Friday, April 11, 2014

Is the Risk for Alzheimer's Disease Declining?


Contributed by: Dennis Fortier, President, Medical Care Corporation

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Stop the press! Is this good news about Alzheimer's Disease? It depends on how you look at it.

A recent perspective article*, published in the New England Journal of Medicine, cites several studies supporting the notion that the risk of having Alzheimer's disease is declining. The article notes that the probability of a person of a given age, having any form of dementia today, is lower than it was a few decades ago. That sounds positive.

Despite the tempting headline of "Declining Risk", such a trend is most likely driven by overall improvements in population health. Today's seniors are unquestionably wealthier and better educated than those of the past, they smoke less, have fewer strokes, have better managed cholesterol, and have lower blood pressure. All of those factors affect risk of Alzheimer's disease and other causes of dementia.

Also, while risk at a given age may be declining, the number of people reaching old age (and even very old age) is sharply climbing. Prevalence at a given age may be lower, but incidence at older ages is clearly rising.

There is no reason to believe that the risk of Alzheimer's disease is magically declining. There is much hope, however, that awareness about risk factors and the importance of managing them, is helping us to forestall the ravages of dementing illnesses, and buying time for the nation's R&D efforts to find better treatments.

So keep exercising, eating right, using your brains, and managing your chronic conditions.  For now, that is your best strategy for keeping your brain healthy for the longest time.

n engl j med, 369;24, nejm.org, december 122013

Tuesday, March 25, 2014

Screening for Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Yesterday, the U.S. Preventative Services Task Force (USPSTF) ruled that there is insufficient evidence to make a recommendation, either for or against, routine screening for cognitive impairment in older adults. Today, the press is ablaze with sloppy reporting on the matter.

Many news stories (like this from US News and World Report) are conflating cognitive impairment with dementia, but readers of this blog understand that cognitive impairment may be very mild whereas dementia is, by definition  a severe loss of cognitive capacity. Many others (like this from Time), are interchanging dementia and Alzheimer's disease, which inappropriately implies that the two are one in the same, and obscures the fact that Alzheimer's is but one of the many causes of dementia.

To be clear, the USPSTF did not rule against anything. They merely concluded that the evidence is not strong enough to make a recommendation one way or the other. More importantly, their ruling was related to "screening" of "older adults" for "cognitive impairment". In other words, should the healthcare system invest in regular cognitive assessment of all older adults, whether they suspect a problem or not? Their conclusion? They're not sure.  They're not for it and not against it.

Rather, the public should monitor their cognitive health vigilantly and promptly report concerns to their physicians for a thorough evaluation. This will allow early intervention against treatable problems like thyroid dysfunction, vitamin deficiency, anxiety/depression, sleep disorders, and out of control diabetes, all known contributors to cognitive deficits. It will also facilitate early diagnosis of Alzheimer's disease.

This is important because Alzheimer's can be effectively managed for a significant percentage of patients. Effective management of Alzheimer's includes early diagnosis, physical exercise, proper diet, strict control of hypertension and diabetes, poly-therapy with a cholinesterase inhibitor and Namenda, ongoing social and intellectual stimulation, and caregiver education. All of these interventions have been shown to promote optimal disease management and, when brought together as a robust therapeutic regimen, can be surprisingly effective.

Friday, March 21, 2014

Time to Redefine Alzheimer's Disease


Contributed by: Dennis Fortier, President, Medical Care Corporation
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Daily news stories abound with coverage of new treatments and diagnostic tests for Alzheimer's disease.  Many include controversial musings about the value of measuring risks or "predicting" future diagnoses.  Most of these discussions are poorly informed, and further limited in their usefulness by a lack of agreement about the definition of Alzheimer's disease.  After all, detecting the disease "early" is a relative concept, completely dependent on your definition of when it begins.

As we wrote earlier in a post about when Alzheimer's disease really begins, there are wide disparities in the opinions of scientists, clinicians, patients, and journalists.  The scientists look at pathological changes prior to symtoms, the clinicians adhere to a strict definition that includes severe symptoms, patients define it's onset in accordance with minor symptoms, and journalists, often unaware of these nuances, frequently muddy the waters with inadvertent generalizations.

There is strong rationale, in terms of promoting proactive healthcare and enabling an aggressive research agenda to develop better treatments, in favor of universally adopting a definition based on known pathological changes that occur early in the disease process. Doing so would peg the start of the disease at an early time, prior to the development of clinical symptoms.  This approach, with which we agree, is highlighted in a clear and objective report from NPR today.