Stroke and depression; implants for better hearing; drug for early Alzheimer's: Upstate Medical University's HealthLink on Air for Sunday, June 16, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a speech pathologist and a rehabilitation psychologist discuss depression that may develop after a stroke.

Jessica Mungro, PhD: Somebody may be feeling a sense of loss, even if it's temporary, while they're rehabilitating. But sadness would certainly be a normal reaction.

Host Amber Smith: An audiologist explains who may benefit from a cochlear implant.

Jeffrey VanTassel: There are electrodes implanted deep inside the ear that are adjacent to nerve tissue, and they work by simply, for lack of a better term, zapping our nerve to get us to hear.

Host Amber Smith: And a neurologist tells about the new infusion drug designed to slow the progression of Alzheimer's disease.

Tinatin Chabrasvili, MD, PhD: This slowdown of the cognitive decline was associated with clearing of amyloid-beta in the brain.

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll learn about cochlear implants. Then a neurologist tells about the new Alzheimer's drug that can slow cognitive decline. But first, why might depression develop after a stroke, and how is it treated?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

People who survive stroke commonly may experience depression, and that can make rehabilitation a little more challenging. With me to talk about this are two Upstate providers who care for people who are recovering from stroke. Carrie Garcia is a speech pathologist, and Jessica Mungro is an assistant professor of rehabilitation psychology.

Welcome to "HealthLink on Air," both of you.

Carrie Garcia: Thank you.

Jessica Mungro, PhD: Thank you. Happy to be here.

Host Amber Smith: What percent of stroke survivors would you estimate deal with some form of depression?

Jessica Mungro, PhD: The research in this area estimates about 30% of people post-stroke will experience depressive symptoms. There is some variation in the research, though.

Host Amber Smith: That seems like a pretty big number. Are people who had depression prior to the stroke more at risk?

Jessica Mungro, PhD: Yes. Prior depressive symptoms are considered a risk factor.

Host Amber Smith: So what causes depression after stroke?

Jessica Mungro, PhD: So that's a complicated question. There's not one single cause of depression. The etiology is likely more multifactorial, with biological, psychological and social factors. So by that I mean there's ways that the anatomy of the brain, the neurotransmitters and the neural networks may be impacted. But there's also ways that changes in function and cognition and language abilities may impact how people feel about themselves, impacting things like their identity, their role in the family, their career trajectory, their ability to engage in all of the activities that bring them joy. So all of these things can impact the development of depression.

Host Amber Smith: Is there a specific type of stroke or area of the brain that you see that's more affected in post-stroke depression? Does it all look the same in different patients?

Jessica Mungro, PhD: Another complicated question. A number of studies have aimed to better understand this question, but there's a lot of inconsistencies in the research in terms of stroke location and how it impacts post-stroke depression. The way I look at it is, is ultimately anybody who suffered a stroke may experience symptoms of depression, making psychological health a huge component of stroke rehab, regardless of the type of stroke or the location of the stroke.

Host Amber Smith: Does the severity of the stroke, do you see depression in people who've had a more severe stroke than in those who their symptoms are minor?

Jessica Mungro, PhD: Yes. So stroke severity is another factor that's considered a risk factor for developing stroke depression.

Host Amber Smith: Well, let me ask you to compare this to non-stroke depression. Are there similarities or differences that you can see in stroke-based depression versus non-stroke depression?

Jessica Mungro, PhD: The clinical symptoms that are assessed are the same, although I will say it's important to parse out the symptoms that may be implications of the brain injury. So things like fatigue, or initiation, or sleep changes. It's important to assess how those symptoms are presenting. But an important piece is whether it's depression occurring post-stroke, or not associated with the stroke. They both can be treated with therapy and/or medication.

Host Amber Smith: Now, sometimes I think depression is tied in with anxiety. Do you see that in post-stroke survivors?

Jessica Mungro, PhD: Yes. So post-stroke anxiety, estimates are around 20 to 25% of people that experience post-stroke anxiety.

Host Amber Smith: How soon during recovery would depression emerge?

Jessica Mungro, PhD: The highest rates of depression are in the first three months. But with that being said, there's not a single time that depression can surface. I've worked with people experiencing post-stroke depression who may still be in the hospital, but also people who may be well into a year past a stroke. So, just something important to keep in mind.

Host Amber Smith: Are there symptoms that loved ones might recognize before depression sort of settles in? Are there triggers or red flags to be aware of?

Jessica Mungro, PhD: So the most prominent symptoms are depressed mood and anhedonia, which is really that lack of interest or enjoyment or pleasure in activities. They're the most frequently reported, but also paying attention to things like fatigue, changes in sleep, changes in appetite, feelings of guilt or worthlessness. Sometimes suicidal ideation (thoughts) can surface. Those are all things to pay attention to.

Host Amber Smith: Is some sadness to be expected, though, after this sort of medical crisis?

Jessica Mungro, PhD: Well, of course. Sadness is a natural reaction to a traumatic situation. It can also be a natural reaction to loss. I know we often think about grief and loss in the context of death and dying, but we also experience grief reactions in response to several different kinds of loss.

In the context of stroke, for example, somebody may be feeling a sense of loss even if it's temporary while they're rehabilitating. But sadness would certainly be a normal reaction.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host Amber Smith. I'm talking about post-stroke depression with two Upstate providers who care for people recovering from stroke -- speech pathologist Carrie Garcia, and rehabilitation psychologist Jessica Mungro. We're talking about how depression affects overall recovery.

So, Ms. Garcia, how does depression impact speech therapy? Because I know that's often part of the recovery after a stroke.

Carrie Garcia: Depression can impact a patient's participation in speech therapy, their motivation in participation in speech therapy, and just their overall recovery because depression can stand in their way of, obviously, their mood, their affect and just in overall interest.

Host Amber Smith: So do you see a difference in the progress made by patients who have depression compared with those who don't?

Carrie Garcia: Yes. We tend to see a slower progression, like Jessica was saying, you know, depending on if they're sleeping, if they're eating, if they have interest. Patients with depression, especially overt depression, aren't really interested or motivated and not always willing to do the work that a patient who is not experiencing those overt signs and symptoms can accomplish.

Host Amber Smith: Well, correct me if I'm wrong, but isn't stroke recovery, it's important to do it as soon after the stroke as possible? So you can't just let a patient be depressed for weeks and put off their efforts for recovery, right?

Carrie Garcia: Nope. And we surely don't, especially on the acute-care units, especially on the inpatient rehab units. We are in there early. We are in there from day one. Inpatient rehab is five days a week for at least three hours of therapy a day. So no. We are not letting that happen, and we are encouraging their participation. The hardest part is if they're still having post-stroke depression and they're discharged to home because we're not in there every day, and that falls to the family members to help them and encourage them and motivate them. Because on outpatient, we might only be seeing them one to two times a week.

Jessica Mungro, PhD: I just wanted to emphasize that rehab psychology is a part of the multidisciplinary rehabilitation team at the acute inpatient rehabilitation program. So again, just echoing Carrie's voice in that it's something that's attended to right from the beginning.

Host Amber Smith:

Well, let's talk more about the treatment. Is a psychiatrist or a psychologist always involved?

Jessica Mungro, PhD: So I work as a rehabilitation psychologist, so I don't prescribe medications. Frequently I'm working with a physiatrist (doctor who specializes in physical or cognitive functioning) who's managing the medical care post-stroke. So certainly medications can be a conversation with that provider. If need be, there's also psychiatry that can be part of the discussion with medication.

Host Amber Smith: Is there talk therapy? Is that part of it?

Jessica Mungro, PhD: Yes, that is my role. I tend to work with people who are struggling with the depressive symptoms I mentioned earlier. So really, my focus is that talk therapy component that helps with reducing symptoms of depression, of anxiety, helping to promote overall health and adjustment to their current abilities and functioningsubsequent to stroke.

Host Amber Smith: Do you see people whose personalities change after a stroke?

Jessica Mungro, PhD: Stroke can impact a person's brain functioning in a lot of different ways, so it certainly can impact how people behave, how they regulate emotions, how they react to different situations and stressors, which all are sort of interpreted as personality change.

I tend to see people who may be struggling with changes like depressed mood or apathy, maybe irritability or anger. Like we were mentioning earlier, also anxiety or difficult-to-control worry. And all of those symptoms that may be impacting their overall functioning.

Host Amber Smith: So are those changes permanent or will they go away as the person's recovery moves along?

Jessica Mungro, PhD: They're not always permanent. For example, the changes I mentioned associated with post-stroke depression and anxiety, they're quite treatable. In terms of changes associated with, like, cognition or things like impulsivity, problem solving, memory or attention, speech language therapies and occupational therapies can also be very helpful.

Host Amber Smith: As patients see progress in their speech therapy and other therapies after a stroke, does that have an effect on depression? Does that help it get better or go away?

Carrie Garcia: I think it absolutely does have an impact on it. It does improve their mood. It improves their motivation, especially when they can see the progress. I think one of the barriers is when our patients don't always see the progress that they're making, because not all of our patients can remember ground zero and where they started from.

So it is very important to help them see the gains, whether it's via video or photo, as well as, even, sometimes we use testing scores to show them the gains they've made from the beginning, to the middle, until the end. Especially on outpatient therapies, we're required to do outcome measures and goal review every 10 visits. So every 10 visits we're really reinforcing the progress and the gains made.

Host Amber Smith: Well, before we wrap up, I'd like to ask both of you, Dr. Mungro and Ms. Garcia, how can friends or loved ones help? What can they do that would be helpful during this time? Dr. Mungro?

Jessica Mungro, PhD: In general, I think one of the most important things you can do is to be present with your loved one, to really listen, to be patient with them, to validate their emotions and their experience. I also think it's really important, as Carrie alluded to, to learn as much as you can about the individual's strengths and challenges. I think knowing the challenge areas allows you to know where to help, to know how to help. But I also think knowing their strengths helps you to know where to foster feelings of independence or a sense of competency and all those things that can really help with those depressive symptoms. And the only other thing I think about with families is the importance for self-care. It can be a huge adjustment to the entire system, and I think it's really important that the family members who are assisting someone through this experience are also taking care of themselves and giving themselves grace and getting their needs met.

Carrie Garcia: The only other thing I would add to what Dr. Mungro said is including being present, but to also making sure not to facilitate that isolation. It's very isolating to have a stroke. A lot of our stroke survivors feel alone. They feel like they're the only one. So encouraging the participation in life and in life events.

And we have multiple support networks in the community. We have the stroke support group. There's another stroke support group that runs locally, but we also have events and activities and fundraisers that run at least monthly or a couple times a year that those stroke survivors and their family members and even extended family can participate in.

Host Amber Smith: That's really good to know. I appreciate both of you making time for this interview, Dr. Mungro and Ms. Garcia.

Carrie Garcia: Thank you.

Jessica Mungro, PhD: Thank you.

My guests have been Carrie Garcia, a speech pathologist, and Jessica Mungro, an assistant professor of rehabilitation psychology, both at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Host Amber Smith: Who may benefit from a cochlear implant? Next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Electronic hearing devices called cochlear implants can help people with hearing loss improve the ability to understand speech and hear more sounds. Here to tell us about cochlear implants is Upstate audiologist Jeffrey VanTassel.

He's part of Upstate's otolaryngology ambulatory care.

Welcome to "HealthLink on Air," Mr. VanTassel.

Jeffrey VanTassel: Thank you, Amber. It's good to be here.

Host Amber Smith: Can you start by describing what a cochlear implant is and how it works?

Jeffrey VanTassel: Sure. In the simplest terms, a cochlear implant is an electronic hearing device that works by directly stimulating the nerve in the ear. It takes in sound. There are electrodes implanted deep inside the ear that are adjacent to nerve tissue, and they work by simply, for lack of a better term, zapping our nerve to get us to hear.

Host Amber Smith: So how does it differ from a hearing aid, or do hearing aids do the same thing?

Jeffrey VanTassel: No, hearing aids work in a little bit different manner.

A hearing aid uses what we would consider more of a conventional amplification method. They take in sound, they have an amplifier, much like you'd have in your stereo or in your television, and it takes the sound around you and turns it up to a level that would then be audible for the patient. It then outputs that sound through a speaker, so there's actually a sound coming out of the device.

That differs from a cochlear implant in that the cochlear implant takes the sound in, and it modifies the sound, but there's no speaker, there's no sound that's generated from the device. It generates a pattern of nerve impulses that are perceived as sound by the patient.

Host Amber Smith: So who might need a cochlear implant or benefit from a cochlear implant? Who would be eligible?

Jeffrey VanTassel: Right now, eligibility -- it's usually reserved for people who have very progressed hearing losses.

These are hearing losses that were either very aggressive over a short period of time or may have been systematically changing over long periods of time. And also people who don't derive a substantial level of benefit from their hearing aids. Really, this is a technology that slots in sort of after the patient has had experience with hearing aids, and either has such an extensive amount of hearing loss that hearing aids can no longer provide good listening for them or have had such substantial damage to their system that hearing aids again are not going to be adequate for their communication needs.

Host Amber Smith: Do the implants go in both ears?

Jeffrey VanTassel: Right now, that is actually up to the wishes of the patient and the surgeon. At this time, most insurance companies will certainly support bilateral devices. We will often have that conversation because we do know through a lot of research that listening through both ears provides benefits above and beyond just listening through one ear.

So we will often talk to the patients about their wishes. Do they want to try to use two, or oftentimes, which is more typical, they will try one to see what their level of benefit is. And if they're doing well with it, oftentimes they will then opt to have the second one done.

Host Amber Smith: So insurance will cover this.

Jeffrey VanTassel: Generally. There haven't really been any insurances that have balked at this time. It's been an evolution. I've been doing this at Upstate for, this is my 20th year. I've been an audiologist for 28 years, and when I first started, insurance support for cochlear implants was really sort of a giant gray area. There were some that would. There was some that weren't convinced that it was a beneficial technology.

But as the technology has improved, certainly more and more insurance companies have come on board. And I, in probably in the last five years, I have not noticed any insurance company that would deny support as long as the patient is considered a candidate for the device.

Host Amber Smith: So that includes Medicare, too.

Jeffrey VanTassel: Indeed, Medicare and Medicaid are definitely on board with this.

Host Amber Smith: Now, how long do cochlear implants last? Are they meant to be permanent?

Jeffrey VanTassel: They are. When we talk about the cochlear implants, we have to differentiate between sort of two segments of the device. There is an internally implanted electrode, and then there are external processors that are used to take in the sound and generate the code.

The internal implant -- that is designed to be a permanent implantation. Most of the time, with rare exception, these will last pretty close to a lifetime. Most of the time, the companies will say, "We'll give you a 10-year warranty on this," or what have you. But my experience, honestly, I've been in care of, getting close to 100 cochlear implant patients in my career here, and we've only had to replace two implants out of those.

So they do last a long time. Our impression is that once we implant it, there's going to be a very rare occasion that we'll actually have to go in and replace it.

Host Amber Smith: So you talked about the two pieces, the implanted part and the external part. Are there batteries in the external part?

Jeffrey VanTassel: Actually, the interesting thing that I tend to convey to my patients is that the external part of the device is much like caring for a hearing aid. It's a part that will hook over your ear or attach behind your ear to send the code into the internal array, but it looks a lot like a hearing aid.

It does have batteries. Now, most of the modern devices have rechargeable batteries, which has been quite a benefit to the patients, so they will get a few batteries when the device is initially programmed, and those batteries can last three to four years before they run out of applicable power. So they just recharge them each night, and every day they'll have a nice, fresh, strong battery to be able to use.

Host Amber Smith: Well, I know with hearing aids, you're not supposed to go swimming with them.

Is that the same with cochlear implants?

Jeffrey VanTassel: I'm going to qualify that answer. Usually we say no. A lot of the treatment of the cochlear implant, as far as how it is exposed to moisture, will be similar to that with a hearing aid. Most of the new devices, they're not specifically waterproof, but they are splashproof, so if you get a little rain on them or what have you, those are good.

But there are a couple waterproof devices that are available from a couple of the manufacturers, and the other manufacturers do have sort of an aftermarket system. It's much like, I call it "Tupperware for your cochlear implant." You can actually insert the implant into a rubber sleeve that will reject the water and it keeps the device sealed, so they will be able to swim with them on, yes.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate audiologist Jeffrey VanTassel about cochlear implants.

So what happens to a person's natural hearing ability when the cochlear implants are implanted?

Jeffrey VanTassel: Unfortunately, this is the part that we have to have the real frank conversation with the patients about, because when we implant the electrodes into the ear, a lot of their remaining hearing, unfortunately, does not survive the process. So we have to be very frank with them about the fact that when we go through this process, if, in the rare event that there is some issue that happens, we can't go backwards. Using a hearing aid in an ear that has a cochlear implant in it just will not be effective after the surgery, unfortunately.

Host Amber Smith: So how do you help a patient decide if it's worth trying, if a cochlear implant is good for them, or what do they have to think about?

Jeffrey VanTassel: Well, one of the things we do, we have some very extensive testing that we have to do, first of all, just to be able to demonstrate to the doctors and the insurance companies that this patient is a candidate for the device and would benefit from the device.

Usually it's the results of that type of testing that can really give a good picture to the patient as to where exactly they are in terms of their function, their communication abilities and what type of benefit they may get. We look at the type of benefit they're getting with the hearing aids, and we can contrast that to what we would expect that we can get with a cochlear implant to try to sort of paint a picture for them to see if that step is worth taking.

Host Amber Smith: So if they go with the cochlear implant, if they went to a music concert, for instance, or even just watching TV at home, would that sound different than they were used to hearing it before the cochlear implant?

Jeffrey VanTassel: Generally speaking, it will. There's really two reasons for that.

One reason is, as I talked about earlier, the method that we use to apply the sound to the patient is now sort of an electronic stimulation rather than creating a sound wave, and that comes with some side effects. Now over time, those tend to diminish. At the outset, people will tell me, "Oh, your voice sounds robotic," or "Sounds like a cartoon character" or things like that. But as time goes on, that actually will settle into a more natural type of sound quality. The other thing is that with the cochlear implant, we're able to provide awareness to sounds that the patient had not been typically hearing with their hearing aid. So the quality of sound changes dramatically.

Now, whether or not they can comfortably hear on the television, I usually tell my patients there's a lot of factors that go into that, but if we can get them good, comfortable hearing when they're talking to their friends and family, usually they can hear the television well. But that then depends upon what station they're on, what program they're on, et cetera.

Music, however, that's another can of worms because of the diverse nature of music and how music is performed, how it's generated and things like that. We can't always guarantee that they'll get great perception of music. Most patients will say, "I can listen to music. I understand it. It sounds a little different because the pitches are kind of presented to me in a different way," but most of them understand that music is sort of a secondary benefit of the device, and oftentimes it'll accept a little bit of shifting in that regard.

They still enjoy it, but they will say it's certainly different.

Host Amber Smith: So once somebody decides that they do want to go forward, how do you advise them to prepare for the procedure?

Jeffrey VanTassel: The procedure itself, I usually give them sort of an overview of what the procedure is. The procedure, it's pretty straightforward, but really, as far as preparing for the entire event, it's much like any other surgery.

They'll have to understand they're going to go into the hospital, they'll have anesthesia. Now, under most normal circumstances, this is an outpatient procedure. They'll go home the same day, as long as there aren't any substantial side effects.

But the one thing that's very important that they understand is that when we do the surgery, they're unable to hear in that ear. We have to let the surgical site heal. There's a lot of swelling, there's stitches, and we have to let the scar tissue form on that side because we have to place a device right where the surgical site is, and we can't do that right away for fear of irritating the site and causing a lot of healing problems.

So there's typically a four-week delay between the time they go through surgery and the time we're able to activate their implant. And they have to understand that in that four-week period, they will not have hearing in that one ear, or, in a more dramatic case, if they have bilateral implantation, they won't be able to hear out of either ear for that four weeks.

So they need to prepare to be able to have some sort of alternative communication available, or a method to communicate with people for that short term before we get them activated.

Host Amber Smith: Do you have people who want to do both ears, but will space it out sothat they don't lose hearing for four weeks, essentially?

Jeffrey VanTassel: I do. That's a very big consideration for a lot of patients, is they don't want to feel like they've become disconnected from their environment for that period of time. So oftentimes they know that it is a feasible option to do one, and then within a period of time do the second one.

And they oftentimes feel more comfortable, yes, saying, "I'll do the one, but then I can use a hearing aid in my other ear, which will allow me to have that connection to my environment, to my friends, to my family, so I won't feel that's such a great loss for that month while I'm healing from the surgery."

Host Amber Smith: So after that month, is it a second procedure to have the external part put on, or how does that go?

Jeffrey VanTassel: It's not a procedure per se, it's more like fitting a hearing aid. They would come into my office, I give them a thorough overview of what all the components are, how they work, and how the patient will operate them on a day-to-day basis.

We then show them how to place the device. The device is very simple. Like I said, it looks like a hearing aid. It's magnetic, so you place it on your ear, and there's a magnet that sticks over the implant that we put under the skin, and then it's just a matter of pursuing programming to start to get them to hear well. So, there are no other very in-depth medical procedures that are required.

It's more of just teaching them how to use the device, and then teaching them how to hear again.

Host Amber Smith: So I've seen dramatic videos of babies that are born unable to hear. And when they get the cochlear implant, it opens a new world for them, essentially. But these are generally people who are older and have been able to hear ...

Jeffrey VanTassel: Uh-huh. Right.

Host Amber Smith: ... it's probably not as dramatic, or does it sound different enough that they are surprised?

Jeffrey VanTassel: It can be.

And I'll say one thing. Those videos on YouTube are great because you see children that smile and giggle and stuff, but that's not always the case. That's sort of our little behind-the-scenes secret.

Most of the time, a child that hasn't heard before is absolutely petrified of sound that they don't understand. So oftentimes, because I do work with pediatrics and I do work with older patients, oftentimes when we activate a child, they cry for quite a period of time before they start to settle in and understand that all of a sudden they're hearing sound around them.

But that, I tell the parents, that's a very positive thing because I've changed their perceptual scheme. Now they understand that there's something else here that they have to work with.

Now, with older patients, they have a history of hearing that they can fall back on, so they can immediately start to listen and make comparisons to what they think it should sound like and things like that.

So the reactions can span a sort of a wide range. There are certainly patients that will come in thinking that when I activate the device, everything's going to fly right back to really good. And they don't on day one. It's just the reality of the situation. It takes practice and training to really get your hearing back.

So they'll sort of be a little skeptical, but there are number of other patients that even on Day One, are just like, "I can see where this is going, and I'm already extremely excited," so, it's very rewarding regardless of what the reaction is because I know that I've taken them a big step forward in their hearing health.

Host Amber Smith: Now, do they stay in contact with you if they have questions or issues that come up after the cochlear implant's done?

Jeffrey VanTassel: Absolutely. I provide long-term care for all my patients. Part of the cycle, especially when we're trying to get them to be able to hear, is I will see them almost on a monthly basis or every few weeks to really start, (and) keep, fine-tuning the device as they start to get used to it and to provide them with good sound.

But even when they're sort of settled in, I typically see my patients every six months to a year, almost like our eye care, just to make sure that they're doing well, that there's not any outstanding issues, and that their equipment is functioning well and doesn't need any sort of mechanical attention.

So yeah, I keep in very close contact with my patients.

Host Amber Smith: Well, I appreciate you making time for this interview, Mr. VanTassel.

Jeffrey VanTassel: Certainly. It's been my pleasure.

Host Amber Smith: My guest has been Jeffrey VanTassel. He's an audiologist at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- a new drug that slows the progression of Alzheimer's. From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A new drug that can reduce cognitive and functional decline in people living with early Alzheimer's disease is available for infusion at Upstate University Hospital. The drug is lecanemab. And here to tell us more about it is neurologist Tinatin Chabrashvili, a professor of neurology and the director of Upstate's Neurodegenerative Disorders Center.

Welcome back to "HealthLink on Air," Dr. Chabrashvili.

Tinatin Chabrasvili, MD, PhD: Thank you for inviting me back, Amber.

Host Amber Smith: Is this new medicine, lecanemab, or Leqembi, is this considered a potential cure for Alzheimer's?

Tinatin Chabrasvili, MD, PhD: Lecanemab, or Leqembi, is not a cure for Alzheimer's disease. But this is the traditionally approved treatment that addresses the underlying biology of Alzheimer's disease and that changes the course in a meaningful way for people in the early stages of the disease.

In the clinical trial known as Clarity AD trial, starting approximately at six months across all time points, lecanemab demonstrated statistically significant slowing of cognitive and functional decline with continued treatment. So this is not the cure. It just slows down the decline in terms of the cognitive and functional aspects.

Host Amber Smith: So is this designed for someone who's been diagnosed with mild cognitive impairment, or do they have to have been diagnosed with Alzheimer's?

Tinatin Chabrasvili, MD, PhD: This is a very good point, Amber, because not every type of mild cognitive impairment is caused by Alzheimer's disease.

So, this drug is indicated in those patients who have underlying Alzheimer's disease pathology, either mild cognitive impairment due to Alzheimer's disease or early dementia due to Alzheimer's disease.

Host Amber Smith:

Do the doctors look at beta-amyloid levels to determine whether somebody should try this?

Tinatin Chabrasvili, MD, PhD: Yes, absolutely. That's a mandatory step before we initiate treatment with lecanemab. It requires biological proof that the individual has Alzheimer's disease, and Alzheimer's disease is the one causing the symptoms.

And the next question is how we identify whether someone has Alzheimer's disease or not. And we usually use two diagnostic tools at this moment. One is the amyloid PET scan, and the second is biofluid biomarkers. Currently, we're required to do Alzheimer's disease biomarker assessment in spinal fluid. However, Alzheimer's disease blood-based biomarkers are in development, and we hope that they will be implemented in the clinic soon.

Host Amber Smith: Can you describe what beta-amyloid is?

Tinatin Chabrasvili, MD, PhD: Amyloid-beta is a protein fragment that is closely associated with Alzheimer's disease. And this is actually a peptide composed of 36 to 43 amino acids, and it's derived from the large protein known as amyloid precursor protein. It requires two enzymes to cleave sequentially.

Amyloid-beta exists in different forms and normal biological functions such as in synaptic plasticity (how nerve cells communicate), neurogenesis (growth of nerve tissues), even possibly immune response. However, there are toxic species that are associated with development of Alzheimer's disease pathology, and particularly amyloid-beta 42 has been shown to be toxic and associated with the formation of amyloid plaques in the brain.

So accumulation of amyloid-beta in the form of plaques has been a hallmark of Alzheimer's disease and has been very closely related to development of Alzheimer's disease pathology. It has been thought that accumulation and aggregation of this amyloid-beta in the brain can disrupt the cell function, induce inflammation and, ultimately, lead to neuronal (nerve cell) death.

It is really important to recognize that the balance between the production and clearance of amyloid-beta is crucial for brain health. In Alzheimer's disease, the balance is disrupted, leading to accumulation of this peptide. And we also have to remember, however, that disruption can be influenced by multiple factors, such as genetic factors, mutations in amyloid precursor genes and in other genes, like those involved in cleavage of amyloid precursor protein.

I also want to emphasize that Alzheimer's disease is an ongoing neurotoxic process that begins before and continues after plaque deposition. Amyloid-beta converts into larger and smaller species, including oligomers and protofibrils. And this is really important when we are talking about designing appropriate monoclonal antibodies to scavenge these toxic species. Continuous accumulation of these profibrils contributes to neurodegeneration and eventually to neuronal death.

It's also important to highlight that the amyloid-beta cascade also triggers the downstream molecular pathways, including tau (a protein) pathology, which further contributes to neurodegeneration.

So, this is a very complex process, and recognizing the pathophysiology will help us to design proper treatments.

Host Amber Smith: Do I understand correctly, though, in dementia, or Alzheimer's, there's an increase of the amyloid in the brain, and then this new medication, lecanemab, helps lower those levels? Is that how it works?

Tinatin Chabrasvili, MD, PhD: Yes. That is absolutely correct about lecanemab, which is a humanized immunoglobulin monoclonal antibody, directed specifically against soluble and insoluble forms of amyloid-beta, and clears these toxic species. I also want to emphasize that, specifically, lecanemab is the only anti-amyloid antibody that preferentially binds to neurotoxic protofibrils, approximately 10 to 15 times higher sensitivity versus fibrils and more than 1,000-fold versus monomers.

So, it's a complex biology, and as I indicated earlier, there are different toxic species' efficiency, and there are other monoclonal antibodies similar to lecanemab. And efficacy depends on which species are cleared, and how efficiently they are cleared, from the brain.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with neurologist Dr. Tinatin Chabrashvili about a new Alzheimer's drug called lecanemab that Upstate is now offering.

Let's go over the benefits and the risks of this medication, which I know may be different depending on the individual. But in general, what are the benefits?

Tinatin Chabrasvili, MD, PhD: The clinical trial, (called) the Clarity Trial, showed that it slows down the cognitive decline and functional decline approximately by 27%. So this is not the cure, but it's really slowing down of the process, and this slowdown of the cognitive decline was associated with clearing of amyloid-beta in the brain.

Host Amber Smith: And then what are the risks?

Tinatin Chabrasvili, MD, PhD: All drugs, lecanemab and other monoclonal antibodies similar to lecanemab, are associated with side effects. One of the most important side effects isx amyloid-related imaging abnormality, known as ARIA. Other side effects include allergic reactions, headaches, infusion-related side effects. However, the most common reported side effects are infusion-related reaction, amyloid-related imaging abnormalities and headaches.

Host Amber Smith: How concerned should a patient be about amyloid-related imaging abnormalities?

Tinatin Chabrasvili, MD, PhD: Well, lecanemab has a boxed warning for amyloid-related imaging abnormalities, also called ARIA. And this refers to abnormalities seen on MRI scans that are associated with certain treatments for Alzheimer's disease, particularly those involving immunotherapy approaches like monoclonal antibodies in general, targeting amyloid-beta in the brain. These antibodies are designed to help clear amyloid plaques, which are characteristic for Alzheimer's disease.

However, the process can sometimes lead to unintended effects on brain tissue surrounding the plaques. Sometimes this could be seen only on the MRI of the brain and can be just incidental findings. However, sometimes they can manifest symptomatically, so monitoring of these patients who are receiving lecanemab is very important.

And to add one more thing, ARIAs are two different types. One is ARIA E, which is ARIA with edema (fluid buildup). And the second type is ARIA H, which is, area with hemosiderin deposition (a condition resulting from hemorrhaging). There is one particular group of patients who are especially susceptible for this type of side effects, and these are the APOE4 homozygous. So we have to be especially careful with those patients. And that's another black-box warning for this particular medication, that patients who are APOE4 homozygous, have to be counseled very carefully about these particular side effects.

Host Amber Smith: And you're saying APOE4, that's a particular gene.

Tinatin Chabrasvili, MD, PhD: That is correct.

The full name is apolipoprotein E, epsilon 4.

Host Amber Smith: So let me ask you, before we get some basics on how this drug is infused, are there any medical conditions that would disqualify a person from having lecanemab?

Tinatin Chabrasvili, MD, PhD: Yes. There are certain conditions that disqualify the patients, and more importantly, if someone has dementia not related to underlying Alzheimer's disease pathology. So that's one of the most important.

Another important contraindication (reason not to use the drug) is if someone has more than four microhemorrhages in their brain. So obtaining an MRI of their brain and evaluating for the risk in the development of ARIA is also important.

Any psychiatric disorders with psychotic symptoms, such as hallucinations, delusions or major depressive disorders, they are also contraindications. Any autoimmune disorders that are not well controlled. And also TIA (transient ischemic attack, or "mini-stroke") or stroke or seizures within the past 12 months of screening. And obviously, someone allergic to this drug should not be infused.

Host Amber Smith: Once you have patients who are qualified, it's a drug that has to be infused into their body.

How long does that take, and how often do they come for infusions?

Tinatin Chabrasvili, MD, PhD: Usually it takes one hour to infuse, and it's administered every two weeks. We try to have a consistent schedule, but if it's delayed one day or so, we can accommodate the patient, adjust the schedule.

But we try to be very structured in terms of scheduling, because besides these biweekly infusions, we need to also monitor these patients that we have to order their scans MRI scans, between fourth and fifth, sixth and seventh, and before 13th and 14th infusions. So having that schedule, it really helps to avoid any confusion.

Host Amber Smith: From the patient's point of view, does this feel like getting intravenous fluid, or do they experience any sensations during the infusion?

Tinatin Chabrasvili, MD, PhD: Mostly the sensation is the same as during any other infusion of the drug. They may feel like that there is some slight warmth or slight fullness at the site of infusion.

After the infusion, they may experience some fatigue, maybe some emotional response as well. So we have to remember that as well. And later on they may have more of these infusion-related reactions. Overall, the experience of receiving lecanemab can vary from patient to patient, but many patients overall find the process to be manageable and relatively comfortable.

Before anyone starts this infusion, any patient should really have a very honest and frank conversation with their health care providers. Discuss all: side effect profile, what to expect during the infusion, what temperature to expect at the infusion site, and that helps to make the experience more comfortable.

Host Amber Smith: How soon might patients or their loved ones notice a difference?

Tinatin Chabrasvili, MD, PhD: Well, that's a very good question. And that can vary, again, from patient to patient. Obviously it depends on the individual disease state, and it can be either short-, medium- or more long-term observed effects. But again, this can vary.

And we will probably learn more when we have more real-world data.

Host Amber Smith: The Alzheimer's Association says the manufacturers of lecanemab have set the price at $26,500 a year. Is it covered by Medicare or Medicaid and private health insurers at this point?

Tinatin Chabrasvili, MD, PhD: The Centers for Medicare and Medicaid Services, known as CMS, announced that they will cover lecanemab, as long as any patient enrolls in a CMS-approved registry. So my experience has been that we can work with Medicare, Medicaid, and we can work with the private insurance companies, but it really varies from state to state, as I understand, and it also depends on the specific private insurances as well.

Host Amber Smith: I'm curious how you feel, as a provider, having a medication like this to offer. Are you optimistic that it will have an impact?

Tinatin Chabrasvili, MD, PhD: I think that this is a very important step forward, because this is a new hope for Alzheimer's disease patients and for the entire Alzheimer's disease community.

Of course, by current evidence, this was only by 27% a slowing down. however, this is a very important step forward. We are learning a lot. So I am optimistic, Amber, I am optimistic. I am very cautious, but I'm very optimistic as well.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Chabrashvili.

Tinatin Chabrasvili, MD, PhD: Thank you so much for having me and allowing me to participate in this very important topic discussion.

Host Amber Smith: My guest has been Dr. Tinatin Chabrashvili, the director of Upstate's Neurodegenerative Disorders Center. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Ubong Johnson, a fourth-year medical student from Nigeria, sent us a poem about how his brother's tragic death both inspired his decision to become a doctor and helped him avoid a public humiliation during his training.

"Locked Jaw"

i walk into the pediatric ward today,

blue scrubs, sticking to my black skin like kin,

and i am reminded of that Tuesday my mother lost herself.

that morning, my twin brother,

who was born a bright-eyed flower, died a tree.

stiff necked. jaws locked. limbs like branches.

death had weeks before crawled into his eight-year-old

body through a dirty puncture wound underneath his big toe,

seizing him by the nape like a bully.

he died a faulty machine, jerking and spasming, doctors

racing to keep life from escaping through his nostrils, my mother's

wails slicing into the air; my father's sclerae like wet red clothes.

i silently complete the arc of medical students around a small bed,

and my consultant's eyes regard me as though she considers tossing

me outside for arriving late for rounds yet again.

she withdraws her glare, and the question meant to

humiliate me, my punishment, clambers out of her throat:

you, tell me what you think afflicts this child? everything about it, i mean.

and God save you if you don't know.

i look down, and i smile. another chance to tell

my twin brother's story. to describe clostridium tetani;

the reason i have chosen to become a doctor.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air" -- when is it safe to eat after head and neck surgery?

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.