Is it possible to pin-point Alzheimer’s disease? The answer, I’m afraid, is no. In fact, the only way a person can truly be diagnosed with the disease is during an autopsy. So how can we better target the potential that a person actually has Alzheimer’s? The picture below shows what a PET scan can show in terms of the brain’s activity. Even though this is still not the perfect way to determine if a person has Alzheimer’s, it is a definite manner by which a neurologist can determine if a medication can be used to help maintain helathy brain activity.
So what are some of the advancements being made today in the study, treatment, and preention of Alzheimer’s and dementia? The following article was published in the Summer issue of Inspire Magazine. Written by Dr. Peter Lichtenberg of Wayne State Univeristy, it offers a glimpse into what advances are being made on this topic.
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Understanding Risk Factors for Alzheimer’s Disease and New Approaches to Care
by Peter A. Lichtenberg, Ph.D., ABPP, Director, Institute of GerontologyProfessor of Psychology at Wayne State University
Alzheimer’s disease has become a household word, affecting over five million Americans and feared by millions more. The MetLife Foundation reported in a 2006 study that after cancer, Alzheimer’s is the second most feared disease among both middle-aged and older Americans. Despite its prevalence and the increasing attention to it by the public and healthcare professionals, Alzheimer’s disease remains a difficult disease for families and general health practitioners to recognize and treat.
In 2006, the Michigan Dementia Coalition conducted a statewide behavioral surveillance survey about memory loss. One of the survey’s most striking results was the lack of public awareness about where to get help for Alzheimer’s disease. The majority of those surveyed (60%) said they would seek help from their family doctor. The next most popular response was searching the Internet for information (10%). Sadly, only 1% had heard of the Alzheimer’s Association or would contact them for information, indicating a large gap between the public’s fear of Alzheimer’s disease and their actual knowledge about it and its treatment. To assist in reducing that gap, this article will cover (1) the essential elements of the disease in late-onset, sporadic type which is defined as having no one specific cause; (2) the known risks for developing Alzheimer’s disease; (3) our recent research and educational work on early detection; and (4) the place of Alzheimer’s disease in health disparities.
CAUTION: AGEISM CAN CAUSE HEALTH PROVIDERS TO NEGLECT SYMPTOMS OF ALZHEIMER’S DISEASE
Ageism is loosely defined as discriminating against older people based on a strong tendency to stereotype. Because age is by far the most significant risk factor for Alzheimer’s disease, it is important to be aware of ageism both in the general public and among healthcare professionals. Ageism is particularly destructive in medical treatment settings. Practitioners with strong ageist views are less likely to act aggressively on patient reports of memory loss, believing that aging always brings some memory loss and that even if Alzheimer’s disease is diagnosed, no effective treatment exists.
As part of ageism, older adults are often viewed as a homogeneous group that is frail and prone to disability and memory loss. In truth, older adults are quite heterogeneous. One 80-year-old may be bed-bound while another 80-year-old still skis and swims. Whether active or slowing, we do know that many older adults are not suffering from Alzheimer’s disease, and the majority of older adults are making enormous contributions to their families, professions, communities and society.
ESSENTIAL ELEMENTS OF ALZHEIMER’S DISEASE
Alzheimer’s disease is a clinically diagnosed disease that affects a person’s brain, cognitive function and ability to function in daily life. A clinical diagnosis means that there are no definitive tests or biomarkers that can be obtained from the living patient to confirm the diagnosis. At present, no blood test can detect Alzheimer’s disease, no brain scan can definitively determine its presence, and no laboratory tests can diagnose it with complete certainty. Alzheimer’s disease can be diagnosed with 100% accuracy only by examining the brain’s pathology at autopsy.
Despite this, the accuracy of diagnosing Alzheimer’s disease can be as high as 90% in the first year of clinical assessment and higher as the disorder progresses. Research has demonstrated that the brain pathology of Alzheimer’s disease precedes actual symptoms of dementia by years. More recently, Mild Cognitive Impairment has been described and identified as a significant risk for the development of Alzheimer’s disease. In Mild Cognitive Impairment, memory functioning is significantly decreased although functional abilities are not.
The early symptoms of Alzheimer’s disease itself include: pronounced memory loss; changes in daily functioning (e.g. work, hobbies, community participation, driving, financial management); and often a change in behavior such as increased irritability, anger or depression. As the disease progresses, cognitive and behavioral symptoms worsen. Eventually, the person with Alzheimer’s disease needs intensive caregiving for basic activities of daily living such as feeding and bathing.
RISKS OF ALZHEIMER’S DISEASE
As stated earlier, a person’s age is by far the biggest risk factor for sporadic Alzheimer’s disease. At age 65, only 2 out of 100 people have Alzheimer’s; by age 85, 30-35 out of 100 have the disease. Researchers continue to identify genetic risks for Alzheimer’s disease of which the Apolipoprotein allele (ApoE-4) on Chromosome 19 is the best understood. Although this genetic information is important, the clinical sensitivity and specificity of ApoE-4 is not an accurate enough genetic test to diagnose Alzheimer’s or to predict its risk at this time.Lifestyle risks may also increase the odds of acquiring Alzheimer’s disease or dementia. The main risks are early life experience including education (as noted in the Nun study), chronic diseases such as diabetes, hypertension and heart disease, high cholesterol (which also affects blood flow to the brain), and diet and nutrition.
An intelligent assessment of risk considers the cumulative effect of these experiences across the lifespan.In the Nun study (which followed a fairly homogenous group of Catholic nuns who had lived together for decades in a convent), there seemed to be something in the childhood experiences of many of them that made them vulnerable to late life dementia. Other studies of early childhood experiences link them to higher rates of chronic disease in later life, including cancer and stroke. Level of education (a broad variable for socioeconomic status and environmental living situation) in early life is also inversely proportional to risk of Alzheimer’s disease in late life. The higher the education and socioeconomic status, the less likely a person is to suffer from Alzheimer’s disease. Diseases such as diabetes, high cholesterol, hypertension and heart disease (which begin most often in mid-life) also correlate with an increased risk for Alzheimer’s disease in later life.
Low cognitive activity has been linked to higher risk for Alzheimer’s disease, as has a weak social network, a lack of regular exercise, and poor diet and nutrition. In a recent study by Columbia University, risk of Alzheimer’s disease across a three-year, follow-up period was reduced for those following a Mediterranean diet. Even smoking cessation in mid-life and regularly taking non-steroidal medications have been linked to a reduced risk for Alzheimer’s disease in late life. Risk factors can be misleading; however, since risk studies such as these are investigated across a population, and may not impact an individual’s experience.
In the community talks I give, people often feel hurt and betrayed by the confusing message of risk studies. I often hear comments such as, “My husband had no risk factors for Alzheimer’s disease and yet he got it!” Let me illustrate how risk studies work and how they apply to each of us as individuals.
Let’s pretend I conduct a research study on 200 people and find that after they follow a particular diet, the risk of Alzheimer’s disease is reduced by 20%. What does that mean exactly for the 100 persons who followed the diet and the 100 who did not? It means that across my study, 10 of the 100 persons who did not change their diet developed Alzheimer’s disease. Eight of the persons who did change their diet developed Alzheimer’s disease, which translates to a 20% increased risk of contracting the disease among the persons who did not change their diet. Another way of putting it is that out of 200 persons, only two of them had a different result between the two groups. Remember that those two persons represent only 1% of the total number of participants. The other 99% were unaffected by the risk. They either did not develop the disease or developed it at the same rate regardless of diet.Thus, you see that an increased risk factor stated as a 20% greater chance of developed Alzheimer’s disease impacts only a small number of actual persons. We still advise everyone to establish healthy habits for living—including diet, exercise, social support, and cognitive activity. These are likely to improve overall quality of life and aging. But even eliminating all known risk factors from a person’s lifestyle will not guarantee that Alzheimer’s disease can be avoided.
THE IMPORTANCE OF EARLY DETECTION
Alzheimer’s disease is chronic. After diagnosis it can be treated but not cured; so early detection and treatment remain the best options for improved quality of life. Several new medications are being developed to protect the brain’s neurons from damage and to significantly slow the progress of Alzheimer’s disease. Sadly, many persons in the early stages of Alzheimer’s are not receiving these neuroprotective medications because their disease has not been diagnosed.
To address some of the difficulties the primary care physician can have in spotting the clues of early Alzheimer’s, the Michigan Dementia Coalition created a Primary Care Dementia Network. Its work emphasized three areas for early detection: (1) reports from family, friends or other persons familiar with the patient; (2) behavioral triggers for further evaluation and (3) testing technology for cognitive screening that is easy for both the physician and patient to use. Many family physicians are currently treating the spouses or adult children of an older parent. By implementing this single question at the annual exam, “Have you noticed any significant changes in memory for your spouse/parent?” better early detection of Alzheimer’s can be achieved. Other, more in-depth questions for family and friends are also available.
Behavioral triggers refer to activities or events that an older person displays that often co-exist with early Alzheimer’s disease. The most common behavioral triggers include: confusion about medication; calling the office more than once for the same instructions or appointments; new falls in the home, and hospitalizations—especially when combined with an acute episode of delirium-induced confusion. These triggers should automatically lead the physician to perform more functional and cognitive screening for dementia.
Our Primary Care Dementia Network uses a technique called Academic Detailing to instruct physicians in this type of care. A trained physician, accompanied by an outreach worker for the Alzheimer’s Association and the Area Agency on Aging visits the primary care physician’s office to conduct a 30-45 minute session on Alzheimer’s assessment and treatment. Educational modules are also available on our website at www.dementiacoalition.org.
Improving cognitive testing, and in this case cognitive screening, has been one of my main areas of research. Study after study has indicated that for primary care physicians a lack of time and testing skills restricts cognitive screening. Rather than squeeze yet another task into the physician’s brief visit with the patient, we developed computer-based, internet-scored cognitive testing. Our Cognitive Screening Test of memory and executive functioning (created by the company Headminder) demonstrated it can be quickly and easily used in primary care offices and is highly accurate in detecting Alzheimer’s disease. Potential users of the test can view it at www.headminder.com. This and other computer-based screening tests provide an outstanding opportunity for physicians to improve their early detection and treatment of Alzheimer’s disease.
ALZHEIMER’S DISEASE AND HEALTH DISPARITIES
Much of my research in neuropsychology has focused on improving the accuracy of cognitive testing in African American urban populations. Educational and literacy biases in most cognitive tests lead to the over-diagnosis of cognitive impairment in older African Americans. Due to poverty, lifespan exposure to environmental and other risk factors, and high rates of stroke, Blacks and other minority older adults are at higher risk for Alzheimer’s disease than non-Hispanic Whites. As the aging population increases in diversity, it will be important for us to improve our ability to detect Alzheimer’s disease across all ethnic minority groups.
Stigma, language differences and the validity of cognitive assessments across languages are the biggest barriers to improved care of Alzheimer’s disease in diverse populations. Alzheimer’s disease tends to be more highly stigmatized in minority elders, often associated with being “crazy” and losing one’s personhood. Often this stigma is directly related to a lack of understanding and knowledge about the disease.
Language is a second barrier to detection and treatment of Alzheimer’s disease. In southeast Michigan alone, older citizens (many of whom immigrated to the United States) speak only in their native language. We do not have enough providers fluent in Spanish, Arabic, and dozens of other languages spoken by older adults to provide care and assessment. The last barrier, cognitive testing, is related to the language issue. We have few cognitive tests translated into languages other than English. Those that are available have a small normative database, which makes interpretation of the results of translated tests extremely difficult.
SUMMARY
In our quest to detect and treat Alzheimer’s disease we must do four things: (1) reduce ageism to make everyone more sensitive to unique and genuine changes in older adults; (2) understand risk assessment and adhere to risk-reducing measures; (3) employ new models of Alzheimer’s detection and treatment for primary care settings; and (4) ensure that treating Alzheimer’s disease in diverse elders is a priority. Incredible progress is being made in Alzheimer’s research. Now, those of us who care for older adults must work to translate that research into meaningful, real-life change.
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