[00:00:01] Speaker A: The journey from eloise's Alzheimer's in 1907 one unusual case to his 1911 paper several unusual cases to roughly the late 20th, early 21st century is really a period of a descent into a dark ages. And the descent into the dark ages is not just because the scientists were struggling and they couldn't figure things out. And you know, it isn't. It really is a story of social, political and ideological movements, forces, conditions destroying or otherwise distracting from or forgetting the science.
[00:00:48] Speaker B: Welcome to the Age of Aging, a show about living well with an aging brain. Produced by the Penn Memory center in the Michael Nadoff Communications Hub. I'm Terence Casey.
On today's episode, we're traveling back more than a century to the very beginning of our understanding of dementia. It's a story that starts in a Frankfurt Asylum in 1901 with a woman named August Dieter.
August died in the spring of 1906, and while her life ended in profound confusion, her legacy changed the course of modern medicine.
In was her brain that a young doctor named Eloise Alzheimer stained and placed under a microscope, revealing for the first time the strange plaques and tangles that we now recognize as the hallmarks of the disease that bears his name.
As we'll discover today, the path from August's asylum bed to the research centers of 2026 is anything but a straight line.
It's a history marked by world wars, scientific rivalry and a decades long period in which the world Simply forgot what Dr. Alzheimer had discovered. And as you'll hear, there are uncomfortable echoes of that forgetting in the world we live in right now.
To help us tell this story, I'm joined by Dr. Jason Karlewish, co director of the Penn Memory center, executive producer of the Age of Aging, and the author of the Problem of How Science, Culture and Politics Turned a Rare Disease into a Crisis and what We Can Do About It. But first, a word from our sponsors.
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[00:04:23] Speaker B: Thanks for being back on the show, Jason.
[00:04:25] Speaker A: Great to be here. Terry, how are you?
[00:04:27] Speaker B: Good, I'm doing well. I'm excited to hear more about the foundation of of our center and the diseases that have needed it.
[00:04:34] Speaker A: Yeah, yeah, we're in. This month of April, Sunday, April 8, 1906, is an important day in the history of Alzheimer's disease, in the history of the diseases that cause dementia. Because it was on that day, that Sunday, that a woman died in an asylum in Frankfurt. She was August Dieter and she was now considered, quote, the first case of Alzheimer's. But at the time, Loyolis Alzheimer's didn't know what he had, but knew there was something special. And indeed that's the title of the case report was on an unusual disease of the cerebral cortex. So I thought we'd do is talk a bit about August Dieter and the story about her and what followed.
[00:05:13] Speaker B: Yeah, I'm excited. I think we often hear not just with this disease, but many others, the story of the scientist or doctor who had discovered it. But very infrequently do we talk about the patients.
[00:05:25] Speaker A: Yeah. And yeah. So how did we get to know all these teeters? So Lois Alzheimer's is a German psychiatrist and as this psychiatrist in Germany, he's based in an asylum in Frankfurt and He admits a 51 year old woman on November 25, 1901 and she's bought in because her husband Carl is at wit's end taking care of her Beginning in her late 40s, she had begun to develop confusion, difficulties with cognition, and over time, fairly rapidly, actually, difficulties with behavior comportment. And he can't have her at home anymore because not only is she unable to function as the housewife he's expecting, he's a hard working railway clerk, she's accusing him of marital infidelity and et cetera. So he brings her to the asylum and Eloise Alzheimer's admits her. And pretty quickly he feels that he's onto something.
And later, of course, he would write this case report about her.
[00:06:21] Speaker B: Now I want to hear more about that, but you've used the word asylum a couple of times and I think in 2026 there's a pretty negative connotation. People think of, you know, a place where you lock up people who are crazy. Yeah.
[00:06:33] Speaker A: Bedlam. Bedlam is the stereotype which was an asylum in England that became notorious for the stereotype of an asylum. But asylums of the late 19th century into the early 20th, but particularly 19th century, particularly in Germany and other areas, were very much modeled on a therapeutic model. They were not considered places of confinement and exclusion, but rather places of nurturing almost in a model, if you will, of a monastery or another sort of place for seclusion from the world and healing. They had strong therapeutic models. For example, it included the arts At a typical asylum, if it was well run, had a vigorous, what we would now call arts program, as well as gardening and related outdoor activities, under a very strong therapeutic belief that the arts and engagement with nature were valuable for helping people live with, overcome, be cured of their mental illness. That's not a hospital, correct? Yeah. What's interesting about the asylum, because it was for people with mental illness, it's almost as if they had been listening to the age of aging because they had really embraced a model of mind number one and of how the world around the brain, the world that makes the mind, is so important for trying to get a mind healthy. So this person's admitted by OLS Alzheimer's and he's interested in her right away because the bottom line is she doesn't fit any of the categories. She doesn't fit the diagnoses that were common then.
She's got features that look like someone with what was then called senile dementia, dementia senilis, senility. He details these in his case report. But of course I already kind of gave away. The problem was she's not old, she's 51.
And it's interesting to read in the case report, he's clearly saying to you, various things she doesn't have that would be the other common causes. Stroke, a history of alcoholism, epilepsy, a pupillary, and other findings that we would now take to be tertiary syphilis, which is a very common cause of any younger person of her age for developing the signs and symptoms she has. But she's got none of these things. And he knows I'm onto something here. It's interesting and here's where things get really interesting, which is Eloise Alzheimer's is a psychiatrist. Now, our stereotype of a psychiatrist, particularly a psychiatrist trained in the 20th century when I trained was they don't touch patients, they don't do any of that. But he was of an era where not only do they touch their patients and examine them and he details a detailed neurological examination, but when they died, they got their brains and they examined their brains.
In fact, adjacent to the areas where patients lived and were cared for at his asylum was a neuropathology room for the removal of the brain and then using a very recently developed staining technique, staining that brain tissue to examine it.
And that's what he did with this patient four and a half years later. She would die on that Sunday, April 8th, and he would have that brain then he was in Munich, sent to him so he could stain it and look at it and examine it. And that leads us to this case report.
[00:09:32] Speaker B: That's interesting because you say that the, the. They weren't involved in touching patients. That's when you were training. But now, you know, neuropathology is so closely integrated to our work. And at the Penn Memory center, maybe that's more with the neurologist.
[00:09:46] Speaker A: Yeah, see, here's the thing. A psychiatrist back then, if you let read what they wrote, which is what we've got, because we can't speak to them, they sound a lot like neurologists and psychiatrists. Psychiatry and neurology back then were fields that were very different than what we see now.
And the separation that when I trained and still exists between psychiatry and neurology was really a 20th century, mid to late 20th century artifact. In Eloise Alzheimer's time, both those fields were sort of developing oftentimes well. For example, his original case report is published in the General Journal for Psychiatry and. And Psycholegal Medicine. And another paper which he publishes, which we'll talk about, was published in the journal for the entire field of neurology and psychiatry. So the two fields were very much kind of merged into one. And again, the key thing, though, with OS Alzheimer's is neuropathology that you were expected to have skills in neuropathology. If you were a psychiatrist in Germany, that was part of your training. That's something that you did.
[00:10:44] Speaker B: Now, today, we're lucky to have these incredibly detailed images of the brain, both in life and in postmortem. At the time, they weren't having brain scans, essentially just sketching.
[00:10:56] Speaker A: Well, brain scans, of course, are done in a living human. No such imaging was obviously possible then, but instead what it was was wait till the person dies, slice up their brain, stain it and sketch out. You're right. And that's what Alzheimer's would do. In his case reports, when you read them. I think the key thing about the case report that was often missed is this. And here's a key point.
He's saying, I don't know what she's got. That's essentially what he's saying.
She looks like senile dementia, but she can't have senile dementia because she's not elderly. And here's the thing, what I'm seeing on her brain might explain what's going on. In other words, her autopsy is telling me something. And he sort of leaves it at that. And so when I remember reading that case report, you're kind of left with, well, what do you think's going on? What are you thinking about? And really, the case report is incomplete, not because he didn't do a good job, but because he had to do more work. And that's what takes us to another case report that he writes, which is really important. And I'll talk about that in a minute. But I do have to add one important historical point, because already resources enter into Alzheimer's research. Even in the early 19th century, Eloise Alzheimer's was at Frankfurt asylum, and he would. After he admits El Goose Dieter, he moves. He moves to Munich and takes a job there under his mentor Kraeplin, who was a prominent psychiatrist at the time and who would champion this case report. For example, he moves to Munich, but he keeps track of Augusta here.
And the reason why he keeps track of her is he wants to get this brain.
He gets word from his colleagues. Carl Dieter can't pay for her fare anymore. In other words, the cost of repair is too much and he's going to move her to a public asylum.
And Alois Alzheimer's gets word of this, and he realizes, if this happens, I'm going to lose my choice.
So he's got money. Eloise Alzheimer's married a widow of a diamond merchant and himself, therefore had money.
And he gets in touch. He says, I'll take care of her called care. And he actually pays for her continued stay in the asylum so that he has continued contact with her so that upon her death, he can get her brain.
[00:13:01] Speaker B: It's kind of an incredible two ends of a spectrum here. One husband who is no longer going to pay for this fabulous care, and the other husband who is benefiting from his wife's wealth.
[00:13:13] Speaker A: Yeah. And also, you know, even then, problems of the cost of care for someone with dementia were very real and very, very much a problem.
And so a theme in early 20th century remains here in the 21st century.
So the case report that really is the one which is the eye opener is not the 1907 paper that reports on an unusual illness of the cerebral cortex, but a 1911 paper called on Certain Unusual Diseases of Old Age that allies Alzheimer's rights. So the switch here is from one case to certain unusual diseases. And here's where things get really interesting. And here's where you begin to see how forward thinking he and his colleagues, particularly Oscar Fisher, were. And we'll talk about Oscar Fisher, because what they realize is we're seeing more and more of these people who have the signs and symptoms of senility, but they're not elderly.
And when we take their brains and we examine them, they look a lot like the brains of the people who are senile.
And so they're up against this sort of conundrum, this sort of question, which is, how is it that young people can seem like they have senility and have pathologic findings that look like senility, but they're not senile, meaning old age. And this is a really important point. Because senile dementia was considered a product of aging, it was not considered the result of the disease, but rather just the degeneration seen with aging. And this is a very important point, because when you say that something in medicine is the result of aging, medicine loses interest fairly quickly because it's not a disease.
There's no pathology at work. And therefore research, let alone diagnosis, treatment, are just not of great interest. And that's the world I trained in. When I trained, an older adult with dementia was considered to have senility. An 80, 90 year old. Sure. And that was just extreme aging. And we were very uninterested in it.
[00:15:10] Speaker B: So what would have happened in 1901 if August Dieter had been 80?
[00:15:15] Speaker A: They would have said, she's got senility. This is what we see. Sent her home, or because of the care issues, she would have still remained in the asylum, but there wouldn't have been the same interest. Perhaps it's these early onset cases that were getting these psychiatrists interested. And again, the key thing is they had these new staining technologies that they were using. And the new staining technologies, together with the fact that they examined their patients brains upon death, have them now trying to make sense of who are these young people, what's going on with them. So here's the key insight that Elias Alzheimer's. I'm going to read it to you here from the case report.
In the 1911 case report he's writing about another young person who's got what looks like senility, but of course can't be have senility because Johan F, that's this new guy, is in his early 60s.
And I'll read you the writing, I'll read you what Alzheimer's concluded. These observations demonstrate to us in an impressive way how difficult it is to define diseases solely with respect to their clinical features.
It cannot be doubted that the plaques in these specific cases do in all relevant respects correspond to those which we find in dementia senilis. So what he's saying there is. I'm seeing plaques in young people with dementia, relatively young, that look just like older adults with senility.
What he's essentially saying is that I think senile dementia and pre senile dementia are the same thing. And this distinction between aging and disease just doesn't hold up anymore. This is a revolutionary statement that he's making.
The question therefore arises as to whether the cases of disease which I consider peculiar are sufficiently different clinically or histologically to be distinguished from senile dementia or whether they should be considered under that rubric. In other words, pre senile and senile are not distinct but the same. That is a revolutionary statement being made in 1911. And again, remember when I trained, I was taught older adult dementia, senility, younger adult dementia, Alzheimer's disease. But that's not what Alzheimer's was saying. What he's saying is that I think they're the same thing. I think there's a disease going on here. It's not very common in the young, but it's really common in the old.
So what happened between 1911 and when I went to medical school in 1991?
Something seems to have happened, right?
[00:17:40] Speaker B: A couple of somethings, yeah.
[00:17:42] Speaker A: Yeah. So let's talk about.
[00:17:43] Speaker B: Yeah, yeah. Global conflict likely.
[00:17:45] Speaker A: Yeah. Well, that's just it. It's not that the science got stalled because it's not. The science couldn't advance because they couldn't figure things out as scientists. And that's the key point, which is what happened from 1911 until about the late 1990s was a whole lot of non scientific events. And of course, where were we? 1911, we're in Germany.
Three years later, what happens?
[00:18:11] Speaker B: It's the kickoff of all the global conflict.
[00:18:14] Speaker A: The Great War. The Great war, World War I. And very rapidly, what's like many wars, it starts out, everyone thinks it's going to be a quick excursion, a quick event, and years later it finally ends. And World War I, of course, the mechanized level of destruction and carnage was, was unprecedented. But by the end of that four years of World War, Germany comes out the other side, not only defeated, but economically in disarray. And so for the progress of science, of course, this would be devastating.
So the asylums that Eloise Alzheimer's worked in would become increasingly difficult to keep funded, let alone the economic conditions that would surround Germany in general. Hyperinflation and unemployment would plague Germany throughout the 1920s.
And many of the scientists, physicians who would have been doing this work were killed during the war.
Elias Leila himself would die of kidney failure just before the war really got going.
There's a key actor here which I think further emphasizes how political events intruded. I mentioned him already, which is Oscar Fisher. And in that 1911 case report that Eloise Alzheimer's talks about where he is seriously questioning this distinction between senile and non senile dementia. He mentions the work of Oscar Fisher many times because it's Oscar Fisher who really was leading progress in understanding the neuropathology.
Alzheimer's did good work, but Fisher really was the better guy.
[00:19:41] Speaker B: Yeah, I think one of the overarching questions that I have about Alzheimer is is it brilliance at the right time or what you mentioned the stains that had come out that have really made a lot of these possible or was it more of just luck that happened to be with a capable doctor?
I guess it's when you look back at history, you can't say for sure, but there was a lot of.
It was a lot of luck in terms of the timing of the August Theater case.
[00:20:09] Speaker A: Yeah, yeah, I think so. Oscar Fisher, had he been allowed to continue his work, probably would have, along with, in collaboration with Lars Alzheimer's and Belchowski and others. I think they probably would have reached the general conclusion that senile dementia is a disease caused by these plaques that they're seeing and would have really contributed to casting away the idea that dementia, older adult is quote, normal aging.
But of course, the problem is you've never heard of Oscar Fisher. And few people have heard of Oscar Fisher because Oscar Fisher got swallowed by history. Sure, because Oscar Fisher lived in a difficult time. Post war, he was a socialist and he was a Jew, lived in Prague. And by the 1920s, anti Semitism was on the rise and Oscar Fisher would lose his faculty appointment and so he would lose his laboratory. And so he was no longer able to do this excellent work that he had been doing that Alzheimer's and others were citing and using to do their work as well. And indeed, his life would end in catastrophe because of course, by the 1930s, Germany would be taken over by autocratic fascists. And when they invaded Prague, occupied Prague, Fischer would not only now out of his job, was imprisoned, and within a year later would die under the prison run by the Nazis. And so I often look back on this history and I think if the war hadn't happened, if the post war events, economically and culturally and politically hadn't happened, Alzheimer's could have continued his work. Maybe he was, as I say, he died a kidney failure, but certainly Oscar Fisher could have continued his work. And if Oscar Fisher had continued his work, I think he would have been one of those physicians who would have said senile dementia is caused by a disease. It's these mysterious plaques that we're seeing which were named Fisher's plaques, and they're called Fisher's plaques. These were the amyloid plaques.
[00:22:01] Speaker B: And so it's gonna be the Fisher's Disease center that we're working in today.
[00:22:05] Speaker A: One could argue that, yeah, we should at least instead of calling them amyloid plaques, give him the honor of calling them Fisher's plaques. But you could also make a strong case that the disease should not be called Alzheimer's disease, but should be called Fisher's disease. If you want to put a name to it. It doesn't help that other Alzheimer's mentor, Emil Kreplan, championed the idea of Alzheimer's disease, but he himself also was a vicious anti Semite and probably would have objected to having a Jewish physician's name ascribed to it.
[00:22:32] Speaker B: Yeah. So in many ways, you know, I referenced the luck, if you will, the timing, the introductions of these new stains
[00:22:38] Speaker A: for Alzheimer, for amyloid and whatnot.
[00:22:40] Speaker B: Correct. Yeah. But at the other end of that extreme is Fisher with this incredibly poor timing and placement that sounds like it was in any way his fault for being Jewish between World War I and 2. But yeah, yeah, the incredible misfortune completely changed two different scientists or trajectories yeah,
[00:22:59] Speaker A: well, also, you've already mentioned it, World War II. So really the, the knockout blow to the work of these German psychiatrists would be World War II, because by then, what happens then is Nazi ideologies of eugenics thoroughly take over views about mental illness and essentially ruin German psychiatry and neurology such that by the end of the Second World War, it's a bit of a wreck. At this point, the country, both in terms of, you know, social and economic structures that have to be rebuilt, which they do with the support of the United States, the Marshall Plan, but also the reputation and quality of the work they were doing had really been just run into the ground, courtesy of the eugenic theories of the Nazis.
So by the end of World War II, the incredible work that really had gotten going by Alois Alzheimer's, Oscar Fisher and others had really ground to a screeching halt and was really at that point sort of forgot, gone and neglected. And this is. Things only get weirder. And they get weirder because an alternative theory of brain disease starts to take hold in neurology and well, in particular in psychiatry, namely a psychodynamic theory of disease.
So remember, Lewis Alzheimer's is a psychiatrist. He's what we might now call a biological psychiatrist. He's examining his patients brains. He's looking to find out the pathologic causes of their illnesses. At the same time, there's a competing theory of mental illness that's arriving, championed by the likes of Sigmund Freud.
And what Sigmund Freud is championing is what might call psychodynamic model of mental illness. Now I think it's a legitimate model, but much like the biologic model, it can't explain all mental illness.
Indeed, I think much of mental illness is a bit of both biology and psychodynamics anyway. But the psychodynamic theory of mental illness would pretty much then dominate psychiatry in particular throughout the 20th century. And one of the reasons why was World War I. Because World War I produces this Legion of young, seemingly healthy men who were profoundly mentally ill, courtesy of what we would now call post traumatic stress disorder. Sure.
And shell shock to.
[00:25:09] Speaker B: Exactly.
[00:25:10] Speaker A: Shell shock would be the name of the time. And much of the work in asylums pivoted to and took on the care of these young men. They were mostly men who had what we would now call PTSD using psychodynamic theories. And I'm in no way criticizing what was going on as wrong, but what it did was shift the lens of attention in psychiatry from examine your patient's brain to figure out what's.
To interrogate the patient's brain using psychodynamic theories to figure out what's wrong and what you could do to help them. So things really are in a bad state. Now to figure out why do older adults develop dementia? Because you've completely forgotten all this work of these elegant psychiatrists who did all the biological psychiatry been talking about Oscar Fisher and others.
And you have a new theory to explain mental illness which is sweeping western psychiatry. Name of the psychodynamic model of mental illness. And this is where things get kind of funny and well, you have to somewhat laugh, which is the United States steps in. And in the United States post war psychiatry took off and it took off. Fueled by Freudian ideas. American psychiatry exploded in number and scope and influence in the post war America. And if you read the writings of Menninger and others, they have taken Freudianism and sort of put a bit of an American dash splash to it and are championing. This is why we have the diseases we have that cause the mental illnesses. Well, you can imagine they have no interest in senility in dementia because persons with dementia aren't amenable to the psychodynamic approach.
You know, it's, it's, it's, it's a result of aging. There's nothing you can do about it. So now you see another reason why the problem of dementia is essentially just forgotten and cast outs from medicine's interest because it's aging. And the way we understand mental illness is psychodynamic theories. So why, what, what, what do we offer the elderly with dementia?
[00:27:14] Speaker B: Now you're here, you're talking about dementia, but at this time where they, they weren't using that term. Right? They were still referring to senility.
[00:27:21] Speaker A: Yeah, no, the dominant term was senility. Maybe you would say senile dementia to better qualify it. But yeah, I mean, senility was.
You would certainly meet physicians in America in the 70s, 80s into the 90s who would talk about people having senility. Yeah, she's got senility, he's got senility. And that meant dementia caused by old age. Nothing you can do about it except palliate the most extreme symptoms of anxiety and restlessness with antipsychotics and some of the antidepressants that were available, but otherwise medicine had very little interest in it.
[00:27:52] Speaker B: Now was there any either at the time of Freud or as with the introduction of the American psychiatrist as well, at any point were, were people lumping senility in and sort of this trajectory or was it just let's not worry about that anymore because we're, we're focused on sort of the, the. The shell shock patients of the younger generation. Did they see them as connected at all or.
[00:28:14] Speaker A: No.
[00:28:14] Speaker B: Outcasts.
[00:28:14] Speaker A: No, no. I mean, with this, which. Yeah, I mean, American psychiatry, neurology together had very little interest in understanding why did people develop senility. And what we can do about.
Was viewed as extreme aging, unfortunate, not an illness, not amenable to psychodynamic theory. Hence psychiatry wasn't interested in it. And neurology was interested in lesion based diseases. And senility was viewed as a diffuse problem in the brain.
A very little interest. You may remember from one of our earlier episodes when I talked with Dan Gibbs, who trained in the 70s into the 80s, we interviewed him. He's living with Alzheimer's now, he's a neurologist. And he remembers the least interesting patients he had when he was a neurologist were the persons with dementia. You know, he came out of that era where neurology was very uninterested in dementia as a problem. It was just extreme aging. Not much you can do about.
Just didn't interest neurology.
Before we move on From World War
[00:29:11] Speaker B: II era, one of the things that really stood out to me and you mentioned eugenics among the Nazi regime and all. We think a lot about how World War II impacted the Jews of the world and particularly racial minorities. But when it comes to those living with some sort of mental illness, one of the terms that you had used was about racial hygiene, obviously. But when it came to persons with mental illness, there was the phrase useless eaters.
[00:29:39] Speaker A: Yeah. No, the Nazis championed a view of, you know, cleaning the genome of. They felt that the majority of mental illnesses and neurological illnesses were the result of genetic defects. And they viewed those who were living with these diseases as useless eaters, consumers upon society's precious resources and would have a program of essentially murder, I mean, euthanasia in the asylums. And it would enact that. Yeah, both persons with developmental disorders, such as persons with down syndrome, as well as elderly with senility. So I think the message here is the journey from eloise's Alzheimer's in 1907, one unusual case, to his 1911 paper, several unusual cases to roughly the late 20th, early 21st century is really a period of a descent into a Dark Ages. And the descent into the Dark Ages is not just because the scientists were struggling and they couldn't figure things out. And you know, it isn't. It really is a story of, of social political and ideological movements, forces, conditions destroying or otherwise distracting from or forgetting the science.
So as you and I are recording this episode, we're several weeks to now, almost months into a war with Iran, and it's starting to have not just regional but global economic ripples. In particular, energy markets are quite volatile, inflation's back on the table.
Most economists who look at these events project a long term economic outlook that is dark.
At the same time, the executive branch just proposed a budget that dramatically increases defense spending, perhaps understandably, given the fact that there's a war, but also cuts NIH and related research funding. So what you've got are big adjustments occurring in national priorities. So when I look at the early 20th century, it's a story of upheaval, of hyperinflation, war costs, political instabilities, and the scientific infrastructure crumbling. And sadly, I recognize notable bits of a pattern repeating themselves. It wasn't that the scientists stopped being curious or capable. It was that the conditions that around them began to make what they wanted to do impossible. You know, Oscar Fisher didn't lose his laboratory because he ran out of ideas or moved onto something else. He lost it because the world around him fell apart. So too the laboratories of Alzheimer's and his colleagues.
So what I'm thinking about and what I really hope listeners take away from this episode is that progress in medicine and in science, medical science, is not inevitable. It's not self sustaining. It's a very fragile progress because it depends on a host of conditions, funding, stability and that funding and society's willingness to invest. And you know, the sad thing is what we don't discover because of the disruptions today will truly be unknown because we won't know what we missed. We won't know what we could have done. And that's the story of the early 20th century until it was finally rediscovered in the late 20th century. And I worry now about our current times.
[00:32:41] Speaker B: So we had wrapped sort of the beginning of these dark ages as mid 20th century. We talk about where we are in 2026, but you know, somewhere in the middle of there there was a young doctor. Carlo is getting started in his career in geriatrics. You had mentioned a little bit about the diagnosis of senility at that time. But when did things start to shift in your career toward where we are today?
When did we stop calling it, when did you stop calling it senility?
[00:33:11] Speaker A: By the time I was doing my fellowship in geriatrics, it was dementia. And you certainly wouldn't say senility. You would say dementia. You still might Say senile dementia. But I saw this is like mid-90s. I was making the pivot at that point with my colleagues to saying that we don't say senility anymore. We say dementia. And the causes are vascular and are Alzheimer's. Those were our two dominant causes. Of course, several decades, two, three decades would pass, not that much time where we would identify other diseases as the cause, namely Lewy bot disease, TDP 43 disease, et cetera. But that was occurring in the late 1990s. But as I wrote about in the Problem of Alzheimer's, when I was in medical school, I remember we went to see a patient out of an elderly woman. The chapter is called the Old Woman in the Tower. And she was presented by a colleague of mine, a medical student. And I'll never forget, the attending was kind of speechless. And we all just kind of stood there after she presented this patient, who was admitted with what sounded like a delirium. And he had nothing to say, the attending, about delirium. He had nothing to say about dementia.
And we just sort of stood there for a while after she presented the case and looked at her. And we're kind of like, why are we here? And what was the point of presenting her? I'll never forget that. And it just showed you how, I'll use a blunt word, dumb. We were to the problem of dementia, and we just had a fundamental lack of knowledge. And that was essentially 1991 that that occurred.
[00:34:43] Speaker B: So we're here now 120 years after August Dieter's death.
[00:34:47] Speaker A: Yeah.
[00:34:48] Speaker B: Is there anything that she or Dr. Alzheimer would have identified as familiar in a Penn Memory center clinical visit?
[00:34:57] Speaker A: Yeah. I actually think if Elois Alzheimer's walked into the Penn Memory center, he would recognize a lot of what we do.
He would recognize us getting a history from the family member because he talked to Carl Dieter. It's very clear he got a history from Carl. He would recognize a lot of our exam of August Dieter, the neurological exam, and the questions that we asked her to assess her cognition. He didn't measure her cognition with metric measures, didn't have the mini mental state exam, et cetera. But a lot of the bedside cognitive exam he did has a lot of features of ours. So I think he'd sit there through much of the clinical evaluation and say, and he was kind of a witty, kind of charming guy. You know, he'd be smiling and saying, this is a lot like what I'm doing. And I think where his breath would be taken away is when we put up the results of MRI scans, amyloid PET scans, tau PET scans, and begin to explain what's going on by looking at those results, blood tests for P Tau217, et cetera. I think he'd be astounded for those individuals being prescribed anti amyloid therapies and I guess to sort of wrap up, you know, when I trained in the field and got going, one of the complaints that you often heard was we're not making any progress. We're not making any progress. And there certainly were a lot of fits and starts. But if you think about it, the field really got going. I'll make a round number. The Alzheimer's centers were first funded in 1984.
Some of the big initiatives to develop the biomarkers didn't really get going into the late 90s, early aughts like Adni, the Alzheimer's disease neuroimaging initiative.
We're now 2026.
In about 25, 30 years we have made some spectacular progress in our cultural understanding, in our ability to diagnose the diseases in living individuals, and in the last few years in our ability to treat those diseases. We still have a lot to go in all those areas and as well improve our system of care. But in the arc of history, 25, 30 years is, is not a lot of chronologic time. But qualitatively, a lot has happened in that time. So on this anniversary of August Dieter's death, I think we should look back with frustration over what happened across much of the 20th century because it shows you how society, how culture, how politics can really undo the progress of medicine and science and the ability to take care of people and improve our lives. But I think as we sit Here now in 2026, we can look back over the last several decades and see how we were able to correct much of that. Though I think now we face a lot of challenges as we've talked about in our current social and political environment. Great.
[00:37:29] Speaker B: Well, I think that wraps it up. I appreciate you joining us today and talking August Dieter.
Thanks for listening to this episode of the Age of Aging. This show was made possible by generous support from the Michael Madoff Communications Hub Fund and our sponsor, Rothkoff Law Group.
The Age of Aging is a Penn Memory center production hosted by myself and co host Jake Johnson. Contributors include Dalia El Said, Jason Karlewish, Emily Largent, and Alison Lin. If you enjoyed this episode, consider subscribing to the podcast, leaving us a review or giving us a like these types of things really help others find the show. And if you know someone who might be interested in these conversations? Share this episode with them.
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