By Kate Scannell MD, Contributing columnist Bay Area News Group
PUBLISHED IN PRINT 08/22/2010
SO MANY news reports about Alzheimer's dementia flooded the media within the last few weeks that it's hard to remember them all.
Where to begin? That question not only prompts topics for this column, it also presents a fundamental question about the most appropriate time to begin diagnosing someone with Alzheimer's. Can a diagnosis of dementia ever be made too soon in a person's life?
In this regard, we learned about two new tools that might diagnose people with Alzheimer's earlier than was previously possible. (Way earlier.)
Traditionally, physicians diagnose dementia only after a person develops three conditions: impaired memory; a deficiency in at least one other intellectual capacity (like recognizing familiar objects or performing familiar tasks); and, as a result of those impairments, the inability to continue functioning within the world of his own making -- at home, at work, among friends.
But our two new tools -- a certain type of brain scan (a PET scan) and a spinal fluid test -- aim to detect Alzheimer's before a person even demonstrates any evidence of memory or functional impairment.
Instead, these tests look for evidence of "amyloid" buildup in the brain -- what many scientists consider to be the cause or precursor of Alzheimer's. The new tests establish, in essence, a pathological condition of "pre-dementia Alzheimer's" in an otherwise healthy person.
Diagnosing "pre-diseases" -- like "pre-diabetes" or "pre-hypertension" -- has become an increasingly common practice in our medical culture. Ironically, this tendency continues to expand all the while that millions of Americans find it increasingly difficult to access and afford health care for established, de-facto illnesses.
And, it should be noted, this trend also enlarges the already sizable pool of people with "pre-existing conditions" -- or, I suppose, "pre-pre-existing conditions" -- who will surely do battle with insurance companies in hopes of securing health coverage.
The pre-disease bandwagon additionally offers pharmaceutical companies the promise of a great ride. As prospectors used to claim during the old Gold Rush era, "There's opportunity in them thar' ills." Speculating on pre-illnesses raises opportunities to encourage medication intake earlier in patients' (or pre-patients') lives, and to develop new and extended drug markets.
And on a cultural level, every time we diagnostically label millions of healthy people with a "pre-disease," we progressively pathologize the human condition. In the U.S., the so-called national character has come to resemble Woody Allen more than the Marlboro man (without his cigarette pack). If we are not ill, we should expect to be so and to suffer the attendant anxiety. We may have entered "Prozac Nation" a decade ago, but now we squarely reside within a pre-Prozac state.
Of course, it is often helpful to know about one's "pre"-disposition to develop a disorder if there exists some chance to ward off the disease. That may work well with diabetes or high blood pressure, where weight control and lifestyle changes may exert preventive effects. But no such pre-emptive intervention exists for people who might develop dementia in the long run.
Even for people carrying firm diagnoses of Alzheimer's, news on the therapeutic front remains guarded. A few days ago, one of the "more promising" therapies for Alzheimer's -- Eli Lilly's semagacestat -- was abandoned after a trial showed that it actually worsened memory loss and also increased the risk of developing skin cancers.
Our newfound tools to diagnose Alzheimer's in pre-demential stages provide real hope in one regard: they may allow researchers to understand how the disease begins and progresses, and how it may be circumvented before it wreaks havoc on the human brain. That may lead to effective therapies -- someday in the future.
But for now, in my opinion, those tools should be used primarily within a controlled research setting that seeks to answer those questions. It is too easy for such tools, greased by the technological imperative, to slip into mainstream medical practice.
Besides, it is well-known that the presence of brain amyloid cannot accurately predict that someone is going to acquire Alzheimer's, and upward of one-third of elderly adults function normally with these plaques in their brains.
Some people will want to undergo the new tests for Alzheimer's the moment they first forget where they placed their car keys. But for many others, the tests could prove harmful with little or no benefit in sight.
Psychological distress -- for the patient and his family -- coupled with threats to insurability, job protections and legal standing could easily result and impinge upon the quality of a person's life for years or decades to come.
Last month, the National Institute on Aging and the Alzheimer's Association proposed revised diagnostic guidelines for Alzheimer's that incorporate use of the new, imprecise and costly tests. It's not evident that these guidelines have kept most patients in mind.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––-
Kate Scannell is a Bay Area physician and syndicated columnist. Her new novel is "Flood Stage."
Copyright by Kate Scannell, 2010
PUBLISHED IN PRINT 08/22/2010
SO MANY news reports about Alzheimer's dementia flooded the media within the last few weeks that it's hard to remember them all.
Where to begin? That question not only prompts topics for this column, it also presents a fundamental question about the most appropriate time to begin diagnosing someone with Alzheimer's. Can a diagnosis of dementia ever be made too soon in a person's life?
In this regard, we learned about two new tools that might diagnose people with Alzheimer's earlier than was previously possible. (Way earlier.)
Traditionally, physicians diagnose dementia only after a person develops three conditions: impaired memory; a deficiency in at least one other intellectual capacity (like recognizing familiar objects or performing familiar tasks); and, as a result of those impairments, the inability to continue functioning within the world of his own making -- at home, at work, among friends.
But our two new tools -- a certain type of brain scan (a PET scan) and a spinal fluid test -- aim to detect Alzheimer's before a person even demonstrates any evidence of memory or functional impairment.
Instead, these tests look for evidence of "amyloid" buildup in the brain -- what many scientists consider to be the cause or precursor of Alzheimer's. The new tests establish, in essence, a pathological condition of "pre-dementia Alzheimer's" in an otherwise healthy person.
Diagnosing "pre-diseases" -- like "pre-diabetes" or "pre-hypertension" -- has become an increasingly common practice in our medical culture. Ironically, this tendency continues to expand all the while that millions of Americans find it increasingly difficult to access and afford health care for established, de-facto illnesses.
And, it should be noted, this trend also enlarges the already sizable pool of people with "pre-existing conditions" -- or, I suppose, "pre-pre-existing conditions" -- who will surely do battle with insurance companies in hopes of securing health coverage.
The pre-disease bandwagon additionally offers pharmaceutical companies the promise of a great ride. As prospectors used to claim during the old Gold Rush era, "There's opportunity in them thar' ills." Speculating on pre-illnesses raises opportunities to encourage medication intake earlier in patients' (or pre-patients') lives, and to develop new and extended drug markets.
And on a cultural level, every time we diagnostically label millions of healthy people with a "pre-disease," we progressively pathologize the human condition. In the U.S., the so-called national character has come to resemble Woody Allen more than the Marlboro man (without his cigarette pack). If we are not ill, we should expect to be so and to suffer the attendant anxiety. We may have entered "Prozac Nation" a decade ago, but now we squarely reside within a pre-Prozac state.
Of course, it is often helpful to know about one's "pre"-disposition to develop a disorder if there exists some chance to ward off the disease. That may work well with diabetes or high blood pressure, where weight control and lifestyle changes may exert preventive effects. But no such pre-emptive intervention exists for people who might develop dementia in the long run.
Even for people carrying firm diagnoses of Alzheimer's, news on the therapeutic front remains guarded. A few days ago, one of the "more promising" therapies for Alzheimer's -- Eli Lilly's semagacestat -- was abandoned after a trial showed that it actually worsened memory loss and also increased the risk of developing skin cancers.
Our newfound tools to diagnose Alzheimer's in pre-demential stages provide real hope in one regard: they may allow researchers to understand how the disease begins and progresses, and how it may be circumvented before it wreaks havoc on the human brain. That may lead to effective therapies -- someday in the future.
But for now, in my opinion, those tools should be used primarily within a controlled research setting that seeks to answer those questions. It is too easy for such tools, greased by the technological imperative, to slip into mainstream medical practice.
Besides, it is well-known that the presence of brain amyloid cannot accurately predict that someone is going to acquire Alzheimer's, and upward of one-third of elderly adults function normally with these plaques in their brains.
Some people will want to undergo the new tests for Alzheimer's the moment they first forget where they placed their car keys. But for many others, the tests could prove harmful with little or no benefit in sight.
Psychological distress -- for the patient and his family -- coupled with threats to insurability, job protections and legal standing could easily result and impinge upon the quality of a person's life for years or decades to come.
Last month, the National Institute on Aging and the Alzheimer's Association proposed revised diagnostic guidelines for Alzheimer's that incorporate use of the new, imprecise and costly tests. It's not evident that these guidelines have kept most patients in mind.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––-
Kate Scannell is a Bay Area physician and syndicated columnist. Her new novel is "Flood Stage."
Copyright by Kate Scannell, 2010