16 Mar 2009

Ken Kosik, a neuroscientist at the University of California, Santa Barbara (UCSB), is the executive director of Cognitive Fitness and Innovative Therapies (CFIT), a “one-stop cognitive shop” that opened 6 March in Santa Barbara (see ARF related news story). The center aims to remove Alzheimer’s and its manifold related issues from the hospital ward. Its goal is to combine all of a person’s cognitive needs—diagnostic, social, psychological, practical, treatment-related—under one roof in a homey, friendly setting. CFIT aims to serve its already impaired clients in a more holistic way and help younger clients delay the impairment that often comes with aging by taking proactive advantage of new research about mid-life risk factors for late-life dementia.

Before coming to Santa Barbara, Kosik spent two and a half decades as a professor at Harvard Medical School and neurologist at the Brigham and Women’s Hospital memory clinic in Boston, Massachusetts. In 2004, he crossed the country to become co-director of UCSB’s Neuroscience Research Institute. UCSB offered everything he wanted in the way of research, but lacked a medical school to nourish his clinical interests so Kosik conceived of CFIT as a different approach to cognitive fitness.

Q&A

ARF: How did the idea of CFIT come about?

KK: In looking over how the problem of cognition in elders is handled now in tertiary [specialized] care centers, it became more and more obvious to me that that model, although it has certain strengths, was not doing the job. It is not really getting at the problem of Alzheimer disease, in terms of the numbers of people affected, and in terms of all the communities that are being impacted.

One problem with putting a lot of our attention to Alzheimer’s in tertiary care settings is that they are often based in close relationship to academic hospitals. And the economic engine of a hospital is generally surgery; this is how hospitals make their money. If you look at some of the leading killers of people in the United States, like cancer and heart disease, part of the treatment does involve surgery. So hospitals have no problem paying attention to those very serious and really important conditions.

Alzheimer disease is a non-surgical condition. Therefore, it is treated as a kind of poor sister. It is marginalized and may get the least desirable real estate. It is sometimes hard to find those [clinics]. I remember the memory disorders clinic at the Brigham was located in a place where, if [patients] found it, you already knew that they were navigationally intact.

Alzheimer’s is also marginalized in other settings, such as the offices of doctors who are splitting their time between academia and private practice, or are entirely in private practice. Even in that group, there is little incentive to treat Alzheimer disease. The amount of time that is required for an Alzheimer’s patient is totally disproportionate to what you get reimbursed. You get much better reimbursed by doing procedures. Many doctors do not want Alzheimer’s patients in their waiting rooms, because they can be disruptive to other patients. When Alzheimer’s patients begin to ask questions about moving to an assisted living facility, or about genetics, clinical neurologists and primary care doctors are not trained to answer those questions.

A lot of the services that Alzheimer’s patients and their families really need are non-physician services. The physician is an important piece, but it’s not necessarily the main piece. In fact, after the diagnosis is made, what the physician can do becomes diminishingly small. If you want to go into other settings, you really have to put together your own package. Who are you going to talk to about diet? Who are you going to talk to about social work? There’s nothing where this all exists in one place.

Something else has happened that has made it even more important to do what we’re doing. That is the realization that if you intervene in midlife, you can actually delay the onset of Alzheimer’s, or if you have it, you can slow its progression. The data for those interventions, most of which are lifestyle and medical optimization, are by now unequivocal. If we’re really going to have an impact on this disease, we have to be able to recognize it before it even happens. The best time to treat Alzheimer’s is before it strikes.

ARF: How is this center different from any other Alzheimer’s clinic?

KK: What we’re doing is to move the treatment of Alzheimer disease out of the tertiary care setting and set up cognitive shops in communities and try to demedicalize it so that in one place, all the services that people need are available. One community, to begin with, is here in Santa Barbara.

Although we will certainly help people who have Alzheimer disease or cognitive impairment, we focus on people who are at risk, or who may be worried about Alzheimer’s. When you think about who’s at risk, it’s almost everybody. We put all of the various services and needs of people who are either at risk or have the disease in one physical place. They don’t have to assemble their own package; we have already assembled it.

On the other hand, we are not a medically fringe operation. We have a data set that we require on everybody, important standard medical information that has been established as a risk factor for cognitive impairment. We have MDs here who, like a human Web crawler, will go through people’s records to find flags about future cognitive impairment.

I won’t pitch this beyond what the reality is. We are the first to admit there is no cure for Alzheimer’s. We are not preventing disease; we are simply delaying its onset.

ARF: How is the physical setting of CFIT different from other clinics?

KK: We call this a living room setting. We have attempted to take away the medical feel of the location, because so much of what goes on related to cognition is not really medical. It involves exploration of one’s life goals; it involves diet; it involves exercise; it involves things that are outside of the strictly medical model.

ARF: Are there similar efforts elsewhere?

KK: I don’t know of anything quite like this. I’ve looked carefully and haven’t seen anything at all.

ARF: What were the challenges in putting this center together?

KK: Because it is so novel, communicating what we’re doing is very important. And to understand what exactly this is has been sometimes challenging for some. While I think ultimately we will reduce medical costs, it has required some up-front investment. But the community has been very generous with us. [CFIT is funded by private investors; patients will have to pay for services, although Kosik hopes to eventually offer “scholarships” for some clients.]

ARF: How will the center integrate research with clinical practice?

KK: In several ways. One, we are very interested in the outcomes for people who participate in this program. This includes, first, an evaluation, and then we introduce people to a series of interventions. If you do all this as a package, then we’re interested in your outcomes.

ARF: So you’re not setting up a clinical trial with specific groups of people assigned to certain therapies?

KK: A lot of this is personalized, so we are letting people figure it out for themselves. But we also appreciate the importance of control groups, and doing research in a way that is going to be statistically valid. We are tied in to a number of the assisted living communities in the Santa Barbara area, which we would be able to tap for a control group—people who didn’t buy into the whole lifestyle optimization and medical optimization. So one aspect of our research is outcomes. Another aspect is the building of a virtual online community of elders associated with CFIT that would allow us to use social network principles for getting adherence to cognitively healthy regimes.

ARF: Like a CFIT Facebook group?

KK: It is a bit like a CFIT Facebook group but actually goes beyond that. The motive for many kids who plug into Facebook is that they want to see what their friends are up to: I just went to this great party; I just found out about this great band. The motive for our groups to log in is to keep track of how people are doing with regard to cognitively healthy parameters in their lives. Whether it’s their amount of exercise, the kind of diet they eat, they can see how their social network is dealing with an age-specific problem. We know from very elegant studies among smokers, and people trying to control their weight, that social networks do have influence on medically relevant behaviors (Christakis et al., 2008).

Another area in which we are intent on doing research—we have to if we are going to survive—is medical economics. It’s important that we validate that our approach is going to save money. I think it will because we reduce the amount of MD time such patients need. We move the problem out of more expensive real estate settings. We may also find that we reduce transitions to assisted-living facilities, or visits to emergency rooms. If this proves to be true, it will be a good argument that our model reduces medical costs.

ARF: What can the center offer for people who are mentally healthy at the point they come in?

KK: Our first client was very mentally healthy. He was a 45-year-old athlete who wrote about CFIT for Outside magazine. We were not yet open; so we actually just did a condensed version of what we do. We developed a program that would help him keep his cognition optimized and age successfully, all of the things that we talk about. I think that if we’re going to have an impact on Alzheimer’s in this country, it’s the middle-aged people we’ve got to pay attention to.

ARF: Suppose I came into your center and my genetic profile showed a high likelihood of getting AD. What advice would you give me?

KK: We’re very interested in genetics. We have established a relationship with Navigenics [a personal genome-scanning service in Redwood Shores, California]. We are acutely aware that, increasingly, people are going to come in here with some genetic knowledge. It may be as simple as the fact that a parent had Alzheimer’s, all the way to carrying their personal genome in the folder as they walk in the door.

What you get here, in contrast to what you would get in most medical settings, is a degree of genetic sophistication about what that risk actually means. When you say you are at risk for Alzheimer’s, does it mean that you’re in a family that carries a dominant gene and there is a 50 percent risk? Or does it mean you are ApoE4 positive and your risk goes up, but it’s not that high? It’s very important to us that people really understand the nature of probabilities in genetics. That kind of conversation is very hard to have with most doctors; they’re not trained in the area.

If you come in and you say, “Okay, now I fully understand my genetic risk. What are we going to do?” then we simply say that you should be a bit more aggressive about actually implementing these lifestyle modifications that can make a difference.

ARF: What lifestyle modifications do you recommend?

KK: Step one: an evaluation. Step two: preparing a program of cognitive challenges for the person. That is often computer-based. Three: preparing an exercise program for the person, something suitable for elders, something other than going to a gym with a lot of muscle-bound guys. Four: providing information about diets. Five: we’re not afraid to talk about supplements. There is scant data on supplements, and we’re not pushing any of them. But we will talk about the data. We believe that an informed individual is what really is most important. Six: through our virtual environments and through our encouragement of bringing people in as groups, we try to prevent isolation among elders and enrich their social milieu. So all of those are lifestyle adjustments that you can get here. Seven: perhaps the final one might be some attention to stress, and what the future may hold. So we are prepared to talk about lifestyle, goals, all those aspects that elders may want to consider now that they are retired and things have changed for them.

ARF: Do you envision, ultimately, that every town is going to have one of these centers?

KK: I don’t mean to be grandiose. I don’t know how this will actually play out. But we definitely need in this country more attention to cognition at the community level. And how do we go about that? One way is to introduce cognitive shops more widely. They have to be viewed like your gym; they have to be viewed as a fun place to go.

Amber Dance Interviews Ken Kosik

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