Brain Today

Alzheimer's Cure by 2025: An Unnecessary Goal?

noreply@blogger.com (Dennis Fortier) — Fri, 27 Jan 2012 23:53:00 +0000

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.

Memory Loss More Common in Men?

noreply@blogger.com (Dennis Fortier) — Thu, 26 Jan 2012 23:25:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

There is much press this week about a study published in Neurology that measured the incidence of mild cognitive impairment (MCI) in an aging population.

MCI is a subtle loss of thinking ability, such as impaired memory or judgment, that is not severe enough to interfere with the person's normal activities of living. The study showed about a 20% incidence rate which is squarely in line with previous estimates.

The press has been largely focused on the fact that, in this study, men between the ages of 70 and 89 years had a higher incidence of MCI than women of the same age. This is probably true. It is also probably easy to explain.

MCI is not a disease, it is merely a descriptor term for a certain level of cognitive impairment. It refers to the degree of impairment that falls between normal cognition and the severe loss of function that we call dementia. Asking "why" a person has MCI is a whole different question with a host of common answers including depression, thyroid disease, stroke, sleep disorder, Alzheimer's disease, and anxiety, to name just a few.

The question of "why" a person has MCI was not adressed in this study, but may shed some important light on the observed gender differences. For example, sleep disorders and certain cardiovascular conditions, like hypertension and stroke, are common causes of MCI and are somewhat more prevalent among men than women. Clearly, conditions that impair memory and are also more common in men, could fully explain the observed gender differences in this study. In that respect, these results are hardly surprising and, in fact, make perfect sense.

It would be truly worthy of a media frenzy if researchers controlled for each cause of MCI and still found that one gender was more susceptible than the other. But despite many misleading headlines, that was not the case in this study.

Can Genetic Risk for Alzheimer's be Reduced?

noreply@blogger.com (Dennis Fortier) — Wed, 25 Jan 2012 23:51:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

As genetic testing has become more commonplace in medicine, we have all seen frequent examples of overstatement, where writers and speakers confuse "higher risk" with "absolute certainty". This has been an especially maddening component of arguments against testing for the APOe4 gene associated with increased risk for Alzheimer's disease.

A great many of these faulty arguments state that learning about a genetic risk for an incurable disease is pointless. (I have refuted that argument many times but that is not the point of this post). This week, research published in Archives of Neurology strengthens the case for genetic testing.

In a study from the University of Washington in St. Louis, more than 200 participants aged 45 to 88 reported on their physical exercise habits and submitted to spinal fluid measures or PET scans to determine the amount of accumulated amyloid protein in their brains. They also had their APOe4 status checked and researchers found that, among those who carried the APOe4 gene, regular exercisers had less amyloid load than sedentary members of the group. Interestingly, this was not the case among the APOe4 non-carriers.

This was a small study and needs replication before we can conclude that physical exercise staves off amyloid accumulation in those with genetic risks for AD. However, the study has a very intuitive finding and gives credence to a much larger body of work showing that good cardiovascular health may reduce the risk of Alzheimer's disease.

The suggestion from this study is very significant. It could be that genetic risk for AD (usually considered to be an unmodifiable risk), could possibly be reduced by physical exercise. If so, it will put a whole new spin on those old arguments against genetic testing.

Alzheimer's Treatment Update: IVIG Steps Forward

noreply@blogger.com (Dennis Fortier) — Wed, 25 Jan 2012 19:13:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

As we noted here late last year, there are several promising new Alzheimer's treatments in the FDA pipeline. While the early stages of the pipeline are predictably more full than the later stages, we expect to see data this year on at least two agents that are nearing the end of the trial process.

Earlier this week, Baxter announced the successful conclusion of their futility analysis on IVIG for treating symptoms in mild to moderate stage Alzheimer's patients. The futility analysis, conducted by the Data Safety and Monitoring Board (DSMB), indicated that further trial efforts could proceed with no modification to the protocol. With that result, Baxter immediately announced plans to initiate a confirmatory Phase III trial to begin in early 2012.

IVIG, or intravenous immunoglobulin, has been marketed for some 25 years to treat autoimmune diseases, but has not previously been studied and approved for treating Alzheimer's disease. Given it's historical safety profile and early data indicating efficacy in Alzheimer's patients, it may be the next drug approved in this field.

Best Evidence Yet: Using Brain Keeps it Healthy

noreply@blogger.com (Dennis Fortier) — Tue, 24 Jan 2012 19:31:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

Cognition, or thinking ability, is a complex concept and is difficult to measure. Nonetheless, many studies have shown that intellectual activity seems to be correlated with some measure of"better cognition". This makes intuitive sense and has given rise to many "use it or lose it" type slogans aimed at our aging population.

In a study published online today in the Archives of Neurology, researchers from Berkeley's Neuroscience Institute found that, seniors who pursued intellectual hobbies throughout their lives, accumulated less amyloid plaque in their brains later in life. This is interesting in a couple of ways.

First, while cognition can be difficult to measure, accumulated amyloid plaque in the brain has become increasingly easier to measure with new agents that bind to amyloid and "light up" during a PET scan of the brain. We can now get a fairly accurate read of amyloid load which is, by all accounts, much more tangible than our best measures of cognition.

An important caveat to this point is that, while we can accurately measure the amount of amyloid in the brain, we are still somewhat unclear on what that means. For sure, amyloid accumulation is neurotoxic (harmful to brain cells), but such accumulation may be a reaction to some other disease process that would be even more damaging without the presence of amyloid plaques. This is a topic of intense, ongoing study.

The second interesting take-away from this new research is that the subjets reported a lifetime of intellectual activity. If this work is repeated in larger studies and deemed to be conclusive, it will not mean that playing bridge and studying music in retirement will keep amyloid plaques out of the brain. It may be that an entire lifetime of brain exercise is the minimum threshold for a meaningful benefit.

In any case, it is very encouraging to see pathological evidence supporting the theory that brain exercise can have cognitive benefits during our elder years. We will watch ongoing research in this area with great interest.

The War on Alzheimer's

noreply@blogger.com (Dennis Fortier) — Thu, 19 Jan 2012 10:17:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

Declaring war on a disease or social problem is no guarantee that it will be vanquished. However, the passage of the National Alzheimer's Prevention Act (NAPA) a year ago, and the near ready draft of a strategy to wage such a war, are both good signs.

I am encouraged by the top-level recognition of Alzheimer's as a major social problem, and by the seeming seriousness of the current administration to tackle it. However, the lack of funding in these fiscally challenging times is concerning. For perspective, we commit more than $6B annually in federal funds to cancer research compared to about a half a billion for AD research. Current lobbying efforts are aiming for a $2B budget to implement a strategy under NAPA.

If we are to wage a war against this disease, then research funds to better understand Alzheimer's and to develop a cure must be the center-piece of the strategy. However, I hope that the planners do not overlook more certain, and more immediate opportunities to win many battles. Great progress can be achieved with not much more than a dose of pragmatism and public will. I described those opportunities in some detail in an earlier post "Antidote for the Alzheimer's Epidemic".

Given the fast pace of research in this field over the past decade, coupled with historically slow adoption of new knowledge into clinical practice, there is a large gap between the state of our medical knowledge and the standards of care we commonly practice in the clinic.

So let's commit to a national plan for thwarting Alzheimer's and focus on developing a cure. But let's make sure we also take care to update clinical practice with all of the new discoveries we have made, and will continue to make, as we race toward that ultimate goal.

The End of Dimebon

noreply@blogger.com (Dennis Fortier) — Wed, 18 Jan 2012 23:30:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

Dimebon, an experimental Alzheimer's treatment, has failed its Phase III clinical trial, and will not be further developed by its co-sponsors, Pfizer and Medivation.

The Associated Press article reporting on this failure described it as a "major setback" but it really comes as no surprise to those who have followed the trajectory of this potential new drug.

As we described in an earlier post, Dimebon failed its initial trial showing no cognitive benefits and no improvement of function among those research subjects who took it. Undaunted by the initial failure, the drug's sponsors pushed forward with three additional trials: one measuring the drug's effect over a longer period, one measuring the drug's effect as poly-therapy in conjunction with Aricept, and one measuring the drug's effect in patients with Huntington's disease. All three trials have now failed.

This is not good news for the field but I think it important to comment on how this might effect attitudes toward further research. By and large, even the first Dimebon failure in March of 2010 was expected by most experts who follow this space. Despite the fact that Pfizer and Medivation chose to push forward and complete three additional studies, consensus was that the drug was unlikely to be effective, and success in those trials was considered an absolute long-shot.

Now, those expectations have been met, and no one is really surprised. Research will continue at a cautious but steady pace, perpetually fueled by the lucrative potential of success.

Increasing Longevity Drives the Alzheimer's Epidemic

noreply@blogger.com (Dennis Fortier) — Wed, 11 Jan 2012 21:52:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

According to the Center for Disease Control and Prevention, longevity has ticked up in America with life expectancy climbing to almost 79 years.

Homicide and cancer, two prominent causes of death, both declined in the past year and contributed to longer lives across the American population. This is good news overall, but belies a trend that will continue to redefine which risks and priorities demand our national focus.

An obvious implication of a longer life span is that medical conditions correlated with aging will become more prevalent. This portends a rising incidence of Alzheimer's disease as a higher percentage of the population lives will into the years when they are most at risk for that terrible disease.

We all want to live longer, healthier lives and the general trend suggests that each of us enjoys a rising likelihood that we will do so. But as we all traverse the lengthening arc of our elder years, we must face a shifting set of threats to our livelihood. In today's reality, one of the key risks we must prepare to manage in the final years of our projected lives, is the risk of dementia caused by Alzheimer's disease.

Fortunately, a vast research effort is underway to identify manageable risks for AD and to develop guidelines for minimizing the likelihood of suffering its consequences. We review that research on a regular basis in this blog and strive to keep our audience abreast of the latest developments in this important field.

Bio-Markers for Developing Alzheimer's Treatments

noreply@blogger.com (Dennis Fortier) — Thu, 05 Jan 2012 22:46:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

It's been a long time coming, but the FDA might finally have enough evidence to allow bio-marker measures into clinical trials for Alzheimer's treatments. This change could potentially speed the trial process, reduce the risk of failed trials, and yield new AD therapies in the near future.

Based on an analysis of prior publications about bio-markers for Alzheimer's disease, an expert panel convened by the Alliance for Aging Research and the FDA, found ample scientific evidence for including changes in bio-markers as outcome measures in FDA clinical trials. This means that, rather than relying solely on measures of cognition and function (which are measures of worsening symptoms), a drug could now be approved based on its ability to prevent pathological changes that are only evident through an examination of bio-marker measures.

An obvious precedent for this approach comes from the cholesterol field. Since high cholesterol is a condition with no immediately apparent symptoms, a trial based on symptomatic improvement would always fail. To approve cholesterol reducing drugs, the FDA allowed trial designs that used blood-based measures of cholesterol as a bio-marker, in lieu of any symptoms produced by a high cholesterol level.

It has long been known that Alzheimer's disease is characterized by a series of pathological changes. These changes progress from shifting protein levels in the spinal fluid, then to lesions in the brain, and eventually to brain atrophy. However, the precise relationship between the disease and these pathological changes had not been well enough understood for the FDA to allow their measures as part of a clinical trial. With a massive research focus over the past five years and what appears to be an objective, expert review of the evidence, it appears as though future trials may well include bio-marker measures as critical trial outcomes.

Many Alzheimer's related stories get massive press coverage, despite minimal importance in the grand scheme of our efforts to thwart the disease. This story has been relatively uncovered in the mainstream, but might well be one of the most important stories of the year.

Antidote for the Alzheimer's Epidemic

noreply@blogger.com (Dennis Fortier) — Tue, 01 Nov 2011 08:31:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

Surely, you’ve all read the grim reports about Alzheimer’s disease. The advancing age of the US population will usher forth an Alzheimer’s epidemic in the coming decade. The emotional toll of this epidemic will be immeasurable, and the financial impact could bankrupt the Medicare system.

That dire version of the story might sell newspapers, but it doesn’t really reflect the available options to a nation with a will to fight back. The good news is: we can manage this problem. And no elusive scientific discoveries are required to do so. We merely need to implement the medical knowledge that is already in hand.

To be clear, scientific advances yielding better treatments and more accurate diagnostic approaches will greatly improve our prospects in this battle. We need to aggressively fund research and push forward on that front. However, it is important to recognize the sizeable gap between the high standard of care that is achievable based on the current state of medical knowledge, and the lagging standard of care that is routinely implemented in a primary care clinic.

Pragmatism: Closing the Gap

Closing the gap in the Alzheimer’s field could yield tremendous benefits. It will take some effort, but we can achieve such a goal through pure effort and public will. Compared to solutions based on the hope of new scientific discoveries, this has the appeal of greater certainty.

To close the clinical gap, we must address three key areas where “common practices” are significantly lagging behind “best practices”.

1) Education: We need to promote public education and awareness about the many, common medical conditions that impair memory (depression, anxiety, sleep disorders, thyroid malfunction, vitamin deficiency, medications, etc). This will reduce stigma associated with memory loss and encourage patients to be more proactive in expressing early concerns to their physicians.

2) Proven Clinical Standards: We need to help primary care physicians adopt proven standards for differentiating between signs of normal aging and subtle symptoms caused by medical conditions that impair memory. Out-dated assessments for identifying dementia are aiming too late in the process; we need to facilitate effective intervention at an earlier, subtler stage of impairment. Newer clinical assessment tools can ensure that emerging problems are addressed in a timely manner, prior to unnecessary disease progression and declining health.

3) Effective Treatment: We need to ensure that patients, physicians, and caregivers can recognize what effective treatment looks like; doing so will aid ongoing compliance with a prescribed regimen of care. Compared to treatments for other causes of memory loss, expectations for treating Alzheimer’s disease are often unrealistic. For AD, effective treatment is not a complete reversal of symptoms, but rather, a slowing of functional decline. Importantly, everyone must appreciate that proper treatment for AD involves more than just drugs; it also encompasses proper diet, regular physical exercise, and tight control of other chronic conditions.

Concrete steps in these three areas will narrow the gap between “current practices” and “best practices”. Doing so will mitigate the impact from two of the most destructive components of the Alzheimer’s disease problem: under-diagnosis and under-treatment.

Under-Diagnosis

According to the World Alzheimer’s Report 2011, published by Alzheimer’s Disease International, there may be 36 million demented people in the world and 28 million of them are undiagnosed. That is, no doctor has diagnosed the underlying cause of the dementia and prescribed treatment to resolve the problem. According to well-accepted prevalence data, a large percentage of these people are demented due to Alzheimer’s disease (AD). For all of those people, their disease is progressing unabated, their symptoms are progressing, and the ongoing costs of their care are moving irreversibly upward.

Under-Treatment

As of today, AD cannot be cured, but a timely intervention including careful management of diabetes and hypertension, a proper diet, physical activity, and poly-therapy with approved Alzheimer’s drugs, can significantly slow progression for a meaningful percentage of those 28 million people who have been neither diagnosed nor treated. Additionally, many other conditions that cause memory loss are both common and completely treatable. If no diagnostic work-up is performed, these conditions go untreated at the ongoing peril of the patient’s health, which ultimately drives the cost of care higher.

Certainly, a better-educated public, timelier diagnosis of medical conditions that impair memory, and robust treatment are all central facets of a solution to the Alzheimer’s epidemic. Each has deep economic implications underscoring the importance of addressing them. As shown by examples like the Orange County Vital Aging Program*, all of these can be achieved through pragmatic, community-based efforts to improve knowledge and raise standards of care among primary care physicians.

Overall, the looming threat of an Alzheimer’s epidemic is a real problem that may well have painful consequences. We would all like more certainty that scientific efforts will soon thwart the disease, but we cannot yet count on that with high confidence. In the meantime, a concerted effort to pragmatically implement the scientific advances from the past decade of research will significantly reduce its likely impact.

PLEASE HELP spread this message by clicking the share buttons below.

*For more information about the Orange County Vital Aging Program, please visit the OCVA site or download this summary of Year-1 results.

A Community Approach to Managing Brain Health

noreply@blogger.com (Dennis Fortier) — Tue, 01 Nov 2011 08:30:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

Science is important, but let’s not overlook pragmatism.

As described in this complimentary post, a pragmatic solution to the looming threat of an Alzheimer’s epidemic is more likely to bear fruit than the most progressed scientific solutions. It is clear that a better-educated public, timelier diagnosis of medical conditions that impair memory, and robust treatment are all achievable endpoints in a successful campaign against this disease. Importantly, each of these can be achieved through pragmatic, community-based efforts to improve knowledge and raise standards of care among primary care physicians.

Orange County Vital Aging Program - A Community Example

How such a pragmatic program could be implemented in any given community depends largely on the particular make-up of the organizations and healthcare providers in that community. As a point of reference, the Orange County Vital Aging Program (OCVA) in southern California is already demonstrating this concept with encouraging early results. That program provides a template for success worthy of further consideration.

The philosophy behind the OCVA is that timely discourse between an educated public and a well-trained physician community can catalyze better care and improved cognitive health on a mass scale.

The program supports a free website where local residents can gather information, view a community calendar of events and lectures, use free tools for risk identification and management, and find physicians who are trained to manage cognitive health. Local physicians can use the site to register for ongoing CME courses about managing cognitive health, download guidelines for diagnosing and managing conditions that affect cognition, and to learn about community resources that might benefit their patients with memory disorders.

Having accomplished a foundation level of public education and physician training through public lectures and CME courses in its first year, the OCVA program is seeing three community trends:

1) Patients who are aging normally, but who are worried about perceived declines in their cognition, are raising concerns to their physicians and then being objectively reassured about their good health without an expensive and unnecessary work-up.

2) Patients with Alzheimer’s disease are being detected in a timely manner and can now benefit from robust intervention while their brains are still relatively healthy.

3) Patients with other causes of cognitive impairment (depression, stroke, thyroid, sleep disorder, anxiety, etc.) are being diagnosed and treated effectively.

Conclusive evidence demonstrating that the OCVA program improves health and/or lowers costs of care will not be available until longer-term follow-up is complete. But the early data suggest that the program has engaged the community and is changing the dynamic between patients and their physicians in the primary care channel.

For more information about the Orange County Vital Aging Program, please visit the OCVA site or download this summary of Year-1 results.

Intriguing New Insight into Cause of Alzheimer's

noreply@blogger.com (Dennis Fortier) — Fri, 28 Oct 2011 16:03:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

As the experts in the field readily acknowledge, they really don't understand Alzheimer's disease very well. A new hypothesis, based on a recent publication in the Journal of Neuroscience, suggests that previous views and treatment approaches might be aiming at the wrong target.

The dominant theory (the amyloid hypothesis) is that excess accumulation of beta-amyloid, a naturally occurring protein in the brain, aggregates into toxic plaques that disrupt cell function and lead to cognitive decline. Based on the new research, it is plausible that beta-amyloid is in fact the main culprit, but that it does its damage inside the brain cells, prior to breaking free and accumulating into plaques.

Some of the general press on these findings have described the science as a complete contradiction of the amyloid-hypothesis. In reality however, it is fairly consistent with one important difference.

The new insight is that beta-amyloid might be causing harm earlier in the biological process than previously believed. This study suggests that once the beta-amyloid has been dispensed from brain cells and clumps together into a plaque, the damage has already been done. Previously, it has been theorized that the formation of the plaque is the beginning of a toxic biological process.

The implications for treatment are that we should be looking to reduce the presence of beta-amyloid inside the cells, as opposed to clearing it away later, once it has aggregated into a plaque. Fortunately, two of the most promising agents in the FDA pipeline, Bapineuzumab and Solanezumab, are both antibodies that bind to beta-amyloid and clear it away through the natural immune function. It is hoped that one or both of these agents might function at the early, biological stage suggested by this new insight.

Deep Brain Stimulation for Parkinson's Disease

noreply@blogger.com (Dennis Fortier) — Thu, 27 Oct 2011 16:24:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

A great overview article on deep brain stimulation (DBS) for the treatment of symptoms caused by Parkinson's disease was posted today at WebMD.

DBS is accomplished by implanting electrodes directly into the brain and a transmitting device below the collarbone. The transmitter stimulates regular electrical impulses from the electrodes, which effectively "turn off" parts of the brain where many Parkinson's symptoms originate. Among those symptoms most commonly improved by DBS are tremors, slow movement, rigidity, and problems with walking and balance.

This is an FDA approved procedure but is commonly reviewed with caution because scientists cannot convincingly explain how or why it works. However, the data collected in carefully designed trials on real patients is very clear and very positive.

There are many considerations in the decision to undergo DBS as part of a treatment regimen. After all, it requires surgery that includes incisions through the skull and into the chest, so it is not a minor procedure. However, compared to alternative approaches that intentionally destroy brain tissue, this might be considered a less invasive approach.

The cited WebMD article is fairly comprehensive and touches on a wider summary of advantages and disadvantages. I encourage you to click through and read more about it.

Memory Lapses at a Young Age are Unlikely to be Alzheimer's Disease

noreply@blogger.com (Dennis Fortier) — Thu, 20 Oct 2011 17:54:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

I hope this is the beginning of a new trend. A recent article in the Washington Post took a very sensible, scientifically prudent, and optimistic approach to a story about Alzheimer's disease. Essentially, the article develops the important point conveyed in the headline; that baby-boomers who sometimes misplace keys of struggle to recall a name, probably have no pernicious brain disease to worry about.

There is a fine line between dismissing concerns that are associated with normal aging, and ignoring clear signs of a real a memory problem, but this summary of evidence and quotes from experts did a nice job in achieving a proper balance.

I hesitate to criticize this story given the clear progress it represents in terms of highlighting science over sensationalism, but I do wish the headline had been more carefully written. The actual headline in the Washington Post is "Forgetfulness at an Early Age is Rarely a Sign of Early Dementia". It doesn't reference Alzheimer's disease although the story is written as though it does. This disconnect suggests that dementia is actually Alzheimer's disease and begins with mild symptoms in early stages.

As readers of this blog know, "dementia" describes a state of very impaired thinking, and can be caused by many different medical conditions and diseases; Alzheimer's is the most common. Once a person is demented, their impaired thinking abilities are severe enough to affect their daily life. I think the headline inappropriately suggests that minor forgetfulness might be the beginning of a disease called dementia -- which is a common mis-understanding that the Brain Today blog works hard to clarify.

Lewy Body Dementia Awareness

noreply@blogger.com (Dennis Fortier) — Tue, 18 Oct 2011 21:04:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

As per this press release from the NYU Langone Medical Center, October is Lewy Body Dementia (LBD) Awareness Month.

Like Alzheimer's disease and Parkinson's disease, LBD is characterized by impaired thinking and behavioral disruptions. Because of these similarities, it is often misdiagnosed and improperly treated.

Three out of 4 LBD patients are initially misdiagnosed and the majority of patients see more than 3 doctors for more than 10 visits over 18 months before a diagnosis is established.

The obvious solution to the problem of delayed diagnosis is education, for both the public and for their doctors.

Here are a few facts about LBD to start you on the process of building higher education and awareness:

LBD core symptoms include: memory and thinking problems, movement problems, hallucinations, sleep disturbances and fluctuations in attention and concentration
LBD patients have more prominent problems with visual-spatial skills (such as depth perception, bumping into objects, not seeing things in front of them)
LBD patients experience a more rapid functional decline than Alzheimer’s disease patients with shorter intervals to nursing home placement and death
LBD patients have personality changes such as loss of interest, become more passive, quiet or withdrawn, and have trouble paying attention
The combination of cognitive, motor and behavioral symptoms place severe burden and stress on caregivers who often find themselves socially isolated
LBD patients are more likely to suffer from depression

Family History and Alzheimer's Risk

noreply@blogger.com (Dennis Fortier) — Thu, 13 Oct 2011 22:24:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
This is not a simple topic. The relationship between a family history of Alzheimer's and one's own risk for the disease, is probably more complex than previously expected.

While the evidence is fairly clear that the APOe4 gene plays a role in risk for Alzheimer's, affecting both the likelihood of getting the disease as well as the age of onset of symptoms, accumulating evidence suggests that many genes play a role, as do environmental factors.

A recent study, conducted at Washington University in St. Louis and published in Archives of Neurology, looked at changes in biomarkers in the brains and spinal fluid of 269 research subjects, 160 of whom had a family history of the disease and 119 of whom did not. Among those with a family history of AD, only a portion had inherited the APOe4.

Interestingly, the biomarkers in the "family history" group, regardless of APOe4 status, showed similar changes compared to the "no family history" group. Specifically, a family history was associated with accumulation of beta-amyloid in the brain and a reduction of beta-amyloid in the spinal fluid. This suggests that, while APOe4 genes are certainly important, there are other factors that play contributing roles in this complex process.

Drug Prospect for Treating Early Alzheimer's

noreply@blogger.com (Dennis Fortier) — Wed, 12 Oct 2011 00:55:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
We like to help keep news about potential new Alzheimer's treatments in proper perspective. This week, there have been many news stories about an agent in the FDA pipeline that looks promising, but is in a very, very early stage of the process to becoming an approved drug.

The new agent, called Gantenerumab, is being developed by Roche Holding AG. Like other antibody approaches in the FDA pipeline, it binds to amyloid plaques in the brain. When the the body's natural defense system flushes the antibody from the brain, it takes the plaques along as well. In theory, this is a direct attack on the plaques that many believe to be the cause of Alzheimer's disease.

Two agents with similar mechanisms are well ahead of this one in the FDA pipeline: Bapineuzumab (being developed by Pfizer and J&J) and Solanezumab (being developed by Eli Lilly). Each of these are in Phase III (the final phase) of the FDA process whereas Gantererumab is in Phase I.

This is promising news and worthy of cautious optimism. But don't think this portends of a new treatment in the near term, it will take a lot of ongoing science and many years before this agent could be established as an effective treatment and approved for sale.

Horrible Alzheimer's Advice from AARP

noreply@blogger.com (Dennis Fortier) — Tue, 11 Oct 2011 18:55:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
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.

Smokers Have Twice the Risk for Stroke

noreply@blogger.com (Dennis Fortier) — Mon, 10 Oct 2011 22:57:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
We all know that smoking is bad for health. The questions that require ongoing study and clarification are "how bad" and "bad for what, specifically".

In research presented last week to the Canadian Stroke Congress, scientists from the University of Ottawa Heart Institute provided some answers. They concluded that smokers are twice as likely to suffer an ischemic stroke (caused by a blocked blood vessel) as non-smokers, and four times more likely to suffer a hemorrhagic stroke (caused by a ruptured blood vessel) than non-smokers.

These findings were accompanied by more bad news. The researchers found that, among smokers who had strokes, the strokes occurred about a decade earlier (on average) than strokes among non-smokers. They also found that continuing to smoke following a minor stroke, greatly increased the likelihood of a major stroke later on.

Smoking is a preventable risk; a life-style choice with serious consequences. In addition to the well-publicized damage that smoking can cause your heart and lungs, I am hopeful that sharper insights into how it might damage your brain, will help more people make wiser choices about smoking.

Alzheimer's Diagnostic Test, Misleading the Reader?

noreply@blogger.com (Dennis Fortier) — Fri, 07 Oct 2011 16:48:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
The popular press carries more stories like this in a given week than we could possibly highlight in this blog.

I am referring to this article describing a diagnostic test for Alzheimer's disease. The test measures proteins in the spinal fluid and, according to the company with hopes of one day commercializing the test, it can diagnose Alzheimer's disease with 90% accuracy. I believe that is a scientifically plausible claim and I suspect that careful measures of various biomarkers will achieve such accuracy in the very near future.

The potentially misleading element of this story comes from the following quote:

"Right now, diagnostic accuracy for Alzheimer's disease can be as low as 70 percent, meaning three out of 10 people who are diagnosed with this disease might not actually have Alzheimer's disease, but rather some other kind of dementia".

It is true that diagnostic accuracy for AD "can be" as low as 70 percent, if a physician does not follow published guidelines for working up a memory complaint. However, when published guidelines are followed, then diagnostic accuracy is already better than the 90% target for which this new test is striving.

I think this test, and others, may pan out, but let's not mischaracterize the problem. We need to help physicians update their knowledge to keep pace with the constant advances in medicine. A new test, with inferior accuracy to the already achievable standard, is not a breakthrough, and the word "promising" probably does not belong in the story's headline.

6 Ways to Prevent Memory Loss

noreply@blogger.com (Dennis Fortier) — Thu, 06 Oct 2011 16:35:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
This summary, published online today at Fox News, cites evidence supporting 6 lifestyle choices you can make to reduce the likelihood of cognitive decline.

Of course, there are no guarantees and bad genes combined with age can overwhelm even the best life-style. Nonetheless, it is worthwhile to know the steps that might help, and to pursue as many of them as possible.

I suggest you click through and read the short story, but here is the list:

Stay Physically Active
Eat Fruits and Veggies
Reduce Risk Factors for Heart Disease
Embrace Cultural Activities
Care for Your Teeth
Challenge your Intellect

Remember, there is no certain method to eliminate all risk of cognitive decline, but doing what you can to stack the odds in your own favor seems like an attractive course of action.

Is AD contagious? Beta-amyloid and Prion Proteins

noreply@blogger.com (Michael Rafii, MD, PhD) — Wed, 05 Oct 2011 23:58:00 +0000

Contributed by: Michael Rafii, M.D., Ph.D - Director of the Memory Disorders Clinic at the University of California, San Diego. ______________________________________
A prion is an infectious agent composed of protein in a misfolded form. The word prion was coined in 1982 by Dr. Stanley B. Prusiner, and is derived from the words protein and infection.

Normal prion proteins are produced naturally in the brain, but can cause disease when they come into contact with an infectious form of the protein that folds into an unusual conformation. These infectious prions convert innocuous prion proteins into the infectious form, which forms clumps and leads to neurodegenerative diseases, such as variant Creutzfeldt-Jakob disease, the human form of mad cow disease. Prions slowly destroy the brain tissue of infected people by causing a cascade of misshapen proteins. They're known to spread via consumption of contaminated food, by getting a transfusion of blood or tissue transplant from someone who is infected.

In 2009, researchers led by Dr. Stephen Strittmatter at Yale, showed that prion proteins produced naturally in the brain interact with the amyloid-ß peptides that are hallmarks of Alzheimer's disease. Blocking this interaction in preparations made from mouse brains halted some neurological defects caused by the accumulation of amyloid-ß peptide.

Now, researchers led by Dr. Caludio Soto at the University of Texas Health Science Center, have shown that, in fact, Alzheimer's disease itself, may be a prion-like disease. His team injected the brain tissue of a confirmed Alzheimer’s patient into mice and compared the results to those from injected tissue of a control without the disease. None of the mice injected with the control showed signs of Alzheimer’s, whereas all of those injected with Alzheimer’s brain extracts developed plaques and other brain alterations typical of the disease.

These findings suggest that in an experimental setting, misfolded beta-amyloid can behave in a similar way as infectious prions. It remains to be proven whether at least a proportion of human AD cases could be due to a transmissible prion-like mechanism. It must be kept in mind, that prions are not contagious via normal human contact.

A Blood Test Predicting Rate of AD Progression

noreply@blogger.com (Dennis Fortier) — Mon, 03 Oct 2011 22:28:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
This study out of Johns Hopkins, showing that a blood test might be useful in predicting the rate of cognitive decline in Alzheimer's disease, is being widely covered in the press. Here are some thoughts on the new science and what it might mean.

First, as the authors admit, this is very early stage work that has not yet been properly validated. Second, if the research is eventually validated, that would be only the starting point for the long product development process prior to the day when a physicians might have a test they could use in practice. Third, predicting the rate of progression may have some benefits, but if those benefits cannot be cost justified, then such a test might never be developed by any commercial interest.

I generally write optimistically in this space about new technologies and scientific advances that portend better care in the Alzheimer's arena. In this case, I am surprised at the amount of mainstream coverage that has been afforded such an early stage study with (in my opinion) dubious clinical value.

On that note, I think there is a very interesting aspect to this research. Given the massive recent investments in clinical trials to test agents for treating Alzheimer's disease, having a better understanding of each subject's propensity for cognitive decline could be highly valuable.

In a typical clinical trial, we apply a treatment to one group and a placebo to another group, then we look for differences in pre-determined outcomes. In the future, if we could segment the research subjets into groups based on their expected rate of cognitive decline (slow, medium, and fast), as this new blood tests suggests is possible, then we might more clearly detect a treatment effect by comparing expected decline with actual decline.

In this regard, I think a blood test for predicting the rate of cognitive decline in Alzheimer's patients, if validated and commercialized, could play an important role in the effort to develop new solutions to the looming Alzheimer's epidemic.

World Alzheimer's Report 2011

noreply@blogger.com (Dennis Fortier) — Thu, 29 Sep 2011 17:54:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________

Alzheimer's Disease International is the federation of national "Alzheimer's associations" around the world. Each year, they compile a world report summarizing the state of scientific knowledge in the field of Alzheimer's disease.

This year's version, World Alzheimer's Report 2011, was released last week. You can use these links to download the Executive Summary or download the Full Report.

The highlight of this year's report is encompassed in its subtitle: The Benefits of Early Diagnosis and Intervention. This is an important message that is undermined daily by the mantra of the popular press, where messages about the futility of treatment are persistent. In this summary of scientific evidence, vetted by some of the world's greatest experts in this field, it is clear that detecting AD at an early stage and adhering to a robust regimen of treatment, can have tremendous health and economic benefits.

I am happy to see this report's strong and optimistic emphasis on such a positive side of the story. I hope you will join me in sharing this report as broadly as possible by passing it along to your online networks.

Perspectives on Health and Retirement

noreply@blogger.com (Dennis Fortier) — Wed, 28 Sep 2011 20:37:00 +0000

Contributed by: Dennis Fortier, President, Medical Care Corporation

_______________________________________________________
We have written previously in this space about the relationship between retirement and dementia. A fascinating new study shows that, in general, retirement is often less enjoyable than what many expected prior to retiring.

Most of the differences, as summarized in this report, are related to poor health and the costs of healthcare. Given the central importance of cognitive health on overall fitness and the costs of medical care, the conclusions in the report may resonate with readers of this blog.

While many correctly anticipate the ways their lives will change in retirement, about a quarter of retirees say that life after retirement is worse than it was prior. As noted, poor health is a common theme in that reality.

Fortunately, there is also good evidence that a high number of retirement-aged individuals are engaging in sound, health preserving strategies like those you constantly read about here.