By Dr. William Shankle
The National Institute of Health and the National Alzheimer’s Association recently announced new guidelines for the diagnosis of Alzheimer’s disease, the fourth-leading cause of death in Orange County, that will make it possible to more effectively delay its progression.
Since the last revision of the guidelines in 1984, there has been great progress in understanding Alzheimer’s – the mechanisms, risk factors, biomarkers and treatments. The new guidelines incorporate this knowledge and emphasize that earlier detection will lead to more effective treatment.
The new guidelines emphasize to the public that Alzheimer’s is a disease that can be diagnosed before dementia develops, during the stage called mild cognitive impairment, or MCI. MCI begins seven to 22 years before dementia actually develops, and can be difficult to distinguish from the memory and cognitive decline due to normal aging.
Both normally aging people and those with MCI can experience a progressive decline in memory, language, judgment, reasoning, executive function or other cognitive ability. This decline may make it more difficult to perform one’s usual activities of life, but they can still be performed without assistance. Brief tests have been developed for use in primary-care medicine that can distinguish MCI from normal aging. Once MCI has been detected, the guidelines indicate how to diagnose whether it is due to Alzheimer’s or a related disorder.
The new guidelines clarify that MCI and dementia are not diagnoses, but rather levels of severity, which can be due to many causes, including (but not limited to) depression, Parkinson’s and Lewy body disease, multiple sclerosis, stroke, heart disease, diabetes, hypertension, kidney, lung, liver and thyroid diseases, sleep apnea, head injury, chronic pain, chronic fatigue syndrome, hormonal and vitamin deficiencies, and various medications.
While controversy exists about treatment efficacy, recent, carefully analyzed studies have found that Namenda® plus a cholinesterase inhibitor (Aricept®, Razadyne® or Exelon®) delays progression at all clinical stages of Alzheimer’s by 25 percent to 60 percent. Such delays substantially improve quality of life, lower healthcare costs, and significantly relieve caregiver burden.
These studies also showed that giving a cholinesterase inhibitor only is no different from not treating Alzheimer’s patients at all. Unfortunately, many patients only receive a cholinesterase inhibitor, which, combined with late detection, has led to an incorrect perception about treatment efficacy.
A public and professional educational effort is needed to help communicate the potential benefits of early, effective treatment of MCI due to Alzheimer’s and related disorders. Members of the community need to be aware that:
- Early detection of MCI can lead to more effective treatment than detection once dementia has developed.
- Early detection of MCI will require annual screening of memory and cognition for at-risk patients in primary care. After 50 years old, risk for developing MCI substantially increases.
- The tests that have been used in the past, such as the Mini-Mental State Exam, are not sensitive for detecting MCI. Other tools are available that can quickly and accurately detect MCI in clinical practice.
- Identifying and managing risk factors for Alzheimer’s is associated with up to a 50 percent reduction in the risk of developing MCI.
- Earlier detection of MCI will make it possible to develop even better treatments.
More information about what can be done to forestall MCI due to Alzheimer’s can be found through the Orange County Vital Aging Program (www.ocvitalaging.org), which also provides information about other services for aging individuals in Orange County.
Dr. William Shankle is the program director for memory and cognitive disorders at the Hoag Neurosciences Institute.