America’s Collision Course With The Debt Ceiling
As the nation counts down to default, Diane talks to longtime Congress watcher Norm Ornstein about the debt limit negotiations, what's at stake and whether he sees a way forward.
Scientists from around the world are meeting in Washington, D.C. this week to share research on Alzheimer’s. Five million Americans suffer from this disease, and without preventative strategies or a breakthrough in treatment, experts predict this number will exceed 13 million by 2050. But there is some good news: Researchers say they are developing better tools to determine an individual’s risk for developing Alzheimer’s later in life and are learning more about the kinds of interventions that can slow the progression of the disease. We get an update on the latest Alzheimer’s research.
MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA Today sitting in for Diane Rehm. She's on vacation. Scientists are racing against time on Alzheimer's. Without improvements in diagnosis or the discovery of a cure, millions of baby boomers will develop the disease in the coming decades. Joining me to talk about promising areas of Alzheimer's research, Dr. Nancy Donovan of Brigham and Women's Hospital in Boston, Dr. Murali Doraiswamy of Duke University and Keith Fargo of the Alzheimer's Association.
MS. SUSAN PAGEWelcome to "The Diane Rehm Show."
MR. KEITH FARGOThanks.
DR. NANCY DONOVANThank you, very nice to be here.
DR. MURALI DORAISWAMYHappy to be here.
PAGEWe're going to invite our listeners to join our conversation with their calls, their comments, perhaps their own experience with Alzheimer's. Later in this hour, our toll-free line will be open, 1-800-433-8850. You can always send us an email at email@example.com or find us on Facebook or Twitter. Well, Keith Fargo, let's start with you. The Alzheimer's Association hosting a conference for Alzheimer's researchers from around the world. Tell us a little bit about this gathering.
FARGOSo the Alzheimer's Association hosts the Alzheimer's Association International Conference, which you'll hear me call AAIC probably throughout the hour. We host this AAIC conference every year to bring together, as you mentioned, the scientists from around the world. We actually have close to 4500 people here this year in Washington D.C. from 65 countries. And this is really where the world comes together to talk about the latest in dementia research.
PAGEDr. Murali Doraiswamy, give us a sense of how big a problem Alzheimer's is at this point in the United States.
DORAISWAMYIt's huge. It affects approximately about 5.5 million people and the numbers are expected to triple in the coming decades as the population ages. And another unusual fact that many listeners may not know is that women bear the preponderance of the burden of Alzheimer's both in terms of the numbers of people who are affected and women are also the majority of caregivers.
PAGEAnd in terms of the cost to our healthcare system, to our healthcare programs like Medicare, how much is it costing us?
DORAISWAMYCurrently, the best estimate is around $600 billion, perhaps. But if you look at unpaid costs, such as the cost of care-giving at home, et cetera, it's probably in the trillions and the numbers are going to go up. I think it's been estimated that if Alzheimer's was a country, it would probably rank in the top 30 or 20 GDP economies of the world so it's a very expensive problem.
PAGEAnd we see this looming, becoming an even bigger issue ahead in the United States. Is it the same around the world?
DORAISWAMYYes. China is going to face the biggest burden because the population is aging very rapidly. I think China already has the most numbers of people with Alzheimer's disease and the numbers are going to grow very rapidly in low and middle income countries around the world.
PAGEDr. Nancy Donovan, you say this is an important time for Alzheimer's research. What do you mean?
DONOVANWell, I think that recent developments in the detection of preclinical Alzheimer's disease are really exciting and this opens up the possibility of intervening early, perhaps even in pre-symptomatic phases of the disease. We're not there yet, but actually at our institution and at other institutions across the country, we have initiated the first prevention trial for sporadic Alzheimer's disease.
DONOVANSo research is showing us that we can detect preclinical stages of Alzheimer's disease using neuro-imaging and we're actually starting to intervene now in trials in A-symptomatic people.
PAGESo when you talk about preclinical, this means maybe you have not symptoms at all and so what do you -- how do you go about determining that someone is either developing Alzheimer's or at high risk of developing it?
DONOVANWell, currently, there are research criteria which define three stages of preclinical Alzheimer's disease and the first is defined by the accumulation of a protein called amyloid in the brain and that's able to be detected with a certain type of a brain imaging. And that is how we define the first stage of preclinical Alzheimer's disease.
DONOVANAnd in the second stage, there are also neuro-imaging changes that are defined by a loss of brain tissue or increases in a protein called tau in the cerebral spinal fluid. And also, what's really exciting right now is just in the past couple of years, researchers at our institution and elsewhere have started to image this protein called amyloid -- I'm sorry, this protein called tau in the brain and that helps us identify people who've not only experienced changes characteristic of phase one, but also the stage two changes.
DONOVANAnd then, stage three is when people are starting to have subtle changes. They don't yet have cognitive impairment, but they do have subjective cognitive changes. And we think they also may have some subtle behavioral changes.
PAGEKeith, this is really a big change. I can remember when it came to Alzheimer's that you couldn't diagnose it until someone died and you did an autopsy.
FARGOThat's right. It hasn't been that long ago so about 10 years ago in 2004, we saw the first publication on a compound called Pittsburg compound B, which was really the first time that you could image amyloid in the living brain and so, as you said, instead of waiting till autopsy to find out whether a person actually these plaques and tangles, you could tell at least about the plaques while a person is still alive.
PAGESo Dr. Doraiswamy, you can now find out that you're developing Alzheimer's. Can you then do something about it?
DORAISWAMYNot yet. There's no magic bullet to prevent the onset of Alzheimer's or delay its course, but there are a number of trials underway and those are some of the most promising areas. Nancy talked about them. There are about half a dozen prevention trials currently underway that are testing various strategies, including drugs and lifestyle strategies such as exercise, brain training and Mediterranean diet.
PAGEYeah. So what seems to be working? Are there -- you have these trials going on. Is anything helping to slow the progress of the disease?
DORAISWAMYWell, nothing is proven yet, but I think the best evidence comes from what we call observational studies, which suggest that regular aerobic exercise, leading a heart-healthy lifestyle. In other words, what's good for the heart is good for the brain. A Mediterranean diet that's low in saturated fats, lots of vegetables, an occasional serving of red wine. I think those are the strategies perhaps best studied.
PAGENancy Donovan, when people are at the early stages, these preclinical stages of Alzheimer's, do they know something has happened? Do patients come to you and say, I can't really -- something is happening. I don't know what it is.
DONOVANWell, what's really interesting is the research into what we call subjective cognitive concerns. And certainly, as people age, it's almost universal that people notice changes in their cognition. However, we're trying to identify which particular changes in cognition are signal and not noise and it's likely that memory-related changes, as opposed to other types of changes are most salient.
DONOVANSo but then, as people progress in the disease, it turns out that individuals start to lose their awareness of their own cognitive changes and it's actually their loved ones that provide more important information about whether or not they're declining.
PAGEIf there's not much--if there's nothing proven that you can do to slow the progress of the disease, is it better to know? Keith Fargo, what do you think?
FARGOIt is. And the reasons for that are several. And number one, Alzheimer's disease is a progressive disease that, unfortunately, always ends in death. So once you have Alzheimer's disease, you will get worse until the end comes. And what that means is that the earlier that you know about your own condition, the more that you can participate in your own care, the more that you can make decisions about what you want to happen financially with your estate, the more that you can -- and this is really critical -- participate in clinical trials for Alzheimer's disease because the only way that we're ever going to get to where we do have a medication that works with Alzheimer's disease is if people can participate in those clinical trials.
PAGEBut Dr. Doraiswamy, this must be a tough conversation to have with a patient.
DORAISWAMYYeah, it is because lots of times, you know, people are worried they're going to lose their driver's license, they're going to lose their financial, you know, ability to sort of write checks or manage your own affairs, but...
PAGEAnd they're right.
DORAISWAMYAnd they are right. And so I think it's very important to make an accurate diagnosis and that's why some of these newer tools, such as neuro brain scans, new genetic tests are going to be very important because until recently, maybe about 30 percent of patients who we used to call as Alzheimer's just on the basis of clinical exams, currently it appears that they may have other conditions other than Alzheimer's.
PAGESo what kind of conditions are misdiagnosed as Alzheimer's?
DORAISWAMYRight. So that's the other reason why it's important to get tested because a number of metabolic conditions, depression, stress, anxiety, sleeplessness, all of those can mimic some type of dementia. So you can potentially reverse vitamin deficiencies, such as B12 deficiency. You can potentially reverse thyroid problems, depressions that's detected can be treated with anti-depressants or therapy.
DORAISWAMYIf someone's just very anxious, they can be reassured and very often, that's a huge benefit of early diagnosis and assessment.
PAGEYeah. So definitely one reason to try to find out. You know, I do the kenken puzzle every morning. I do the crossword puzzle until Thursday when it gets too hard for me. And I see these ads on TV that offer brain exercises and the implication is that this is a way to stave off things like Alzheimer's. Nancy Donovan, can that help?
DONOVANYes. I think it can help, certainly. I think that involvement in more complex mental activities and in novel cognitive activities is probably very helpful as well rather than doing the same types of puzzles over and over again. You know, there are other factors, social interaction seems to be very important in preserving cognition and that may also be a cognitive test as well as a way of, you know, feeling better and experiencing more pleasure.
DORAISWAMYYeah, so there's this concept that's a very exciting new concept called cognitive reserve. In other words, it's kind of almost like building up extra hardware and software in the brain and having -- it's almost like if you think about cell phone towers, if you have multiple cell phone towers in the brain, even if a few get knocked out, your call doesn't get dropped because you can switch to another tower. And so one of the theories is that the more you do novel and challenging activities, such as crossword puzzles, it builds up cognitive reserve.
PAGEWe're going to talk about the prospects for a cure of Alzheimer's when we come back after a short break. Stay with us.
PAGEWelcome back. I'm Susan Page of USA Today sitting in for Diane Rehm. And with me in the studio, Dr. Nancy Donovan. She's a geriatric psychiatrist at Brigham and Women's Hospital. She's at the Center for Alzheimer's Research and treatment and an instructor in psychiatry at the Harvard Medical School. Also joining us, Dr. Murali Doraiswamy. He's a professor of psychiatry and behavioral sciences and director of the Neurocognitive Disorders Program at Duke University. And Keith Fargo, he's director of scientific programs and outreach at the Alzheimer's Association, which is hosting a big conference in D.C. this week with more than 4,000 researchers from 65 countries.
PAGELet's take some of your calls and questions. We'll go first to Winston-Salem, North Carolina, and talk to Claudia. Claudia, hi, you're on the air.
CLAUDIAHi, thank you for taking my call. My question has to do with the genetic factor. My mother's father died of Alzheimer's, my mother now has Alzheimer's and is in a facility, and I'm just wondering about my chances. And what can I do? Can I get tested? And I'll take my answer off the air.
PAGEClaudia, thanks for your call. So what, Dr. Doraiswamy, what is the genetic factor? If your parents, your grandparents, have Alzheimer's, should you consider yourself at high risk?
FARGOYeah, I think if you have a dad or a mom with Alzheimer's, then your risk goes up about two- to three-fold. So let's assume the average person's risk is about one in 10 of getting Alzheimer's, if you have a family history, your risk might be about three out of 10. So it's still probably not 60 or 70 percent. The second issue is the younger the age at which your parents have gotten Alzheimer's, the greater the risk for yourself.
PAGEHow -- we think of Alzheimer's as being a disease of the elderly. How young can people show signs of Alzheimer's now?
DORAISWAMYWell, with familial Alzheimer's, the youngest cases have been in the 30s. So it depends on how aggressive the genetic risk that you've inherited from your dad or your mom.
PAGEBut the older you get, the higher the risk is that you develop it?
DORAISWAMYYes, age is a risk factor, as well, but if your parents got it at a very late age, like in their 90s, then the genetic inheritability is a little bit weaker than if your parents got it in their 60s.
PAGEWhat are the other risk factors, Nancy Donovan, Dr. Donovan, for Alzheimer's besides a family history?
DONOVANCardiovascular health or cardiovascular risk factors are very important. In our research, we're interested in looking at psychiatric risk factors, actually, and other, more lifestyle-related risk factors. For older adults who have depression, there's an increased risk of Alzheimer's disease, as well.
PAGEOr stress. Is stress a risk factor?
DONOVANYes, there's increasing evidence for that. I presented work looking at loneliness as a form of psychosocial stress that, along with depression, seems to increase the risk of cognitive decline.
FARGODiabetes is also an important risk factor for Alzheimer's disease, and we've known that for a while now with type 2 diabetes. And actually we just saw a presentation earlier this week, at AAIC, for the first time looking at type 1 diabetes as also increasing a person's risk for Alzheimer's disease.
PAGEIs the problem having stress? Because we all of stress in our lives. Or is it your response to stress? Because I have to say, I've got a kind of a stressful life, which I kind of, I like. You know, I sort of like being under stress. If I'm on vacation, I feel like gee, I wish there was a little more stress.
FARGOI think it depends on how you handle stress. If you feel you can control the stress, then obviously it's almost like riding a choppy water with a surfboard. You know, if you drowned by the water, then that's when I think stress starts affecting you. So we have a model in animals called learned helplessness. If you're not able to control the stress, it's overwhelming you, then your body has a surge of a hormone called cortisol, and cortisol is a stress hormone, and evidence suggests that cortisol can damage brain cells if there's prolonged exposure to cortisol.
PAGEDr. Nancy Donovan, you talked about loneliness being a kind of a risk factor. How about not being -- being pretty sedentary. Is that also a risk factor?
DONOVANYes, there was also research showing that a sedentary lifestyle, even in mid-life, is a risk factor for cognitive decline and dementia risk. In fact, they looked at -- in this particular study, they looked at the number of hours of TV viewing, and TV viewing over four hours a day was an independent risk factor.
PAGEYes, let's go back to the phones and let some of our listeners join our conversation. Let's go to Christine, who's calling us from Columbia, Missouri. Christine, thanks for joining us on "The Diane Rehm Show."
CHRISTINEHi, thank you so much for taking my call. I was caregiver to my mother for three years before she passed away at age 82, and she was diagnosed with a non-specific dementia, and we were referred to the local Alzheimer's support group. But I feel like I had to fight for her with siblings, other family members. Her Dr. Beversdorf (PH) was just wonderful. He stuck by us. But my argument was when I lay things out clear and concisely to her, she could make her own decisions.
CHRISTINEAnd I was so disappointed with the support group, you know, with their attitude that, don't worry, they won't remember, she won't remember in the morning, or she won't remember tomorrow whether you were there or not. And it's so much about being in the present and in the moment and keeping their sense of dignity.
PAGEChristine, thanks so much for your call, and I'm sure your mother very much appreciated your care of her in those final years. Keith?
FARGOI mean, support is difficult. Being a caregiver is a really, really hard job. And we talk about there are more than five million Americans who are living with Alzheimer's disease today. There are over 15 million people who are difficult job of providing care for those folks. And we know that not only does that produce stress in the caregiver, that stress actually also has physical consequences.
FARGOAnd we know that people who are caregivers for someone with Alzheimer's disease actually spend $9 billion more per year on their own health care in the U.S. So caregiving is difficult, and keep trying to find the most support that you can.
PAGEWhat do you advise families that are facing having a loved one who's been diagnosed with Alzheimer's, beginning to show the signs? What should they -- what should they do, and how should they proceed, do you think?
FARGOSo the most important thing is to talk to your physician. If you think you have -- if you think you have memory problems or concerns, or if you notice something in a loved one, definitely talk to a physician. Do not assume that this is normal aging. Do not assume that it's Alzheimer's disease. But consult with a physician, get a good diagnosis and figure out what the prognosis is for your particular case.
PAGEDr. Nancy Donovan, what do you advise families or patients when they're facing an Alzheimer's diagnosis?
DONOVANWell, it's not something that progresses overnight. I think that's something to keep in mind. There's a traumatic effect to getting that diagnosis, but in general it's about an eight-year course of disease for people after the time of diagnosis. It can vary. And I think that we do have ways of potentially slowing the progression by engaging in mental activities and optimizing lifestyle. I think that with respect to the previous caller, some people have more pure forms of Alzheimer's disease, and other people have more mixed forms of dementia. So I think you really have to take a very individualistic approach to the patient and the family and respect the person who is suffering from the disease and try and preserve that person and the family structure, the dynamics of the family.
PAGESo we've talked about risk factors and about experiments on trying clinical trials and trying to figure out how to slow the progress of the disease. What about curing it, Dr. Murali Doraiswamy? Is there a prospect that we can find a cure for Alzheimer's?
DORAISWAMYWell, that is the holy grail, and I think the first thing we have to do is try to fully understand what causes Alzheimer's, and that's the puzzle we are getting very close to cracking, I think. For example at this year's conference, there have been a number of presentations that have given us some insights as to what are the timelines of Alzheimer's disease and what are the mechanisms underlying the disease.
DORAISWAMYFor example, it was mentioned that there's a buildup of certain pathologies in the Alzheimer's brain, the plaques and tangles. And now what we know is that the plaques might start accumulating in the brain silently 15 or 20 years before the full clinical symptoms begin. Now the tangles, or the second kind of pathology, appear to start, you know, accumulating in the brain maybe closer to the onset of symptoms.
DORAISWAMYSo now that we know that timeline, we can begin to target each one of these pathologies with specific types of drugs that we are -- currently they are using a type of drug called antibodies, which are almost like they go and hone in to that specific abnormal pathology. So these trials are going to -- they're underway, a number of trials. They're going to report in about three to four years. Some trials are actually being reported this week at the conference.
DORAISWAMYI think cure is still far away. I won't use that word yet, in the next three to four years.
PAGEHere's a tweet from Alicia. She writes us, has there been any breakthrough with learning how to dissolve amyloids without damaging other tissue? Is that the kind of thing that is trying to be done?
PAGEAnd do you have signs that you can do that?
DORAISWAMYYeah, I think so, and I think animal studies, we've been very successful, and today, for example, there are going to be at least four or five new studies that are going to be presented. They all look quite promising.
PAGEAlicia, thanks for your tweet. Let's go back to the phone. We'll talk to John. He's calling us from Marble Falls, Texas. John, you're on the air.
JOHNHey, thanks for the call, and I really appreciate the discussion. We have a couple of family members, one who sadly passed away recently, both of whom suffered -- suffering from Alzheimer's, (unintelligible) Alzheimer's. I teach mindfulness and compassion meditation, and certainly there's a lot of evidence recently of the positive changes in the brain from this type of mental training. I was wondering if your guests could speak to that in relation to possibly staving off the onset of Alzheimer's or even working with individuals who have the onset of Alzheimer's, and I'll take your question off the air.
PAGEAnd John, before you hang up, tell us what, when you say mindfulness training, tell us briefly what that is.
JOHNSure, so mindfulness and compassion training both include a type of training where we work on directing the attention, being able to guide attention, as opposed to simply letting it wander around like one when you watch four hours of television, as your guest mentioned. It allows us to be present. It allows us to gain access to more clarity of inner experiences, as well as outer experiences. It allows us to have a sense of equanimity when it comes to stress, reducing cortisol levels.
JOHNSo that -- the type of training we're talking about would include doing those things, and the evidence shows that it has -- the type of changes in the brain that occur reduces the size of the brain that is associated with stress and increases the parts of the brain that are associated with well-being.
PAGEJohn, thanks very much for that explanation. Well, let me ask our panel. Is there signs that that can be helpful?
DORAISWAMYOh absolutely. I think it can help with a variety of stress-related issues. It produces a relaxation response. And as the caller referred to, there are studies using MRI scans that have actually shown that a six-week course of mindfulness meditation can enlarge the memory centers in the brain and can reduce age-related shrinkage. Now these are not definitive studies saying it can prevent Alzheimer's, but anything that helps reduce the stress, both for the caregiver and for the subject, I think is going to be extremely helpful.
DONOVANYes, I just wanted to mention, yes, that I think that those kinds of techniques are particularly beneficial for the caretaker and that that can have secondary benefit for the patient.
PAGESo the caretaker takes mindfulness training and tries also to include the patient?
DONOVANOr even on their own, it can reduce their own stress level and therefore, you know, make them more patient and more observant and responsive to the patient.
PAGEI'm Susan Page, and you're listening the Diane Rehm Show. We're taking your calls, 1-800-433-8850. Well, we talked about risk factors. I was sorry to hear that at your conference, one of the risk factors now identified is just being female. And I think -- I had assumed that women were more likely to have Alzheimer's just because women are more likely to live longer than men. You've got research now that shows that may not be the case. Tell us about it.
FARGORight. I mean, that has been the traditional wisdom, if you will, or the conventional, that the reason that women are more likely to have Alzheimer's disease is that they live longer. However, it's true that we are seeing now hints in various research projects that that may not be the case, that there may actually be different age-specific risk for women. Women may experience the diseases differently. Women may have different genetic risk for Alzheimer's disease.
FARGOAnd I think actually Dr. Doraiswamy can speak a little bit about some of those issues because I know some of his research was presented this week at the conference.
PAGEPlease tell us about it.
DORAISWAMYYeah, so I completely agree. I think there are two factors at play. It's a double hit almost. You live longer, so you're more likely to get Alzheimer's, and I think there's a true, underlying, biological and/or environmental vulnerability. We haven't exactly found out the X-factor, if you will, as to why women are at greater risk.
DORAISWAMYWhat -- the study that we presented yesterday and we're also presenting today is that women who are risk for Alzheimer's, with mild memory complaints, appear to decline over time twice as fast as men. And so we don't know why. I think it should be a priority for the field to uncover that, and I think the Alzheimer's Association is spearheading some of those efforts.
PAGEDr. Nancy Donovan?
DONOVANYes, an important area of research has been brain changes that start to occur at the time that women experience perimenopause and menopause and whether or not women should be administered hormone replacement therapy. And there was a plenary session yesterday that addressed this point, and unfortunately we don't know the answer to that. There are both transdermal and oral forms of hormone replacement therapy, and it's possible that if they're administered early, they may have benefit, but that has not yet been shown, and they may also have adverse effects if they're administered too late or in a particular formulation. So it's really an important question to figure out.
FARGOSo I also want to stress that I don't think people should be freaking out just based on this research right now. In a sense, it's still early. I would give the same prevention advice to both men and women at this point in time.
PAGEWhat are the implications, though, for future research if women are much more at risk for Alzheimer's and decline more rapidly than men? What does -- what are the implications for researchers like yourselves?
DORAISWAMYTo me, the most important thing is we still haven't found the magic bullet to prevent Alzheimer's. So, you know, gender research may uncover some new mechanisms that could then yield a new treatment target or a new lifestyle intervention strategy that could help us reduce the risk. I think that's the single biggest gain we could get from this kind of research. And of course if women comprise two-thirds of the people affected by the disease, we owe it to them to spend two-thirds of the research to try to find out why.
PAGEAnd is race also a risk factor?
FARGOIt is. So it turns out that at least in the U.S., African-Americans are about twice as likely to develop Alzheimer's or other dementia, as are Americans of European descent. And Latinos or Hispanics are at about one and a half times the risk. So it does seem to play a role. One of the things -- we don't yet know exactly why. We have some ideas. One of the things we saw reported out at AAIC this year, the conference that we're talking about, was that African-Americans appear to have more vascular components to their dementia than do Americans of European descent. So there may be issues with, you know, microstrokes and this kind of thing that contribute to that risk for dementia or Alzheimer's disease.
PAGEDo you feel like there are a lot of fundamental things we just don't know about this disease yet, when you think about where we are in terms of discovering it?
DORAISWAMYWell, we know a lot more than we did 15, 20 years ago. But, you know, it's with science with any disease, you -- it's progressive information over time. So...
DONOVANAnd I think there are a lot of related factors. You mentioned race. It's also the case that people who have lower income, lower wealth, lower educational attainment, those are independent risk factors for cognitive decline. So I think it's going to be important to identify people at the highest risk because they have multiple risk factors.
PAGEWe're going to take a short break, and when we come back, we'll go back to the phones. We've got some people on the phones waiting, who have their own stories about dealing with Alzheimer's and some questions also about how you can diagnose Alzheimer's versus other types of dementia, several people asking us about that. We'll get to those questions and more after a short break. Stay with us.
PAGEWelcome back. I'm Susan Page of USA Today, sitting in for Diane Rehm. And with us in the studio, Keith Fargo of the Alzheimer's Association. Dr. Nancy Donovan of the Brigham and Women's Hospital. And Dr. Murali Doraiswamy, who's a Professor of Psychiatry at Duke University. He's -- Duke University Medical Center. He's the co-author of a book, "Alzheimer's Action Plan." You know, we've got several people with a question with a question like this. I'll read the one from Lee, who writes us from Bethesda.
PAGEShe writes, how can you differentiate between Alzheimer's and other forms of dementia and how to treatments differ? Who could address that? Dr. Doraiswamy.
DORAISWAMYYeah, sure. So, Alzheimer's accounts for probably anywhere from 50 to 60 percent of most cases of dementia, so by and large, that's sort, of, you know, in our favor. That, so and 80 percent of the time when we diagnose someone with Alzheimer's, we're accurate. So, the way we differentiate Alzheimer's from other disorders is a combination of things. You know, we take a history from the person, from the family, we run a brain scan, you know, an MRI scan to rule out things like strokes. And now, we can do a new type of scan that Nancy referred to called an amyloid PET scan, that can detect the buildup of plaques.
DORAISWAMYAnd then we also do laboratory tests to look for vitamin deficiencies, thyroid imbalances. And then we do a psychological assessment to look for things like depression and stress. So, that's how we differentiate Alzheimer's from a number of these other conditions that can cause memory problems.
PAGELet's take a phone call. Let's talk to Rosa. She's calling us from Washington, D.C. Rosa, you're on The Diane Rehm Show.
ROSAThank you so much for taking my call and thank you so much for having this show. I hope you have it every month. Something new to give us hope. My mother and her female siblings all showed signed of dementia when they were in their late 80s, early 90s, and they all lived past 95. Their brother lived until 96 with zero dementia. Now, I'm faced with my husband, who's about 20 years older than I am, who has been diagnosed with possible frontal dementia, measured by MRI and CAT scan.
ROSAAnd, you know, the thing that I see vastly different between my mother and my husband is my mother could tell she was getting something. And it was diagnosed as Alzheimer's. With my husband, it's a sort of blissful ignorance. You know, for a brilliant man to just sort of shrivel down and not realize that there's a problem. So, there's, in many ways, he's absolutely independent and dresses himself, all of that. Kind of, he comes across as sort of eccentric. But more or less connected.
ROSABut what I'm really asking about is what is being done to find out if there's any kind of treatment, drugs, whatever, that might be developed for that part of the brain. I know it's tricky, cause it's, you know, the center of so many things.
PAGEYeah, Rosa, thanks very much for your call and telling us your story. Dr. Donovan?
DONOVANWell, I think most of here are probably Alzheimer's Disease specialists, but I think the caller is talking about fronto temporal dementia, and although -- the Alzheimer's Association meeting is focused not only on Alzheimer's Disease, but also on other types of dementia, including fronto temporal dementia. And, in fact, there was a wonderful (unintelligible) session, given my Dr. Bruce Miller at UCSF who described the tremendous progress that has been made in understanding the biology of understanding fronto temporal dementia.
DONOVANWhich is very different, involves a different, accumulation of different types of proteins in the brain. And I think the caller is talking about a variant called the behavior variant. And people have a lack of empathy, they have a lack of insight, behavioral changes. Right now, we don't have specific treatments for that, unlike Alzheimer's Disease, you know, where there are a couple of approved treatments. There are not pharmacological treatments for fronto temporal dementia, but those are -- will be on the way.
PAGEI wonder what drew the three of you to this particular field. You mention you're experts in Alzheimer's Disease. What made you want to specialize in that?
DORAISWAMYWell, I think for me, it was a mentor that I worked with who inspired me, and he was working in the Alzheimer's field. But also I saw this as a big challenge. It's almost like the final frontier, understanding how the brain works, understanding how memory works and it's such a big public health challenge. So, that's what drew me to it.
PAGEHow about you, Dr. Donovan?
DONOVANWell, I was a General Psychiatrist for many years. I've been practicing psychiatry for 25 years and about five years ago, I transitioned into geriatric psychiatry because of the experience of taking care of my own father with dementia. And I realized that as a psychiatrist, I had a tremendous skill set to apply to the problem. And I really wanted to also get involved at a research level. And I also was inspired, in fact, by the people who helped care for my father. And advised me during the process. I was brought into contact with just the most wonderful people and I wanted to be part of that community.
PAGESo, you already knew a lot, because you were a doctor, a psychiatrist. What was the advice that you got when you were trying to deal with your dad that you found helpful?
DONOVANI don't know if it was the specific advice. I think it was more the process of people being concerned and really relating to us as individuals and trying to help us come up with individual solutions for the problems that occur every day when you're taking care of someone with this diagnosis.
PAGEYeah, big challenge. Keith Fargo, how about you?
FARGOWell, this is a, really, a coming public health crisis. And I see this as an area where a person can really make a huge difference. So, if there are any young scientists listening to this, actually, and you want to make a major difference in the world, Alzheimer's Disease is an area where you can do that now.
PAGESo, we know it's a big problem now. And going to be bigger as the population ages. How much government research funding is now spent on Alzheimer's research?
FARGONot enough. So, currently, a little bit less than 600 million per year. Which sounds like a lot of money, but the scientists tell us that to really make a difference in this disease by 2025, say, we really need about two billion dollars per year in IH funding.
PAGEAnd what are the prospects for that?
FARGOThey're looking better, so we're making steps. Actually, something we're very excited about and very pleased with, a couple of sub-committees in the House and in the Senate have recently recommended some fairly large increases in Alzheimer's Disease research funding. On the order of about 300 to 350 million, which would basically be a 50 to 60 percent increase in Alzheimer's Disease funding in a single year. So, if that makes it all the way through the House and the Senate and is signed into law, that would be a historic increase and a true step in the right direction.
PAGEHere's an email from Sandy who writes us from Land 'o Lakes, Florida. She writes, has there been a discussion of what causes the process to start in Alzheimer's? Do we know what triggers it to begin?
DORAISWAMYI don't think so. I think it's a combination of perhaps genetics and other unknown factors we haven't yet identified. So, some of the earliest changes we see in the brain are the buildup of these plaques. So, one way to look at it is the plaques may be the trigger that starts the whole process. But then, there's something else starting the plaques accumulating in the brain and nobody knows what that is.
PAGELet's go to Adam. He's calling us from Miami, Florida. Adam, thank you for giving us a call on "The Diane Rehm Show."
ADAMThank you for taking my call, ma'am.
PAGEYou bet. Go ahead.
ADAMSo, I just have a quick question. I have heard from a few cases. I have a neighbor whose mother actually had a very severe form of Alzheimer's. She was in (unintelligible) and then her daughter started giving her a measure of two herbal supplements, Ginkgo Biloba and Gotu Kola. And then, so, we started giving it to my grandfather, who was showing early signs of Alzheimer's, and 10 years later, he's sharper than ever. So, I was wondering, and my neighbor as well, she improved tremendously. She got out of diapers. She was doing much better. So I was just wondering if there was any validity, any research behind it supporting it and if so, why hasn't it become a more widely recommended form of treatment?
PAGEAll right, Adam, thanks for your call. Do we know if this is accepted as something that could help?
DORAISWAMYSo, Ginkgo Biloba, you know, has been studied for about 30 to 40 years. It's had some mixed results in the US, but in Germany and a number of other countries, it's in very wide use, including as a prescription agent. Gotu Kola is an Indian herbal supplement that's probably been best studied in India for its use in memory applications. But in the US, it's not really been put through rigorous national trials. That said, I'm pleased to hear of the success of the caller's experience and with, you know, their own family and their friends. So that's great, but run it by your physician, because some of these products could have side effects and interactions with some of your other prescription drugs.
FARGOYeah, I think that's exactly right. I think that until a large, controlled, placebo controlled clinical trial is done, we won't know whether other people can expect the same kinds of results that you've seen. And whether it would be safe.
PAGEDo you ever urge your patients to try that kind of -- take that kind of medicine, I don't know if you call it medicine, but...
DONOVANThe supplements? There are no supplements that I recommend to my patients right now. Cause I don't think there's an evidence base for that. But people do try coconut oil and other types of interventions and I encourage them to do that if that's something that they want to do.
PAGEAre there things that some people, you know, the kind of things that people hear, you know, this might help, try this, that they shouldn't try? That you really advise patients to be very wary of.
DORAISWAMYWell, if anything sounds too good to be true, it's probably not true, right? Because every day, we hear an ad on TV or something or the other claiming that it's going to cure or reverse a symptom, so be wary of those kinds of quick fixes. For example, the latest, sort of, I don't want to call it a fad, the latest popular, sort of, treatment going around is what's called bulletproof coffee. Where you put coconut oil in coffee with a dollop of butter. And it may help. We don't know. It's just never been put fully through rigorous studies, so just be wary of anything that promises a quick rapid big effect.
PAGEIs that supposed to help on Alzheimer's?
PAGEAll right. Let's go to Overland Park, Kansas and talk to Bowen. Bowen, thanks for giving us a call.
BOWENYou bet. Thanks for taking my call. There are all these ads on TV about brain training. Luminosity is, you know, spends a lot of time or effort marketing their product. And is there really any evidence that shows that brain training is actually better than exercise, both aerobic exercise and balance training? In terms of growing brain neuro generation and neuro-plasticity, as well as increasing synaptic connections?
PAGEAll right, Bowen, thanks for your call.
DONOVANI'm not a Neuro Psychologist. I'm generally aware of this work. I don't think that there's evidence for a popular program such as Luminosity. We did review that recently in our research group. There are -- there may -- I don't want to dismiss brain training as a potential avenue. I think the concern has been that you, as you practice these particular types of cognitive exercises, they may only improve your performance on those cognitive exercises and may not be generalizable.
DORAISWAMYSo, I think the caller's question was a comparison of brain training verses aerobic exercise. I don't think that's the right question. I think it's a very important question. I think, ultimately, we're going to recommend both. So, what I recommend patients is take a walk and discuss a book with a group of people, because when you're walking, maybe your brain is more receptive to brain training and novel ideas. Because a lot of times, ideas just pop through my mind when I'm taking a nice stroll in the woods.
DORAISWAMYSo, I think ultimately we're going to need combinations of these lifestyle interventions. The second point I want to make is, you know, I don't think Lumos Labs should get a bad rep. They have a product out there. It's up to the field to really put it through a rigorous clinical trials and we and other institutions are working with the company to do a very rigorous, large national trial. We analyzed data from 60 million people who had done Lumos brain training and we found that multiple cognitive domains improved.
DORAISWAMYAs was pointed out, we don't know if they transfer to everyday life, but they may. You can't rule it out.
PAGEI'm Susan Page and you're listening to The Diane Rehm Show. We've gotten a tweet that says, listeners might want to know how to join these clinical trials. You've mentioned that clinical trials are underway. Keith Fargo, how could they do so if they wanted to explore that possibility?
FARGOWell, I think the easiest way, actually, is through the Alzheimer's Association Trial Match Program. This is a free service. Very easy to use. You can simply go to alz.org/trialmatch or just Google trial match. If you don't want to use online, you can actually call our 800 number, as well. And we can help you with that.
PAGEIs it a good idea? I mean, it's a public service, in a way, to join a clinical trial. Is it good for you, the patient?
DONOVANWell, I think it's an individual decision, but I know that in our own research center, I think that there's a lot of support. And benefit that derives to the families. And there is a sense of being part of the solution.
PAGEHere's an email we've gotten from a listener, Daphna, who writes, your guests refer to early diagnosis, to enable the Alzheimer's patients to arrange financial matters and designate others to manage their affairs once they are no longer able to do so. But how do we care for an Alzheimer's patient who is clearly impaired, declining, unable to manage her affairs, but who absolutely insists that she must remain in charge? This must be a situation, Dr. Donovan, that you've faced.
DONOVANYes. Unfortunately, it's not uncommon, and as I mentioned earlier, as people progress in the disease, particularly Alzheimer's Disease, as opposed to sort of the more mixed dementias, or other types, individuals very often lose insight into their own deficits. And the ideal scenario is when, in advance, the person, the patient has designated a healthcare proxy. And in that case, the healthcare proxy can step in and make, or a durable power of attorney. And with those powers, the family member designee can step in and make more reasonable choices.
DONOVANSometimes it has to, you have to appoint a guardian and go through the court system.
PAGEThat's gotta be tough, if someone is healthy but not mentally healthy. To try to tell them that they can't have control of their own affairs.
DONOVANWell, you know, that's the beauty of when people have a network or family members that they trust. Even in the absence of insight, you can often kind of find kind of a residual sense of trust and move them in the right direction.
PAGEHere's another question by email from Deanne, who writes us from Durham, North Carolina. Is it true that loss of taste and smell are signals of Alzheimer's? Dr. Doraiswamy, is it?
DORAISWAMYI think so. I think there's increasing research suggesting that there are impairments in smell, as well as your loss of insight into your loss of smell. So, but that said, all of our sensory systems play a vital role in our memory, so people with hearing loss, people with vision loss, with cataracts, with, you know, loss of taste, smell. All of those affect our memory, and a recent study showed that if you corrected hearing, through the use of cochlear implants, something like 30 to 40 percent of patients who were diagnosed as having memory impairment were now diagnosed as normal.
DORAISWAMYSo, essentially, their memory reversed back to normal when the hearing was corrected.
PAGEYou know, to end on a more positive note than some of this hour, I understand that the research indicates that younger people are less likely to develop Alzheimer's. I don't mean when they're young. I mean, over their lifetimes. Do -- is that true, Keith Fargo?
FARGOWell, it's an open question. We've seen lots of intriguing results from several populations that that may be the case. That there may be decreasing incidents and therefore prevalence of Alzheimer's Disease. However, the one thing that those studies all have in common is they come from typically Western countries with homogenous populations. What we don't know is what's going to happen in the developing world or countries with more diverse populations, such as the United States.
PAGEAnd is there a reason why people born, say, since 1930, or since 1940, would have a lower lifetime risk factor for Alzheimer's?
DORAISWAMYWell, a couple factors. I think education levels have gone up in both genders. I think public health efforts have improved. I think the environment's slightly improved, even though, perhaps not by much. And even though we're perhaps not exercising as much, I think, in general, we are leading, you know, having better access to healthcare. So, I think if we exercise more and cut down obesity and diabetes, you'll see an even bigger reduction in the rates in subsequent generations.
PAGEProbably a good idea on many fronts. Dr. Murali Doraiswamy, thanks for joining us. Also, Dr. Nancy Donovan and Keith Fargo, thanks for being with us this hour.
PAGEI'm Susan Page of USA Today, sitting in for Diane Rehm. She's on vacation. Thanks for listening.
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