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.