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.

Perspective on "A Cure for Alzheimer's"

Contributed by: Dennis Fortier, President, Medical Care Corporation

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Sometimes the facts are very misleading.

For some reason, when Alzheimer's Disease is discussed in the popular press, the discussion often includes a reference to the fact that "there is no cure" for this disease. This is a true statement, but somewhat misleading.

This is misleading because it establishes "a cure" as the appropriate frame of reference for evaluating our ability to fight against this disease.

However, in medicine, we know this is not true. For example, we have no cure for hypertension, but we treat it effectively for most people. Clearly, the "no cure" frame of reference is not the most meaningful perspective on hypertension.

Also, we have no cure for diabetes, but like hypertension, we control it to a large extent for very many years.  We have no cure for the common cold, eczema  asthma, allergies, migraine, anxiety, heartburn, cancer, osteoporosis, depression, lupus  or a thousand other common, and sometimes deadly, medical ailments.  The truth is, cures are very rare in medicine.

To be clear, everyone would love to have a cure for Alzheimer's. It would greatly improve the world and eliminate much tragic suffering  But "no cure" is not the same as "no treatment", and we should not allow the "no cure" label to fill us with pessimism.

In fact, with an early Alzheimer's diagnosis (prior to the dementia stage), doctors can often delay disease progression through a robust regimen of proper diet, physical activity, tight control of chronic conditions, and poly-therapy with approved drugs.

At present, we should not despair that there is no cure. Rather, we should keep searching for a cure while embracing the reality that, like so many other medical conditions, Alzheimer's must be vigilantly diagnosed in its earliest stages and treated to the best of our current abilities.

The cure may or may not come, but initial treatments have arrived, and better treatments will follow.

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.

Alzheimer's Cure by 2025: An Unnecessary Goal?

Contributed by: Dennis Fortier, President, Medical Care Corporation

The National Alzheimer's Prevention Act, signed into law one year ago, calls for a national strategy for defeating this terrible disease. A late-stage draft of the strategy sets a goal to develop a cure by the year 2025.  While many have suggested a timeline with more urgency, say by 2020, others have suggested that this timeline is too ambitious.

On the one hand, given our still poor understanding of the disease, coupled with a dismal track record of success for pipeline drugs over the past decade, it seems unlikely that a cure could be developed prior to 2025.  In fact, against the backrop of recent evidence, it may well take longer than that.

On the other hand, we could stop short of a cure and still have great success.  For example, many chronic diseases like diabetes and hypertension have no cure, but we have effective treatments, and we manage those diseases with high efficacy.  It is likely that new drugs, developed well before 2025, will give us greater treatment benefits for patients with Alzheimer's.

Perhaps of greater importance is the fact that we already have approved therapies that can significantly slow Alzheimer's disease progression.  However, since we commonly detect the disease too late and intervene only after massive brain damage has occurred, the perception among physicians is that treatment is unhelpful.  This nihilistic perception actually perpetuates the cycle of late intervention because, believing that there is no treatment, many MDs don't look for early signs Alzheimer's.

In this regard, a key element to an effective national Alzheimer's strategy would be to update physicians about the benefits of early detection and equip them with the tools and training to proactively monitor the cognitive health of their patients.  When a cure is developed, that will be great.  But in the meantime, we can find the disease early and treat it as effectively as possible with robust therapy (drugs, diet, physical exercise, control of diabetes and hypertension, intellectual stimulation, social engagement, and caregiver education).  Such a comprehensive approach has been shown to significantly delay disease progression in a meaningful percentage of early-stage patients.

Want a Healthy Brain? Stay Physically Active.

Contributed by: Dennis Fortier, President, Medical Care Corporation
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There are no guarantees, but this is our current best bet.  The evidence linking physical fitness to good cognitive health in later life continues to roll in.

At the International Conference on Alzheimer's Disease in July, researchers from the University of California, San Francisco presented data showing the high correlation between physical fitness and brain health.  Their research on "modifiable risk factors", or lifestyle changes we are all free to make, showed that regular activity was the most likely to reduce the risk of cognitive decline.

Importantly, several of the other risk factors that are highly correlated with cognitive decline, may also be reduced through physical activity.  Hypertension, obesity, diabetes, and even depression, all of which confer higher risk of cognitive decline, can be managed to some degree through regular physical exercise.

We have known for some time that staying active is good for our hearts and it has always made sense that a regular supply of oxygen-rich blood is probably good for our brains.  This latest research is more evidence that it is likely to be true.

Alzheimer's Treatment May Be More Effective Than You Think

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The message in this post may be one of the most important that the Brain Today blog regularly supports.  Alzheimer's treatment is more effective than the typical news story reports.

This is evident by the news from the UK today, where their governing health authority, the National Institute of Health and Clinical Excellence (NICE), extended coverage of approved drugs for Alzheimer's patients in earlier stages of the disease.  Authorities cited "better evidence" about treatment efficacy as the key motivator for the decision.

In general, the misconception about treatment effectiveness is based on three misleading frames of thought:

Drugs don't treat the disease, they only lessen the symptoms
Many well done studies support the claim that approved drugs offer no disease delaying effects.  The problem with this frame of thought is that all of the studies have been conducted on patients who are demented due to Alzheimer's.  Based on the long disease course, this means they are in a very advanced state of disease progression, and have already accumulated massive damage in the brain.  As such, it is not surprising that drugs cannot delay disease progression when treatment is initiated at such a late stage.  It stands to reason, and most experts agree, that the earlier stages of the disease are much more treatable.

The beneficial effects of drugs on symptoms last only a year or less
Again, there are many well done studies that support this notion.  However, the studies isolate "drug treatment" in order to measure its effects, whereas in the real world, Alzheimer's treatment involves more than a drug.  A robust treatment regimen includes proper diet, physical exercise, proper management of hypertension and diabetes, intellectual stimulation, social engagement, and an educated caregiver.  Many patients derive meaningful, long-term benefits from such an approach, especially if the intervention is begun at an early stage of the disease.  A drug alone may not be an effective treatment, but effective treatment does not consist of a drug alone.

There is no cure
This is absolutely true.  But the public has a tendency to interpret that statement to mean "there is no treatment".  For perspective, there is no cure for hypertension or for diabetes, but we commonly treat them, and the public generally acknowledges the benefits of such treatment.  For sure, the efficacy of our Alzheimer's treatments pale in comparison to the efficacy of our hypertension/diabetes treatments, but we need a healthy appreciation for the difference between treatment and cure for Alzheimer's disease.

I hope this high level decision by the health authority in the UK will foster a growing optimism and a more clear perspective on treatment efficacy for Alzheimer's disease.  I concur that we need better treatments than those available today, but we also need the public and the medical community to embrace a more constructive view of what can be done now.

6 Ways to Keep Your Brain Healthy

Contributed by: Dennis Fortier, President, Medical Care Corporation
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There is some great advice in the Huffington Post regarding 6 well-validated approaches to maintaining a healthy brain.  Each of these has been covered to some extent in past posts here, but this is a nice presentation of the evidence in one article.

While I would recommend that you click through and read the full article, the 6 tips are listed here as an overview:

1. Manage chronic conditions under your control
2. Incorporate Mediterranian diet
3. Stay physically active
4. Avoid Tobacco Smoke
5. Stay intellectually and socially active
6. Watch for signs of Depression

Each of these is well within your control and proven to reduce your risks for cognitive decline.

Metabolic Syndrome and Memory Loss

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

Treating Alzheimer's Disease Without Drugs

Contributed by: Dennis Fortier, President, Medical Care Corporation
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One of the common themes in this blog is that "current treatment for Alzheimer's disease is better than many headlines indicate".

We write this because the argument against treatment efficacy is almost always framed through the narrow lens of drug-based interventions when, in reality, drugs are only one part of the most effective approach. A robust approach includes management of risk factors like smoking and excessive drinking, controlling co-morbid conditions such as diabetes and hypertension, proper diet, physical exercise, and both social and intellectual engagement.

We also point out that many reports of poor treatment efficacy are based on studies of Alzheimer's patients in whom the disease is too far progressed, and the brain too ravaged, for treatment to have a fair chance at working.

There is an additional area of treatment that has shown impressive efficacy and should be emphasized as well; it is psychosocial interventions. These include care-giver education, structured communication techniques, home safety, family counseling, and problem resolution. The results have been clear; caregivers who know what to expect and how best to deal with problems as they emerge, are less stressed, less depressed, and more effective in giving care. The result is healthier patients who maintain higher quality of life and a prolonged ability to avoid institutionalized care.

The Huffington Post has a great summary today of this approach and I encourage all readers to click through and to share this with their interested peers.
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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.

Are Alzheimer's Drugs Better than Previously Thought?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A very big story about Alzheimer's treatment is unfolding in Europe. This story is big from a news coverage point of view and also from the perspective of real world impact. I am referring to the story about the National Institute for Health and Clinical Excellence (NICE) in the U.K. that has reviewed ongoing science and reversed their earlier stance on Alzheimer's drug efficacy.

Background
In 2006 and 2007, NICE recommended against National Health Services paying for cholinesterase inhibitors (the primary class of Alzheimer's drugs) for patients with mild to moderate Alzheimer's disease. They based this recommendation on a financial analysis suggesting that the economic benefits of treating AD with those drugs (Aricept, Exelon, and Razadyne) in its mild and moderate stages did not outweigh the costs of the treatment.

Naturally, that recommendation sparked lots of debate, including an argument that most experts considered very legitimate. The argument was that "average treatment effect" is merely a composite derived from some patients who responded well to treatment and others who did not. Since it was clear that treatment has meaningful benefits for some patients, and no one can predict which patients will respond, then everyone deserves the chance to find out.

New Position
Now, based on an ongoing review of emerging data from new studies, NICE is planning to revise that recommendation. This is great news for the patients afflicted with AD who have not yet progressed to the severe dementia stage. It is also important for the effect this move will have on the global conversation and the public perception of treatment efficacy.

Optimal Treatment
The one point I think needs to be added to this story is that, the drug class in question is only one part of the robust treatment approach we know to be most effective in delaying the progression of Alzheimer's disease. Optimal treatment includes poly-therapy (cholinesterase inhibitor plus Namenda), a balanced diet, physical exercise, and tight control of other conditions such as diabetes and hypertension.
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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.

Medicare Coverage for Detecting Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation
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One of the constant themes of this blog is that Alzheimer's disease is routinely detected too late in today's medical environment. The data show that diagnoses are most common in years 8-10 of a typical disease course that runs 14 years. This means that the opportunity for treatment during years 1 through 7, when the brain is still quite healthy, is lost.

This practice of "late intervention" manifests itself in many of our blog topics. It contributes to the impression that treatment is completely ineffective when, in fact, earlier intervention can lead to meaningful delay of disease progression for some patients. Late intervention not only mitigates treatment effect but drives up health care costs because patients with impaired thinking do not practice effective self care. Also, late intervention has fueled the misdirected belief that Alzheimer's and dementia are one in the same. Sure, a person with Alzheimer's pathology will eventually become demented, but there is a long period of disease progression when the patient has only subtle cognitive difficulties.

As we have written, there are some understandable reasons why we intervene late. However, with the Health Care Reform Act passed in March and clarified last week, this could soon change.

Beginning in January of 2011, Medicare will reimburse primary care physicians to perform a more complete "Welcome to Medicare" visit with newly eligible members. They will also pay physicians to perform a complete "Wellness Visit" on an annual basis. Both the welcome visit and the wellness visit will include "detection of cognitive impairment".

This is a great step in the right direction. It will force a conversation between patients and doctors that has been sorely needed but ignored for some time. I know that not every Medicare recipient will schedule these visits and not every physician will follow all of the guidelines. In fact, I suspect only a small percentage of those on Medicare will actually have their cognition assessed in 2011. But I predict an overwhelmingly clear picture will emerge from this "toe in the door" to better care.

Here is what I envision: Some physicians will take this opportunity seriously and perform careful assessments of their patients. Some of their "seemingly healthy" patients will perform poorly on a simple cognitive test and a diagnostic work-up will ensue. The physician will find and treat a range of memory-impairing medical problems from depression to thyroid disorder to early Alzheimer's disease. Overall, patients will benefit from treatment of these conditions and their cognition will improve. As their minds become sharper than they would have been without treatment, they will do a better job managing their hypertension and their diabetes. They will be less depressed; they will feel better and stay more active. Their overall health will improve and the cost to Medicare for keeping them healthy will plummet.

Such an ideal will never be achieved in an entire population. However, I believe that the impact of such care on even a small scale will be discernible in the data. If so, then each year, more and more physicians and a growing number of patients will embrace the concept of managing their cognitive health. I think we are finally on the right track.

Managing Risks for Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation
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One of my favorite types of scientific research is the "review paper" when authors collect and review the literature in a certain field and report on the depth and breadth of findings in the targeted area of study. As such, I was happy to see a recent report by the BBC that the Alzheimer's Society had chaired a panel of experts and reviewed more than 70 research papers on reducing the risk of dementia.

The report contained some elements that may be as surprising as they are important. Notably, they suggested that age 35 is probably the right time to start managing known risks in an effort to ward off dementia later in life.

I strongly suggest you click to read the BBC's synopsis of the report but the highlights are noted here:

Strong Evidence in support of:
- Get Physical Exercise
- Don't Be Obese
- Bring Down High Blood Pressure
- Reduce High Cholesterol
- Don't Smoke

Some Evidence in support of:
- Drink Modest Amounts of Alcohol
- Eat a Mediterranean Diet
- Remain or Become Socially Active

The Jury is out on:
- Brain Training
- Vitamin Supplements

The importance of this review, and other similarly scientific reviews, can not be overstated in this era of aggressive commercialization of unregulated health care solutions. There is a lot of hype in the press that has not yet been scientifically validated. Some of it might ultimately prove to be worthwhile but this review let's you know the current state of the science.

Alzheimer's: Prevention Through Delay

Contributed by: Dennis Fortier, President, Medical Care Corporation
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It is true that we cannot yet cure Alzheimer's but, somehow, this reality has come to seem more dire than it really should seem. After all, there is no cure for diabetes nor for hypertension and we have no problem with the approach of detecting these diseases early and managing them. I understand that Alzheimer's is more devastating relative to the other examples but the sense of nihilism is still out of proportion.

For those of you seeking a comprehensive overview of our current knowledge about AD, I recommend this recently updated report from the National Institute on Aging. It concisely describes the scientific landscape in terms of the pathology of AD, risk factors (including how to manage them), and treatment strategies (both current and in the pipeline).

The title of the report is Can Alzheimer's be Prevented? There is growing evidence for the case that, for may of us, it can probably be delayed until we are likely to die from some other malady. We call this concept "Prevention through Delay".

One day we will have a cure but for now, prevention through delay offers a realistic approach to reducing the tragic impact of this poorly understood disease.