For those of you who may have just arrived, my name is Ron Aaron. I work with Carol Zerniel and Dan Calderon and Debbie Billa and Eva Trevino and the gang at WellMed Medical Management and WellMed Charitable Foundation and have the privilege and it is a privilege of co-hosting a radio show that we hope a lot of you listen to and if not you will after today called Caregiver SOS On Air. Carol Zerniel is our expert and you're going to meet and hear from Carol in just a moment. Most of you I'm sure know her already. The show airs on KLUP Radio 930 AM on your dial at 6 PM Sundays and we encourage you to listen. Podcasts are available as well at caregiversos.org and more about that a little bit later. I want to welcome you and thank you for participating in the 2014 Caregiver Summit here at the Whitley Theological Center, Oblate School of Theology. What a nice space. Have any of you been in this space before? In this pretty cool? This is neat and we're delighted to have a chance to be here and to introduce you to the space. I want to give a special thank you to Terry Vasquez whose book My Beloved Mother has Alzheimer's. Terry, stand up, take a bow. She's donated a number of copies for door prizes. She is a native San Antonio and currently lives in Old Town, Alexandria, Virginia about a block from where George Washington worshipped and lived. Although she swears to me she did not go to church with George. And you don't look that old anyhow. I was going to say you're pretty well preserved if that were true. Also a thank you to the UT Health Science Center Geriatric Education Center. They donated, big D, donated the CEUs for this program. Normally you pay 25, 30 bucks, right? So how many of you are here to get CEU or so today? Raise your hands. Well, let's say thank you to the UT Health Science Center Geriatric Education Center. That was cool. We'd also like to thank the group down the hall whose name I have no idea for the free food. Many of you I know have enjoyed that. Our food and beverages are courtesy of Well-Mid Medical Management and we thank you for the refreshments and the lunch as well. And we did not invite the people down the hall to join us. So if they're not part of this group they shouldn't be there. This is a program and a tight schedule. Carol Zerniel keeps looking at her watch. So let me press on. Carol as you know is Executive Director of Well-Mid's Charitable Foundation and she holds a master's degree in social gerontology, has been involved in the field of aging for more than 20 years. She is chair of the board of directors new position for her for the National Council on Aging. Her background includes work at the 1995 White House Conference on Aging. She must have been a student intern there. The American Association of Homes and Services, chair of the National Institute of Community Based Long Term Care and a board member of the National Association of Area Agencies on Agencies known affectionately as AAAs. She currently serves as the Vice President of Community Relations for Well-Mid Medical Management and she earned and received the 2008 Outstanding Professional and Aging Award in Texas for contributions to the field of aging. And I tell her every week when we do our one hour radio show that she has forgotten more about this field than I will ever know. And I know many of you who know Carol are aware of her incredible depth of knowledge and experience with aging. So please welcome Carol Zerniel. I wasn't planning on being red, white and blue when I got up here. Thank you for that gushing introduction, Ron. It is my pleasure on behalf of George Rapier who is the chairman of the Board of the Well-Mid Charitable Foundation to welcome you to our 2014 Caregiver Summit and this is a community service for everyone. We wanted everything at no cost. We wanted everyone to come and we're so pleased that you did that the big smile on my face is because you did come, the rain stopped long enough for you to drive through the streets. I didn't think I'd say that, you know, that I was thankful that it wasn't raining but it wasn't and we're pleased to have a wonderful day here. And I want to also recognize Nowcast SA who is live streaming these presentations this morning and they'll also be loaded on our website. So Nowcast SA helps connect the community to important events. I'm waving at the camera and waving at you back there, Nowcast. So thank you for joining us. So be sure and, you know, look good the whole time you're here. You never know where the camera is. Actually I think the camera is pointed this way and you're safe. But we're very pleased to be streaming and we send greetings besides the professionals and the family caregivers we have in the audience. We send our greetings to everybody that is looking at this on Nowcast and on the website. So good morning and good afternoon and good evening whenever you're watching it. What I would really like to do today is tell you a little bit about the WellMed Charitable Foundation and a little more about our work in caregiver services because I don't think everybody does know exactly the services that we do provide in the community. Our foundation was started in 2006 by Dr. George Rapier who's the CEO of WellMed Medical Management who founded WellMed and he wanted to give back to the community and he's a very wise man and a very generous man and he recognized that the family caregiver is an integral part of the care team. The family caregivers need to be involved in the conversations. They need support and it's impossible for the clinics to give them the additional support that they need so that they can provide the best care and also care for themselves. So we got into the caregiver business through his vision. The WellMed Charitable Foundation gives away about a half a million dollars a year to the communities where WellMed provides services. So we're the philanthropic partner. We're an independent 501c3 but where do we get our money? Well it's kind of cool because all of the WellMed doctors and nurses and staff donate money ten, twenty dollars out of their paycheck every week so that we can provide caregiver services in the community which is very, very cool. And we raise several hundred thousand dollars just from our employees donating to our program and I want to thank the WellMed employees who are here for those checks. We'll take those. We're very proud to operate senior centers across Texas. We operate two of the largest senior centers in San Antonio. The Elvira Cisneros Center on the southwest side of town is exclusively run by WellMed and then we partner with the city of San Antonio for the Elisa Trevino Lopez Center and that's off Calabra. We're going to be opening a new senior center in District 7. It'll open in December and grand opening in January by Ingram Park Mall also in partnership with the city of San Antonio. I see Victor Ayala in the eyes. Victor Victor is going to be working at the new District 7 senior center with us. We're pleased to have that partnership. Our senior centers, we also have senior centers in the lower Rio Grande Valley and in Austin. We serve about 17,000 seniors through our senior centers, which is a lot of fun. We love the senior centers and but the other core service that we do is caregiver services and you see caregiver SOS all over the tables. Hopefully you've seen our staff in the back and the yellow bags around the tables have information about the programs that I'm going to talk about. We actually run five caregiver resource centers in Texas, two in San Antonio, one in Corpus Christi and two in the lower Rio Grande Valley. And I would like my two caregiver program managers for San Antonio to stand up because I saw Gloria just sink and she disappeared from view. So Gloria Miranda and Joy McQueen are the folks here in San Antonio that you want to get to know. Joy is at Northern Hills starting in January and Gloria is at the Cisnero Center on the south side of town. Also she's already there, we're moving some people around. And then is Debbie Billis, Debbie's in the room too. Debbie Billis runs our caregiver programs. Thank you Debbie for putting all this together today. And the two programs besides the caregiver resource center. So our resource centers are walk-in centers or call-up centers where caregivers can get wellness, information, support, and education. So we try to know about the resources. We provide support groups. We provide access to exercise and information and all those things that make caregivers journeys a little bit easier. But for those that can't come to our centers, we operate the caregiver teleconnection. And I hope at least, how many in the room have used the caregiver teleconnection? If you, good, I'm glad to see that. It's a telephone-based program because what could be easier than the telephone? You know, you're completely anonymous. You can have your hair sticking up, wearing an old bathrobe and chewing on something. And no one knows that. They don't know who you are. And you get to talk to professionals, lawyers, doctors, social workers, people that are experts and have information valuable to caregivers. And then the caregivers also get to talk to other caregivers on the phone. So we have some socialization. There's a calendar in your bag. We have a new series every month that we offer different sessions. And it's available throughout the state of Texas. And actually, we have people calling from all over the country for our caregiver teleconnection. We have a, you can also get the schedule in our e-newsletter. I want to mention Sue Ellen Lewis. She's not here today, but she does our e-blast and provides lots of information about the teleconnection, the SOS centers. If you'd like to be on that e-blast, please sign up at the registration desk. I want to ask Minerva to stand up. She coordinates the caregiver teleconnection. Minerva's the friendly voice on the phone. Thank you, Minerva. And the other program I want to mention, I know we've got partners in the room, is our stress-busting program for family caregivers of persons with Alzheimer's and related dementias. So this is an evidence-based program. It means it's grounded in science. It was developed right here by Dr. Sharon Lewis at the UT Health Science Center. And it has proven to reduce stress, reduce anxiety, reduce anger, and improve quality of life. And I don't know any of us that wouldn't like all of those things to happen. But it's especially important if you're caring for someone that has Alzheimer's. So if you're a professional in the room and you're interested in delivering a program that can help manage stress, our caregivers actually learn techniques to reduce their stress. They learn to practice them and pick which ones work for them. Or if you're a caregiver and you haven't gone through the stress-busting program and you're caring for someone with Alzheimer's, please call Minerva, the friendly voice on the phone, and she can tell you when our classes are. All of our information, as Ron mentioned, is on the web at www.caregiversos.org. And so that's kind of the nuts and bolts of our caregiver services. You know, we want you to call, we want you to take advantage of them, and we want you to partner with us. But that brings me to today in our caregiver summit. I think you heard Ron mention that we do caregiver SOSR on air, our radio show. And we met our keynote speaker just on the radio show this past year. And Dr. Sitto Bryant, you know, we've been doing this for three years, and some of the topics we deal with are tough. And the diseases we talk about and the conditions of the caregivers. And, you know, I've been in the field for 20 years, and sometimes Ron and I will walk away from the studio, and our faces are long and our hearts are heavy for what everyone has to go through. But Dr. Sitto Bryant is the first person that made me smile talking about Alzheimer's disease. He's the first person that actually gave me hope about the future, and where research is going in Alzheimer's disease.  You know, he just has a whole different way of thinking about it. And we're so excited that he agreed to come down here today. He's flying down this morning, so you'll meet him in a little while. But very excited for him to share the information. And I hope that you're going to walk away with a smile on your face as well. We're fortunate to have Dr. Oakes, our own Dr. Oakes from WellMed, who's with Palliative Care. You know, and Palliative Care is something I hear about it all the time. I never heard about it. I hear about it all the time. It's a growing field. It's an important field. It's not hospice, but it's where medicine is going. And Dr. Oakes is one of the best, so we're thrilled to have her. And Dr. Aravello Fletches, I don't know. I haven't had the privilege of talking with her before, but she must know everybody in this room, or at least half the people, because wherever I mention her name, they talk about her expertise. They talk about how wonderful she is, so we're thrilled to have her as well. But the most important thing that I want to say today is that we've come together, you know, as a family of caregivers and professional caregivers, and it's important for us to come together and to learn new things. But it's even more important to step away every once in a while from the every day that we do, on and on and on, and sit shoulder to shoulder with each other, and for other people to see us, and we're doing something for ourselves.  You know, all of us do the best that we can every day, and it's important for us to be recognized and for people to see us and to allow us to have this day for ourselves. This day is for you. Thank you for coming, and welcome to the Caregiver Summit. Thank you, Carol, and for the few of us in the room who may be over 70, like me. We're hoping that Dr. O'Brien brings the cure today. Wouldn't that be cool? Just line up, get a shot, and Alzheimer's be gone, so let's wait for that. In the meantime, Carol mentioned that Dr. Liliana Oaks is our geriatrics and palliative care specialist for WellMed Medical Group. It's in the Specialist for Health Multispecialty Practice, and she is a provider at WellMed's Bridges to Complex Care program and palliative care as well. She provides at-home interprofessional healthcare services to homebound seniors with chronic diseases. Let me put that into English. WellMed makes house calls. Oh, yeah, she'll tell you about that as well. So if you have a caregiver, if they're a WellMed patient, or about to become a WellMed patient, and it really is threatening to them and very difficult for them to go to the clinic, we come to you, which is what doctors used to do. I grew up in Cleveland, my uncle, Sal, long deceased in the 1950s. I made house calls with him, driving around his old beat-up Chrysler, and it was amazing to see how much he could do with just a touch and a look. So we're going to hear from Dr. Oaks. She participates in the largest outpatient palliative care clinic in San Antonio, helps patients who are facing threatening illnesses, helps manage their symptoms, and she can give you everything you need to know about palliative care and a whole lot more. So please welcome Dr. Liliana Oaks. I think we need a mic to take it. Ladies and gentlemen, please welcome Pete. Dr. Hevers, patients, and colleagues from the Health Science Center, the VA, I have been around a little while, and it warms my heart when I'm here seeing the passion and the interest to really work for the next step in the care of our seniors in United States.  Unfortunately, we don't cure many diseases. We cannot do it. It's part of this broken world, it's part of the disease process that we do, but we can care, and that's the reason you are here.  In a world where, unfortunately, the revolving door is about procedures and hospitalization and pain and suffering and fragmented care, and trying to change a little bit that outlook and starting to look into the whole picture. So I suppose to have here, let me just get prepared here. So we're going to review a little bit what is palliative care. We're going to talk about why we need to do palliative care, the difference between hospice and palliative care. I'm going to talk a little bit about the model that we have developed in San Antonio because this is a well-made summit. We wanted to tell you what well-made is doing, that the city, unfortunately, is not providing as fast as it should. Who will be a good candidate to receive these services? And then we can share stories and I will be glad to hear your questions and I will be glad to address any concerns that you have or questions. So let me introduce you a case. We're going to work this story and we're going to analyze it and come together into understanding by making it real. So this is one of my patients that I have seen in the past year. She's 72-year-old, she's Hispanic. She has been diagnosed since the last October, last year, from ovarian cancer. That's a very aggressive tumor. So that's a cancer that we can do things but we cannot cure usually because it's very aggressive. They did surgery, they couldn't remove completely the tumor from her belly. And when they did all of those tests that we doctors like to do to see if the cancer has traveled, they found that she got already small lesions in other parts of her belly. She got some other lesions in the bone and in the lung. She's very active. She's a precious lady with a tremendous faith. She got a community of believers that she chaired Bible study. She got a beautiful family and grandkids. But she likes to be independent. She lives in her home and she wants to keep that as long as she can. She doesn't want it to be cared by anyone and that was very clear when we met her. And then she came because when you have been diagnosed with a frightening illness, a very threatening illness, these patients are very appropriate for palliative care. Because as we will learn today, we can walk that journey with the patient and the caregiver and then decide what are the trade-offs and what things can we do based on their preferences. So if you were visiting with her today and I wanted that you discuss in your tables for two minutes, what would you like to know about her in regard to her disease, her future, and what do you think is important to her? So this course does for two minutes in your tables and this will be a great opportunity to know your neighbor. So two minutes to discuss those questions, please. Okay, let's see what our collective work can bring. So can you share from your table something that one of the points you discussed? Let us pay attention here so we can move on. What did you guys want to share? There is two things. The gentleman brought up about making sure that you had a, I would say a chart, where the numbers are big enough and visible for them to see. And another thing is trust. And the numbers in relationship to what medications or medications, doctors, anything, I believe. So they're mentioning that one of the important things that when you're visiting with her is what other things can we offer to her and be mindful that she can read it. What about many of our seniors, one out of ten in Texas, don't have formal education if you're Hispanic and you don't read or write and then we feel so proud when we give them this stack of materials that they're going to put in their shelf as a beautiful collection of magazines. So again, very important. I love that. So how are you addressing the cultural needs of this patient and see that she reads, who reads English, what are, then I will entrust and that's a huge topic for another hour, but let's see what other tables can enlighten by wonderful. Thank you. Somebody wants to share here. First thing, the first question, what would you like to know? First thing I would say, after I tell you what my problem is, I don't want to know what can you do for me. Exactly. You wanted to address how much the patient knows about the disease and what are the options. And not about using really big medical terminology that patients cannot understand. We want simple language. We want to speak and are we aware that they can hear us? I have a beautiful lady yesterday that came with the mention, Sid will talk to you and probably share stories and my nurse came really frustrated. All the patient is really demented and she started laughing inappropriately when I talk. So when I see with her, you know, she speaks Spanish and I noticed that she had a profound hearing impairment. So I put my hearing amplifiers and a new person came in the visit. She couldn't hear what the nurse was saying and she looked really demented. I mean she's demented. Don't take me wrong. But it was a very different relationship when she understood what I was saying and the daughter is like, she never let me touch her. I could do a complete exam because I was able to tell her in Spanish everything that I was going to do and she allowed me to do the care. So very important, you know, exploring how the patient understanding is, what are their options. Very good. Thank you. Here. Anything different? Yes, actually this lady right next to me put it best is to find out what brings this lady joy, what makes her heart smile because we want her to continue to have the best quality of life and the most meaningful part of her life with what her hobbies may be or, you know, special family and friends to keep around to share this journey with her to the end. Isn't it that what makes medicine so beautiful? It's not the disease.  It's what they love and enjoy. It's not because they want the cancer gone. It's because they want it to be able to enjoy what they are doing and don't be dependent to others. But in a very sick medical system, we focus on the disease. So one of the things that we're trying to do with palliative care is what you have here. What is your story? What do you do for living? What do you enjoy doing now? What do you think will happen in the future and are you willing to trade off all of those things that you love because of the treatment? And sometimes the answer is yes, I take the chances. Sometimes the treatment is really bad. The patient says I'm not willing to do the trade off because the treatment could be worse. But how do we know about the treatment and we don't hear the story? And by hearing the story we're discovering and see probably mentioned that later, we can understand how to treat the patient, enjoy and make it a dignity process. And music has played a role in how we use even music as a therapy for pain management as we do in palliative care. But we need to hear the story and what is important to the children, maybe the values and the quality of life and their goals are going to be different, but it's about hearing everyone. So that's very critical. Okay, what about this table? You love to talk. Oh, I'm a talker.  I think we were, well, it's three social workers and we're thinking more of the future of, okay, so does she have a long-term care insurance that she's going to need, you know, care later on and she prepared for that. She have rural, you know, plans, does she have a POA, you know, all of these things who are wanting to know. Well, what an amazing issue is when I encounter patients and families that haven't had the opportunity to talk about that. They don't even know it. If you have data and research in Hispanics and what in a very heavy Hispanic state, many of our Hispanics do not know what advanced care planning is. They haven't heard it. They haven't even thought about funeral plans. I mean, we live day by day. It's a culture where we like the present, you know, we eat what we need to eat today. And this is a huge issue in palliative care. How we help not only this family to listen about their preferences, their hopes, their trust, their interest and what is in the future, but are we ready to face challenges when Plan A of being independent fails? So we work in palliative care with, I say it, Plan A, Plan B, Plan C, Plan D. We hope for Plan A and we work for Plan A, but let us have Plan B and C in case it comes. And that's what this table is saying. There are a lot of issues that families get overwhelmed with, especially if you have a low income, if you are struggling to pay for medications, if you don't have enough food, we have had a lot of patients with well-med with very limited income and there is not even food in the house. And so how you mobilize all of that. So I'm going to keep moving. Otherwise, we can be here for three hours and we can know. But thank you for the sharing and I bet there are more. So we're going to review that. So you are correct. Palliative care is a visit about that. It's about all the things that you mentioned in the ones that I couldn't even ask in your tables. We wanted to hear the whole story. We want everybody involved in the journey. We wanted to hear their voices and we wanted to facilitate negotiations based on those values that the patient and the family has. So the interesting part of how we are in United States is we have a huge number of Medicare recipients. The baby boomers have arrived and will keep growing and we will have more workers than strollers. Japan just sold for the first time in history more adult diapers than children diapers. So we have an aging population that's no news to you. Sixty seven percent of people want a natural day process. So how natural did happen? Well, dead is part of the process of life. And it's one of the most difficult. I'm Colombian by the way if you haven't noticed my accent. And we see dead and dying very differently. We actually accepted much more in our culture than in United States. Why? Well, we have a lot of things to offer in technology in this country. So the news are filled with the miracle story. The transplant first time in history. Little person received first small gut transplantation living 14 years. Person having the third time a cardiovascular craft process in the heart. And you see all of these miracles that is part of the culture. The expectation that can we live forever. And somehow life brings dead in some point. So what we're trying to do in palliative care is hearing that story from the patient. Have you ever thought about dying? Yes, no. And I hear a lot of oh yes. I have some that says oh yes but I don't like to talk about it. I hear some that says no. And depending on the answer we ask more questions. Can you share with me? Are you afraid? What are your thoughts about that?  Are you afraid? Yes. No. Why? The why is very important because the why brings something in palliative care and geriatrics that is valuable to all of us. It brings the other dimensions of the person. Not the physical pain but we're bringing the spiritual pain. The social pain. Well I was a bad person. I don't think God will forgive me. So then you hear the story of a spiritual pain and we can bring other professions and other disciplines to address the spiritual pain. Well I cannot die. My family lives in my social security check.  That is social pain. So pain is not only what we have here. I have a boo-boo and it hurts.  And those are equally valuable or sometimes even more complex and difficult to treat that the boo-boo that you have in your body. So it's very important that we talk about this story of dying and demitify that and make it part of a natural process and prepare this family and this patient in that journey to transition based on their values in the most gentle way. Do I have patients that do not want gentle dead? Absolutely. And they are very minimal but there are people that have profound pains or fears and will choose very aggressive dead processes like a resuscitation in your chest or putting chocks in your chest or putting a ventilator or a machine. And those are okay if you have a very good communication with the patient and you have a spoken about options. The problem sometimes is we don't hear a lot of options and patients do not understand all of these processes. So palliative care helps to bridge those conversations with the specialty doctors and their primary care to help to have an understanding and have a fair kind of dialogue and what are those choices are. 66% said it was extremely important to them to avoid pain. Raise your hand if you like pain. Oh, she was raising her hand. Just kidding. Nobody likes pain as far as I know. Now if some of you like pain and you can talk to me afterwards, you know. But the majority of people don't like suffering. And I'm talking about here no pain only physically but any kind of pain. And that's one of the most neglected symptoms when people are facing end of life issues. Horrible. So we do a great job with machismo ventilators, pressers to keep that heart pumping, the kidney. And then you read the records. I helped the state hospital to do their reviews. There is nothing mentioned about pain. And it's one of the, again, more people are saying, please don't let me have pain when I die. 70% prefer to die at home rather than the hospital. People like to be with their own pillow and their own bed and their house where they have been there for 30, 50, 70 years where they know, especially if you have cognitive impairments, which is so prevalent in our communities due to the diseases and Hispanics mainly and metabolic things, they do very poorly with new environments. So people say, my mom does well in her home. She's not agitated. We can handle her. She goes and toilet well. When we take her to the house of my brother, she will toilet in the plantita or in the corner because she doesn't have queues in the environment, right? So when you are dying also, you want it to be in your more kind of pleasant environment in that home. So these numbers are telling us that we have a voice and we need to do something to meet those goals of care. And palliative care helps with that. So palliative care, it has been growing over the past 15, 10, 15 years as an specialized medical social care for people with serial illness. So if you have a serial illness or you have a low one that you care for with a serial illness, you could qualify to get palliative care services. It doesn't mean you are dying, but it means that that disease is going to impact your life profoundly. And it focused a lot of things into the things that are really important for the patient, not only to get the treatment, which is vital if it's available, and get the doctors, the specialty care, but to focus on the other questions that our medical system doesn't ask very often, like, tell me about your pain. Tell me about nausea. Do you have fatigue? Do you feel drowsy? Are you depressed? Is there anything that bothers you that cannot allow you to be independent in the things that you enjoy? And I love when I introduce myself to patients because I don't say to them, hey, I'm your non-doctor, major nutrition, palliative care, but I am the doctor that will let you eat whatever you want. And that gets me in. Wow, finally a doctor that doesn't tell me, you need to no more sugars, cut the cakes, no more tortillas, exercise, 30 minutes daily. So I'm the doctor that I work with you to make you happy. You don't want it to bathe every day. Don't bathe every day. Bathe twice a week. We get you good stuff. There are so many products these days in the market that you can apply dry so the elders can be clean that you don't need to put them in the shower. Oh, the caregivers love that a lot. Really? I thought they needed to do everything.  And so palliative care is that specialty that works with families about what is important to them. And sometimes the important to them means we need to stop pills. Oh, they love that too. I don't need to take that. Not anymore. You're 95. The statin, the cholesterol pill already did what you needed to do. Do you really want it? No. Okay, take it out. That is what we focus. What are the trade-offs? Where we are in the journey? We're not moving anymore into prevention of all of... We're moving into, well, if you don't take the medication now you can eat that pie or you wanted to eat that ice cream or whatever you have been removed from that you mean so much. Don't take me wrong. I love the three dove. It is. And I like those hemoglobinates. One sees to work accordingly to the frailty of the patient. Don't think that, you know, what a doctor is that? What I'm saying is I will... Palliative care help the physicians to say, oh, the goal of care is different. Can we liberalize the diet? Can we stop some meds? Can we allow the patient to do things because they're going to be dead in two years? So how much it matters to take in all of those guidelines of medication? So the trade-offs are completely different. And I love that we don't work by ourselves. So geriatricians and palliative care doctors work with other disciplines. So we're very heavy into our social workers. We're very heavy into our nursing staff. We're really heavy supporting a spiritual support through chaplaincy or connecting families through their churches or pastoral care if appropriate. And we meet together every week and we talk about, you know, what are the things that we found? What are the roadblocks who will need more services? Who is ready or fighting a natural the process because there is a spiritual pain. So again, we work as a team and each individual in his discipline has a tremendous power and a voice so we can honor the patient's wishes. The World Health Organization has tons of other things in the definition of palliative care. The one that I wanted to mention is, again, affirms life in regards to dying as a normal process, enhanced quality of life. And this is the biggest one, let's see. The idea is that we're coming too late into the ball game. That's the sad part and we're trying to change that by doing cutting-edge processes like in Welmed where we are trying to educate our own community of primary care doctors and specialty clinics that is not when the patient is dying at the hospital, which is appropriate but it's too late. So I give you an example. If a patient has congestive heart failure, this is the second admission this year, we want that patient to be seen by us. Congestive heart failure is a disease that has ups and downs and every time that there is a down and the patient gets admitted, more functional decline comes and more difficulties are with that patient. So we don't want the patient, when he's already with 10 medications and ICU, to call palliative care, which we get called, the opt-in doctors and palliative care gets called. But we want that patient, when they are still strong, when we can talk about depression, when we can talk about nausea, when we can talk about drowsiness and we can hear from them who is going to speak and be the voice that we were talking about, the medical power of attorney, choosing somebody that knows them well, that can speak for them when they cannot speak and how they see and view that and dying and what they understand from the disease. Many of our patients do not understand congestive heart failure. They think that they get better or that they are not going to get worse. So we can help them to trace the roadmap and tell them what to expect in the future so we can have a plan. Again, plan A, stay home be independent, don't be, you know, care about it, but let us also plan B, plan C and plan D. If we never use those, we never use those, but if we need them, the families are no surprise. I encountered a lot of patients that after their loved ones died and nobody ever did this, the memories are horrible, meaning you, the caregivers, are going to be living with those decisions of your loved ones. And when you live with those decisions, sometimes the memories can be very hard if we in the healthcare system cannot help you or provide you with options. And I have your things like if the doctors would have been honest with me, I will never have taken that chemo. I didn't know that that treatment was going to destroy completely other organs and now the cancer is treated, but I don't have a quality of life because our family is saying, wow, we keep going and keep going. And instead of enjoying the things that were important to us and closing the memories and building the memories, our memories are at the hospital and pain, putting needles. Why? Because we are not doing what we need to do, which is help you to consider the options. So what is the difference between palliative care and hospice? Palliative care can be given with any aggressive treatment. So Ms. RR in our story developed a variant cancer. She met with her oncologist and said, I want the surgery. I wanted to get chemo. This cancer required four rounds of four potent medications. And she said, I understand she has cognition that allowed her to make those decisions. That's very important. We always hear the patient understand how sick they are because sometimes they don't and it's due to cognitive impairment or older issues. So in that case, again, the decisions are going to be more toward the person that will represent them. But in this case, she knew. She knew very well the name. She struggled with the name of the cancer because it's a really difficult cancer to pronounce, but she knew what she was facing. So she came early and our job wasn't to tell her to stop chemo. It was to hear her story. What you want and let us help you. Let us prepare for the chemo. These are going to be the symptoms. These are the medications that we will collaborate with the oncologist. And she came and she also talked to us about who she trusted that will be her voice. So we did the medical power of attorney who she knew and we met with that person. And do you know your mom?  This is a very important concept for all of you as caregivers. When we are giving that responsibility, it's not to choose what we want. It's to get to know or love one so well that when we need to bring that person into a crisis and that or love one cannot speak. And we call that in palliative care. We bring the person into their room. And the question is if your mom will be here today or your dad, like in this case RR or your dad, if your long one will be sitting with us today, will she want it to have A, B, C, or D, which she would like to be kept alive in the machine? Do you think that she will say today to do this procedure or not? So that's the reason being a caregiver and a medical power of attorney career is our responsibility, but the more than you can do your diligent job to understand and know your love one values, that decision makes easier. And it's much easier when we the healthcare providers facilitate the dialogue and it's written in documents and it's written in the record. So if by any confusion or emotion, you do not know what to do, we will guide you because we get to know your story too. So again, it's a very active collaborative process. We can focus, again, patients' goals. We do not require physicians' order or referrals. So families can request and well met, well, the primary care is referring that, but you can tell your primary care, I want my mom because this disease to get a palliative care evaluation. Hospice care is a benefit and a service paid by Medicare, okay? Because as a service and a benefit by Medicare is not a place. Even though we have inpatient units where the patient could be admitted, if the symptoms are really severe, hospice is a service that can be delivered whatever the patient is. So that's a big difference.  That's wrong. Hospice is a service, it's a benefit. And because Medicare pays for the benefit that service, there is criteria. So when you are in hospice, the criteria is clear. One, you need to have a terminal illness.  Sometimes two diseases can be very close together.  You need to be believed that the physician that is making the referral or the thought process about that is thinking that the person is going to be dead in six months. So how do we know that? Because we think, I might be surprised if this patient will be dead in six months. If the answer is no, I won't be surprised. That's probably a good guideline that this person is facing a terminal illness. And that prompts us physicians to say the patient will benefit from that. There are a lot of diseases under Medicare from neurological diseases, cardiovascular diseases, and stage renal disease, cancers. All of those have specific criteria and usually show somebody that is really sick. They depend on all the care, the majority of the time. They are having multiple infections. They are showing other signs of complications. So again, each disease has criteria. And we need to refer. It's a physician referral. So for palliative care, you don't need the physician to refer and well-made you do because you are part of her system. But in general, you don't need a referral in palliative care. So I wanted to ask you, is that clear? Because that's what I see a lot of confusion. And I'm going to show you a graphic for the people that are visual that can help you to see. But any questions so far? Sure. Very good. So there are different models in how palliative care is being paid. And well-made because we, the government give us a lump sum for each one of the beneficiaries. We have opted to add it and get paid from the same pad. And the interesting thing from the business perspective in the country is that when you offer palliative care, we don't make money. We save money. So when we work with patients and family, we are helping them to avoid unnecessary imaging, unnecessary hospitalizations, unnecessary things that were not appropriate. And that's how palliative care gets sort of in the system reimbursed. It's mainly right now in the United States a hospital movement. So if you see palliative care, it's mainly at the hospitals. Baptist has the best palliative care in patient service in San Antonio. There are other places that announce that in the private sector, VA has had the longest palliative care in the city. They train the fellows that go to these hospitals, by the way. So VA takes all the credit because I used to run the geriatric program and Sandra Sanchez Riley run the palliative care program. So we used to produce the geriatricians in the palliative care in the city. So the VA is the academic model for palliative care. But in the community, Baptist has been filled by physicians that are trained on these. University Hospital has two faculty in palliative care. The other hospitals have a website and we have calling. You don't reach anyone. So again, if somebody's on Methodist, get busy and get your show together. But what I'm saying is all hospitals should have this program because why we need to choose certain, all the systems should have the best practices in the cities because all seniors should benefit from these or younger people.  Young people get very sick, too. Very appropriate for palliative care. So we see those in UHS, University Hospital. Somebody's here from UHS. Palliative care unfunded, younger people, very aggressive tumors. You bet they need to get palliative care. So the family, the children, the bereavement, it's a very intense process. So palliative care has helped tremendously in UHS. So the models get paid because hospitals said, oh, man, if I get this palliative care processes, patients are happier. We don't need to do all of these horrible things to them. So again, they commend that ICU admissions decrease. So there is a lot of data in how palliative care helps economically to sustain these programs. Okay, so this, okay, this is a very good phrase to remember. All hospitals care as palliative, but not all palliative care as hospice. Because again, when you imagine, this is the image I wanted to show you. The old model, we used to have live prolonging care, hospitalizations, tons of treatments, all of that is appropriate. If it's appropriate, and then the person is really going to die, we need to send them to hospice. They have a lot of symptoms that were not addressed. They were unhappy, depressed, nausea, vomiting. The model in the bottom is saying, you can have a life prolonging care with whatever your choices are for that care, curative treatments, if that's appropriate. But we will be shoulder to shoulder. In some point, we will do more care than attempted curative treatments, and then we will help that person to transition and said, we have done everything to try to ameliorate the disease. We're switching gears to provide much more care. Equally important like ICU is when we do palliative care. So it's when people said, oh, you are giving up on me opposite. I'm actually going to give you much more than an ICU will give you because we're going to talk to you about what is important to you and your family. So you see, so never make these, oh, you are giving up on me because we never give up on humans. We shouldn't. Nobody should die alone. And there are movements in the country and hospitals where you should die with somebody and not only unless you choose to die by yourself, which there are patients that the majority like to have somebody next to them. Very few will say they wanted to die lonely. So again, think about this early. This is what we're targeting and you and the caregiving movement can help us. We wanted to get these palliative care services early in conjunction with your specialty doctors in your primary care to improve your quality of life and symptoms. So how these work pretty much in well met because that's what I wanted that you understand. There are different models. Palliative care is starting to move in the outpatient clinics and the majority of the models are coming from managed care. Why? Because there is much more case management and case coordination and managed care. But there are some other models that with the accountable care organizations are trying to look at how not only you offer this in the hospital, but can we move this in the community so people don't need to necessarily be in the hospital to get a consultation. Approximately in the fall of 2013, Dr. Elizabeth Glaser, who is our medical director, initiated a pilot project opening a clinic and admitting patients that needed palliative care and a subset of them also were very frail and homebound. And you know, you have been there in the winter. They have dementia. I don't want it to go to the doctor. Why are you going to get me in the car? They're going to kill me there. I don't want it in the caregiver is trying to drag them out of their house and bathing. Forget about just put perfume because the bed is not going to work. So it gets really challenging, right? So by doing the household program, they can be with their hair like this and they can wear their pajamas and their slippers and we go and meet their needs at home with the nurses, the social work and we can do x-rays at home. We can do ibifluids at home. We can, did I say droplet? We do everything at home. We do wound care in the home.  We try to help them to reach spiritually. It's fading important to you. Some of them have been unfortunately neglected by their spiritual communities because churches didn't know they couldn't live anymore. That's very painful when you see isolation and I see Abba care here with Timothy Spickman that is trying to move and get to get all the churches to try to go to the houses of the seniors and do programs that can help them spiritually. Five minutes. He's a bad guy. Five minutes. Okay. So we did all of that with our art. We asked her about how she understands. When you ask a family and a patient, how much they know about their illness. What is important about her life and what is their definition of quality of life? Then you can talk about the trade-offs and that based on that we can make recommendations about code status and natural death because we understand the story. So in our case, she wanted to be independent, don't be a burden. She chooses her daughter and she says, I understand everything you are saying, Dr. Oaks, but I wanted to give it a try to the chemo. So she went through the chemo and all her bone marrow, her tuétanos like we say in Spanish, shut down. She required an imminent transfusion. She developed chest pain. She hated it. She went back home with a walker. She wasn't using a walker. So we meet again. Now at home. She used to come to my clinic and I said, I'm ready for your program. I don't want it to leave my home anymore. I'm very fatigued. So we continued the conversation and then she says, I don't want transfusions. I'm done with the chemo. Well, the kids came. How are you going to give up, man? You cannot do that. Let us bring the doctor. So we did a big family meeting and the children understood from the oncologist that she was going to be cured. They didn't understand that what he was offering was what we call palliative chemo. Shrinking the tumor, give her a few more months and now that the chemo failed, she can receive more chemo. So they're going to offer her radiation, which is a potent wave to all the intestine that would also damage the rest of the intestine and the bladder. Meaning she will peel the time. She will develop pain. She didn't have pain so far. So we have a meeting and we talk about the roadmap, the future. And they were surprised. They said, we understood a cure. That wasn't curative. So we are still working with her. And she said, I don't want any more transfusions, but I wanted to meet one more time a CT to see if the chemo did anything. We honored. Absolutely. Get the CT. And we will be meeting next week. So come next year and I give you a close in the case. So your doctors can refer to us. We have right now, well-made works with Optum. We have three MDs and one nurse practitioner. And we have all the areas in the city, palliative care clinics where your loved one can get a palliative care consultation.  We cannot go outside 1604. I drive between 60 to 100 miles a day. And the goal is each physician will carry 250 patients the sickest of the sickest. And I love it. I love all of you. I love complicated seniors. I love the cases where everybody says, well, I don't know what to do. I do. You let them eat ice cream and they love you. But you know, don't share the secret. So who should be referred? Anybody with a bowel illness, comorbidities, a patient that has multiple hospitalizations, ER visits, a lot of what we do in well-made and hospitalizations are related with patients that have no been diagnosed with dementia. And we keep giving them prescriptions and they will collect the bottles. They will collect the prescriptions. They won't follow the treatment. Not because they are poor compliance. They just cannot do it. So we have addressed the dementia issue in well-made and tried to work more with the primary caregiver. He is next to me. I know you are here. Okay. Just these are resources and the slides for you. You can click those links and get to know more about palliative care. And again, more resources. I already told you that. I wanted to close with a trivia. It's three minutes. I promise. No. Okay. I have two patients at home that I need to see. Okay. He will answer the questions for me. So well, if there is time at the end, he can show you the video. Okay. Thank you so much for having me. Thank you, Dr. Oaks. And fortunately, she's not my physician because when I saw her next, the needle would be this long. You did a fabulous job. Thank you. And I'm just sorry we ran flat out of time. Okay. We're going to take a short break, 15 minutes. Before you go out in the hall, we have yogurt right out here. Down the hall, the free food, they have bananas and apples. What can I tell you? It's right as you go to the restroom. And then we'll do door prizes when you get back. Thank you. Just I think many of you know has earned a reputation for cutting edge research on the factors influencing Latino, Hispanic caregivers' perceptions of the experience of caregiving for a relative with Alzheimer's disease. She's known nationally and internationally as well. Her nursing career spans more than 25 years, including working as an operating room nurse, teaching university students and becoming a researcher. Her passion for research is triggered when she was triggered when she started working with Hispanic, Latino caregivers and realized the gap in cultural and linguistic needs required to address this growing population. Born in Bogota, Colombia. Well, we have two folks from Colombia speaking today. That's fabulous. That's neat. And then her research interests include Latino, Hispanic caregiving, the concepts of caregiver satisfaction and duty fulfillment and formulation of culturally informed theory of caregiving. Dr. Fletchis is a bilingual and bicultural investigator with special interests in the cultural and linguistic competency of intervention programs for Latinos and Hispanics. Please welcome Dr. Revolo Fletchis. Thank you very much, Ron. Thank you. Well met for having me here. I'm very, very happy to see lots of familiar faces, caregivers, people who were part of my dissertation study many months ago, people that grew me up in the academic world. And again, well met. Jennifer, Debbie, thank you for the invitation. Why am I here today? Because I thought it was very funny that, well met, we'll put two Colombians with very heavy accents back to back and said, God, they're going to give it to San Antonio. What in the name of God are they thinking? But I said, okay, whatever. Fine. We'll be doing the warm up for our keynote speaker later. So ladies and gentlemen, I'm really sorry you blame well met on whoever organized, because those are some very heavy accents. But by now you may have known that we have something in common with Lily Oaks and it's a tremendous passion for what we do. I am in a very awkward position because Lily is a very passionate speaker as you could see.  So why is it that I'm interested in this caregiving thing? I came into the world of caregiving through the back door as a research assistant for Dr. Sharon Lewis, the person who is the mastermind and the developer of the stress busting program for family caregivers. She took me under her wing and allowed me to interview caregivers who happened to be bilingual at the end of the program. And I run into a very surprising situation and it's that these caregivers, every time they were bilingual, they would not answer my questions in English, but rather they would start code switching. Code switching is nothing else than going back and forth between two or more languages. And here in Texas, I don't know, I think Tex-Mex is considered a third language. So some of them will speak in English to me, then they will code switch to Spanish and then I enriched my vocabulary with those interviews because I had to learn a lot of Tex-Mex to be able to interpret. The more and more I got to know these caregivers and some of their journals and the notes and so many things that Dr. Lewis allowed me to have access to, the more I realized the tremendous gap in how people were experiencing and what we were trying to provide. So what you see here is nothing else. It's this part. The program was focused right here. What are the stressors that the caregivers are experiencing? What are some of the strains? What is the illness process? Here is where the program was intervening and I keep thinking something is seriously missing here. When we look at more formal theory of stress and coping and we have famous people like Lazarus and Fokman and they have said, okay, we have stressors. We have the way in which we embrace things and we're going to have some sort of reactions, but if you really look at the long-term effects, we have been very, very focused on the physiological and emotional response and all along there was a disconnect between classic models of stress and coping and what the caregivers were telling me in Spanish and how every time that I put them in a bad position asking about the word burden and how difficult the responsibilities were, they will code switch and they will detach themselves from speaking Spanish to me and start speaking English and in English they did use the word burden, but if I, by the grace of the Lord, introduce the word carga, oh boy. I had people in tears. I had people very upset. It's just all those concepts collided. There was definitely a disconnect. So the purpose of my presence here today is to introduce you with a different light of two different ways of looking at caregiver. Taking care of somebody is extremely difficult. It doesn't matter what language they speak, what cultural background they come from, if it is Alzheimer's, if it is Parkinson's, whatever it is. So the demands are the same. The disease process may be the same, but where we come from and the language that we speak as we are growing up, our emotional language plays a tremendous difference in how we approach the business of caregiving. I will not perhaps have the time to show you a nine-minute summary of experiences and some of my research with Alzheimer's caregivers, but the link is there. If you Google TEDx and Antonio Arevalo, Alzheimer's caregivers are not created equal, you can get to that nine-minute PowerPoint or TEDx presentation October of 2012 because otherwise the same thing that happened to Liliana is going to happen to me. We talk too much. See, Colombians are terrible. So I said, you know what? I'm going to skip the video and I'm just going to give you the link. So what you get today is the long version. All those things that I wanted to say that day on stage at Trinity University and people told me this is a TED event and TEDx and you have 10 minutes, so get going. So you get the long version today. Language is a tremendous issue because someone along the line decided to translate the word caregiver to Spanish. The Spanish language is incredibly rich. We do not have a word that translates literally, one word that translates the meaning of the word caregiver, and somebody in their infinite wisdom decided to translate it to cuidador. Well, cuidador is somebody who takes care of things. Cuidador is somebody that takes care of animals. Cuidador is somebody that maybe, your head's going, uh-huh. See, we connected already. So somebody's understanding what I'm saying. So why is it that we're calling people cuidadores in Spanish? I don't have this lightest idea. The fact is sometimes even in English, those of you in the audience know that many people do not see themselves as caregivers. Who are they? And you're going, yes, who are they? People like their moms and dads and brothers and sisters. Moms and dads and brothers and sisters. And when you ask people of Hispanic descent and Spanish speakers, they're going to say that with a lot of pride. Okay? Not just, yeah, people with a lot of pride. I am the husband, I am the son, I am the spot, whatever it is, but not cuidadores.  But if you guys watch the news, there were some people from the Royal Academy of the Spanish language who in October 14, went to the king and the queen in Spain and gave them the brand new version of the Spanish dictionary. And now the word cuidador has a little thing on the side that says used sometimes as a now. So my feeling is that we're going to end up introducing it. I hate it. I really hate the idea, but I think it's filtering. Just like the word stress became estrés. Stress became estrés. Okay? And now we have estrés en español. And I think it's taking something like 20, 25 years, you know? So maybe we're going to see Google in the Spanish dictionary too. And texting because I think we have chatting and canting flasks already, so maybe we'll see that. Okay? We're going to see it. I would like to bet some money. But the word cuidador was not my only problem. Worse than that was the translation that somebody did of burden to cargo. Because cargo is nothing else that's something very negative. Cargo is the equivalent of cargo, what you put in the back of a mule, what you throw in the back of the p-cap. So what is it that for the last 40 plus years in research when we've been asking about burden and cargo to people of Hispanic descent, have we been measuring? Because we have all these wonderful programs to support caregivers. We bring them in. We have all these psychoeducational interventions in the hopes that they will gain some coping mechanisms that they will learn to deal a lot better with the stress, but we measure burden at the beginning of the intervention and at the end of the program. So what is it that we have been measuring? I don't have the slightest idea because the concept does not exist in my language and it does not exist in my culture. So that's the disconnect that I've been trying to look at. My window into the world of caregiving came from watching and participating the vast majority of the part last distance in the care of my grandparents. No one told me that when I grew up or as an adult I had to take care of my parents or my older adults. It's something that gets role model. It's something that is lived on a daily basis. No one is going to teach you in the Hispanic culture that you will become a caregiver. What do we see when I meet somebody? How much do I know about that person? All I see are their behaviors, but each person is truly an iceberg. All we see is this very little thing. The part below the water, the level of the water, is just a compounding of who we are, our traditions, the language that we speak, the values, our religious beliefs, spirituality, and how we grew up and what are the things that have impacted who we have become. So who's my time keeper? I don't have a time keeper and you have a sign that you're going to show me or you're just going to stand here next and say, sure, next or what? Okay, so please give me five and then I start talking really, really fast. All right. I am preaching to the choir here, caregivers, our silent heroes, our hidden patients, and I really dislike all that terminology because they cannot be silent anymore and they cannot be hidden anymore. They need to come up front. But what is characteristic of them as they assume the role of caring for somebody else? They don't complain. They don't ask for help. It's one of the hardest things. They put the welfare of their loved one first at the expense of their psychological needs, at the expense of their financial and physical needs. It's a very high price that they pay. Let's talk a little bit about these Colombians and Peruvians and Mexicans and all these people that somehow have Hispanic descent and respond to that set of values. And I hope that no one feels offended in the audience today, so I'm going to say it now and then I'll clarify it later. I am not saying that one culture is better than the other. I'm not saying that one set of values is better than the other. My purpose here today is to raise awareness that we behave in different ways because our values are different. It's not that they may be different. They are different. So we cannot treat everybody the same because people are different. To begin with, I may be Latino and the way that I approach my non-Hispanic people or patients of European descent is different from the way that I treat them, greet them, anything like that. Thank you. I'll need that prompt. Okay. In Hispanics, why is it that it takes so long for Hispanics to be diagnosed with Alzheimer's or dementia or to do something about it? There is a cultural value called respect. We do not question early enough how come that our grandpa is confused. We're really quiet about it. We do not want to be disrespectful. Care in general, and it's very marked in Hispanic culture, is the role assumed by the females in general. I'm not saying that there are not wonderful males in the Hispanic culture who assume roles of caring for others, but the vast majority will be females. We are awful. We are absolutely awful and pitiful at asking for help. We do not like to hear that home health services are available. If somebody says that our respite services is like, what respite? It is my responsibility. It is my duty. I mean, I'll give you some of the expressions from some of my research, but it's just not. We have a very hard time accepting that it's time to ask for help. Liliana was talking about the nursing homes. It's almost an impossible conversation. It's just not part of the culture. Anybody here works in a nursing home? Yes? Just an approximate statistic. What is the percentage of Hispanics at your institution versus the percentage of residents that are white known Hispanic? Fifteen percent? That's how odd to you. Fifteen percent. Do you know what is the number of Latinos Hispanics in San Antonio? Are we 15 percent in this city, people? No. Unofficially, I think we are like 67 percent or 69 and official is like 67.3 or something like that. What are the numbers? 68, officially or unofficially? Officially 68 percent. So why is it, I mean, isn't it common sense that if we are 68 percent in this community, we should be 68 percent institutionalized, but it does not happen. It's only 15 percent. So that thing about institutions, we have a very hard time accepting that. Hispanics always look at a very personal relationship with their healthcare providers. They're not just the physician out there or the nurse or the social worker. And I'll give you a couple of examples. If I greet somebody here in the audience, the person will say, hi, how are you? And the other one says, fine, thank you, how are you? Have a great day. Have a great day. But if I approach this table over here and I find a Hispanic and say, Terry, how are you? What would you say, Terry? Terry? Hi, Terry. But I know we have a relationship from before, but most likely she's going to say something like, and how are your kids, Lita? It's very different that fine, thank you, how are you? Have a great day. And the same thing happens when we go and seek physicians. My parents adore Dr. Ian Thompson. Yes, he is one brilliant urologist and urologist oncology. But I don't think that's the reason or that because he speaks Spanish that my parents feel so safe. My parents don't speak English, but they feel very safe when they go on. They have an appointment. It's one of those appointments that I don't need to go as a translator or as a cultural broker or as a healthcare system broker. They tell me, we have an appointment with Dr. Thompson. Lita doesn't need to be there. My parents know the names of Ian Thompson's grandchildren. My mother takes little sacks of Colombian coffee to Dr. Thompson, and then she takes candy, and then Dr. Thompson tells her, don't bring me more candy because my wife is going to get mad. And then Dr. Thompson asks about the grandchildren on the other side. It's like they visit a friend. It's not just the doctor, okay? Other healthcare providers that don't get dead, Lita has to come from round rock and navigate the thing because they don't like it. Okay? So very personal relationships. So what we see, what I just mentioned to you is just the behaviors that we see, but they respond to an incredible accumulation here underneath. It's an accumulation over time. This is the part that we don't see, and I think I lost this here. All these parts is what we do not see. All we are able to say is those Hispanics don't like respite. Hispanics stay way too long to diagnose the people. They take forever. They don't show up on time. Anybody in the audience knows how to say tomorrow in Spanish? Are you Spanish speakers? Very few. But you know about mañana. See? Hispanics, but that's the part that we see, the only part that we see. So what are we? All this addition of values, customs of traditions and our language, all those things are really who we are. 90% of who we are, we don't show. We get to see only that 10%. That is the behaviors that we see. So let's look at some of the values of a different group of people, and again, and it's sitting up there on the slide, okay, just to make sure that people don't get me wrong here. They are not wrong, and they are not right. It's just like feelings. They are not wrong or right. They are just feelings. Well, same thing with values. That's what you hold dear to your heart. Individualism. Anybody identify with this? This is one of the reasons why this country is such a superpower. It's about me, about competing, about achievement, wonderful, wonderful qualities. Hard work, action, how much money, more money can I accumulate, and achieving, being very successful. Anything wrong with being successful? Hello? Okay, we're back. Okay, good. Until the body disappears again. Okay, so self-reliance and independence. Isn't this what in this country kids are taught? I mean, just the idea behind the kid trial with his or her own carry on. Okay? You need to learn very quickly to do things for yourself. You graduate from high school, and you are gone. You spread your wings, and you fly.  Am I exaggerating? Anything wrong with that? No, of course it's all good things, very good things. When I first came to this country and started, so may I have a battery please for this thing? I will go through the torture of speaking from here, only for a well man. I love well men. Did you tell? Okay. So as I'm attending nursing classes, and this concept is presented by the faculty about empty nest syndrome. And I said, and I tried to pay attention, it's like empty nest syndrome. Okay, so mentally, I had a tree, and I had a nest with no birds. Well, isn't that an empty nest? I had absolutely no culture or family background to understand what people were trying to convey in terms of developmental psychology at the time, because such thing had never been part of my culture. It has not been part of my culture, because Hispanics are responding in a very different way to family structure. Timeliness, we start on time, and we finish on time, and you don't want to finish on time? Check one, check. Here you are. Thank you. So that I can continue to do things on time, because God forbid we stop at some point in time to create and enjoy and cultivate personal relationships. Okay, personal relationships are very, very important in other cultures, and Hispanics are one of those people that could care less about in general. I have to start lecture on time. My students know that it's very normal for me to start lecture at 9.01, but we trade. I finish lecture at 12, and it's 1 p.m., and we're still chit chatting there, okay? But I know who they are. Okay, so we like to think that we value productivity, that we're able to compete in this society, and we like winning. How many world wars has the United States lost? Ah, we have. Well, that one was so short that you had to glue it for me. You couldn't just sit there. World, okay? But let me tell you something. How many countries come to compete in the United States for the World Cup series? I'm waiting. In the World Cup series? And the Baseball World Cup series? And the World Champions on this? And the World Champions of that? Oh, no, no. Soccer is a very different story, and you're talking to a Colombian here, okay? Did you see the performance of Colombia in the last one? Ah, don't go there. Don't go there. Personal space. I love this one. Because we define it in such a different way. I could stand right here, and I could get this close, and I'm talking, and I'm perfectly fine, and he's going like, what the heck is she doing to me? Okay? What is this? This country? For Hispanics? Nah. Right? Right? We're done. We're done. We connect like that. Personal space is crucial how we use that with our patients of Hispanic descent. Time for yourself. Because individualism is so valuable, then we teach. You need to take time for yourself, space for yourself, things about yourself, your success, your independence. This is not valued in other cultures. In fact, it's seen as a very negative and selfish thing. Okay? This is your self thing. Okay, so let's talk about Hispanics, so that you can start seeing the contrast. And again, of course I'm going to say that's a wrong set of values, like that's where I come from. But my hope is that I can help you navigate how other people actually see the world, especially as it's going to apply to caregiving. Familyism. We do not compete individually. In fact, competition is not very high up there on the list. Clash. What do you mean you don't like to be the first? Achieve, succeed, more money, be the first. Individual as a person. Self-reliant. As long as my family is fine, who cares? And you will find that in many, many families. Okay? Very important to preserve that structure and something that is agonizing for social workers, for healthcare professionals, the decision making. You hear Lily Oak say, we have all sorts of conversations, but we continue to delay them and all that. Yes. Five minutes. Finish on time, Lida. Run for your life now. Okay. So we need to make a decision about mom or dad that is not going to happen, at least the entire family is involved. So allow yourself some time. I said that we're about personal relationships. So whenever a Hispanic person tells you, hi, how are you? I bet you any money that at least 90% of the time the person is actually asking how you're doing. It's not, hi, how are you fine? Thank you. Have a great day. Great. No. Okay. I am ready. And when I ask you, how are you doing? I want to know. And it's not out of being nosy, it's out of my values are I want a personal relationship with you. We're very collectivistic and that ties it into the concept of family. We try to stay together and it's very hard for Hispanic families because of globalization jobs and all that. People are all over the place. So long distance caregivers and the Hispanic culture face very specific challenges. We don't start on time and we don't finish on time except today because Ron is going to kick me out of the stage. Okay. Personal space. I already made Dr. Ryan very uncomfortable. They're getting really close to him. And you saw it's like, we like a lot more closeness, not as much as Chinese people, okay? They made me very uncomfortable in Beijing three months ago. I'm thinking like, oh my God, what is going on here in this elevator and getting up on the plane and it's like in a pharmacy and it's like, I'm here, you know, like don't start going over me. But okay. So not to that degree, but yes, a lot closer than Americans. Marianismo sounds like the Virgin Mary, right? But it's not really a religious connotation as much as the emulation of virtues of sacrificing for others of abnegation of humility. Those things are very valued in our culture. And then this is key. And at this step, many people blow it because they think that saying Hola, come with Stas in the first encounter. They think that's really cute. You just blew it. You don't use two and Stas and that until you know that person, especially if he's an older adult, if he's somebody older than you. Two is for your very close friends, the Stas, very close friends and children. So all their adults are not going to appreciate being addressed like that. So because of all those values, this is how Hispanics see caregiving is an opportunity to give back is my responsibility. And therefore they do not like respite because it's my duty and my responsibility. So you have to sell those ideas and refrain them for them. Caregiving is a learned behavior and a tremendous sacrifice. Oh, you're stretching me. Okay. I'm stretching.  So my message really is we need to be very cognizant of where we come from. I stole that from the Gary Weaver and a sociologist. I'm not the author of that slide. I borrowed it from my presentations because in fact, this is what happens. We have two icebergs colliding. Many times when we try to address the needs of Hispanic families, is where are they coming from? What are the adaptations that we need to make in our care and in the delivery of our programs? From instead of 10 to 11, maybe we want to say 930 to 1130 and we know that we're going to get to know each other from 930 to 10, then we start on time, we finish on time, but we have time to hang out for a little bit so we can create that personal relationship. Who delivers a program? We like to see people seen among color like me, with an accent like me, people that understand who I am, so those programs get delivered in a very competent, culturally proficient and linguistically competent manner. Therefore, a little bird told me that WellMed has committed, WellMed has committed, right, to translate stress busters to Spanish. Okay? Because WellMed realizes that the program is wonderful, but a big change needs to happen. So we're going to deliver that program, translate it, adapt it so that people can benefit from the tremendous research that came out of the program and WellMed has committed to do that. So Ron, my time is up, but you were just bluffing. Oh, if I like. And there are any questions in the audience? Yes? The husband, that's his job or that's his obligation. How do we convince him that he does need respite care? He does need it, we can see. I love you because he opened the can of worms, so let me show you how you're going to do that. I said I can cut here, but since he opened the can of worms I can use the time. Respite is a bad word. So what you're going to do, why? Because it's my duty and my responsibility, and I'm going to do it and no one can do it better than I can. I'm not going to pass the honor of fulfilling my duty to an agency or to a stranger. So you're going to rephrase this. And you're going to tell them, just like an airplane will never take off without you receiving a briefing about your oxygen first before you help somebody, and that it works wonders, okay? So respite, el relevo, is a responsibility. Respite must be one of your duties. It's not an option.  So when you reframe it as a family responsibility and as a part of your duties, you may be able to convince him to do that. Any other questions? No questions? Okay. It's a pleasure having been here with you today. Thank you very much for coming. Dr. Senator Bryant is at the University of North Texas Health Science Center, interim director of the Institute on Aging and Alzheimer's Disease Research and associate professor of Department of Internal Medicine. And as Carol Zerniel mentioned, we had him as a guest on our radio show, caregiver SOS on air. He was fabulous. I guess we're going to find out how you do here because we've got a real test here, you're live and in person. Dr. Bryant's laboratory studies factors related to cognitive loss during the aging process, particularly Alzheimer's disease. He's known as a global leader in the area of blood based biomarkers of Alzheimer's disease and led the international working group that recently generated the best practice guidelines for pre-analytic methods in the research area. He's generated and cross validated a blood based screener for Alzheimer's disease. And more recently, he has generated methods for identifying subpopulations of patients suffering from Alzheimer's disease. So targeted personalized therapeutic approaches can be generated. And you can read more about him in the program. I don't want to take any more of his time and we'd like you to please to welcome Dr. Siddle Bryant. All right. Does that work? Okay. I'm a good Southern boy who has to use my hand. So if I use a microphone, it's going to end up in someone's lap and I'm throwing in or doing something. Okay. So there's a clicker somewhere. First of all, thank you very much for having me here. It really is a wonderful opportunity and honor to speak to you. I'm a little disappointed that I have to speak after the two speakers this morning who are both more they're prettier, smarter and better, more articulate than me. So I will try not to let you down too much. I am going to talk to you today about advances in Alzheimer's disease research. And I promise you, I will actually speak to you in a manner that you understand. I'm not going to use words that no one knows. And if I do just throw some food at me and I'll correct myself. So I always have to make some disclosures that we have. There are patents pending and we've been funded from multiple organizations to do this research. I'm going to talk about a variety of different things today. And if there are questions or anything, I think you want to leave it towards the end. Okay. All right. Because my normal, I'll tell people, just raise your hand and shoot them out, but I don't want to get in trouble. So we're going to talk about some recent work about the blood test. I'm going to cover this new concept called endophenotypes, but I'll explain exactly what that means. So why is this important? Alzheimer's disease is, in my opinion, the single biggest problem facing the medical system today. Not just in the United States, but globally. There are over 5 million patients right now in the United States. Texas has the third largest population of Alzheimer's disease patients in the United States. So that's a lot of patients. That's nothing. What's coming, some like to term the silver tsunami? I don't know that I don't find that pejorative. I haven't figured that out yet. But then again, I'm going bald, so I won't be silver. You take what you can get. Hey, at least I'm still have a head. It becomes more and more important when you put this in the context of the aging nature of our country and the globe. So those above the age of 85 are the fastest growing segment of the population. In the next several years, you're looking at over 14 million new individuals reaching the age of 65. Why is that important? Well, age is the biggest risk factor for Alzheimer's disease. It's the biggest risk factor for memory loss. So I'm going to take just a step aside for just a second and say I'm going to use the word dementia only because that's what the medical field says I'm supposed to use. I almost never use that word in my daily work because almost everyone that I work with is Hispanic. And dementia in the Hispanic community means crazy and it's very rude. I've learned that clinically. So I'm going to use it, but what I mean is the clinical definition of changes in memory, changes in thinking. That's all I mean. All right. So right now, every 69 seconds, it's estimated that someone is developing the disease. Within the next few decades, that's going to drop down to every 30 seconds. The emotional impact is immeasurable. The financial burden is astronomical. Interestingly enough, there was a recent survey that looked and showed that care, Alzheimer's and dementia care is as expensive or more expensive as cancer and heart disease. Alzheimer's disease became the number one fear of the elderly about four years ago. So this is a major issue that we have to deal with. There is the estimated annual cost of Alzheimer's disease to the United States by 2050. So what you see by these numbers is approximately anywhere between 10 and 13% of individuals above the age of 65 are suffering from Alzheimer's disease. However, when you look at it broken down by decades, what you see is advancing age is the number one issue. With those above age 85, it's almost 50% who are suffering from the disease. That's whether they know it or not. 300,000 Texans suffering from the disease. Then there's this pre Alzheimer's disease. Some of you have may have heard of the concept of mild cognitive impairment, MCI. All that means, the thing about memory is if we wake up and our memory is drastically different, our language skills are drastically different overnight, that's not Alzheimer's disease. That's a stroke. That's a tumor. That's something that has happened to that person immediately. Alzheimer's disease is a slow process that takes a lot of time and it develops over decades. So when you get into the pre Alzheimer's, all this means is memory has changed or language or something about their thinking has changed, but they still function. When you cross over into the dementia diagnosis, what that means is the person can no longer function by themselves. Someone else has to manage things for them. My wife says I'm demented already. She manages me. So here it gets some interesting things. Approximately 15% of those diagnosed with MCI will convert to Alzheimer's disease every 12 months, but that's only 15%. About 15% actually quote unquote revert. So MCI as a prodromal pre syndrome doesn't mean someone is slated to have Alzheimer's disease. It means they are at significant risk for the disease. I'm just going to press the wrong buttons. So it's estimated that 10 to 30% of those age 65 and above suffer from MCI. So when you combine that with Alzheimer's disease and other dementia statistics, 15 to 40% of individuals 65 and above are suffering from memory loss or some other cognitive loss. Explains Congress. Just saying. All right. So just by base rates. So caregiver sorts of things. I'm going to get into the science components in a moment, but some of the things that I end up trying to address. I'm a psychologist by training, by the way. So I'm a neuropsychologist. I'm the person who does memory testing and does the diagnosis of dementia. So I wasn't trained in a lab. I was trained with people and I'm still licensed in the state of Texas. As a psychologist, the thing that bothers me most about this disease is as follows. In life, you have one thing that's yours and only one that cannot go away. And that's you. That's who you are. Your sense of self. Everything else can go away. Alzheimer's robs the people of that. I find that fundamentally wrong, which is why we do this work. But what it does to the family, the loved ones, the community, society, that's the consequences of the disease that oftentimes we don't appreciate. I sit down with patients and families and, you know, let's be honest. The most stress suffered is by the family 90% of the time. My grandmother passed of Alzheimer's disease. My mother was a caregiver twice. She cared for her mother when she died of cancer. So she was a caregiver for her for about three years in their home. She passed in actually the bedroom that I grew up in. Then within 12 months, my father's mother got diagnosed with Alzheimer's disease and she was a caregiver for eight years. 12 months after my second grandmother passed, my mom got diagnosed with cancer. And she went through three surgeries, two rounds of chemo. She is, by all accounts, partially cancer-free at the moment and has been for a while. Do I think being a caregiver caused cancer? No. Do I think being a caregiver exacerbated and made it worse? Absolutely. From the basic biological effect that being a caregiver has on the person, you're at increased risk for the cold, the flu, cancer, stroke, heart attack. If you have diabetes, it's worse. If you have depression, it's worse. If you have anything, it's worse. It's like taking a hundred pound weight, weighted vest, and laying it on top of someone, and saying, have a great day, and expecting them to do everything they normally do without assistance. It's unfair. Caregiver, the number one thing that I've dealt with with caregivers was touched on previously is the guilt. No one can do it like I can. I had this wonderful, wonderful patient. She was 96, and her husband was just this most amazing gentleman. He tells me the story. He says, you know, son, how long have you been married? I said, at the time, we'd be married about 10 years. I said, he said, how long did you court? Well, six years. The first song in our wedding was Ed Last Bayard of James. That's not a joke. My wife picked it out. So he tells me, he says, you want to know when I knew I was going to marry this lovely woman? Been married over 70 years or something. He said, the first moment I saw her, he said, I went in to go see my best friend, never been to his house. I saw her and I literally walked into her room and asked her to marry me. He said, two years later, whatever, she finally married me. And they'd been together all that time. And he said, Dr. Brown, I can't let someone else take care of her. The week before he had fallen, trying to take care of her, fortunately, nothing major happened.   Well, I guess I hadn't thought of that. Finally, I actually met with him about six times to get him to agree. Got her in a place to be taken care of because he actually did have some medical issues. And then he wanted to take her out when he was better. I called him. His daughter called me. I called him. You got to come back in. We had a nice discussion about it. And I told him, I said, no, you can't, you can't do that. Well, you start your decision, not my decision. I said, but how are you doing? I'm good. How is your wife? She's lovely. She loves the place she's at. She's happy. They take great care of her. I spend six hours a day over there. And then I go home. I said, so you're healthy. She's happy. Why do you want to muck this up? He finally got over the guilt and she was taken care of. Then I can't stress how important this is. And you have to, you have to convince, you have to convey the importance and you have to work with your caregivers, friends, families, loved ones, that it's okay to take a day. It's okay to have some time to yourself. So that's, now I'm going to get into the research. So why a blood test for Alzheimer's disease? So this is your brain.   This area right here, that's memory, or at least one of your primary pieces of your brain responsible for memory. That here is this little sliver right there. That's why Alzheimer's disease hits memory systems first. There's a basic biological reason. The plaques and tangles in biology hit that area of the brain earliest. Then it spreads elsewhere. That's why later on you get other things, but very early in most patients you have a memory loss. So why is a blood test for the disease important? I'm a clinical neuropsychologist by training. I live 1500 miles away when my grandmother was starting to show signs of Alzheimer's disease. So I had to walk, push, kick, and drag my family through the diagnostic process because they didn't want to do it. And two, they couldn't find anyone. They couldn't find anyone to go see. They didn't know what to do. The primary care doctor didn't know what to do with him. He said, I don't know what's going on. It might be Alzheimer's disease. So you do the neurologist, went through the neurologist, wrong neurologist. That neurologist didn't specialize in Alzheimer's disease, et cetera, et cetera, et cetera. So in my opinion, the diagnostic process is broke. It's completely broke. It's not that it's bad. It's broke. What is this current gold standard? It's a specialty clinic. Dementia specialist, physician, most of the time neurologist or geriatrician, sometimes a psychiatrist. But dementia specialist, I promise you, not all neurologists know anything about Alzheimer's disease. You do blood work, why do you do blood work to rule out other things? That's the point of the blood work. Brain imaging, why do you do brain imaging to rule out other things? There's not an MRI scan that's going to tell you you have Alzheimer's disease. Confirmation at autopsy. So the gold standard to diagnose someone is to diagnose them after they're dead. Kind of a problem, don't you think? Especially for someone like me who's a scientist and wants to prevent the disease, treat the disease. I'd like to see people pre-immortal. So you have now some really interesting and fascinating things. So there's now what's called a brain scan, an amyloid PET scan, beta amyloid and tau, plaques and tangles. Plaques, beta amyloid, tau, tangles. That's all it is. And those are just proteins.  They're proteins that just become abnormally formed and they clump together like glue for the plaques or the tangles basically get embedded into the neurons and the neurons die. You can do a PET scan of that and see the plaques. We also now have PET scans to see the tangles. Has anyone in, well, I'm not going to ask that question. People in here have had loved ones like myself who have been diagnosed with cancer. Was a PET scan how they got diagnosed? No. PET scan is confirmatory diagnosis. Why is that? Do you know, did you ever see your bill for your PET scan? Yeah. Even when your insurance covers it, it's still your stomach basically hits your toes because a cheap PET scan is about five grand. And that's a cheap PET scan, by the way. I've seen bills over 20 grand for one scan. This at a minimum is five grand a pop. So obviously not going to be used for our front line screening purposes. Just not going to happen. The other thing is how many PET scanners are there? Not enough to do brain scans on the 40 million Americans age 65 and above. So that's why some of us have decided we have to do something about this system. Can we create a method that can be used in primary care providers' offices regularly? That's cost effective? That's time effective? That can be that referral? It can be the reason that your primary care doc says, you know what? You need to go to this specialty clinic. You need to get a bain amyloid scan. Exactly how you get to your cardiologists. Exactly how you get to your oncologists and many other specialists. Now the problem with this is when I started this work about a decade ago was that there was about 30 years worth of science saying it wouldn't work. So being that good southern boy, never tell me I can't do anything. That's just a nice way to make me say I'm going to do it. So what we think a blood test can do, how can it change practice? Well it can be used for primary care providers to do that screening so that anyone, anytime, anywhere can walk into any clinic, get a blood draw.  But there are other things. One of the reasons that we don't have more drugs for Alzheimer's disease is because trials cost so much. Alzheimer's disease trials, major trials last two to three years sometimes. Can't your trials last three months, six months? You can see the tumor shrink or it doesn't. Alzheimer's disease is different. The trials cost so much money that the companies are very hesitant to do it. So if you can reduce the cost of the trials, you can increase the number of trials. So here's a decade worth of work in one slide so it's always disappointing. But it really is a decade worth of work in one slide. So here's where we started. This summarizes a lot of work. So we started off up here. The approach that I take and that I took towards this is do I think we can create an Alzheimer's disease blood test? Absolutely. I think we just used the wrong tools. Do I think there is a thing in your blood that tells me you have Alzheimer's disease? Absolutely not. As a matter of fact, in the cancer world, they have blood tests that will predict whether or not you're going to respond to therapies. They have blood tests that will predict whether you're going to relapse or have an additional occurrence. None of those blood tests have one protein. None of those are single markers. They're very rare things that will tell someone you have a risk for a disease that's one thing. The BRCA, genetic test, BRCA stages, sorry, BRCA mutations, BRCA stages is also an Alzheimer's thing. But there are a couple of genetic tests but other than that, that doesn't happen. So we started off with a broad panel.  I just want to know is there a profile of the disease? 108 markers, it was 95% accurate. Okay. So yes, there is a profile. But 108 proteins cost about $1,200 a person. So yeah, not very cost effective. So we got down to 30 proteins, 94% accurate. Okay. Here's where this should be a different color because this is incredibly important. This is where we went to a different study which you can create whatever you want in your own study and in your own lab and in your own clinic. But if it doesn't work in a different clinic, it's not useful. So this is where the first ones ever do this. We took it and went from a Texas-based group of over, actually there's over 1,000 people in this study now, and looked at a US-based group and it retained it was 90% accurate at the blood test. And that, by the way, is only 11 markers. This one, 92% accurate. It's more accurate, right? Women in here gave birth. Did you have an epidural? Yeah. How many men in here have ever had an epidural? Yeah, that's what I thought. Not many. That's how you do a CSF. It's a lumbar puncture. So people simply don't jump in line to have it. It's accurate, but yeah, they're not jumping up and down, say they have it. So most recently, this hasn't even come out yet, but actually the journal is based out of San Antonio. 21 protein version, 98% accurate. So now what we have is a blood test that can be done in any lab because we also change the way the blood test is done. It's not a send out. We've created it in a manner that anyone can buy the equipment. They can bring it to, so Quest Lab Core, anyone can pick it up and run with it and it just, it flows. It's nice and straightforward. One of the things that I've been criticized, not me, my work. I don't take it personal. I say very facetiously. What we've been criticized for is what is it in the blood that has anything to do with the brain? Now your neuroscience sorts of people like to say that. I like to say they've lost their mind because there's nothing that says, if you think that anything in the outside of the brain doesn't influence the brain, then you really don't know the biology of the brain. There is this thing called the blood brain barrier, but it's not as fortnoxious as we like to think it is. So things cross. So we said, fine, we will cross validate it. We'll look at it somewhere else. So let's do that. So this was really fun. What we looked at is human brains actually and said, all right, I'm going to run these same proteins in the brain. So it's the exact same proteins that I've run in the blood. Does it predict the brain pathology? 100% accurate. So then I said, all right, what about mice? Because we have mice models of Alzheimer's disease. You know how a mouse gets Alzheimer's disease? We give it to him.  And if I draw the blood from those mice out of their little arms, it's 100% accurate. Depending on I can go 90% with this is with three markers. If I go to five markers, it's 100% accurate. So the blood test works incredibly well. It also predicts this is what a brain scan of beta amyloid looks like. This is actually from our Mexican American study. And this is someone with Alzheimer's and someone without. And it's 80, yes, 85% accurate at detecting brain scan positive Alzheimer's disease as well. So that got me thinking, which is a dangerous thing. If there's a blood test for Alzheimer's disease, shouldn't there be a blood test for Parkinson's or frontal temporal dementia or Down syndrome or any other neurological something? That's heresy, by the way, in the science field. We took 13 proteins. Here are the number of patients per group. This is called frontal temporal dementia, Lewy bodies dementia, Parkinson's disease, Down syndrome, Alzheimer's disease and normal controls. 100% accurate at detecting and discriminating every single one of the groups. So there's an international initiative right now just on this, which is led out of Texas. But it includes seven countries so far, four continents, I think. Specifically looking at how do we understand all of these diseases, not just one of them, because there's a lot of overlap. So this is what we've now done. And a lot of what we've done is I said we have a study looking at Latinos, Mexican-American, the outlay study. We've partnered with numerous people to look at how the blood test works. And this is brand new data. This has never been published. We look, this is our Mexican-American only study. Our blood test is 90% accurate detecting Alzheimer's disease. Now this is a community-based sample. This isn't people coming into the clinics. This is us going to the community, finding people. They come in, we recruit and we look at them and they were 90% accurate. So this is just like testing it in a primary care setting. It's just normal people. This is the data we had showed you. This one was fun. I just got back from Panama. And we just ran 200 samples from the first ever aging study conducted in Panama City, Panama. And they are 96% accurate at detecting Alzheimer's disease. The blood test we have is can detect it in that community as well. This one is detecting that pre Alzheimer's disease. You can see we're 93% accurate at detecting it in our Mexican-American cohort. Less accurate here, but I know why that is. So we've already addressed that. So here's where we're going to take a left turn. So you'll have to follow me. So what I've been talking about so far is diagnostics. How do we fix the diagnostic process? If I can get that blood test in the primary care provider's hands, that can let the docs know who to send to what specialist, who to refer. Right now I can tell you that if I go into a primary care setting and start doing cognitive testing, 60 to 70% of those 65 and above, if I interview them, are you having changes in your memory? Yes. So how do they refer? That's the issue. That's what's going on. So the primary care docs are inundated and aren't sure what to move on. We think the blood test is a way of fixing that. Now what has happened though over time is there's this saying, serendipity is a scientist's best friend. Basically I've been doing this work for so long and when you stare at the numbers as long as I have, I don't sleep, you start seeing things. There's medications for that. But what I started seeing were patterns and you would see that there seem to be subgroups of patients. So I started digging into this and our group has done a lot in this. So what we're going to do now is I'm going to parallel something for you so I want you to understand exactly how we treat Alzheimer's disease. So I'm going to start off with heart disease. I'm going to give you, to my opinion, the best example in healthcare in terms of treating specific organ-based disease is heart disease. I don't think anyone's done better. So heart disease, big disease, lots of things. You can break down essentially into four types of heart disease. Big heart disease for primary, primary sorts of disease. So if I go from heart disease just to hypertensive, now it goes down to different subtypes of hypertensive heart disease, which is a subtype of. So you break it down. Just look at atherosclerosis, breaks down to different markers of the disease. Now, do we treat at this level? Do we treat at this level? Nope, we treat down here. That's how heart disease has been so successful. They've taken the disease and understood it. They've torn it apart and understood that not everybody's heart disease is the same. Okay, so let's parallel that to brain disease. All right, there it is. That is the entire schematic. We have neurological disease, Alzheimer's, Parkinson's, multiborosis, et cetera, et cetera, et cetera, and we treat right here. In what world is the brain less complicated than the heart? I mean, really? That's how you treat Alzheimer's disease. You enroll anyone with a clinical diagnosis of the disease into a clinical trial, assuming that every patient is the same. I've seen over a thousand patients. Yeah, they're not the same. When you've seen an Alzheimer's patient, you've seen an Alzheimer's patient. There are different types of the disease, in my opinion. Here's why this scenario doesn't make sense to me. Let's say Alzheimer's disease. All of these things are risk factors. As a matter of fact, the original one that I had in the schematic was so big you couldn't read anything. Risk factors for Alzheimer's disease include the beta amyloid, the tau. Here I put in largely biological driven things. Things like diabetes, inflammation, oxidative stress, neurotropic dysfunction, psychiatric, head injuries, depression, poverty, poor education, sedentary lifestyle, obesity, smoking, heart disease, diabetes is the number one midlife first factor for lay life Alzheimer's disease. All of these things increase risk for the disease, yet we still treat it as a single disease. Here's the hypothesis. Here's what many of us are trying to now start looking at. Let's tease it apart. In my opinion, the complexity of the disease is a gift to science because that's how you beat it. You beat the disease by tearing it apart into its small components. It's a lot easier to climb a mountain one step at a time. Why not segregate it out and just look at those with the beta amyloid, those with tau, those with inflammation, etc. You can break it out into many. This is just one version of it. What we've done over the last couple of years, we've been thinking this was there for many years. What we've started formalizing is saying that these are what we're calling endophenotypes subgroups. If I write subgroups, it doesn't sound as catchy, so I can't get published or funded. Come on, that's a joke. We use the term endophenotypes because what that means is basically it's a biologically based way of identifying a subgroup of patients. The reason these have been selected is because they're biological systems. These are things that, right here, inflammation, that's an immune response. That's your immune response. It gets upregulated when you have a cold. Why? To fight the cold.  That's inflammation, very simplistically. What you have are these systems that get dysfunctional. What we think you should be able to do is target a clinical trials. Why not treat the biology of the disease of the patient? This is akin to enrolling someone into a diabetes trial by actually testing their glucose or their HbA1c instead of them coming in saying, oh, by the way, I'm diabetic. Guess what? It's happening right now. First-ever trial in the history of humankind, that's a true prevention trial of Alzheimer's disease, has now started. The A4 trial, that is, by Dr. Risa Sperling. How's this trial happening and why is it absolutely so ingenious? They're doing those brain scans that you saw earlier on people without the disease. Not people with the disease, people who have brain scan positive plaques in their head and they're cognitively normal, which is 20% of everyone walking around above the age 65. Now, amazing trial, but it's also the most expensive study we've ever done because it costs about five grand a pop to scan about 4,000 people. And it's about a three-year trial. So it's the best trial we've ever done. Risa is my hero, I want to be her when I grow up, if I grow up. However, why can't we do this other ways? So there was a really big splash. I guess it was two years ago, maybe three. Suzanne Kraft, now at Wake Force, published this work that showed that intranasal insulin improved memory in those with Alzheimer's disease, made huge, huge, huge media stuff. That's now into a full phase two, potentially phase three trial called the SNF trial, which is ongoing right now. What I've told her, and I'm hoping she'll give me the blood samples, is why don't we look at specifically those who have metabolic dysfunction and see whether or not it works for that subgroup of patients. But here's the one where I've spent most of my time and I'm most passionate or I don't know, perseverative. Inflammation.  We've had three clinical trials use anti-inflammatory agents to treat Alzheimer's disease. Every one of them has failed. Every one of them. Why did they fail? Well, here's why. So what we've done is created a way of taking a blood test and determining whether or not someone has dysfunction in their inflammatory system. Not one protein, because that didn't work for the blood test for Alzheimer's disease. What we took was a way of profiling inflammation as a biological system and said someone has dysfunction. They're either split into three groups, low, middle, and high. What that means is someone who's low in inflammation are basically immune suppressed at some level. Those who are in the middle group, which is about 70% of people, are just somewhere in the middle. Inflammation isn't really high, it's not really low. But then you have a small group about 15% where inflammation is through the roof. It's elevated. What happens if you take someone who has, is immunosuppressed and you put them on an anti-inflammatory or an immunosuppressant drug? Bad things happen. So this is a real clinical trial. This is a failed clinical trial. This came from this right here. The Alzheimer's disease cooperative studies, they did two Alzheimer's, one Alzheimer's, one pre Alzheimer's. We took the blood samples from this trial. Those blood samples taken before they are rolled to the study. So it's pre-ranomization. Took the blood from the patients and created a profile, split them up by low inflammation, medium inflammation, and high inflammation. So let's look at this group. You take people who have low inflammation and you don't treat them. You leave them alone. They stay normal over 12 months. They don't really change. The bar graphs are in each group because of one person. They don't change. What happens if you take someone who has no inflammation and you put them on an anti-inflammatory drug? Normal decline in an Alzheimer's patient somewhere around here. They decline worse. So in other words, you give them an anti-inflammatory drug and you made them worse. In the middle group, they're in the middle group. There's no difference between these two groups. They're just somewhere in the middle. Now, the high group. You take people who have elevated inflammation. Their inflammation is through the roof system-wide. This isn't one marker. They have true system dysfunction and you do not treat them. They decline worse over 12 months than if you would not have treated them at all. If you'd have left them alone, they would have actually been just fine. If you treat them, however, that's the comparison. They get better. When you go from this group to this group, what happens is basically 64% of the patients in this group actually got better over 12 months. Now, it's a subgroup. It's 15% of the patients. This graph is a graph of a doomed clinical trial because adverse responders, responders, 15%, 15%, non-responders, 70%. Every clinical trial that's designed is oversensitive to this because we don't want to treat people and make them worse. So if you have adverse responders trials are stopped. That's those people. This is the other 70. So you've got 85% of the patients who are somewhere in here and only 15% got better. So what you have is true identification of a subgroup of patients with Alzheimer's disease who you can treat with specific drugs. So if I back up and do this and you go from brain disease, Alzheimer's disease, Alzheimer's disease, inflammation, treat, and you have a clinical trial that says that it works. I presented that in Copenhagen this year at the Alzheimer's International Conference. What we're working on now is this is inflammation, as I said earlier. It's not unique to Alzheimer's disease. Beta amyloid might be. This may be very specific to Alzheimer's disease. This is not specific to Alzheimer's disease. Matter of fact, beta amyloids and other diseases, but this is prominent in some other diseases, particularly FTD. This, and this, and this, and this are prominent in Parkinson's, in frontal temporal dementia, in multiple sclerosis, and et cetera, et cetera, et cetera. So what you have now is potential of subdividing patients into therapeutic groups. So one of the things that we were asked to do, and this is something that actually just happened, so it's not even, because I gave you this slide, this like a week or so ago, subsequent to that, we now have data where we've taken and looked at this pro-inflammatory, this group, this sub, this biological group, to determine does it exist in animal models? Because the animal models are kind of how we start finding new drugs. We play around in those models that we think are the biology of the disease and we move forward. Actually, it's incredibly prevalent. As a matter of fact, when you go to these three groups, in the animal models, without Alzheimer's disease, 30% are here, 70% are here, so your control mice, zero here, by the way, none. When you're in the Alzheimer's triple transgenic mutation Alzheimer's disease mice, where we know they have the disease because we've minibidlated them genetically to have the disease, 60% here, 40% here, 0% here. So even in our animal models, which we think are, by the way, most people think that your animal models are all the animals are the same. They're in a such thing as subgroups. There are very clear subgroups even in the animal models. Well, okay, so what about, sorry I'm doing this because I couldn't update this because they already had it. It's his fault. Everything's your fault today. You know that, right? It's my plane's late. It's your fault. Interestingly enough, that same group, that's 15% here, that inflammatory group, it's 20% here. It's about 60% here. It is 50% here, 40% here, and it's about 70% of Down syndrome patients. So this group is, it's a biological system is all it is, but it's dysfunctional across neurodegenerative diseases. So what we're trying to do now, there's a clinical trial pending where if funded, it will do this. We will enroll patients by the blood test. They get a clinical diagnosis of Alzheimer's disease.  If their blood test shows this profile, they go into the trial. They get an anti-inflammatory drug, determines whether or not it makes them better. Does the slow progression, does it make them better? It would be the first true targeted trial for Alzheimer's disease that has happened other than beta-amyloid. So we're pretty excited about that. What it has though is larger implications in that it may be a way of addressing neurological issues, dementia, right? We tease apart dementias because as scientists, we like classifying things. As clinicians, we want to know what the disease is. So we put a name to it, we understand the biology of it, and we treat it. Unfortunately, in neurological diseases, that has helped us zero. We don't have effective treatments for Alzheimer's Parkinson's frontal temporal multiple sclerosis. We don't actually have effective treatments for any of them. But what's interesting is that when you look at the diseases together, there's a lot of commonalities, a lot of commonalities. You can find beta-amyloid in Parkinson's disease. You can find tau in Parkinson's frontal temporal other diseases. There was this genetic mutation that was going to be the test for frontal temporal dementia. Unfortunately, it was found in Alzheimer's Parkinson's and multiple sclerosis. These diseases are alike, just like they are different. The blood tests, when I showed you, one of them is inaccurate, right? It's discriminating amongst the diseases. It is, but there's a caveat. The profile of every disease is different with overlap. So you have inflammation that's in there, but the profile is still a little different. The profile of one disease. So there's overlap in there, differences between the diseases, but that could open up novel opportunities for treating a whole lot of things. Actually, in the airport, on the way home today, I'm meeting with a Japanese company that's testing a new drug about using this to predict treatment response in their new drug for Alzheimer's. And last week, I met with a company that wants to do it in multiple sclerosis. What is this called? Personalized medicine. This is person-centered therapy. You're treating the patient based on the biology of that patient. That's why cardiology has done so well. Does anyone know what the death rates of heart diseases have had in the last 20, 30, 40, 50 years? That. What are the death rates due to cancer done in the last 20 years? That. What are the death rates due to AIDS done in the last 15 years? It's gone down. Why? Because we've understood the complexity of the diseases. If you go into the science of oncology, there are people in oncology who don't even want to use word cancer anymore. They want it to go away. Because telling someone they have cancer tells them what? Nothing. It tells you, you may be dying, but that's all it tells you. What kind of cancer? Is it breast cancer? Okay. What kind of breast cancer? Cancer is treating now. They're looking at treatments that are specific to the molecular makeup of the cancer cell. We have treatment cure rates in cancer that are amazing. Heart disease. They're amazing. Why? Because we've deconstructed the disease. The disease as there's no such thing as heart disease. Really? There's no such thing as. I love that. Dislipidemia. Okay. That means my lipids are somehow messed up. How useful is that? Go see your cardiologist. He's going to treat you very specifically. So that's where some of the newer work. And why I say, I get frustrated oftentimes when I see the news. Because what I see is another failed trial in Alzheimer's disease. Another blah, blah, blah. And it's disheartening to the community. It's disheartening to society. And I feel it is my responsibility as a scientist to say, stop it. We're working very hard. And the science has moved on. When you see about those clinical trials, those failed clinical trials, when they go back and look at them, 30% of the patients who were in those beta amyloid drug trials didn't even have beta amyloid in the brain. Well, that's called a doomed trial. It's like treating people for diabetes who don't have diabetes. Right? So, but that's not a failure. Because of that, we now have the A4 trial. We have the first ever prevention trial in human history for trying to stop this disease from ever happening in the first place. The field, and this is why oftentimes when you see, I'll say it, a hope for the future. The field is actually, I believe on the verge of some amazing things. We've got potential for not only using a blood test to diagnose the disease, but we have potential for diagnosis of blood tests who will predict future onset of the disease. Well, why do I want to know I might have Alzheimer's in the future? Because now we can try to prevent it. Treating prevalent Alzheimer's disease is like treating stage three and four cancer. How successful are we when we treat stage four cancer? It's abysmal. It's too late. We need to treat earlier and earlier and earlier if we want to get at the disease. When I showed you that picture of the brain, I'm sorry, I'm just back.  I hope you don't mind. But this is a very important point. The brain doesn't regrow. That's a very fundamental phenomenon you need to understand. If I'm treating this and want it to look like that, it's impossible. It's impossible.  Okay? Not like this. I can't. So what we want to do is treat it when it still looks like this, when they're still in brain to protect, when there's still neurons and there's still a memory center left in the brain. We want to protect it. We want to keep it there and keep it robust. So what we have as a field is on the horizon. We have potentially a blood test that will be useful for the identification of patients in primary care settings. So how do you actually get a diagnosis? How about we not make it last six, eight, ten months and cost $3,000, $4,000? Why don't we make this a little easier on our patients? How do we enroll into clinical trials? By the way, the exact same process that you get clinically to get diagnosed is the exact same process to get enrolled into a clinical trial. So if it costs $2,000 to get a diagnosis, it costs $2,000 to get enrolled into a clinical trial. So if we can remove some of those barriers, we can expedite the process, reduce the cost of the trials and get more trials in the pipeline. The other thing, which is a really big deal for clinical trials, where and how do you get enrolled into an Alzheimer's trial? Has anyone in here ever seen an advertisement for an Alzheimer's clinical trial? Raise your hand if you have. That's what I thought. Where do they happen? Specialty clinics. You recruit through specialty clinics. Has anyone in here actually seen maybe a diabetes trial? Hypertension trial? They're everywhere. You don't have to go to an endocrinologist to find a diabetes trial. You don't have to go to a cardiologist to find a hypertension trial. If you can have a means of primary care providers referring patients, it also increases the population pool for studies. A lot of people want to be enrolled in studies. They just don't know anything about them. So blood tests can increase access to clinical trials and reduce costs of clinical trials. But fundamentally, more important is this new work where it's a reconceptualization of the disease. I want you to walk away from here today not thinking of Alzheimer's disease. I want you to be thinking of Alzheimer's diseases. It's complex. There's more than one cause. There are a lot of things that relate to the risk for Alzheimer's disease. Until we understand the one thing that doesn't exist, in my opinion, we have to understand the complexity of the disease. When we understand that there are subgroups of the disease, just like there are subgroups of cancer, hypertension, cholesterol, everything else, if we treat it that way, we're going to treat the disease better. We're going to start actually finding improvement in patients, prevention in patients. The field is moving in this direction. It's taking a while. I can tell you that in science, things move slowly. And for someone like myself, that's incredibly frustrating. However, I believe that on the horizon are some wonderful things. I do this not so that my generation or myself doesn't have to face this disease. I do this so my kids don't face the disease. I have two daughters, four-year-old and one turning nine. Actually, I was telling someone, we have six, seven nine-year-old spending the night tomorrow. And my wife decided, I'm the entertainment. I want them to look at Alzheimer's disease in textbooks. I wanted them to talk about it as, you know, yeah, it happens sometimes, but it's really not all that. That's just pretty rare, isn't it? That's what I want them to see. And that's where I think we're headed. I think we're getting there. If you ever have the opportunity to get involved in research, please do. If you ever have the opportunity to advocate for support of science, please, please do. The annual budget for cancer research at the NIH is over six billion. The annual budget for heart disease research is over five billion. The annual research for HIV is over four billion. The annual research for Alzheimer's is 500 million. We spend $300 million a year on costumes for pets at Halloween. That's almost the annual budget for Alzheimer's science. We have messed up priorities, to say the least. My thought is, I think we should simply take a billion dollars out of the cancer budget, throw it in the Alzheimer's budget, and the cancer people will get so mad they'll just raise the money anyway. That's what's happened already. Advocates. I do all the time, anytime I speak to anyone, I always, look, we can, we, you've heard from one of the physicians, I actually respect most in this state early this morning, we can provide wonderful care for our patients. Without the science, we will never cure this disease. Period. Okay? The only hope for beating it is the science. And in my opinion, the science is very hopeful. There's some wonderful things on the horizon. I'm going to stop there. I appreciate, I don't know if I'm running out of time, but I'm going to say. Love to. I love Q&A. So can I, I'll stop there and we'll have questions. Wonderful. Yes, ma'am. People are turning in cards and I'm asking, am I going to get in trouble for that? Okay. Go ahead. We have a clinical trial starting in our group right now. And we have six clinical trials pending support. So we, this approach, I had not I, there's a brilliant scientist who happens to be my wife has identified, she's the brains of the operation, has identified subgroup of patients who we think you can actually treat in pre Alzheimer's stage with antidepressants. Because what's actually the depression is one of the most common symptoms in pre Alzheimer's disease. There's a subset of patients that we think depression is driving their disease. And we can treat them with an antidepressant. It's a subset of patients. Again, we've got a subset of patients. So another one we're looking at to treat with an anti-inflammatory drug. We've got another one looking at treating behavioral problems with a cholesterol drug. We think there are very interesting ways to treat this disease that have simply been overlooked. So yes, we are also looking at drugs. Very, very good. And we're also looking at drugs and animals. I just started a new 3xTG animal colony. Our group by itself does everything from animals to blood proteins to clinical treatment to clinical trials. We do everything. Over here. Yes, sir. Hey, how you doing? Good. Met you earlier. Can you comment on the likelihood of increased financial aid for research in the political climate where we have a predominant party that's against science? Yes. So that's a loaded question. Although I did make the Congress comment earlier, didn't I? So, you know, the funding climate for Alzheimer's disease in an atrocity. So you can plot the funding for cancer, heart disease and HIV to cure rates. And you can plot the amount of money versus cure for the disease. And it's directly proportional. So the more money we invested in heart disease, the death rates went down. Why? Because we did the science and figured out how to prevent the disease. Do you treat a heart attack? No. You prevent heart attacks. You prevent strokes. We haven't got there in Alzheimer's disease because we haven't invested the money. The political climate, I have significant concerns because the wonderful thing that's happened is NAPA was signed in the law, National Alzheimer's Project that President Obama signed into law. That did for at least a short term add $500 million on top of the $500 million to the NIA. So that's $100 million. Sorry, $1 billion. So we're still not quite a sixth of cancer. But I don't think it's going to stay. I think it's going to go back down. I think what's happened in cancer, HIV, heart disease, there have been faces. There have been people. Magic Johnson did more for HIV science than most people realize because he was an advocate and he was a very powerful advocate. Alzheimer's doesn't have it. We have a few people, Seth Rogen actually is an actor. Some of you may know. If you don't know him, especially this group, you should know who he is. He's absolutely hilarious. But he's now funding caregiver work. It's a wonderful thing he's doing. But until it becomes a societal push like cancer was 30 years ago and the cure cancer motion and the heart disease stuff, until it becomes that, we don't have a shot and because it will bankrupt us if we don't invest in it. Yes, ma'am? There is a thinking among some of the integrative medicine docs that statin drugs is very closely related to some of the dementias that we're seeing. They're thinking that the use of statin drugs for patients who are really not seriously in need of it is causing some changes in the cholesterol use in the system a