Integrative medicine in the care of elders: Interview with author-clinician Mikhail Kogan, MD
April 5, 2018
by John Weeks, Publisher/Editor of The Integrator Blog News and Reports Editor’s note: This analysis article is not edited and the authors are solely responsible for the content. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of Integrative Practitioner. George Washington University integrative medicine leader Mikhail (Misha) Kogan, MD, was one of the first academicians to adopt Dale Bredesen, MD’s ReCode protocol aimed at slowing down or reversing Alzheimers disease and cognitive decline. Kogan remains closely linked to the formerly UCLA-based researcher. He contributes his experience with a set of his patients to the global understanding of the outcomes of the method. Yet the editor of Integrative Geriatric Medicine, a new 600-page volume in the Weil Integrative Medicine Library at Oxford University Press, is quick to draw a distinction. On the one side there is the field of anti-aging medicine – or “Immortality Medicine” as he says it is called in Russia. Here the focus is often on healthy, active, engaged and well-to-do patients. On the other side is the growing mass of pro-aging human beings in the United States and elsewhere who are typically beset by multiple chronic conditions. Most are on at least four medications and many on 10 to 15. These seniors – who Kogan prefers to respect as “elders” - are contributors to the first declines in life span in the United States over the last 2 years. For most of these, anti-aging explorations are financially out-of-reach. Kogan says his core mission with the book is to bridge integrative practices into regular care of those in the second category. To do so, this Geriatric specialist - who is also boarded in Internal, Palliative, and Integrative Medicine - recruited an interprofessional set of over 4 dozen authors to write the book’s 36 chapters. Some chapters are modality specific and some condition specific. Others are especially specific to this population: falls, long-term care, integrative palliative care, and more. I caught up with Kogan to explore what he has learned from developing and editing the book, and from his practice experience across both these elder population sub-categories. I also asked him to share outcomes from his clinical experience with the Bredesen protocol. Weeks: Other than in the anti-aging area, we don’t see a lot of content on senior care or elder care at integrative conferences. How challenging was it to find the expertise for the chapter writers for this edited volume? Kogan: It’s extremely hard to find good people who are focused in this area. We have many who focus in anti-aging medicine but this is a different demographic. The typical longevity-oriented patient is 60-70 years old, vibrant and healthy, on 1-2 meds and very well off. There is a huge gap between them and the 60% of elders who are quite sick and have little access to integrative care. The hardest part of getting the book together was finding the right chapter authors. Weeks: So then are you trying to kick-start interest? Kogan: Exactly! This book is meant to bridge the anti-aging field and those in medical geriatrics. I do think it is interesting how much anti-aging practice has entered into medicine, especially in Europe. There are people saying that with knowledge gain in the next 10 years it will not be surprising to have people routinely live to 120-years-old. I think there is a lot of over-selling now, but that there will be some gems that will be discovered and incorporated in regular geriatric care. Weeks: What areas come to mind? Kogan: Stem cells. Some tissue regeneration methods. A lot of genetics and a lot of the microbiome work. These may not be “wholistic” or “integrative” at their core, but the fact is there is a huge amount of financial interest circulating in this area from investors who believe that there is a large amount to be learned. While they may be investing millions, just one breakthrough may pay off big. Weeks: What engaged you with the elder population? Kogan: I think I always had profound respect for elders, maybe it was cultural, growing up in Russia. Also my early experiences in medical school and internal medicine residency were a big influence. I quickly realized that our elders are heavily overmedicated while life style and integrative approaches are underutilized. By the time I was in the middle of the residency, I knew I would be practicing integrative medicine and serving mostly elders. My current personal biggest concern is seeing the slowing down and reversal of life expectancy growth in US. People are saying it’s opioids – that more people are dying young and that brings down average life span. But if you carefully look at the numbers, they don’t pan out. While of course opiates are big time contributors, this alone can’t explain why the US is the only developed country in the world where we are seeing decrease in life expectancy in last 2 years. The problem is the rapid rise in neurodegenerative diseases like Alzheimer’s and Parkinson’s and growing poly-pharmacy problem that disproportionally hits elders. Weeks: How much was weaning people off meds a subject for your authors? Kogan: In geriatrics it’s a common conversation, all the time. The problem is, most regularly trained geriatricians are not trained in alternatives to the drugs. Integrative practitioners may know 20 different things that can be tried for each common geriatric condition before medications are prescribed. The book is aimed at providing readers with these options. Weeks: How has the uptake of the book been? Are you penetrating the right communities? Kogan: It’s been slow. The American Geriatric Society is very conservative. They have a wellness group I was involved with some years ago. A group of us put together a day-long seminar on integrative practices for their conference. They said it was ‘totally irrelevant’ and shot it down. They are not going to listen. Maybe after some of their members read the book this will begin to change. Weeks: That’s disheartening. Kogan: I am trying some smaller venues – a state society, some hospital groups. There I am having better luck. Weeks: If you could wave a magic want and get your hands on some of that $142-million in the new NIH National Center for Complementary and Integrative Health budget for geriatric care, what would your research priorities be? Kogan: First I would look at the Bredesen ReCode approach to Alzheimer’s disease systematically, compared to regular care. I know Bredesen tried to get an NIH grant, without success. We need to do that – maybe through the National Institute on Aging. Weeks: That’s a shame. The NCCIH has not generally been very open to exploring multi-agent, individualized care models that are fundamental to Bredesen and virtually all other integrative health approaches to chronic conditions. Kogan: We need pragmatic trials. I wouldn’t try to do randomized controlled trials with this population. There are just too many variables. Another area I think we need to look at is the value of mobile, home-based, team-care models that utilize electronic care coordination. It can sound expensive but if you can just keep one person from needing an ER visit from the side effects of their PPIs [proton pump inhibitors] – for one example - you can afford a lot of home care. Dr. Vic Serpina’s GI chapter in Integrative Geriatrics has a great overview of managing acid reflux without use of PPIs. A third area for research would be hospice. Someone should look at integrative medicine as a cost-saving measure in hospice care. Weeks: Talk about the geriatric-palliative and hospice care overlap. Kogan: The palliative care and hospice care are another under-explored area for integrative practice. We in integrative medicine are not very good with this bridging over, in my experience. At least once a week I see someone who has stage 4 advanced cancer and clearly are not going to get better but some integrative practitioner is not seeing this. They are still giving them IV vitamin infusions, supplements, and keeping them to a strict diet while end of life conversation has not happened. We are not educated enough in palliative care and have a lot of work ahead in our field to learn how to bridge people. And this is unfortunate because geriatrics palliative care is a very holistic field. The key concept is a patient’s quality of life and not interventions aimed at cure or reversal of given medical problem. Weeks: One last thing. You mentioned that you have now had 20 patients at some level of cognitive decline with whom you have applied the Bredesen approach. What can you briefly share of your results? Kogan: The results are mixed. We have several patients who are doing surprisingly well and we are publishing some of these cases now and collaborating with Dr. Bredesen to also include our data into his growing database. What is very reassuring is that in patients who reverse cognitive decline, we are also seeing objective brain volume improvements. We are utilizing a program called NeuroReader, that uses MRI imaging to provide us with detailed brain volumetrics. I would have never believed 10-15 years ago that patients can regrow part of their brain at age 60 or 70. Now it appears that we are seeing it at increased frequency. In a few years I will answer your question much better, especially since we are in the process of starting a research study to assess all our patients who are willing to have their data analyzed. At this point, my main clinical question is to learn how to predict who will benefit from the ReCode program the most. So far I don’t have a good handle on this. I have several patients who did well or are doing well despite very advanced forms of Alzheimer’s disease. On the other hand, some patients with early, mild forms are progressing no matter what we do. It’s a steep learning curve for everyone involved. We are also learning that poor oral health and sleep play much larger role than anyone ever suspected and we are designing rather specific dental and sleep evaluation and treatment protocols for all our ReCode patients. This is why we formed a new company called MK Cognition Institute where we are creating effective collaborative work between medical and biologic dentistry teams in addition to a geriatric case manager, nutritionist, health coaches, and other providers. Weeks: Thanks for your time. Now – go find a chink in the American Geriatric Society’s armor so you can educate the practitioners. And get AARP to write an article on the book for their gazillion members. Kogan: I am just getting to the point in my career where maybe it is the time to learn to get more involved in the political questions. Weeks: Good! We need more of that.