Long-Distance Caregiving

Contributed by: Dennis Fortier, President, Medical Care Corporation

An aging population is the macro-driver of the trend toward increased demand for caregiving.  Within that trend, it is cognitie impairment, or declining brain health that is really fueling the growth.  A such, caregiving is a topic we watch closely in this blog.

As the geographically dispersed, sandwich generation is increasingly called upon to provide care for an aging parent or relative, long-distance caregiving is also gaining prevalence.  Performing this role from afar comes with its own set of challenges, and I am pleased to direct today's readers to the an article posted by Medical E-Compare, a marketer of medical insurance products.

The article offer tips for caregiving from a distance and features a set of practical suggestions for those finding themselves in this role, along with links to additional reources.

The Misdiagnosis of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

Yesterday we commented on the common misdiagnosis of Lewy Body Disease, a problem often mistaken for Alzheimer's Disease.  In keeping with that theme, we look today at results from an international physician survey on Alzheimer's diagnoses.

Based on a survey of nearly a thousand physicians in five countries (USA, Japan, UK, France, and Italy), we are not doing a very good job at diagnosing Alzheimer's disease in clinical practice.  In fact, about half of all physicians agreed that the disease is "often misdiagnosed" and that diagnoses are "always or often" made too late to treat in a meaningful way.

None of this is news to regular readers of this blog as late detection of cognitive impairment is one of our frequent themes.  However, the survey revealed an interesting perspective from the physicians, in terms of "why" they feel diagnoses are so commonly late.

According to the physicians surveyed, the major contributing factors to late diagnosis are:

  • lack of a definitive diagnostic test;
  • lack of communication from patients/caregivers; and
  • stigma

Not mentioned among their reasons is the one glaring problem that primary care physicians confess to me on a regular basis.  I hear frequently from physicians that investigating memory complaints takes too much time, and often leads to a diagnosis of a problem they don't feel they can treat effectively.  This perspective often leads them to "just keep an eye on the concern" until symptoms worsen and the need for medical intervention is clear.  As the survey noted, this is "too late".

Managing the cognitive health of an aging population is a complex problem, and a difficult one to approach within the confines of our current "fee for service" healthcare system.  As new models evolve, like the Accountable Care Organizations described in the Healthcare Reform Act, we will have an opportunity to greatly improve our standards of care in this important field.

Lewy Body Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation

While this blog strives to clarify the daily news about brain health, sometimes it serves best by simply "emphasizing" the news about brain health. A very well reported article about Lewy Body Dementia, published in the The New Old Age blog of the NYTimes, is worthy of such emphasis today.

Like Alzheimer's disease, Lewy Body disease is a debilitating brain disorder that impairs cognition and leads to dementia. However, because the symptoms are similar, it is often mis-diagnosed as Alzheimer's disease, and subsequently mis-treated.

A key difference between the two diseases is in their most typical initial symptoms: short term memory disruptions are most typical in Alzheimer's disease, whereas executive function (completing complex tasks) and visual/spatial abilities are most commonly the first impairments noted in Lewy Body disease.

Along with low awareness of Lewy Body disease, symptomatic similarities to Alzheimer's disease are two drivers of mis-diagnosis. Making matters worse, other common symptoms, such as rigidity and altered gait, sometimes lead to mis-diagnoses as Parkinson's disease.

Hopefully, with growing awareness and the formation of organizations like the Lewy Body Dementia Association, clinical efforts to correctly diagnose and treat this disease will continue to gain efficacy.

5 Reasons to Support World Alzheimer's Day

Contributed by: Dennis Fortier, President, Medical Care Corporation

What's with every disease and medical condition having a day or month geared toward raising awareness?  Are such efforts effective? Wouldn't it be better to put our time and energy into new treatments and cures?

Those are fair questions.

Here's a link to a great argument in support of Alzheimer's awareness, and why awareness matters.  The article explains how heightened awareness can drive real benefits in five important ways, each of which are carefully explained in the full article:

1. Low Awareness drives higher medical costs
2. Awareness facilitates timely medical intervention and better treatment outcomes
3. Awareness erodes stigma and further enables timely medical intervention
4. Awareness and management of risk factors can lower incidence of Alzheimer's disease
5. Awareness accelerates scientific progress

It is easy to overlook “awareness” as an important part of the solution to the Alzheimer’s problem. This is especially true given the clear need for better treatment. However, a little reflection on the benefits of awareness, weighed against the relative ease with which we can spread information today, shows the massive benefits of greater awareness.

Awareness matters. Please do your part to increase awareness by clicking through, and then reading and sharing the article with your online social networks.

Calories, Obesity, and Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation

The stated purpose of this blog is to clarify the daily news about brain health.  Certainly, a lot of the reporting in this space needs to be filtered and contextualized for clarity.  But not all of it.

I noticed a very well-written article published today in the Pacific Standard,  describing research about the relationships between high calorie diets and memory loss, as well as between obesity and overall cognition.  I will summarize the main points below but I encourage you to click through and read this excellent piece of reporting.

According to a Mayo Clinic study published in the Journal of Alzheimer's Disease, high calorie diets (exceeding a threshold of 2143 calories/day) are associated with higher risk for cognitive impairment among the elderly.  The article also summarizes other research concluding that obesity in mid-life is a risk factor for dementia, and that weight loss can improve memory and organizational skills.

Overall, this is a well-organized summary of evidence that managing cardiovascular health through proper diet may have a clear and significant impact on overall cognitive health.

Is "Mini-Stroke" a Misleading Term?

Contributed by: Dennis Fortier, President, Medical Care Corporation

As our population simultaneously ages and becomes more obese, poor cardiovascular health has driven the incidence of certain medical conditions ever higher.  For example, general awareness and acceptance of transient ischemic attacks, alternatively known as TIA's and mini-strokes, has risen notably over the past two decades.

While awareness of medical conditions and the risks that cause them is generally a good thing,  a false comfort, based on a perception of "good medical outcomes", can be quite dangerous.

Sticking with the example of TIA's, the tone of much public discourse on such a clear symptom of severe cardiovascular disease, has been somewhat benign.  Because "mini-strokes" are common, and immediate outcomes are often fairly good, we may be developing a false notion that a mini-stroke is a minor occurrence.  On the contrary, a mini-stroke is a serious sign that immediate, medical attention is needed.

A recent study published in the journal Stroke showed that lingering disabilities, following a mini-stroke, are highly prevalent.  In fact, about 15% of patients who had a single TIA had lingering disabilities after three months and, for those who had a series of TIA's, more than half (53%) had lingering disabilities.

More importantly, TIA's are a major warning sign of an underlying problem that could lead to a much bigger stroke and major debilitation of the brain.  While the symptoms of a small stroke may fade quickly, immediate medical attention is still required.  Ignoring such events could lead to dire consequences including death.

The term "Mini-Stroke" may connote an insignificant event, but the evidence suggests that any stroke is serious, and the concept of "mini" might be misleading in terms of its health-related consequences. 

Diet and the Brain

Contributed by: Dennis Fortier, President, Medical Care Corporation

On the one hand, we all know intuitively that our diet effects the way we feel. Many of us feel tired after a heavy meal, many of us are irritable when hungry, and many of us are familiar with the boost/crash cycle of eating sugary snacks. Most would also agree that a light, nutritious meal makes us feel differently than one based on junk food.

On the other hand, many claims about certain foods and their impact on brain health, have been either overblown or misinterpreted by the masses. As far as we know, there is no particular oil, berry, fish, root, herb, or vegetable that we should all start consuming in massive quantities, as a means to an immediate improvement in brain function.

Rather, it is important to think about diet and the brain in both the short term and the long term. This is true because dietary habits have both short-term and long-term effects on the brain. Guidelines for a healthy brain diet have been discussed here and elsewhere many times.

The point of today's post is to emphasize the importance of the word "habit" in the phrase "dietary habit". If you consistently consume a lot of preservative filled, sugar laden, trans fat based snacks, you can't undo the damage with a giant bowl of spinach and a glass of fish oil. Despite claims you may read about coconut oil, green tea, and gingko biloba, don't fool yourself into thinking that you can add those elements to a poor diet and your brain will be fine.

Can Blood Pressure Drugs Prevent Alzheimer's?

Contributed by: Dennis Fortier, President, Medical Care Corporation

If you only read the headlines, and not the news beneath those headlines, you might be inclined to think that a certain class of blood pressure medications (angiotensin receptor blockers) can prevent Alzheimer's disease.

A recent publication in Archives of Neurology has spawned a number of sensational headlines about Alzheimer's prevention.  The study showed that, among nearly 900 subjects who died at old age and had brain autopsies, those who had taken angiotensin receptor blockers had fewer amyloid plaques in their brains.  This was true of patients with Alzheimer's disease, patients with other causes of dementia, and patients with normal cognitive health.

Amyloid plaques in the brain are a hallmark sign of Alzheimer's disease, but it is not yet well understood if the plaques are the cause of the disease, or if they are a protective response by the brain against some other biological process.  For this reason, it would be a great leap to suggest that blood pressure drugs could play a role in treating Alzheimer's disease.  While that might be true, it is equally possible that such drugs could play a role in preventing the body's natural attempt to protect itself from other facets of the disease process.

Every new clue is useful in assembling the big picture and understanding this complex disease.  This study yielded a great finding, an interesting correlation, and the possibility of new insights. But as far as we know, it did not uncover a preventative treatment for Alzheimer's disease.

New Generation Alzheimer's Drugs: Do They Work?

Contributed by: Dennis Fortier, President, Medical Care Corporation

We've all been hopeful that a new class of Alzheimer's drugs (monoclonal antibodies) would soon bring effective treatment to the growing number of Alzheimer's patients.

The latest approach is based on using antibodies that bind with harmful amyloid protein.  The idea is that the antibodies will be naturally flushed from the body by the immune system, and take the harmful amyloid away as well.

Major trials have now concluded on two such drugs: Bapineuzumab and Solanezumab.  The primary outcome measures of these trials were "improved cognition" and/or "improved function" versus a placebo group.  That is to say, if subjects who took these drugs had either better cognition or better physical ability to perform daily activities, compared to subjects who did not, then the drugs were probably effective enough to be approved by the FDA. On these measures, all trials have failed.

But that is not necessarily the end of the story for either drug.

A secondary analysis, performed on a combination of the data from the multiple Solanezumab trials, shows a small improvement in cognition among treated subjects.  It is a weak signal, but it provides some hope on which to build.  Especially noteworthy is that the positive effect was most evident in the earlier stage patients with healthier brains.

A stronger signal has come from a look at the targeted biomarkers (amyloid and tau proteins) that these drugs target.

Researchers have speculated (and common sense has suggested), that using such drugs to remove amyloid from the brains of subjects who have already suffered a fair amount of brain damage, may not be helpful.  The obvious experiment would be to remove the amyloid at an earlier stage, before brain damage occurs, which is before symptoms of memory loss and other cognitive decline are noted. This makes intuitive sense and is well-aligned with the possible effect detected in the Solanezumab trial on early stage subjects.

As such, a key indictor of the true potential for each drug may be actual measures of amyloid reduction in those subjects who were treated.  Researchers involved in the Bapineuzumab trial announced yesterday that the drug did in fact dramatically reduce amyloid in the brain and spinal fluid of trial subjects.  Similar biomarker data from the Solanezumab trial is expected in the coming weeks.

Overall, we wish that the drugs had produced great improvements in cognition and function.  While those goals were not met, it is encouraging to note that some, small measure of cognitive improvement may have been realized in the Solanezumab trials, and a clear reduction in amyloid protein was seen in the Bapineuzumab trials.

This leaves us with a hopeful hypothesis that, if used on subjects at an earlier stage of Alzheimer's disease, before extensive brain damage has occurred,  either or both drugs may yield more effective treatment than what is currently available.

Straight Talk: Mild Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation

Mild Cognitive Impairment (MCI) is a term we are seeing more and more frequently in the general press.  Unfortunately, efforts to clarify its meaning often serve to further confuse the issue.

Case in point is a lengthy discussion about MCI, with an associate professor of psychiatry, published recently in the New York Times "New Old Age" blog.  While lots of important ground is covered in the interview, most of the information is geared toward MCI caused by Alzheimer's disease, without proper emphasis and clarity about other, arguably more common causes of MCI.  Population-based studies suggest that prevalence of MCI cases caused by depression, poorly controlled diabetes, sleep-disorders, thyroid conditions, alcohol/drug abuse, medications, and cancer treatments, far exceed the number of cases caused by early stage Alzheimer's disease.

That oversight, that most MCI is caused by common, treatable, medical conditions and not early Alzheimer's disease, undermines the clarity of the piece.  Most of the discussion is geared toward understanding MCI caused by Alzheimer's disease, as opposed to MCI caused by the many other, more common, medical conditions that impair cognition.

This confusion about MCI and the proclivity to attribute MCI to Alzheimer's disease are not new phenomena.  I wrote about it more than three years ago in a post about MCI converting to Alzheimer's disease. In the years since, increased interest in cognitive health has brought increased coverage of these issues.  Unfortunately, much of the coverage is poorly presented and does not aid clarity.

Here is a constructive way to understand the term MCI: While some decline in cognitive function is normal with aging, MCI refers to changes that are more severe than would be expected at a given age, but not so severe as to prevent a self-reliant lifestyle. When cognitive decline is severe enough to prevent self-reliance, we use the term "dementia".  In this way, cognitive health can be viewed as a continuum from "normal aging" to "MCI" to "dementia". One crosses from MCI into dementia when the cognitive decline is severe enough to prevent effective self-care.

Alzheimer's Drugs in the Pipeline

Contributed by: Dennis Fortier, President, Medical Care Corporation

Recent history has not been kind to R&D efforts aimed at developing new Alzheimer's drugs.  While four approved drugs can help manage symptoms of the disease, and perhaps slow its progression to a small degree, the field has aggressively pursued new treatments that can significantly slow or stop progression.

These efforts have been hampered by the complexity of the disease and by, what most experts consider, a fairly rudimentary understanding of its pathology.  We understand that Alzheimer's disease manifests as a decline in cognitive function, and that the decline is caused by a loss of brain cells and the connections between them.  We also understand that an accumulation of amyloid proteins in the brain, and a chemical change in Tau proteins (phosphorylation) in the brain, are major factor contributing to that loss of brain cells.

However, the picture becomes less clear when we try to identify the many possible processes that start the pathology.  The answer may be related to cell metabolism, to brain chemistry, to inflammation, or trauma, just to name a few of the leading areas of scientific inquiry.  Probably, a host of these processes interact and lead to a cascade of biological responses along the way.

The questions to which we do not yet have solid answers are: which processes matter most, are they inter-related, and why do they lead to this disruptive outcome?  Without those answers, it is difficult to develop drugs that will target the right process, at an early stage.  It is a very complex problem involving the most complex of organs.

Nonetheless, research persists and scientific efforts are ongoing.  At this point, several promising agents are moving along the pathway in FDA clinical trials.  A good overview of the Alzheimer's pipeline was recently published by Fierce Biotech.  It is slightly technical, and geared toward financial analysts, but it is comprehensive and gives a good foundation of the theory behind each approach.

Depression and Aging

Contributed by: Dennis Fortier, President, Medical Care Corporation

This is a great overview on common triggers for depression as you age, including a few life-style choices that effectively keep depression at bay.

The link goes to a WebMD presentation of 21 slides that can be viewed and read in about 5 minutes.  For anyone over age 40, or with an interest in depression, I highly recommend clicking through and reading; it is very well done and informative.