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.

Horrible Alzheimer's Advice from AARP

Contributed by: Dennis Fortier, President, Medical Care Corporation

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We clarify the news about brain health.  When someone gets the story wrong, we feel it is important to provide a more balanced perspective.  The AARP got it horribly wrong in this article about early diagnosis of Alzheimer's.

While laudable for its intent to protect the public from invalid claims about Alzheimer's diagnostic tests and treatments, this article is remarkably misleading. I would expect much better from such a trusted source as AARP.

The sensationalistic statement opening the third paragraph (falsely propagating the notion that there is no diagnostic test and no effective treatment for AD) is about as harmful a message as anyone could direct at this audience.  True, there is no single medical test to diagnose AD, but as the author eventually admits, primary care physicians can diagnose it with high accuracy through a series of routine diagnostic steps.  The medical literature shows that better than 90% accuracy is easily achievable when published guidelines are followed.

As for treatment, the willingness of writers to substitute the terms "drugs" and "treatment" for one another is deplorable.  I think most experts agree that the cholinesterase inhibitors provide only moderate, symptomatic relief for Alzheimer's patients who are already demented.  However, robust treatment that includes early intervention (prior to the dementia stage), physical activity, a proper diet, strict control of diabetes and hypertension, ongoing social/intellectual stimulation, and a combination of a cholinesterase inhibitor with Nameda, has shown a much more optimistic treatment result than a single drug shows when isolated from all other aspects of treatment.

Trusted sources like AARP are invaluable as consumer advocates and they play a key role in sorting bogus claims from real science.  But in this instance, they could have done a much better job in characterizing the truth.  Suggesting that people with a memory concern should "ignore it" is alarmingly irresponsible.

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.

3 Stages of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

Alzheimer's disease was clarified today.

With the announcement of new diagnostic guidelines, developed in tandem by the National Institute of Aging and the National Alzheimer's Association, we can now conceptualize the disease across a continuous spectrum with three contiguous stages of progression.  There is a pre-clinical stage, a mild cognitive impairment stage, and a dementia stage.

Pre-clinical Stage
The purpose of defining this very early stage, before the presence of any clinical symptoms, is purely to benefit research.  While there are no symptoms of disease in this stage, researchers have noted that certain biological changes, including protein levels in the brain, blood, and spinal fluid, seem to change in fairly predictable ways during the years before Alzheimer's patients manifest symptoms.  The changes are not sufficiently telling to diagnose the disease at this early stage, but identifying these individuals and enlisting them as research subjects is an important goal for the field.

Importantly, physicians will not use these criteria to diagnose such early stage Alzheimer's. The definition of this stage is purely to help researchers speak a common language about similarly characterized research subjects. 

Mild Cognitive Impairment Stage
In this stage, patients have clear underlying pathology consistent with Alzheimer's disease, and have also developed clinical symptoms of memory loss or other cognitive deficits.

The identification of this stage is the most important aspect of the new guidelines, as it will enable earlier intervention for patients who are, almost certainly, in the progressive throes of Alzheimer's, but still have relatively healthy brains.  It is hoped that existing treatments, and new treatments in the pipeline, will be optimally effective in these early stage patents.

Dementia Stage
This stage is quite consistent with our former view of the disease.  It requires the hallmark pathology of amyloid plaques in the brain, plus cognition so impaired as to meet the criteria for dementia (two or more realms of impaired cognition that interrupt daily activities of living). In the past, we did not call the problem "Alzheimer's disease" until the patient reached this end stage condition.

New Guidelines for Alzheimer's Disease are a Step in the Right Direction

Contributed by: Dennis Fortier, President, Medical Care Corporation

The announcement of new guidelines for diagnosing Alzheimer's disease is being widely covered in the press today.  The move is a solid step in the right direction, but is spawning some confusion about why the change is necessary, and how it might help.

Biggest Change: AD starts prior to Dementia
The most important change is that we will now recognize Alzheimer's disease in its early stages, prior to the patient suffering massive brain damage and becoming demented.  This is a more difficult diagnosis to make and, as such, requires a thoughtful approach.

I wrote more extensively about the benefits, and the ensuing confusion about new diagnostic guidelines for Alzheimer's disease, when the draft versions of these documents were first discussed in the summer of 2010.   I encourage you to click back and read those thoughts, but the short summary is below.

Perspective on Former Guidelines
According to the former guidelines, put in place nearly 30 years ago, Alzheimer's disease was defined in part by the presence of dementia.  As readers of this blog know, dementia requires impairment so severe that a person cannot independently care for themselves.  In this regard, the term "mild Alzheimer's" means "barely demented due to Alzheimer's pathology"'  This is a misnomer because, even in its "mild" stages, dementia is a severe condition.

To put that in perspective, imagine if we could note the high blood sugar and blurry vision caused by diabetes, but we couldn't diagnose and treat it until the patient's kidneys failed.  Any guideline, suggesting that symptoms must be severe before diagnosis, is in direct conflict with early intervention.

The former guidelines were problematic as illustrated by this example:  Suppose a 75 year old person, with a family history of Alzheimer's, noticed subtle signs of memory loss and visited a physician.  The physician then confirmed the declining memory and sought the cause of the problem.  After ruling out depression, sleep disorders, medications, thyroid malfunction, poorly controlled diabetes, vitamin deficiency, and stroke as possible causes, he noted on an MRI scan of the brain that the patient's hippocampus was shrinking.  This would be a strong indication of Alzheimer's disease.

However, since the patient in this example had only subtle memory loss, not severe cognitive impairment meeting the criteria for dementia, the physician could not diagnose Alzheimer's and initiate treatment.  According to the old guidelines, the physician would let the Alzheimer's pathology progress for months or years, until the patient suffered enough irreversible brain damage to become demented, and then they could diagnose Alzheimer's and initiate treatment.  That clearly makes no sense.

New Guidelines
Under the new guidelines, if a patient has memory loss or other cognitive deficits, and common causes of such deficits are ruled out, and pathology is consistent with Alzheimer's, then we should recognize the condition as early stage Alzheimer's disease and begin treating it.  This holds even if the patient's cognitive problem is subtle and does not meet the criteria for dementia.

Since earlier intervention bodes well for better treatment outcomes, this is a solid step in the right direction.

Can a Brain Scan Predict Alzheimer's?

Contributed by: Dennis Fortier, President, Medical Care Corporation

There is a lot of recent press suggesting that a brain scan may be useful in predicting Alzheimer's disease.

The excitement has been generated by a new study showing that a good read on the size and shape of particular portions of the brain, can be useful in predicting which patients, among a group with subtle symptoms of memory loss, will develop Alzheimer's disease.

The journalists at MSNBC, provide a good example of how the concept of "predicting" is frequently misused in the press, when they are actually writing about "identifying".  Almost invariably, the confusion between predicting and identifying Alzheimer's, is coupled with the misleading notion that subtle symptoms of memory loss sometimes "progress" to Alzheimer's.

I want to untangle these various notions, and offer a clear summary of what I think these journalists are trying to convey.

Mild Cognitive Impairment
When a person has mild symptoms of memory loss that are more severe than those we expect with normal aging, but not severe enough to qualify as dementia, we describe their condition as "mild cognitive impairment" (MCI).  By definition, MCI is not a part of normal aging.  This means that it is caused by some underlying medical condition such as vascular disease, a  thyroid disorder, depression or a number of other causes.  It might also be due to early stage Alzheimer's disease.

Predicting vs. Identifying
The key point is, if you have MCI due to Alzheimer's disease, then you have Alzheimer's disease.  There is no need to predict, only to identify.  There is no concept of "progression", the disease is already present.

So, the recent study that has generated much press, is a good study with a potentially valuable conclusion.  When a person has mild cognitive symptoms that we call MCI, and a physician must diagnose the correct cause of the symptoms in order to administer appropriate treatment, the ability to identify Alzheimer's disease  as the cause (or not the cause), is very important.  If a scan of brain structure is valuable in this regard, then we have gotten better at diagnosing this terrible disease.

We have not, however, found a new way to predict anything.  Only a new way to better identify a disease that is already present.

Alzheimer's Diagnostic Accuracy: Theory vs. Reality

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The reports on diagnosing Alzheimer's disease are maddeningly conflicting.

Research in academic journals makes it clear that a primary care physician can achieve a high level of diagnostic accuracy by following published guidelines.  However, journalists report every day that Alzheimer's disease can only be definitively diagnosed with an autopsy.  So which is it?

It turns out that both statements are correct.

Definitive vs. Clinically Acceptable
It is technically true that an autopsy is required for a "definitive diagnosis".  However, in the world of practiced medicine, we rarely operate with definitive diagnoses for any disease or condition.  Instead, we rely on "clinically acceptable" diagnoses that are accurate about 85%-95% of the time.  The emphasis on "definitive", or 100% accuracy, is actually quite misleading since it establishes an unrealistic standard that is rarely met in the real world of medical practice.

As for the academic perspective, a clinically acceptable level of accuracy is indeed achievable by following published guidelines.  These guidelines involve a complete medical history including a review of medicines, neuro-psychological assessment, blood tests, and an MRI or CT image of the brain.  In some cases, a PET scan of the brain might also be required.

Diagnostic Guidelines
To paraphrase the guidelines: if a patient shows impaired short-term memory as well as impaired cued recall, is not taking any medications known to disturb memory, is not abusing alcohol or other drugs, is not depressed or suffering from anxiety, does not have any apparent or detectable infections, has no uncontrolled diabetes or hypertension, has a properly functioning thyroid and no particular vitamin deficiencies, has not suffered a recent head trauma, and has no evidence of strokes or tumors in the brain, then the physician can be quite confident that the patient has Alzheimer's disease.

Essentially, the hallmark forms of memory impairment need to be objectively confirmed by cognitive assessment, and other known causes of such impairment ruled out.  A family history of Alzheimer's disease, or a genetic test showing a particular predisposition, would add confidence to such a diagnosis.

Why the Different Perceptions?
The reason for the stark difference in the academic perception of diagnostic accuracy and the journalistic perception of diagnostic accuracy is "lag".  In this case, lag refers to the well documented time-gap between medical advance and implementation of medical advance.  In other words, medical research leaps forward much faster than physicians can learn about and implement new findings and guidelines.  Right now, there is a significant gap between best practices in the field of memory loss and the actual practices that physicians are using in their clinics.

Half of Alzheimer's Cases Misdiagnosed
Recent articles from CNN and WebMD have reported that about half of Alzheimer's cases may be misdiagnosed in clinics.  Oddly, this probably indicates progress from recent years when memory problems went largely undiagnosed and ignored, to current times when many memory problems are being improperly attributed to Alzheimer's disease.  Progressing from "doing nothing" to "doing the right thing half the time" is actually a favorable development.

With time, our over-worked physicians will gain a better command of emerging guidelines.  This will improve their collective ability to recognize problems and to accurately determine their cause before prescribing treatment.

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5 Things I Wish Everyone Understood about Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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There is much needless confusion about certain aspects of the Alzheimer's field.  In fact, this blog exists almost solely to help reduce that confusion.

Many bloggers, and some sloppy journalists, compound the problem with their inaccurate daily descriptions and ambiguous word choices.   Here are 5 things I wish they would all get straight:

1. Alzheimer's is but one disease, albeit the most common, of many that can lead to dementia.

Parkinsons's disease, stroke, head injuries, and a host of other medical conditions can also lead to dementia.  Alzheimer's is a progressive disease that seems to begin with an accumulation of amyloid protein in the brain, followed by subtle symptoms of memory loss, and eventually, enough brain damage to render a person demented.

2.  The term "Dementia" does not refer to a disease.

Dementia is a term that describes a fairly advanced state of cognitive decline, when diminished brain health is so severe that it interferes with a person's life.  How a person has arrived at that state of diminished brain health is a separate and distinct matter.

Importantly, when you hear about "early dementia", you are hearing about the earliest stages of a condition that is already quite severe.  A little memory loss is a problem that should be evaluated, but it is not "dementia" until it becomes so severe that it interferes with daily living.

3. Early detection of Alzheimer's is not the same as "predicting" Alzheimer's disease.

In the first case, we would identify the pathology of AD and provide optimal treatment, prior to the massive brain damage that eventually causes dementia.  Predicting risk, on the other hand,  is still a very uncertain science with complex pros and cons.  (So complex, in fact, that many bio-ethicists are currently able to earn a living discussing them.)

4. Having "no cure" for Alzheimer's is not the same as "having no treatment".

Controlling symptoms and slowing disease progression are both beneficial outcomes short of a cure.  Because we don't understand the disease well, it has been difficulty to identify drugs that significantly alter the disease course.  However, much of the perceived inability to treat the disease is driven by the fact that we identify AD much too late, and intervene only after major brain damage has occurred.

The negative perception of treatment is also driven by a narrow focus on drug efficacy, as opposed to the combined effect of a more robust treatment approach involving diet, exercise, and management of contributing conditions.

5. Very few diseases can be diagnosed with 100% certainty, Alzheimer's is not particularly unique in this regard.

By following published guidelines for a diagnostic work-up, physicians can accurately diagnose AD more than 90% of the time.  This is well within the range of acceptable clinical certainty.  The repeated mantra in the press, that an autopsy is required to diagnose AD with 100% certainty, may be true but is also nearly meaningless.

With more careful reporting on these 5 aspects of Alzheimer's disease and dementia, we could eliminate much unnecessary confusion which could help us approach solutions with more clarity and success.  Please share this post with your online networks to help spread the message.

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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.

Does Early Diagnosis of Alzheimer's Really Create an Ethical Dilemma?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Does early diagnosis of Alzheimer's really create an ethical dilemma?

For all of the press devoted to scrutinizing the pros and cons of delivering an Alzheimer's diagnosis to a patient with only mild symptoms, including a front page article in today's NY Times, it is easy to overlook the question posed above. In fact, anyone could be forgiven if they assumed, based on the constant characterization in the press, that a dilemma is at hand.

The Dilemma That Isn't
Posing this question may generate provocative headlines and robust debate but, if we step back and consider the larger context, there really is no dilemma. We do not need any ethicists to ponder and rule on this question because it doesn't require a single, universal answer.

Some people seek clinical information and get comfort from having it available, even when the information consists of bad news like an Alzheimer's diagnosis. Others prefer ignorance when new information will cause them to worry needlessly about a situation they cannot change.

Patients Choose
Rather than debating which approach is better and pronouncing the presence of a dilemma, all we need to do is let individuals choose their preference. Those who want to know should be told; those who do not want to know, needn't have the information thrust upon them. When someone has a sign or symptom of a medical problem and then seeks a physician's opinion about the underlying problem, they are pretty much declaring that they want a diagnosis. In the real world, the "want-to-know vs. don't-want-to-know" decision is made by either consulting a physician or not.

This situation is not as black and white as described here, but it certainly is far less gray than characterized by the press. In general, people seeking medical attention for a cognitive complaint want help and physicians have an obligation to diagnose the problem and treat it as effectively as possible.

Sometimes this will involve giving patients news they would rather not hear, but the symptoms and the angst that comes with those symptoms, are already a reality in the patient's lives. A definitive diagnosis reduces uncertainty and helps the treatment process move optimally forward.

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Misplaced Moral Argument about Predicting Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation
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When following the press in the brain health space, it is very common to find well-written opinion letters and perspective pieces about the moral dilemma of predicting Alzheimer's disease in healthy adults. Common headlines vary around the "would you want to know" or "would you take the test" theme. The crux of the argument is that, with no cure, we should not bother predicting the disease and revealing such a tragic fate.

In a nutshell, these are the usual defenses:

• Predictions allow vigilant monitoring and timely intervention when symptoms appear which leads to better treatment.
• Predictions allow for financial, legal, and spiritual preparation for end of life.
• Predictions identify important research subjects who can greatly improve scientific efforts to develop new treatments by volunteering for trials.

There are other arguments but those are the most common and most compelling justifications.

The purpose of this post is neither to condemn nor condone the notion of predicting Alzheimer's disease but to point out how often the moral debate is misplaced. For predictive approaches, like genetic tests, I say let the debate rage. However, for identifying approaches, those that indicate with certainty if a person has Alzheimer's pathology that has not yet progressed to a stage producing obvious symptoms, then the whole notion of "prediction" is misplaced.

But the moral debaters do not respect this important difference between predicting the disease and identifying the disease. People who have it, have it. And when they present to a physician and complain of cognitive difficulties, they are asking their physician to figure out the cause of the problem and treat it as best as possible. No moral dilemma; these people want to know.

Remember, everyone has the right to not visit their doctor and not investigate emerging cognitive problems. Those who want to actively manage their health should be allowed and those who wish to remain ignorant have rights as well.

Soon, we will have the ability to identify Alzheimer's pathology with a PET scan which will enable earlier and more accurate diagnoses. In the not too distant future, we will likely have a spinal fluid test (followed by a blood test) that will accurately diagnose Alzheimer's disease at even early stages through more cost effective means. These are great steps forward and there is no moral or ethical downside to gaining these important clinical abilities.

Predicting Alzheimer's disease is a topic worthy of moral debate; identifying the disease is a categorically constructive step in the right direction.

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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.

Revised Definition of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With a publication slated for the November issue of Lancet Neurology, the International Working Group for New Research for the Diagnosis of AD has updated their position paper from 2007. In the new publication, they suggest that AD should be defined as impaired episodic memory plus one bio-marker (either MRI, PET, or spinal fluid) indicating known disease pathology.

Importantly, the presence of dementia would no longer be required as part of the new definition of Alzheimer's disease. This will allow physicians to diagnose the disease and intervene with therapy at an earlier stage of symptoms.

As we have discussed here often, the current practice of late diagnosis, which is driven in many ways by the old definition requiring dementia, is a major obstacle to effective treatment.

This recommendation is in line with similar proposals from US expert panels and bodes well for future advances in this field.

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Predicting Alzheimer's Disease is a Misnomer in the Press

Contributed by: Dennis Fortier, President, Medical Care Corporation
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I think there will come a day, decades from now, when a massive amount of genetic data can be combined with a massive amount of demographic data, lifestyle date, social data, and other pertinent medical data, to predict with useful accuracy, the likelihood of a particular person getting Alzheimer's disease.

The expert consensus is that we are not even remotely close to that day. Nonetheless, stories about "predicting Alzheimer's disease" abound in the general press.

The point of this post is not to discuss if, or when, we might gain such an ability to predict Alzheimer's disease. Nor is the point to debate whether or not such a prediction would be beneficial, moral, dangerous, or inconsequential. The point is to highlight how the popular press continuously confuses "predicting Alzheimer's" with "identifying Alzheimer's". This story, published online by U.S. News and World Report is a perfect example.

According to the new diagnostic guidelines from the NIH and the National Alzheimer's Association, which were penned to clarify this exact situation, Alzheimer's disease has a long period of progression that passes through a mild cognitive impairment stage prior to the later stages of dementia. Therefore, stories about new technologies for evaluating subjects with mild cognitive impairment and "predicting" if they will progress to Alzheimer's are nonsensical. Either these subjects have mild cognitive impairment because Alzheimer's is already present, or they have mild cognitive impairment due to something else.

For those with the disease, there is no need for a prediction. For those without the disease, their current state of cognitive health may or may not play a role in such a prediction. The press constantly mixes the notions of "identifying" and "predicting".

These stories perpetrate confusion and prevent a clear understanding about which scientific advances are likely to yield benefits in the real world and which are merely interesting.

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Predicting vs. Diagnosing Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Once again, a major news source has published a high profile article about the utility of analyzing spinal fluid as a means of diagnosing neurological disorders like Alzheimer's disease. Today, it is this article in the LA Times.

While a great many of these articles waver unconscionably between the concepts of prediction and diagnosis, the LA Times article has taken a more responsible look at the full utility of spinal fluid as a bio-marker for many diseases. They present a balanced overview of how bio-markers may be used to better understand disease, to gauge severity and progression of disease, and to better measure treatment effects. In my opinion, this is an example of good journalism.

Less good are the recent (and more prevalent) articles that refer to recent research demonstrating the accuracy of a spinal fluid assay for diagnosing Alzheimer's, but then write sensationally about the ethical dilemma inherent in using the assay as a predictor for an incurable disease. While I concede that there are some valid downsides to predicting this incurable disease, it is a shame to overlook the value of the spinal assay as a pure diagnostic tool.

When a patient experiences cognitive difficulties and they seek a doctors opinion about the cause, it is very beneficial that physicians may now have an accurate spinal fluid test that can help them confirm, or rule out, the presence of Alzheimer's pathology.

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The Most Immediate and Practical Use for an Alzheimer's Diagnostic Test

Contributed by: Dennis Fortier, President, Medical Care Corporation

Sometimes, a debate is framed in such a way that important perspectives are under-emphasized if not completely overlooked. I think this is the case in the spirited debate about if and when we should use biomarkers to help diagnose Alzheimer's disease.

I can understand that many young, healthy people would prefer not to know that Alzheimer's lurks with certainty in their future. That whole discussion is important but perhaps off-point. Here is what we should not overlook.

An increasing number of people are expressing memory complaints to physicians on a daily basis. Some are depressed, some have early stage AD, some have had a small stroke, some have a thyroid disorder, and among the others, many are perfectly healthy but correctly perceiving changes associated with their advancing age. It is the physician's job to accurately diagnose any underlying medical conditions and to treat them. In these cases, an accurate test for Alzheimer's disease has great value.

The published research in this area is clear. A great many AD patients go undiagnosed and untreated for many, destructive years as their doctors grapple with an uncertain diagnosis. Others are treated for Alzheimer's disease based on an educated guess, when in fact their true condition could have been more effectively (and perhaps less expensively) treated had the diagnosis been correct.

I do not suggest that we run out and test people with no symptoms of cognitive decline. I do suggest that a great many patients and their doctors will benefit enormously when a commercially viable diagnostic test for AD is available.
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Ethical Dilemma: Who Should Test For Alzheimer's?

Contributed by: Dennis Fortier, President, Medical Care Corporation

Is this really a dilemma?

Researchers have devised what seems to be a highly accurate test to identify the signature proteins of Alzheimer's disease in spinal fluid. In a publication about the test in this month's Archives of Neurology, the test showed perfect accuracy in patients known to have Alzheimer's disease.

One particular application of this technology could have great clinical utility. When aging patients present to their physician with memory loss, the physician must consider many possible causes of the problem before prescribing treatment. In some instances, the physician can find an obvious culprit such as stroke, depression, or a number of metabolic conditions. In other instances, the diagnosis is less clear. This new test might add much needed clarity to the diagnostic process for identifying Alzheimer's disease. This will help get AD patients on proper treatment in a timely manner while preventing others, who might otherwise be misdiagnosed with AD, from receiving wrong treatment.

Some more difficult questions about the value of this new test have arisen from the fact that, in the study, the test showed that about one third of subjects who had no symptoms of memory loss, also had the signature proteins in their spinal fluid. One interpretation is that these subjects have early stage pathology and will eventually develop the symptoms. This has given rise to the dilemma: Who should get tested and what should we do with those who test positive?

I would argue that this question, which is framed in terms of the entire population, poses no dilemma at all if you frame it at the individual level. Those who wish to inform themselves about risks in their future, so as to prepare themselves legally, financially, and spiritually, as well as to engage in life style modifications that could prolong health, should be free to have a test and learn what they can. Those who prefer not to know should be allowed that option as well. There are compelling arguments on either side.

As our understanding of the disease and our ability to treat it improve, the "find out early" side of the argument will be generally adopted by the masses and no debate will remain. In the meantime, there is no need to persuade everyone to accept one approach or the other. Those who prefer information should have access to it, while those who prefer ignorance should be allowed their bliss.

In a well-written summary of the ethical questions surrounding this science, bio-ethicist Jonathan D. Moreno commented on this development in The New Republic.
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Predicting Alzheimer's Disease with Spinal Fluid

Contributed by: Dennis Fortier, President, Medical Care Corporation

For some years now, the research community has been intensively investigating bio-markers to help diagnose Alzheimer's disease at an early stage while the symptoms are still subtle and minimal brain damage has occurred. It is hoped that bio-markers progressing in advance of symptom progression will also be useful in understanding the disease and in unlocking the secrets of effective treatment.

There is massive press this week (NYTimes, CNN, WebMD, LATimes) on a new study published in the Archives of Neurology. The study shows that protein levels in the spinal fluid are useful in diagnosing Alzheimer's disease, even in subjects with mild memory deficits that would not meet today's criteria for a diagnosis of Alzheimer's disease. This is good news and bodes well for ongoing efforts to understand and treat this debilitating disease.

Interestingly, this finding also adds importance to another debate that has been recently prominent in the press. The debate concerns the utility of new proposed guidelines that would define Alzheimer's disease based on the presence of mild symptoms plus pathology as opposed to the current guidelines which require severe symptoms (dementia) before making the diagnosis. What began as a hypothetical (if we had a good bio-marker, would we consider subtle memory loss plus a positive indication from the bio-marker as a conclusive indication of AD?) has now become a more concrete and more urgent question.

Personally, I side with the growing consensus of experts who believe that memory loss, when coupled with a bio-marker known to be associated with AD (hippocampal atrophy, amyloid plaques, or now, signature proteins in the spinal fluid), should be diagnosed as Alzheimer's disease and treated accordingly if other common causes of memory loss (depression, thyroid, vitamin deficiency, etc.) have been ruled out.
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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.

Early Detection of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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It has been a long time coming but the the press and the general public are finally beginning to grasp the benefits of detecting Alzheimer's disease at an early stage.

A publication this week in the Archives of Neurology described a highly accurate test of spinal fluid for definitively diagnosing the pathology we associate with Alzheimer's disease. While the debate about "when the disease begins" will continue to rage (does it begin at the onset of definitive pathology or at the onset of symptoms?), a consensus has emerged that earlier detection is better.

Regular readers of this blog know that I am often flabbergasted at what I consider to be negative interpretations of scientific advance, superficial skepticism about progress, and nihilism with regards to our overall ability to combat dementia in an aging population. However, the press this week around this new diagnostic approach has been very positive.

As a case in point, this brief editorial posted today in the New York Times makes a cogent argument supporting early detection and diagnosis of Alzheimer's disease. While many cling to the outdated dogma that, until a cure is found, it is better "not to know", recent scientific advances and some progressive thinking are ushering in a new paradigm.

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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.

Confusion about Alzheimer's Diagnostic Guidelines and Clinical Care

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The press is currently overflowing with coverage of the proposed changes to the outdated guidelines for diagnosing Alzheimer's disease. Most of the articles I have read have taken a sensationalistic and misleading slant. It may be superficially interesting to emphasize that early identification of AD will benefit drug makers, but that should not overshadow the real clinical benefit of earlier intervention.

Facts in a Nutshell
Current guidelines dictate that a person who consults a physician and complains of memory loss does not have AD until they become demented. Physicians can look for other causes of memory loss, such as depression, stroke, or thyroid disorder, and treat any problems they find. However, if nothing is found, and AD is strongly suspected, the guidelines prevent an actual diagnosis and treatment until the patient's symptoms progress to the dementia stage. The new guidelines would allow physicians to identify the disease at an earlier, and perhaps more treatable, stage of progression.

This point, that our current practice of late diagnosis is partially driven by outdated diagnostic standards, is highlighted in a report today from the Medical Research Council in the UK. This report clearly shows that primary care physicians are waiting too long to diagnose dementing illnesses and therefore, not treating them optimally.

I understand the mistrust of big pharma; they've earned their reputation. But I also understand that the effort to contain the growing Alzheimer's problem will absolutely enrich those with a piece of the solution. Don't forget that it will also diminish returns for those who currently profit from caring for demented patients.

Alzheimer's disease starts with a long slow period of accumulating pathology that is still not well understood. The current practice of waiting for clear symptoms before diagnosing and treating the disease has proven disastrous because too much brain damage occurs prior to the emergence of definitive clinical signs.

Merely recognizing that the disease is underway prior to full-blown dementia is not a greedy plot underwritten by the pharmaceutical and imaging industries; it is a scientifically sound approach to improving care in this field. It will enable more timely intervention and a clearer understanding of treatment efficacy with currently approved approaches.

Yes, we need to understand the pathology better and yes, we need new treatments that stop or slow disease progression; but we will never get those if we don't look at the disease clearly. Adhering to the current guidelines that deny the presence of AD prior to the patient becoming demented is a barrier to progress.

New Guidelines for Diagnosisng Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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As we write here often, late diagnosis is the key barrier to better treatment of Alzheimer's disease.

We routinely identify the disease after about 7 years of symptoms when irreversible brain damage has already occurred. Earlier intervention, even with today's modestly effective drugs, would be more beneficial if started earlier and combined with improved diet, regular physical exercise, and careful management of other medical conditions such as hypertension and diabetes.

One reason we have historically been slow to diagnose Alzheimer's is that the guidelines for making such a diagnosis included "dementia". That is to say, until the disease process has diminished a person's thinking capacity to a point where they can np longer function independently, they don't yet have Alzheimer's disease.

The proposed changes to the guidelines suggest that the disease is indeed present, and should indeed be treated, prior to the patient becoming so mentally debilitated. This makes great sense and I see the proposed changes as a winning strategy in the battle against this terrible illness.