Can we Thwart Alzheimer's in a Decade?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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In a well written opinion piece in the New York Times, former Supreme Court Justice Sandra Day O'Connor joined with Stanley Prusiner and Ken Dychtwald to summarize the magnitude of the Alzheimer's problem and the fiscal path toward solving it.

A few interesting facts that are well publicized individually but placed effectively together in the NYTimes piece:
  • 10,000 Americans will turn 65 every day for the next 19 years
  • for every penny that the NIH spends on Alzheimer's research, American society spends $3.50 caring for patients with the disease
  • the NIH spends about $3 billion on Aids research compared to only $469 million on Alzheimer's
There is a bill before congress requesting $2B in annual research funds for Alzheimer's and a dedicated official overseeing a national strategy to fight the disease. Given that the expert community generally agrees on which scientific problems must be tackled and solved in order to develop effective treatments for AD, this seems like a good cause to me.
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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 buttons below to spread this educational message as widely as possible.

Federal Funding for Alzheimer's Research

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The National Institutes of Health has announced that they will fund a second phase of the Alzheimer's Disease Neuroimaging Initiative (ADNI). This initiative is a major partnership involving both public and private funding sources, more than 50 research locations, and a target of nearly 1500 research subjects.

The first phase was funded in 2004 and is now following approximately 800 subjects in various states of cognitive health (200 normal controls, 400 with mild cognitive impairment, and 200 with mild Alzheimer's disease). The intention is to thoroughly evaluate cognitive health, track various bio-markers, and study the progression from normal health to Alzheimer's in those subjects who get he disease. Researchers are also closely studying those subjects who do not get the disease as they may offer important clues about preventative strategies.

The second phase of this initiative, ADNI2, has a $40 million commitment from the NIH to be distributed over the next 5 years. This sum will be augmented with an anticipated $25 million in additional funds provided by various private sector sources.

One of the unique aspects of ADNI is the public availability of the research data being collected. To date, more than 1700 researchers have accessed the database and analyzed findings. This massive sharing of resources has been touted as an important catalyst in scientific progress for the field in recent years.

One of the challenges for the ADNI team is to recruit healthy volunteers who wish to participate as research subjects. The potential benefits to volunteers, in terms of state of the art monitoring and care for any emerging problems, are fantastic. For interested readers, more information is available from the NIA Alzheimer's Disease Education and Referral (ADEAR) Center at 1-800-438-4380 or www.nia.nih.gov/Alzheimers.

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Smoking Increases Risk of Alzheimer's Disease and Vacular Dementia


Contributed by: Dennis Fortier, President, Medical Care Corporation
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Many of smoking's detrimental effects on long-term health have been well know for decades. Research has clearly shown that smoking can lead to lung cancer, emphysema, and heart disease. Now, based on research published this week in the Archives of Internal Medicine, we know that smoking can also dramatically increase risk for Alzheimer's disease and for vascular dementia.

In a study of more than 21 thousand subjects who were followed for an average of 23 years, Kaiser Permanente tracked smoking habits and incidence of dementia. The findings were clear:

Compared with non-smokers, those who smoked more than two packs of cigarettes a day in midlife had a "dramatic increase" in the incidence of dementia -- more than a 157 percent increased risk of developing Alzheimer's disease and a 172 percent increased risk of developing vascular dementia, Whitmer's team found.
- Lead Researcher, Rachel A. Whitmer

It should be noted that these heightened risks were demonstrated in middle-aged subjects (50-60 years old) who smoked more than 2 packs per day. Because data were not available across the full age spectrum, we cannot say with certainty if the same risks apply (or do not apply) to older or younger subjects. Those who smoke less than two packs per day did not have the same heightened risks.

While we have long known about the many risks that smoking poses to our physical health, the evidence that it could also impair our cognitive health has been historically, less substantial. This well designed study on a large sample population and a long follow-up period draws a highly valid and important conclusion.

It's another good reason to quit. More importantly, it's another good reason not to start.
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Early Detection of Alzheimer's is Best

Contributed by: Dennis Fortier, President, Medical Care Corporation
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This article from Voice of America bears an important headline: Early Diagnosis of Alzheimer's Better for Patients and Caregivers. That's a message we promote vigorously in this blog.

The article itself is not based on any particular new findings or recently published research. It is merely a summary of aggregated conclusions and an important reminder that we often intervene late. When we do so, we lose an opportunity to treat AD at an early stage when minimal brain damage has occurred. This then leads to therapeutic nihilism and the ongoing, but incorrect belief, that attempting to treat Alzheimer's disease is futile.

I highlight this today as a reminder about the importance of early detection.
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Alzheimer's Risks, Signs, and Prevention

Contributed by: Dennis Fortier, President, Medical Care Corporation
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On most days, I use this space to wrap perspective around "news" about brain health that is open to misinterpretation. Today, my job is easier.

This summary, written by Dr. Glenn D. Braunstein and published by The Huffington Post, is excellent. It articulates the facts about Alzheimer's risks, signs, and prevention in an informed and unbiased way. Please click through and read it.
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Can Vitamin B Reduce Risk for AD?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A short time ago, we reviewed the promising evidence that Vitamin B levels are negatively correlated with brain atrophy. That is, higher levels of Vitamin B were correlated to less brain shrinkage. This spawned hope that these vitamins might be somehow preventative of diseases that result in brain atrophy.

Today, there is more news about B Vitamins and brain health.

The Karolinska Institute in Stockholm, has published in Neurology, a study showing that elevated levels of homocysteine, an amino acid related to Vitamin B12, seemed to increase risk for developing Alzheimer's disease. However, high levels of the biologically active portion of Vitamin B12 (holoTC) was correlated with reduced risk. The results make sweeping conclusions difficult to draw.

At this point, the strongest conclusions that should be drawn from these studies of Vitamin B are that, (1) Vitamin B seems to pay some important role in brain biology, an (2) no one really knows for sure what that role is.

I have already seen several headlines suggesting that Vitamin B prevents Alzheimer's. That might someday prove to be the case, but it is far too early and too many questions remain for anyone to defend such a position.

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More Than 1 of Every 2 Americans Knows Someone with Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A recent poll by Abt SRBT, a social policy research and consulting firm, showed that 55% of Americans know either a friend or family member with Alzheimer's disease. This is consistent with other reports showing that 1 out of every 2 families has been directly touched by this progressive neurological disorder.

While this is an alarming figure, the high prevalence of exposure is driving rapid increases in awareness and education which are, in turn, reducing the stigma historically associated with dementia. This is a painful but important process that will help us prepare to face this disease head on, to increase vigilance toward early signs of memory loss, and to actively voice concerns to our physicians when subtle symptoms emerge.

While it is a shame that Alzheimer's disease is now touching such a high percentage of American lives, its rising impact is driving visible increases in awareness, understanding, and new research in the field.
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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 buttons below to spread this educational message as widely as possible.

Is Retirement Bad for Your Memory?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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We've all heard the "use it or lose it" mantra. It was originally intended as a descriptor for maintaining physical fitness and, in recent ears, has crossed over to the realm of mental fitness.

Research from the University of Michigan shows a correlation between memory capacity in older adults and the age at which they retired. Specifically, it showed that adults from countries where retirement happens at earlier ages, did not perform as well on memory tests as adults from countries where work is more prolonged.

That seems like a fairly indirect path to a conclusion that may have been tighter had the researchers merely collected "age of retirement" from each subject, rather than using the average retirement age of the country from which each subject hailed. However, there is something to be said for the latter approach. Perhaps cultural norms extend across similarly aged people and keep them similarly engaged in intellectual activities, with employment being only one of those activities.

Regardless of the design of this particular study, there is ample research suggesting that keeping your brain engaged seems to preserve mental function. I recently commented on it with this post that links to an excellent summary of the evidence.

Retirement sounds inviting, but disengaging from all intellectual rigor is probably not be a beneficial path to pursue.

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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.

A Daily Walk is Surprisingly Good for Your Brain

Contributed by: Dennis Fortier, President, Medical Care Corporation
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We often cite research that correlates physical fitness with brain health. Surveys have shown, however, that many read the phrase "physical fitness" and conjure images of gym memberships and grueling workouts. Such a perspective may be a deterrent for those who assume that minimally intense workouts yield no benefits.

This post aims to dispel the notion that only an intense physical exercise is helpful.

Research published online yesterday in Neurology shows that a brief regular walk may meaningfully reduce the likelihood Alzheimer's disease. Specifically, the research showed a significant correlation between walking regularly and maintaining the volume of gray matter in the brain throughout later adulthood. More importntnly, walking regularly was negatively correlated with incidence of cognitive impairment.

This evidence is very consistent with other studies that have shown a daily walk of a mile or so can be part of a fantastic regimen for long-term health. In this regard, the Alzheimer's Association's tradition of holding "memory walks" to raise awareness about the disease is especially apropos.

Walk forth and be well.
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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 buttons below to spread this educational message as widely as possible.

Can You Prevent Alzheimer's Disease?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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While we have no sure fire approach to preventing Alzheimer's disease today, each of us can meaningfully lower our own risk of suffering from Alzheimer's down the road.

Some important risk factors, like age and genetics, are beyond our control. Others, such as our physical fitness, our diet, our cardio-vascular health, our management of other medical conditions, and the degree to which we stay intellectually and socially engaged, are all directly affected by our life style choices.

A great summary of preventative advice was published this week as an opinion piece at CNN. While such articles are commonly propagated online by merchants selling unvalidated supplements or brain-exercise programs, this one stays within a message that is well supported by scientific evidence.

Other good online sources of Alzheimer's prevention information are the non-commercial websites PreventAD.com and OCVitalAging.org.
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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 buttons below to spread this educational message as widely as possible.

Revised Definition of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With a publication slated for the November issue of Lancet Neurology, the International Working Group for New Research for the Diagnosis of AD has updated their position paper from 2007. In the new publication, they suggest that AD should be defined as impaired episodic memory plus one bio-marker (either MRI, PET, or spinal fluid) indicating known disease pathology.

Importantly, the presence of dementia would no longer be required as part of the new definition of Alzheimer's disease. This will allow physicians to diagnose the disease and intervene with therapy at an earlier stage of symptoms.

As we have discussed here often, the current practice of late diagnosis, which is driven in many ways by the old definition requiring dementia, is a major obstacle to effective treatment.

This recommendation is in line with similar proposals from US expert panels and bodes well for future advances in this field.

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Do Clinical Tests for Alzheimer's Miss the Highly Educated?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With the forthcoming changes to regulations by National Health Services in the U.K., many Alzheimer's patients who have formerly been denied treatment with cholinesterase inhibitors may soon have the opportunity to benefit from such treatment. With that in mind, a story in today's Telegraph raises an interesting point.

The point is that the Mini Mental State Exam (MMSE), a short test of memory and judgment used by many physicians to detect cognitive problems, is not sensitive enough to distinguish early stage Alzheimer's disease from subtle symptoms associated with normal, healthy aging. As such, many people, particularly those who are highly educated, might continue to pass that test until deep into the progression of a debilitating disease like Alzheimer's. These people, it is argued, would be presumed healthy and neither evaluated further nor treated for any emerging problem. It's a valid point.

The solution is for clinicians to embrace a newer generation of assessment tools suited for a primary care environment. A comprehensive, expert review of such technologies is currently underway through the non-profit organization Prevent AD 2020. A summary of their findings is expected to be published in the Journal of Alzheimer's & Dementia (the journal of the National Alzheimer's Association) early in 2011.

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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.

Are Alzheimer's Drugs Better than Previously Thought?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A very big story about Alzheimer's treatment is unfolding in Europe. This story is big from a news coverage point of view and also from the perspective of real world impact. I am referring to the story about the National Institute for Health and Clinical Excellence (NICE) in the U.K. that has reviewed ongoing science and reversed their earlier stance on Alzheimer's drug efficacy.

Background
In 2006 and 2007, NICE recommended against National Health Services paying for cholinesterase inhibitors (the primary class of Alzheimer's drugs) for patients with mild to moderate Alzheimer's disease. They based this recommendation on a financial analysis suggesting that the economic benefits of treating AD with those drugs (Aricept, Exelon, and Razadyne) in its mild and moderate stages did not outweigh the costs of the treatment.

Naturally, that recommendation sparked lots of debate, including an argument that most experts considered very legitimate. The argument was that "average treatment effect" is merely a composite derived from some patients who responded well to treatment and others who did not. Since it was clear that treatment has meaningful benefits for some patients, and no one can predict which patients will respond, then everyone deserves the chance to find out.

New Position
Now, based on an ongoing review of emerging data from new studies, NICE is planning to revise that recommendation. This is great news for the patients afflicted with AD who have not yet progressed to the severe dementia stage. It is also important for the effect this move will have on the global conversation and the public perception of treatment efficacy.

Optimal Treatment
The one point I think needs to be added to this story is that, the drug class in question is only one part of the robust treatment approach we know to be most effective in delaying the progression of Alzheimer's disease. Optimal treatment includes poly-therapy (cholinesterase inhibitor plus Namenda), a balanced diet, physical exercise, and tight control of other conditions such as diabetes and hypertension.
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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 buttons below to spread this educational message as widely as possible.

The Global Cost of Dementia


Contributed by: Dennis Fortier, President, Medical Care Corporation
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With each new study, the numbers get bigger and scarier. The latest report, The Global Economic Impact of Dementia, released by the non-profit group Alzheimer's Disease International, is no exception. The full report can be downloaded here.

At a top line level, the report estimated the annual cost of care for demented patients at over $600B or about 1% of the world's gross domestic product. Astoundingly, that figure is dwarfed by the projected rise in costs over the next decades. In fact, the report estimates that costs could reach nearly $2 trillion by the year 2050. A good summary of these findings are published online by Time.

While a cure is the goal that everyone seeks, a cold economic look at the disease makes it clear that the crippling expense of care comes primarily from patients in the moderate to severely demented stages of illness, when they cannot administer their own lives. While delaying progression to those stages might seem to be an uninspiring health care goal, it is a very attractive economic goal.

To that end, earlier intervention and robust treatment, including a balanced diet, physical exercise, pharmaceutical therapy, and tight control of diabetes and any present cardiovascular risks, should be a high priority in the primary care setting.

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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.

Predicting Alzheimer's Disease is a Misnomer in the Press

Contributed by: Dennis Fortier, President, Medical Care Corporation
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I think there will come a day, decades from now, when a massive amount of genetic data can be combined with a massive amount of demographic data, lifestyle date, social data, and other pertinent medical data, to predict with useful accuracy, the likelihood of a particular person getting Alzheimer's disease.

The expert consensus is that we are not even remotely close to that day. Nonetheless, stories about "predicting Alzheimer's disease" abound in the general press.

The point of this post is not to discuss if, or when, we might gain such an ability to predict Alzheimer's disease. Nor is the point to debate whether or not such a prediction would be beneficial, moral, dangerous, or inconsequential. The point is to highlight how the popular press continuously confuses "predicting Alzheimer's" with "identifying Alzheimer's". This story, published online by U.S. News and World Report is a perfect example.

According to the new diagnostic guidelines from the NIH and the National Alzheimer's Association, which were penned to clarify this exact situation, Alzheimer's disease has a long period of progression that passes through a mild cognitive impairment stage prior to the later stages of dementia. Therefore, stories about new technologies for evaluating subjects with mild cognitive impairment and "predicting" if they will progress to Alzheimer's are nonsensical. Either these subjects have mild cognitive impairment because Alzheimer's is already present, or they have mild cognitive impairment due to something else.

For those with the disease, there is no need for a prediction. For those without the disease, their current state of cognitive health may or may not play a role in such a prediction. The press constantly mixes the notions of "identifying" and "predicting".

These stories perpetrate confusion and prevent a clear understanding about which scientific advances are likely to yield benefits in the real world and which are merely interesting.

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National Response to Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The aging of the population, our current difficulties in detecting early symptoms and intervening effectively, and the massive financial burden of caring for demented patients, are three converging forces that foretell a major crisis for our nation.

As a means to developing a strategy for resolving this potential crisis, the Obama administration recently convened a panel of experts and administrators to initiate a formal dialogue on how to move forward. They comprehensively outlined our current state of scientific understanding about how the disease progresses, the best strategies for developing better treatment, the social impact of letting it grow unchecked, and the biggest risks associated with anything less than a bold approach.

The meeting was recorded on video and posted to the White House blog. It is a long video including the testimony of three expert panels but, for those deeply interested in this problem, it is well worth watching.

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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.

How to Best Detect Early Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Sometimes, a lot of press coverage is devoted to an interesting misinterpretation of a fact that, once correctly understood, is not nearly as interesting. This is one of those times.

Over the past week, I have seen intense coverage of a story about how friends and family are better at spotting early signs of Alzheimer's dementia compared to traditional tests that a doctor might use. This sounds great until you unpack the headline and understand the facts.

Even Mild Dementia is a Severe State of Health
The problem, as we point out often in this space, is the definition of "dementia". Even mild dementia, which sounds like a subtle condition, is actually a severely impaired state of mental health. To meet the definition of dementia, even mild dementia, a patient must be so impaired that their loss of function interferes with their occupational or social life. Demented people, even mildly demented people, cannot completely care for themselves.

Detecting Dementia does not Require a Test
With this is mind, many experts make the case (and I agree with them), that a test for dementia is not necessary. Dementia is a readily apparent condition that a friend or family member should easily recognize. The fact that doctors still use tests that cannot accurately distinguish between a demented person and a non-demented person is indicative of ineffective clinical practices.

For the record, there are newer, more accurate tests, such as the MCI Screen, that detect dementia with almost perfect accuracy. More importantly, they also identify much earlier and subtler stages of decline known as mild cognitive impairment. However, this current finding from Washington University and published in Brain, compared the ability of friends and family at spotting spot Alzheimer's dementia with the accuracy of "traditional" tests. This is a clear and damming comment about the poor accuracy and minimal utility of the "traditional" test they used for comparison, the Mini-Mental State Exam (MMSE).

In this study, input was collected with an instrument called the AD8, an eight item questionnaire that is completed, on behalf of the patient, by an informant (friend of family member). It was shown to be better at identifying demented patients than the MMSE. That is great news and the AD8 is a non-invasive tool that would be a pragmatic improvement over the MMSE in a primary care setting.

The Bottom Line
I think the most important message, buried in this recent spate of press, is that the traditional tests are not as good as the AD8 at detecting dementia, but detecting dementia doesn't really require a test. To intervene early against Alzheimer's disease, and to reassure healthy patients that their perceived memory decline is not caused by underlying disease, physicians need instruments that accurately detect mild cognitive impairment.

Advances in detecting dementia are not interesting stories, regardless of how much press they get.

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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.