespoons just throw it on your salad and it has some beneficial effects um but again if you're diabetic you have to be careful but the fruits like what we call high glycemic fruits and and juices and so on so you have to be careful about that but generally more of a vegetarian diet with a little bit of you know poultry and fish is probably you know best vitamin D is also very important for immunity brain health and bone health maybe a couple thousand units in in Canada because we don't get the sun in quite the same way as other countries Dr Black thank you so much for this incredibly informative um presentation and I think that I've been wanting to do it I mean I have a very personal interest in this as well but you know I think that there's really a lack of awareness among in terms of the correlation between our heart health and our brain health I mean you know when I give a lot of my presentations and talks people really don't realize the correlation between the two and what really stood out uh for me from your presentation was how you were talking about you know really maintaining our or managing our what we call the comorbidities but managing the cholesterol managing the blood pressure throughout the decades right um you know I think people have this this impression that you know vascular dementia or Alzheimer's disease I don't have to worry about it because it's a disease that affects older people but I I think based on your presentation today it's what we do throughout the decades will have an impact on our health later on am I correct yeah hypertension is just so injurious to the brain and you know we were we were letting people run at 140 systolic for years until they did the study just a few years ago the Sprint trial it's called and they figured out oh my God it should be 120. and so we've been under treating hypertension for decades and now we have much better medications better tolerated medications now we aim for 120. likewise with diabetes there are diabetic drugs now that may be beneficial for cognition so there's there's some real advances that mean that you can if these are identified early and you get treated properly then you can really make a big difference to your later outcomes the cholesterol I think is checked more often now probably by family doctors if you get to have a family doctor and it you know it gets treated it gets treated if you have the stroke you get put on it immediately also for heart disease but I think people don't what I was also trying to convey is that this Alzheimer's disease and the vascular pathology are very interlinked so we want to make the you know we talk about Alzheimer's disease and vascular dementia or Alzheimer's dementia but in one sense Alzheimer's disease is also a vascular it leads to a vascular dementia and that gentleman who had the amyloid along the vessels with with the Hemorrhage so that was a hemorrhage um you know he had Alzheimer's disease and we were just seeing the early manifestations of it along the vessels so that's the other concept is that we try to have these different worlds you know we have the stroke world and the dementia world and then finally the beginning you know even the Alzheimer's Association where there's a lot of lobbying that has to do with you know this charity versus that charity and the truth is we need you know we need everybody to work together and to actually have people try to choose a healthy lifestyle because that helps everything and also be aware of you know the fact that you see hypertension may not even be something people are aware of until our blood pressure is done and we did a very interesting study of just for a few minutes at Sunnybrook they were just they decided they were just going to check people when they're going to the cafeteria and they take the blood pressure and they were shocked it's a number of people 20s to you know 60s who had high blood pressure and they weren't even aware of it and they weren't they you know they didn't they weren't sick enough to go see a doctor I mean now that's happening a lot more but now there are no doctors but anyway um it was a real eye-opener and there's a sort of responsibility for everybody you know once you're 21 years old and you're supposed to be independent you need to know your blood pressure you need to know your cholesterol in the case of some of the families with this familial hypercholesterolemia they had you know they had people dying at 35 you know from a heart attack so that's something on the radar if you've got a family history like that you know your cholesterol is checked and you're on you're on you're on cholesterol lowering agents as a teenager right and that means those those people are getting to live to be older so we need to we need to have people a lot more aware that the vulnerability can be when you're still young well I'll use I'll use myself as an example so I my mother suffered um minor strokes in her late 60s and she actually was one of those Prime examples at the age of 74 she had vascular dementia with Alzheimer's disease and um history of heart disease in her family so I I'm like the case study where I have afib atrial fibrillation which I've had since I'm 19 years old wow I have high cholesterol which is genetic I and so I'm now 54 and at the age of 50 I was put on blood thinners and and you know we take our life we take our health for granted right so I was put on blood thinners and I'm like what do you mean I'm 50 why am I on blood thinner so I'm on Lipitor I'm managing my cholesterol I was on blood I'm on blood thinners twice a day but it was very hard for me to accept this because I'm like I'm only fifth level I'm 54 now but I'm 50 but and so working with the team of cardiologists because I'm at a high risk they said you have to sort of really managing there's some new blood thinners that may be even safer for the brain by the way so there's some advances there that some of the places someone wants to be but you see that's so important I didn't I left out the section showing the micro infarcts because it's very terrifying and especially associated with atrial fibrillation so um you know you're I guess it was discovered but what a oh my goodness at age 19 wow yeah well I mean you know and I've I've had what McGill cares webcast on this for those people that are interested in learning about pacemakers but I've I've had even a pacemaker since I'm 19. I was diagnosed with six sinus syndrome and you know this is where we take our health for granted I was at an additive tennis player uh I had six sinus syndrome where you're literally I I the Electoral the electrophysiology of my heart wasn't working properly um so I've had patience you're a bionic woman right yeah and it shows you see the pacemaker so the pacemaker helps you not pause and die okay right but the afib you still have to manage and there's a lot of yeah a lot of people think you wait you know they don't know what to do with people who are under 50 or even 50 to 65 that's all still up in the air yeah they're a lot better blood thinners now I mean you probably were I don't want yeah because that's the safest also for the brain but I think the message is really and what you say is you know and so I wanted to do this this webcast is that you cannot take your health for granted I mean in all ages right and you mentioned it earlier somebody has high cholesterol in their 20s which could be all genetic you know you need to manage it and don't say I don't want to take my pills I don't you need to manage your diabetes your blood pressure you have to and I and I'm a good example of like the importance of doing that so I discovered early so that you had they didn't have they didn't have all the drugs we have now right that protected you in the way because what's also nice is the new blood pressure medications the diabetic medications there are a lot of advances that are making these much more tolerable and I can tell you we're doing a clinical trial with no more Nordisk which makes magnetite one of the diabetic drugs and they think it's disease modifying in Alzheimer's disease because it it affects neural inflammation in the brain and also brain metabolism so there's a trial going on of of semaglitide it's oral agent in Alzheimer's disease as we're as we're talking and again it just sort of emphasizes the intermixable instance right and the black concern with the antibodies is that they can cause amyloid to exit along the vessel a little too fast and you can get bleeding and vasogenic edema that white matter hypertensity that is showing around the manuals is Major genic edema sleeking of the vessels so what happens when you give these antibodies is a subset of people they they AMOLED sort of overcrowds the exit and you get the edema you can have seizures confusional State Etc or you can even have a bleed so that's the complication of them right again illustrating that says uh it's it's all I I should have shown the family of cells which is that it's not just a neuron you've got an you know the nerve cell you've got the glial cells you've got the endothelial cells you've got the smooth muscle cells around the vessels and you've got the microglial cells you're like a family of cells all of whom have to take care of each other and if any one of them are not doing well then you're in trouble so the neuron is really looked after by a whole family and I I I should have showed that slide but I talked too much anyway because it sort of makes and I do this to to the clinicians because everybody's in their silos right they have their favorite and we think it's all neuron the neuron is just this little child that needs to be looked after by a whole bunch of you know okay if you want to personify it the astrocytes are the nannies and the microglena are the you know daddies or the you know the Guardians and then the blood supply is coming from the endothelial cells or the you know the vessels and they all are part of brain health so if anything goes wrong with any of those those key players cells this kind of family of cells you're in trouble so I always talk about the neural gliovascular unit that's the unit of the brain and people need and so you have to take care of all of those family members and you also have all these family members trying to help this poor little neuron do its thing right well Dr Black thank you so much for taking the time to be with us today I'm I'm so grateful to have you uh on McGill cares and I have no doubt that this webcast will be so informative and educational to so many people so thank you for being with us today I guess the one thing one of your questions was is there any treatment for basket convention it is treat all the vascubus factors essentially that's I mean it's right so take care of your heart health that's right your heart and your vascular Health yes so it sounds like you're a living example of it but I hope I answered most of the questions that you had and So to avoid it you take care of your vascular health and you're less likely to have it and that's you know the other thing is when you start having prevention interventions the age-specific incidence of stroke in Ontario because they they looked at before the introduction of the stroke system which include not just rescuing with TPA whistling thought the clot busting agents but a stroke prevention plan across the whole Province so they set up stroke prevention clinics even in Family Family Health teams right or family doctors they showed in 10 years the age-specific incidents of stroke went up by 33 people were older before they had their first stroke and they also looked at dementia but you need a long there's a longer gap that went up by about eight percent and that was just probably because of the stroke prevention initiatives right so it's sort of a living example that even within 10 years you can make a difference and also because the drugs are getting better and more tolerable um you know even the anticoagulants I mean there's sort of you know much better ones in eloquist is a very one so um and I think you really are somebody who's benefited from that and you're around to ask these questions I am and I make sure to go to my appointments every six months and and trying to invest as possible to follow a lot of the directives but anyways thank you so much for being with us I hope it wasn't you so much it was great thank you so much this webcast is an initiative of the McGill dementia education program which is funded by private donations if you would like to make a contribution to our program please visit us at mcgill.ca dementia and if you would like to join our mailing list to be notified about upcoming episodes of Miguel cares as well as other important programs and resources please sign up at www.mcgill.ca Dementia or you could email us at dementia mcgill.ca thank you for watching

Channel: McGill University

Views: 4,370

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Id: mfXy3xSlCsY

Length: 48min 41sec (2921 seconds)

Published: Wed Feb 08 2023