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.

7 Facts about Stroke and Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Each year, about 700,000 people in the USA suffer a stroke. While it is certainly true that stroke can be deadly, it is the third leading cause of death behind heart disease and cancer, it can also cause significant cognitive changes in those who survive.

These changes may be subtle and cause mild cognitive impairment or they may be more severe resulting in dementia. Following are 7 interesting facts to help you better understand the impact of stroke.

1. While stroke is the third leading cause of death, it is the second most common cause of cognitive impairment and dementia.

2. Even damage to a small portion of the brain can have serious consequences. In fact, a thimble full of damaged brain due to stroke can cause dementia.

3. Stroke begins after age 50 and can gradually build up in the brain for decades. This gradual accumulation of tiny strokes can interfere progressively with the brain’s function until the individual becomes demented.

4. The risk of developing cognitive impairment is highest in those persons with vascular risk factors. These factors include:

• High Blood Pressure or Low Blood Pressure
• High Cholesterol
• Obesity
• Diabetes
• Atherosclerosis (hardening of the arteries)
• Minimal physical exercise (less than 2 days/week and 30 mins/session)
• Smoking
• Alcohol dependence
• Prior stroke.

5. The most common types of cognitive problems due to are disturbances of attention, language, memory and executive function. Executive function is the ability to analyze, interpret, plan, organize, and execute complex instructions.

6. The risk of cognitive impairment and dementia, as well as the rate of cognitive decline in cerebrovascular disease, is highly correlated with underlying risk factors for stroke.

7. If left untreated, vascular cognitive impairment and dementia worsen. Annual screening for cognitive impairment in attention, memory and executive function starting at age 50 will help detect gradually accumulating cerebrovascular disease that may otherwise typically be undetected for many years.

A good additional source of information about risks for dementia is PreventAD.com. The site is sponsored by Medical Care Corporation but, like this blog, it is non-commercial and seeks only to educate. This content about stroke was a popular article from a past issue of Ounce of Prevention, the newsletter associated with that site.

What Causes Dementia?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Because the general media commonly interchanges the terms "Alzheimer's" and "dementia", there is much confusion about the definition of each and the difference between the two. As such, I like to offer a clarifying viewpoint on a regular basis.

Alzheimer's is a disease. We don't completely understand it but the development of amyloid plaques and neurofibrillary tangles in the brain seem to play a role.

Dementia is a descriptive term for the symptoms caused by disorders that impair cognition. Specifically, if memory and at least one other realm of cognition (judgment, executive function, verbal fluency, etc.) decline to the point where they interfere with daily life, then the condition is dementia.

A key point is that there are many causes of dementia; Alzheimer's is merely one of them. Vascuclar disease, Parkinson's disease, and Normal Pressure Hydrocephalus and others are also on the list. The conditions and disorders that cause memory loss are worth learning about.

The distinction between memory loss and dementia, and the causes of each are well developed in a recent article on examiner.com by Patricia Grace. This perspective and other good views are presented regularly at the blog: AgingwithGrace.net.

Poor Vascular Health is Bad for Your Brain

Contributed by: Dennis Fortier, President, Medical Care Corporation
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We are virtually swimming (if not drowning) in the evidence that managing your vascular health may be the best approach to maintaining a healthy brain. In the past few days, I have blogged about several studies on this topic and many more have been published in the scientific literature.

To emphasize this important theme, here is a quick review of the very recent evidence:

• This study out of UCLA and published in Human Brain Mapping showed a strong link between obesity and less brain tissue.
• According to Helpguide.org and many other sources, vascular disease follows Alzheimer's disease as the second leading cause of dementia.
• As described in this post about strokes, one may be quite different from another but all impair cognition and vascular risk factors almost always play a role.
• Diet and exercise matter for both vascular and cognitive health. This has been repeatedly verified through careful research and will continue to be a popular theme in the news.
• This study out of the University of Alabama and published in Neurology showed that high blood pressure is linked to memory loss.
• In surprising news, Kaiser Permanente published research showing that even borderline high cholesterol significantly raised the risk of dementia.

The facts are abundant. Please take care of your vascular health and keep that brain functioning at a high level.

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.

Not All Strokes are Created Equal

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Although physicians are fairly precise in their discourse amongst themselves, they sometimes use the term "stroke" with the lay-public to describe a wide range of occurrences in the brain. A new study published in Neurology suggests that we might all benefit from the practice of more carefully characterizing one form of stroke from another.

In a study at Columbia University, researchers looked at brain scans of 679 subjects aged 65 and older and compared those with white matter hyperintensities to those with areas of dead brain tissue. The first group had suffered what is sometimes called "mini-stroke" and were more than twice as likely to have mild cognitive impairment with memory loss compared to the latter group of stroke victims that was more likely to have mild cognitive impairment without memory loss.

The key finding was that the different events (mini-stroke vs. stroke) led to different types of cognitive problems. While mini-strokes and strokes have traditionally been considered as originating from the same source, this study suggests they might be quite different.

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.

Forget "High" Cholesterol, Even Borderline Levels Increase Risk for Dementia

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With today's release of a study from Kaiser Permanente, published in the journal Dementia & Geriatrics Cognitive Disorders, we have strong evidence that even borderline high cholesterol in mid-life (aged 40-45) significantly raises the risk of dementia in later life (aged 65+).

For high cholesterol, defined as 240 or higher milligrams per deciliter of blood, risk for dementia was increased by 66%. More alarming was the finding that even moderately high cholesterol (200+ milligrams per deciliter) increased risk by 52%.

The Kaiser study looked at 9,844 men and women who were 40 to 45 years old between 1964 and 1973 when their cholesterol levels were first collected. Of the total participants, 469 were diagnosed with Alzheimer's disease between 1994 and 2007 when the members were between 61 and 88 years old, and 127 developed vascular dementia.

The good news is that cholesterol levels can often be modified through diet, exercise and lifestyle changes in addition to cholesterol lowering drugs. This news should serve as additional evidence about the importance of maintaining good cardiovascular health as a means of reducing risk for dementia.

The Costs of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
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With the intensity of current discussions on Healthcare reform, I am re-posting this earlier comment (from March 23) on the costs of AD and Dementia. The figures may surprise you.

March 23, 2009 - This week has seen extensive media coverage of a report from the National Alzheimer's Association stating that the annual costs of care for an Alzheimer's patient are triple the cost of an elderly person without Alzheimer's Disease. These figures are very consistent with a bevy of other studies indicating a similar cost differential but can viewed with more clarity from another perspective.

First, it is useful to compare the demented elderly vs. the non-demented elderly as opposed to Alzheimer's patients vs. non-Alzheimer's patients. This adds clarity because the driver of the cost increase is the presence of dementia, regardless of its cause (Alzheimer's is the cause of about 65%, vascular disease 20%, Parkinsons/Lewy Body and all others 15%).

Second, since these diseases cross all socio-economic strata, some of the afflicted pay for their own institutional care while others rely on public support programs. As such, aggregating figures that include the costs of institutionalization muddies the view.

Here are the figures comparing the costs of medical services (physician appointments, hospital stays, procedures, and medications) for demented vs. non-demented people aged 65-74:

Average Annual Cost of Non-Demented: $3,851
Average Annual Cost of Demented: $15,998

The demented are more costly by a factor of 4.2. However, it is very rare for an elder, demented person to be completely free of other chronic conditions. Chronic conditions require management via thorough and consistent self-care which is often difficult when coupled with dementia. As such, it is the combination of dementia and other chronic diseases that drives costs most impressively.

Consider these figures showing prevalence of four common chronic medical problems in the aged 65-74 population:

29% Coronary Heart Disease (CHD)
28% Congestive Heart Failure (CHF)
23% Diabetes
17% Chronic Obstructive Pulmonary Disease (COPD)

Now look at the costs associated with these medical problems when combined with dementia compared to the costs associated with those problems in cognitively vital elders:

Dementia +CHD - $27,237 ($10,894 no dementia)
Dementia + CHF - $34,304 ($17,993 no dementia)
Dementia + Diabetes - $24,392 ($7,469 no dementia)
Dementia + COPD - $28,463 ($12,059 no dementia)

It is clear that dementia drives higher utilization of medical services, especially when combined with other common medical problems. Of course, figures associated with the cost of institutionalized care (and informal care giving) make the picture all the more bleak but this view is perhaps the most clear.

The costs of Alzheimer's Disease

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

This week has seen extensive media coverage of a report from the National Alzheimer's Association stating that the annual costs of care for an Alzheimer's patient are triple the cost of an elderly person without Alzheimer's Disease. These figures are very consistent with a bevy of other studies indicating a similar cost differential but can viewed with more clarity from another perspective.

First, it is useful to compare the demented elderly vs. the non-demented elderly as opposed to Alzheimer's patients vs. non-Alzheimer's patients. This adds clarity because the driver of the cost increase is the presence of dementia, regardless of its cause (Alzheimer's is the cause of about 65%, vascular disease 20%, Parkinsons/Lewy Body and all others 15%).

Second, since these diseases cross all socio-economic strata, some of the afflicted pay for their own institutional care while others rely on public support programs. As such, aggregating figures that include the costs of institutionalization muddies the view.

Here are the figures comparing the costs of medical services (physician appointments, hospital stays, procedures, and medications) for demented vs. non-demented people aged 65-74:

Average Annual Cost of Non-Demented: $3,851
Average Annual Cost of Demented: $15,998

The demented are more costly by a factor of 4.2. However, it is very rare for an elder, demented person to be completely free of other chronic conditions. Chronic conditions require management via thorough and consistent self-care which is often difficult when coupled with dementia. As such, it is the combination of dementia and other chronic diseases that drives costs most impressively.

Consider these figures showing prevalence of four common chronic medical problems in the aged 65-74 population:

29% Coronary Heart Disease (CHD)
28% Congestive Heart Failure (CHF)
23% Diabetes
17% Chronic Obstructive Pulmonary Disease (COPD)

Now look at the costs associated with these medical problems when combined with dementia compared to the costs associated with those problems in cognitively vital elders:

Dementia +CHD - $27,237 ($10,894 no dementia)
Dementia + CHF - $34,304 ($17,993 no dementia)
Dementia + Diabetes - $24,392 ($7,469 no dementia)
Dementia + COPD - $28,463 ($12,059 no dementia)

It is clear that dementia drives higher utilization of medical services, especially when combined with other common medical problems. Of course, figures associated with the cost of institutionalized care (and informal care giving) make the picture all the more bleak but this view is perhaps the most clear.