THINKWELL

AGEWELL

Navigating Memory Loss: A Neurologist’s Journey Through Cognitive Care

Dr. Heather Sandison, ND (00:00.844)
Welcome back to the Think Well, Age Well Podcast. I’m your host, Dr. Heather Sandison. And today I have the pleasure of speaking with Dr. Katherine Madison. She’s a board-certified neurologist whose career has been devoted to helping individuals and families navigate one of the most challenging journeys in medicine: cognitive decline and dementia. Dr. Madison is currently serving as the medical director of Seniors at Home and Rhoda Goldman Plaza.

She was the founding director of the Ray Dolby Brain Health Center in San Francisco, a pioneering center focused on brain health and cognitive care. What makes Dr. Madison’s perspective especially meaningful is that her expertise extends beyond the clinic. Like so many of the families she serves, she personally experienced the heartbreak, uncertainty, and complexity of caring for a loved one with Alzheimer’s. Those experiences caring for her own mother.

Shaped not only her approach to medicine and patient care, but also inspired her book, Navigating Memory Loss: Essential Questions and Answers on Alzheimer’s and Dementia. So today we’re going to explore what every family should know about memory loss, dementia, the diagnosis, brain health, caregiving, and how to live well in the face of uncertainty. In the face of uncertainty. Dr. Madison, I’m so grateful to have you here. Welcome to the Think Well, Age Well Podcast.

Catherine Madison (01:20.625)
Okay.

Catherine Madison (01:25.419)
Thank you so much, Heather. It’s my pleasure.

Dr. Heather Sandison, ND (01:28.184)
You’ve spent your career caring for people with cognitive impairment and I’d love to start with your own story. What what first drew you to neurology and what keeps you passionate about this work today?

Catherine Madison (01:38.857)
Neurology was always a great puzzle, and because I love learning, that seemed like a a great career path to follow. And I’ve actually dabbled in many different things in the field of neurology. I’ve really concentrated on dementia alone over the last twenty years or so. And that was indeed shaped by my personal experience.

When we moved back to California, my mom was just starting to come down with cognitive impairment and confusion, and I went down that path. I’m the youngest of four, but because I’m the doctor and the family, of course I was expected to handle everything. And as many women can understand how it was working, I had three small children and a husband to take care of.

And so I really understand that feeling of being in the trenches and looking so closely down at your feet to make sure you don’t stumble that you’re not sure if the light coming over your shoulder is from the sun or the moon because you just can’t take your eyes off of putting one foot in front of the other.

Dr. Heather Sandison, ND (02:55.989)
Yeah, that sandwich generation, right? Where you’re expected to raise children, work, and care for an aging parent. How did you do it?

Catherine Madison (03:05.126)
Well, there was a lot of juggling. you know, it and must confess there were several years there where I wasn’t working full time. because if you’re working a forty hour a week it is it is virtually impossible. And I made sacrifices or compromises with advancement of my career to try to keep that balance.

Dr. Heather Sandison, ND (03:28.705)
Yeah, there’s trade-offs always, right? Caring for your mother with Alzheimer’s, I mean, it gave you this perspective that no medical training can provide, right? So you like when you describe that like that trade-off of balancing your career by going to part-time, but it was almost like in the trenches training. It must have changed when you went back to full-time or even when you went to see a patient in the part-time that you were working. It must have changed the way you related to patients.

Catherine Madison (03:48.592)
Mm-hmm.

Catherine Madison (03:59.217)
I think it changed significantly because I I understand the perspective from the other side. And I’ll I’ll share another, you know, personal story with you. When I was in medical school, I ended up in the hospital with a severe gastroenteritis that was I got me so ill I had to be hospitalized. And the experience of of being in the hospital really taught me a lot.

and and so similarly when I’m trying to share a diagnosis, that’s always the most heartbreaking when I knew I was gonna have to meet with the family and share that the testing all looked consistent with the diagnosis of an early stage dementia. That really took some grounding to come into that meeting and and you have to really approach it with openness.

and share some vulnerability there with the patient and their their family and then just kind of choose a path that seems to fit their needs.

Dr. Heather Sandison, ND (05:13.751)
What are some of the most important things for families to understand if they’re sitting in that room getting that diagnosis?

Catherine Madison (05:20.956)
I think one of the most important things to understand is up until now it it wasn’t a real specific diagnosis. This whole field is changing in the air around us real time right now. And that’s fabulous. And so again, now doctors walking into that room, they don’t have the feelings I had when we had no cure, because now we actually have we now have treatments. but

I’m sorry, Heather, where were we going with this?

Dr. Heather Sandison, ND (05:52.588)
Just what you know, w what is it important for families to understand? And I think it it sounds like you’re saying hope, right? 10 years ago, 20 years ago, when you as a doctor provided a neurologist, provided a diagnosis of a dementia pathway, testing consistent with the early dementia, there wasn’t a lot of hope. It was basically this downhill slide. And now there’s more interventions available. So there’s there’s kind of more hope. There’s there’s more tools in the tool belt.

Catherine Madison (06:00.615)
Mm-hmm.

Catherine Madison (06:12.744)
Correct. Yes.

Dr. Heather Sandison, ND (06:21.313)
And then are there other things that you know that patients might think about or I I feel like often this comes up with cancer, right? You patients in that room, once they hear the word cancer, they can’t think clearly, they hear nothing else. Everything shuts down. And I think that that’s similar with Alzheimer’s. And I think now, like with the PTAW testing, I’ve had several people come to me who have full cognitive capacity. They are still working.

Catherine Madison (06:34.364)
their head shuts down. Mm-hmm. Mm-hmm.

Dr. Heather Sandison, ND (06:49.185)
And they have an Alzheimer’s disease diagnosis. And they go through sort of a similar experience of like, should I quit my job? Do I need to put my affairs in order, even though I’m in my early f sixties or late fifties? And I think that an understanding, I think maybe one of the things you’re speaking to is like there’s a there’s a spectrum here, and then an Alzheimer’s diagnosis doesn’t always mean a dementia diagnosis or doesn’t mean that dementia is happening in the next few days, right?

Catherine Madison (07:01.81)
Yeah.

Dr. Heather Sandison, ND (07:17.249)
that there can be a process and that there can be lots of interventions there along the way that a provider can support you with.

Catherine Madison (07:24.74)
Everything you said there is completely accurate to our current terrain. We we do have treatments now and we speak of it as a spectrum. We now know that neurodegenerative illnesses begin decades before there might be any clinical signs in terms of the blood tests which are available out there right now. The recommendation is that people not get

Those as a screen because we simply what don’t know what to do with the information. The blood tests are approved to help confirm a diagnosis when somebody has some early cognitive changes. But the the case that you are referencing there, if somebody gets gets a positive blood test and then they’re in their early 60s, and it’s like, do I change my

my whole life. And and as you very well know, there are things you can do to make changes in your life that will alter that trajectory. And that is the hope that we have today. In addition, in the field of neurosciences, you know, there are well over one hundred drugs being studied right now. And I do believe within the next several years we will have a a treatment cocktail that will approach

neurodegenerative damage to the brain from multiple facets, with inflammation being one of the major ones. I’m so happy to see that being focused on because I myself have been interested in the gut interested in the gut brain access for decades.

Dr. Heather Sandison, ND (08:59.809)
Yeah, so it’s so exciting. Such an exciting time with the advancement of science and technology. You know, one of the things that comes up for a lot of patients is this lack of self awareness. And I think sometimes especially the adult daughter, sometimes the spouse, other people in the family relating to that patient feel like maybe the patient is in denial. So how can a a family member or someone in that

Catherine Madison (09:11.739)
Mm-hmm.

Dr. Heather Sandison, ND (09:29.077)
in that orbit of a patient struggling with cognitive changes who lacks self-awareness around it, how can they distinguish between what’s driving that and and how can they help and support that patient to make good decisions?

Catherine Madison (09:43.24)
So that of course is my favorite question, because I talk a lot in my book, Navigating Memory Loss, about the condition which is called anosognosia. It’s a mouthful of a word, anosognosia but it’s a neurological term which has been around for about a hundred years. We I most people I think are familiar with it around psychiatric diagnoses. People understand that someone with a

diagnosis of schizophrenia might stop taking their medication because they don’t see where they’re needed. That’s anosognosia They don’t see that the that medicine is keeping them in a functional state. So when you have damage to the brain, if you have a neurodegenerative illness, which is destroying cells, as you destroy cells, you disrupt connections or networks in the brain. And those networks are really what allows us

to think and function at the level we do. And so there are networks in the brain which facilitate what we think of as referential thinking. So I can think about, you know, my exercise schedule that I I did this morning and I can think about the exercise schedule that I did 20 years ago and I can see where there’s a difference. I’m different.

And you mentioned an adult daughter and I always say I pick on the women because we’re two thirds of the cases. And it usually is a daughter who’s caring for her parents, although I’ve seen sons do phenomenal jobs as well. But I would have a daughter bring in her mother and I always ask about exercise because that is one of our cornerstones for brain health. And an older woman would say to me, I walk every day and the daughter would Mom, you haven’t been walking every day for a year.

Well, if you understand an alcignosia, you would understand that the mother and the daughter have different perspectives here. Because of damage to her brain, the mother cannot reference these two events in time, her walking a year ago and her walking yesterday. In her mind she’s lost the ability to make that comparison, so they’re the same. And when people can understand that.

Catherine Madison (12:03.682)
It allows them to approach communication with someone who has cognitive impairment from a completely different perspective. There was a really nice publication put out in the UK called Dementia Truths, where they interviewed individuals with impairment. They individu interviewed family members, care providers, professionals, and they explored this question.

What is truth? And they tend to promote in that something which I believe firmly in that you can have different realities. If someone’s brain is changed by a ch an illness, a neurodegenerative condition, their reality is different than yours and mine. So if you want to try and find a solution to a problem, you have to approach it.

very differently. Try to find a reality that is acceptable to them but meet the mutual goal. My my good example is when we had a woman who had she had an early stage dementia. This was several years ago, and we needed to move her out of her high-rise condominium in San Francisco where she’d been for decades and she didn’t want to leave because the view was so lovely and everything, but she wasn’t safe.

Dr. Heather Sandison, ND (13:31.426)
Yeah.

Catherine Madison (13:31.579)
Living there. And so we came up with the theory, and some people call this therapeutic storytelling. we came up with the idea that they had to replace the windows because San Francisco had changed the building codes. And if you’ve ever been in San Francisco in a high-rise, you’ll know that this is very plausible. Those old single single pane windows and that fog is rolling in. It’s freezing. So we got her out of the condo and

into a care facility where she eventually assimilated extremely well. And in terms of the construction on the windows, well, you know, there were delays in permitting. Then they needed supplies. We had contractor issues. Then there was a labor slowdown and the you know, we just kept rolling this along until it faded away.

Dr. Heather Sandison, ND (14:24.65)
Yeah, this is such a great point. I think we call it connection over correction, right? It’s how do we get on the same team? If the goal is their you know, their best interests are at heart, right? What we want is what’s best for that person and the safest place for them is in a c care community or living with loved ones. Some you know, there’s something that they’re resistant to. How can we meet them where they are? How can we create that shared reality that works for everyone? And also

Catherine Madison (14:29.882)
Mm-hmm.

Catherine Madison (14:36.24)
Right.

Dr. Heather Sandison, ND (14:53.442)
I think the the flip side of that, and this is really well explained in in Learning to Speak Alzheimer Alzheimer’s, that book, it’s I think from the nineties. Joanne Koenig Coste. The it’s the idea is that if we go in and correct them, right? If we force our issue and we’re right, then what we do is we degrade the relationship and and it spirals into defensiveness and and now we escalate emotionally rather than diffusing. And it’s an

Catherine Madison (15:08.996)
Mm-hmm.

Catherine Madison (15:15.59)
Mm-hmm.

Catherine Madison (15:22.608)
Mm-hmm.

Dr. Heather Sandison, ND (15:23.358)
All of our best interests, right? Everybody’s gonna have a better day if we can diffuse. And sometimes that no, you’re never because you live in different realities. And and so because you’re the one with cognitive capacity, it’s up to you to find the the energy and the creativity and and like to let go of some ego and meet that person in their reality. So I I’m curious, yeah, go ahead.

Catherine Madison (15:26.574)
Right. You’ll never win an argument.

Catherine Madison (15:32.88)
Correct.

Catherine Madison (15:43.216)
Mm-hmm.

Catherine Madison (15:47.855)
And then understanding that there is a neurological condition which is driving their resistance, I think really helps people. Just saying meet them in their reality is really hard. But if you understand that there is a physiologic basis for their actions, then I think we can ground ourselves better and approach it more reasonably and

Definitely get a better outcome.

Dr. Heather Sandison, ND (16:18.37)
And more compassionately, right? When when we can say this is their brain, not my person, not my mom, not my husband, then that all of a sudden makes it a little easier to cope with, I think.

Catherine Madison (16:20.271)
Yes.

Catherine Madison (16:26.48)
Yes.

Catherine Madison (16:32.728)
I agree one hundred percent and that’s what I stress in my book is and I weave an osatnosia through all of the book, just keeping it in people’s mind that don’t forget about this. Now there can also be denial. Actually I think the most denial is from the family members and friends. We all deny it because we don’t want to see it happening.

Dr. Heather Sandison, ND (16:51.07)
Yeah. Yeah, you know. That’s interesting. I’m sure you’ve had patients like where I’ll ask I’ll ask a person with full cognitive capacity what their exercise routine is, and they’ll share something that their husband or wife then jumps in and says, Well, you don’t really do it that many days a week. You know, so there’s I think there’s our aspirational projection and of our identity, and then there’s what’s closer to reality. And I guess where’s the line between something

Catherine Madison (17:13.018)
Yes. Yes.

Dr. Heather Sandison, ND (17:20.046)
pathological that you would call anog l anosagnosia and and just like and it’s and maybe denial or a projection of an aspirational view of ourselves.

Catherine Madison (17:23.704)
And offshog nosia. There you go.

Catherine Madison (17:34.982)
I think that’s all normal. We all want to aspire to be our best self.

Dr. Heather Sandison, ND (17:40.086)
And and be seen that way by others, including the provider we’re giving this information to. I

Catherine Madison (17:46.934)
I heard that so many times when a a a partner will say, They just put on such a good show for you. You should see what I deal with at home. And I would always say there, I believe that you deal with something very different than I deal with at home. I think it’s it’s really unconscionable if a provider doesn’t, you know, acknowledge that what they’re seeing in the office can be very different from what’s going on at home.

Dr. Heather Sandison, ND (17:56.055)
Right. Right. You know

Dr. Heather Sandison, ND (18:14.71)
Yeah. Now you’ve worked alongside a variety of dementia care approaches, really an impressive spectrum of interventions, including lifestyle based interventions. And I’m curious your experience Dean Ornish is up in the Bay Area and you have some familiarity, I think, with the Ornish Lifestyle Medicine program, and I’m I’m curious what your experience with that was like.

Catherine Madison (18:36.697)
Well, I actually worked with Dean for almost two years on his lifestyle intervention. I was the neurologist running the program. and so I I I had a very, very good and positive experience with that. I I came into it with a very open mind because I think that’s the way we should approach all problems. And and his the

His intervention is very similar to Dr. Bredison’s, which I know you you’ve also talked spoken with Dale Bredison and and I believe in all of those approaches and I think they really they really can help. And it it’s implementing a change in diet, which then changes your gut biome, which affects your metabolic health, inflammatory status, and again.

this whole process of inflammaging, which is now being talked about, we’re dampening that, combined with group support, regular exercise, meditation, and he always added the extra ingredient of love and community, you know.

Dr. Heather Sandison, ND (19:53.295)
Yeah. And supplementation, some nutrients, right, were included in that. Yeah.

Catherine Madison (19:57.584)
Correct. Correct. And that’s what differs. And and you’re gonna find a tremendous number of opinions on what exactly are the right additional nutrients that one should add to their diet. I don’t try to give advice there, Heather, because there are simply so many different opinions on you know, some of them I I take myself, I I take the E and the you know, the D and the C and K and you know, things like that. But

But you know, I then over the years, Dean would always offer me to get into the program and do the vegan diet. Must confess though, I never quite did that. I tend to find follow more of the meta training or the mind diet. And then I cheat. I use a really, really good pre and probiotic. So I’m afraid I must confess that.

Dr. Heather Sandison, ND (20:54.678)
Yeah it well it’s interesting, right? Because we we use a ketogenic approach. So I I Dr. Madison is my mentor. I absolutely follow his work all day long in my clinical practice and in what we do. And we spend a few hours a week reviewing patients with him. So definitely that has been our approach.

Catherine Madison (21:01.903)
Mm.

Dr. Heather Sandison, ND (21:18.112)
And I know that what’s really hopeful about it when I saw the the Ornish paper came out the week before my book did, which was really fun. And there are these two alternatives instead in terms of diet. And people are so dug in around their diet that it was really like this breath of fresh air to be like, okay, don’t go keto, go vegan, or maybe go back and forth. Right? There’s not gonna be one perfect diet for this. And I think it’s pretty well established that the Mediterranean diet and the mine diet are both great for reducing risk.

Catherine Madison (21:37.06)
Right.

Dr. Heather Sandison, ND (21:47.257)
But you’re not going to get reversal of cognitive decline. And what you saw, what you guys saw with the vegan diet, with these more drastic dietary interventions, you do see improvement in cognition. And so I think that it depends where you are, right? And so for you, Dr. Madison has great cognitive function, right? So working.

Catherine Madison (21:51.578)
Correct.

Dr. Heather Sandison, ND (22:07.934)
You don’t need to worry about maybe you’re in that luxury of prevention, right? Say same as I am. So I go in and out of ketosis. I go plant-based sometimes, especially in the summer when it’s hot and I don’t want like warm grounding foods as much. But I I think you and I are probably both a little more vata and like could use the grounding of some meat. And we saw in the recent trial that was published that that it looks like even people with ApoE four positive status with high genetic risk for dementia.

Catherine Madison (22:12.98)
Mm, mm.

Dr. Heather Sandison, ND (22:36.746)
Do better with some unprocessed red meat. So I think that there’s there’s debate in the field around this, and we don’t we don’t know exactly what the right thing to do is. I suspect that it’s gonna be pretty much your diet, right? A good, high-quality, unprocessed diet with variation, right? With room for you to go to Italy and have the gelato or to go to a birthday and enjoy the dessert on the table, right? And so it’s not

Catherine Madison (22:44.442)
Correct.

Mm-hmm, mm hmm. Right.

Catherine Madison (22:55.887)
Yes. Yes.

Catherine Madison (23:01.945)
Yeah.

Yeah.

Dr. Heather Sandison, ND (23:06.222)
Quite so so rigid. Do you have a brain health prescription for the average adult who’s looking to prevent cognitive decline as they age?

Catherine Madison (23:16.831)
I I think it’s the one that we we all agree on, you know, with which you know, which the Ornish approach, as we said, you know, vitality is based on keeping your brain stimulated, being involved with novel learning, social connections, the regular exercise, which then also needs variety, a healthy diet.

concentrating on unprocessed foods, vegetables, nuts, legumes. For me, there’s some meat thrown in there as well. But basically you want to try and make everything yourself as much as you can. And then I think we understand now you really need a good night’s sleep. sleep is not a passive process. We

consolidate memories from during the day and with the recent discovery of the glymphatic drainage system, we now understand that we drain toxins from our brain during our deep sleep. So it’s a combination of all of those things. Then we also have to throw in the mindfulness and which will help us sleep, exactly. And help us focus as well, you know. So I mean

Dr. Heather Sandison, ND (24:33.4)
Which can help us sleep.

Catherine Madison (24:40.064)
It’s a it’s a a fairly extensive yet simple solution, Heather. If you think about it, all of the things that you and I are talking about here, they’re simple. They’re clean.

Dr. Heather Sandison, ND (24:54.39)
Yeah. They’re sort of common sense, but uncommon practice is one of the ways we talk about them. Because I think society isn’t set up for that, right? You can sleep when you die, and convenience foods are cheap and easy and convenient, right? And it’s you’re encouraged to sit at your desk and just plug away and grind away and be as productive as possible and buy this and that. And it doesn’t it doesn’t support the socialization and prioritiz prior

Catherine Madison (25:07.278)
Correct, yes.

Catherine Madison (25:12.579)
Right.

Dr. Heather Sandison, ND (25:21.198)
prioritization of sleep and and good food and and movement. And so we’re kind of against the grain in terms of what society is supporting. But it’s so worth it. you know, I’m sure you’ve had this experience personally and maybe you can speak to watching patients go down this path. But there’s upside that’s more than just improvement in cognitive function and brain protection. I think I see people just living more full in engaged

Catherine Madison (25:44.942)
Mm-hmm.

Dr. Heather Sandison, ND (25:49.898)
Lives. Do you see the same?

Catherine Madison (25:53.037)
I do. but you also have to recognize that people will only do what they’re willing to do. And in practice I would always say, you know, you can we can only put our hands out and and offer interventions and such. And so then a lot of that is as a provider, really bringing yourself openly to the the d meeting with your patients for new for a conversation.

It’s not you walking in there and telling them what to do because that’s not gonna work. And so I think we will continue to forge ahead personally and professionally in setting example. And when we’re working with patients and families, laying out options and saying, Well, do any of these work for you? And this is the one I recommend the most highly.

given your situation and can we work on figuring out a way to make that fit into your life? Because again, you can recommend everything, but if it doesn’t fit into someone’s life, they’re not going to do it.

Dr. Heather Sandison, ND (27:01.366)
Yeah, it’s interesting, right? That’s always the rub. and I think that i you know, we we try to balance both because we want it to be easy enough for someone to get started. And then hopefully, you know, they’ll get that positive feedback and be able to layer more and more and more on. And when someone’s struggling with cognitive impairment, you know, we’ve we’ve thought about this because of cost, we’ve thought about this because of bandwidth, we’ve thought about this because of support. There’s all kinds of constraints that we can come up with.

Catherine Madison (27:13.486)
Mm-hmm.

Dr. Heather Sandison, ND (27:29.592)
But it’s like if you’re asking for the miracle of an improvement in cognitive decline on an Alzheimer’s path, then we’ve gotta be all in. We’ve gotta do as much as we can yesterday. And so I think there’s balance in how that is presented, that it can’t be self-righteous and it can’t be, you know, too rigid. And it has to be encouraging so that people are inspired to actually do it because it doesn’t work if you don’t.

Catherine Madison (27:29.742)
Mm-hmm.

Catherine Madison (27:36.622)
Right.

Catherine Madison (27:47.298)
Yes.

Catherine Madison (27:53.284)
Mm-hmm, mm-hmm, mm-hmm.

Dr. Heather Sandison, ND (27:54.637)
Right. And so that’s it’s a challenge. I I love having this conversation with someone else in this space because I think it really is there’s a way to navigate it. and it’s not it’s not easy. It’s not and it’s not cut and dry. It’s nuanced and it depends on the person in front of you and so many variables.

Catherine Madison (28:11.767)
Right. And we all do better when we’ve got feedback, when we’ve got positive feedback, and that’s why working with a group can generate better results.

Dr. Heather Sandison, ND (28:23.35)
Yeah, we see that in our coaching programs too. When you watch someone else, they for us it’s like getting into ketosis. We often see there’s like this light switch. Like all of a sudden they’re more articulate, they’re more present. And when you see that happen to someone else, all of a sudden you’re like, okay, maybe it’s time for me. Or you see them start exercising and you see their body changing, and maybe you haven’t fully committed and it’s like, okay, all right, I’m up, let’s do it.

Catherine Madison (28:35.543)
Mm.

Catherine Madison (28:40.769)
Yeah, yeah.

Dr. Heather Sandison, ND (28:49.686)
which is really fun. It’s part of the magic, I think, of those that group dynamics. It’s so easy for me to be, I’m sure you feel similarly. It’s so easy for me to be telling people about this, but when you watch it happen to someone else or you hear it from someone who’s implemented, that’s a game changer. I’m curious, you know, sleep is one of my favorite topics. I order a sleep study for every single one of my patients. I think my opinion is anyone struggling with cognitive impairment who should have a sleep study to rule out apnea because

Catherine Madison (28:54.147)
I agree.

Catherine Madison (29:04.867)
Mm.

Dr. Heather Sandison, ND (29:18.678)
it can have such a huge impact on cognitive function during the day. I’m curious, you know, do you do that? And also what are what are some practical things people can do to improve that deep and REM sleep that you were discussing to support long long term brain health?

Catherine Madison (29:22.72)
Mm.

Catherine Madison (29:33.367)
okay.

I would order sleep studies on anybody that I thought might have a sleep apnea. I I can’t say I would order my everybody. But if people report non restorative sleep in the morning, I would frequently order sleep study. I did a sleep study myself because I as I said to the pulmonologist at the time, I Gee, I’m ordering sleep studies on patient. I should see exactly what I’m asking them to do And I’m really glad I did it because I now I know.

Dr. Heather Sandison, ND (30:01.688)
Yeah.

Catherine Madison (30:04.427)
exactly what it is to go through sleep study. so I I do think it’s useful to order them and unfortunately you can’t go by the thinking that it’s only people who are overweight who are gonna have sleep apnea. As you mentioned, sleep apnea is a problem and it gets worse with aging, as I would say, you know, to particularly to my male patients that it’s not us women who sag

We all do with aging and all of those soft tissues in the back of your throat sag and they can block your airway when you’re trying to sleep at night. And so I’ve seen people who were very thin who have sleep apnea. Now you need to do that kind of diagnostic testing though before someone has the level of impairment that they’re not going to be able to use a CPAP device.

although for the people who are getting into these lifestyle interventions, generally weight loss will do the trick for those whose sleep apnea is being caused by excessive weight. For sleep hygiene, that’s something we can always counsel people on. And even though we we focus on hours of sleep and it

Research is suggesting that it isn’t necessarily the hours of sleep that are as important as regularity of sleep. And so for ourselves with a little bit of effort, we can follow a regular schedule, and that’s one of the most important things you can do to improve your sleep health. Then the standard things like not exercising late at night,

Limiting alcohol or more and more we’re saying virtually no alcohol is the best for our system. Limiting your fluids in the evening, concentrate your fluids early in the day.

Dr. Heather Sandison, ND (32:10.04)
Yeah.

Catherine Madison (32:11.049)
As we take water there. because then i you’re not gonna need to get up as much in the night to empty your bladder. If you are having that problem, talk to your doctor about medications and get you know, maybe get your bladder checked out because we can have changes in the bladder and and there are treatments for that outside of medications. So so lots of different things. But I tell people to

Most important is to focus on having a regular schedule.

Dr. Heather Sandison, ND (32:43.714)
Yeah, getting to bed within this like a thirty minute window. If a your bedtime is nine thirty, then you’re in bed by nine fifteen or nine forty five and really trying to f make that window as small as as sh tight as possible. We we see that people their efficiency really shifts when they can commit to one bed bedtime. and so it’s almost like jet lag, right? If you’re going to bed at eight thirty one night and eleven thirty the next night and eight thirty and then two AM and that is it’s like a type of jet lag. You’re

Catherine Madison (33:04.771)
Yes.

Dr. Heather Sandison, ND (33:13.666)
Your brain’s very confused. I’m curious, after spending your career caring for patients with dementia and witnessing your mother’s journey, do you know your own genetic risk? And how do you think about, you know, communicating with your own family about that risk or what you would want if you were ever diagnosed?

Catherine Madison (33:37.239)
I cover that in my book because I think that’s really important. As a culture, we don’t generally like to talk about death, you know, which is really correct. I know. I’ve had my kids say to me, Mom, not everybody’s as comfortable talking about death over the dinner table as you are. And I I have been known at the dinner table to bring out a card game called Go Wish.

Dr. Heather Sandison, ND (33:46.626)
Well, it was even uncomfortable for me to ask you that question. Yeah.

Catherine Madison (34:07.52)
Which is a fabulous card game produced by a nonprofit called the Coda Alliance, which is over in Berkeley. And it’s a deck of cards which put out things that one may or may not want if they’re at the end of life, you know, or they’re very close to the end of life. And it’s from like having my family with me to being at home versus being in a hospital. And you sort through the cards into

what is the most important to you, what’s kind of in the middle, and what’s a discard. And you have different sets of cards. So each person does that and then you compare the most important pile and it’s a great conversation starter and extremely valuable. So that’s one thing that I have done in my home that I recommend to people a lot.

I then also am a big advocate for writing a dementia specific directive. When I would ask people, do you have your advanced health care directive in place? And the automatic answer is yes, and then I’d follow up with, Do you know what it specifies and where it is? what what what it’s somewhere? you know. So we need to update those and

I actually put together a dementia specific directive combining several sources, but I made mine very, very short and sweet. I was also influenced by an immersion experience at the Holkovek in the Netherlands, which is their dementia community, where moderate to severe dementia patients live and they’re given free roam.

Around the community, their physical health improves. And they approach life very differently. In the Netherlands, there were trip hazards everywhere. We were stunned, you know, fountains and you know, stairs and things like that. And we said, we would point them out, and the directors there would say, literally, things happen. And so that’s kind of what I have in my dementia-specific direct.

Catherine Madison (36:33.442)
In that if I ever come down with a dementia where I’m no longer able to control my life and make my own decisions, I don’t want my life prolonged. And for everything we do, for all of the strategies we implement, we might still end up in that sort of a state. And so I’ve said very clearly to my family that I

If I’m impaired and I I’m not living independently, I don’t want any diagnostic medical tests or treatment that would prolong my living or my dying. I want comfort care only. I further stipulate that let me eat whatever I want. Don’t ever folks coax or cajole me to eat, even if there’s risks with that. Because I’ve

Dr. Heather Sandison, ND (37:27.574)
Like choking or aspirating.

Catherine Madison (37:30.878)
Risk of the risks are aspiration. But I’ve seen too many cases where people developed severe cognitive impairment and ended up in a non-ambulatory, bedbound state with someone feeding them, bathing them in bed, and changing them. And the family members would be standing around saying, She never wanted this. But she ended up there because we’re all well meaning.

And we think that we’re helping someone by when they get a pneumonia and they have severe cognitive impairment. Of course, we want to get a chest x ray, of course, we want to start them on antibiotics. And our middle daughter, we have three daughters. Our middle daughter is the first one for making healthcare decisions, and she’s in that point because the entire family agrees she’d be the first one to pull the plug. And every now and then she’ll ask me.

Mom, do you really mean that? And I’m like, Yes, sweetheart. I really do because I saw my own mother go through that. And it was terrible.

Dr. Heather Sandison, ND (38:40.574)
Yeah. You know, a friend of a very close friend of mine lost her dad this past week and they went through the process with physician-assisted end of life. And he had had pancreatic cancer and was in a huge amount of pain. And it was really this eye-opening journey they went on because it was so different from what most people choose.

And when he decided that he was ready to drink the drink that would end his life, he, you know, he like got this burst of energy and he was able to talk to his wife and talk to the kids and the grandkids, and they he decided who he wanted in the room, and it was very intentional. And the kids, his granddaughter was reading her book, and his grandson, who’s five, was doing a puzzle, and it really normalized and

created this kind of ceremony and they had you know there were flowers of course and and all of these well wishes and it was a spiritual process but I think I saw the pictures after and there’s pictures right there’s pictures of this process and all these people who were present for it and it was so radically different from what I think most people experience was like this you can choose something else and that might not be the right thing for everyone of course but

Dying in a hospital with all of the bells and whistles ringing and Yeah. That isn’t the right thing for everyone either. And so to have this ability to intentionally choose is really kind of this radical notion.

Catherine Madison (40:10.185)
The tubes.

Catherine Madison (40:16.384)
Right.

Catherine Madison (40:22.795)
Well, we have to have the conversation first. And so we’ve got to talk about it. And in our society, we have to write things down. so I’ve also seen families where they had the conversation but they never wrote anything down. And then there are disagreements among family members about what the right thing to do. And so for family members, making tough decisions is made easier if you write down what you want your family to do.

Dr. Heather Sandison, ND (40:24.876)
Yes, you gotta talk about it.

Catherine Madison (40:52.871)
And what you’re talking about there, the death with dignity, they it specifically excluded anybody with cognitive impairment. They had quite a bit of difficulty in the state of California getting that law over the finish line in the first place. And there were too many people who felt that if they included anything with cognitive impairment, that was a slippery slope. so I have known people who’ve gone to Switzerland.

Dr. Heather Sandison, ND (41:21.486)
Yeah.

Catherine Madison (41:22.185)
where you can either get an you can take a potion or you can get an injection. But it’s interesting, you know, you have to be very careful in doing that in that you have to have a a psychiatric evaluation over there. You’d have to have two, to determine that you have the capacity to make that decision to take your life. So if someone waits too late, then they may not have that option.

This is a really heavy talk we’re having here, Heather. It’s hard and every situation is unique.

Dr. Heather Sandison, ND (41:52.406)
And even if

It’s very hard. Yeah. And there’s another episode for anybody who’s interested in this. We have another episode with Keith where he his wife decided to go to Switzerland and take that path. And he talks through what that looks like because as you’re mentioning, logistically, it’s a lot. You know, he was talking through she was at a stage where he couldn’t let her go into the women’s restroom and the international airport by herself because she wouldn’t be able to find her way back to him. So she was that.

Catherine Madison (42:09.041)
you did that good.

Dr. Heather Sandison, ND (42:25.304)
far along. And so he had a female friend come with them. And then yeah, that even just the experience of international travel, she was much more disoriented. And so the psychiatrist might not have allowed her to go through with it because of the disorientation just associated with jet lag. So they needed to have enough time for her to get settled, to regroup, to get on the time zone. And then they went and met with them.

Catherine Madison (42:30.846)
Wow.

Catherine Madison (42:37.365)
Yeah.

Catherine Madison (42:41.761)
Correct.

Dr. Heather Sandison, ND (42:51.938)
But she was very, very, very clear that that was the option she wanted, right? And it’s not for everyone. And I do think it’s worth everyone knowing that it exists. And yes, there’s not a state in the US where there the death with dignity is a possibility for someone with cognitive impairment. You have to have that six month prognosis. And so understanding that and knowing that that’s something that may need to be navigated.

Catherine Madison (42:58.646)
This is

Catherine Madison (43:10.997)
Right.

Dr. Heather Sandison, ND (43:19.436)
these timelines they lengthen and shorten without us with outside of our control, right?

Catherine Madison (43:23.423)
Right. Yeah. What what I talk with families about is and I talk with patients about this, is that you know, as we age and we accumulate medical conditions, because that simply tends to be part of aging. And life does become more difficult. We might look upon if if we’re at that point where life is difficult.

We might look upon something like a pneumonia as an opportunity to make a graceful exit. And so that’s kind of how I phrase it. And for the people, not not many people want to choose to take their life. You know, that’s that is uncommon. it’s nice that it’s out there. I’ll be surprised if we see it in the United States. But anyways.

There are other I look at it as there are other opportunities which do present themselves. And I have been with families where someone is really very impaired and they get something like a urinary tract infection, I will say, Well, we could give antibiotics or we could call in hospice support here. And they may even be on hospice and I’ll say, We could ask hospice to focus on comfort care. And the family will say, No, no, no, no, I’m not ready for that yet. That’s fine.

That’s fine. Because oftentimes something else comes along and then the next time they are ready for that. It’s a process.

Dr. Heather Sandison, ND (44:55.838)
Yeah. Yeah. It’s a process and there’s not one right decision. There’s different dynamics in every family. There are so many considerations and understanding the options and that you’re not trapped sometimes you are, but that there are things to consider along along this path. I think it’s hopefully gives people more agency.

Catherine Madison (45:03.765)
Correct.

Catherine Madison (45:20.543)
Mm-hmm.

Dr. Heather Sandison, ND (45:21.23)
I’m curious the lessons that you’ve learned about aging and resilience and purpose and meaning from your patients over the years.

Catherine Madison (45:25.92)
Mm-hmm.

Catherine Madison (45:30.516)
I’ve learned a lot from the patients who I found were grateful for what they had. basically looked were who concentrated on counting their blessings. I always learned a lot from those individuals because I think if we look th if we go through life and we look at the raw deals that we got.

I think that that negative perspective has negative consequences on our health and well-being. So I always grow with individuals who I surround myself who share mutual positive energy. It’s synergistic. And so I’ve grown from a lot of patients and their families. And I feel really good when they can understand what I’m trying to teach them about anosognosia, about

planning, about approaching decisions, that helps me feel better grounded that I’m doing good work.

Dr. Heather Sandison, ND (46:36.342)
That’s beautiful. For someone who’s facing a diagnosis or even high genetic risk and feeling overwhelmed about that, what would you most want them to know?

Catherine Madison (46:47.37)
That there are strategies they can implement in their life right now to alter that trajectory. And with altering that trajectory in the near future, I think we will have more medications that they can then add to those treatments. So it is indeed getting brighter in the fairly near future. I mean, is that gonna be three years, five years? I I think that’s quite realistic.

Dr. Heather Sandison, ND (47:17.134)
That’s a very hopeful message. On this podcast, we talk about living well, not just living longer. And I think you are certainly a model for that, not just for your patients, for for everyone that you touch. With everything you’ve learned as a neurologist, a daughter, a mother, an author, a wife, and a caregiver, the many roles. What brings you the most joy in your life at this stage?

Catherine Madison (47:34.291)
Yeah.

Catherine Madison (47:41.194)
I’m sorry, what’s most wet? My dog is barking in the background.

Dr. Heather Sandison, ND (47:44.248)
the most joy.

Catherine Madison (47:48.501)
my goodness, that’s an interesting question because I I can’t say I would ever pin it on any one thing. I I I think it’s almost like a field of flowers. So I mean how can you pick out how can you pick out the one which is the prettiest? And so I look at life like that. I I would have to say though, at this stage in my life, grandkids are the biggest joy.

Dr. Heather Sandison, ND (48:17.614)
That’s fun. That is so fun. Good stuff. Dr. Madison, thank you for sharing both your professional expertise and your personal wisdom and journey with us today. It’s really a privilege. One of the things I appreciate most about your work is your ability to have hard conversations and bring both clarity and compassion to topics that feel so overwhelming and challenging.

Dementia affects memory, but it affects those relationships as well. Identity, the way that we think about the future, and even think about that graceful exit. And so your insights are just this wonderful reminder that we can’t control everything, but we can approach these challenges with understanding, with clear preparation, and with humanity. I want people to know where they can find your book.

Catherine Madison (48:41.344)
Thank you.

Dr. Heather Sandison, ND (49:05.659)
And it’s called Navigating Memory Loss Essential Questions and Answers on Alzheimer’s and Dementia. So again, tell them where they can find that, Dr. Madison.

Catherine Madison (49:14.79)
It’s it’s available anywhere online. where books are sold, I mean locally at book passages, but you know it it it’s available online, it’s it’s available digitally, and I I really enjoy the feedback I get on it with people appreciating the way it’s organized in a question answer format, so it’s simple. And as you said, I tried to take

Dr. Heather Sandison, ND (49:18.18)
where books are sold.

Catherine Madison (49:42.804)
the difficult questions over the years where I found that the answers were the most valuable and put them together into a short read that you can get through in an afternoon.

Dr. Heather Sandison, ND (49:53.844)
Nice, wonderful. What a fantastic guidebook and resource. Where can people find out more about you? Do you have a website? Are you still taking patience?

Catherine Madison (50:03.488)
kind of no in tune taking patients. Yeah, I I I I work I work with seniors at home and as as you mentioned earlier, I’m the medical director at Rhoda Goldman Plaza. So again, as we talked about, working in a group and a community helps you support yourself. And so I’m working with a wonderful group of people and I consult on the patients that are in that organization.

Dr. Heather Sandison, ND (50:06.443)
Read the book.

Dr. Heather Sandison, ND (50:32.579)
Wonderful.

Catherine Madison (50:32.704)
but otherwise I’ve really tried to dial down the wide exposure in my life. I I w went through many years where too many people wanted a piece of me and that was too draining. Yes.

Dr. Heather Sandison, ND (50:44.62)
Yeah. Yeah. Now you can focus on grandkids. Yeah. So wonderful. Well, Dr. Madison, it is a absolute pleasure to have you here. Thank you so much for your time, your expertise, and all of the work you do to care for our community. It’s been a pleasure. And until next time, for all of you out there, please share this if you have found it valuable with friends and family alike. And until then think well and age well.