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

**Peter Attia** (0:11)
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My guest this week is Dr. Gaia Devi.
Dr. Devi is a neurologist and psychiatrist specializing in memory disorders, cognitive neurology, and women's brain health. She is the founder of New York Memory and Healthy Aging Services, and a clinical professor of neurology at Zucker Hofstra Northwell School of Medicine. Her practice spans the full spectrum of Alzheimer's disease from asymptomatic high-risk individuals through advanced dementia, and she is known for a personalized multimodal approach that integrates biomarker-guided diagnostics, anti-emolloid therapy, hormonal factors, and lifestyle interventions. I've wanted to have Dr. Devi on the podcast for a while now because the field of dementia is changing rapidly. For a long time, Alzheimer's disease was viewed as really kind of a one-way decline, diagnosis with very little room for nuanced intervention. But she takes a very different approach, one that is highly individualized, focused on early detection, careful risk stratification, and matching the right combination of treatments to the right patient.
In this episode, we talk about how to think about dementia as a spectrum, including Alzheimer's disease, but also vascular dementia, Lewy body dementia, and many other mixed presentations in between, as opposed to discrete diseases. The evolving biology of Alzheimer's disease, including amyloid, tau, neuroinflammation, and why pathology does not always map neatly onto symptoms. How she evaluates high functioning patients with very subtle cognitive changes, and how she thinks about biomarkers, ApoE4 risk specifically, and testing asymptomatic people. We talk about anti-amyloid therapies, which have become very controversial, although slightly less so today than when they were initially released, including Lecanomab and Decanomab, their risks and benefits, and her approach to reducing side effects, including the most devastating side effects which we talk about. Why some patients with Alzheimer's disease may stabilize or even improve with a personalized multimodal treatment strategy. The overlap between Alzheimer's disease, vascular dementia, and Lewy body dementia, including why Lewy body disease is often confused with Parkinson's disease. The relationship between menopause, estrogen, and cognition, including her specific concept of menopause-related cognitive impairment. And finally, how early detection, AI-assisted monitoring, neuroinflammation, targeted therapies, and more personalized treatment may reshape the future of our dementia care. So without further delay, please enjoy my conversation with Dr. Devi.
Gaya, so great to be with you today. Very excited to talk about this. It's a topic that we've discussed a number of times on the podcast. But unfortunately, there's always a lot to talk about here. And I think you're a physician that of course is near and dear to our heart in the practice. We co-manage a number of high-risk patients, and I've just always been impressed by the way that you have taken a very personalized approach to managing this condition. But I just want to let folks get to know you a little bit better. So you're both a neurologist and a psychiatrist, is that correct?

**Gayatri Devi** (4:28)
That's correct. I'm imported in multiple specialties, neurology, psychiatry, brain injury medicine, pain medicine, and behavioral neurology. But my subspecialty is really memory disorders, primarily from a neurological perspective. But all these other areas allow me to better handle people with cognitive impairment.

**Peter Attia** (4:50)
I'm just kind of curious as you think about the evolution of your career. When you started, which is obviously not that many years ago, you're still quite young. To where you are today, what has been kind of the biggest shift in your understanding of the de-menting conditions that we're going to talk about today?

**Gayatri Devi** (5:13)
I think two things, Peter. One, that over the years of my practice, I've come to realize that pretty much all de-menting conditions, and particularly Alzheimer's disease, can present variably depending on the person who has the condition, and also depending on comorbidities. So there really is a spectrum aspect to Alzheimer's and dementias, which people don't recognize. They think of it as an all or nothing disease, and that's not true. Much like autism, it really can span the spectrum from very mild impairment that doesn't get worse, to severe impairment that kind of deteriorates rapidly. That's number one, that dementias are really a spectrum disorder.