Starting Fresh in the New Year

Contributed by: Dennis Fortier, President, Medical Care Corporation

It is that season when it is enjoyable, and in some ways instructive, to pause and reflect on the passing of another year. It is also an excellent time for setting priorities and establishing habits that we will be happy to reflect upon twelve months from now. With that in mind, this article suggests 5 simple practices with clear “brain health” benefits that you may wish to consider as you embark on a fresh new year.

To be sure, there are higher ideals than those I have listed here, toward which we could all strive. However, my intention is to provide readers with some ideas that are relatively easy to pursue but can still yield important benefits; the goal is to offer maximal return for minimal effort and sacrifice.

With that said, here are five considerations for starting fresh in 2010:

1. Improve Cardio-Vascular Health

This suggestion is not new but deserves repeating because it has been proven beyond a doubt that good cardio-vascular health leads to better over all health and lower risks for heart disease, diabetes, and Alzheimer’s disease. What is new is certain evidence about how easy it may be to start moving the needle in the right direction.

Improving cardio fitness need not involve strenuous exercise and really doesn’t even require that you sweat. Walking is one of the overall best and most underrated forms of exercise and can often be incorporated into daily errands. Also, don’t think that because walking is easier than running or swimming that you must do it longer to gain a benefit; a daily 30-minute walk is immensely beneficial to a person with no current routine of physical exercise. Especially if the walk can be augmented with a few trips up and down the stairs in lieu of the usual elevator ride.

In terms of staying motivated to maintain a routine of physical exercise, try to find a quantitative measure that will reveal your progress and keep you looking for more gains. In the past, much emphasis has been placed on body weight, a measure that is easy to obtain but can be difficult to improve. As an alternative, check your pulse rate at the end of your work out and track it for one month of daily walks; you might be surprised to see it fall. When you consider how many beats of your heart you can save over the course of a year by keeping your heart rate low, it can be very motivating.

Also, whether or not you suffer from high blood pressure or high cholesterol, be sure to get these measures from your physician during your next check-up and keep track of them as you exercise. Even something as simple as a daily walk is good for your brain and can produce meaningful improvements in both of these bio-markers as you gain better fitness.

2. Reduce Stress

This suggestion might top the all time list of things that are easy to suggest but difficult to achieve. However, it turns out that for many of us, a high percentage of the daily stresses we encounter are self-inflicted. That’s right; choices we make and attitudes we willingly assume end up creating stress that we could otherwise avoid.

Reducing stress is important because we know how detrimental stress can be to our health. Real physical processes are triggered by emotional reactions to stress and, as far as our science can tell, none of those processes are beneficial while all have harmful side effects.

Here is a simple suggestion for reducing stress that, although it won’t work for all of you, must be tried by the rest of you before you can fully believe its effects. Put simply, you should make a conscious decision to drive with patience and courtesy. Look for other drivers trying to cut traffic and motion them in. Don’t speed up to close the gap when another car wishes to enter your lane; slow down and allow them in. Embrace yellow lights for the opportunity they foretell to pause for a moment – this is certainly less stressful than treating them as a threat to your rapid progress. Don’t tailgate or change lanes incessantly seeking opportunities to move one car length closer to the front of the crawling traffic; it is just not worth it. Instead, accept the pace, listen to some music, and keep an eye out for other drivers who might benefit from your courteous cooperation.

If you are not aggressive driver and cannot benefit from that tip, perhaps you can benefit from becoming a less aggressive “parker”. When visiting an establishment with a large parking lot, rather than seeking the spot nearest to the entrance, subjecting yourself to the anxiety of passing up a mediocre spot for the possibility of finding a better one, all the while monitoring the flow of motorists who might be competing for the best spot, try driving to the far end of the lot and parking in the open expanse of remote spots. It is a stress-free approach with the added benefit of a short cardio workout as you walk to your final destination.

While this might seem silly, it’s a step toward avoiding self-inflicted stress that just might carry over into other realms of your life as well. Get the right attitude, reduce your stress, and enjoy a healthier brain and body.

3. Stay Socially Active

While most of us are not in danger of becoming accidental hermits, making new friends and interacting socially are activities that have been documented to decline as we age. We are most prolifically social as young students, followed by fairly intense socialization in adulthood when our children are students, and we tend to be least active when we are older and our children have grown and moved on.

Much research on the benefits of intellectual stimulation, the act of using our brains in challenging ways, has shown a positive correlation with maintained cognitive health. I will write more on that below but will make a separate point here. Meeting people, learning about them, interacting and cooperating with groups, and cultivating relationships are all activities that require deep and comprehensive cognitive activity. In socializing, especially with persons we are still getting to know, we use memory, verbal skills, and judgment along with a poorly understood melding of emotions and executive function. In the opinion of many scientists, socializing may be the best mental activity we have.

Two great ideas for remaining socially active are club membership and volunteering. While you may or may not have interests that lend themselves easily to club membership, a regular card game or social activity with a committed group brings the same benefits. As for volunteering, hospitals, churches, and many non-profit organizations are begging for help in nearly every community. Incidentally, one of the most meaningful gifts you can offer through volunteering is friendship and interaction with a lonely, usually elder, person. Doing so will yield a double benefit because every interaction will be a work-out for both of your brains, not to mention the good it will do for your hearts.

4. Eat Well

You had to know this one was coming. As I did with the section on cardio-vascular fitness, I will try to present this in a new perspective that might be easier to embrace than those perspectives you have heard in the past.

Here is my fresh take on eating well. You needn’t necessarily deny yourself the junk food you’ve grown to love nor worry too much about your daily intake of calories. You do need, however, to worry about getting proper nutrition first. While consuming empty calories is harmful because it leads to weight gain and poor vascular health, the more damaging impact is that it strips away your appetite and prevents consumption of necessary vitamins and nutrients. A fresh approach to diet in the new year might be to focus first on what you should eat and set, as a second goal, the elimination of foods that you should not.

The good news is that the diet shown to produce the best vascular health was also shown this year to also promote the best cognitive health. One should be sure to consume a diet rich in cruciferous and green leafy vegetables, nuts, fish, and tomatoes and low in red meat and high-fat dairy products. Ideally, you will eventually adopt a diet whereby you take in what you need and avoid what you do not, but an easy place to start is to ensure that you get enough fruits and vegetables prior to filling up on junk; this will offer the best opportunity to keep your brain functioning at a high level in the new year.

5. Seek Intellectual Stimulation

If you have pondered the health of your brain at all, you have likely read or heard about the importance of ongoing intellectual stimulation. While it is not yet completely understood, it does appear that active brains decline more slowly with age than those that are relatively unchallenged.

A potential red herring in the discussion is the value of crossword puzzles, sudoku, and the like. Yes, they are mentally challenging activities but they may not produce the rich neural rewards that other activities, such as socializing, might yield. The key seems to be related to the concept of “learning”. If you don’t know the rules of crossword or sudoku then these may be great activities for your brain. However, if you know how the games are played, then merely working through new forms of each puzzle requires no new learning and may offer few benefits to brain health.

Among the most challenging yet rewarding intellectual activities that you pursue are learning to play a musical instrument and learning to speak a foreign language. Both of these have become much easier in the digital age with the advent of tools and software to aid in the learning process. While this might seem counter-intuitive it is actually quite well-grounded. With better tools, the learning becomes easier so the process yields faster proficiency and remains interesting through time. Despite the ease, the learning is real and the brain builds new circuits in accordance with the new learning. The whole process can be great fun, deeply rewarding, and very good for your brain.

So there you have 5 good suggestions to start fresh in the new year and keep your brain healthy in the process. Work on that cardio-vascular fitness, reduce your stress, stay socially active, eat well, and challenge your brain with new learning. If you do so, you can expect that twelve months from now you can look back with clarity and reflect on a year when you made a worthy commitment to the health of your brain.

Bio-Marker Diagnostic Test for Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

Researchers at the University of Pennsylvania have published in the Annals of Neurology the development and standardization of a test to accurately diagnose Alzheimer's Disease (AD) by measuring the levels of beta-amyloid and tau protein in the spinal fluid. While many news stories are forwarded to me on a daily basis, I sense a particularly high level of interest in stories such as this one.

My primary take on news about bio-marker diagnostic tests is two-fold.

First of all, it is tremendously positive in the following sense. We are currently detecting patients with AD, on average, when they have end-stage pathology (up to 95% of patients are detected 8-10 years after the onset of symptoms according to published data). One of the reasons we intervene so late is that many physicians believe (erroneously) that a brain biopsy is the only reliable method of establishing a certain AD diagnosis. While it is true that a brain biopsy is one certain diagnostic method, following the published NINDS-ADRDA diagnostic criteria yields a very acceptable diagnostic accuracy rate of about 90%-95%. Nonetheless, the presence of a lab test with high accuracy would increase physician comfort with the diagnostic process and hopefully lead to a more proactive attitude toward early intervention.

My second reaction is rooted in 20 years of experience commercializing health care technologies. The discovery of a scientific means to diagnose a given condition is a very early step on the long and often arduous path to making a product available. This scientific advance is absolutely positive but the practical implications of the discovery are many years away from helping real patients.

Does Surgery Cause Memory Loss?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Sometimes there are contradictions between anecdotal evidence and scientific evidence. Even when the two are aligned, there is often a disconnect between the published evidence and the way it is reported in the lay press. Such is the case with the seeming correlation between surgery and memory loss.

A recently published study in Anesthesiology, did not contradict the widespread sense that memory loss is a common consequence of surgery but some of the press coverage indicated that it did. As you can see, the story to which this posting is linked opens with the statement that researchers found "no post-surgical issues in older patients". However, it is clear in the publication (and even from the rest of the story) that there were indeed two areas of concern.

First, in patients who did not recover well physically from the surgical procedure, lingering cognitive issues were indeed present. That is essentially a confirmation of the link between surgery and cognitive impairment.

Second, even among those patients who had complete physical recoveries, cognition was not always fully restored until a period of six months to a year later. To suggest that anything short of a permanent disability should be ignored is not really a defensible approach to reporting this science.

Both of these findings are perfectly consistent with the anecdotal belief that cognition is sometimes impaired following a surgical procedure. It is unclear why the author of this article chose to open with a contradictory position but should serve as a reminder to readers that scientific research must be carefully interpreted and many journalists do not exercise care when reporting on new findings.

Is Western Medicine Clueless about AD?

Contributed by: Dennis Fortier, President, Medical Care Corporation

It is not always the most important stories that get the most press. Often times, a provocative title or a contrary view can drive news circulation to impressive heights. A story published this week by Natural News has had a lot of online coverage and I wanted to comment on it here.

The title of the story, "New Research Proves Western Medicine is Clueless about Alzheimer's Disease", is indeed provocative. However, despite the sensationalistic slant, this is really not news. Practically every published story includes the comments that the disease is poorly understood and no cure is available. I think both of those comments communicate that scientists the world over, not only those in the "west", have not yet figured out this complex disease.

If taken literally, the term "clueless" really distorts the truth. I contend that the research community has learned much about the disease in the past twenty years. For example:
  • They understand that there is a pretty clear distinction between the early-onset form of AD and the more common late-onset form.
  • They have identified some twenty risk factors that increase likelihood for AD and other forms of dementia.
  • They have gained much insight into possible genetic factors that may drive disease progression in individuals with certain genetic profiles.
  • They have developed treatments that operate on at least two distinct mechanisms (cholinesterase inhibition and glutamate blocking) that improve symptoms in most patients and slow disease progression in some.
  • They have developed a host of additional treatments, operating on novel mechanisms, that are currently progressing through the FDA pipeline.
  • They have developed multiple bio-markers for diagnosing the disease with increasing certainty.
While we have a long way to go and everyone recognizes as much, it seems to me that this particular article was probably written to attract attention and not to inform the public in a meaningful way.

When will we get a cure for Alzheimer's Disease?

Contributed by: Dennis Fortier, President, Medical Care Corporation

There is no definitive answer to this ubiquitous question. The best we can do is to watch the advance of science through the published literature and to follow the clinical trials from which the answer will one day emerge.

While the pathology of Alzheimer's disease is still not well understood, scientists have developed a host of well-grounded theories. Several treatment agents, based on those theoretical foundations, are currently in development or in clinical trial.

Here is an excellent summary of the leading treatment hypotheses as well as the development status of the most promising treatment agents. Some of the information is a bit technical but I think the lay person can read this and get a good sense of the time frame for a meaningful advance. It should be clear that no cure is imminent but equally clear that several treatment agents are in advanced stages of clinical trial.

Predicting the results of these trials is hampered by our vague understanding of what causes Alzheimer's Disease. On the bright side, one or another of these agents may be surprisingly effective in altering the disease course and could be available in less than five years. On the dark side, they may all turn out to be ineffective in which case we would be more than five years away from a meaningful new medication. Only time will tell.

In the meantime, we all need to be proactive in identifying and managing our risk factors for cognitive decline (the topic of an upcoming blog) and physicians must be vigilant about acting on evidence or suspicion of decline among their patients. Until better treatments are discovered, we must intervene as early as possible with the current medications to maximally delay the progression of Alzheimer's disease.

7 Facts about Stroke and Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation

A good source of information about risks for dementia is The site is sponsored by Medical Care Corporation but, like this blog, it is non-commercial and seeks only to educate. This content about stroke was a popular article from a past issue of Ounce of Prevention, the newsletter associated with that site.

Stroke is the third leading cause of death, behind heart disease and cancer. Each year, about 700,000 people suffer a stroke. Stroke can be a cause of dementia and cognitive impairment.

The following are 7 interesting facts about stroke and cognitive impairment.

1. Stroke is the second most common cause of cognitive impairment and dementia.

2. A thimble full of damaged brain due to stroke can cause dementia.

3. Stroke begins after age 50 and can gradually build up in the brain for decades. This gradual accumulation of tiny strokes progressively interferes with the brain’s function until the individual end’s up demented.

4. The risk of developing cognitive impairment is highest in those persons with vascular risk factors, including hypertension, hyperlipidemia, atherosclerotic vessel disease affecting the aorta, carotid, vertebrobasilar, or major cerebral arteries, homocysteinemia, diabetes, heart disease, hypotension, obesity, physical exercise less than two days per week and 30 minutes per session, smoking, alcohol dependence, coagulopathies, and prior stroke.

5. The most common types of cognitive deficits arising from stroke are disturbances of attention, language syntax, delayed recall and executive dysfunction affecting the ability to analyze, interpret, plan, organize, and execute complex information.

6. The risk of vascular cognitive impairment and dementia as well as the rate of cognitive decline in cerebrovascular disease is highly dependent upon the control of the underlying risk factors for stroke.

7. If left untreated, vascular cognitive impairment and dementia worsen. Annual screening for cognitive impairment in attention, memory and executive function starting at age 50 years old will help detect gradually accumulating cerebrovascular disease that may otherwise typically be undetected for many years.

Depression and Memory Loss

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego.

Studies show that prolonged stress leads to elevated levels of cortisol, a "stress" hormone produced by the adrenal glands. This in turn appears to shrink or atrophy the hippocampus, the sea-horse shaped part of the brain associated with many kinds of memory and learning. The hippocampus is a part of the brain that is particularly vulnerable to stress and stress hormones.

While cortisol levels normally fluctuate over the course of a day and night, they often soar when a person is faced with a stressful situation. Many studies have shown that this affects short term memory. For example, researchers have shown that people taking cortisone pills (which metabolize to cortisol in the body) were not as good at remembering a list of words as people taking placebo pills.

For many people, depression appears to cause similar damage; their cortisol levels remain slightly elevated as long as they are depressed. This moderate, but constant elevated cortisol appears to wear down the hippocampus--and lead to memory difficulties.

More studies are needed to fully understand the molecular connection between stress, depression and memory, and perhaps better treatments.

Can Alzheimer's be Prevented?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Recently I noticed an article published in Scientific American that succinctly summarized the current state of treatment and our march toward a cure for Alzheimer's disease.

For those of you who would appreciate a slightly more comprehensive overview of our current knowledge about AD, I recommend this recently updated report from the National Institute on Aging. It concisely describes the scientific landscape in terms of the pathology of AD, risk factors (including how to manage them), and treatment strategies (both current and in the pipeline).

The title of the report is Can Alzheimer's be Prevented? There is growing evidence for the case that, for may of us, it can probably be delayed until we are likely to die from some other malady. We call this concept "Prevention through Delay".

One day we will have a cure but for now, prevention through delay offers a realistic approach to reducing the tragic impact of this poorly understood disease.

Clear Summary on the Many Links Between Diabetes, Alzheimer's, and Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation

This article about the links between Diabetes, Alzheimer's disease, and dementia, published by Huffington Post, has been well publicized over the past week or so. I think the publicity is well deserved and I want to summarize some if its highlights for my readers.

First of all, the article describes Diabetes in a clear and simple manner: an inability to control levels of sugar in the blood. You can get more complex and drill down on diffenerences between Type I (body doesn't make insulin) and Type II (body doesn't respond to insulin) but it can be grasped quite usefully in its simplest defined form.

What I found so valuable in the article was the clarity with which it established the path by which diabetes increases risk for both Alzheimer's and dementia. This passage is particularly noteworthy:

The most obvious reason that Diabetes increases the risk of Alzheimer's Dementia is because it increases the incidence of heart disease; high blood pressure; high levels of fat in the form of triglycerides in the blood; decreases in the levels of the good cholesterol, HDL; and increases in levels of the bad cholesterol, LDL. All of these factors are individually known to increase the risk of Alzheimer's Dementia. These conditions also increase the risk of stroke and other forms of damage to blood vessels in the brain, which thus increases the risk of vascular dementia.
Additionally, the article goes on to describe several direct roles of insulin in a healthy and normally functioning brain. If the body, for whatever reason, is either not producing or not responding to insulin, many neurological processes may also become disrupted and cognition can be impaired.

While the relationship between Diabetes and Alzheimer's is often mentioned in the press, rarely is it so cogently described.

More Evidence that Beta Amyloid May Not Be Not All Bad

Contributed by: Dennis Fortier, President, Medical Care Corporation

I recently wrote here about research published in the online Journal of Alzheimer's Disease suggesting that beta amyloid, widely considered a key culprit in Alzheimer's pathology, might play a key role in learning. This alludes to a more complex relationship between beta amyloid and overall brain health compared to the more simplistic view that this particular molecule is always bad.

Now, a new study out of Tel Aviv University's Department of Physiology and Pharmacology, and published in Nature Neuroscience, has offered the first biological explanation of how beta amyloid might aid learning. The research, performed in vitro on mouse brains, demonstrated that beta amyloid helps regulate synaptic function. The results support the earlier hypothesis that there is an optimal level of beta amyloid as opposed to the original thinking that "less is better".

If these results are confirmed and further found to hold true in human brains, it could greatly alter current drug development activities, many of which are pursuing strategies to prevent the production of beta amyloid or to eliminate it from the brain.

Validity of a "Home Alzheimer's Test"

Contributed by: Dennis Fortier, President, Medical Care Corporation

One type of Alzheimer's news stories that I see on a recurring basis is that a test of some sort has been developed to diagnose the disease easily and accurately. Usually these stories take one of two forms.

The first form of these stories are those about "basic science" which means pure, theoretical science that has not yet embarked (and may never embark) on the long and arduous path to commercialization. Often times however, the stories are written in a manner that suggests the scientific endeavor has been successfully concluded and that doctors are now ready to improve care using a new advance in medical knowledge. Sadly, that is almost never the case. The chasm between a scientific discovery and an applicable clinical product is both wide and difficult to cross but stories in the popular press usually convey the opposite.

The other form of these stories is to take an existing technology and tout it with claims that are misleading or unrealistic. An example of this was recently noted in an article on Live Science where several "questionable screening tests" were discussed. One example is the Alzheimer's Smell test that has been marketed for some time as a do-it-yourself approach to identifying the disease. While the test is not regarded as valid in the scientific community, consumer marketing messages imply otherwise.

It is difficult to to understand the evolving landscape of technologies for identifying and treating Alzheimer's disease without access to the scientists performing the research and without a solid understanding of how these technologies might pass through a regulatory process on the way to becoming part of a clinical solution. The purpose of this blog is to help readers gain a more accurate perspective on the daily news and what it means in terms of real progress in this area.

Perspective on Funding for AD Research

Contributed by: Dennis Fortier, President, Medical Care Corporation

Amidst all the news stories about the science of Alzheimer's disease, there are also stories about it's economic toll on our health care system and stories about the allocation of research dollars aimed explaining the disease and developing treatments. This week, the NIH released a statement about the American Recovery and Reinvestment Act and how some of its funds are directed at the Alzheimer's problem.

Overall, it is an encouraging piece of news citing the fact that more than 100 Alzheimer's related grants, aimed at identifying risk factors, improving diagnostics, isolating bio-markers, conducting trials, and developing new therapeutic agents, were funded through the act. Specific details were provided for the Alzheimer's Disease Neuroimaging Initiative (ADNI) which will receive $24 million in funds, and the Alzheimer’ Disease Genetics Consortium (ADGC) which will receive about $5.4 million in funds. Certainly these are large grants and represent opportunities to advance the science.

However, this news should be considered against the larger funding context that is also discussed frequently in the news. The big picture is painted clearly by Harry Johns, CEO of the National Alzheimer's Association, through his daily comments to constituents across the country.

A summary in The Detroit News on Monday makes his point. The NIH awarded $6B to cancer research last year. They awarded a further $4 billion for cardiovascular disease and $3 billion for HIV/AIDS. In comparison, the NIH funds for Alzheimer research was $428 million.

With this perspective, it is clear that the potentially devastating impact of Alzheimer's disease on the boomer generation is not reflected in the funding support of the federal government.

Is Memory Screening a Good Idea?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Is Memory Screening a Good Idea?

Yesterday was National Memory Screening Day and, as usual, there were many editorials in print and online discussing the pros and cons of memory screening. As is often the case, the answer to the question that headlines this article varies greatly depending on whom you ask. When discussed in the press, I rarely see a balanced view of pros and cons but rather a biased presentation of the "facts" aimed at supporting the author's opinion. Here's a summary of what I consider to be the most important considerations.

First, the term "screening" is open to interpretation and is generally used inconsistently from author to author depending on their respective attitudes toward screening.

For those who tend to be against memory screening, they usually adopt the traditional definition of screening which suggests that programs are perpetrated on large populations of symptom free subjects, perhaps even against the will of the subjects. I would agree that a comprehensive, population-based approach is probably not a good idea for many pragmatic reasons related to educating and further evaluating the multitudes of people whose screening results would warrant further attention.

Those who support memory screening tend to adopt a definition consistent with "case finding". This essentially means performing a memory assessment on those with concerns about their memory or evidence that it is declining. With this definition, I would support the general argument that, for people who have a memory concern, some type of evaluation (a screening if you will) should be available to them. This makes sense and would greatly improve our ability to intervene against problems in their earliest stages.

It strikes me that if we could all adopt a common understanding of what is meant by "memory screening", most of the controversy and debate would likely vanish. Having said that, there are three other prominent themes in the argument against memory screening that are not related to the definition of “screening”. Here are my comments on those themes.

Type I Errors – False Positives

This pertains to the possibility of inflicting unnecessary angst in healthy people who could be improperly assessed and mistakenly told that their memory is impaired. Those against memory screening speculate that this could lead to undue anxiety, depression, and even suicide. While that may be plausible, there is really no supporting evidence and it is probably off base. The few studies that have been conducted on attitudes toward screening have shown that people seeking memory assessment are often anxious from the outset and learning the result of an assessment, be it positive or negative, tends to reduce their anxiety.

Type II Errors – False Negatives

This pertains to the possibility that unsophisticated screening instruments or untrained screeners could miss signs of impairment and mistakenly tell symptomatic subjects that they are healthy. This of course might reduce the likelihood of that person seeing a physician and getting good care. That’s a reasonable argument and is likely to be true because we know that patients may seek second opinions when they get “bad medical news” but they are far less likely to do so after receiving “good medical news”. I think it is reasonable to insist that a beneficial memory assessment program would require both the use of a well-validated assessment instrument and well trained administrators.

The Importance of Medical Expertise

This argument suggests that, regardless of mistakes in either direction, people learning that they have a memory problem may fear Alzheimer’s disease as the underlying cause and these people should be counseled and educated immediately to assuage their anxiety. If the structure of a screening program is “high volume” and “public” in nature, then it may be conducted in an environment lacking the medical expertise that some patients will require. I would agree that there may be some real costs associated with screening programs that are not conducted within a framework capable of providing proper follow-up attention to subjects who learn of memory impairments. These costs must be considered in the evaluation of any program's merit.

A Commonly Neglected Perspective

In general, the discussions I see in the media tend to consistently neglect one important aspect of the anxiety consideration. A high percentage of the people that seek to participate in self-selecting memory assessment programs (that is, programs for which one may voluntarily seek to have their memory assessed), are already somewhat anxious about a perceived decline in their memory. We know that such anxiety is often unfounded and that many worries are merely a slowing of name recall or diminished concentration associated with normal aging. As such, voluntary memory screening programs may reassure and relieve anxiety in a high number of normally aging individuals who have been needlessly worrying about their cognitive health. This is a real benefit that should be weighed against other costs when evaluating the value of a given program.

To summarize, we may not be ready for widespread memory screening but we are certainly ready for programs that provide accurate assessment and expert follow-up for those individuals who perceive a decline in their memory. Doing so is one of the best approaches available for promoting early intervention and effective treatment for many aging people with medical conditions that impair cognitive function.

What Causes Dementia?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Because the general media commonly interchanges the terms "Alzheimer's" and "dementia", there is much confusion about the definition of each and the difference between the two. As such, I like to offer a clarifying viewpoint on a regular basis.

Alzheimer's is a disease. We don't completely understand it but the development of amyloid plaques and neurofibrillary tangles in the brain seem to play a role.

Dementia is a descriptive term for the symptoms caused by disorders that impair cognition. Specifically, if memory and at least one other realm of cognition (judgment, executive function, verbal fluency, etc.) decline to the point where they interfere with daily life, then the condition is dementia.

A key point is that there are many causes of dementia; Alzheimer's is merely one of them. Vascuclar disease, Parkinson's disease, and Normal Pressure Hydrocephalus and others are also on the list. The conditions and disorders that cause memory loss are worth learning about.

The distinction between memory loss and dementia, and the causes of each are well developed in a recent article on by Patricia Grace. This perspective and other good views are presented regularly at the blog:

Stigma and Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation

Here's the definition of "stigma": a mark of disgrace associated with a particular circumstance, quality, or person.

It's really a shame that so often, stigma is a pure social construction based on poor understanding of a circumstance. Having an illness, for example, should never be stigmatizing and in a more informed world, it never would be.

Readers of this blog know how strongly I feel about the importance of awareness and education as parts of a solution to the growing dementia problem, specifically as it pertains to dementia caused by Alzheimer's disease. The greater the understanding and the more prevalent the discourse, the more we can reduce the stigma that holds many back from seeking help while they are still quite healthy and more likely to respond to treatment.

I recently read a great entry at one of the blogs I follow, ElderCareTalk, written by Laura Bramly. She tells an inspiring story about the strength of elders who rise above the stigma and help the rest of us see them for all that they are. I encourage you all to read it.

The Brain Healthy Lifestyle

The “Brain Healthy” Lifestyle Contributed by: Dr. Bernard Croisile, MD (Neurology), Ph.D, Chief Science Officer, HAPPYneuron

We are all eager to learn how best to keep our brains healthy as we age and much research is underway in that regard. While evidence is still building in many areas, it is clear that certain aspects of a “brain healthy” life style have no downside and should be considered as potential, immediate additions to our regular routines.

Among the approaches with meaningful evidence of benefit are the following six:

1. Physical Exercise
2. Balanced Diet
3. Socialization
4. Stress Reduction
5. Adequate Sleep
6. Cognitive Stimulation

While the most well researched avenues to brain health are balanced diet and physical exercise, there is mounting support that these other four areas should be seriously considered in anyone’s strategy to age with cognitive vitality. Among the public, there is particularly strong interest in learning more about the benefits of cognitive stimulation.

To stay sharp and defer brain decline, the scientific evidence shows that the odds of success are significantly increased by living a “brain healthy” lifestyle and that wide and varied cognitive stimulation is a critical element of such a lifestyle. To achieve that, one must engage regularly in brain activity that spans the use of all the major brain functions of language, memory, attention, visual-spatial and logic and reasoning activities. This can be difficult to achieve consistently over time. One way to activate all these brain functions on a consistent and regular basis is to play specially designed brain games and to participate in evidence based brain-training programs.

These games are designed to be engaging and by most accounts they are generally fun and entertaining. You have nothing to lose and a lot to gain, most notably, staying sharp!

High Protein Diet and AD

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________

A research team from the US, Canada, and the UK have concluded a study comparing the relationship between four different diets and Alzheimer's pathology in mice.

For 14 weeks the mice were fed one of four diets: (1) a regular (reference) diet; (2) a high fat/low carbohydrate diet; (3) a high protein/low carbohydrate diet; or (4) a high carbohydrate/low fat diet. After this, the researchers did post mortem analyses on the brains of the mice and measured their weight, plaque build up and structural differences in those regions known to be involved in the memory defects of Alzheimer's disease.

Amyloid Precurser Protein's role in the brain is not fully understood; however it is of great interest to AD researchers because the body uses it to generate the amyloid plaques typical of Alzheimer's. For each diet group, the researchers looked at the brain and body weight of the mice, as well as plaque build up and differences in the structure of several brain regions that are involved in the memory defect underlying AD. Unexpectedly, mice fed a high protein/low carbohydrate diet had brains five percent lighter that all the others, and regions of their hippocampus were less developed.

However, until researchers test for this effect in non-genetically engineered mice, it remains unclear whether the loss of brain mass is linked to the amyloid plaque found in Alzheimer's disease. The only way to verify this in humans would be to do prospective randomized double blind diet trials.

Beta Amyloid: Friend or Foe?

Contributed by: Dennis Fortier, President, Medical Care Corporation

According to the amyloid hypothesis, an accumulation of this protein in the brain leads to the formation of plaques which eventually kills neurons and causes dementia. It is a popular theory given a fairly high correlation between amyloid load and loss of cognition and given that lowering amyloid load (through a variety of strategies) has been associated with improved cognitive function. This theory is driving a large portion of drug development activity in current FDA trials.

However, there are some troubling aspects to the theory. Notably, there are many well-documented instances of autopsied brains that were full of amyloid plaques but came from the skulls of persons with high cognitive function. Perhaps this can be explained by timing. Perhaps the plaques build, then there is a period of progressive brain damage due to the presence of the amyloid, then cognition declines. It is plausible and would explain why we sometimes find cognitively vital people with lots of amyloid in their brains.

New research from Saint Louis University and published in the online Journal of Alzheimer's Disease suggests a more complex relationship between amyloid and the brain. In a study on mice, researchers demonstrated that amyloid was associated with improved learning and memory, the exact opposite of what might have been expected. This suggests that viewing all amyloid as bad may be too simplistic. Perhaps having either too much or too little is the real problem and therapeutic strategies should be refined to "regulate" amyloid as opposed to "eliminate" this important protein.

Each day we find another answer and pose another question to this complex puzzle but slowly, it is coming together into a more comprehensive understanding of how to treat the disease.

Is Memory Loss a Normal Part of Aging?

Contributed by: Dennis Fortier, President, Medical Care Corporation

In a recent posting supporting the value of awareness in our collective fight against Alzheimer's disease, I wrote that memory loss is not a normal part of aging. Based on comments left by readers, it became clear to me that, among some portion of the population, that is a difficult fact to accept. In fact, by most readers' accounts, the evidence seems stacked in the other direction with a high percentage of elders complaining of eroding ability to store and retrieve information.

Given this response, I think it is important to reconcile the two perspectives. There are two important points to consider.

First, what many label as "memory loss" is actually something else; commonly "slow recall" or "distraction". Each of these is described in full in this earlier post. It is clear that the term "memory loss" is interpreted quite widely and many consider all sorts of cognitive deficits to be memory problems when often they are something else. At the end of the day, there are probably far fewer actual "memory complaints" than many of the readers perceive.

Second, because medical conditions that impair memory are prevalent in old age, memory loss is indeed common. People with depression, thyroid disease, vitamin deficiencies, multiple medications, metabolic disorders, vascular disease and early stage Alzheimer's may all complain of memory loss. My earlier posting took the position that having one of these conditions is not normal.

In hindsight, it would have been more clear for me to write that memory loss is not a normal part of healthy aging.

Alzheimer's Awareness: Why Bother?

Contributed by: Dennis Fortier, President, Medical Care Corporation

As you may have read elsewhere, November is National Alzheimer’s Awareness Month. But surely, the public is already well aware of this horrible disease. After all, Alzheimer’s has directly affected approximately 1 in every 2 families and the others must have certainly noted its prominent coverage in the news. We don’t really need more awareness, right?


Some of the information below may surprise you. That is to say, it is information about which you are not presently aware. However, by merely learning the seven facts below you will be helping to reduce the Alzheimer’s problem. That’s right…making you aware of this information and encouraging you to share it with your social networks will facilitate a more informed and more effective approach to combating the threat we face from this disease.

First, here are a few facts and figures that you may already know. Alzheimer’s currently affects more than 5 million Americans and that number is likely to triple by 2050. It is the sixth leading cause of death in the USA and is climbing steadily in the rankings. Also, Alzheimer’s is the leading cause of dementia and accounts for about 65% of all dementia worldwide. These are all sobering facts but perhaps not new to your understanding.

7 Facts You Need To Know
Now, here are some points you may not know but should. It is the following information that I hope will stimulate discussion and promote a better understanding of the disease. With more discourse, we can begin to erode the lingering stigma that currently prevents some people with early symptoms from seeking timely medical attention.

1) We generally detect Alzheimer’s at the end-stage of the disease. On average, Alzheimer’s follows a 14-year course from the onset of the first symptoms until death. There is some variability across patients but 14 years is pretty typical. The more surprising news is that, on average, we diagnose Alzheimer’s in years 8-10 of that disease course. This means that for most patients, symptoms go undiagnosed and untreated for at least seven years, during which time the lesions spread through the brain and cause irreparable damage. Please be aware that we diagnose Alzheimer’s disease far too late to optimize the effects of currently available treatments.

2) Sudden or Severe Memory loss is not a part of normal aging. The point about end-stage detection raises an obvious question about “why” we diagnose this disease so late. There are many contributing factors but most of them can be reduced through awareness and education. Some patients with memory concerns resist medical attention in the early stages because they fear a stigmatizing label or because they are misinformed to believe that Alzheimer’s cannot be treated. Many people, including a startling number of physicians, incorrectly believe that memory loss, even sudden or severe loss, is a normal part of aging. Improving the timeliness of diagnoses for Alzheimer’s is, in many ways, a problem that can be addressed through awareness and education. Please be aware that sudden or severe memory loss is not a part of normal aging and, regardless of the cause of the memory loss, timely medical intervention is best.

3) Current Alzheimer’s drugs are probably more effective than you think. Our widespread practice of late detection has many negative consequences. For example, one of the reasons that current treatments are often deemed ineffective is because they are routinely prescribed for patients with end-stage pathology who already have massive brain damage. With earlier intervention, treatment can be administered to patients with healthier brains, many of whom will respond more vigorously to the recommended therapy. Yes, we need better treatments, but a great start would be to intervene earlier with the treatments we already have. Please be aware that currently approved treatments may be more effective than some headlines indicate.

4) Alzheimer’s disease can be treated. Another treatment related concept about which everyone should be aware is this. Preventing or slowing further brain damage is preferable to letting the damage spread without constraint. Yet, many physicians, patients, and caregivers conclude that any treatment short of a cure is not worthwhile. While today it is true that we have no cure for Alzheimer’s, that does not mean there is no treatment. With a good diet, physical exercise, social engagement, and certain drugs, many patients (especially those detected at an early stage) can meaningfully alter the course of Alzheimer’s and preserve their quality of life. Please be aware that “we have no cure” does not mean “there is no treatment”.

5) The Alzheimer’s drug pipeline is full. Here’s another fact of which you should be aware. Through an intense research effort over the past twenty years, scientists have gained a lot of insight about Alzheimer’s disease mechanisms and about other factors that increase the risk for the disease. Much has been learned and some very promising drugs, based on sound theoretical approaches, are in FDA clinical trials right now. While much of the disease remains shrouded in mystery and we may still be a long way from better treatments, it is possible that an effective agent is already in the pipeline. Please be aware that, although we don’t know when, better treatments for Alzheimer’s are certainly on the way.

6) Taking good care of your heart will help your brain stay healthy. Know this; the health of your brain is very closely tied to the health of your body, particularly your heart. Researchers have shown conclusively that high cholesterol, high blood pressure, and obesity all confer greater risk for cognitive decline. The mechanisms that keep oxygen rich blood flowing through your body play a key role in maintaining a healthy brain. Everyone should be aware about the close association between vascular health and cognitive health. Please be aware that maintaining good vascular health will help you age with cognitive vitality.

7) Managing risk factors may delay or prevent cognitive problems later in life. There are well-identified risk factors for Alzheimer’s disease that are within our power to manage. These include diabetes, head injuries, smoking, poor diet, lethargy, and isolation. With greater awareness of these facts, we can imagine a world where diabetics take more care to control their blood sugar, where helmets are more prevalent in recreational activities that are likely to cause head trauma, where people smoke less and eat more fruits and vegetables, and where everyone makes a better effort to exercise and to stay socially engaged on a regular basis. While these facts may not be well known, they are all well proven. Galvanizing an effort to publicize them is one purpose of National Alzheimer’s Awareness Month. Please be aware that many risk factors for Alzheimer’s can be actively managed to reduce the likelihood of cognitive decline.

So why bother with Alzheimer’s awareness? Because it is a terrible disease poised to ravage our aging society and the lack of education and awareness has lead to a stigma that prevents a more proactive approach to early intervention. The result is that we diagnose it too late, which hampers the efficacy of available treatments. A more educated public could manage risk factors to minimize the likelihood of Alzheimer’s, could monitor personal cognitive health with greater vigilance, and could seek medical attention at the earliest sign of decline. Physicians could then diagnose problems earlier and prescribe appropriate treatment including diet, exercise, and drugs to slow disease progression as much as possible. In the end, we could have fewer cases, more effective treatment, slower progression, higher quality of life, and lower healthcare costs. The social, emotional, and fiscal benefits of awareness and education in this area are too large to quantify.

By reading this article, you have increased your understanding of the problem and raised your awareness about what can be done. That is a great step in the right direction but you can do one thing more. You can help to spread this message.

In the spirit of National Alzheimer’s Awareness Month, please share this article with your friends to promote more widespread awareness. Post it to your Facebook page, Link to it from your Newsletter, Tweet it, or email it. It doesn’t matter how you do your part, it only matters that you get it done.

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A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share button below to spread this educational message as widely as possible.

Vision Problems and Variant AD

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________

In a minority of Alzheimer's patients the disease shows up first as problems with vision rather than memory or other cognitive functions. But diagnosis can be difficult because standard eye exams are often inconclusive for these patients.

Neuro-ophthalmologists Pierre-Francois Kaeser, MD, and Francois-Xavier Borruat, MD, Jules Gonin Eye Hospital, Switzerland, examined and followed 10 patients with unexplained vision loss who were ultimately diagnosed with the visual variant of Alzheimer's disease (VVAD). Their study -- presented at the 2009 Joint Meeting of the American Academy of Ophthalmology and the Pan-American Association of Ophthalmology (PAAO) -- describes clinical clues that may improve ophthalmologists' ability to detect VVAD and refer patients for further tests. When patients receive neurological assessment, treatment and family counseling early in the disease, outcomes may be better for all concerned.

VVAD patients differ from typical Alzheimer's patients in a number of ways. At the time they report visual problems, many are younger than those for whom memory loss is the tell-tale sign. In Dr. Kaeser's study the median patient age was 65, and only 3 of 10 reported memory loss. In comprehensive neuro-ophthalmic exams even though most patients' visual acuity was adequate, all but one had difficulty with reading, 8 of 10 with writing, and 6 of 10 with basic calculations. The visual field was altered in 8 of 10 patients.

All had trouble identifying colored numbers despite being able to name colors correctly, and, importantly, 8 of 10 patients had difficulty recognizing and interpreting components of a complex image (simultagnosia). This is an early indicator of the brain damage that prevents later-stage Alzheimer's patients from recognizing people they know and navigating familiar surroundings. MRI and PET scans revealed neurological changes consistent with VVAD in all study patients. Though VVAD patients' first symptoms are visual, Alzheimer's memory and personality impairments eventually occur in most.

Interestingly, in the neurology field VVAD is referred to as Posterior Cortical Atrophy (PCA), because the posterior, or back of the brain, shrinks. When pathologists examine the brain tissue from these patients, they see amyloid plaques in the occipital lobe, which is in the posterior part of the brain, and resposible for vision.

New Dimebon Trials Launched

Contributed by: Dennis Fortier, President, Medical Care Corporation

As we have chronicled in past posts, there are multiple agents for treating Alzheimer's disease in the FDA pipeline. One of the most advanced, and by many measures, most promising, is Dimebon.

The co-developers of this agent (Pfizer and Medivation) have announced two additional trials that are now enrolling subjects. While it is not completely understood, Dimebon appears to have a novel mechanism compared to the currently approved drugs Aricept, Razadyne, and Exelon, all of which are cholinesterase inhibitors and Namenda, which is a glutamate blocker. The mechanism is theorized to be one of improving mitochondrial function to promote ongoing cell health. The new trials will explore poly-therapy with Aricept and with Namenda.

To learn more details and to inquire about enrolling in the studies, please follow these links to the CONTACT study (or email and to the CONSTELLATION study (or call 1-877-377-4476).

Inflammation and AD

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________

Microglia are the housekeepers of the brain, digesting foreign bodies and protecting neurons from damage. In culture, these cells are well known for ingesting amyloid-β, and in Alzheimer disease they surround amyloid deposits.

But in a study published in the October 18 Nature Neuroscience online, researchers in Germany have almost completely removed microglia from the brains of transgenic mice, and to their surprise they found absolutely no change in plaque size or number.

This leads to the hypothesis that the microglia may surround the plaques, but are essentially protecting the rest of the brain and not involved in modifying, depositing, or removing the plaques. The study also raises the possibility that cell-mediated inflammation does not promote more amyloid or more Aβ, which has been a hypothesis for a long time.

The Value of Memory Tests

Contributed by: Dennis Fortier, President, Medical Care Corporation

In the news today you may read about the value of memory tests for identifying subtle memory loss at an early and more treatable stage. The findings are published in Neurology by a team of researchers at Oxford University.

In the study, the research team followed healthy volunteers for 20 years and assessed their memory at regular intervals. For those whose cognition eventually declined, the scientists were able to look back and identify specific, measurable signs of diminishing memory and language skills.

These findings are consistent with our understanding that many conditions that impair cognition, particularly Alzheimer's disease, follow a long course that slowly damages the brain. The findings are important because they speak to the potential for very accurate tests that detect subtle changes to facilitate much earlier intervention and better treatment results. Currently, most causes of dementia go undiagnosed for many years while unnecessary brain damage accumulates irreversibly.

Alzheimer's: Cure vs. Treatment

Contributed by: Dennis Fortier, President, Medical Care Corporation

As I read the daily news in the field of brain health, I see the same facts used to support and round out almost every article on Alzheimer's disease. There is nearly always a reference to the 5.5 million Americans stricken, usually a brief description of the disease as a "progressive neurological disorder", and frequently, the nihilistic proclamation that there is no cure.

It is true of course; there is no cure. However, I am alarmed by the tendency of many to interpret that to mean that there is no treatment, which is inaccurate. The two statements are very different.

This problem doesn't seem to plague other diseases. There is no cure for hypertension or diabetes but that particular comment never seems to be appended to related news stories. Ditto for high cholesterol and osteoporosis. With all of those maladies, and many others, we have grown entirely comfortable with the notion of identifying them and treating them to best manage their forward course.

The reality is that Alzheimer's disease can be treated. Not yet with the efficacy with which we treat other diseases like those I mentioned but certainly well enough that people with memory concerns should pursue a diagnosis and, if it is Alzheimer's disease, seek treatment.

There is no denying that we need better treatments and ultimately a cure. In the meantime, a good diet, physical exercise, social engagement, and poly-therapy including a cholinesterase inhibitor plus Namenda can have a meaningful impact on the disease within many patients. We have no cure but that does not mean we have no treatment.

As we write here often, education and awareness about Alzheimer's disease will help to reduce the stigma of memory loss and promote more timely intervention. Please share this information with your online networks using the share button below.

Do Alzheimer's Patients Who also have Diabetes decline more slowly?

Contributed by: Dennis Fortier, President, Medical Care Corporation

According to a study from the French National Institute for Health and Medical Research, it appears as though Alzheimer's patients with diabetes lose memory function more slowly than Alzheimer's patients without diabetes. This seems counter-intuitive given that diabetes increases the risk for both Alzheimer's and for memory loss.

In fact, this study published in the October 27, 2009 issues of Neurology, may not be as conclusive as it seems on the surface. The study followed 608 Alzheimer's patients, about ten percent of whom also had diabetes, and assessed their memory twice annually for the four year duration of the study. The results showed that the diabetes group fell about four tenths of a point on a 20-point cognitive scale every six months whereas the group with no diabetes fell about three times as much; about one and a quarter points at each interval.

However, a few limitations in the study prevent a tidy conclusion. Most glaringly, the cognition of those in the diabetes group may have benefited from the diabetes treatments they took in addition to the Alzheimer's treatments. It was also unclear if the diabetes group and the no-diabetes group had similar levels of cognition at the start of the study. If the diabetes group was more impaired (that is, had already declined more precipitously), then a slower ongoing descent would be considerably less interesting.

6 Steps to Diagnosing Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation

One of the keys to better Alzheimer's care is education. We need a more informed public that knows how and when to seek expert advice from a medical doctor. We also need the medical community to adopt a consistent approach to applying the latest standards of care for an aging public with many memory concerns, be they real concerns or false alarms.

While there is a lot of information posted online that can help educate the public, there is also lots of suspect information as well. One site that has a wealth of high quality information in this field is You may have noticed one of their articles that was picked up by the general media; it described the types of information a family will want to collect and consider if they suspect the early stages of Alzheimer's disease.

The article outlines six practical steps to take when memory concerns are first present. Following these steps should keep the diagnostic process moving in a constructive direction toward a beneficial conclusion. The steps, each examined in more detail in the full article, include:
  1. Creating a record - writing down observations about the nature and frequency of any behaviors that seem problematic.
  2. Educating yourself - learning about all the possible explanations for cognitive changes to avoid jumping to an overly dire conclusion.
  3. Identifying a qualified physician - this may be the patient's usual primary care physician but it may not be. Not all M.D.'s are equal.
  4. Getting a thorough diagnostic work-up - this will include more than a medical history and a physical exam as blood work, cognitive assessment, and brain imaging may all be required.
  5. Seeing a specialist - whether the primary care physician initiates this step or not, the family should pursue such a consultation.
  6. Seeking a second opinion - as the medical community endeavors to absorb new medical knowledge in this field, there is a wide range of expertise among primary care physicians. Getting a second opinion is a prudent step.

Is Dementia a Disease?

Contributed by: Dennis Fortier, President, Medical Care Corporation

We write about this topic frequently as the general media tend to be fairly inconsistent in their characterization of dementia. As we are careful to point out, dementia is the loss of cognitive capacity that results from various diseases, accidents, and medical conditions. In and of itself, dementia is not a disease.

Having said that, an important new perspective presented this month by Time might add ongoing confusion to this topic. In a well-written piece, based on a publication in the New England Journal of Medicine, researchers advocate the perspective that patients actually die of dementia. This perspective is akin to viewing dementia as a disease, not a symptom of other medical problems.

While I agree with the author's main point, that patients with dementia are suffering all sorts of systemic biological failures due to a progressive level of brain damage (and will most likely die from these failures), it is the underlying diseases that produce both the dementia and the death.

One key point in the article that I want to support and emphasize is this: For physicians and caregivers, it is important to recognize that, once demented, the patient's health may have reached such a poor state that a focus on palliative care is warranted over aggressive treatment of the underlying problems. While I think it would create undue confusion to define "dementia" as a disease and to identify it as a "cause of death", the point about approaches to better care is well taken and should be noted.

When Can We Expext a Cure for Alzheimer's?

Contributed by: Dennis Fortier, President, Medical Care Corporation

There is no definitive answer to this ubiquitous question. The best we can do is to watch the advance of science through the published literature and to follow the clinical trials from which the answer will one day emerge.

While the pathology of Alzheimer's disease is still not well understood, scientists have developed a host of well-grounded theories. Several treatment agents, based on those theoretical foundations, are currently in development or in clinical trial. Here is a short summary of the three leading treatment hypotheses:

The Cholinergic hypothesis proposes that AD is caused by reduced function of a certain chemical in the brain called acetylcholine. The chemical is known to be important in memory formation and brains of patients with AD have less acetylcholine. In fact, most medications currently approved for AD act by increasing acetylcholine levels in the brain. However, their ability to treat the disease has been limited, indicating other factors at play.

The Amyoid Hypothesis states that a buildup of deposits (amyloid) is the fundamental cause of Alzheimer’s disease. It is a compelling theory because a gene associated with this form of amyloid is located on chromosome 21 and people with an extra copy of this gene (those with Down Syndrome) almost universally exhibit AD by 40 years of age. Also, APOE4, the major genetic risk factor for AD, leads to excess amyloid buildup in the brain before AD symptoms arise. Thus, amyloid buildup precedes clinical AD.

The Tau Hypothesis encompasses the idea that tau protein abnormalities form damaging tangles inside nerve cells. When this occurs, the cell's transport systems disintegrate and malfunction which may disrupt communications between cells and later cause cell death.

While these are the primary theoretical drivers of drug development, there are other agents in clinical trial that were not developed on the basis of a particular theoretical approach to the disease. Dimebon, currently in Phase III FDA trial is a pre-approved antihistamine that was shown to correlate with low dementia prevalence. Although scientists are not sure how or why it might effectively treat Alzheimer’s disease, results of the Phase I and II trials were positive and Dimebon may in fact be the next approved treatment for Alzheimer’s disease.

While it is premature to say that a cure is imminent, it should be clear that several treatment agents are in advanced stages of clinical trial. However, predicting the results of these trials is hampered by our vague understanding of what causes Alzheimer's Disease. On the bright side, one or another of these agents may be surprisingly effective in altering the disease course and could be available in two to five years. On the dark side, they may all turn out to be ineffective in which case we would be more than five years away from a meaningful new medication. Only time will tell.

In the meantime, we all need to be proactive in identifying and managing our risk factors for cognitive decline and physicians must be vigilant about acting on evidence or suspicion of decline among their patients. Until better treatments are discovered, we must intervene as early as possible with the current medications to maximally delay the progression of Alzheimer's disease.

Remember, we need a cure but there is much we can do while we await its arrival. Current treatments are more effective than many headlines suggest. With early intervention and a robust therapeutic regimen (including physical exercise, mental and social activity, a healthy diet, and currently approved medications), we can already meaningfully delay the progression of this terrible disease.

Blood Tests for Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation

Bio-marker development is a very common news topic in the Alzheimer's field. Each day there is news about a blood test, a spinal assay, a binding agent that aids imaging, or a new cognitive measure. These developments are important as they will lead the way to earlier detection and more accurate diagnoses -- two areas where improvements could have a great positive impact on treatment outcomes.

A particular approach that has gotten a lot of media attention, including this story today, is to measure the amount of beta-amyloid in the blood. The theory is that people with subtle memory loss and high levels of beta-amyloid may be in the early stages of Alzheimer's disease and should be treated immediately before symptoms worsen. Those with subtle memory loss and normal levels of beta-amyloid probably have some other medical condition disturbing their memory.

While this work is theoretically intriguing, one particular obstacle still stands in the way of clinical utility. The challenge is that the beta-amyloid levels in the blood of healthy individuals range widely. Therefore, it is difficult to meaningfully identify the "normal" level in any given patient. As such, measuring amyloid in the blood or spinal fluid is a promising avenue but still quite some time from clinical feasibility.

One possible improvement in this approach is to compare the ratio of beta-amyloid to tau proteins in the blood. Doing so may offer a more meaningful measure, particularly when observed over time within a given patient. A rapidly changing ratio may indicate pathological changes that foretell the onset of Alzheimer's disease. Work on this approach is proceeding at several locations.

We look forward to ongoing news and developments in this area. For the time being, the most accurate and clinically feasible bio-marker is cognition. Eventually, it is likely that a combination of biomarkers will be used in conjunction to accurately identify diseases and medical conditions in early stages when treatment effect is optimal.

Does Web Surfing Ward Off Dementia?

Contributed by: Dennis Fortier, President, Medical Care Corporation

If you read many of the recent headlines you might think so. A closer look at the study producing those headlines suggests that some of them are probably worded a bit more strongly than the research can support.

The good news is that this study provides further confirmation that ongoing intellectual stimulation is usually correlated with lower prevalence of dementia. We have seen this in many studies and there can be little doubt that using your brain creatively, to solve problems, to socialize, and to learn new information or skills is generally beneficial to cognitive health.

An important message that is sometimes lost amid the rush to identify those games and activities that provide the most effective work-out for the brain, is that many simpler and more natural human activities also provide a healthy cognitive challenge. One activity that requires a broad range of cognitive skills is making and maintaining personal relationships.

The key take away is this: Don't underestimate the importance of social activity as you seek new ways to exercise your brain. Perhaps joining a club or volunteering could bring you a natural and rewarding approach to the sought after cognitive benefits.

Cut AD Risk with Nuts, Veggies, and Fish

Contributed by: Dennis Fortier, President, Medical Care Corporation

You may have seen this story elsewhere in the news but it bears repeating here as we view diet to be one of the most well studied and most effective approaches to maintaining good cognitive health. Our food intake is one of the factors that is most easily within our control and appears to have an important impact on risk for Alzheimer's disease.

According to a study at Columbia University and presented at the annual meeting of the American Neurological Association, a diet rich in cruciferous and green leafy vegetables, nuts, fish, and tomatoes and low in red meat and high-fat dairy products may be protective against Alzheimer's disease.

In the study, 1,691 subjects aged 65 and older with no signs of cognitive impairment were surveyed about their dietary habits. Based on the amounts of protective nutrients (omega-3 fatty acids and vitamin E) and risk-increasing nutrients (saturated fatty acids) in each food, the researchers divided the subjects into groups. The groups were subsequently followed for 4 years to assess the rates at which each group showed cognitive decline.

The results showed that the 1/3 of subjects who most closely adhered to the "protective" diet was 38% less likely to be diagnosed with Alzheimer's disease in this time frame than the 1/3 of subjects who most deviated from that diet. These results held true even when age, physical activity, smoking, body mass index, and overall caloric intake were all controlled.

A 38% reduction in risk simply by eating well -- that's too good to pass up. We can't say it enough - eat your fruits and vegetables and cut back on some of the saturated fats.

Reelin and beta-Amyloid

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________

The layering of neurons in the developing brain requires Reelin, a protein located on the outside of the cells. Reelin, also acts as a "green light", stimulating neurons to respond more strongly to their neighbors' signals. A recent study showed that applying Reelin directly to brain slices from mice prevents excess beta-amyloid from completely silencing nerves. In the study conducted using mouse models, the researchers determined that Reelin and beta-amyloid interact with the same receptor, (the NMDA receptor), which plays an important role in coordinating chemical signals between adjacent neurons.

They found that Reelin activates and strengthens the response of the NMDA receptor. In the presence of too much beta-amyloid, the receptor goes back into the cell, reducing the cell's sensitivity to incoming signals. By contrast, in strong concentrations of Reelin, the receptor remains active and the cell has the "green light" to continue receiving normally.

More work will be needed to see if Reelin can be used as a potential treatment in AD.

Proc Natl Acad Sci U S A. 2009 Sep 15;106(37):15938-43.

Concussions and AD

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________

Former professional football players suffer from Alzheimer's disease or other memory-related conditions at rates far higher than the general population, a new study commissioned by the National Football League shows. Retired players between the ages of 30 and 49 are 19 times more likely to struggle with memory problems than similarly aged men who never played professional football, the study found. The findings could have implications that reach far beyond the National Football League. Head injuries are not uncommon among college and high school players.

The new study of former pro players has not been peer-reviewed, but the results mirror several other recent studies suggesting a link between dementia and head injuries. The results of the study, conducted by the University of Michigan's Institute for Social Research, were first reported by The New York Times this past September.

For the NFL survey, the Michigan researchers contacted 1,063 retired players by phone late last year. The players, who had to have played at least three seasons to qualify for the survey, were asked a series of questions on a series of topics, including questions on health, financial well-being and satisfaction with life. Most of the questions came from the standard National Health Interview Survey. That way, answers could be compared to previously collected data from the general population. In some cases, a player's wife answered the questions. The Michigan researchers found that, among players aged 50 and older, 6.1% of them said they had received a dementia-related diagnosis -- five times higher than the national average of 1.2%. Players between the ages of 30 and 49 had a dementia-related diagnosis rate of 1.9% -- 19 times higher than the national average of 0.1%, according to the survey.

The management of concussions has been a major area of research in the field of neurology the last few years, with the American Academy of Neurology having published guidelines on its management in the past year. Much more work is needed to identify the mechanism by which the concussion brings about the changes seen in AD, and where intervention is needed.

New Treatment Guidelines for ALS

Contributed by: Dennis Fortier, President, Medical Care Corporation

In the October 13 issue of Neurology, the American Academy of Neurology has published new treatment guidelines for amyotrophic lateral sclerosis (ALS), often called Lou Gehrig's disease.

The guidelines are designed to help physicians optimize the quality of life for their ALS patients. While many with ALS with succumb to the disease within 3 to 5 years, others live as long as ten years after diagnosis. For these patients in particular, much can be done to ensure overal health and comfort throughout the disease course.

A more complete summary and link to the full publication can be viewed here but the basic guidelines are as follows:

  • prescribe Riluzole, the only FDA approved drug for ALS
  • use an assisted-breathing device
  • use a feeding (PEG) tube
  • offer botulinum toxin B to treat drooling if oral medications do not help
  • consider screening for behavioral/cognition problems because such problems might affect patients’ willingness to accept suggested treatments
  • enroll early in a specialized multidisciplinary ALS clinic to optimize care
As with other neurological disorders such as Parkinson's and Alzheimer's disease, there is no cure for ALS. However, as we see across all of these diseases, we have increased our ability to manage symptoms, prolong survival, and maintain a high quality of life. One key to such success is ongoing dissemination of guidelines outlining the highest standards of care.

Declining Visuospatial Skills May Indicate Early Alzheimer's Pathology

Contributed by: Dennis Fortier, President, Medical Care Corporation

According to a study published this month in Archives of Neurology, declining visuospatial skills may be one of the earliest cognitive indicators of emerging Alzheimer's disease. If confirmed, this could alter the current perspective that short-term memory is the earliest cognitive realm to show impairment.

In the study, conducted at the University of Kansas, 444 dementia-free subjects were enrolled and followed with a battery of neuropsychological assessments for an average of 5.9 years. During the course of the study, 134 subjects became demented and the cause of dementia was confirmed as Alzheimer's disease in 44 of them.

By looking at the performance of each subject across the battery of assessments, researchers were able to identify which realms of cognition declined earliest in those subjects who eventually suffered from dementia. The results suggested that multiple domains, including attention, executive function, episodic memory, and surprisingly, visuospatial skills may all play roles in indicating early stage cognitive decline.

This finding may shift the current emphasis from episodic memory to a broader set of domains, including visuospatial skills, in the ongoing effort to develop better assessments for detecting the onset of dementing disorders such as Alzheimer's disease.

Dementia's Effects Vary with Cause

Contributed by: Dennis Fortier, President, Medical Care Corporation

I borrowed this headline directly from this article in today's Baltimore Sun.

The headline filled me with optimism that the article could be useful in my ongoing campaign to clarify the fact that "dementia" is not a disease but rather a symptom caused by many distinct medical conditions. I think it is important for all to understand that we don't "treat" dementia, rather, we treat the Alzheimer's or Parkinson's or stroke or other underlying cause of the dementia.

The headline makes it clear that dementia has more than one cause so I was hopeful that the body of the article would be beneficial in clarifying what I have summarized above. Alas, this is not the case and the article will be just one more of the many that add to the confusion around the term dementia.

However, the descriptions of the various causes of dementia are useful and accurate as are the summaries of typical symptoms associated with each cause of dementia. In this regard, the article is a worthy read. Just be sure to disregard the opening sentence stating that "Dementia is an illness..." because it is actually a symptom of some other problem.