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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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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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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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.

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.