The Business of Aging

Predicting Alzheimer's - A Glimpse into the Future

A Miami Herald article titled New exams, treatments for Alzheimer's in the pipeline gives an encouraging glimpse into the future when test can predict Alzheimer's "much like cholesterol now serves as a biomarker for heart disease" and "treatment will come in the form of a vaccine".

"A ton of work is being done in the field,'' says Dr. Maria Carrillo, director of Medical and Scientific Relations for the Alzheimer's Association. ``We are on the hunt for early detection tests that can be done in a general practitioner's office. And as far as medicines are concerned, we're looking at a very robust pipeline."

What kind of tests may be used to predict AD?

Blood. The Alzheimer's Association singles out test that they believe is farther along in clinical research trials. It targets lymphocytes, or white blood cells. The test measures CD-69, a protein involved in white blood cell growth and production and was accurate 91 percent of the time in identifying Alzheimer's patients. 

Other test include Positron emission tomography (PET scans) and Spinal fluid.

As far as what to do once early AD is determined?  The article gives a decent overview of the state-of-the-state of current research and therapies. Check it out.

Alzheimer's Update - Two Findings This Week

Couple of interesting announcements this week:

One: UK drug shows early promise against Alzheimer's

A new drug against Alzheimer's disease called CPHPC, a protein known as serum amyloid P component (SAP) developed by British researchers (I believe in collaboration with Roche), has shown promise in tests on a handful of patients. Researchers found CPHPC caused the disappearance of the protein SAP which is thought to be involved in the disease, from the brains of five Alzheimer's patients who took it for three months. CPHPC targets SAP and removes it from the blood.

The results were published in the journal Proceedings of the National Academy of Science. Larger scale clinical studies are now planned. Details on the research can be found here.

Two: No benefit from tube feeding in advanced dementia

Despite the fact that up to one third of patients with severe dementia are tube fed, there is no evidence that this practice prolongs survival or improves quality of life, according to a report in the online issue of the Cochrane Database of Systematic Reviews. In fact, some data suggest that tube feeding may actually increase the death rate and the number of new illnesses, and decrease the quality of life.

By searching through multiple healthcare databases, Sampson and associates at the Royal Free & University College Medical School, London, identified seven observational studies that compared groups of patients with dementia who did and those who did not undergo tube feeding.  Of the 1821 subjects, ages 63 to 107 years, 409 were tube fed. Reasons for tube placement included inadequate food consumption, weight loss, refusal to eat and trouble swallowing.  None of the studies found a significant association between tube feeding and decreased risk of death, improved nutrition, or incidence of bed sores, the review indicates, and none of the studies evaluated quality of life or physical function.

 

Alzheimer's (and health care jobs) On the Rise

Two separate but related articles in the USA Today.

Good news and bad news.

The good news is a handful of big industries have added jobs at a remarkably high rate throughout the recession according to the Bureau of Labor Statistics reports. One of those lucky industries is health care where every part of the $2.5 trillion industry is growing and hiring has continued non-stop at hospital, out-patient clinics and physician offices. Nearly every job is in demand: nurses, lab technicians, physician assistants.

The bad news is that this increased hiring activity is a direct result of the aging population and their increased need for services. In particular - Alzheimer's - where the USA Today article titled Alzheimer's on a relentless upward trajectory   discusses how the number of people who have Alzheimer's disease is creeping insidiously higher year after year and adding increasing pressure on the health care system. A report out today, the 2009 Alzheimer's Disease Facts and Figures, indicates that an estimated 5.1 million Americans over 65 now have Alzheimer's.

The triple whammy for Alzheimer's victims, their family and society is that health care costs for dementia are more than three times higher than costs for older Americans who are not afflicted! Trust me, after having just dealt with caring for a loved with Alzheimer's I can assure you this is a fact.

Unfortunately says Bill Thies, chief medical and scientific officer of the Alzheimer's Association (which compiled the report) "we're seeing the government reducing dollars for Alzheimer's disease. Clearly, that's an equation going in the wrong direction."

I agree. 

Another Potetial "drug" in the Fight Against Alzheimer's - Vitamin B3

Another potetial "drug" in the fight against Alzheimer's is an over the counter vitamin - B3 (Nicotinamide). Researchers at the University of California have discovered that Nicotinamide lowers levels of a protein called phosphorylated tau that leads to the development of tangles associated with Alzheimer's disease.  In the study, researchers added Nicotinamide to the drinking water of mice with AD. They then tested the rodents short and long term memory and found that treated Alzheimer's mice performed at the same level as normal mice and untreated mice experienced memory loss. This suggests that people with Alzheimer's (even people without AD) may find their memory improves by taking Nicotinamide which can be found at more health food stores.

I also updated my previous blog posting that gives a nice overview of all currently approved FDA drugs and those in the pipeline for the treatment of Alzheimers. 

Another Alzheimer's Drug Making Headlines

Another new Alzheimer’s drug (this one from TauRx Therapeutics) could prove at least twice as effective in treating Alzheimer’s disease as current medications and significantly slow the progression of dementia, researchers say. This according to a research team at the University of Aberdeen that concluded the drug (Rember - what a great brand) slows progression of the disease by up to 81 per cent. 

Sufferers taking the drug three times a day for 50 weeks showed a slower decline in blood flow to the parts of the memory that are vital to the memory. Those taking a 60mg dose of Rember experienced an 81 per cent reduction in mental decline compared with the placebo group. Those taking Rember did not experience a significant decline in their mental function over 19 months, while those on the placebo got worse.

Experts hailed the study as a major development in the fight against Alzheimer’s, which affects an estimated 26 million people worldwide. It is projected that the number suffering from the disease will leap to over 106 million by 2050.

Here is what's cool. The drug is the first medication directly to attack the “tangles” that develop in the brains of those affected. These tangles, made up of a protein known as tau, form inside nerve cells in the brain and impair concentration and memory. The tangles first destroy the nerve cells linked to memory and then destroy neurons in other parts of the brain as the disease progresses.

Other Alzheimer's drugs have also shown early promise but failed so time will tell if this one actually works. Derek Lowe posted a very informative blog about Alzheimer's drugs in his blog In the Pipeline:

"Accumulation of amyloid protein has long been suspected as the cause of the disease, but there have always been partisans for another pathology, the neurofibrillary tangles associated with tau protein. Arguments have been going on for years – decades – about which of these has more to do with the underlying cause(s) of Alzheimer’s. Rember is the first clinical shot (that I’m aware of) at targeting tau. If the first attempt manages to show such interesting results, it’s a strong argument that tau must be important. (Other people are working in this area, too, of course, but my impression is that it's nowhere near as many as work on amyloid)." 

Here is a summary of some Alzheimer's drugs - some approved and some experimental. I'm not a Dr. and I compiled this list doing Internet research so please don't hold me to it.

Most currently approved Alzheimer's drugs are cholinesterase inhibitors including:

• Donepezil (Aricept)  
• Galantamine (Razadyne) 
• Rivastigmine (Exelon) 
• Memantine (Namenda) works by regulating the activity of glutamate, a different messenger chemical involved in learning and memory.
• Tacrine (Cognex)

Other drugs focus on anti-amyloid and include (all experimental):

• Tarenflurbil (Flurizan)
• Bapineuzumab (from Elan)
• Tramiprosate (Alzhemed)

Some researchers are beginning to focus on alternative targets to amyloid. Some of these include:

• Dimebolin (Dimebon) - antihistamine drug first used in Russia more than two decades ago to treat alergies
• Methylthioninium chloride (Rember) - from TauRx and described above.

An over the counter (OTC) vitamin showing promise:

• B3 (Nicotinamide) 

I wish them all luck.

This article from Forbes discusses these drugs. Another good read is from the Alzheimer's Association  and from CNN Health.

 

Assisted Living for Individuals with Alzheimers. Do Your Homework. Manage Expectations.

My mom has advanced Alzheimer's disease (AD). In the early stages of her dementia we kept her in her home. Something I highly recommend for any senior who wants to remain at home, be safe and can still communicate this preference. Eventually, as my mom's needs increased, we hired a 'companion' from a local home care company. The one I used was Comforcare - excellent agency but it's a franchise business model so quality may vary by location.

Initially the companion visited my mom for a few hours each day (about $20 per hour and covered by most Long Term Care insurance policies) but as my mom's needs increased we increased the hours. Eventually, we hired a full-time live in from the agency for about $200 per day. Sounds like a lot and it is but quality residential care (e.g., assisted living) can be more than this in some locations.

Eventually, my mother's needs became more than what a single caregiver in the home could effectively manage. At this point we moved her to an assisted living facility. But wait, how can you place someone with AD into "assisted living" if they can't care for themselves?

As it turns out, most assisted living facilities have a dedicated floor for residents with AD. If a family can afford it, it's a better option than a nursing home (way better). If you do choose this option, in addition to the obvious questions to ask a facility , make sure the AD section is on a ground floor, residents can walk outside on their own (fenced in area of course), the staff is trained in AD, rooms have sensors to detect at-night wandering, there is plenty of stimulation, residents can get out once in a while (via a bus with a lift) and daily schedules are flexible.  One such facility that I am familiar with that meets all of these requirements is Aegis Senior Living - in particular, the Aptos, CA location. This is a very impressive facility. They "get it" when it comes to assisted living for AD.     

Now, here is where it gets interesting and why you need to do your homework when considering assisted living for people with AD.

Assisted living facilities do not typically provide one-on-one care. So if you need assistance getting dressed, going to the bathroom, getting to-and-from meals, etc. your going to have to pay extra for these services or hire an outside agency (like Comforcare) to provide "supplemental" care. And as your needs increase an assisted living facility may ask you to provide 24/7 supplemental care. So it is not uncommon to be paying close to or in excess of $100,000 a year for care in some areas.  In my experience the good assisted living facilities will be very clear about this but the not-so-good ones will be vague about it. Remember, when you take a tour of an assisted living facility the tour guide is a sales person. They get paid to place residents.

So what can a family do that can't afford this option? They typically end up spending all of the elder's money on care and then qualify for Medicaid. True, you can "spend down" or "gift" assets to other family members to qualify for medicaid faster but the laws make it very difficult to do this - and part of me understands and accepts the reasons why. 

Crazy isnt it? Yes it is. The sad truth is that families of AD patients get a double whammy because they need to spend so much more on supplemental care. And to make matters worse, the tax code and LTC insurance companies do not distinguish between elders with AD and those without so you are subject to the same daily maximums and restrictions.

I don't blame anyone for our imperfect system but as one Geriatric Care Manager recently told me "when congressional leaders have to begin caring for loved ones with AD I think the rules will be changed".

I hope you are right Nancy and I have a feeling changing this imperfect system is the final legacy the Baby Boomers will leave us with. They have the numbers and the influence to do so.

At least I hope so.

"Breakthrough" research for Alzheimer's disease

Two new studies published in the UK medical journal The Lancet  discuss potentially better treatments for Alzheimer's disease.

Study One:
Researchers at the Baylor College of Medicine did a controlled trial to test the safety and success of the orally-taken drug Dimebon  (a drug once used in Russia as an antihistamine)  to see if it reduced the symptoms of mild to moderate Alzheimer's disease. Patients were assessed over six months using a scale that measures brain function such as thinking and memory. They found that it significantly improved the course of the disease and that benefits increased over the course of 12 months. Commenting on the trial, Susanne Sorensen, head of research at the Alzheimer's Society, said: "This encouraging research suggests Dimedon may be an effective treatment for the symptoms of Alzheimer's disease. These initial findings imply that Dimedon could be more effective than treatments currently licensed for people with Alzheimer's, however this was a modest sized study."

According to information on wikipedia, "Dimebon appears to operate through multiple mechanisms of action, both blocking the action of neurotoxic beta-amyloid proteins and inhibiting L-type calcium channels, modulating the action of AMPA and NMDA glutamate receptors, and may exert a neuroprotective effect by blocking a novel target that involves mitochondrial pores,[9] which are believed to play a role in the cell death that is associated with neurodegenerative diseases and the aging process."

Study Two:
The consensus amongst dementia scientists has always been that removing amyloid plaques was the key to defeating Alzheimer's but according to this 2nd study, that may need to be rethought.  British researchers discovered that drug vaccination can remove amyloid plaques in the brains of people with Alzheimer's disease but that this did not necessarily slow down the disease. The five-year study examined 80 patients with mild to moderate dementia who had been immunized with AN1972, a drug which acts to clear these plaques from the brain. Contrary to predictions, removal of amyloid plaques did not result in an improvement in cognitive function or survival. Several patients with complete plaque removal deteriorated severely.  Lead researcher Professor Clive Holmes of the University of Southampton said: "Our results suggest that brain deterioration can occur in Alzheimer's despite the removal of plaques. It may be that these toxic plaques trigger the neurodegeneration but don't have an ongoing role. This study opens up numerous avenues for further research."

Rebecca Wood, chief executive of the Alzheimer's Research Trust, commented: "It is disappointing that anti-amyloid treatments did not prevent the disease's progress, but we still need to do more research into whether earlier removal of this initial 'motor' of the disease could slow its progression. These findings underline the need to take a variety of research approaches in a multi-pronged attack on this devastating disease."

Follow-Up: Wyeth Alzheimer's Drug Fails to Meet Goal in Trial

We blogged about a potentially promising new treatment for Alzheimer's back in April 2008 but unfortunately, the Phase 3 clinical trials were disappointing. According to the drug makers (Wyeth and Elan), "bapineuzumab's ability to improve Alzheimer's symptoms was not significantly different from those on placebo."

New Way to Fight Alzheimer's and Actually Reverse Damage?

Interesting article I read today about a new kind of Alzheimer's drug designed to "hitch-hike" into cells that reverses the signs of Alzheimer's disease when injected into the brains of mice - it may become a potent new treatment for humans according to researchers.

Read the entire article.

Here is a synopsis:

"The compound effectively blocks an enzyme responsible for the build-up of sticky deposits, or plaques, in the brain by attaching to exactly the right spot on the cell wall where the toxic activity takes place. If all goes well, a version could be available for use by patients in five to 10 years, said Kai Simons of the Max Planck Institute of Molecular Cell Biology and Genetics in Dresden.

"It's clear that when it is injected into the brain of mice it works," Simons told Reuters. "The next stage is to see if can cross the blood-brain barrier ... if we get it through, it has huge potential."

Alzheimer's is a hot area for pharmaceutical research, since the incidence of the degenerative brain disease is rising rapidly as people live longer. But developing effective treatments has proved notoriously difficult. Existing drugs such as Aricept from Pfizer and Eisai, Exelon by Novartis and Razadyne or Reminyl from Johnson & Johnson and Shire can ease symptoms but do not stop the disease. One new drug that could make a real difference is an experimental antibody-based treatment called bapineuzumab from Wyeth and Elan, which is now in final Phase III clinical tests.

The World Health Organization estimates there are about 18 million people worldwide with Alzheimer's disease and this figure is projected to reach 34 million by 2025."

New Study: One in Seven Americans over Age of 70 Suffers From Dementia

Thanks to David J Levy, JD CCE from the American Association for Caregiver Education who sent me the following details of a recent study showing that one in seven Americans over the age of 70 suffers from dementia.

Published in the November 2007 issue of Neuroepidemiology, the study is based on data from 856 men and women who participated in the Aging, Demographics and Memory Study conducted in 2002 by researchers at the University of Michigan Institute for Social Research (ISR) and Duke University Medical Center and funded by the National Institute on Aging. The study was part of the larger ISR Health and Retirement Study, a nationally representative survey of Americans age 51 and older.

About 3.4 million people, or 13.9 percent of the population age 71 and older, have some form of dementia, the study found. As expected, the prevalence of dementia increased dramatically with age, from five percent of those aged 71 to 79 to 37.4 percent of those age 90 and older.

About 2.4 million of those with dementia, or 9.7 percent of the population age 71 and older, were found to have Alzheimer's disease, the most common cause of dementia, according to the study.

Overall, the researchers found that Alzheimer's disease accounted for approximately 69.9 percent of all dementia, while vascular dementia -- often caused by stroke -- accounted for 17.4 percent. With increasing age, Alzheimer's disease accounted for progressively more of the dementia cases, so that in the 90+ age group, it comprised 79.5 percent of dementia cases, compared to 46.7 percent among those in their 70s.

The study provides the first prevalence estimates based on a nationally representative sample of older adults from all regions of the United States. Four previous national estimates of the prevalence of Alzheimer's disease were all obtained by extrapolation from regional samples. These estimates ranged from 2.1 million to 4.5 million.