The primary purpose of this blog is to make sense of important news stories about brain health that are often confusing and/or misleading in their original, published form. Sometimes (although rarely) the media coverage is so well written and perfectly on-point that I merely direct readers to the source via an online link and encourage you all to read it on your own. Today let me direct you to an editorial by James Lah, MD, PhD at Emory University espousing his opinion on on the importance of early detection of memory loss. Thank you Dr. Lah.
This week has seen extensive media coverage of a report from the National Alzheimer's Association stating that the annual costs of care for an Alzheimer's patient are triple the cost of an elderly person without Alzheimer's Disease. These figures are very consistent with a bevy of other studies indicating a similar cost differential but can viewed with more clarity from another perspective.
First, it is useful to compare the demented elderly vs. the non-demented elderly as opposed to Alzheimer's patients vs. non-Alzheimer's patients. This adds clarity because the driver of the cost increase is the presence of dementia, regardless of its cause (Alzheimer's is the cause of about 65%, vascular disease 20%, Parkinsons/Lewy Body and all others 15%).
Second, since these diseases cross all socio-economic strata, some of the afflicted pay for their own institutional care while others rely on public support programs. As such, aggregating figures that include the costs of institutionalization muddies the view.
Here are the figures comparing the costs of medical services (physician appointments, hospital stays, procedures, and medications) for demented vs. non-demented people aged 65-74:
Average Annual Cost of Non-Demented: $3,851
Average Annual Cost of Demented: $15,998
The demented are more costly by a factor of 4.2. However, it is very rare for an elder, demented person to be completely free of other chronic conditions. Chronic conditions require management via thorough and consistent self-care which is often difficult when coupled with dementia. As such, it is the combination of dementia and other chronic diseases that drives costs most impressively.
Consider these figures showing prevalence of four common chronic medical problems in the aged 65-74 population:
29% Coronary Heart Disease (CHD)
28% Congestive Heart Failure (CHF)
17% Chronic Obstructive Pulmonary Disease (COPD)
Now look at the costs associated with these medical problems when combined with dementia compared to the costs associated with those problems in cognitively vital elders:
Dementia +CHD - $27,237 ($10,894 no dementia)
Dementia + CHF - $34,304 ($17,993 no dementia)
Dementia + Diabetes - $24,392 ($7,469 no dementia)
Dementia + COPD - $28,463 ($12,059 no dementia)
It is clear that dementia drives higher utilization of medical services, especially when combined with other common medical problems. Of course, figures associated with the cost of institutionalized care (and informal care giving) make the picture all the more bleak but this view is perhaps the most clear.
Recent evidence from Harvard University and Massachusetts General Hospital shows that combination therapy of cholinesterase inhibition (Aricept, Exelon or Razadyne) plus Namenda is most effective in slowing disease progression. These combinations can preserve ADL's (Activities of Daily Living) and delay nursing home placement by several years in some patients.
Earlier today, Forbes.com published an article titled "Do You Really Want That Alzheimer's Test?". I see pessimistic articles like this with alarming frequency where some "expert" laments the lack of effective treatment for this disease while entirely ignoring a solid decade of evidence that early intervention and appropriate treatment can be tremendously beneficial. Here is the comment I posted at Forbes.com:
From daily, first-hand experience, I can tell you that articles of this nature do an unintended disservice to humanity. While it is clear that treatments must get better, physicians, researchers, and the general public must all begin to divorce themselves from the stale dogma that "there is nothing you can do about Alzheimer's disease".
The biggest, and most immediately solvable, problem in treating this terrible disease is that up to 95% of patients are diagnosed in years 8, 9, and 10 of a typical 14-year disease course. This means that the patients have end-stage pathology with severe brain damage when they are first diagnosed and put on treatment. While the currently approved drugs will not reverse the progression of the disease at this late stage, they can slow its advance and afford a higher quality of life for a meaningful period of time. In those fortunate instances when patients have been diagnosed earlier, when less damage has occurred in the brain, the progression of the disease has been slowed by about 50% on average. In the best cases (but clearly not all), this can delay nursing home placement by up to several years and allow the luckier patients to live out their lives in their own home.
Although this clinical benefit (delaying progression) is not as appealing as a cure, it is still significant for patients facing end-of-life decisions. Additionally, better treatment efficacy based on more timely intervention is not the only reason why patients might "like to know" if they had Alzheimer's disease. Knowing early on gives them time to plan for the difficult period ahead and to participate in their care decisions prior to losing the ability to do so. There are also legal and financial plans to attend and, in some cases, the spiritual and philosophical preparation some choose to pursue when facing their mortality.
No one wants to see such diagnostic tests forced upon people who would prefer to remain ignorant but for the growing number who choose a proactive approach to their health, such medical clarity will be greatly beneficial. Nihilistic articles (of which there are many on this topic) tend to perpetrate the nation's sense that there is nothing we can do and no reason to know when Alzheimer's disease is present. I hope you and Dr. Smith will join the campaign to highlight the growing body of evidence that we can already help Alzheimer's patients in many ways. Acknowledging as much will not slow the research effort for a cure nor will it derail the scientific community's conviction that a better approach is needed. It may, however, begin to spur more patients and more primary care physicians to engage in the dialogue that will help us begin detecting and treating this disease at an earlier and more manageable stage.
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.
Drug therapy works best when started early and prescribed in conjunction with a healthy diet, physical exercise, ongoing social/intellectual activity, and an educated caregiver.
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, this one has come to me in extraordinary abundance. My primary take on this news story 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 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.
I commonly encounter this question in the press, I hear it discussed at conferences, and physicians pose it to me on a regular basis. Despite the centrality of this question in so many forums of cognitive health, it is a nonsensical inquiry with inherent flaws. Additionally, it propagates a pernicious brand of confusion that I want to clarify today.
As per my earlier post, Mild Cognitive Impairment 101, there are many medical conditions that can cause a subtle cognitive deficit. Pondering whether or not MCI will "convert" to Alzheimer's Disease (AD) obscures the fact that MCI is a symptom of an underlying medical problem (not the problem itself). In fact, some MCI is actually caused by AD and therefore, the prospect of converting does not belong in a logical, informed discussion.
When MCI is present, the correct question is "what is the cause of the impairment?". If the answer is AD, then the folly of a conversion outcome is clear; the disease precedes the impairment and not vice-versa. If the MCI is caused by some other medical condition (depression, vascular disease, anxiety, etc.) then it is equally futile to consider whether or not it will convert to AD; these medical problems are separate and distinct. That is not to say that such a particular person will never get AD because they may. In fact, the medical condition causing their impairment might even confer a greater risk for AD, but the notion of "converting" from MCI to AD is illogical.
A good analogy would be to learn of a patient with excessive thirst and blurry vision and then wondering if these symptoms will ever "convert" to Diabetes. Most physicians would perform a diagnostic work-up, take note of the high blood sugar, and diagnose diabetes immediately. There would be no debate about whether or not the symptoms would covert to the disease -- they would conclude that the presence of the disease has caused the symptoms. We must do the same with MCI. That is, perform a work-up and identify the underlying cause of the symptoms so that the patient may benefit from timely intervention.
So why have I labeled this as "a pernicious brand of confusion"? Because the perpetration of the idea that MCI might or might not convert to AD prevents some (if not many) primary care physicians from proactively diagnosing the cause of MCI and treating it. Giving any credence to the notion that MCI is a sporadically progressive precursor to AD is a barrier to clarity and interferes with a higher standard of care in this field.