NFL Players at High Risk for Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation

This is not surprising. Such a conclusion is perfectly consistent with our best theories as well as our casual observations. The fact that persons with a history of head trauma have greater risk for dementia is well documented and the connection to the NFL has been highly speculated for some time.

Now, as reported in the NY Times, the NFL has released the results of their own study on the matter. As part of a phone survey conducted by the University of Michigan's Institute for Social Research last year, 1,063 retired NFL players were asked questions on a variety of health topics. The conclusions were stark, especially for younger aged retirees.

According to the survey, 6.1% of players aged 50 and older had cognitive impairment which is five times higher than the 1.2% rate of prevalence in the general population. More importantly, 1.9% of younger players, aged 30 to 49, had impairment which is nineteen times higher than the .1% rate seen in general.

These figures are even more alarming than many experts would have presumed and will undoubtedly raise new questions about the prudence of suiting up 9-year olds and sending them onto the little league field to bang heads. I love football as much as anyone but it is looking more and more like the costs of the game are greater than the enjoyment it provides.

The Most Overlooked Opportunity in the Field of Alzheimer’s Care

Contributed by: Dennis Fortier, President, Medical Care Corporation

We all know about the obvious problems associated with Alzheimer's disease (AD). The media carry daily stories about the aging of the population (nearly 10,000 baby boomers turning 65 each day).  We are also inundated with messages about how current medications seem to be minimally effective against this poorly understood disease. Certainly, our limited ability to treat a disease that affects a burgeoning, elderly population makes for dire headlines.

However, there is a third problem that seems to be commonly overlooked in this conversation.

Late Intervention: Both Problem and Opportunity
This third problem is less obvious than the aging population and minimally effective treatment, but solving it will greatly mitigate the impact of these more widely noted themes. The problem is the unacceptably late intervention that we practice against this progressive disease. We routinely diagnose AD near end-stage pathology.

There is a fair degree of variability from case to case but, on average, AD follows a 14-year course from the onset of subtle symptoms until death. This usually includes a 7-year period of mild cognitive impairment (MCI) during which patients remain independent and able to care for themselves. The MCI stage is typically followed by a 7-year period of worsening dementia. In most instances (95% of instances according to one study), AD is first diagnosed during the mild or moderate dementia stages. This correlates roughly to years 8 through 11 on the 14-year time line.

We are dealing with a progressive disease that ravages the brain with each passing year and, on average, we are not intervening with treatment until end-stage pathology and massive brain damage have occurred. Yes, we need better treatments, but we can improve outcomes meaningfully by treating earlier with the currently approved interventions.

Alas, earlier intervention is a sensible but slippery goal. This is because early-stage AD patients, those in the MCI stage, have only mild symptoms. In this way, they look to a physician precisely like the multitudes of "normally aging" patients who have accurately sensed a slowing of their word or name recall, and are needlessly worried about AD. As you might imagine, these two types of patients are difficult to distinguish from one another.

Major Challenge: Discernment of Healthy Patients from Unhealthy Patients
Since the chances are high that a 65-year old patient complaining of subtle memory decline does not have early stage AD, such concerns are usually not closely evaluated until symptoms worsen considerably. This has lead to the current practice of intervening only after the disease has progressed to the dementia stage when, by definition, the symptoms are quite pronounced.

Today, however, there are short neuropsychological assessments, scored with sophisticated computer algorithms, that accurately distinguish MCI from normal aging. These assessment tools perform an efficient traffic control function to escort the worried well out of the health care system, while retaining those with objectively measured deficits for a comprehensive diagnostic work-up. With such brief and inexpensive assessment tools, physicians can now intervene earlier and treat memory disorders like AD before unnecessary brain damage has occurred. Doing so will foster a major improvement in standards of care for Alzheimer's patients.

Education and Awareness: Next Opportunities for Better Care
In this regard, the major challenge to an immediate improvement in care becomes one of awareness and education for the public and for primary care physicians. This is difficult but perhaps more certain in its achievability than the more scientifically challenging process of fully understanding AD and developing treatment agents that will halt its progression.

We need to tackle this disease from all angles and getting an earlier start with intervention seems to be an immediately graspable approach that does not, in my opinion, get enough attention in the field.

Global Dementia Burden Underestimated

Contributed by: Dennis Fortier, President, Medical Care Corporation

Just when you thought the threat of Alzheimer's and dementia had been fully recognized and emphasized in the media, a report from King's College in London suggests otherwise.

According to their study, published as part of the World Alzheimer's Report, more than 115 million people will be demented by the year 2050. Previous estimates compiled in 2005 had the figure at about 100 million. According to Professor Martin Price, the earlier figures had underestimated the problem in South Asia and Latin America where life expectancy is advancing.
"The current investment in research, treatment and care is actually quite disproportionate to the overall impact of the disease on people with dementia, the carers, on health and social care systems, and on society." Professor Martin Prince, King's College London
Importantly, this upward revision of the figures suggests that current global investment and research efforts, which are widely considered to be inadequate, are even more so than previously believed.

A Short Course in Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

There are lots of facts and figures published about Alzheimer's Disease along with many articles, editorials, and overviews. Whereas a brief overview should capture the disease from a distant perspective, a longer write up can tackle more detail. Many of the publications I see do not adhere to that simple approach and I often see wordy websites with very little information or short blurbs that open a topic that cannot be appropriately treated with such brevity.

I noticed this recent summary from the Ethiopian Review which, in my opinion, has struck the perfect balance. If you want a two-pager on the causes, risks, symptoms, and treatments of Alzheimer's disease, written in a straight forward and understandable manner, with nary a wasted word, then this is for you.

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.

Alzheimer's: Prevention Through Delay

Contributed by: Dennis Fortier, President, Medical Care Corporation

It is true that we cannot yet cure Alzheimer's but, somehow, this reality has come to seem more dire than it really should seem. After all, there is no cure for diabetes nor for hypertension and we have no problem with the approach of detecting these diseases early and managing them. I understand that Alzheimer's is more devastating relative to the other examples but the sense of nihilism is still out of proportion.

For those of you seeking a 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.

6 Ways to Lower Your Risks for Alzheimer's

We cannot yet cure Alzheimer's disease but we can manage the risk factors, reduce it's likelihood and, for some, prevent it through delay. That is, if one can push back the onset of symptoms beyond life expectancy, one can effectively avoid its wrath.

The U.S. News and World Report recently published an excellent summary of the most beneficial steps one can take to reduce the risks of Alzheimer's and dementia. I will give away the findings here but encourage you to click through and view the slide show which is well done and conveys the message effectively.

6 Ways to Lower Your Risks for Alzheimer's:
  1. Physical Activity
  2. Weight Control
  3. Mental Challenges
  4. Social Connections
  5. Healthy Diet
  6. Chronic Disease Control
Much of this advice is good for overall health but it is perhaps additionally motivating to understand the close relationship between maintaining physical health and mental health.

Investing in Alzheimer's Research

Contributed by: Dennis Fortier, President, Medical Care Corporation

The National Alzheimer's Association plays a central role in promoting awareness of, directing research dollars for, lobbying for effective policy against, and providing a framework through which we can all grasp the seriousness of Alzheimer's disease. A current theme that they are promoting is the urgent need for more federal funds for research.

The argument supporting such an investment is cogently summarized in a recent editorial written by Harry Johns, CEO of the National Alzheimer's Association. The statistics are sobering and the call for increased research support is clear.

The Alzheimer's Breakthrough Act, currently before Congress, would authorize $2B in research funding and escalate the urgency we need to effectively combat this disease. For all of you who are politically active, I urge you to voice your support for this initiative. For those of you who are not, I would suggest this might be a good time to become so.

What Causes Alzheimer's Disease?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Some form of this question has titled many previous entries in this blog. It is a topic that continues to be addressed in the news because we really don't know the answer. An excellent summary of the various theories is offered by Forbes in their latest issue.

This is a particularly interesting summary because it also includes a description of the drugs in development based on each theory. The amyloid hypothesis is clearly driving the bulk of development work but several other mechanisms are being tested through the clinical trial process.

The march of scientific discovery will continue onward and the answers will be revealed in time. Until then, we need to press forward with early intervention and management of this disease as best possible with the treatments that are currently available.

World Alzheimer's Day

Contributed by: Dennis Fortier, President, Medical Care Corporation

It's today, September 21, World Alzheimer's Day.

It is a day for global recognition of the major threat we face from this terrible disease. As such, here is a short summary of the five most important and consistent messages that constitute the news and are regularly addressed in this blog.
  1. Early detection of Alzheimer's disease yields best treatment results.
  2. Currently approved medications are more beneficial than many headlines suggest.
  3. Although we have made tremendous strides in understanding this disease, it is still poorly understood.
  4. Several promising new drugs have clinical trials currently underway.
  5. Knowing and managing your risks for Dementia can help you age with cognitive vitality.
We hope that some of you have found benefits in the words and perspectives we offer here. If so, we encourage you to share them with your online social networks. We look forward to ongoing contributions to the global effort to beat Alzheimer's disease.

Cognitive Testing Over the Phone

Contributed by: Dennis Fortier, President, Medical Care Corporation

According to research scheduled for publication in the International Journal of Geriatric Psychiatry, administering standard cognitive tests over the phone yields comparable results to in-person administration.This finding could have many positive implications for research as well as for clinical care.

In the research field, recruiting subjects for a study could be completed more rapidly and at a lower cost if more of the enrollment criteria, such as cognitive status, could be ascertained over the phone. In addition, phone-based assessments could also aid in the challenge of maintaining subjects throughout the course of a study when many follow-up assessments are required. This inconvenience is one that causes some subjects to drop out of longitudinal studies.

In terms of dispensing clinical care, phone-based assessment will be useful for patients who have difficulty getting to a physician's office due to poor health or even due to the long distance many need to travel in rural areas.

Such an approach will never replace the central role of in-person assessments but might serve as an efficient complement to standard practice in many instances.

Fatty Foods May Impair Brain Function

Contributed by: Dennis Fortier, President, Medical Care Corporation

We have often written here about research that links poor vascular health to poor cognitive health and it is clear that a steady supply of oxygen rich blood is necessary to keep the brain functioning at a high level. According to research published in the FASEB Journal, it appears that eating foods with high-fat content not only contributes to poor vascular health but can directly impede brain function through a lesser understood mechanism as well.

The research, conducted at Cambridge University, used rats that had been well trained to complete a series of mazes. One group of the trained rats were then fed a high-fat diet while a control group was kept on the low-fat diet that all rats had eaten during the learning period.

Within a few days of switching to the high-fat diet, rats began making more mistakes in the maze and the number of mistakes increased consistently throughout the period of fat intake. Meanwhile, the rats that maintained a low-fat diet were able to preserve their high levels of performance in the mazes.

As we always point out, rats are not human so it is dangerous to generalize these results to us. However, when a particular diet has such a sharp and significant impact on cognitive function in other mammals, it is worth considering how that same diet might be affecting us.

Youthful Aging?

Contributed by: Dennis Fortier, President, Medical Care Corporation

This is not intended to be a plug for any particular commercial enterprise but it is a story worth reading and a message worth spreading.

Many care givers are thrust into that role by the sudden decline of a loved one. Generally, there is no training, no expertise, and no real playbook for these good people to follow. While many do it alone or with the help of other family members, some rely in part on home health care agencies. This can provide a modicum of professionalism to the approach but often times (of course not always) the upgrade is dismally small.

The home health care industry is fairly unregulated and has sprung up quite quickly as our population has begun to age. As such, it is quite easy to find that the workers in this industry are well-intentioned but not always much better trained than the family care givers I described above.

Today I saw a news release about one particular company called Youthful Aging. I have no idea if they are reputable, capable, or competent and the point of this blog is not to promote their business. The point is, however, to promote the message they carry.

Here is their message: Often times, seniors are capable of much more than either they or their care givers would have expected. They can learn, improve, heal, and regain abilities. All it takes is the right approach and a positive mindset. Certainly, miracle recoveries are not in the cards for all but when care giving is dispensed with nihilism, outcomes are most probably less positive than they could otherwise be.

Growing Old: Expectations vs. Reality

Contributed by: Dennis Fortier, President, Medical Care Corporation

This is a great report published recently by the Pew Research Center from their Social & Demographic Trends survey.

The data were gathered from a nationally representative sample of 2,969 adults. One of the most striking findings is the large gap between the expectations that young and middle-aged adults have about old age and the actual experiences reported by older Americans themselves.

There is a lot of information in the report but some of the key conclusions are worth emphasizing here. I found it interesting that many negative aspects that younger people associate with aging are not reported with the expected frequency by the older cohorts. Most notably, illness, memory loss, and loneliness are significantly less prevalent than expected.

On the flip side, there are many positive aspects of aging that are expected by younger respondents that are also not as frequently reported in the survey. These include traveling, spending time with family and pursuing hobbies. While the downside of aging might not be as negative as anticipated, some of the positive aspects are not as certain as many would hope.

Another note of interest pertains to the question "At What Age does Old Age Begin"? Responses trended progressively later with increasing age of the respondents. That is, younger respondents feel that old age begins at a relatively early age and older respondents think it begins later.

You can read a more complete summary of the report here.

How Does the Brain Recall a Memory?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Perspective is a useful tool in understanding.

An article published today by the Orange County Register gives some excellent perspective on how to conceptualize the function of the brain. Especially with regards to recall of faint memories.

In a recent study published in Neuron, scientists used functional MRI imaging (fMRI) to visualize brain activity in subjects who were recalling a specific event. They found that the pattern of brain activity was similar during recall to the pattern of brain activity during the original experience.

This suggests that recall of a specific memory is achieved by re-activating the brain in a particular pattern. In this regard, it becomes easier to understand why recall can be difficult when one is distracted by many stimuli. After all, if the brain is reacting to many signals, it cannot recreate the specific pattern needed to recall the sought-after memory.

I thought this was a nice description of the science that may be helpful in understanding why recall may be more or less difficult at certain times or in certain situations. Too many people fear the worst when they cannot instantly recall an old piece of information when, instead, they should realize that perhaps there are just too many other signals at the moment interfering with their attempt to remember.

Depression and Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation

If and how depression is related to dementia are two questions that I hear often. A nice summary of important information is posted by Dr. Charles Raison on the CNN Health website.

Of specific importance, I think the closing point about symptoms associated with abnormal thyroid function should be noted. Thyroid disorders are fairly common, can produce a host of worrisome symptoms including memory loss, and are generally treated with success.

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.

Head Injuries and Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation

There has been lots of research into the relationship between head injuries and brain health despite the fact that the connection should be obvious. The purpose of such research is generally not to determine whether or not a relationship exists but to better understand the nature of the relationship and to gain insight into how the brain protects and repairs itself.

Earlier this week I noted a well written summary of evidence that football (both American football and soccer) contributes decidedly to poor cognitive health among the game's participants. While any particular study in this field, with a narrow focus and perhaps a baby step of insight, might be easy to ignore, a compilation of the evidence as presented in the linked article is quite compelling.

You probably cannot get through life without bumping your head a few times but choosing to play contact sports ought to be done with a full understanding of the likely impact on the long-term health of the brain.

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.

AD and Brain Activation

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

The brains of people at risk of developing Alzheimer’s disease may go into hyperactive mode in the very early stages of the disease in order to compensate for deterioration, according to a Cleveland Clinic study published in the medical journal Neurology. Researchers at Cleveland Clinic’s Lou Ruvo Center for Brain Health studied a group of 69 cognitively healthy adults. About 2/3 of the participants were at risk to develop Alzheimer’s disease based on family history or genetic markers. Participants were placed in a functional magnetic resonance imaging (fMRI) scanner and then asked if they recognized the names of famous celebrities. Unfamiliar names also were mixed in during the questions.

The brain activity of the participants was measured during the questioning to determine if persons at risk for Alzheimer’s disease would react differently than persons not at risk. On the fMRI scans, there was increased activation of certain parts of the brain in at-risk individuals. This is thought to potentially reflect a compensatory brain response by these participants to the earliest stages of Alzheimer’s disease. In the study, one third of the participants had no family history or genetic markers (ApoE 4 +) to indicate they are at risk of developing Alzheimer’s disease. Another third had a family history of Alzheimer’s disease, but no genetic markers, and the last third had both a family history and genetic markers indicating risk. It was this last group that showed a substantial amount of brain activation with the memory task. Further research will be needed to look at the use of fMRI in Alzheimer's Disease diagnosis.

Semantic memory activation in individuals at risk for developing Alzheimer disease.Seidenberg M, Guidotti L, Nielson KA, Woodard JL, Durgerian S, Antuono P, Zhang Q, Rao SM. Neurology. 2009 Aug 25;73(8):612-20.

Dementia: Under-diagnosed or Over-diagosed?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Turns out that it is probably both.

In many instances, physicians jump to conclusions based on a short interview with the patient and family members and do not perform a diagnostic work-up in accordance with published guidelines. Often times, the reported symptoms are due to existing medications, a completely treatable metabolic disorder, or even depression.

In other instances, troubling signs of cognitive decline are ignored or attributed to normal aging when a more astute diagnostician would uncover the telltale signs of stroke or early stage Alzheimer's disease. In either case, informed medical advice and appropriate treatment could reduce the risk of further rapid decline.

The under/over diagnosis problem was summarized nicely yesterday in this piece from the Pittsburgh Post-Gazette. It is a widespread problem and one you should be aware about if seeking medical attention in this field.

One more note. Situations like this arise sometimes for good reasons. Usually it is when advances in knowledge are happening rapidly, as they are in the dementia field, and new information cannot be assimilated by the practicing medical community as quickly as researchers are pushing the field forward. No physician, regardless of their acumen, can stay abreast of all medical advances in real time.

Memory and a High Fructose Diet

Contributed by: Dennis Fortier, President, Medical Care Corporation

We know that diet is important in maintaining physical as well as cognitive health. A study conducted at Georgia State University has shown that, in rats, a high fructose diet seems to interfere with recall.

We know that rats are not people and that research on one group cannot always be useful for speculating on the other group. However, given the high sugar diet of many modern humans, it is useful to understand how fructose might interfere with mammalian brain function. This study suggested a possible interference effect and raises questions that should be investigated further through additional study.

Infection, Inflammation, and Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation

A study out of the University of Southampton and published this month in Neurology is generating lots of coverage in the popular press. Most of the headlines indicate that infection accelerates memory loss but the story must be considered a bit more carefully.

First of all, it must be considered that the participants in this study all had Alzheimer's disease. Although it is important to understand the health factors that might exacerbate cognitive decline due to Alzheimer's disease, it is also important not to generalize these findings too broadly beyond the scope of the research. Importantly, this study did not conclude, as some headlines suggest, that every common cold will reduce your ability to store and retrieve information from memory.

Secondly, the study focused on the presence of inflammation (as a surrogate marker for infection) and its relationship to cognitive decline. Researchers have known for some time that there is a relationship, albeit a poorly understood relationship, between inflammation and memory loss. This study suggests that there may be a connection between infection and memory loss but makes no bold conclusions about what that connection entails.

Bottom line: many of the headlines I have seen on this study have overstated the strength of any proven relationship between infection (which can cause inflammation) and memory loss.

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.

Update on Dimebon Trials

Contributed by: Dennis Fortier, President, Medical Care Corporation

As new agents for the treatment of Alzheimer's disease move through the pipeline of clinical trial, we try to highlight milestones and announcements to keep you informed. We have written several times about Dimebon which is one of the most promising agents currently under development.

As pointed out recently by readers in Australia, the Dimebon trial is now enrolling patients down under. More information about that activity can be gathered through the Dimebon Australian Study blog.

Alzheimer's Treatment Perspective #3

Contributed by: Dennis Fortier, President, Medical Care Corporation

Why is the press so nihilistic about the fact that there is no cure for Alzheimer’s disease and that current treatment options only manage the symptoms?

We can say the same about diabetes, hypertension, and high-cholesterol.

True, we are highly effective at managing these other chronic conditions and only moderately so for AD, but I am alarmed at how broadly the “nothing can be done” mantra has been embraced.

Much can be done.

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.