World Alzheimer's Report 2011

Contributed by: Dennis Fortier, President, Medical Care Corporation

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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

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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

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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

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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

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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

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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
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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
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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
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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
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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
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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
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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
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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.