Dr. Jason Karlawish 0:00

I have to say the last several years we have seen really good progress in the field. And Aducanumab was part of that story. Aducanumab, it was part of a story to say there's something going on when you manipulate amyloid, the issues we're dosing the type of amyloid you're going after whether the patient also has elevated tau, the other pathologic marker, the disease, how you measure the endpoints. And I'm of the view that the two Aducanumab studies that FDA looked at weren't yet there. In terms of design. There have been other studies done with Lecanemab and other antibody drugs have donanemab that also show provocative results. But what has happened with this FDA decision by colleagues in share this view, they dropped the evidentiary bar. And what we're worried about now is we're going to pop these other drugs out there without really good data to show that we're the does reducing amyloid benefit a patient? And who were the kinds of patients in whom it benefits? The answers to both those questions, I think remain answers that need scientific study, and we were getting there. I still think we can get there. But this approval muddies those waters rather than clarifies them. And so in that sense, I disagree with the statements that will sort of, quote spur innovation. I just don't i don't find that a very compelling argument. And certainly that's not a reason for FDA to approve a drug to quote spur innovation. That's a business decision. That's not a scientific decision.

Dr. Regina Koepp 1:27

I'm Dr. Regina Koepp. I'm a clinical geroopsychologist, which means that I'm a psychologist who specializes with older adults and families. And this is the psychology of aging podcast, your go to resource for Mental Health and Aging. Since it came on to market in early June, Aducanumab has been a hot topic in the field of dementia and Alzheimer's disease. Aducanumab, also known as Aduhelm, is a new Alzheimer's drug for people with Alzheimer's disease in their early stages with mild cognitive impairment. And Dr. Krlawaish, you may remember him from our podcast episode back in March is on the podcast talking about the risks and benefits of Aducanumab, how the FDA approved Aducanumab, for use with folks with mild cognitive impairment, and his concerns about Aducanumab, I'll also share if he's actually prescribing it, and what the sort of consensus among his neurology peers is. Also, at the end of this episode, Dr. Karlawish and I talked about COVID-19 and brain health, and more specifically about the correlation that's that's been in the news lately, about COVID-19 and memory loss or dementia like symptoms. So listen all the way through to the end, and you'll hear a discussion about that.

Dr. Regina Koepp 2:58

Let me tell you a little bit about Jason Karlawish. Jason is a physician and writer. He researches and writes about issues at the intersection of bioethics aging in the neurosciences. He's the author of the recently published book, The problem of Alzheimer's, how science, culture and politics turned a rare disease into a crisis and what we can do about it. Incidentally, that was what he talked about in March on this podcast, and I'll link to that episode in the show notes as well. His essays have appeared in The New York Times, the Washington Post, Forbes and the Philadelphia Inquirer. He's Professor of Medicine, medical ethics and health policy and neurology at the University of Pennsylvania, and co director of the Penn Memory Center, where he cares for patients. Dr. Karlawish mentions in this episode that the Penn Memory Center actually has a web page devoted to Aducanumab. And so I've linked to that in the show notes, so be sure to check that out. All right, let's jump into the interview with Dr. Jason, Karlawish.

Dr. Regina Koepp 4:02

Thank you so much for joining me again, on the psychology of aging podcast to talk about Aducanumab the new Alzheimer's drug.

Dr. Jason Karlawish 4:12

Great to be back. Thanks so much for having me. Yeah. important topic.

Dr. Regina Koepp 4:16

And and one that I really want expert sort of thoughts and opinions and guidance on because you wrote up an opinion piece at in Statnews.com on May 30 entitled The FDA approved, Biogen Alzheimers treatment. I won't prescribe it. And that was that was in advance of it coming to market. Can you share a little bit about where you were at when you wrote that opinion piece, and I'll link to that in the show notes. And, and then what sort of the, the pulse is among neurologists since its release.

Dr. Jason Karlawish 4:54

So my message was to the FDA, namely, if I don't want to prescribe it, you ought not to approve it. FDA chose not to listen to me; too bad. And they approved it. And I'll say, you know, and I made my case for why the drug shouldn't be approved as a safe and effective treatment for Alzheimer's disease. And in fact, narrowly construed I was the FDA listened to me they didn't approve it as a safe and effective treatment, they approved it under different regulations, with great, therefore uncertainty around its benefit and the need for more study. Having said that, you know, it's available, and the system has made it available. And as a prescriber at a memory center. If the system makes the treatment available for the treatment of the diseases that cause cognitive problems, I have to be very respectful about making it available if I can. And the reason is, because, you know, as we talked about when we got together while ago, Regina, you know, this is a disease of autonomy, you know, early and relentlessly what it goes after is your ability to self determine your life. And I kind of feel a special ethical obligation to respect my patients' autonomy and do what I can to preserve it. And so, you know, if after someone learns the uncertainties of whether this drug is even beneficial, not just the benefit, but the uncertainty of even if it's beneficial, and all of the other things, which I'm sure we're going to talk about, they want to take it and they fit the parameters for prescribing it, of course, you know, I'm a reluctant prescriber, but I truly describe myself as a reluctant prescriber. For a number of reasons that I'm sure we're going to develop as we, as you and I talk more.

Dr. Regina Koepp 6:34

And are you saying that you're a reluctant prescriber for this drug in particular for other early Alzheimer's drugs?

Dr. Jason Karlawish 6:42

No, just this drug. Yeah. Aducanumab

Dr. Regina Koepp 6:44

Yeah. Well, we you share a little bit about what some of the reasons that go into making you a reluctant prescriber?

Dr. Jason Karlawish 6:53

Yeah, there's two broadly, one is about the data, you know, so I think and many others agree in the field, that the data that describe that this drug, treats Alzheimer's disease, meaning translates into benefit for a patient is just a stretch of the data that are there right now, it may actually be an effective treatment. I mean, there are some very provocative data about this drug and drugs like it, that suggest given to the right patient at the right time, they may have a real effect on the disease course. But I've got to go with the data that are available. And by the way, Biogen has been slow to publish the data, and they're just not there. So So in a conversation with a patient, it's about uncertain benefit, documented risks. And that's the kind of drug that should best be given not with a prescription, but with an informed consent form to enroll in a research study, to establish whether in fact the drug works, and really carefully monitor someone and work together as a society to prove that, but unfortunately, that's not the case right now. So So that's, so that's why I'm a reluctant prescriber.

Dr. Jason Karlawish 8:02

The other reason why I'm a reluctant prescriber is the process that led to the drugs approval raises a lot of concerns about the ability of FDA to do its job. And, you know, I'm sure we'll develop more of this. But essentially, there were a series of events, not isolated, I think, but connected in some ways that to put it bluntly, have led to the head of the FDA Commissioner Woodcock, calling for an Office of Inspector General investigation of FDA decision here. It's distressing as well. The Dr. Woodcock says she really wasn't part of the decision making because she was busy with other things, which I find rather shocking. So the other reason why I'm reluctant prescriber is I'm not very confident that FDA is sort of doing the job here to make sure that things have been adequately done. And that's a difficult conversation, of course, to share with a patient but I think they need to know that. You know, a third issue is the drug is costly. And there's a copay that I sure will not be trivial for patients and families. Maybe 60,000 a year total cost co pays off and run about 10%. That's not a trivial amount of money. But, you know, if the drug was beneficial, that that'd be a different conversation about the copay. So you know, the copay is on a list there. But really the issues are the uncertain benefit, the risks, and the the the threats to trust and what FDA did given the way they made this decision.

Dr. Regina Koepp 9:25

Will you talk a little bit about their process for making this decision? I think you you wrote a little bit about this and your opinion piece. Yeah, more controversy about it. Since not just from you, but other

Dr. Jason Karlawish 9:37

I and others have certainly written on this. I've written on a piece in nature reviews neurology. In particular, I have a piece coming out in JAMA neurology as well that examined this and simply put FDA staff it's been revealed we're in really close collaboration with Biogen in ways that raise concerns about the independence and objectivity of the review. Number one, number two, FDA convened an advisory board. They're not required to convene advisory boards, but often they do for especially for a big ticket, first of its kind, difficult decision like this. And they asked the advisory board in November of 2020 questions around whether the drug was safe and effective and dismissed any discussion of amyloid as a surrogate marker for treatment, the board would vote nearly unanimously that the data didn't support finding the drug was safe and effective. Well, what happened since then, was that FDA went ahead and used a different set of regulations, regulations that allow a claim of as surrogate endpoint is good enough for practice, and approve the drug on the basis of surrogate endpoints namely bit pet beta amyloid, not improvement of clinical outcomes. So they dismiss that topic at the November hearing, they never reconvened an advisory board to discuss accelerated approval, not that they're required to have an advisory board, but you would think they would for something as high ticket as this big ticket is this. And then finally, memos that have been released by FDA show that FDA is divided, that within FDA, there were serious differences across different groups, different experts about approving this drug, whether that was for standard approval, or for accelerated approval, and in fact, an internal advisory board recommended against approval, and yet they went ahead and approved it. And so it in the end, ones left wondering what on earth is going on at FDA. And then finally, this is part of a larger story of the use of the accelerated approval mechanism by FDA in the space of oncology in the neurosciences, that questions, whether they're using this regulation in the way that it was originally intended when it was written back in the 1990s. And it seems to be more of a way to let industry get drugs out as quickly as possible, with a minimal amount of follow up to make sure they're actually worthwhile. And so there are a number of larger concerns here that have been raised about this decision about how FDA is functioning right now.

Dr. Regina Koepp 12:12

You mentioned that there are risks that go with this the use of this drug, can you talk a bit about the risks involved with Aducanumab?

Dr. Jason Karlawish 12:20

Yeah, there's the drug can cause in about 30% of individuals who take it smooth, small, microscopic areas of either leakage of fluid, the edema in the brain, or leakage of blood hemorrhage, micro hemorrhage in the brain. There's a term for these called Aria A-R-I-A-S, not the operatic moment, but rather amyloid related imaging abnormalities. Anyway, you know, and I will say, when people talk about it, they say, you know, brain edema and bleeding? Well, you know, it's a dramatic way to describe the out the side effect. And for some, it can be rather symptomatic, and even cause outcomes that are not good like falls. Fortunately, they can be detected with MRI imaging. And generally if the drug has stopped abate, but I'm not trying to minimize them, but I am saying that they're manageable risks in the setting, of course of a drug that's beneficial. In the clinical trials, we were generally able to get on top of ARIA in a way that we, for example, the Safety Board, never shut the studies down, for example. And the reason is, because in a clinical trial, you can really carefully monitor people. Number one, and number two, quite frankly, the patients are often quite healthy otherwise, and they're very sort of compliant with the protocols. So I think there is a concern that this risk of ARIA eight amyloid related imaging abnormalities, the small bleeds and edema in wider clinical practice, I'm sure we're going to see they're not as well tolerated, I think we're going to see probably given the health of patients, and just the sort of messiness of clinical practice that this drug is, is going to have some side effect issues. But again, if the benefit was adequate, you know, these things are part of the personal decision making as to whether someone takes and puts up with those side effects. They do emphasize though, the need for people to go into this with their eyes wide open. And to be habit prescribed by someone who obviously knows, you know, how one detects these side effects has a system in place to monitor for them, etc. I'll wrap up with a very important final point, they're more likely to occur in individuals who have at least one copy of the APOE-e4, the APOE-e4 gene has been described to increase one's lifetime risk of developing late onset Alzheimer's disease. And so what you have is a very interesting issue of I could do a genetic test that will tell you whether you're at higher risk of the side effect. That's something I think many people would want to know. But it's also obviously going to tell you about your family's risk of developing Alzheimer's disease insofar as APOE of course is inheritable through blood relatives. And so it adds to the complexity around decision making certainly about taking this drug.

Dr. Regina Koepp 15:09

Yeah, and if it's helpful or harmful to progeny or your lineage to know if they have the APOE-e4 gene.

Dr. Jason Karlawish 15:15

The APOE result. Exactly. But again, you know, I mean, there are drugs for multiple sclerosis that are not without side effects, but they have documented benefit, and patients with MS make their choice, you know, given the severity of their disease, etc. And I can respect that in Alzheimer's patients and their families. But again, it gets back to the uncertain benefit that surrounds this drug, which FDA agreed wasn't wasn't established. And that's why they want a confirmatory trial. And I just think that that decision was a mistake.

Dr. Regina Koepp 15:44

And so what are the proposed benefits?

Dr. Jason Karlawish 15:49

Well, a slowing of the rate of cognitive decline and subsequent functional loss, so not an improvement. In other words, it's not the drug like say antidepressant, where after several weeks of therapy, your mood is better, but rather a drug which over time, if you take it, you're less likely to develop increasing disability, more troubles managing money, wayfinding, organising a meal, going on a run on your own and not getting lost all the things that matter and someone's self determination of their daily life. And I bring this up in great detail, because measuring slowing of progression of a disease is not easy. Because you have to basically follow a lot of people over a long period of time to show that the drug is actually tapping the brakes of decline, as opposed to people getting better in 12 weeks, compared to people not on the drug. And that's again, all the more reason why, you know, we really needed good data to show that this drug makes a difference. And number two, the proposed confirmatory study is going to be very difficult to conduct because the drug is available clinically. And I can understand the perspective of an individual say, Well, no, wait a minute, you could put me in a clinical trial to get the drug. And I might not get it depending on the design of the trial randomization to placebo, for example, or I can just go take it on my own. And I mean, I think it's unfair to ask people to think that they should join the trial, and not get the drug if they're willing to take the risk. And so that that only adds sort of the concern that many colleagues have about the fact that the drugs available now, if you will, commercially by prescription, and yet needs more study.

Dr. Regina Koepp 17:33

So are you prescribing it?

Dr. Jason Karlawish 17:35

Yeah, no, I mean, I have not written a prescription yet. Because at our center, we need to get our infrastructure in place in order to be able to prescribe it, but I have one or two patients who have expressed an interest. And I have many who have expressed absolutely no interest after they've learned about it.

Dr. Regina Koepp 17:53

What would you need to see before you feel comfortable prescribing it.

Dr. Jason Karlawish 17:58

So in someone who meets the criteria of having cognitive impairment, meets the criteria that they either have mild cognitive impairment, meaning inefficiencies in their daily life because of their cognitive problems, or mild stage dementia, meaning some impairments and daily function, particularly instrumental activities of daily living, so they fit those criteria. And they have an MRI scan that doesn't show micro hemorrhages, which are seen in people with Alzheimer's disease. And then they have a scan that shows elevated amyloid. And they've decided whether they do or don't want to learn they're APOE gene type, and they don't have a bleeding disorder. And they're not on blood thinners. They have controled blood pressure, they can come in every four weeks for the infusion. They have a family member or other people who can help out to make sure around side effects. So they're watched for. If they have all those things. And they still want to go ahead with it. Yep. Sure. I mean, that's a prescription to be written. And again, you know, I know there are a few people who want it on many people after they hear all that the uncertain benefit. They say, I'm just not interested in this. Yeah.

Dr. Regina Koepp 19:07

And then you mentioned earlier the price tag, which is something like $56,000 annually.

Dr. Jason Karlawish 19:14

Right. And the Alzheimer's Association, and others have said is is unacceptable. Although the question then is well, what is the acceptable price ICER Economic Review Group has said it's about in about should be about $3,000 a year not 56. But anyway, it's an expensive drug right now. That's right.

Dr. Regina Koepp 19:34

And that's particularly distressing I think to families living with Alzheimer's because they are already bear a higher cost of care.

Dr. Jason Karlawish 19:45

That's exactly right. The triple digit billion dollar cost of Alzheimer's disease to America is the cost of the American family namely the out of pocket expenses to pay for long term care services and supports or the loss of income because your problem you as a family member, providing Instead of working, and now what you've got is a drug with questionable benefits. Where depending on your copay, you may face several 100 to $2,000, several 1000s of dollars of an annual copay. Not every company is get clever with this, they sort of do. You know, they have, you know, programs where they will support the copay, because they figured out given the price and given how the insurance schemes work here that we can sort of, you know, pay that for people and whatnot. I, you know, I look, this is a business now, you know, once you get into the world of selling drugs, you're in the world of business in this setting prices and leveraging prices and all these other things. But you're right in principle, saying to a family, $6,000 a year maybe out of pocket for this, where they're struggling, say to make the $50 a day Adult Day activity program fee. That's a lot of cash. And for some families, there's no question that that price tag is going to be unapproachable, as certainly that price tag is a challenge for America's insurers as well.

Dr. Regina Koepp 21:03

What's the sort of consensus among your neurology peers?

Dr. Jason Karlawish 21:10

So the consensus in the Alzheimer's field about as you can imagine, is too soon too early excetera. I say consensus, meaning that much of what I hear, having said that, most are sort of willing to say, Okay, I guess we'll be prescribing this. But I think generally folks feel that FDA went on a bridge too far with this decision. I have to say the last several years we have seen really good progress in the field. And Aducanumab was part of that story. Aducanumab, it was part of a story to say there's something going on when you manipulate amyloid, the issues we're dosing the type of amyloid you're going after whether the patient also has elevated tau, the other pathologic marker, the disease, how you measure the endpoints. And I'm of the view that the two Aducanumab studies that FDA looked at weren't yet there. In terms of design. There have been other studies done with Lecanemab and other antibody drugs have donanemab that also show provocative results. But what has happened with this FDA decision by colleagues in share this view, they dropped the evidentiary bar. And what we're worried about now is we're going to pop these other drugs out there without really good data to show that we're the does reducing amyloid benefit a patient? And who were the kinds of patients in whom it benefits? The answers to both those questions, I think remain answers that need scientific study, and we were getting there. I still think we can get there. But this approval muddies those waters rather than clarifies them. And so in that sense, I disagree with the statements that will sort of, quote spur innovation. I just don't i don't find that a very compelling argument. And certainly that's not a reason for FDA to approve a drug to quote spur innovation. That's a business decision. That's not a scientific decision.

Dr. Regina Koepp 23:02

You know, I was thinking in terms of innovation and your your role as a physician and a neurologist working with a degenerative condition like Alzheimer's, to support the autonomy of the individual and the family and to meet them in terms of their wish, balancing risks and benefits and understanding the science behind it. And it kind of brings up to me this question of, is some hope, better than no hope? And who decides? And, and so I'm curious if you have any thoughts about that.

Dr. Jason Karlawish 23:37

Why do people need hope? Well, they need hope, because they're feeling some degree of despair, right. So, you know, what are the sources of despair for persons living with Alzheimer's disease? Well, think about it. One of them. One of them is, I can't hand someone a prescription for a drug I can confidently say slows their disease. But there are other sources of despair. Um, what's the quality of evidence of the drugs that I can hand them, like this drug, the process that led to it? Do you trust it? More generally, what other sources of despair for persons with Alzheimer's disease or try to get a diagnosis, try to get a doctor to spend the time to talk to you try to get long term care services and supports, try to try to find negotiate that system, adequate enough doesn't solve those problems. And indeed, one could argue it adds to the despair, because now you've asked people, here's the drug with uncertain benefits, a controversial process that led to its approval. And yet, you're still going to struggle to find long term care services and supports and struggle to get a clear, coherent explanation of your diagnosis. And so, you know, let's take seriously the sources of despair, that patients and their families experience and in that sense, I would argue that I don't think we're going to drug our way out of our despair, not with this drug.

Dr. Regina Koepp 24:58

Well said. I think also for most types of despair, we're not able to alleviate the distress from medication alone. You know, I really appreciate that you take a stand for ethics around medicine and balancing the pros and cons balancing autonomy and risk. It's such a, you know, there's a big conversation, of course, and Alzheimer's care around Person Centered Care. And then you also have an ethical obligation to do no harm. And if a medication does not have enough evidence to say that it's free of harm, or the harm is fully understood, or the benefits are not fully yet understood. I think you're put in this dilemma and you have to kind of be a gatekeeper slash educator. And so I really appreciate your willingness to take this educational role for all of us. Thank you.

Dr. Jason Karlawish 25:53

Well, thank you. That means a lot to hear from from you.

Dr. Regina Koepp 25:56

I do have a related but a curveball question for you. Sure. So you were describing some of the complexities and nuances with the accelerated FDA approvals, and I know, with the COVID vaccine, what I am a staunch advocate for COVID vaccines, I'm vaccinated, my kids are little, my kids are too little for the vaccine, but when it's available for little kids, they will be vaccinated. And, and so with so many people concerned, though, one of the one of the arguments I hear about people who are not yet comfortable with the COVID vaccine is that it was accelerated through FDA. You were sharing concerns about FDA is accelerated process for Aducanumab. How is that different than the FDA accelerated process for the COVID vaccine?

Dr. Jason Karlawish 26:47

Yeah, a big difference. So the accelerated approval mechanism that was used to put Aducanumab into clinic said that the drug can be prescribed because the drug lowers amyloid, and we think lowering amyloid can translate into a benefit to a patient's daily activities. They agree the FDA that the data evidences and establish the evidence to put COVID vaccines in the field is having done randomized control trials, just like were done with Aducanumab, we've shown a reduction in the risk of getting a COVID infection. That's a real clinical event compared to reducing beta amyloid. In other words, they didn't approve the vaccines on the basis of say, reducing the count of COVID viral particles in your nose, which would which would maybe reduce your likelihood of getting the infection maybe, but but but isn't getting the infection. So so. So that's a big difference. The second big difference is one of process. America knew going into the clinical trials for COVID that the FDA was going to use the emergency use authorization regulations. The FDA advisory board knew that they were reviewing these data on the basis of the emergency use authorization regulations. In Aducanumab, the FDA never talked about using accelerated approval, they never asked the advisory board to consider accelerated approval. And so there are vast differences in the processes that went into it. So in summary, COVID vaccine, well done randomized controlled trials, where it was clear that there were clinical endpoints. Number one, number two, a process that involves a transparent statement by the regulators to the kinds of regulations they would use and what they would ask their EAB. Aducanumab, some questionably designed clinical trials in terms of futility analyses and dosing, mixed results, never asked the advisory board to look at surrogate endpoints didn't use clinical but use surrogate endpoints vast differences between the two. They're not similar stories. They're not even they're not just not apples and oranges. On a one's an apple on the other is an egg, you pick.

Dr. Regina Koepp 28:59

Well, thank you for that. Yeah, because that is one of the arguments that I hear most often about the concern for COVID vaccine. And so how about any concerns for COVID vaccine and neurological impairment? Some people will say, oh, I've heard of these immune responses to the COVID vaccine. Have you? Have you seen any neurological issues in clinic post COVID vaccine

Dr. Jason Karlawish 29:21

Post group? In my practice? No, there is some anecdotal information accumulating about some folks getting a myelitis type of picture. It's rare enough to say it's been noted as a risk, but not to sort of say I think that you shouldn't get the vaccine. Data about taking this drug and getting the vaccine are really not available. My advice, having said that, what we're recommending in our clinical trials where we're testing these anti amyloid antibody drugs is that there should be about a two week excuse me two months, six week at least, interval between getting the study drug and getting your vaccination. So there's no chance of interaction between the two study drug in the vaccine?

Dr. Regina Koepp 30:10

Well, that's helpful information. Now, there was a recent report sticking with COVID, and neurological function for a minute, there was a recent report on NPR, where they were, it was entitled doctors worry that memory problems after COVID-19 may set the stage for Alzheimer's. There's a group in Texas, A neurology group in Texas doing studies on long term effects of the covid 19 virus on the brain, I know you were just at a conference and all some international Alzheimer's conference, Did this come up at all? And what are your thoughts about the long term effects of COVID of the COVID-19 virus on neurological function

Dr. Jason Karlawish 30:48

I think there's a very legitimate reason to want to say we need to study the long term effects. And why is that? Well, I'll give you one of the most provocative sort of bits of data about COVID infection was individuals who had a loss in their sense of smell, taste, in other words, food just didn't taste much. And much of our taste is driven not by our tongue, but our nose, particularly beyond sweet, sour, salty taste. And I many of us when we heard that, so that's really interesting, because that's going after cranial nerve one, or is it two? I always forget that now since my neuroanatomy days, but yeah, the the end of the olfactory nerve. And and the question is, is, you know, is that just a transit effect of the virus on that little factory nerve that then recovers versus the beginning of changes in that function? Because you know, of course, one of the signs and symptoms of Alzheimer's can be loss of taste, because of the effect of, we think, the spread of tau protein from the medial temporal lobe to the smell, nerve. So you know, whether that's what's going on as well, with COVID. That's to be determined. And, you know, long term in this field means 5,6,7,8,9 years, the last, the COVID infections, or maybe the oldest COVID infections, maybe a year and a half, two years old. So you know, we've got a way to go here. But yes, this is something that needs study. I think, though, I would urge people to not panic here. But rather, you know, if you want to help science, and you had COVID, there are studies that want to follow people up longitudinally, about the outcomes of their COVID. So by all means, I think that's a great opportunity to contribute.

Dr. Regina Koepp 32:27

That's a great recommendation.

Dr. Jason Karlawish 32:29

So if people want to learn more about Aducanumab, the Penn Memory Center has created a whole page devoted to up to date information, summaries of information about the drug and they can go to our website. So it's pennmemorycenter.org. And it's very clear from there where to go to learn more about Aducanumab.

Dr. Regina Koepp 32:51

Great. We'll link to that in the show notes and to your website and your book. So thank you so much for being here.

Dr. Jason Karlawish 32:57

Keep up the good work.

Dr. Regina Koepp 32:59

Are you a mental health or senior care professional? I have a professionals guide for working with older adults just for you. It reviews the five must know facts about working with older adults and shares lots of helpful resources to download your free copy, go to mentalhealthandaging.com/proguide all one word. That's all for today. I hope that you enjoyed this episode. And if you do, I would love a subscription and review. And the reason is that it helps people to find this show. Alright, I'll see you next week. Same time, same place. Bye for now.