Screening for Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

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.

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.

Metabolic Syndrome and Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

While better education and higher awareness about Alzheimer's disease are key themes in this blog, we also emphasize the many other medical conditions that are also associated with memory loss.  Among those conditions is Metabolic Syndrome.

As per a recent article posted on WebMD, Metabolic syndrome is a common condition characterized by a cluster of symptoms that can include high blood pressure, too much weight around the waist, elevated blood sugar levels, low levels of HDL “good” cholesterol, and high levels of tryglycerides, a type of unhealthy fat found in the blood.

According to a study published yesterday in Neurology, subjects with metabolic syndrome, are more prone to cognitive decline in their later years.  While this group was previously known to have higher risk for heart disease, it is now more clear that they face an increased cognitive risk as well.

Given a large body of evidence showing that active management of blood pressure, blood sugar, cholesterol, and body fat can reduce the risk of heart disease, it is reasonable to speculate that such practices might also reduce the risk of cognitive decline.  Certainly, it couldn't hurt.
--------------------------------------------------------------------------------
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.

Memory Assessment During Routine Medical Exams

Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

As we have noted in this space before, the Health Care Reform Act will mandate "detection of cognitive impairment" during routine Medicare Exams beginning in 2011. However, the approach by which physicians will comply with this new requirement remains an open question.

How should cognitive impairment be detected in a primary care setting?

The merit of any particular solution must be judged on several factors. For example, with all other factors held equal, a brief test would be superior to a short test as would a non-invasive test be superior to an invasive one. Cost matters as well; surely a less expensive test is preferable to a costly one. Similarly, a test that is highly sensitive to even subtle declines in cognition would be a better solution than one that only detects more severe symptoms.

While I have described attributes for comparing "tests", it may be that a test need not be part of the ideal solution. Perhaps physicians need only be proactive in soliciting memory concerns (or other cognitive complaints) from their patients.

Under such a scenario, those who express a concern could advance to a more sophisticated evaluation and the others would be questioned again at their next annual wellness exam. That's not a perfect solution for detecting problems in patients who are not already concerned, but many experts in this space would argue that such an approach would be a major leap forward. In fact, it might be the only approach that blends enough pragmatism and cost-efficacy to actually work in a busy primary care setting.

I recently listened to a webimar about a brief instrument called the "AD8", an informant-based questionnaire that could be useful in helping physicians identify patients who need a more thorough evaluation of their cognition. Various participants from the audience, many with ties to competing instruments, raised concerns about the whether or not it was a viable solution. An expert panel then discussed various pros and cons of the AD8 during the ensuing dialogue. The point of this post is not to evaluate the AD8 but to highlight the value of a new focus on cognitive health.

From my perspective, the facts that (1) Health Care reform is mandating more attention to cognitive health and (2) national discussions are unfolding to explore competing approaches, are both extremely positive developments. Memory concerns must be identified and addressed as early as possible to ensure timely intervention against progressive illnesses. This is our best bet to avoid future insolvency of our public health care system.

Efforts to initiate discussions about brain health between patients and their physicians are exactly what we need. We are on the right track.
--------------------------------------------------------------------------------
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.

NIH State of the Science Conference

Contributed by: Dennis Fortier, President, Medical Care Corporation


As I write often, the purpose of this blog is to help readers discriminate between press about solid science and press with a hidden or contorted agenda. Of course, every source has some bias so it is best to read broadly, cultivate your ability to discern, and make your own decisions about the state of the science.

One particularly good source of well-vetted, scientific summary is the National Institute of Health. Among the many ways they contribute to objective scientific inquiry is their "State of the Science" conferences. On April 26-28 they will convene such a conference on "Preventing Alzheimer's Disease and Cognitive Decline".

The purpose of the conference is to evaluate the available scientific information on Alzheimer’s disease (AD) and develop a statement that advances understanding of the issue under consideration and will be useful to health professionals and the public.

Discussion topics will include:

• What factors are associated with the reduction of risk of AD?
• What factors are associated with the reduction of risk of cognitive decline in older adults?
• What are the relationships between the factors that affect AD and the factors that affect cognitive decline?
• What are the therapeutic and adverse effects of interventions to delay the onset of AD?
• What are the therapeutic and adverse effects of interventions to improve or maintain cognitive ability, or preserve cognitive function? Are there different outcomes in identifiable subgroups?
• If recommendations for interventions cannot be made currently, what studies need to be done that could provide the quality and strength of evidence necessary to make such recommendations to individuals?

These conferences are free to attend, allow the public as well as professionals with an opportunity to contribute, and culminate with an objective summary about the state of the science in the particular field. If you know someone with an interest, please pass this on to ensure they are aware of the opportunity to participate. Even if attendance is not practical, let's all be aware of the forthcoming consensus report that the conference will generate and make available.