Screening for Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Yesterday, the U.S. Preventative Services Task Force (USPSTF) ruled that there is insufficient evidence to make a recommendation, either for or against, routine screening for cognitive impairment in older adults. Today, the press is ablaze with sloppy reporting on the matter.

Many news stories (like this from US News and World Report) are conflating cognitive impairment with dementia, but readers of this blog understand that cognitive impairment may be very mild whereas dementia is, by definition  a severe loss of cognitive capacity. Many others (like this from Time), are interchanging dementia and Alzheimer's disease, which inappropriately implies that the two are one in the same, and obscures the fact that Alzheimer's is but one of the many causes of dementia.

To be clear, the USPSTF did not rule against anything. They merely concluded that the evidence is not strong enough to make a recommendation one way or the other. More importantly, their ruling was related to "screening" of "older adults" for "cognitive impairment". In other words, should the healthcare system invest in regular cognitive assessment of all older adults, whether they suspect a problem or not? Their conclusion? They're not sure.  They're not for it and not against it.

Rather, the public should monitor their cognitive health vigilantly and promptly report concerns to their physicians for a thorough evaluation. This will allow early intervention against treatable problems like thyroid dysfunction, vitamin deficiency, anxiety/depression, sleep disorders, and out of control diabetes, all known contributors to cognitive deficits. It will also facilitate early diagnosis of Alzheimer's disease.

This is important because Alzheimer's can be effectively managed for a significant percentage of patients. Effective management of Alzheimer's includes early diagnosis, physical exercise, proper diet, strict control of hypertension and diabetes, poly-therapy with a cholinesterase inhibitor and Namenda, ongoing social and intellectual stimulation, and caregiver education. All of these interventions have been shown to promote optimal disease management and, when brought together as a robust therapeutic regimen, can be surprisingly effective.

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.

Alzheimer's Drugs Deemed Effective by Overseas Authorities

Contributed by: Dennis Fortier, President, Medical Care Corporation
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 Efficacy of treatment for Alzheimer's disease is a topic of frequent debate and disagreement.  While the data are relatively clear, the source of the disagreement is often "expectations".

For example, if a person with memory loss and behavioral disturbances due to Alzheimer's disease takes a cholinesterase inhibitor, it would be unrealistic to expect an immediate decline of all symptoms and a full return of cognitive function.  Current drugs simply cannot repair damaged brain cells and restore function.  More likely, the treatments would mitigate the symptoms and perhaps slow their rate of progression.

So the question is, do these drugs help?  If you are expecting them to render a cure, then the answer is "no".  But if you are objectively measuring their effect on the quality of the person's life, which incorporates control of symptoms and disease progression, then the answer is "yes".

The National Health Service in the UK has formerly not payed for its citizens with early stage Alzheimer's disease to be treated with cholinesterase inhibitors.  That decision may have been based, in part, on unrealistic expectations.  However, after collecting several years of additional data and weighing the overall benefits of treatment, they have now reversed that decision.

This is another powerful example that early intervention can make a meaningful difference in the quality of life for a person with Alzheimer's disease.   Be vigilant in monitoring your cognitive health and voice any emerging concerns to your physician.

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A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share button below to spread this educational message as widely as possible.

Alzheimer's Treatment: Combo-Therapy is Best

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A new study presented at the 14th Congress of the European Federation of Neurological Societies (EFNS) strongly supports earlier findings about treatment efficacy of combination therapy. The research showed that, when treating Alzheimer's disease, a combination of a cholinesterase inhibitor like Aricept plus Namenda is significantly better than mono-therapy with a cholinesterase inhibitor only.

In this study of more than 400 patients with moderate to severe Alzheimer's disease, significant improvements in patients receiving combined therapy were noted in cognition, function, behavior, global outcome, and care dependency. These are robust findings that might begin to change nihilistic attitudes toward Alzheimer's treatment.

The most optimistic view of treatment efficacy comes not only from studies like this, showing the benefits of combo-therapy, but from a more robust approach. To maximize treatment effect, we need to intervene earlier in the disease process so that patients can start therapy before massive neuron death and synapse loss occurs. Additionally, we need to augment the benefits of drug treatment with a balanced diet, physical activity, and proper control of other co-morbid conditions such as diabetes ad hypertension. Most probably, staying intellectually active and socially engaged is also beneficial.

Given the generally defeatist tone of most press about Alzheimer's treatment, I am happy to see the occasional positive press about our ability to combat this disease. We have a long way to go but the facts are more comforting than most headlines suggest.
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A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share buttons below to spread this educational message as widely as possible.