Neurodegenerative Diseases – Podcast

man suffering from neurodegenerative disease
By LifeStance Health on October 14, 2020

Dwight Thompson (00:00):
Hi. Welcome to Reset Your Mindset by LifeStance Health. Myself, Dwight Thompson, and my cohost, Nicholette Leanza, will bring you conversations with leading LifeStance Health professionals, who will help guide you on your journey to positive mental health and wellbeing. At LifeStance, we believe in the three pillars of mental health. Mental flexibility, mindfulness, and resilience.
Dwight Thompson (00:35):
Welcome back everyone and thank you for joining Reset Your Mindset by LifeStance Health. Nicky and I are really excited today. We’re joined by Dr. Zachary Dietrich, a neuropsychologist based out of our Louisville office. Zach … Dr. Dietrich, you and I have known each other for a while, and I’ve been really impressed with your unique scope of practice, to say the least. So I just appreciate you joining, man.
Dr. Zachary Dietrich (00:59):
Thanks Dwight, I appreciate being on.
Nicholette Leanza (01:02):
And Dr. Dietrich, I’m new to meeting you and I’m definitely interested as well as our listeners. Tell us a little bit about yourself. Tell us about your specialties.
Dr. Zachary Dietrich (01:11):
So I’m a commissioner at the legal office, primarily focused in on neuropsychological assessment of neurodegenerative diseases and some neuro developmental disorders, primarily at the later end of the lifespan. And the difference between neuropsychologist psychology is primarily neuropsychology is really concerned about how the brain and the central nervous system influence cognition’s and behaviors. And when I say the brain, I really do mean like the brain as an organ. So we’re a little more oriented to trying to find ways to assess different cognitive functions and what that might mean diagnostically.
Nicholette Leanza (01:58):
What got you into this? What got you interested in this field?
Dr. Zachary Dietrich (01:58):
So it was kind of a perfect storm of two different factors. One in my educational life and one of my personal life. So I started off in grad school. I wasn’t really sure what path I wanted to go down. And I started off working at a VSee as an intern actually. And I bumped into Dr. Tom Swales and we’d kind of talked for a little bit, and what’s funny, I brought this up to him 10 years later and he kind of forgotten this even happened, so it always makes the guy feel good whenever something was so monumental in your life is forgotten by somebody else. But anyway, so he said, “Hey, I’ve been talking to you for a little while. Let me show you what I do. I think you would enjoy this more.”
Dr. Zachary Dietrich (02:44):
And that was my first exposure to a neuropsychologist. And it just so happened in my personal life. My grandmother had just recently started the initial progression that was the Alzheimer’s diagnosis. So it was this weird junction of where I was seeing in my personal life the effects of this disease and just reading more and more and more. And then as I went through grad school, focused on my practicums, focused on the electives I could take on neural pathology, neuroanatomy, and all my practicals are centered around assessment. Same deal with internship and postdoc and stuff like that. So, so that’s kind of how I got here.
Dwight Thompson (03:34):
So I think throughout this whole conversation, you’re going to be talking about some certain verbiage and some certain terms, a lot of the information you’re going to be presenting is going to be new to a lot of people and very informative. One thing that’s not going to be new to a lot of people is a lot of people can relate to having a family member, having a friend with Alzheimer’s.
Dr. Zachary Dietrich (03:51):
Dwight Thompson (03:53):
So a lot of what you do, although on surface level, it might seem like what kind of condition is this, guys? This guy has a crazy scope of practice. When you really start to break it down and look at what you work with, you are invaluable because you work with people that are so near and dear to so many people battling a disease that’s so complex. What is it like working with the population that you work with?
Dr. Zachary Dietrich (04:22):
Of course everybody’s first, knee-jerk reaction to that is we’re working with people who a lot of times are terminal and that reality cannot be dismissed. And the commission has always wise to keep that in mind. You’re dealing with a real human being, you’re dealing with a real family. So there’s lots of days where you have to check yourself to make sure you’re giving the appropriate amount of attention to this person that this situation warrants because it is a very serious situation. And those times where you tell somebody that, yes, this is Alzheimer’s or one of those big, scary words, then you have to have real conversations with the family about what to expect and what is the best course of action for their family.
Dr. Zachary Dietrich (05:08):
Give them any recommendations that you can as far as just to ease the process, not just on the loved one, but on the family member because a lot of times the person with Alzheimer’s doesn’t know they have Alzheimer’s.
Nicholette Leanza (05:18):
Dwight Thompson (05:19):
Dr. Zachary Dietrich (05:19):
The family is the one that’s really, really suffering here. And then on the flip side of the coin, there are times where somebody can have certain types of strokes or can have silent strokes, TIAs as we call them. And those things to the layman may look like Alzheimer’s. And one of the greatest joys in my job that I get is whenever I get to look somebody and say, “This is probably vascular in nature and is probably not a neurodegenerative disease. Take care of your cardiovascular health and there’s a good chance that it might not get worse.”
Dr. Zachary Dietrich (05:56):
And you might have three or four bad days in a row where you’ve got to have some real heavy conversations and then you see the look in that one person’s eye when you tell them that, that just kind of makes it all kind of worth it, you know?
Nicholette Leanza (06:09):
Dwight Thompson (06:09):
For sure.
Dr. Zachary Dietrich (06:10):
You definitely go through days where you’re wondering, what am I really doing here? And then all of a sudden you have something like that. So-
Dwight Thompson (06:16):
It makes it worth it.
Dr. Zachary Dietrich (06:17):
Or a family member calls you back and says, “Hey, we tried this and it works well,” that’s when you get that reminder.
Dwight Thompson (06:23):
Absolutely. Yeah. You do special work, man.
Nicholette Leanza (06:26):
Dr. Dietrich, can you walk us through what the testing looks like and the procedures to that?
Dr. Zachary Dietrich (06:32):
Sure. So the first part of the evaluation always starts with a clinical interview, a consultation, if you will, just get better idea of what has been going on, the onset of the symptoms. And that gives me a chance to talk to the patient, to see if they have any understanding of their own symptoms. If they have understandings of their own symptoms, oftentimes that’s actually a good sign. If they don’t have understanding of the symptoms then that tells me a lot about how the assessment process is going to go. And I get a feel for, is this somebody who will sit with me for three hours and go through all these cognitive tests and not get frustrated to the point where it’s not going to be a waste of our time and all this and that.
Dr. Zachary Dietrich (07:20):
So then the follow-up evaluations, the actual assessment, the meat and potatoes, we block off about four hours or so for that. And we do a series of tests looking at different cognitive domains; short-term memory, auditory memory, structured memory, visual memory, different visual constructional skills, how well can they pay attention and to what types of things can they pay attention to, stuff like that so that we get a better understanding of, for lack of a better term, what part of the brain is firing off well and what might not be firing off so well.
Dwight Thompson (07:56):
Dr. Zachary Dietrich (07:57):
And then after the evaluation behind the scenes, then we’re going through medical records. We’re trying to find, is there any medical explanations or anything in their lab work that might explain this? Luckily enough, a lot of times we get neural imaging so we can look at that to see if there’s any correlates here to help us with the diagnosis process. Once the patient leaves, the real work happens after they leave. And now we’re just interpreting data.
Dwight Thompson (08:24):
Got it. So, Dr. Dietrich, let me ask you this. So correct me if I’m wrong, when you really think like what you specialize in, you specialize in neurodegenerative disorders, correct?
Dr. Zachary Dietrich (08:33):
Sure. Yes. Disease. Yes.
Dwight Thompson (08:34):
Okay. What is that?
Dr. Zachary Dietrich (08:36):
So a neurodegenerative disease or dementia is just an umbrella term for a range of conditions that primarily affect neurons in the human brain. All right. And neurodegenerative disease is an incurable debilitating condition where you have a progressive degeneration, all right. And that can cause problems in motor movement, mental functioning, and my job is to try to the best of our ability to look at what might be the actual nature of this disease so that we can give our best practice recommendations, or things to avoid with certain diseases, like there’s certain medications you want to avoid if this person has Lewy body’s disease or something like that. So that’s what a neurodegenerative disease is. It’s just an umbrella term for a slew of different type of dementia’s.
Nicholette Leanza (09:33):
Dietrich, what would be some signs or symptoms that families should be looking for if they do have some concerns with some family members?
Dr. Zachary Dietrich (09:41):
So a lot of people, especially when we’re talking about the ones, everybody knows, like Alzheimer’s and frontotemporal dementia and stuff like that. Everybody knows of those short-term memory deficits, or maybe some language deficits and stuff like that. But what a lot of people don’t know is that actually a lot of times I hear and the literature supports this, that they will say, “You know, my mom was just always a pretty happy person, always pretty flexible, always pretty adaptable to what was going on and then all of a sudden she just got withdrawn. All of a sudden, she just didn’t really like to do new things. Didn’t want to do anything.”
Dr. Zachary Dietrich (10:21):
And if you see somebody that has an entire life of being well adapted, well functioning, and then all of a sudden around age 70 or somewhere in that ballpark. Now, all of a sudden they’re getting way more withdrawn. They don’t want to do the things they like to do. They don’t want to go to church on Sunday anymore, and they’d have a lifetime of that. Or they don’t want to go to Thanksgiving. I’m not trying to say we should knee jerk to assume the worst on that. But oftentimes those little things can be misdiagnosed as depression or something like that when in reality, it’s not true depression. It’s apathy that’s going along with the neuro-degeneration.
Nicholette Leanza (10:59):
No, that’s a really interesting point. I think that might be the first conclusion that a lot of family members might be jumping to if they’re seeing a change of personality or functioning with a family member of maybe they’re just depressed or whatever, and we might be missing, there’s a deeper issue going on. So that’s really interesting for sure.
Dr. Zachary Dietrich (11:13):
Dwight Thompson (11:17):
So what you’re doing, it’s so collaborative because you have family members involved. You’re having multiple people involved in a discussion centered around one individual. One individual who, a lot of the folks you work with, they’re elderly, they’re battling something that they’ve … It’s so scary. Like my grandfather, he had Alzheimer’s and I could see he was scared. You don’t really understand what’s going on, but you know that something is wrong.
Dr. Zachary Dietrich (11:45):
Dwight Thompson (11:45):
And there’s all sorts of defense mechanisms that come with that. What is it like working with that demographic and that population and what are you trying to implement in what you offer to try to manage it and help people navigate potentially the scariest time of their life?
Dr. Zachary Dietrich (12:01):
Sure. When it comes to … Me personally, I kind of look at it two different ways. I have a patient, which is this individual that we’ve done the evaluation with. And almost like that is my patient, but the family is my client. You see what I’m saying?
Dwight Thompson (12:17):
I gotcha.
Nicholette Leanza (12:17):
Dr. Zachary Dietrich (12:17):
The family is who is going to get the book of the behavioral intervention. They’re going to get the bulk of the conversations, you know?
Dwight Thompson (12:26):
Dr. Zachary Dietrich (12:26):
And the one thing that I always try to stress is the absolute worst thing you can do is argue with them, say things to them that confuse them, say things to them that make them angry. Like, “Come on, grandma, you remember me, don’t you?” Stuff like that. And it’s tough for people to comprehend. And it’s tough for people to make this switch that, “One day I might not be able to call my mom, mom because that might confuse her. So I might have to start calling her Judy, if I want to sit down and have a conversation with this woman, and I want her to enjoy her best quality of life as possible and I still want to have some good memories that can be made with this woman. Then I have to make changes myself. I can’t treat this the way it used to be.”
Dr. Zachary Dietrich (13:16):
And that’s very hard for people. I had a patient one time who, I mean, this is just a brilliant example. The patient thought that there were tigers outside the window. And this was well before Tiger King and everything. The patient thought there was tigers outside. And in a moment of brilliance, the wife didn’t say, “Well, there’s no tigers in this area. There’s not this.” All she said was, “It’s a little early in the year for tigers, isn’t it?” And then the patient said, “It might be.”
Dr. Zachary Dietrich (13:57):
And then they moved on.
Dwight Thompson (13:58):
Nicholette Leanza (14:00):
Dr. Zachary Dietrich (14:00):
And not to brag on my father, but my dad had a stroke of brilliance one time. My grandmother went down into the basement and my grandfather just could not get her to come up out of the basement. And we’re a farm family. So the most important thing in a farm family can do is keep the air by fed, right?
Dwight Thompson (14:19):
Gotcha, yeah.
Dr. Zachary Dietrich (14:20):
And my grandfather tried for hours to get her to come upstairs and just couldn’t do it. He called my dad and my dad walked over and said, “I’ll get her out of the basement.” And then just said, “Hey mom, I’m home. I’m hungry.”
Nicholette Leanza (14:37):
And that works. That brought here up.
Dr. Zachary Dietrich (14:39):
Right away.
Dwight Thompson (14:42):
Dr. Zachary Dietrich (14:42):
Right away.
Nicholette Leanza (14:42):
Dr. Zachary Dietrich (14:43):
So the education process is really focused around the environment, focusing on their physical safety first and foremost and then the emotional health of the home.
Nicholette Leanza (14:57):
Yeah, because I would believe it’s like a lot. It’s like the family going through grief of losing their family member, who they used to be and their own memories of who they used to be. I would think that’s a whole process for the family of grieving that loss.
Dr. Zachary Dietrich (15:12):
Dwight Thompson (15:13):
Right because you’re losing … It seems like you’re losing someone that’s still here with you.
Dr. Zachary Dietrich (15:16):
Nicholette Leanza (15:16):
Right. Right.
Dwight Thompson (15:18):
And I’m speaking from personal experience. Like, yeah, I know that that’s the feeling and I’m sure that’s a feeling that so many people have felt. So just generally, this is kind of putting you on the spot, but what kind of tips would you give family members supporting people that are struggling with a neurodegenerative disorder?
Dr. Zachary Dietrich (15:34):
The big thing is the old rules of how our life used to be are out the window. Point blank. Point blank. And you have to choose your battles and you have to choose them wisely.
Dwight Thompson (15:46):
Dr. Zachary Dietrich (15:47):
Nobody has ever died from long fingernails.
Dwight Thompson (15:53):
Nicholette Leanza (15:53):
Good point.
Dr. Zachary Dietrich (15:54):
And some people might not like to see their loved one with disheveled fingernails. But the process of clipping their fingernails might not be a good time to do it for Lord knows how many weeks. You know what I’m saying?
Dwight Thompson (16:10):
That’s a good point.
Dr. Zachary Dietrich (16:11):
And if they want to wear a sweater that makes no sense to a family dinner, whatever, who cares? Is it worth the fight?
Nicholette Leanza (16:21):
Good point.
Dr. Zachary Dietrich (16:22):
You have to focus on, like I said, their physical safety and you can still enjoy your time you have left with these people if you choose your battles. If you try to pull them and fix their hair, that can … Fixing a hair can be just a monumental task rife with strife.
Dwight Thompson (16:44):
Dr. Zachary Dietrich (16:44):
And what are you getting out of it? What are you getting out of it?
Dwight Thompson (16:53):
Dr. Dietrich, a lot of the conversations you and I have had, especially this year, given everything that is going on with our pandemic, we’ve had some discussions about COVID and some of the effects you’ve seen from a neuro perspective. Can you talk a little bit about that?
Dr. Zachary Dietrich (17:13):
Sure. So the one thing I cannot stress this enough is that I don’t have, and I’m not sure if anybody has, a good understanding of how some of the impact COVID can have from a neuroanatomical perspective.
Nicholette Leanza (17:30):
Dr. Zachary Dietrich (17:31):
Myself and a slew of people and Listserv’s and Facebook groups and text threads have been sending articles back and forth because some of the things that myself and some of my colleagues are seeing are just, we didn’t expect to see this in March. And a lot of people’s first go to is, “Well, you know, it’s an upper respiratory infection and it’s decreasing oxygen. So there might be, you know, some stroke like activity or lack of oxygen going to the brain and somehow,” but with the patients that have been referred to me, the handful of them, you don’t see this on a CT scan. You’re not seeing any stroke like activity.
Dr. Zachary Dietrich (18:14):
And primarily what we are seeing is short-term memory deficits. Some people are reporting, informally, in these groups that they are seeing some executive functioning deficits related to language. And the one that I’ve seen, a few other people have seen, is processing speed, how fast the brain is moving. And anytime we talk about processing speed, of course, a lot of us first go to is, well, this is something related to lack of oxygen for some period of time and stroke like activity.
Dr. Zachary Dietrich (18:47):
But it just, again, it is a strange thing. It’s not making a lot of sense to myself and it doesn’t make a lot of sense to the neuro community at large.
Dwight Thompson (18:59):
Dr. Zachary Dietrich (19:01):
But one thing I will say, though, I have had a follow-up with one patient who I I tested around May, I believe and I did talk to him three months later. And just through conversation, the good news is it does seem like he was getting some of those faculties back, which again-
Nicholette Leanza (19:21):
That’s good.
Dr. Zachary Dietrich (19:22):
Which again, he’s not 100% and again, to get them back, it makes no sense either. But the COVID pandemic is impacting more than just people’s lungs, cardiovascular functioning, all this stuff that we hear about.
Nicholette Leanza (19:37):
I think that’s so important to point out because I think that’s what a lot of the assumption is, is that it’ hitting those areas and not neurologically. And here you are saying, there are some neurological effects of COVID. So it’s really important to put that out there, just keep people on that.
Dr. Zachary Dietrich (19:51):
And everybody’s heard of the big one, the loss of smell and taste.
Dwight Thompson (19:55):
Dr. Zachary Dietrich (19:56):
But to go past the blood-brain barrier and get into those neuroanatomical correlates of behavior, that’s something when I didn’t expect, for sure
Dwight Thompson (20:08):
Yeah. I think it’s something, no one expected, but that is super insightful. I appreciate it.
Dwight Thompson (20:20):
So, Dr. Dietrich, I kind of want to shift it a little bit more to a professional standpoint in a lot of the things that you supplement for different neurology departments in your respective area. Can you talk a little bit about what your experience has been like working with those departments?
Dr. Zachary Dietrich (20:37):
Sure. Oh yeah. So I say this to people all the time. The only reason why I still have a job is because neuroimaging, MRIs, CT, fMRI, are not as specific as we want them to be yet. So a lot of times family members will go to, and my biggest referral source is Norton neurology, and a family will go to their MemoryCare Clinic and start to have these mild complaints. And they’ll send them to neuroimaging and the CT scan comes back absolutely fine, because the disease just has not progressed enough. Those amyloid plaques, those neurofibrillary tangles, haven’t done a strong enough job on the hippocampus yet to show hippocampal atrophy.
Nicholette Leanza (21:21):
Dr. Zachary Dietrich (21:21):
So they refer to me to try to supplement to get an idea of where their cognitive functioning is at. This is the heavy Alzheimer’s conversations so we’ll stick with that. The first cardinal feature of Alzheimer’s is rapid forgetting. We see that through formal structured testing more so than you will see that in neuroimaging, obviously. And the tricky part with trying to diagnose something like Alzheimer’s through a conversation alone is that the frontal lobes, especially in the early stages, are fine. This person is intelligent. This person is bright. This person can put things together and they’re not doing it on purpose, but you might ask them a question and they might have a really good response. That kind of makes sense and can kind of explain their memory deficit in a way that’s not something that’s neurodegenerative, you know. Like you might ask them a question, “What month is it?” And that person might just happen to look outside and see that this tree is starting to turn brown and might just throw out there October.
Dwight Thompson (22:34):
Dr. Zachary Dietrich (22:34):
They don’t remember it’s October.
Nicholette Leanza (22:37):
Dwight Thompson (22:37):
Dr. Zachary Dietrich (22:38):
It is just-
Nicholette Leanza (22:39):
They’re more like guessing?
Dr. Zachary Dietrich (22:40):
It is the front … The parts of the brain that are intact, are operating so fast that they don’t even realize they have just done that.
Dwight Thompson (22:48):
Nicholette Leanza (22:51):
Dr. Zachary Dietrich (22:52):
And I can’t stress that enough. They’re not lying and they’re not trying to necessarily overcompensate. It is just almost seemingly like a natural course of what is going on.
Dwight Thompson (23:00):
Dr. Zachary Dietrich (23:01):
So that’s how our science supplements neurology. Looking at those behavioral quantitative and sometimes qualitative methods of assessment to give maybe that missing piece, or at least another piece of evidence to the overall diagnosis. Very rarely can we diagnose confidently based on just one data point. It takes a lot of data points.
Dwight Thompson (23:30):
Nicholette Leanza (23:30):
I’m sure.
Dr. Zachary Dietrich (23:30):
Oftentimes across the person’s lifespan and neuropsych evaluation, lab, work, stuff of that nature to try to get a better explanation.
Dwight Thompson (23:41):
Got it.
Nicholette Leanza (23:42):
Gotcha. I could use your … My gosh, you definitely have provided us with lots of information about this. And I think some of my own takeaways that I’m going to be more mindful of is just, the effects that it does have on the families of their loved ones. And you mentioning the old rules are out of who you thought they were before. You had to throw those out and seeing who they are now and picking your battles with them. If their fingernails along or the hair isn’t comb, is it really worth wrestling with them to clip the nails or comb their hair? It needs to be moving away from that. I think that’s so key right there. Dwight, what about yourself?
Dwight Thompson (24:19):
One of them for sure was the picking your battles. That’s so much easier said than done, but I guess I’ve never actually contextualized it to really have it in my forethought. But again, it’s like I said at the beginning, a lot of what you were talking about is going to be new to a lot of people, but what’s not new is that knowing people with these disorders and these diseases.
Dr. Zachary Dietrich (24:45):
And absolutely and part of picking your battles is putting yourself heavy into check to see, “Why am I trying to get her to remember? For her benefit?”
Dwight Thompson (24:54):
Dr. Zachary Dietrich (24:54):
“Or am I trying to get her to remember for my benefit?”
Nicholette Leanza (24:55):
Good point, yeah.
Dwight Thompson (24:55):
It’s so obvious.
Dr. Zachary Dietrich (24:55):
Dwight Thompson (24:55):
That’s a good point.
Dr. Zachary Dietrich (25:00):
And you can’t be mad at a family member for trying to do that, but that’s just a realization that they all have to come to.
Dwight Thompson (25:06):
That’s a great point.
Dr. Zachary Dietrich (25:06):
You’re doing this for you. You’re not doing this for your loved one.
Dwight Thompson (25:09):
Right. Right. Yeah. Very poignant. Well, Dr. Dietrich, we really appreciate you joining. I can’t speak highly enough for what you do and it’s been great working with you.
Dr. Zachary Dietrich (25:21):
Thank you, sir.
Dwight Thompson (25:22):
I appreciate it.
Nicholette Leanza (25:24):
Yes, thank you Dr. D-