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My former medical school class mate, Hank Paulson, followed his Yale medical degree with a PhD. He has since become an internationally recognized neurology researcher and director of the Michigan Alzheimer's Disease Center. Edited and condensed, here are Hank's comments on dementia research and treatment.
Tia: Some doctors think that because we can’t cure dementia there’s no reason to diagnose it. Do you agree?
Hank: I disagree. Giving people information to help them understand what they face in the future is an important part of our job. And not just saying it but helping them think through it. I take a positive view toward life with cognitive impairment. That person has many things to live for, many things they can still do. Live life now as fully as you can. I know it sounds Pollyanna-ish but I mean it.
T: I’m not sure it’s Pollyanna-ish. The standard view of dementia is so grim it's inaccurate. People imagine only the last stage, not the many years before.
H: I don’t mean for them to spend all their time on sudoku puzzles. I hope they’ll be socially and mentally engaged with friends and family.
T: What do you do to stay healthy and protect your brain?
H: There are 4 things I believe in: aerobic exercise, social and mental engagement, sleep and diet. Diet comes last because we don’t know exactly what to do. You need healthy food, but we don't know that it has to be blueberries or coconut oil.
T: What do you do when patients tell you they’ve heard of a miracle cure for dementia?
H: That happens about once a month. It’s important not to be dismissive. If I’ve heard about it I’ll comment. If not, I’ll look into it. But I add that there are these new nibbles constantly that fail to reach any kind of significance. It’s a good thing patients are trying to learn more and asking about studies and treatments. Exhausting for doctors, but a good thing.
T: Personally, I’m not optimistic that a cure for dementia will arrive in time for baby boomers. I’d love you to tell me I'm wrong. What are your views?
H: I believe we’ll find something that offers a modest slowing of the disease for some subgroup, maybe in 5 to 10 years. Qualified hope. I don’t think an amyloid drug is going to be a home run. At best a single. Tau is a better target, so we may be able to do better with that. But it will be tough to see who is eligible and who can pay, because it will be very, very expensive.
T: What are some of the things you’re working on that you’re excited about?
H: My lab has worked for a long time on quality control pathways in the brain. How are our brains still vibrant at 60? It's because we have tremendous surveillance machinery! It makes sure the DNA is intact, that lipids with toxic modifications are eliminated. We've been working on ubiquitin, a modifier of proteins. If you want to get rid of a protein whose shelf life is over, you often add ubiquitin onto it as a clearance tag. We work on mutations that cause frontotemporal dementia and ALS (amyotrophic lateral sclerosis). We make copies of genes and study how proteins misbehave. I love this work.
T: It shows! How did you get interested in brain science?
H: It was all around me. My father and mother actually met at a mental hospital, the Dorothea Dix Hospital in North Carolina. My grandfather immigrated from Latvia and got a job running that hospital. He loved it. One summer my father, a Yale medical student, came to run the recreation center for male residents, and my mother, a dental student who grew up on the grounds, ran the activities for female residents. They fell in love, my father transferred to Duke, they got married and here I am. My dad was a neurologist and I used to tag along when he gave talks. That was a big influence on me.
T: I am going to ask you a sorrowful question. Suppose that someday you have dementia. What care would you want? What would your life look like?
H: I haven't really thought about it. I should. My first instinct would be, "I'm going to be an outlier. I'll do better. I'll live longer, stay well longer." I am the eternal optimist. I'd want to articulate my end of life choices. Lots of living with dementia is good living. Compromised, but good. But that last stage -- that's hard to navigate. When I reach that phase, I'd consider ending my life.
T: Some people do.
H: For my patients, I see them multiple times over several years. I try to open up the conversation with them about end of life care, not at the first visit, but I don't wait until the end either. I'm good at diagnosis, but hope to learn more from my palliative care colleagues.
Those are thoughts from one expert. Summarized, much of the time with dementia can be good time, but we need to do a much better job on that final phase. Brilliant people, there is plenty of work left for you.
