It isn’t just the testing for the novel coronavirus that has already anxious Americans upset these days. Controversies also are swirling around existing and developing ways for experts to screen older patients for cognitive decline, namely dementia and its most familiar form, Alzheimer’s disease.
Alzheimer’s disease, which accounts for 60%-80% of dementia cases, is the sixth leading cause of death in the United States overall and the fifth leading cause of death for those age 65 and older, researchers say. Medical scientists have engaged in furious efforts for a while now to determine the condition’s causes and to create treatments for it — a response that is sorely lacking now.
But the New York Times reported that experts believe they are nearing a better way to screen and diagnose the illness using the blood rather than current “expensive methods like PET scans of the brain and spinal taps for cerebrospinal fluid.” As reporter Pam Belluck wrote:
“The [new blood] test has the potential to make diagnosis simpler, more affordable and widely available. The test determined whether people with dementia had Alzheimer’s instead of another condition. And it identified signs of the degenerative, deadly disease 20 years before memory and thinking problems were expected in people with a genetic mutation that causes Alzheimer’s, according to research published in JAMA and presented at the Alzheimer’s Association International Conference.
“Such a test could be available for clinical use in as little as two to three years, the researchers and other experts estimated, providing a readily accessible way to diagnose whether people with cognitive issues were experiencing Alzheimer’s, rather than another type of dementia that might require different treatment or have a different prognosis. A blood test like this might also eventually be used to predict whether someone with no symptoms would develop Alzheimer’s.”
Skepticism about Alzheimer’s news
While Belluck provides due cautions in her news story, and the researchers reporting on their work do, too, the public should be skeptical about developments with Alzheimer’s and other complex medical conditions, warns Gary Schwitzer, founder and publisher of the respected HealthNewsReview site and a onetime journalist who has covered health care news almost exclusively since 1973. He decried the latest hype others have given to Alzheimer’s screen:
“Today’s news about a ‘breakthrough’ test is certainly not the first we’ve heard like that about a possible Alzheimer’s test. On Twitter, former hedge fund manager and TV personality Jim Cramer called it a “major game changer.” Dr. Oz called it a “major breakthrough.” The New York Times headlined its story, ‘Amazing, Isn’t It?’ Long Sought Blood Test for Alzheimer’s in Reach.”
He said he scanned his files and easily found multiple times before when developments with the disease have been widely heralded — and then disappointed. A key reason for this rests in the slowly exhausting theory by medical scientists that Alzheimer’s is indicated or caused by “substances called tau protein or beta-amyloid.” As he succinctly reported:
“There have been many reports of tests and treatments based on theories that tau and/or amyloid are at least signs, if not causes, of Alzheimer’s. Scientific uncertainty remains about the precise role of tau and amyloid in the disease.”
So, a blood test that focuses, as the latest experimental iterations do, on finding tau proteins or beta amyloid may be less than optimal, he argued — and Belluck’s story conceded this point and more. That’s because even if a blood test forecasts patients’ suffering Alzheimer’s, then what?
“Blood tests for Alzheimer’s, which are being developed by several research teams, would provide some hope in a field that has experienced failure after failure in its search for ways to treat and prevent a devastating disease … Experts said blood tests would accelerate the search for new therapies by making it faster and cheaper to screen participants for clinical trials, a process that now often takes years and costs millions of dollars … But the ability to diagnose Alzheimer’s with a quick blood test would also intensify ethical and emotional dilemmas for people deciding whether they wanted to know they had a disease that does not yet have a cure or treatment.”
Doubts deepen on tau-beta amyloid theory
Stat, a site reporting on medicine and science, dug deep last year into researchers’ growing disillusionment with what apparently has become over decades a blinding conviction by powerful experts of the tau-beta amyloid theory of Alzheimer’s cause. It has not resulted in effective treatments and may have blocked more fruitful and alternative thinking and study. As Stat found:
“Research focused on amyloid, and the development and testing of experimental drugs targeting it, have sucked up billions of dollars in government, foundation, and pharma funding with nothing to show for it. While targeting amyloid may or may not be necessary to treat Alzheimer’s, it is not sufficient, and the additional steps almost certainly include those that were ignored, even censored. Probably the most shattering turn came … when Biogen halted the study of what proponents called the most promising Alzheimer’s drug in years — an amyloid-targeting antibody.”
The absence of concrete, immediate advances with Alzheimer’s and dementia, more generally, should be greatly concerning to Americans.
Nearly 15% of Americans older than 70 — some 3.8 million people — already have dementia, and that number may swell to 9.1 million people by 2040, more than the current population of New York City, researchers at the nonpartisan and independent RAND Corporation have calculated.
They found that dementia already takes a higher economic toll than heart disease or cancer: at least $159 billion a year, and possibly as much as $215 billion. Those costs could more than double by 2040, when the cost to care for them could exceed half a trillion dollars a year.
To be clear, as the RAND researchers have underscored, dementia is the broad description for a “debilitating and progressive condition that affects memory and cognitive functioning, results in behavioral and psychiatric disorders, and leads to decline in the ability to engage in activities of daily living and self-care … In addition to Alzheimer’s disease, some of the other common types of dementia and conditions that cause dementia include: vascular dementia, Lewy body dementia, frontotemporal dementia, Huntington’s, Parkinson’s, and traumatic brain injury.”
President Trump, of course, created more than meme mirth recently when he obsessed about another key tool in dementia diagnosis and treatment: the cognitive screening, notably the Montreal Cognitive Assessment, widely known as the MoCA test. He sought to make a political point about his mental acuity in undergoing this test, especially as he claimed it showed him to be sharper than his (also) 70-something Democratic opponent. For social media, this was a field day for commentary about the president’s recitation in repeated interviews of a list of words: person, woman, man, camera, TV.
The MoCA test is much more than parroting, and no one should take it or other similar exams lightly, as the Washington Post reported, noting:
“[F]or many Americans, the test Trump keeps trumpeting is one of the most fraught, traumatic turning points in their lives — that moment when they realize their mind is beginning to fail and glimpse the troubled path ahead for them and their families.”
The newspaper interviewed experts and patients who fear the president’s much ridiculed discussion of the cognitive assessment will stigmatize it and those for whom it provides life-changing results. It is not a demonstration of intellect or skill. It is meant to be convenient, direct, and swift. It can be shocking to patients who stumble with it. It may lead to other exams and seniors grappling with what is one of the major dreads of old age: significant cognitive decline, especially if individuals have seen, close up, family and friends experience it.
This is tough stuff. In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to afford and access safe, efficient, and excellent medical care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of therapies and prescription medications, too many of which turn out to be dangerous drugs.
Over testing, over diagnosis, and over treatment are major problems in the U.S. health care system, causing, by some accounts, hundreds of billions of dollars in wasted costs. Doctors and patients need to test seniors with care for cognitive decline, realizing that current screens can be costly and inconclusive. They also can trigger a cascade of more tests and procedures, some of which can be embarrassing, invasive, expensive, and unneeded. Even a seemingly convenient and direct cognitive assessment like the MoCA test requires thought and attention from a practitioner seasoned in its application and wise as to interpretation and communication.
An undeniable issue for a boom generation
Demographers, in the meantime, have warned that among the baby boom generation, one of the largest such population groups in U.S. history, on this day and for every day for the next 19 years, 10,000 individuals will reach the traditional retirement age of 65. By 2060, a quarter or so of U.S. residents will be older than 65, and life expectancy will reach an all-time high of 85 years, U.S. Census Bureau forecasts say.
Yes, older adults can take every step possible to stay healthy and out of the U.S. health care system, with its significant problems with medical error, preventable hospital acquired illnesses and deaths, and misdiagnoses. Yes, they can strive to protect their cognitive health. They can take steps to lower their risk and to help drive down an unacceptably high road toll. They can make careful end-of-life preparations.
But politicians and policy-makers, alas, continue to stick their head in the sand about the burgeoning needs of older Americans, and the giant challenges they and our society will confront with dementia and Alzheimer’s long-term care, or in supporting programs like Medicaid, Medicare, and Social Security.
We’ve got a lot of work to do to deal with seniors’ needs because the giant demand is on us now.