Toolbox in hand, Rhonna Shatz, DO, has arrived as the new medical director and the Sandy and Bob Heimann Chair in Research and Education of Alzheimer’s Disease at the UC Memory Disorders Center. She brings no ordinary toolbox, and she will not be undertaking any ordinary construction project. Working from the ground up, she hopes to build a new approach to brain health for cognitive specialists, primary care providers and residents of Greater Cincinnati and Northern Kentucky.
A new approach is needed, Shatz says, because cognitive decline is a complex, lifelong process. It is not hereditary in most people, and three or more decades may pass before a single symptom emerges. And while no single pill will address all types of dementia, individually tailored strategies may help vast numbers of people delay or avoid dementias, including Alzheimer’s disease.
"We need to build a different infrastructure and model of how we approach brain health,” Shatz says. "We need to approach it in an entirely new way.”
Shatz (rhymes with hats) comes to Cincinnati having built a comprehensive memory disorders center at Detroit’s Henry Ford Hospital, where she served as director of behavioral neurology and the Clayton Alandt Chair. She was among the first in the nation to pilot the National Institutes of Health Toolbox, and she is implementing that protocol in one of her first initiatives at the UC Memory Disorders Center, a center of excellence at the University of Cincinnati Neuroscience Institute.
"The Toolbox is a cognitive test meant to elevate the way doctors evaluate cognition,” Shatz explains. "We want to pick up the very earliest changes, and the Toolbox is refined for very, very, early, non-memory-related changes—the things that happen before function is affected.”
Cognition, like cancer, involves multiple pathologies. Although family history is important, it is not destiny. Cognition is also impacted by medical disorders such as high blood pressure, obesity and lack of exercise, as well as by psychological issues such as anxiety and depression. The most accurate way to evaluate whether a person’s cognition has changed, Shatz asserts, is to compare individuals to themselves from year to year.
"If we can follow you and determine that a change occurred between Point A and Point C, we can take a look at what that change is,” she says. "Because a change doesn’t mean inevitable decline. It means something happened. So let’s find out what it is. Let’s intervene.”
During the next year Shatz will establish her clinic with the new model, establishing baseline cognitive profiles of her patients. She will begin to acquire information about how the model impacts families; she will work with the Greater Cincinnati Chapter of the Alzheimer’s Association to determine which interventions are working and which are not; and she will work to determine the Toolbox’s effectiveness in differentiating among the various types of dementias.
Differentiation is vital in the emerging era of "precision medicine,” as doctors move away from one-size-fits-all treatments, which may help some patients but not all, and embrace therapies targeted to disease sub-types and specific genetic mutations. "There are many more pathologies in cognitive decline than we once realized,” Shatz explains. "Each pathology seems to add a little color to the profile, which makes a big difference. For example, if a pathology called TDP-43 is the cause of your memory loss, you are not going to be helped by any anti-amyloid medication.”
Diagnosing the pathologies has proved problematic, Shatz says, in that what looks like Alzheimer’s isn’t always Alzheimer’s. "This may be why clinical trials have failed: because we include people who didn’t even have the disease.”
Imaging research also will play a role in helping to determine which interventions work and which do not. For while games like Lumosity and Sudoku are challenging, fun and much publicized, Shatz says they have "not been proven” to prevent or delay dementia. Whether interventions involving music and drama can make a difference, Shatz hopes to find out through collaborations with UC’s College-Conservatory of Music, Neurosensory Disorders Center specialists and community outreach programs that others have already created.
Shatz’s short-term focus will be on the education of primary care providers and prevention. "We want to incorporate brain health as an annual focus of primary care from the get-go, not after you’re having symptoms,” she says.
She is implementing that mind-set today in clinics at the Memory Disorders Center and has assembled a team of health care providers eager to spread the word.
With support from primary care physicians, the new infrastructure will help set the stage for clinical trials involving interventions aimed at preventing dementia, slowing progression and, in cases where dementia has taken hold, maximizing quality of life.
Shatz expects to reach out to the Cincinnati community for ideas and support. "Many people need to be part of this, and they’re not all medical,” she says. "We tell people to exercise and everybody groans, but there are so many ways we could do this. We need help from our sociology colleagues, our marketing colleagues, about how to frame these messages in a way that is motivating.”
Access is another hurdle. Studies have shown that the incidence of dementia has peaked and is falling among affluent, educated populations globally. But not everyone has received the message. "There are people who are clued in and have access,” Shatz says. "And there is a group of people who are very high risk and don’t have access.”
Spreading the word through primary care physicians, health clinics and public symposia will be among Shatz’s most important first steps in building a robust Memory Disorders Center for the Greater Cincinnnati-Northern Kentucky community.