Antidote for the Alzheimer's Epidemic

Contributed by: Dennis Fortier, President, Medical Care Corporation

Surely, you’ve all read the grim reports about Alzheimer’s disease.  The advancing age of the US population will usher forth an Alzheimer’s epidemic in the coming decade. The emotional toll of this epidemic will be immeasurable, and the financial impact could bankrupt the Medicare system.

That dire version of the story might sell newspapers, but it doesn’t really reflect the available options to a nation with a will to fight back.  The good news is: we can manage this problem.  And no elusive scientific discoveries are required to do so.  We merely need to implement the medical knowledge that is already in hand. 

To be clear, scientific advances yielding better treatments and more accurate diagnostic approaches will greatly improve our prospects in this battle.  We need to aggressively fund research and push forward on that front.  However, it is important to recognize the sizeable gap between the high standard of care that is achievable based on the current state of medical knowledge, and the lagging standard of care that is routinely implemented in a primary care clinic.

Pragmatism: Closing the Gap
Closing the gap in the Alzheimer’s field could yield tremendous benefits.  It will take some effort, but we can achieve such a goal through pure effort and public will.  Compared to solutions based on the hope of new scientific discoveries, this has the appeal of greater certainty. 

To close the clinical gap, we must address three key areas where “common practices” are significantly lagging behind “best practices”. 

1)    Education: We need to promote public education and awareness about the many, common medical conditions that impair memory (depression, anxiety, sleep disorders, thyroid malfunction, vitamin deficiency, medications, etc).  This will reduce stigma associated with memory loss and encourage patients to be more proactive in expressing early concerns to their physicians.
2)    Proven Clinical Standards: We need to help primary care physicians adopt proven standards for differentiating between signs of normal aging and subtle symptoms caused by medical conditions that impair memory. Out-dated assessments for identifying dementia are aiming too late in the process; we need to facilitate effective intervention at an earlier, subtler stage of impairment.  Newer clinical assessment tools can ensure that emerging problems are addressed in a timely manner, prior to unnecessary disease progression and declining health.
3)    Effective Treatment: We need to ensure that patients, physicians, and caregivers can recognize what effective treatment looks like; doing so will aid ongoing compliance with a prescribed regimen of care. Compared to treatments for other causes of memory loss, expectations for treating Alzheimer’s disease are often unrealistic.  For AD, effective treatment is not a complete reversal of symptoms, but rather, a slowing of functional decline.  Importantly, everyone must appreciate that proper treatment for AD involves more than just drugs; it also encompasses proper diet, regular physical exercise, and tight control of other chronic conditions. 

Concrete steps in these three areas will narrow the gap between “current practices” and “best practices”.  Doing so will mitigate the impact from two of the most destructive components of the Alzheimer’s disease problem: under-diagnosis and under-treatment.

According to the World Alzheimer’s Report 2011, published by Alzheimer’s Disease International, there may be 36 million demented people in the world and 28 million of them are undiagnosed.  That is, no doctor has diagnosed the underlying cause of the dementia and prescribed treatment to resolve the problem.  According to well-accepted prevalence data, a large percentage of these people are demented due to Alzheimer’s disease (AD).  For all of those people, their disease is progressing unabated, their symptoms are progressing, and the ongoing costs of their care are moving irreversibly upward.

As of today, AD cannot be cured, but a timely intervention including careful management of diabetes and hypertension, a proper diet, physical activity, and poly-therapy with approved Alzheimer’s drugs, can significantly slow progression for a meaningful percentage of those 28 million people who have been neither diagnosed nor treated.  Additionally, many other conditions that cause memory loss are both common and completely treatable.  If no diagnostic work-up is performed, these conditions go untreated at the ongoing peril of the patient’s health, which ultimately drives the cost of care higher.

Certainly, a better-educated public, timelier diagnosis of medical conditions that impair memory, and robust treatment are all central facets of a solution to the Alzheimer’s epidemic.  Each has deep economic implications underscoring the importance of addressing them. As shown by examples like the Orange County Vital Aging Program*, all of these can be achieved through pragmatic, community-based efforts to improve knowledge and raise standards of care among primary care physicians. 

Overall, the looming threat of an Alzheimer’s epidemic is a real problem that may well have painful consequences. We would all like more certainty that scientific efforts will soon thwart the disease, but we cannot yet count on that with high confidence.  In the meantime, a concerted effort to pragmatically implement the scientific advances from the past decade of research will significantly reduce its likely impact.

PLEASE HELP spread this message by clicking the share buttons below.

*For more information about the Orange County Vital Aging Program, please visit the OCVA site or download this summary of Year-1 results.

A Community Approach to Managing Brain Health

Contributed by: Dennis Fortier, President, Medical Care Corporation

Science is important, but let’s not overlook pragmatism.

As described in this complimentary post, a pragmatic solution to the looming threat of an Alzheimer’s epidemic is more likely to bear fruit than the most progressed scientific solutions.  It is clear that a better-educated public, timelier diagnosis of medical conditions that impair memory, and robust treatment are all achievable endpoints in a successful campaign against this disease. Importantly, each of these can be achieved through pragmatic, community-based efforts to improve knowledge and raise standards of care among primary care physicians. 

Orange County Vital Aging Program - A Community Example
How such a pragmatic program could be implemented in any given community depends largely on the particular make-up of the organizations and healthcare providers in that community.  As a point of reference, the Orange County Vital Aging Program (OCVA) in southern California is already demonstrating this concept with encouraging early results.  That program provides a template for success worthy of further consideration.

The philosophy behind the OCVA is that timely discourse between an educated public and a well-trained physician community can catalyze better care and improved cognitive health on a mass scale.

The program supports a free website where local residents can gather information, view a community calendar of events and lectures, use free tools for risk identification and management, and find physicians who are trained to manage cognitive health.  Local physicians can use the site to register for ongoing CME courses about managing cognitive health, download guidelines for diagnosing and managing conditions that affect cognition, and to learn about community resources that might benefit their patients with memory disorders.

Having accomplished a foundation level of public education and physician training through public lectures and CME courses in its first year, the OCVA program is seeing three community trends:

1)    Patients who are aging normally, but who are worried about perceived declines in their cognition, are raising concerns to their physicians and then being objectively reassured about their good health without an expensive and unnecessary work-up.
2)    Patients with Alzheimer’s disease are being detected in a timely manner and can now benefit from robust intervention while their brains are still relatively healthy.
3)    Patients with other causes of cognitive impairment (depression, stroke, thyroid, sleep disorder, anxiety, etc.) are being diagnosed and treated effectively.

Conclusive evidence demonstrating that the OCVA program improves health and/or lowers costs of care will not be available until longer-term follow-up is complete.  But the early data suggest that the program has engaged the community and is changing the dynamic between patients and their physicians in the primary care channel.

Overall, the looming threat of an Alzheimer’s epidemic is a real problem that may well have painful consequences. We would all like more certainty that scientific efforts will soon thwart the disease, but we cannot yet count on that with high confidence.  In the meantime, a concerted effort to pragmatically implement the scientific advances from the past decade of research will significantly reduce its likely impact.

For more information about the Orange County Vital Aging Program, please visit the OCVA site or download this summary of Year-1 results.

Intriguing New Insight into Cause of Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation

As the experts in the field readily acknowledge, they really don't understand Alzheimer's disease very well.  A new hypothesis, based on a recent publication in the Journal of Neuroscience, suggests that previous views and treatment approaches might be aiming at the wrong target.

The dominant theory (the amyloid hypothesis) is that excess accumulation of beta-amyloid, a naturally occurring protein in the brain, aggregates into toxic plaques that disrupt cell function and leads to cognitive decline.  Based on the new research, it is plausible that beta-amyloid is in fact the main culprit, but that it does its damage inside the brain cells, prior to breaking free and accumulating into plaques.

Some of the general press on these findings have described the science as a complete contradiction of the amyloid-hypothesis.  In reality however, it is fairly consistent with one important difference.

The new insight is that beta-amyloid might be causing harm earlier in the biological process than previously believed.  This study suggests that once the beta-amyloid has been dispensed from brain cells and clumps together into a plaque, the damage has already been done. Previously, it has been theorized that the formation of the plaque is the beginning of a toxic biological process.

The implications for treatment are that we should be looking to reduce the presence of beta-amyloid inside the cells, as opposed to clearing it away later, once it has aggregated into a plaque. Fortunately, two of the most promising agents in the FDA pipeline, Bapineuzumab and Solanezumab, are both antibodies that bind to beta-amyloid and clear it away through the natural immune function. It is hoped that one or both of these agents might function at the early, biological stage suggested by this new insight.

Deep Brain Stimulation for Parkinson's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

A great overview article on deep brain stimulation (DBS) for the treatment of symptoms caused by Parkinson's disease was posted today at WebMD.

DBS is accomplished by implanting electrodes directly into the brain and a transmitting device below the collarbone.  The transmitter stimulates regular electrical impulses from the electrodes, which effectively "turn off" parts of the brain where many Parkinson's symptoms originate.  Among those symptoms most commonly improved by DBS are tremors, slow movement, rigidity, and problems with walking and balance.

This is an FDA approved procedure but is commonly reviewed with caution because scientists cannot convincingly explain how or why it works.  However, the data collected in carefully designed trials on real patients is very clear and very positive.

There are many considerations in the decision to undergo DBS as part of a treatment regimen.  After all, it requires surgery that includes incisions through the skull and into the chest, so it is not a minor procedure.  However, compared to alternative approaches that intentionally destroy brain tissue, this might be considered a less invasive approach.

The cited WebMD article is fairly comprehensive and touches on a wider summary of advantages and disadvantages.  I encourage you to click through and read more about it.

Memory Lapses at a Young Age are Unlikely to be Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

I hope this is the beginning of a new trend.  A recent article in the Washington Post took a very sensible, scientifically prudent, and optimistic approach to a story about Alzheimer's disease.  Essentially, the article develops the important point conveyed in the headline; that baby-boomers who sometimes misplace keys of struggle to recall a name, probably have no pernicious brain disease to worry about.

There is a fine line between dismissing concerns that are associated with normal aging, and ignoring clear signs of a real a memory problem, but this summary of evidence and quotes from experts did a nice job in achieving a proper balance.

I hesitate to criticize this story given the clear progress it represents in terms of highlighting science over sensationalism, but I do wish the headline had been more carefully written.  The actual headline in the Washington Post is "Forgetfulness at an Early Age is Rarely a Sign of Early Dementia".  It doesn't reference Alzheimer's disease although the story is written as though it does.  This disconnect suggests that dementia is actually Alzheimer's disease and begins with mild symptoms in early stages.

As readers of this blog know, "dementia" describes a state of very impaired thinking, and can be caused by many different medical conditions and diseases; Alzheimer's is the most common.  Once a person is demented, their impaired thinking abilities are severe enough to affect their daily life.  I think the headline inappropriately suggests that minor forgetfulness might be the beginning of a disease called dementia -- which is a common mis-understanding that the Brain Today blog works hard to clarify.

Lewy Body Dementia Awareness

Contributed by: Dennis Fortier, President, Medical Care Corporation

As per this press release from the NYU Langone Medical Center, October is Lewy Body Dementia (LBD) Awareness Month.

Like Alzheimer's disease and Parkinson's disease, LBD is characterized by impaired thinking and behavioral disruptions.  Because of these similarities, it is often misdiagnosed and improperly treated.

Three out of 4 LBD patients are initially misdiagnosed and the majority of patients see more than 3 doctors for more than 10 visits over 18 months before a diagnosis is established.

The obvious solution to the problem of delayed diagnosis is education, for both the public and for their doctors.

Here are a few facts about LBD to start you on the process of building higher education and awareness:
  • LBD core symptoms include: memory and thinking problems, movement problems, hallucinations, sleep disturbances and fluctuations in attention and concentration
  • LBD patients have more prominent problems with visual-spatial skills (such as depth perception, bumping into objects, not seeing things in front of them)
  • LBD patients experience a more rapid functional decline than Alzheimer’s disease patients with shorter intervals to nursing home placement and death
  • LBD patients have personality changes such as loss of interest, become more passive, quiet or withdrawn, and have trouble paying attention
  • The combination of cognitive, motor and behavioral symptoms place severe burden and stress on caregivers who often find themselves socially isolated
  • LBD patients are more likely to suffer from depression

Family History and Alzheimer's Risk

Contributed by: Dennis Fortier, President, Medical Care Corporation
This is not a simple topic.  The relationship between a family history of Alzheimer's and one's own risk for the disease, is probably more complex than previously expected.

While the evidence is fairly clear that the APOe4 gene plays a role in risk for Alzheimer's, affecting both the likelihood of getting the disease as well as the age of onset of symptoms, accumulating evidence suggests that many genes play a role, as do environmental factors.

A recent study, conducted at Washington University in St. Louis and published in Archives of Neurology, looked at changes in biomarkers in the brains and spinal fluid of 269 research subjects, 160 of whom had a family history of the disease and 119 of whom did not.  Among those with a family history of AD, only a portion had inherited the APOe4.

Interestingly, the biomarkers in the "family history" group,  regardless of APOe4 status, showed similar changes compared to the "no family history" group.  Specifically, a family history was associated with accumulation of beta-amyloid in the brain and a reduction of beta-amyloid in the spinal fluid.   This suggests that, while APOe4 genes are certainly important, there are other factors that play contributing roles in this complex process.  

Drug Prospect for Treating Early Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation
We like to help keep news about potential new Alzheimer's treatments in proper perspective.  This week, there have been many news stories about an agent in the FDA pipeline that looks promising, but is in a very, very early stage of the process to becoming an approved drug.

The new agent, called Gantenerumab, is being developed by Roche Holding AG.  Like other antibody approaches in the FDA pipeline, it binds to amyloid plaques in the brain.  When the the body's natural defense system flushes the antibody from the brain, it takes the plaques along as well.  In theory, this is a direct attack on the plaques that many believe to be the cause of Alzheimer's disease.

Two agents with similar mechanisms are well ahead of this one in the FDA pipeline: Bapineuzumab (being developed by Pfizer and J&J) and Solanezumab (being developed by Eli Lilly).  Each of these are in Phase III (the final phase) of the FDA process whereas Gantererumab is in Phase I.

This is promising news and worthy of cautious optimism.  But don't think this portends of a new treatment in the near term, it will take a lot of ongoing science and many years before this agent could be established as an effective treatment and approved for sale.

Horrible Alzheimer's Advice from AARP

Contributed by: Dennis Fortier, President, Medical Care Corporation
We clarify the news about brain health.  When someone gets the story wrong, we feel it is important to provide a more balanced perspective.  The AARP got it horribly wrong in this article about early diagnosis of Alzheimer's.

While laudable for its intent to protect the public from invalid claims about Alzheimer's diagnostic tests and treatments, this article is remarkably misleading. I would expect much better from such a trusted source as AARP.

The sensationalistic statement opening the third paragraph (falsely propagating the notion that there is no diagnostic test and no effective treatment for AD) is about as harmful a message as anyone could direct at this audience.  True, there is no single medical test to diagnose AD, but as the author eventually admits, primary care physicians can diagnose it with high accuracy through a series of routine diagnostic steps.  The medical literature shows that better than 90% accuracy is easily achievable when published guidelines are followed.

As for treatment, the willingness of writers to substitute the terms "drugs" and "treatment" for one another is deplorable.  I think most experts agree that the cholinesterase inhibitors provide only moderate, symptomatic relief for Alzheimer's patients who are already demented.  However, robust treatment that includes early intervention (prior to the dementia stage), physical activity, a proper diet, strict control of diabetes and hypertension, ongoing social/intellectual stimulation, and a combination of a cholinesterase inhibitor with Nameda, has shown a much more optimistic treatment result than a single drug shows when isolated from all other aspects of treatment.

Trusted sources like AARP are invaluable as consumer advocates and they play a key role in sorting bogus claims from real science.  But in this instance, they could have done a much better job in characterizing the truth.  Suggesting that people with a memory concern should "ignore it" is alarmingly irresponsible.

Smokers Have Twice the Risk for Stroke

Contributed by: Dennis Fortier, President, Medical Care Corporation
We all know that smoking is bad for health.  The questions that require ongoing study and clarification are "how bad" and "bad for what, specifically".

In research presented last week to the Canadian Stroke Congress, scientists from the University of Ottawa Heart Institute provided some answers.  They concluded that smokers are twice as likely to suffer an ischemic stroke (caused by a blocked blood vessel) as non-smokers,  and four times more likely to suffer a hemorrhagic stroke (caused by a ruptured blood vessel) than non-smokers.

These findings were accompanied by more bad news.  The researchers found that, among smokers who had strokes, the strokes occurred about a decade earlier (on average) than strokes among non-smokers.  They also found that continuing to smoke following a minor stroke, greatly increased the likelihood of a major stroke later on.

Smoking is a preventable risk; a life-style choice with serious consequences. In addition to the well-publicized damage that smoking can cause your heart and lungs, I am hopeful that sharper insights into how it might damage your brain, will help more people make wiser choices about smoking.

Alzheimer's Diagnostic Test, Misleading the Reader?

Contributed by: Dennis Fortier, President, Medical Care Corporation
The popular press carries more stories like this in a given week than we could possibly highlight in this blog.

I am referring to this article describing a diagnostic test for Alzheimer's disease.  The test measures proteins in the spinal fluid and, according to the company with hopes of one day commercializing the test, it can diagnose Alzheimer's disease with 90% accuracy.  I believe that is a scientifically plausible claim and I suspect that careful measures of various biomarkers will achieve such accuracy in the very near future.

The potentially misleading element of this story comes from the following quote:
"Right now, diagnostic accuracy for Alzheimer's disease can be as low as 70 percent, meaning three out of 10 people who are diagnosed with this disease might not actually have Alzheimer's disease, but rather some other kind of dementia".
It is true that diagnostic accuracy for AD "can be" as low as 70 percent, if a physician does not follow published guidelines for working up a memory complaint.  However, when published guidelines are followed, then diagnostic accuracy is already better than the 90% target for which this new test is striving.

I think this test, and others, may pan out, but let's not mischaracterize the problem.  We need to help physicians update their knowledge to keep pace with the constant advances in medicine.  A new test, with inferior accuracy to the already achievable standard, is not a breakthrough, and the word "promising" probably does not belong in the story's headline.

6 Ways to Prevent Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation
This summary, published online today at Fox News, cites evidence supporting 6 lifestyle choices you can make to reduce the likelihood of cognitive decline.

Of course, there are no guarantees and bad genes combined with age can overwhelm even the best life-style.  Nonetheless, it is worthwhile to know the steps that might help, and to pursue as many of them as possible.

I suggest you click through and read the short story, but here is the list:
  1. Stay Physically Active
  2. Eat Fruits and Veggies
  3. Reduce Risk Factors for Heart Disease
  4. Embrace Cultural Activities
  5. Care for Your Teeth
  6. Challenge your Intellect
Remember, there is no certain method to eliminate all risk of cognitive decline, but doing what you can to stack the odds in your own favor seems like an attractive course of action.

Is AD contagious? Beta-amyloid and Prion Proteins

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________
A prion is an infectious agent composed of protein in a misfolded form. The word prion was coined in 1982 by Dr. Stanley B. Prusiner, and is derived from the words protein and infection.

Normal prion proteins are produced naturally in the brain, but can cause disease when they come into contact with an infectious form of the protein that folds into an unusual conformation. These infectious prions convert innocuous prion proteins into the infectious form, which forms clumps and leads to neurodegenerative diseases, such as variant Creutzfeldt-Jakob disease, the human form of mad cow disease. Prions slowly destroy the brain tissue of infected people by causing a cascade of misshapen proteins. They're known to spread via consumption of contaminated food, by getting a transfusion of blood or tissue transplant from someone who is infected.

In 2009, researchers led by Dr. Stephen Strittmatter at Yale, showed that prion proteins produced naturally in the brain interact with the amyloid-ß peptides that are hallmarks of Alzheimer's disease. Blocking this interaction in preparations made from mouse brains halted some neurological defects caused by the accumulation of amyloid-ß peptide.

Now, researchers led by Dr. Caludio Soto at the University of Texas Health Science Center, have shown that, in fact, Alzheimer's disease itself, may be a prion-like disease. His team injected the brain tissue of a confirmed Alzheimer’s patient into mice and compared the results to those from injected tissue of a control without the disease. None of the mice injected with the control showed signs of Alzheimer’s, whereas all of those injected with Alzheimer’s brain extracts developed plaques and other brain alterations typical of the disease.

These findings suggest that in an experimental setting, misfolded beta-amyloid can behave in a similar way as infectious prions. It remains to be proven whether at least a proportion of human AD cases could be due to a transmissible prion-like mechanism. It must be kept in mind, that prions are not contagious via normal human contact.

A Blood Test Predicting Rate of AD Progression

Contributed by: Dennis Fortier, President, Medical Care Corporation
This study out of Johns Hopkins, showing that a blood test might be useful in predicting the rate of cognitive decline in Alzheimer's disease,  is being widely covered in the press.  Here are some thoughts on the new science and what it might mean.

First, as the authors admit, this is very early stage work that has not yet been properly validated.  Second, if the research is eventually validated, that would be only the starting point for the long product development process prior to the day when a physicians might have a test they could use in practice.  Third, predicting the rate of progression may have some benefits, but if those benefits cannot be cost justified, then such a test might never be developed by any commercial interest.

I generally write optimistically in this space about new technologies and scientific advances that portend better care in the Alzheimer's arena.  In this case, I am surprised at the amount of mainstream coverage that has been afforded such an early stage study with (in my opinion) dubious clinical value.

On that note, I think there is a very interesting aspect to this research.  Given the massive recent investments in clinical trials to test agents for treating Alzheimer's disease, having a better understanding of each subject's propensity for cognitive decline could be highly valuable.

In a typical clinical trial, we apply a treatment to one group and a placebo to another group, then we look for differences in pre-determined outcomes.  In the future, if we could segment the research subjets into groups based on their expected rate of cognitive decline (slow, medium, and fast), as this new blood tests suggests is possible, then we might more clearly detect a treatment effect by comparing expected decline with actual decline.

In this regard, I think a blood test for predicting the rate of cognitive decline in Alzheimer's patients, if validated and commercialized, could play an important role in the effort to develop new solutions to the looming Alzheimer's epidemic.

World Alzheimer's Report 2011

Contributed by: Dennis Fortier, President, Medical Care Corporation

Alzheimer's Disease International is the federation of national "Alzheimer's associations" around the world.  Each year, they compile a world report summarizing the state of scientific knowledge in the field of Alzheimer's disease.

This year's version, World Alzheimer's Report 2011, was released last week.  You can use these links to download the Executive Summary or download the Full Report.

The highlight of this year's report is encompassed in its subtitle: The Benefits of Early Diagnosis and Intervention.  This is an important message that is undermined daily by the mantra of the popular press, where messages about the futility of treatment are persistent. In this summary of scientific evidence, vetted by some of the world's greatest experts in this field, it is clear that detecting AD at an early stage and adhering to a robust regimen of treatment, can have tremendous health and economic benefits.

I am happy to see this report's strong and optimistic emphasis on such a positive side of the story.  I hope you will join me in sharing this report as broadly as possible by passing it along to your online networks.

Perspectives on Health and Retirement

Contributed by: Dennis Fortier, President, Medical Care Corporation
We have written previously in this space about the relationship between retirement and dementia. A fascinating new study shows that, in general, retirement is often less enjoyable than what many expected prior to retiring.

Most of the differences, as summarized in this report, are related to poor health and the costs of healthcare.  Given the central importance of cognitive health on overall fitness and the costs of medical care, the conclusions in the report may resonate with readers of this blog.

While many correctly anticipate the ways their lives will change in retirement, about a quarter of retirees say that life after retirement is worse than it was prior.  As noted, poor health is a common theme in that reality.

Fortunately, there is also good evidence that a high number of retirement-aged individuals are engaging in sound, health preserving strategies like those you constantly read about here.

The Economic Burden of Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation
Memory loss is costing our nation billions of dollars annually.  This is an easy argument to build and the widely published data are compelling from every conceivable perspective.  But today, I am citing a new publication in the Archives of Internal Medicine, because it has been broadly covered in the general press.

According to a study conducted by the VA Medical Center in White River Junction, Vt., more than 600 primary care physicians were surveyed and the results confirmed much of what was strongly suspected.  About 42% of the physicians admitted that their patients receive "too much care" and 28% indicated that they order too many tests and too many expensive referrals to specialists.

The key driver of these expensive habits?  Fear of malpractice lawsuits was indicated by an alarming 76% of physicians.

This is an important concept in the brain health space because the early boomers are now reaching the age of risk for Alzheimer's disease and are well into the risk-prone years for stroke.  Combine that demographic trend with rising awareness about Alzheimer's disease, and we see the number of memory and cognition related complaints climbing steeply in primary care settings.

A standard work-up for such complaints involves blood work and an MRI scan of the brain, which can cost between $1500 and $2000. However, because subtle declines in working memory and processing speed are common in a healthy aging brain, the vast majority of brain scans ordered due to a memory complaint are negative. This means primary care physicians are aggressively ordering unnecessary tests in this space.

Some simple math shows that this could become a devastating economic problem for our healthcare system.  With 120 million people aged 65+, performing a work-up on even 1% of them would cost the nation about $2.4 billion. Given that about 80% of people aged 65+ have concerns about their memory, this is a scenario that could get out of control quickly.

The challenge is that, not working up a memory complaint on a patient in the early stages of Alzheimer's disease is akin to letting the disease progress without treatment.  That approach is obviously costly in both economic and emotional terms.

The solution is expand the adoption of better "memory assessment tools" in primary care so that physicians can effectively discern normal aging from cognitive decline caused by an underlying medical condition.  A review of the medical literature shows that new cognitive assessment tools with sophisticated computer scoring are pragmatic and cost-effective in a clinical setting.  More importantly, they can greatly improve healthcare in a fiscally prudent manner.

Brain Health Ranked by State

Contributed by: Dennis Fortier, President, Medical Care Corporation
This might surprise you.

A study that ranks each of the 50 US states (and the District of Columbia) on brain health has a high concentration of rural states near the top.

The rankings were based on the following criteria:
  • Diet and nutrition: A healthy diet that is low in saturated fat and added sugar but rich in brain-enhancing foods such as good fats like DHA omega-3, antioxidant-rich fruits and vegetables, and algal DHA supplements.
  • Physical health: Staying physically active for at least 30 minutes a day most days of the week and making wise lifestyle decisions such as getting enough sleep and not smoking.
  • Mental health: Continually challenging the brain through activities such as game playing, creative pursuits like gardening, dancing or painting, or learning a new language or skill.
  • Social well-being: Nurturing human connections and engaging in social activities to give life purpose, such as volunteering.
To avoid the confusion that many commenters have noted, the graphic of the states above is merely an icon for "the states", it has no meaning in terms of brain health.  Please, click this link to view the complete state rankings.

Best Foods for a Long Life

Contributed by: Dennis Fortier, President, Medical Care Corporation
This summary of foods you should eat for a long life, was compiled by WebMD, and is well worth clicking through and reviewing.  It is not specifically about brain health, but the overlap between overall fitness and maintaining cognition is significant.

The 5 second version is fruits, vegetables, olive oil, berries, fish, beans, nuts and dairy.  But for a short blurb on why each of those foods helps which facet of your health, I highly recommend you review the WebMD slides.

Can B-12 Vitamins Prevent Memory Loss?

Contributed by: Dennis Fortier, President, Medical Care Corporation
Can B-12 vitamines prevent memory loss?  As with so many questions, the answer to this one is "it depends".

Remember, there are many causes of memory loss, including depression, anxiety, diabetes, medications, thyroid disorders, head injuries, strokes, Alzheimer's disease, Parkinson's disease, tumors, sleep disorders, and drug use, just to name the most common. Vitamin deficiency is also on the list of common causes, especially for older adults who become less proficient at absorbing B vitamins from the foods they eat.

According to a recent study conducted at Rush University Medical Center and published in Neurology, research subjects who had markers for vitamin B deficiency, such as brain shrinkage and high homocysteine levels, also performed worse on cognitive tests compared to subjects without vitamin B deficiency.  These findings are consistent with other studies linking vitamin B deficiency to poor cognition.

So, it would be a stretch to conclude that taking a B-12 supplement will protect a person from all causes of memory loss or cognitive decline.  However, the evidence suggesting that proper intake of B-12 is important to ongoing brain health is quite strong.  In that regard, think about including fish, meat, poultry, eggs, milk, and cheese in your diet as good sources of B vitamins.

A National Strategy for Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation

Since the National Alzheimer's Prevention Act was passed into law in November of 2010, the Obama administration has been legally bound to develop a national strategy to fight Alzheimer's disease.  As the first draft of the plan is nearing completion, certain themes have been clearly expressed by the public in terms of what they hope the plan includes.

As described in this Associated Press article published by Time,  the plan should address three elements that have been consistently advocated in public forums:
  1. Primary care physicians need better training to make earlier diagnoses of cognitive problems
  2. Huge spending discrepancies by the National Institutes of Health need to be adressed as Alzheimer's disease receives a tiny fraction of the support that cancer and AIDS receive
  3. More community support programs are needed to help Alzheimer's patients and their caregivers survive at home during later stages of the disease
While it is still unclear what the first version of the strategy will look like, or how detailed it will be, I am pleased to see those priorities rising from the public realm.  Two of them are completely focused on the pragmatic benefits of doing a better job with the scientific knowledge we already have, while only the NIH budget issue seems to be focused on funding new (and probably elusive) scientific breakthroughs.

Treating Alzheimer's with Insulin

Contributed by: Dennis Fortier, President, Medical Care Corporation

As published recently in the Archives of Neurology, Alzheimer's subjects who nasally inhaled insulin performed better on memory tests than subjects who inhaled a placebo spray.  For the most part, I think the general press has reported this quite responsibly, without premature claims of imminent new treatment options on the horizon. Much to the contrary, they might be under-selling the potential for such a breakthrough.

A possible relationship between insulin therapy and Alzheimer's disease (AD) has been appreciated for some time.  Researchers established that diabetes is an important risk factor for AD and have also determined that insulin plays a role in the brain during cell repair and new cell formation.  However, the therapeutic potential for insulin has been hindered by the challenge of getting it into the brain, without introducing it to the rest of the body through the blood.

To be specific, the delivery barrier has been one of controlling where the insulin goes once introduced into the body, given that high doses of insulin would need to be introduced into the blood in order for any significant amount to travel to the brain.  Such an approach would have obvious impact on blood-sugar levels and would quite possibly disrupt other normal biological processes.

As such, a key finding in this research is that nasal injection may deliver significant amounts of insulin to the brain without introducing it to the bloodstream in undesired quantities.  Sounds very promising.

Is Sponge Bob Bad for Your Brain?

Contributed by: Dennis Fortier, President, Medical Care Corporation

This small study is getting lots of coverage in the mainstream media and I think it is an excellent example of how scientists raise an "interesting possibility" only to have journalists misconstrue it as a "sensational fact".

The study in question was published this week in Pediatrics, the Journal of the American Academy or Pediatrics.  Researchers studied 60 four-year olds to determine the effect of fast-paced, fantastical television viewing on the children's executive function.  Executive function is critical for goal-directed behavior and includes attention, focus, working memory, and problem solving.

In the study, the children were randomly assigned to one of three groups where one group watched 9 minutes of Sponge Bob SquarePants, a second group watched 9 minutes of a PBS educational cartoon, and a third group spent 9 minutes coloring.  Each group then completed a series of tests designed to assess executive function.  The Sponge Bob group performed more poorly on the tests than the other two groups which suggets that this cartoon impairs executive function.

As I described in my opening, scientists would probably look at this study in one way, while journalists would report it in another.  Here's a plausible scientific perspective on the results: It seems that viewing a show with fast paced scene changes and fantastical content, may put the brain into a certain condition for rapidly absorbing a wide range of inputs.  That condition may not lend itself to deep analytical thought and structured problem solving, but is perhaps best for integrating lots of information as quickly as possible.

In this regard, the study would suggest that the brain can adapt to its immediate environment and take on a set of characteristics that is optimal for the situation at hand.  That sounds like a good thing.

However, the journalistic position has been that, because the children who watched Sponge Bob performed poorly on a set of tasks that are very different from making sense of a fast-paced TV show, then such TV shows must be bad for the brain.

I understand that it makes better headlines, but be careful of this journalistic interpretation.   It is a leap to suggest that temporarily changing the brain's state, to one less equipped at particular cognitive task, is automatically bad.  Especially if the brain has assumed a new state more relevant to the immediate challenge.

Consider this.  What if the researchers repeated this experiment but, rather than testing the 4 year olds on their ability to sustain focus, they tested them on their ability to multi-task?  What if the results showed that the "Sponge Bob group" outperformed the others?  Would we then see tantalizing headlines about how cartoons help kids' brains?

Want a Healthy Brain? Stay Physically Active.

Contributed by: Dennis Fortier, President, Medical Care Corporation

There are no guarantees, but this is our current best bet.  The evidence linking physical fitness to good cognitive health in later life continues to roll in.

At the International Conference on Alzheimer's Disease in July, researchers from the University of California, San Francisco presented data showing the high correlation between physical fitness and brain health.  Their research on "modifiable risk factors", or lifestyle changes we are all free to make, showed that regular activity was the most likely to reduce the risk of cognitive decline.

Importantly, several of the other risk factors that are highly correlated with cognitive decline, may also be reduced through physical activity.  Hypertension, obesity, diabetes, and even depression, all of which confer higher risk of cognitive decline, can be managed to some degree through regular physical exercise.

We have known for some time that staying active is good for our hearts and it has always made sense that a regular supply of oxygen-rich blood is probably good for our brains.  This latest research is more evidence that it is likely to be true.

A Milkshake for Alzheimer's?

Contributed by: Dennis Fortier, President, Medical Care Corporation

The story of a milkshake that could aid metabolism and improve cognition for Alzheimer's patients has gotten a fair amount of press, including this piece in the Wall Street Journal.  Here are a few facts to consider:

  • The product is called Axona and is marketed as a "medical food", a category that does not require FDA approval.
  • In the key clinical study, patients taking Axona had slightly improved cognition after 45 days, but not after 90 days.
  • The group that showed the most improvement was the group with no known genetic disposition to Alzheimer's disease.
  • The "experts" have fulfilled their duties as consumer advocates and pointed out all of the reasons why the limited data is not scientifically conclusive.
While I agree that there is limited data, and that patients should be cautious when interpreting the manufacturer's claims about efficacy, I think we also need to be careful not to bury novel hypotheses before they are proven incorrect.  Remember, lack of proof that something works is not the same as proof that it does not work.  In this case, the jury is still out.

The bottom line on this is that it probably has little or no beneficial effect.  However, any resourceful person with Alzheimer's disease, who is looking for every possible means of maintaining their cognitive health, might want to check it out.  There doesn't appear to be any major health-related downside and, given how little we understand about Alzheimer's disease, it might be worth the effort for some.

Diagnosing Alzheimer's: Bio-Markers vs. Cognitive Tests

Contributed by: Dennis Fortier, President, Medical Care Corporation

Journalists keep surprising me.

They, of all people, should be accustomed to choosing their words carefully.  However, in today's LA Times, a journalist reviewed a study comparing bio-markers and cognitive tests for their relative merits in diagnosing Alzheimer's disease, and probably misled a lot of readers with a poor word choice in the headline (below).

LA Times: Alzheimer's tests using pen and paper still the best

If a study compares two of the many possible approaches to a problem, and one approach is deemed superior to the other, then it is "better".  But it is not necessarily the "best".

In the body of the article, the words "old-fashioned tests using pen and paper" were probably chosen with much more care.  I say this because the field of cognitive assessment has made great progress in recent years using sophisticated math and computers to score test performances, and to compare performances across large databases of carefully studied patients. This has been a great imrprovement over the pen and paper approach.  But even the newer, hi-tech assessments are not the "best" approach.

The "best" approach in the practical sense, is to use all of the available diagnostic information that can be collected in a cost-effective manner.  In the process of an evaluation, routine bio-markers can rule-in or rule-out some routine causes of cognitive dysfunction and help physicians arrive at a correct diagnosis.  As for Alzheimer's disease (AD), a bio-marker that suggests AD combined with a cogntive test (be it an old-fashioned test or a more modern test), is currently the "best" approach.

I admit that the difference between the choice of "better" and "best" is subtle, and probably completely innocent.  But by choosing "best", the author framed the problem into a misleadingly small, either-or scenario, and may have given physicians and patients another reason to delay their own educational process about how to best manage emerging cognitive problems. That is sloppy journalism and it is counter-productive to the challenge we all face from the growing threat of Alzheimer's disease.

The Power of Art Therapy

Contributed by: Dennis Fortier, President, Medical Care Corporation

Does art therapy improve the health of people with cognitive disorders?  The literature on this topic is slim but growing, and there is lots of evidence that art therapy enriches lives. 

This video (below) was produce by the Cognitive Dynamics Foundation, an organization with the goal of improving the quality of life for those who are cognitively impaired, and their caregivers, through expressive arts therapies.  The video tells the story of Lester Potts, an Alabama sawmiller who first took to painting after being diagnosed with Alzheimer's disease in his 70's.  To the surprise and delight of his family, Lester expressed himself poignantly through his art, even though he had lost much of his verbal communication.

Admittedly, this story is not scientifically conclusive.  We know that every patient is unique and that some respond to certain therapies and others do not.  However, in an age when so much therapy is focused on biology, it is great to be reminded about the complexity of the human condition.  This is a strong dose of anecdotal evidence that sometimes, what is good for the spirit, might be what is most helpful for the body and the brain.  It is a touching testament to the possible power of art therapy.

A New Approach to Treating Alzheimer's?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Promising new research, has suggested a novel approach to Alzheimer's treatment.

Regular readers of this blog are familiar with the amyloid hypothesis which suggests that the most likely approach to treating or preventing Alzheimer's disease will be to somehow limit the accumulation of beta amyloid in the brain.  Beta amyloid peptides are formed when a longer protein called amyloid precursor protein (APP) is chopped up into smaller fragments as part of the body's normal recycling process.  This hypothesis is based on the fact that beta-amyloid is notably present in the form of a sticky plaque in all cases of Alzheimer's disease.

The new research, published in the Proceedings of the National Academy of Sciences, has determined that APP travels through the brain cells along a different pathway than the beta secretase enzymes that chop it up and aid the formation of the harmful plaques.  This opens the opportunity for a "road block" strategy whereby it might be possible to limit the production beta-amyloid by preventing contact between APP and the enzymes that help to trasorm it into beta-amyloid.  Doing so could possibly prevent unwanted side effects that sometimes arise from treatments that completely block or eliminate the production of otherwise important proteins and enzymes.

While this is science is promising, the implications are still uncertain and the new knowledge is only applicable at a very basic and hypothetical level.  Nonetheless, it is another avenue through which scientists may soon be able to bring the amyloid hypothesis forward to a real world treatment against the rising threat of Alzheimer's disease.

Controversy over High Dose Aricept

Contributed by: Dennis Fortier, President, Medical Care Corporation

 A consumer advocate group is calling for a ban on the 23mg Aricept dosage, which was approved by the FDA for more severe stages of Alzheimer's.

While Aricept is the mostly widely prescribed drug for the treatment of AD, it is most commonly prescribed in 5mg and 10mg doses.  Its efficacy in controlling symptoms is only moderate, but it has been on the market for more than a decade and has a solid safety profile.  The more recently approved, higher dosage of 23mg has been associated with a higher incidence of side effects and, according to the advocacy group Public Citizen, has no greater efficacy.  The primary side effects are nausea, vomiting, and agitation.

It is unclear whether the FDA will act on the petition to review the data and reverse the former approval for this dosage.  However, the most salient point for treating physicians to understand is that, regardless of the dosage, cholinesterase inhibitors like Aricept yield the most clinical benefit when prescribed as poly-therapy along with Namenda.  The data supporting this clinical approach are clear and compelling.

A Call for Funding for Alzheimer's Research

 Contributed by: Dennis Fortier, President, Medical Care Corporation

 This is interesting.  At a time when partisanship seems to have reached a high in the US political process, at least one prominent Republican is calling for an increase in spending.

Specifically, as reported by NBC News, Newt Gingrich is making the case for dramatically increasing funding for AD research.  I am sure that is not a popular position with his party, but it is the right long-term perspective.

To reiterate some statistics that are widely published, we spent about $6B of federal funds last year on cancer research, about $3B on HIV research, and only $500M on AD research.  All are worthy causes, but the AD program is clearly underfunded.

This is especially true when considering the full economic argument that shows the enormous cost of caring for patients with diminished cognitive capacity.  It is well documented that once memory and judgment begin to slip, patients become less effective at administering self-care, and their chronic conditions such as diabetes and hypertension often spiral out of control.  This leads to poor health and stark increases in the costs of their care.

Spending on AD research can not only accelerate our progress toward better treatments but can facilitate a return to sustainability for the US health care system.

Recent Press on Preventing Alzheimer's

 Contributed by: Dennis Fortier, President, Medical Care Corporation

There is no hope? 

Eating well, staying fit, and using your brain have no effect on your risk for Alzheimer's?  Many headlines have implied this dire message over the past 24 hours.

The source of these headlines is an article published in the Archives of Neurology, online edition.  The article reviewed the evidence that actively managing modifiable factors could reduce the risk of AD, and concluded that only a low level of evidence suggests a relationship between the risks and the disease.

Let's be sure not to misunderstand this.

What is a "Low Level" of Evidence?
The authors classified the level of evidence for each risk factor in accordance with accepted scientific standards.  These standards allow for three levels of evidence: low, medium, and high. 

Importantly, a "low" level of evidence means that real research, conducted with sound methods, that was published in peer-reviewed medical journals, showed an association between the risk factor being studied and the incidence of AD.  Perhaps the association was not overly strong, perhaps the sample size was small, perhaps similar studies have not been completed to verify the result, but even a "low" level of evidence is a pretty good start in finding a meaningful association.

The panel authoring this paper, on behalf of the National Institutes of Health, found a low level of evidence that diabetes, high cholesterol, and tobacco use all confer a higher risk of Alzheimer's disease.  Sure we want more evidence and a higher level of confidence, but all work so far suggests that these are real risks that need to be managed.

The panel also found a low level of evidence that a Mediterranean diet, folic acid intake, light alcohol consumption, cognitive activity, and physical activity all reduced risks of Alzheimer's.  That's more good news.

This review constitutes unbiased, expert confirmation that many modifiable risk factors should in fact be managed to reduce the risk of AD.  The evidence is not as strong as we would all like, but it has reached a minimum threshold of scientific scrutiny to establish a likely association.

The problem here is the massive and consistent misinterpretation of these findings by the press.  In every day jargon, a "low level of evidence" is a negative testimonial as to the likelihood of an association.  But in the scientific world, where facts are closely scrutinized before they qualify as "evidence", a low level of evidence connotes a pretty good start toward proving a point.  It is a shame that this is not understood by the major media outlets and is not more clearly represented in their publications.

Bapineuzumab: Speculation on Alzheimer's Drug

Contributed by: Dennis Fortier, President, Medical Care Corporation

Bapineuzumab is an Alzheimer's drug that is now in the final stage of FDA approval. We described the mechanism of Bapineuzumab in this earlier post.

No one can say with any degree of certainty if it will be approved or not, but as noted in an update provided by Fierce Biotech,  there has been an interesting development in the progress of the clinical trial.  The companies sponsoring the trial, Pfizer/Wyeth and J&J, amended the protocol last year to expand the study by several thousand research subjects.  This is a very costly move in terms of research investment and time required to conclude the study, and has led to much speculation as to why the trial was expanded.

A leading theory that makes lots of sense, is tied to the recently revised guidelines for diagnosing Alzheimer's disease.  Under the new guidelines, the presence of disease pathology can be recognized much earlier, when symptoms are much subtler, compared to the former standards.  This bodes well for more effective treatment.

However, the new guidelines also create a potential conundrum in terms of currently approved treatments.

The FDA has approved 4 drugs for treating Alzheimer's, but all of those approvals are based on the former definition of the disease, that requires a later stage of disease progression and more severe symptoms before the diagnosis can be made.  It is possible that the Bapineuzumab trial was initiated to demonstrate efficacy against the late stage disease that was defined in the old guidelines, but revised to demonstrate efficacy against an earlier stage of disease as defined in the revised guidelines.

Although the trial protocol was amended about a year before the new guidelines were released, a draft version of the revisions have been available and mounting industry consensus has been visible for quite some time.

If the drug works, and the trial sponsors can demonstrate that it works at very early stages of Alzheimer's, this could be a giant leap forward for the field.

The Case For Alzheimer's Research

Contributed by: Dennis Fortier, President, Medical Care Corporation

The case for funding Alzheimer's research, and for participating in such research,  is a compelling one.

You've all heard or read the numbers: more than 5 million Americans diagnosed, probably at least that many in early stages and not yest diagnosed, with all numbers approximately tripling by 2050.  Neither our health care system nor our society can absorb the looming impact of this epidemic.

In this excellent opinion piece posted at CNN, Dr. Ronald Petersen of the Mayo Clinic describes an approach to averting a national, disease-driven crisis.  I encourage you to click through and read it.

Larry King: Alzheimer's Special

Contributed by: Dennis Fortier, President, Medical Care Corporation

Many of you may have seen Larry King's CNN special last night on Alzheimer's disease.  It was a one-hour special report on the urgency of the challenge this disease poses for our aging population, for our health care system, and for our society.

Overall, I thought there was a fair amount of good information presented.  The expert testimonies from Dr. Ron Petersen at the Mayo Clinic and Dr. Jeffrey Cummings from the Cleveland Clinic were excellent and clearly characterized the nature and the magnitude of this epidemic.  Heartfelt stories from care givers brought a very personal face to the disease and provided an in depth look at the way this disease can affect an entire family.

Having said that, I also thought the show performed one major disservice to the public.  There was much dramatic emphasis on the fact that Larry King and Ron Reagan visited the Cleveland Clinic to be evaluated for early signs of Alzheimer's and Ron Reagan chose to forgo an evaluation based on his preference to remain "blissfully ignorant".

To be clear, everyone has the right to make such a decision and I don't begrudge Reagan his right to do so.  However, he couched his decision against the backdrop that "there is no cure" and implied that it is therefore better "not to know" about the early presence of disease process.  This is a myth we need to stop perpetrating and Larry King missed the opportunity to set the record straight.

While there is no cure for Alzheimer's disease, there is certainly treatment.  Importantly, some people respond remarkably well to treatment, adding years of independence to their lives.  Broadcasting the message that it is "better not to know", as King did last night,  may prevent some people from gathering the facts and making a more informed decision,based on the knowledge that early intervention and appropriate treatment could be significantly beneficial.