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.

Alzheimer's Facts and Figures

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Each year, the National Alzheimer's Association compiles facts and figures about Alzheimer's disease and releases a report that is both impressive and scary.  The 2011 report was issued earlier this week and can be downloaded here.

I encourage you to download the report and read it.  Here are a couple of the things that struck me:

1. As recently as two years ago, most estimates of the annual cost of the disease to the US economy, were about $100B.  Many considered that estimate to be high and questioned its validity.  With arguably tighter measures yielding a more accurate estimate, this report has placed the annual cost of Alzheimer's disease at $183B.  That's "B" as in "Billion".
2. Alzheimer's is the 6th leading cause of death in the US.  That is not startling.  However, the other 5 leading causes are all declining while deaths due to Alzheimer's disease increased by 68% last year.  That is eye-opening.
3. There are an estimated 15 million unpaid caregivers for Alzheimer's patients in the US.  That's about 3 times as many unpaid care caregivers as there are patients.  This is clearly a disease that is not being effectively managed through more traditional health care channels and services.

This is a carefully researched and well prepared report.  I encourage you to download it and get familiar with the magnitude of the growing burden this disease carries.  It is sobering, but we all must face it.

Non-Clinical Benefits of Early Detection of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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In this short video from PBS, the National Alzheimer's Association's Medical Director, William Thies summarizes the non-clinical benefits of getting an early diagnosis of Alzheimer's disease.

He doesn't touch on the emerging evidence that treatment, even with currently approved medications, may also have greater benefits at an earlier stage of disease progression when the brain is still quite healthy. The extent of such treatment benefits is generally moderate but, for some patients, it can be quite meaningful.

William Thies, Ph.D., Chief Medical and Scientific Officer, Alzheimer’s Association

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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.

A Daily Walk is Surprisingly Good for Your Brain

Contributed by: Dennis Fortier, President, Medical Care Corporation
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We often cite research that correlates physical fitness with brain health. Surveys have shown, however, that many read the phrase "physical fitness" and conjure images of gym memberships and grueling workouts. Such a perspective may be a deterrent for those who assume that minimally intense workouts yield no benefits.

This post aims to dispel the notion that only an intense physical exercise is helpful.

Research published online yesterday in Neurology shows that a brief regular walk may meaningfully reduce the likelihood Alzheimer's disease. Specifically, the research showed a significant correlation between walking regularly and maintaining the volume of gray matter in the brain throughout later adulthood. More importntnly, walking regularly was negatively correlated with incidence of cognitive impairment.

This evidence is very consistent with other studies that have shown a daily walk of a mile or so can be part of a fantastic regimen for long-term health. In this regard, the Alzheimer's Association's tradition of holding "memory walks" to raise awareness about the disease is especially apropos.

Walk forth and be well.
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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.

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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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.

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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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.

Brain Scans for Diagnosing AD

Contributed by: Dennis Fortier, President, Medical Care Corporation
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In this cleverly written, but wantonly provocative article in the Forbes blog “The Science of Business”, it takes the author only 53 words to completely mislead his audience.

In his attempt to find controversy in a straight forward advance, there are two areas where the author has blurred the truth. First, the guidelines he references, which define a very early stage of Alzheimer’s, are not intended for physicians seeing patients but for researchers doing scientific work in a laboratory. Second, adoption of a new definition by the research community has nothing to do with approval of a diagnostic process, like brain scans, that physicians would use in diagnosing patients.

Here is a more sensible summary of the situation than the one Robert Langreth has thrust upon his readership:

An expert panel, convened by the NIH and the National Alzheimer’s Association, has drafted new guidelines for defining Alzheimer’s disease. These new guidelines are intended to correct a major deficiency in the existing guidelines that were established in 1984.

Original Guidelines
The original guidelines suggest that Alzheimer’s disease is not present until the subject has dementia. Recall that the term “dementia” defines a state of impaired thinking that is so severe that subjects can no longer care for themselves without human assistance. This means that, under the old definition of Alzheimer’s disease, a subject with accumulating amyloid in their brain, and clear symptoms of memory loss, does not have Alzheimer’s disease until their impairment progresses to the point where they become dependent on others.

Obviously, this makes no sense. We wouldn’t set some late stage criteria, like blindness, before diagnosing diabetes, and we shouldn’t do so for Alzheimer’s disease. It is this old and problematic definition that has primary care physicians around the world, watching patients with memory loss, and doing nothing to treat the problem until the patient becomes demented. Only then can they consider diagnosing Alzheimer’s disease and prescribing a very late and predictably ineffective treatment regimen.

Proposed Guidelines
The new guidelines cover 3 stages of the disease:
1) AD Dementia – the definition of this progressed state is largely consistent with the original language used to describe the entire disease continuum.
2) Mild Cognitive Impairment due to AD - an earlier stage of the disease. This definition will facilitate timely intervention for patients with memory loss who are not yet demented.
3) Pre-Clinical AD - the earliest and least certain stage. It includes the period when pathological changes are underway but there are no outward symptoms of disease. These guidelines, which are the ones cited by Langreth, are clearly and expressly intended for researchers, not physicians.

Adoption into Clinical Practice
Finally, there is really no need for alarm that adoption of new definitions in the research community will unleash massive, premature change in clinical practice. Langreth makes a dangerous, conceptual leap based on the word “approved”. He states “…once a plaque brain scans gets approved the next step will be that aggressive doctors will start using it in patients with the slightest sign of fleeting memory or cognitive problems”. Lets be clear about this; adoption of new language by an expert panel has absolutely nothing to do with the FDA’s possible, eventual approval of a diagnostic test that can be used in clinical practice. The author implies a close association between these discrete events that is not justified. It is pure artistic license and sensationalism.

These are the kinds of articles that perpetrate the public’s nihilistic attitudes toward Alzheimer’s disease and prevent the kind of constructive discourse that will help us tackle the problem in a meaningful way. It is really a shame that the credibility of the Forbes imprimatur was lent to this misleading report on such a clear step forward for AD research.

Why is AD More Prevalent Among Minorities?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With yesterday's release of the Alzheimer's Association's report (2010 Alzheimer's Disease Facts and Figures), one aspect of the report has been greatly emphasized in the press over the past day and a half. I refer to the report's stark conclusion that African-Americans and Hispanics are being especially hard hit.

In fact, according to the report, older African-Americans are about twice as likely as older Whites to have Alzheimer's disease and older Hispanics are about one and a half times as likely. The most obvious conclusion that readers may jump towards is that some genetic difference predisposes risk differently across the human races. However, there is a much better explanation described in more detail by U.S. News and World Report.

Many risk factors play a role in determining the likelihood of any given individual getting Alzheimer's disease. Some of the more well-established risk factors, such as high blood pressure, diabetes, and stroke, are known to be more prevalent in certain populations. There is certainly a correlation between the higher incidence of these risk factors among African-Americans and Hispanics and the incidence of Alzheimer's disease in those populations.

The good news is that these risk factors can be controlled through medical intervention. Theoretically, this should allow us to also reduce the prevalence of Alzheimer's disease in those populations.

Public Alzheimer's Discussion

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A great online forum for discussing Alzheimer's disease was conducted today through Twitter. Mayo Clinic's lead expert in the area, Dr. Ronald Petersen, joined the National Alzheimer's Association and USA Today in responding to questions from the public.

Given yesterday's release of the National Alzheimer's Associations report (2010 Alzheimer's Disease Facts and Figures) about the disease, I had expected many questions about specific prevalence statistics, differences across minority groups, and rising cots of managing the disease. Instead, the questions tended toward the more personal and more locally relevant.

While the national discussion about Alzheimer's and Dementia is becoming louder and more intense, it is generally based on aggregated data that have been evaluated from afar in a scientific and impersonal manner. I found today's dialogue, which you may review here, to be refreshingly intimate.

I am hopeful that such discussions will flourish and that such public access to the central players in this field will catalyze a growing base of activism. Great job by the Mayo Clinic, the National Alzheimer's Association, and the USA Today.

Perspective on Funding for AD Research

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Amidst all the news stories about the science of Alzheimer's disease, there are also stories about it's economic toll on our health care system and stories about the allocation of research dollars aimed explaining the disease and developing treatments. This week, the NIH released a statement about the American Recovery and Reinvestment Act and how some of its funds are directed at the Alzheimer's problem.

Overall, it is an encouraging piece of news citing the fact that more than 100 Alzheimer's related grants, aimed at identifying risk factors, improving diagnostics, isolating bio-markers, conducting trials, and developing new therapeutic agents, were funded through the act. Specific details were provided for the Alzheimer's Disease Neuroimaging Initiative (ADNI) which will receive $24 million in funds, and the Alzheimer’ Disease Genetics Consortium (ADGC) which will receive about $5.4 million in funds. Certainly these are large grants and represent opportunities to advance the science.

However, this news should be considered against the larger funding context that is also discussed frequently in the news. The big picture is painted clearly by Harry Johns, CEO of the National Alzheimer's Association, through his daily comments to constituents across the country.

A summary in The Detroit News on Monday makes his point. The NIH awarded $6B to cancer research last year. They awarded a further $4 billion for cardiovascular disease and $3 billion for HIV/AIDS. In comparison, the NIH funds for Alzheimer research was $428 million.

With this perspective, it is clear that the potentially devastating impact of Alzheimer's disease on the boomer generation is not reflected in the funding support of the federal government.

Investing in Alzheimer's Research

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The National Alzheimer's Association plays a central role in promoting awareness of, directing research dollars for, lobbying for effective policy against, and providing a framework through which we can all grasp the seriousness of Alzheimer's disease. A current theme that they are promoting is the urgent need for more federal funds for research.

The argument supporting such an investment is cogently summarized in a recent editorial written by Harry Johns, CEO of the National Alzheimer's Association. The statistics are sobering and the call for increased research support is clear.

The Alzheimer's Breakthrough Act, currently before Congress, would authorize $2B in research funding and escalate the urgency we need to effectively combat this disease. For all of you who are politically active, I urge you to voice your support for this initiative. For those of you who are not, I would suggest this might be a good time to become so.

10 Signs of Alzheimer's

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The National Alzheimer's Association has revised and re-issued their ten signs of Alzheimer's disease.

Knowing these signs is important because the best treatment results and the best opportunity to plan for the challenges of a dementing disorder both come after an early diagnosis. Recognizing a warning sign and seeking timely medical intervention can have a tremendous impact on quality of life for the patient and for the patient's caregivers.

One point of clarification. Each of the ten warning signs concludes with a short note about "What's typical". These comments describe behavior that is typical among healthy individuals, not among individuals with an early sign of Alzheimer's disease. I found that potentially confusing and wanted to clarify it.