Do Clinical Tests for Alzheimer's Miss the Highly Educated?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With the forthcoming changes to regulations by National Health Services in the U.K., many Alzheimer's patients who have formerly been denied treatment with cholinesterase inhibitors may soon have the opportunity to benefit from such treatment. With that in mind, a story in today's Telegraph raises an interesting point.

The point is that the Mini Mental State Exam (MMSE), a short test of memory and judgment used by many physicians to detect cognitive problems, is not sensitive enough to distinguish early stage Alzheimer's disease from subtle symptoms associated with normal, healthy aging. As such, many people, particularly those who are highly educated, might continue to pass that test until deep into the progression of a debilitating disease like Alzheimer's. These people, it is argued, would be presumed healthy and neither evaluated further nor treated for any emerging problem. It's a valid point.

The solution is for clinicians to embrace a newer generation of assessment tools suited for a primary care environment. A comprehensive, expert review of such technologies is currently underway through the non-profit organization Prevent AD 2020. A summary of their findings is expected to be published in the Journal of Alzheimer's & Dementia (the journal of the National Alzheimer's Association) early in 2011.

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Straight Talk About AD Prevention and Cure

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Published online today by Scientific American is a fantastic interview with P. Murali Doraiswamy, a leading researcher in the Alzheimer's field and an occasional contributor to this blog.

In the interview, Doraiswamy succinctly summarized some misconceptions about AD treatment and described the need for earlier intervention against this disease. He also commented on some promising research in both the diagnostic and treatment fields.

I especially appreciated, and want to emphasize, his careful distinction between "curable" and "treatable" as these terms pertain to AD. His comment is captured here:

The larger point is that while Alzheimer’s is still incurable it’s not untreatable. There are four FDA-approved medications available for treating Alzheimer symptoms and many others in clinical trials. Strategies to enhance general brain and mental wellbeing can also help people with Alzheimer’s. That’s why early detection is so important.

As the age structure of the population continues its march upward, it is imperative that we raise general awareness about the benefits of earlier detection. Articles like this can be very useful in accomplishing that goal and I encourage all of you to read it and to share it with others.

Detection vs. Diagnosis

Contributed by: Dennis Fortier, President, Medical Care Corporation
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These are two terms that are similar but distinct in their meaning and, unfortunately, often used interchangeably by the press when writing about health care and clinical practices. The primary purpose of this post is to sensitize readers that news stories can be misleading when writers are careless in choosing between them.

In clinical practice, to "detect" a problem is to objectively observe symptoms caused by the problem or to hear a subjective but credible complaint from the patient about a symptom that is not visible (i.e. back pain). To "diagnose" a problem is to ascertain the specific medical condition that is causing the problem.

Here is an example from the field we follow. A physician would "detect" memory loss by objectively establishing that a patient's recall ability is not in the normal range for the patient's age and educational peer group. The physician need not know the cause of the problem to detect it.

Once detected, the memory loss would then be "diagnosed" as (for example) a thyroid disorder, or as Alzheimer's disease, or as any number of other memory impairing medical conditions. The diagnosis informs the forthcoming decisions about treatment.

In general, much of the news about neuro-psychological tests being developed is news about improving our ability to detect problems. Much of the news about bio-markers is news about improving our ability to diagnose problems. In the realm where I see the most common misuse of these terms, much of the news about imaging techniques crosses between the two.

Alzheimer's Detected Too Late

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The Atlanta Constitution Journal has a nice piece today about the poor state of Alzheimer's detection. While we refer to this reality quite frequently in this blog, it is worth reading the article because they do a good job describing the magnitude of the problem and they frame a possible solution.

The focus of the article is on the lack of screening in physician offices. While I agree that a general screening approach to the aging population could be a factor in solving this problem, I don't think it is necessarily the only approach and probably not the most efficient approach. I would suggest a "case-finding" mentality where physicians are well-educated about what questions to ask and which signs to watch and where they have viable assessment tools to help them further evaluate patients likely to have an emerging problem.

The article describes several reasons that such screening is not more common including lack of physician education, lack of screening standards, and lack of time for screening in an office visit. On slow news days going forward (if there are any), I will revisit this post and give my thoughts on each of those barriers.

Alzheimer's Test in the News

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Over the last two days, many news outlets have reported this story about a "new Alzheimer's test". It is based on analysis of a small sample of skin cells and holds promise for accurately detecting Alzheimer's disease in its early stages. For perspective, I offer the following comments.

Bio-markers
This is a bio-marker test. A bio-marker, as defined by researchers at Stanford University is "a specific biological trait, such as the level of a certain molecule in the body, that can be measured to indicate the progression of a disease or condition". In this instance, the test measures the presence of a phosphorous binding enzyme which is theorized to contribute to the Alzheimer's disease process.

Detection vs. Diagnosis
Despite the characterization in many headlines I have seen, this will be a test for "diagnosing" Alzheimer's disease, not for "detecting" it. This means that once a patient is deemed to have a medical condition interfering with normal cognition, a physician will need to consider the possible causes and diagnose the correct one. Since we currently diagnose Alzheimer's disease partially by ruling out other causes, this new test might be an inexpensive, non-invasive, and hopefully accurate means for arriving more directly at a diagnosis of AD.

With a projected cost of several hundred dollars per test, this approach could add certainty while reducing time in the diagnostic process. The test is being co-developed by the Blanchette Rockefeller Neurosciences Institute and Inverness Medical Innovations Inc. with a possible commercial product available within 18 months.

5 Truths that Spawned 5 Myths about Alzheimer's and Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Sometimes the truth can be very misleading. This is often the case with complex topics when an “expert” makes a narrow but accurate statement that is subsequently generalized by the lay public. This is a common phenomenon in the fields of Alzheimer’s and dementia.

Here are five examples of true statements that have been so commonly misinterpreted that they have spawned five harmful yet well-entrenched myths.

Narrow Truth: There is no cure for AD.
General Myth: Because there is no cure, nothing can be done for patients diagnosed with this disease.

Like diabetes and hypertension, we cannot yet cure Alzheimer’s disease. However, physicians can intervene and manage the symptoms with more success than most headlines would indicate. In fact, with a timely diagnosis, a physician can prescribe a treatment plan including pharmaceutical therapy, improved diet, physical exercise, mental and social activity, and certain OTC supplements. When this approach is combined with an educated caregiver, disease progression can be commonly slowed for some meaningful period of time.

Narrow Truth: The only certain method for diagnosing Alzheimer’s disease is to inspect a sample of brain tissue during autopsy.
General Myth: Alzheimer’s disease cannot be accurately diagnosed until death.

If “certain” means 100% accuracy, then there is no certain diagnostic method for many well known diseases (Lou Gehrigs disease springs immediately to mind). However, physicians following published diagnostic guidelines can get a highly accurate diagnosis of Alzheimer’s disease (90%-95), even at a fairly early stage of the disease. This diagnostic accuracy is on par with commonly accepted clinical practice.

Narrow Truth: Current treatments do not stop the progression of AD.
General Myth: Since the disease will continue to progress, there is no need to bother with treatment.

There is no doubt that reversing all memory loss would be the best treatment result and halting further memory loss would be better than ongoing decline. However, this does not mean that slowing the pace of further decline is not a worthy pursuit. We all want better treatment options in the future but until they arrive, preserving quality of life during a patient’s final years is definitely a worthwhile and attainable goal.

Narrow Truth: Cognitive decline is a part of normal aging.
General Myth: Pronounced cognitive deficits just need to be expected and tolerated

As we age, all of our organic functions tend to slow. Our ability to think, make calculations, use judgment, and store and retrieve information is not immune to this process. However, a pronounced loss of cognitive capacity severe enough to impact a person’s ability to lead an independent life is not normal. When such decline occurs, there is some underlying pathological explanation that can be identified and treated by a physician. Accepting significant loss of mental function as a normal artifact of aging is a tragedy.

Narrow Truth: It’s best not to know if you have Alzheimer’s disease
General Myth: It’s best if the problem stays undiagnosed

This final “truth” is a stretch to begin with. I can imagine that, if it were possible, an Alzheimer’s patient might enjoy life more if they could receive the highest standards of care without ever knowing they had a terrible disease. However, this does not make the case that the problem should be ignored. The published evidence in favor of managing the symptoms and prolonging a higher quality of life outweighs the presumed benefits of bliss. Additionally, patients need to know about their condition if they are to participate meaningfully in their own care and end of life decisions.

I hear and read these narrow “truths” in the media everyday. I also see first hand how the public mischaracterizes them and takes away a broader and more harmful message than is intended.

Education remains a major barrier between our current ability to care for AD patients and the higher standards that are within our immediate grasp. I hope we can begin to divorce ourselves from these sound bites of misleading truth and begin to see the Alzheimer’s picture with more clarity.

AD Treatment Perspective #2

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The fastest path to better treatment for AD is to start diagnosing the disease at an earlier stage and intervening while the brain is still somewhat healthy. On average, we currently diagnose AD about 8-10 years after the onset of symptoms when the pathology is in the end stages and massive brain damage has already occurred. The current drugs may not cure the disease but they can delay progression quite well if patients get access to them as soon as symptoms manifest.

Solution: Patients and Primary Care physicians must engage in proactive dialogue about cognitive health and be vigilant toward investigating suspicion or evidence of memory decline.