Preventing and Reversing Alzheimer’s: Dr. Heather Sandison on the Bredesen Approach, Ketosis, and Root-Cause Care
Dr. Heather Sandison is the founder of Solcere Health Clinic in San Diego, California and Marama, a pioneering residential care facility focused on personalized, root-cause approaches to dementia. She is also the primary investigator and author of a peer-reviewed study published in the Journal of Alzheimer’s Disease demonstrating improvements in cognition using a personalized lifestyle intervention, and the author of the New York Times best selling book Reversing Alzheimer’s. Her website is DrHeatherSandison.com.
Transcript:
Dr. Weitz: If you’re looking for clinically useful insights, not wellness hype, then this is the place for you. Welcome to the Rational Wellness Podcast, the podcast for functional and integrative practitioners who wanna practice with greater clarity and precision. I’m Dr. Ben Weitz, and each week, I sit down with the leading clinicians, researchers, and lab innovators to explore the science, lab testing, and clinical reasoning behind modern root cause medicine.
This is a show focused on practical, evidence-informed insights that you can actually use in patient care. Please subscribe to the Rational Wellness Podcast on Apple, Spotify, or YouTube. Please tell your friends and colleagues, and if you could give us a ratings and review on Apple or Spotify, we would certainly appreciate it.
Finally, to access the show notes and the full transcript, please go to my website, drweitz.com. What [00:01:00] if everything we’ve been told about Alzhei- Alzheimer’s disease is incomplete? I’ve been practicing saying Alzheimer’s ’cause I tend to say it with a T. For decades, Alzheimer’s has been treated as a progressive, irreversible condition, managed but not meaningfully improved But a growing number of clinicians are beginning to challenge that model, asking a different question: What if cognitive decline isn’t a single disease at all, but the result of multiple modifiable factors?
Today’s guest, Dr. Heather Sandison, is at the forefront of this shift. She’s the founder of Solcire Health Clinic in San Diego, California, and Marama, a pioneering residential care facility focused on personalized root cause approaches to dementia. She’s also the pri- primary investigator and author of a peer-reviewed study published in the Journal of Alzheim- [00:02:00] Alzheimer’s Disease, demonstrating improvements in cognition using a personalized lifestyle intervention, and the author of the book Reversing Alzheimer’s.
She’s one of six clinicians who participated in the first randomized clinical trial using this precision medicine model pioneered by Dr. Dale Bredesen for managing patients with Alzheimer’s disease, the EVANTHEA trial, which is currently undergoing peer review and hopefully will soon be published. In today’s conversation, we’ll explore how a precision medicine approach can uncover the root causes of cognitive decline, what the latest research shows, and how clinicians and patients can think differently about prevention and treatment.
Dr. Sandison, welcome again for the second time to the Rational Wellness Podcast.
Dr. Sandison: Thank you for having me, Ben. You know, I will just update, I was not a clinician involved in the EVANTHEA trial.
Dr. Weitz: Oh, you were [00:03:00] not?
Dr. Sandison: No, I was not.
Dr. Weitz: Oh, okay. Okay.
Dr. Sandison: I am d- in touch with them and- … have learned a lot from them.
Dr. Weitz: I’m sorry, I’m sorry.
Dr. Sandison: No. And work very closely with Dr. Bredesen-
Dr. Weitz: Oh, okay …
Dr. Sandison: through the NeuroScience Institute, but I was not amongst those clinicians. Although the trial that we did in in our office was a precision-based multimodal intervention. It was the Bredesen protocol, but it was just-
Dr. Weitz: Right …
Dr. Sandison: a single site at my office, and it was-
Dr. Weitz: Oh, okay
Dr. Sandison: randomized and controlled. But-
Dr. Weitz: Oh,
okay … yeah,
Dr. Sandison: o- on the trajectory- … contributing to the research there. Yeah.
Dr. Weitz: There you go. Sorry about that.
Dr. Sandison: No, no stress at all.
Dr. Weitz: So
con-
Dr. Sandison: I appreciate being… it’s an honor to be lumped in that category with those docs. But I’m not quite there yet.
Dr. Weitz: Conventional medicine treats Alzheimer’s as a single disease caused by the accumulation of amyloid plaque in the brain.
Dr. Sandison: Mm-hmm.
Dr. Weitz: Patients are treated at first with symptom-modifying medications like Aricept that increases acetylcholine, Namenda that blocks glutamate, and then with [00:04:00] amyloid-reducing medications like lecanemab and donanemab, but unfortunately, patients don’t get better. The most they can hope for is to slow the cognitive decline. What are the drawbacks of this model of Alzheimer’s, and how should we think of Alzheimer’s disease?
Dr. Sandison: Yeah, great question. So, to your point, the amyloid… There’s these beta amyloid interventions. They’re really good at getting rid of amyloid plaques in the brain. We have established that we can do that. And so you mentioned lecanemab, Leqembi, Kisunla is another one that’s out, and the issue with these medications, so they’re antibody therapies that are infused into the system, and they take amyloid out. Great job getting rid of amyloid. That doesn’t equate to improved cognitive function, unfortunately.
And there was a recent Cochrane review that was published in April of 2026, and in it, the author’s conclusion [00:05:00] after looking, reviewing all of the literature associated with these antibody therapies was that it doesn’t work, that it, there’s no meaningful improvement in cognition. There’s risk of both brain bleeding and b- brain swelling, and we need to look at alternative mechanisms of action. Getting rid of amyloid does not mean anything in terms of clinical improvement in outcomes. And so what does that mean? What are these alternative mechanisms, right? So you have a beautiful houseplant behind you that is thriving. If we were to look at that houseplant, if it was starting to get brown and sad and droopy, we wouldn’t look at it and go must be misfolded proteins.
Let’s get them out.” Right? We would think… I mean, this is, like, common sense but uncommon practice, right? We would look at a houseplant, a complex organism, right, a living thing, and we would think, “Does it have enough water? Does it have enough nutrients? Is it being poisoned? Does it have enough sunlight?” Right? And so why would we think about the human brain or human [00:06:00] body any differently, right? It’s a complex organism with multiple factors inputting and right, inputs and outputs that have feedback mechanisms that all equate to basically a directionality in the health of the system and even at the cellular level.
So for us, we’re talking about the neuronal level, the neuronal health, the cells in the brain. A- and in fact we’re thinking about the microglia, right, the immune system of the brain. We’re thinking about all the cells that make up the brain and how it functions. And are we activating towards attack, defend, you know, we’re basically… Like, are we in that fight, flight, freeze, attack, defend mode, or can the brain get the signal that we are in that reconnect, regenerate, heal, digest, rest, in that mode? And when we’re in that mode, we can make new synaptic connections. We can remember where we left our keys or where we put our phone down. We can remember the appointments on the calendar.
All of our cognitive function [00:07:00] functions better when we’re getting that signal. So what we need to do is upgrade the paradigm, and the literature absolutely supports this. A multifactorial lifestyle-based intervention leads to clinically relevant outcomes and improvements in cognition.
So we’ve seen that in you know, you were mentioning the Evanthea trial, but before that in 2022, Dr. Bredesen led by the lead author on that paper was Kat Toups. They published the first the first intervention on… It’s a multimodal intervention, very similar research design to the one that I published a year later in 2023.
Both of those were published in the Journal of Alzheimer’s Disease. They had 25 participants with MoCA scores, so the Montreal Cognitive Assessment is a way to put a number on someone’s cognitive function Everyone had cognitive decline in that study on a MoCA of 19. 30 out of 30 is perfect, 26 and above is normal.
As you get closer to zero, that indicates a worsening cognitive function. So they had those [00:08:00] 25 participants, 84% of them were better within nine months. Then a year later, I published my trial, which was 23 participants, six-month intervention, and further progressed MoCA scores between 12 and 23. So f- for the progression, we did not excuse pe- exclude people with a diagnosis of Alzheimer’s, and we saw 74% of them improved cognitively.
And then a year later in June of 2024, Dean Ornish up in San Francisco, he published a trial with, Th- this was a controlled trial, and he showed that with the lifestyle intervention, similar but a little bit different lifestyle intervention in just four months, in 20 weeks, he showed improvements in cognitive function as well.
And then just in the summer of 2026… Excuse me, we’re not there yet. Th- just in the summer of 2025, the Alzheimer’s Association had the POINTER trial had funded the POINTER trial, and that was published 2,111 participants randomized into two groups. One was a more structured [00:09:00] lifestyle intervention, so more coaching, more hands-on with diet, exercise, stress management, sleep optimization, versus the control was just the information.
So they were given the information, but not a structured program. And lo and behold, both interventions both of those, both the the control and the more structured intervention improved. But of course, what you would imagine, the structured intervention improved more cognitively. So again and again, we see that these lifestyle interventions are making the difference. That’s how we get clinically meaningful improvements in cognition, not through the medications that you listed on the intro. So what do we need to do? What is this paradigm shift about? Instead of thinking about that houseplant, like we need to take out the misfolded protein, so we’re gonna have this single molecule intervention, that by the way, is patentable, and so it makes sense for pharmaceutical for the pharmaceutical in- industry to invest the millions, if not billions of dollars it takes to get something from concept [00:10:00] to FDA-approved, right? So you can’t get FDA approval on a multimodal individualized lifestyle intervention. Just doesn’t work that way. You can’t patent that.
Dr. Weitz: Right.
Dr. Sandison: And so no one is gonna ma- get the ROI on that. And so-
Dr. Weitz: Right. So you’re talking about the economics of-
Dr. Sandison: Yeah …
Dr. Weitz: medical research and why don’t we have better research, and this is one of the reasons why you hear a lot of criticism of the Bredesen protocol and of functional medicine in general is, you know, why don’t you have randomized clinical trials with thousands of participants that cost millions and millions of dollars? And that’s because who wants to fund that?
Dr. Sandison: Yeah. And so Dr. Bredesen and myself, both of us received philanthropic funding for the studies that we did. Right. Right? These are people who didn’t, it didn’t need the ROI. Right. They didn’t… There wasn’t a business case there.
Right.
And it’s very challenging. You know, that takes luck, right? Like that- Yes. And so- Yeah … and the Alzheimer’s Association is a huge nonprofit so they have significant resources to [00:11:00] put into that. They put $50 million into the first phase of that, and I think have invested another 70 million into another into extending that trial. So the paradigm shift, the way I like to think about it, ’cause we wanna structure this, right?
We want to have… R- it can be overwhelming if we start to say, “Okay, there’s multiple things that cause Alzheimer’s and dementias,” well, then what are those multiple things? How do we systematically move through those and understand if those are important for us? So the Lancet Commission report came out originally in 2016 or 2017, and then it was updated in 2020 when everybody was distracted by COVID, and again in 2024. And it is a commission report on dementia, and essentially they suggest that 45% of worldwide dementias are preventable through modifiable lifestyle interventions. Li- modifiable risk factors. Some of them are lifestyle, others are medical interventions. But that’s a huge number of dementias, a huge amount of cost, a societal cost, right?
As anyone who knows someone with dementia, [00:12:00] Alzheimer’s is aware It can be financially bankrupting. It is so exhausting physically. It is emotionally heartbreaking, right? And so the cost’s not just to the patient, but to everyone in their network. And so if we can reduce, right, if we could prevent 45% of worldwide dementias, this is huge societal benefit. And I would argue that number is closer to 80 to 90%, based on what I’ve seen in my clinical practice and what we’ve seen at Marama, what we’ve seen in, in, in the research we’ve been lucky enough to do. So, okay, the paradigm, the upgrade in the paradigm. Instead of a-
Dr. Weitz: Well, let me point out one thing I think that is something that needs to change in terms of mindset, and unfortunately, there’s probably a lot of things. But one important thing is the thought that the brain, you have a certain amount of neurons that you’re gonna have by the time you reach age 25 or 30, and the rest of your life you just lose neurons, and we thought the same thing about bone. [00:13:00] And the reality is we have to understand that our brains are constantly in, going through building and losing neurons, and that process continues throughout your life. And so even into y- your 70s, 80s, and beyond, you can still be creating new neurons, forming new neuronal connections and forming new synapses, and we have to understand that concept if we’re gonna even think that this is possible.
Dr. Sandison: Yeah, and I would slightly modify that. We don’t you know, the research and my understanding of it is that we don’t really create a whole lot of new neurons.
Now-
Dr. Weitz: Okay …
Dr. Sandison: there’s obviously, like every cell in the body, we’re getting new fats and new proteins and we’re always-
Dr. Weitz: Right …
Dr. Sandison: recreating and modeling. Okay. And new neuronal connections, is that it? The synaptogenesis that’s really important. Okay. And so my understanding is that when Einstein, like when his brain was autopsied, they thought that he would have a bigger brain with more neurons.
What he had was more synaptic [00:14:00] connections And so it’s the connections between neurons that’s so crucially important. It’s the network that is important, and that’s the signaling we want. We want synaptogenesis. We want the creation of new connections, and that is, I mean, I won’t say easy to get, but it’s easy to choose for, right?
It’s easy to do things. And there, there are herbs, there are supplements that help with synaptogenesis. There are peptides that help with that, and there are lifestyle… the foundation of this is the diet, exercise, stress management, and sleep optimization. Those things. And also social connections, right?
Those synaptic c- synaptic connections that we get from, you know, the mirror neurons and from seeing other people. We can see this from the SuperAgers research. There was a p- a study published in the past year out of Northwestern on SuperAgers, and it showed that the common denominator between people who have the cognition of someone in their 50s when they are in their 80s is their s- social connections.
And so [00:15:00] w- and they could see that part of the brain was actually larger on volumetric imaging. So th- there’s a huge impact that our socialization plays in our cognitive function. But the paradigm shift is that we need to take seriously the complexity of this d- disease by having an intervention that matches that complexity.
We need to systematically go through the causal level factors that are going to drive a neuropathophysiological process, and those factors, we need balance in them, right? Not too much, not too little. It needs to be in the right place. It needs… Things need to be happening at the right time, and that is true for toxins, for nutrients, for stressors, for structural issues, for signaling, and then for infections, right? We need enough immune function. We need enough signaling. We’re gonna be exposed to to pathogens, but we need to resolve that and not have it lingering, not have it driving chronic inflammation [00:16:00]
Dr. Weitz: Right. So we don’t necessarily want to remove all inflammation. We just want to keep it under control and keep it balanced, ’cause inflammation is part of how the immune system helps us fight off toxins, infections, et cetera.
Dr. Sandison: Yeah, and Misfolded proteins like phosphorylated tau and beta amyloid, they are part of the immune system. They are both antimicrobial. They are there to protect us, so if we just take them out, if we just rip that out, we end up sometimes with more risk than reward.
Dr. Weitz: Yeah. Essentially, we have to think of the reasons why amyloid and tau are there, and some of the reasons are because they’re protecting the neurons against infectious agents like bacteria and viruses and toxins, and we’ve even found microplastics in the brain, and so the body’s actually trying to protect the brain.
Dr. Sandison: Very well said. Yeah, exactly.
Dr. Weitz: So if [00:17:00] we could remove as many of those triggers to begin with- You might get actually a better benefit from those medications if maybe layered on at the end if needed
Dr. Sandison: I would say instead of might, y- more often than not you do. You get a, you get better outcomes.
Dr. Weitz: Okay. So, maybe we can go through a few of those drivers of cognitive decline.
Dr. Sandison: Yeah, absolutely. So I think toxins are a piece that the conventional system misses most, right? Infections they’re looking for to some degree a- and, a- nutrients to some degree, but toxins are really a place where I think the conventional system falls flat. And so we look for three different types of toxicity. We look for mycotoxins or biotoxins, we look for metals, and we m- look for chemical toxicity. And some of those more than others are directly neurotoxic. But regardless, what we wanna do is reduce toxic burden because you can imagine, you know, it’s just like a… Dr. Bredesen talks about the [00:18:00] brain like it’s a country, right? My Brain-istan. So if you think about a country that’s at war, right, that has toxic invaders and infectious invaders, it, it needs to put all of its resource into fighting that battle. It shouldn’t be building roads and schools, which is gonna be that synaptogenic connection, right? You’re not building infrastructure if you are busy fighting a war. Your resource, whether it’s B12 or glutathione or whatever, or ATP, right, it needs to go to resolving that battle, to, to figuring that out when
you-
Dr. Weitz: and dropping as many missiles as we can onto- Yeah … the brain is probably not gonna effectively resolve that situation.
Dr. Sandison: No. And so what we need is to get up and over that so that we can basically switch where we use those resources, right? It can go into repair and regenerate. So when we can reduce toxic burden-
Dr. Weitz: why do you think the medical profession is, ha- has a tough time seeing toxins as a factor, [00:19:00] despite the fact that there’s tons of research coming out all the time about toxins in the environment and the health effects?
Dr. Sandison: You know, I’d be speculating. I think there’s a handful of reasons. One, they’re so ubiquitous, and they’re also… It’s really hard. Y- mold is such a good example. You have two people in the exact same environment with very different responses to that toxic exposure. And so because it’s, it… You can’t equate, like, a if this, then that very easily because there’s so much variability in how people respond to them.
And a lot of it is delayed, right? You might have atrazine exposure in your teens, and you don’t end up with cancer until your 40s. But a- and there… Again, it’s multifactorial, right? So it’s not an if this, then that. It’s very much, so if genetic predispos- just like Alzheimer’s. So you’ve got genetic predisposition plus toxic exposure, plus you have constipation, so you can’t, and you can’t eliminate, plus you have type 1 diabetes or type 2 diabet- any diabetes, plus you have a traumatic brain injury.
All of a sudden you’re stacking things. Right. Right? You’re stacking factors. For somebody else, that could be very different, right? It might be that they have mercury toxicity from amalgams and fish exposure or… and plus they’ve got herpes virus, and they have shingles, and they, you know, and they have Lyme, right? Very… And they’re sedentary. Very different risk factors, but they’re stacking up to lead to the same diagnosis. And for one person, that might mean cancer. For another person, it might mean Alzheimer’s.
Dr. Weitz: What about some of the other factors, like infections? And when do you screen everybody for all of these factors, or do you try to base it on the history?
Dr. Sandison: Yeah, so I’ve joked with some of my colleagues naturopathic colleagues who are in the longevity space. It’s like my book could have been written for healthy aging, right? We just have this Alzheimer’s kind of bent on it.
Dr. Weitz: Right.
Dr. Sandison: But it’s the same stuff, right? What you for cancer, for heart disease, for brain health, we’re all [00:21:00] singing the same song. You want to get the toxins down, the toxic and infectious burden down. You want to get nutrients balanced, and that means both your, you know, macronutrients. You want metabolic flexibility.
So we don’t want to have insulin resistance or glycotoxicity where we have too much glucose in the system. We don’t want diabetes. And so we want to be able to go back and forth between burning fat for fuel, burning sugar for fuel, keeping our blood sugar pretty stable, getting off that roller coaster of spikes and drops.
And then- so
Dr. Weitz: That’s actually kind of an interesting concept that I think most people tend to be in the either/or. Either you’re gonna follow a vegan diet or you’re gonna follow a ketogenic diet. And so what you’re suggesting is something where you are somewheres in between a Mediterranean diet and a keto diet, where you your body’s able to use ketones for energy as well as glucose.
Dr. Sandison: Yeah, it kind of depends where we are in the spectrum. So the Ornish trial did [00:22:00] use a vegan diet, and I think that what we will see… The study has not been done. Again, I am speculating. But I think what we will see play out in the literature over time is that the best thing to do is go back and forth.
So when we think about our ancestral diets, the consistent thing about ancestral diets was inconsistency. So you would have periods of famine, periods of abundance. You would have, you know, seasons where there were lots of fruit. Blueberries and raspberries and blackberries were in season. You would have more sugar in your diet.
And then you had, would have periods where that, all you had was animal protein available, so you were in ketosis. And so I think that what we’ll see is that going back and forth, having that ability and that metabolic flexibility exposes you to variety, which I think is really important for nutrient balance. I had a patient once who was so sensitive to so many foods, all he ate was steak and broccoli for months. He ended up with a thallium toxicity from the broccoli.
Dr. Weitz: Oh, wow.
Dr. Sandison: So a- and I’ve had patients who are vegan who, you know, they add, “Okay, I’ll add salmon.” They end up with high mercury, [00:23:00] and salmon doesn’t have that much mercury, but if you’re me- eating salmon 12 meals a week–that’s gonna significantly impact your- Right … mercury levels. Eggs. If you have, you know, if you’re eating 16 eggs a week, you’re gonna ha- it’s gonna have an effect on your cholesterol. But if you eat six eggs a week, probably not. And you eat salmon four times a week- you’re gonna have a different profile, right?
So I think what we want is variety. We want to mix things up. And w- the biggest take-home around diet is to eliminate processed foods. We also see the biggest jump in cognitive function when people get into ketosis. So it’s the single intervention that gives you the biggest benefit. Not for everyone, and it’s not guaranteed, but consistently we see that when you can get your ketone levels up, your blood ketone levels up over two, we see big jumps in cognitive function
Because the brain can function on ketones.
It’s resource. So what we see in the [00:24:00] very rare cases, this is in basically research scenarios only, where ketones and sugar are available to the brain your brain prefers to burn ketones. You have less oxidative stress. There’s a detox component to burning ketones as fuel, and it seems to be a better energy, a better fuel source, particularly as we age.
Regardless of our diabetes status, as we age, the brain is less sensitive to insulin, and it has a harder time turning glucose into ATP, that fuel our cells run on. And so when we’re like… I mean, it’s amazing. It’s just this incredible divine design, right? Like, we can switch fuel sources. We’re like hybrid engines.
We can switch to ketones, and you can do that either through, through diet, right? Through restricting carbohydrates, increasing fats and proteins, but you can also add exogenous ketones, and that can be a helpful way to get those ketone levels up without limiting, without restricting so much.
Dr. Weitz: Yeah. There used to be a lot of exogenous [00:25:00] ketone esters and other ketone products on the market, and not so much anymore. I’m not sure why, but do you-
Dr. Sandison: They’re out there. They’re definitely out there.
Dr. Weitz: Do you have a particular product that you like?
Dr. Sandison: Yeah, there’s a few. So there’s ketone salts and then ketone esters, and then there’s some middle ground in there.
Dr. Weitz: Okay.
Dr. Sandison: And the ketone salts are less expensive. All of them taste like gasoline in my opinion. Some are better than others, but the ketone salts are, they do have salt, so, like, for somebody with salt-sensitive hypertension, we want to avoid that. And they’re not gonna raise your blood ketone levels quite as much, but they will help get you up over the edge. They can help with sugar cravings.
They can help… I use them, I call them my donut days, so when I’m first getting into ketosis I, like, obsess about carbs. I haven’t eaten donuts in a long time, but I will think about donuts or sandwiches or I don’t even eat sandwiches when I’m not in ketosis, right? I will be obsessed with carbs for, like, that first 24 to 48 hours, and if I have some ketones, then that can help get me over the edge.
Also, fat bombs are these [00:26:00] delicious, yummy, sweet treats that we use, like allulose or monk fruit or stevia as a sweetener, and they’ve often got cacao and cinnamon and, like, all kinds of yummy flavor. So fat bombs are another way, if you’re well prepared. When you’re getting into ketosis, you could do that instead of a donut.
So the ketones, the ketone salts tend to be cheaper. We use Perfect Ketones. They’re available on Amazon. I… They don’t pay me to say that. And then I love Ketone IQ is one of my favorites. Again, it tastes very chemically, but it, Ketone IQ is a ketone ester precursor. So it’s not a ketone ester, so it’s not $20 per serving.
It’s like four or five, three to five dollars per serving. I see. So very expensive. And then like the Delta, there’s a Delta something. I don’t buy these often because they’re so expensive. But the ketone esters are the ones used by like professional athletes, and those can run 20 to $25 per dose. So you’re not g- that’s not sustainable to usually use those every day.
The other thing is coconut [00:27:00] oil or MCT oil. Right. So those are… Yeah. Th- Mary Newport a friend and a mentor of mine who I adore, she is a proponent of coconut oil. And coconut oil is depending on which coconut oil, there’s a significant amount of medium chain triglycerides. So these shorter chain, they are saturated fats, but they’re very short chain.
They’re absorbed differently in the system, and they are the building block. So they are the precursor to beta-hydroxybutyrate or the ketone that your brain will burn. So that is a nice alternative. You can just take tablespoons of coconut oil or MCT oil itself. But the tablespoons of coconut oil, also coconut oil will h- be a little bit antimicrobial, so it can help with sugar cravings, it can help to reduce candida in the system.
So it’s a nice way to get started. You don’t want to do too much at first because it can lead to diarrhea, so you want to go slowly on that. I usually have people start with like a teaspoon three times a day, so it’s [00:28:00] divided doses, and then increase. Mary Newport will sometimes get people up to, you know, 15 tablespoons of coconut oil a day, very high doses.
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So when evaluating a patient for Alzheimer’s disease using the precision functional medicine model- … what cognitive test do you like to administer?
Dr. Sandison: Yeah. So depending on where someone is, we’ll use the MoCA score. The Mo- the Montreal Cognitive Assessment is [00:30:00] great. It’s well-validated. It tracked almost exactly with the Cambridge Brain Sciences, a much more nuanced… when we did our clinical trial, we did both of course, and the Cambridge Brain Sciences and the MoCA scores, they tracked almost, the, it right in sync.
There was one patient who improved on Cambridge Brain Sciences and was the same on the MoCA score. So th- there was just this one exception where they weren’t dire- like, exactly in sync. We get a lot more information from, like, a longer neuropsych eval, but they tend to be extremely stressful. MoCA scores are best for people who have more pronounced…
Like, it’s not just subjective cognitive changes. It’s actually measurable and, like, it’s… If we pick it up on a MoCA and it’s below 24, below 22, the MoCA’s probably our best tool. M- when MoCA scores are above 22 but people notice changes, then we use CNS Vital Signs, so, like, Central Nervous System, CNS Vital Signs.
Right. And that’s something you can do at home on your computer, and it, again, [00:31:00] there’s, it’s more nuanced in terms of what it picks up in the different domains of memory and cognition. So- Those are the primary two tools we use and then I’m happy to get into the blood testing for Alzheimer’s as well.
Yeah.
Dr. Weitz: First mention what type of imaging, and then let’s go into the labs.
Dr. Sandison: Yeah. So imaging we run in we run MRIs, brain MRIs without contrast. We do volumetrics, and w- we also do ASLs, which is the arterial spin labeling, which looks at perfusion. And perfusion typically is going to be-
Dr. Weitz: Wait, wait. What is that called again? Arterial…
Dr. Sandison: Spin labeling. This is hard to get, and I hesitate to even talk about it because there’s only one place that I know of in the world that does it and only one… we work closely with Pacific Neuroscience Institute, Tower Imaging, d- Dr. Raji.
Dr. Weitz: Oh, they’re right down the block from where I am
Dr. Sandison: Yeah, they’re right near you.
Dr. Weitz: In santa monica.
Dr. Sandison: Yeah, and we, yep, we send all our patients up to Santa Monica, and then we work with Dr. Cyrus Raji a pr- a t- a preventive neuroradiologist to review all of those. And w- it’s labor-intensive, but we review each of them [00:32:00] one by one.
Dr. Weitz: And what does that test get you?
Dr. Sandison: Well, it tells us certainly volumetrics. And it… Well, you know, with imaging, it’s important for anyone with cognitive changes to get imaging because there are things like normal pressure hydrocephalus, which is a treatable form of dementia. You can have a lesion. You want to understand if you have vascular dementia.
If you have an amyloid angiopathy, we wanna be really careful that you don’t end up with a bleed, right? So there’s there are really important things to get out of just a conventional MRI, so I recommend that people do it. What we do is sort of that on steroids, where we’re looking at perfusion studies because a reduction in perfusion is going to come before a reduction in volume, right?
You’re gonna have less blood flow that’s going to lead then to a shrinkage of the hippocampus or area the prefrontal cortex, where- whatever we’re looking at, right? So we want to… And then also, on the flip side of that, if we’re looking for improvements in brain volumes, which we see in some of the studies, [00:33:00] then what often predates that, right, we’ll see before that as a precursor, is an im- improvement in perfusion.
And so that, those studies can be very helpful. They’re most helpful when you have serial studies, and I… So that means, like, annually. If you just have one, can be very helpful, but it’s even more helpful if you’re looking year over year, right? Because we all have, you know, anomalies in our anatomy, and so we don’t know if you start with low brain volumes, have you always had lower brain volumes on that bell curve, or is this a progression from something that was once normal or even above average in terms of volumes?
So Imaging is important to get. We do it in a relatively nuanced way that’s not widely available, but we find very helpful, and I hope that will be adopted, you- you know, more broadly.
Dr. Weitz: That’s great. I gotta give them a call. Which let’s talk about lab testing.
Dr. Sandison: Yeah. Lab testing is a bit nuanced as well.
So what’s exciting is you [00:34:00] no longer have to do an amyloid PET scan to basically confirm that there’s an amyloid pathology happening, an Alzheimer’s disease process going on. Now, p-tau217 is the marker that you can get that is basically correlated very closely to those amyloid PET results, and it’s called p-tau, which is confusing because that stands for phosphorylated tau, but the p-tau217, two one seven, directly relates to amyloid pathology.
So confusing, but true. Aß ratios are at 42/40 are another blood biomarker that you can run. NfL is another one more associated with traumatic brain injuries a- and inflammation. But I would caution people, you know, the what we see is that the p-tau217 does not correlate to cognitive function. So you can have amyloid present and have great cognition.
It does not mean that you have Alzheimer’s dementia if you have a positive p-tau. It means that you have [00:35:00] an Alzheimer’s process at play, and it increases your risk, almost the way that genetics increase risk. But the p-tau might go up, and f- so it might be more abnormal And cognition might be improving.
Wow. It might go down, and cognition might be declining. So it might get closer to normal, and cognition might be declining. So I do not recommend using it as a serial marker. I look at them annually. I, we were told that it was supposed to work that way, so I used to look at them every 12 weeks. I no longer do that because it’s very upsetting when the number gets worse, but it can change.
It can get worse, right? Like, the p-tau can become more abnormal with weight gain, with weight loss, so with weight changes, with synaptic, synaptogenic activity. We- p-tau’s elevated in children, right? So an increasing p-tau can be a good sign, and we don’t yet know how to interpret it exactly, so I recommend that people hold it loosely.
Look for trends. I think in the next [00:36:00] few years we’ll understand a lot better how to interpret it, but it, we cannot interpret it the way that it was originally designed.
Dr. Weitz: Ah, interesting. Fascinating. Great.
Dr. Sandison: Okay. Aβ ratios, on the other hand, seem to correlate a little bit better with cognition, but I wouldn’t rely on them entirely, right? Use the CNS vital signs, MoCA scores, neuropsych evals. Those are definitely a better indicator of cognition, of course, ’cause that’s what we’re measuring.
Dr. Weitz: And then let’s talk about the other biomarkers.
Dr. Sandison: So the you know, our cognitive testing, our imaging, our p-tau, Aβ ratios, NFL, these, I kind of think of them as, like, a measuring stick. “Okay, where are we on the spectrum? W- are we just in the risk category? Are we in early stages? Are we more moderate? Are we more severe?” And those what they don’t tell us is why. Imaging does to some degree, right? Vascular dementia or or an NPH or Lewy body, whatever. It- we can pick up some of those things, but we those [00:37:00] things aren’t really gonna tell us about the treatment or about unraveling these imbalances driving the disease process, right?
They just kind of tell us where we are. And what th- this other category of workup, right, for toxins, nutrients, stressors, structure, infections, signaling, that is really where we’re excited to play, right? That’s those causal level factors that if we cor- where we correct the imbalances and that leads to these downstream effects of better neural, neuronal health, excuse me, and better cognitive function. That’s what’s exciting. That’s the real fun that we get to have.
Dr. Weitz: Right. Can you make a comment about nutrient status? The cheapest, most widely available nutrient tests are serum levels, and I often have issues with complaints about the fact that the serum B12 is above the range, or that the serum folate is above the [00:38:00] range.
And I find a significant percentage of patients who maybe have a elevated homocysteine and some of these better functional measures of B vitamin status. And so I continue to see benefits in adding B vitamins, and then somebody who maybe isn’t doesn’t run nutrients that readily will see an elevated B12 and tell the patient they have to stop all their B vitamins.
Dr. Sandison: Yeah. Great point. So this happens to us, too. My… I tell patients, you know, d- f- that’s why I get paid the big bucks, right? Is to help interpret these labs. Because just because it’s flagged doesn’t mean that we need to do something about it, it doesn’t mean that it is abnormal. And sometimes things that aren’t flagged are abnormal. Like triglycerides, it’s crazy. They don’t flag them until, like, 200 or 150. I think 150. I want triglycerides-
Dr. Weitz: Yeah …
Dr. Sandison: I want triglycerides under 75. Like, less than half that. Right. S- and then B12, I want that to be flagged as [00:39:00] high. I want it up over 2,000. I want your folate up over 20. And-
Dr. Weitz: Thank you for saying that. I hope some of my patients- And to- … hear that
Dr. Sandison: And to your point, what am I using to guide that? It’s homocysteine. If you have a homocysteine over seven a- and it, homocysteine over 10 is associated with accelerated brain atrophy. And different people, some people don’t take a single B vitamin. They’ve got really low B12, really low folate, and their homocysteine is at seven. It’s right on target. They have different genetics when it comes to methylation status. And so somebody else might have really high B12 and folate and their homocysteine is at 15 We have to add other methyl donors, whether it’s SAMe or trimethyl glycine.
We’ve got to add even additional methyl donors to get that homocysteine level down. Because it’s reflecting, you know, like this is the phenotypic ex- expression, right, of the genotype. So genetically they’re not methylating, [00:40:00] and then we can see that in the outcomes, right? This phenotypic outcome of homocysteine.
If it’s true for homocysteine, it’s probably true for histamine and anything else for neurotransmitters, for anything else that requires methylation to be turned on or turned off. So we need to add additional methyl donors. It’s gonna have a huge effect on detoxification, on immune function on cognition ultimately. And homocysteine is just a marker for that, that gives us an indication of how much this individual needs.
Dr. Weitz: Right. Similar issues is some of the labs that I see, the conventional labs have started putting a level of vitamin D as normal between 30 and 50, and patients come in with 60 and they’re told they have to stop all their vitamin D.
Dr. Sandison: Oh my gosh, I haven’t seen that range. Oh. Usually it’s like at 110 or something they’ll flag it, or 100 that they’ll flag it. I like patients to be between 60 and 90 on vitamin D, and then always watching calcium. You know, parathyroid [00:41:00] adenomas will drive cognitive decline, amongst many other things.
So we’re always kind of screening for parathyroid adenomas, making sure that calcium level is under 10.0. That’s another one that won’t get flagged until, I think, 10.5, and th- that’s pretty high for an adult. Adults should not be over 10.0, and if they consistently are, if they have had kidney stones, osteoporosis, if they have fatigue, cognitive changes, irritability, GI complaints, that can be a parathyroid adenoma, and I’ve probably seen a dozen of those in my 15-year career so far. It’s enough, it comes up enough that I don’t want to miss it, ’cause it’s such an easy fix. I mean, relatively. It’s a, it can be a relatively quick, simple surgical fix, which is never sim- you know, there’s no such thing as minor surgery, right? But, you know, people are better within a week. It’s wild.
Dr. Weitz: Great. Let’s get into treatment. I do have a hard stop around 9:00.
Dr. Sandison: Yeah, me too.
Dr. Weitz: Okay. So [00:42:00] when it comes to treatment strategy we have ma- patients often have multiple drivers. How do you prioritize treatment?
Dr. Sandison: Yeah, I don’t. I, you know, it, well, I guess you, you sort of asked this question earlier and I didn’t answer, but it depends on where someone is, right? If we are in the luxury of prevention, right, you know your ApoE status- Okay … and your family history, and we have that luxury, then where do we start? You know, we start with the gut. We do some detox. We give you some of these foundational pieces, but we’re not in a rush the way we are- Right … if somebody has more significant decline, when we wanna do everything yesterday.
Dr. Weitz: Okay.
Dr. Sandison: And then y- you’re a provider, right? It’s just, a lot of that is the art of figuring out what’s gonna work for someone. Yeah. How, you know, financially, do they have support? Someone with cognitive impairment, man, it’s hard for me to change my lifestyle, let alone- Yeah … somebody who’s cognitively struggling.
Dr. Weitz: Sure.
Dr. Sandison: And so they’re gonna need to have that caregiver support. Is the rest of their family on board? Do they [00:43:00] have access to Erewhon, or do they Or, you know, or do they you know, live in a relative food desert where it’s really hard to get good, high-quality food? Do they have access to physical therapy
Dr. Weitz: or- Or can afford a $25 strawberry
Dr. Sandison: Right. Yeah. It’s it that, it’s very real, right? The pragmatic application of this- Sure.
Yeah …
has to be considered. But you know, in my book, Reversing Alzheimer’s, at the end, I think it’s page 317 one of our coaching participants, Barbara, she came up with a daily dozen of 12 things you can do for free every day to help with your cognitive function. And so it doesn’t have to be expensive. But if you wanna go faster, you know, it, you can spend more money.
Dr. Weitz: Right. So, what is some of the core pillars of treatment? Yeah. So a- again, diet, exercise, life- you know, it’s these lifestyle things. We look… If I, if there was one takeaway from today, right? It’s testing for sleep apnea.
Dr. Sandison: If I have someone in my office who has a change in [00:44:00] cognition or is at risk for dementia over the course of their lifetime, then I want to know if they have sleep apnea, and I want to know that they don’t have it. So I order a sleep study on anyone with cognitive changes or at high risk for dementia.
Dr. Weitz Home sleep study or in office?
Dr. Sandison: Do it at home. Yeah, we typically do it at home. And the gold standard of sleep studies is an overnight sleep study in a clinic. However, the WatchPAT, again, they don’t pay me to say this, but WatchPAT is tech- technology that we really appreciate because it simplifies it.
You can do it at home with a watch and a ring, and it beams the information up to a sleep doctor somewhere who can then get you a CPAP covered by insurance. Amazing, right? So that we want to take advantage of, because I’ve seen too many patients who have undiagnosed, untreated sleep apnea, and that’s essentially like mild brain damage every night.
All of us know who’ve, like, been jet lagged or, like, sleep deprived, your brain doesn’t work if it doesn’t get good rest, and there’s many of explanations for the mechanism of why this is. We need that deep sleep to get that glymphatic rinsing. We need to process [00:45:00] our memories and during REM sleep. We need enough sleep.
We need high-quality sleep so that we can function each day. So that is a, that’s a huge one that often will get missed. But we just systematically go through toxin panels, nutrient panels. We look at cortisol levels for stress. We ask a lot of questions about: What brings you joy, and where do you find purpose and meaning, and what are your stress management practices, and do you live in the place you consider home?
You know, all of these things have a big impact. Caregivers are at very high risk for dementia later in life because of the stressors. And then structurally, we’re looking for the airway. We’re looking at for obstructive sleep apnea. We’re curious about cardiac calcium scores and carotid artery patency.
Can you get blood flow in and out of your brain? Are you getting that sleep? Do you have a chronic pain? Those are all structural issues. What’s your genetic status, your ApoE status and how is your… How do we evaluate your risk for dementia? Signaling. We’re looking at stress hormones, sex hormones.
We’re looking at thyroid hormones, vitamin D, all of the hormones, BDNF. Like, [00:46:00] the-
Would you say hormones are a something that really tends to move the needle?
It does, yeah. Not for everyone, but for a lot of people, yes, it does. And then infections. And,
and when it comes to sex hormones, especially women
Yeah, and men.
You know, we see testosterone and we use, I use enclomiphene. I don’t tend to use testosterone for men. Okay. But I do use DHEA and enclomiphene and it does make a difference for men. It makes a difference in muscle, right, of course, and that’s gonna send the signaling, the BDNF signaling. But hormones, when we’re, when our hormones are peaking, you know, in our late teens and early 20s, that’s when we’re making social connections.
We’re learning trades. We’re going off to school. Like, our brain is ripe for those connections to be made, and we don’t need to go back to the hormone levels of our early teens or late teens and 20s, but we do wanna approximate that. Those are youthful hormones. Those are youthful signals that help us.
The brain has receptors. All neurons have receptors for DHEA, pregnenolone, estrogen res- progesterone, and testosterone. So we [00:47:00] need … we don’t necessarily need it. Obviously, there’s a lot of people who do just fine without, but we often benefit from getting those signals to the brain.
Dr. Weitz: And the newest signaling molecules that are very popular these days are peptides.
Dr. Sandison: Yeah. Now, there’s not a single peptide that is great for cognition. You’ll hear Selank, Semax, Cerebrolysin, Dihexa. These are ones that come up in the cognition space. There’s sort of risks and benefits to each of those, and I see them be, like, okay. They’re not-
Dr. Weitz: Okay …
Dr. Sandison: phenomenal. They’re not like GLP-1s. If you want a peptide for weight loss, man, have I got one for you, right?
Like, they’re not you know, gut healing. Man, Liraglutide and BPC I mean, there’s not much that work- Aloe is amazing, but it doesn’t work like Liraglutide. You know, it is, it’s, I, there are so many great things that we can do with peptides. Insulin, of course, obviously, right? For diabetes for 10
Dr. Weitz: But are these GLP-1s being misused?
It’s, you just [00:48:00] look at some of the photographs of some of the celebrities and it’s really scary.
Dr. Sandison: You know, I can’t speak to that. I’m not a doctor for any of them. But I think- … that there’s, like any tool, there’s a time and a place. Yeah. And with weight loss, you’re gonna get some, like, misuse of that.
But I used to be afraid of them, and I use them more liberally this, these days, in smaller doses. But for inflammation, certainly for weight loss, I think if you can get down A1C, if you can get down lipids, if you can get inflammation down, you’re going to ru- reduce the burden of disease. And and if you need GLP-1s to get there, e- especially temporarily, I’m the, and you need to get enough protein, you need to get enough weight-bearing exercise, you ne- you need to get strength training.
There’s ap- an appropriate way to use them, but they’re a tool, just like many of the others.
Dr. Weitz: That’s great. So I think we’re gonna wrap right there. And of course, we could talk for hours. I but that’ll be for another time.
Dr. Sandison: It’s such a privilege to be here with you. Thank you for having me here.
Dr. Weitz: And it’s such a privilege [00:49:00] for you to come on here and share your time and knowledge with us.
How can listeners find out more about you, get in touch with you, your programs, your centers?
Dr. Sandison: My website is Dr. Heather Sandison, S-A-N-D-I-S-O-N, drheathersandison.com, and my book is Reversing Alzheimer’s, which is available wherever books are sold.
Dr. Weitz: And your memory care center,
Dr. Sandison: You know, I am actually now consulting with other- Oh, okay
larger memory care centers. And so we don’t have those ones available anymore.
Dr. Weitz: Oh, okay. Okay. Sorry. But they’ve informed- I should have updated my bio.
Dr. Sandison: No. They’ve informed a ton of what we do and how they, basically we’ll have a bigger impact working with, you know, 300 bed communities versus us having a couple of 12 bed ones.
So.
Dr. Weitz: I see.
Dr. Sandison: Different strategy to have a bigger impact. We’re excited about
Dr. Weitz: it. That’s great. Excellent. Thank you so much.
Dr. Sandison: So good to see you. Thanks for having me.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help overcoming a gut or other chronic health condition, and want to prevent chronic problems, and want to promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a consultation for functional medicine.
And I will talk to everybody next week
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