Imagine two 747 jetliners loaded with passengers crashing every day, that is the number of Americans that are dying due to Alzheimer’s and dementia. It is by far the greatest health crisis the country faces and the burden keeps increasing every year as the population ages.
Snowfish has been focused on multiple disease states associated with aging such as heart disease, cancer, and dementia including Alzheimer’s. We recently attend the Alzheimer’s Association International Conference (AAIC) with the goal of understanding the latest dementia developments and what the future holds.
Much of the excitement surrounded advances in the science (understanding the pathophysiology, identifying potential drug targets, determining genetic indicators, preclinical markers) and the search for a cure. Unfortunately the few drug trial results were quite underwhelming. Technology and new discoveries have grown the dementia community’s knowledge base by leaps and bound, yet a cure is still beyond our grasp.
Filling this gap was all of the other research featured at the conference that emphasized a variety of non-pharmacologic ways to care for those already with the disease and prevent it in individuals characterized as having “pre-dementia”. We’ve highlighted thought-provoking themes we picked up on either through the sessions or conversations with a number of the poster presenters.
Alzheimer’s Disease in the Oldest Old
When we think of the burden of Alzheimer’s disease we tend to forget that it is the oldest old who have the highest chance of developing it. Maria M. Corrada-Bravo, ScD, of UC Irvine co-lead investigator of the 90+ study also reminded us that this age group is the fastest growing demographic in the U.S. and it is predicted to make up almost 5% of all elderly by 2020. At this time, there is a lack of accurate data for cognition and function in the oldest old due to the complexity of their physiologic and psychosocial situations. For example, incomplete data resulting from study visits cut short significantly impacted cognitive scores. Creative trial design is important to ensure that accurate data for Alzheimer’s and other forms of dementia are captured in the oldest old in order to best service this important dementia population moving forward.
Behavioral Approaches to Dementia Management
An entire plenary was devoted to Alzheimer’s and dementia management. Behavioral health expert Laura Gitlin, PhD, from Johns Hopkins, highlighted a number of coordinated care models that empower professionals such as nurses and occupational therapists. The ability to leverage these disciplines is very important given the fact that there are not enough physicians to take on these functions. Dr. Gitlin noted that while studies of such care models are small, they have shown an effect on caregiver burden and nursing facility placement.
Similar approaches appear to be going on in various areas of the U.S. as well as globally. One example is a group at Wake Forest that is conducting a comprehensive counseling program for dementia patients and their caregivers. The director is both an MD and certified counselor. Another is the UCLA Alzheimer’s and Dementia Care program, which will provide comprehensive, coordinated care, as well as resources and support, to patients and their caregivers. It is led by a team of geriatricians and nurse practitioners. Beyond the initial interaction much of the follow-up is conducted remotely.
A challenge that we heard time and again related to patient access. For example, the UCLA program has a waiting list of around 200. Funded with grants, this model is not yet completely conducive to standard forms of reimbursement (i.e., Medicare).
Another challenge is geographic reach. When asked about the uptake of the Wake Forest counseling program, we heard “around 50% of patients enroll”. This is due to issues with patients/caregiver having to travel long distances to participate. At this time the program is not implemented too far beyond the Winston-Salem region. Telemedicine approaches, a potential solution for travel requirements, are not being utilized at this time.
The potential of an Alzheimer’s cure is not likely within the short-term. However, there are millions currently with the disease and those who will soon develop it that need support. Maintaining independence and quality of life through behavioral interventions and coordinated care should be a priority. There is opportunity to identify and map the multiple coordinated care pilots being conducted across the U.S. and determine the best practices within each of them. With this, such models can be replicated and more effective care implemented while research for new therapies continues.
Lifestyle Modifications to Prevent Conversion from Pre-Dementia to Dementia
A recurrent theme was the role of lifestyle modifications, those common in cardiovascular risk reduction, in the prevention and slowing of Alzheimer’s disease. Per Laura Fratiglioni of Stockholm University in Sweden, lifelong exposure to multiple factors may have a strong influence on one’s likelihood to develop Alzheimer’s disease. She outlined three strategies, which if implemented in middle age, could reduce the risk. These include:
- Healthy lifestyle (moderate alcohol, physical activity, diet)
- Decreasing vascular burden (treat hypertension, diabetes, heart disease)
- Increase brain reserve (mentally complex activities, physical activity, social network)
A few points about a few of these risk prevention strategies. With respect to physical activity, it is not “exercise” but “movement” that has demonstrated benefit. One study reported that being more physically active over the course of the day results in lower risk of both MCI and Alzheimer’s disease.
She highlighted the FINGER study, which is the most robust trial of lifestyle intervention in Alzheimer’s disease prevention. It concluded that a multi-domain intervention can improve or maintain cognitive functioning in at-risk elderly people from the general population.
David Bennett, MD, of Rush Alzheimer’s Disease Center presented his perspective on the forms of psychosocial risk factors. He noted that increased social activity, “less constricted life space” (how far you go out beyond your room or home), lower levels of depressive symptoms and neuroticism along with increased conscientiousness and higher purpose in life correlate with a reduced risk of Alzheimer’s disease and MCI.
A conversation with members of the Alzheimer’s Research and Prevention Foundation reinforced these points as their mission is to expand knowledge regarding disease prevention through lifestyle modification – diet, activity, stress management and spiritual fitness. They showed us some results of studies that demonstrated a positive effect of yoga and meditation on measures of cognitive function, frontal lobe activity, and cerebral perfusion. Interestingly enough during our conversation, a young neurologist approached and cited her own study being conducted utilizing yoga in dementia.
There is growing interest in lifestyle modification for the prevention and management of Alzheimer’s disease. This is further demonstrated by the creation of dementia assessment and prevention clinics at Weill Cornell and University of Alabama Birmingham. Additionally, centers such as the Lou Ruvo Center on Brain Health (at the Cleveland Clinic) offers an on-line assessment and risk reduction plan through their website.
Many of the risk factors addressed are the same as those for cardiovascular disease and diabetes. There may be significant opportunity for the dementia community to collaborate with specialties like cardiology and diabetes educators (who have already laid down much of the groundwork) to create an integrated risk reduction plan that will also decrease Alzheimer’s disease along with these other important conditions. As surveys have noted, people tend to be more afraid of dementia than a heart attack, this could serve as a valuable motivator to engage not only in a plan which is multi-modal, but multi-effect.
Other Interesting Findings
- An individual’s identity beyond the diagnosis of dementia is key to their well-being. This includes recognition by social relationship, family relationship, occupation, etc.
- A physical therapist at University of Michigan in Flint has taken the lead to educate others in her field in how to screen patients for dementia when performing physical therapy. A survey she conducted of 542 physical therapists indicated that cognitive screening is not conducted routinely.
- A discussion with a geriatrician noted that certain large dementia assessment centers may indeed have a waiting list of six months to a year. This is a significant problem if the medical community is to increase screening and identification.
- One poster initiated a discussion on medical cannabis in patients with dementia. It cited results from a small study carried out in a nursing facility in Israel. Of 19 patients treated with medical cannabis, 17 achieved a healthy weight. Additionally, muscle spasms, stiffness, and pain were reduced. Medical cannabis has not yet been formally explored in the U.S. as a treatment for patients with dementia.
There is rising awareness on a global level of the importance of developing a systematic plan to identify, treat, and manage Alzheimer’s and dementia. For example, on January 4, 2011, President Barack Obama signed into law the National Alzheimer’s Project Act (NAPA), requiring the Secretary of the U.S. Department of Health and Human Services (HHS) to establish the National Alzheimer’s Project to:
- Create and maintain an integrated national plan to overcome Alzheimer’s disease.
- Coordinate Alzheimer’s disease research and services across all federal agencies.
- Accelerate the development of treatments that would prevent, halt, or reverse the course of Alzheimer’s disease.
- Improve early diagnosis and coordination of care and treatment of Alzheimer’s disease.
- Decrease disparities in Alzheimer’s for ethnic and racial minority populations that are at higher risk for Alzheimer’s disease.
- Coordinate with international bodies to fight Alzheimer’s globally.
The level of funding has been increasing as both citizens, industry, and government realize the need to develop better solutions. For FY 2015 the U.S. Government devoted more than $1.170 billion to research at the National Institutes of Health focused on geriatric research. We are still early in the game. Having worked in the field for over twenty years, I am finally starting to see progress. Hopefully, as awareness increases and resources are devoted to these devastating conditions, old age will not involve the loss of mental ability.
David Fishman is President of Snowfish, a leader in commercial analytics for life science companies with products in all stages of the life cycle. Snowfish specializes in driving innovation and challenging companies to look in new directions through a unique collaboration of strategic vision and sophisticated analytics overlaid with solid domain expertise. He can be reached at firstname.lastname@example.org.