#399 ‒ The evolution of Alzheimer's disease and dementia care: how early detection, personalized treatment, new therapies, and a multimodal approach are changing the landscape | Gayatri Devi, M.D.

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Gayatri Devi is a nationally recognized neurologist specializing in memory disorders, including Alzheimer's disease and related dementias. In this episode, Gayatri explains how to think about dementia as a spectrum—including Alzheimer's disease, vascular dementia, Lewy body dementia, and mixed presentations—while exploring the evolving biology of amyloid, tau, and neuroinflammation and why brain pathology does not always correlate with symptoms. She discusses her approach to detecting subtle cognitive decline in high-functioning individuals, the role of biomarkers and APOE4 testing in asymptomatic patients, the benefits and risks of anti-amyloid therapies such as lecanemab and donanemab, and strategies for minimizing treatment-related complications. Gayatri also examines why some patients may stabilize or even improve with individualized care, the overlap among different dementia syndromes, and the relationship between menopause, estrogen, and cognition—including her concept of menopause-related cognitive impairment. Finally, she discusses how advances in early detection, AI-assisted monitoring, targeted therapies, and precision medicine are reshaping the future of dementia care.

We discuss:

• Gayatri's training and clinical focus, why dementia is a spectrum disease, and how personalized treatment is changing Alzheimer's care [3:45];
• How Alzheimer's disease fits within the broader spectrum of dementia: diagnosis, biomarkers, and early pathophysiology [7:15];
• The emerging role of neuroinflammation and viral infections in Alzheimer's disease [13:30];
• Gayatri's comprehensive approach to evaluating cognitive decline in high-functioning patients [17:45];
• Why forgetting names is usually normal and when word-finding problems become concerning [29:00];
• Why women are at higher risk for Alzheimer's disease and how menopause influences cognition [33:45];
• The promise and limitations of blood-based biomarkers for diagnosing Alzheimer's disease [40:15];
• When preclinical Alzheimer's screening is appropriate and how to interpret positive biomarker results [45:00];
• Case study: early Alzheimer's prevention in a highly-functional woman in her 50s with two copies of APOE4 [47:15];
• Anti-amyloid therapies: balancing clinical benefit with ARIA risk using slow titration [51:45];
• The aducanumab controversy, why it was discontinued, and why Gayatri would still choose it [1:00:00];
• How anti-amyloid therapies cause ARIA, strategies for detecting and managing these complications, and how future therapies may improve safety and accessibility [1:03:30];
• Two patient examples of exceptional responses to anti-amyloid therapy [1:12:30];
• A multimodal approach to Alzheimer's treatment: combination therapy, MRI-guided TMS, GLP-1 receptor agonists, and more [1:15:00];
• Vascular dementia, Lewy body dementia, and the overlap with Alzheimer's disease [1:21:00];
• Lewy body dementia and Parkinson's disease: distinguishing two alpha-synuclein disorders [1:26:45];
• Risk factors for Lewy body dementia and what remains unknown [1:36:15];
• Treating menopause-related cognitive impairment: hormone therapy, brain rehabilitation, and balancing breast cancer risk [1:38:45];
• How biomarkers changed Gayatri's perspective on the potential for Alzheimer's patients to improve [1:47:15];
• The future of Alzheimer's care: AI, precision medicine, and personalized treatment [1:49:30]; and
• More.

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