Alzheimer’s Disease – More Insight

The August 1, 2019 issue of the journal Neurology carried a report of a team of researchers who have developed a blood test that can detect the presence of amyloid in the brain with 94% accuracy.  Amyloid is one of the chemical constituents found to be tangling up the neuron nerve communication pathways in humans with Alzheimer’s disease.

The article emphasizes this is currently a strict research tool. It is not a laboratory test that your physician or clinic can order or use to detect this form of dementia early. The results of the blood test correlate well with imaging studies currently in use. It is one small step in the investigation of the causes of this progressive, and fatal, heartbreaking disease and hopefully will allow us to evaluate Alzheimer’s at its earliest stages.

In a journal specifically dedicated to this disease entitled Alzheimer’s and Dementia, researchers at the University of California, San Francisco discussed the increased tendency of patients with Alzheimer’s disease to nap and sleep inappropriately and ineffectively. Previously it was felt that this inappropriate sleep pattern when observed was in fact a risk factor and marker for the development of the disease.

Lea Grinberg, MD and her co-authors feel it is a symptom of the disease instead. They believe that the disease process has already destroyed or inhibited those neurons (brain nerve cells) responsible for wakefulness and alertness. In the absence of this stimulation, patients nap and sleep ineffectively and inappropriately.

Imaging of these areas is difficult to obtain because of their location in the skull and brain but, on detailed studies, more tau protein deposition in these wakefulness areas is visualized.   This concept now allows researchers to zero in on other brain chemicals associated with wakefulness, alertness and sleep as a potential form of treatment of Alzheimer’s disease in addition to those chemicals in the cholinergic system that most medications attack.

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Fitness Lowers Your Risk of Dementia

Over the years I have read and passed on to my patients the benefits of exercise on quality of life and healthy aging. This hypothesis was supported by a recent publication in the journal “Primary Care” by Peter Lin, MD, CCFP. Dr Lin and colleagues followed a group of woman aged 38 to 60 years for 44 years to determine the relationship between fitness and development of dementia. They chose to follow 191 women from a group of 1462 patients and selected a balanced number of patients in each age group up to age 60. They performed a physical fitness test on the women in 1968 and then grouped them into high fitness category, intermediate fitness category and low fitness category based on their performance in the physical fitness test. The women then received neuropsychiatric evaluations in 1974, 1980, 1992, 2000, 2005 and 2009.

The patients within the high fitness group showed an 88% reduction in dementia rate compared to those with medium fitness. Those in the lowest fitness group had a 41% increase d risk of dementia compared to the medium fitness group. Those patients in the high fitness group who developed dementia showed symptoms 9.5 years later on average than the patients in the medium fitness group.

The message for young adults is simple. Stay fit at a high level doing something you enjoy and you may reduce your risk of developing dementia by up to 90%.

Controversial Study on Body Weight and Development of Dementia

As the Baby Boomers age and develop more chronic diseases there is a predicted epidemic of cognitive dysfunction and dementia expected to occur. At the same time the Baby Boomer retirement explosion is occurring the nations of the world are experiencing a significant increase in obesity and its health related problems. In the April 10th issue of The Lancet Diabetes & Endocrinology researchers in Great Britain published a paper suggesting that being overweight might be more protective against the development of dementia than being at a normal weight or underweight. In fact they felt that underweight individuals having a Body Mass Index of < 20 had a far higher risk of developing dementia than normal weight individuals or obese individuals (BMI > 30). The data was collected and analyzed from the United Kingdom Clinical Practice Research Datalink by Nawab Qizilbash, MSc, DPhil, from the London School of Hygiene and Tropical Medicine. The study looked at records of people aged 40 or older between 1992 and 2007.

The author concluded that “If increased weight in midlife is protective against dementia, the reasons for this inverse relationship are unclear at present.” Previous smaller studies on the issue suggested just the opposite that being overweight in midlife was a risk factor for developing dementia. Deborah Gustafson,, PhD, from SUNY Downstate Medical Center in New York cautioned that these results are certainly not the “final word” on the topic.

As a clinician we always advise patients to live a life and eat a diet based on moderation. The study did not make it clear if the protective effect of being overweight extended to the massively obese or not. What is clear is that being at an extreme seems deleterious, while being at normal body weight or mildly overweight may be protective.

Medicare Will Never Be Able to Reduce the Cost of Care in the Last Three Months of Life

We are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning.  Living Wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human nature. I will provide some examples in the next few blogs.  Patient “L.J.” is my first example.

 I have a sweet 97 year old patient L.J., who lives in an upscale skilled nursing facility. He has a living will and a yellow “Do Not Resuscitate” sticker on his room door.  Three years ago he went into a severe depression after losing his second wife, to dementia.  His diabetes and chronic kidney disease have exacerbated because in addition to the natural progression of his diseases, he chooses not to take care of himself or follow instructions. His depression has been refractory to treatment despite the best efforts of two caring and experienced geriatric psychiatrists and their staffs.  He suffers from myelodysplasia and requires periodic blood transfusions to keep his blood count at a level that will keep him comfortable.

In recent months he has refused to be transported to an infusion center for his transfusions.  Despite his blood count dropping he remains comfortable, in no pain and able to participate successfully in those facility activities that he chooses to.   His nurse has become exceptionally attached to him.  As the patient’s health declines, despite being in no discomfort, the nurse is tortured by his decline. She calls and emails the out-of-state children and makes suggestions for additional care that the patient does not need or want.

Three months ago she suggested a palliative care consult.  I asked her “why” and questioned what services the palliative care team will provide that the patient is not already receiving or that he needs?  The children had demanded the palliative care consult so one was called. 

The local hospice program has a new palliative care program. They bill Medicare Part B for their services.  The palliative team arrived and wrote a consult that basically said there was nothing for them to do. They saw no need for their services. 

Three months later the same nurse contacted the family and said the patient needs Hospice care. I asked “why”?  She told me her mother had died of cancer and Hospice had been very helpful. I have no objections to working with Hospice and have over the years been a voluntary hospice medical director as well as referring many patients for end of life care. There is nothing for them to do at this point.  When the nurse contacted the out of state children they chose to “not leave any options on the table” and asked for Hospice to evaluate the patient. They did and billed Medicare Part B. They had nothing new to offer other than sending in a social worker and chaplain periodically to meet with the patient. Each time they visit the patient they bill Medicare Part B.

It is unclear if hospice is treating the floor nurse or the out of town children but they are certainly not adding anything to the patient’s care.   The taxpayers’ foot the bill as the system fails from expenses it cannot meet.

 

Today’s Seniors Are Not as Healthy as Their Parents

In the online version of the Journal of the American Medical Association an analysis of data compiled by the National Health and Nutrition Examination Survey ( NHANES) suggested that today’s baby boomers are not as healthy as their parent’s generation. The baby boomers, born between 1946 and 1964, may live longer but they do so with more complaints and more chronic illnesses.  The study compared the two generations at ages 46 and 64 on several health measures using the years 2007- 2010 for the baby boomers and comparing it to data they had from 1988- 1994 for the prior generation.

The demographics in the two groups indicated a larger number of Hispanics and non-Hispanic Blacks in the baby boomer generation than the previous generation.  The data in many cases was self-reported with only half as many baby boomers 13% reporting their health as “excellent” while their parents’ generation had 32% respond excellent to the same question.  The baby boomers reported that more were using walking assisted devices, more were limited in work and more had functional limitations than their parents’ generation. As a group, obesity is more common in the baby boomers (39% vs. 29%), as is high blood pressure, elevated cholesterol and diabetes.

The prior generation got more physical exercise than the baby boomers by a margin of 50% compared to 35% when asked if they were getting exercise at least 12 times per month. Smoking was more common in the prior generation.  The study authors concluded that we need to “expand efforts at prevention and healthy lifestyle promotion in the baby boomer generation.”

It is hard for me as a clinician to gain much insight from this data. Clearly the previous generation lived through a depression and fought two major wars. Their definition of “excellent” may be different than baby boomers whose expectations may be completely different from reality.

An epidemic of obesity has contributed to an increase in its associated diseases including diabetes, high blood pressure and lipid abnormalities. The goal of education and prevention is a wise one and needs to start in the preschools and elementary schools if we wish to be a healthier society

 

What’s New in Dementia, Alzheimer’s

Alzheimer’s Disease is a form of dementia and considered to be a progressive, fatal neurologic disease. Medications to slow it down are successful in about 50 % of patients for a very limited amount of time (6 -12 months).  As Baby Boomers age and move into the retirement sector, we are always looking for positive data regarding the disease to offset the expected epidemic of dementia.  We have a limited amount of good news to report.

Japanese researchers report that they have developed several types of contrast material for imaging studies which will allow doctors to see accumulating plaque in the brain and possibly the tangles of neurons associated with the disease at a much earlier stage.  At the same time researchers now claim to be able to do a spinal tap and, by examining the spinal fluid, make an earlier and more accurate diagnosis. At this point there might not yet be an advantage to early detection of the disease but as research proceeds it may become an important advantage.

The British Medical Journal is reporting that cognitive decline actually starts in midlife. They studied a mix of 7,300 men and women at five years intervals beginning in 1997 and found a decrease in intellectual functions beginning at 45 years old. They concluded that “what is good for our hearts is also good for our heads.”  They stressed the importance of controlling hypertension, obesity and abnormal cholesterol as a way to prevent dementia.

You might ask why I consider the fact that dementia begins in midlife a positive?  It’s a positive because we have the ability to control our weight, blood pressure, cholesterol and exercise level. Anytime a disease is modifiable by how we live our life we are given the chance to prevent it or limits its impact. This fact is supported by a recent study published in the Archives of Neurology looking at individuals with a genetic variant which predisposes them to develop Alzheimer’s Disease.  They found that older adults with the genetic predisposition for Alzheimer’s Disease who exercised regularly, at or above the American Heart Association recommended levels, developed “amyloid deposits” on scans of their brain less than expected and in line with the general public who did not have a genetic predisposition to develop the disease.

These are small but positive steps in facing dementia. We can find it earlier and slow down or turn off genetic predisposition by living a healthy life.

Moderate Drinking Can Reduce Dementia, Alzheimer’s Risk

In an article in the International Business Times 08/19/2011 edition, Loyala University Medical Center researchers admit that moderate consumption of alcohol reduces the risk of developing cognitive dysfunction and Alzheimer’s type dementia.

They reviewed 143 studies, which included about 365,000 members from 19 different countries. The health benefits were seen in 14 of the 19 countries including the USA.  Moderate drinking was defined as one drink daily for women and two for men. Further clarification defines moderate intake as 1.5 ounces of spirits, 5 ounces of wine or 12 ounces of beer.

It was not clear why moderate alcohol intake reduced the risk of Alzheimer’s disease but it is believed to be due to its anti-inflammatory effects.  Neuroinflammation which occurs in both Alzheimer’s disease and other dementias can be altered by moderate alcohol consumption. They did caution however, that heavy drinking defined as 3-5 drinks per day actually causes neuroinflammation and memory problems.  The study, published in the Neuropsychiatric Disease and Treatment Journal, showed that wine consumption was a better choice to reduce the risk of dementia.

The study review showed that moderate drinking didn’t impair the cognitive functions in younger subjects aged 18 -50 and actually reduced the risk of dementia and Alzheimer’s in participants over the age of 50.