Here are key takeaways from an episode of Kentucky Health examining Alzheimer’s disease and dementia. Host Dr. Wayne Tuckson speaks with Dr. Gregory Cooper, chief of adult neurology and director of the Memory Center at the Norton Neuroscience Institute in Louisville.
1) Between six and seven million Americans are currently diagnosed with Alzheimer’s disease. And that number is expected to double in the next 25 years.
“Think of dementia as a broad umbrella term,” Cooper says. “It’s a disorder where someone has impairments in multiple spheres of cognition. It may be memory, it may be language, it may be visual-spatial function, judgement, or executive function.”
Cooper explains that a diagnosis of dementia occurs when a person is impaired in one or more of these areas to the degree that he or she is unable to communicate and/or perform the routine tasks of daily living, such as managing finances, maintaining a schedule, or dressing and bathing oneself.
Alzheimer’s disease is the most common cause of dementia, according to Cooper, affecting 60 to 80 percent of people who are diagnosed with cognitive impairment. The disease was first described by Alois Alzheimer, a German neuropathologist, in November 1906, after diagnosing a 50-year-old woman with increasing memory loss, confusion, and paranoia.
Alzheimer treated the patient as she declined, and after her death he studied her brain, which revealed abnormalities in the cerebral cortex. “He was the first person to describe the plaques and tangles that we now think of as hallmarks of Alzheimer’s disease,” Cooper says.
For several decades following Alzheimer’s discovery, Cooper explains, the medical community regarded patients younger than 65 who have tell-tale beta amyloid protein plaques in the brain as distinct from older ones who were more generally regarded as having normal cognitive decline. But then more studies revealed the disease could affect adults in various stages of life. “That’s when we realized what a common, common condition this is,” he says.
Cooper says the main reason for the expected acceleration in Alzheimer’s diagnoses in the coming years is because more people in the U.S. are living longer, often decades past age 65. And the main risk factor for developing Alzheimer’s disease is advanced age.
On the positive side, however, Cooper says that with advances in treating other risk factors for the disease – such as controlling hypertension and diabetes, for example – the chance of someone developing Alzheimer’s may actually decrease.
“The incidence might be going down slightly, while the overall prevalence is ballooning,” he concludes.
2) There are several warning signs of developing dementia, but they should not be confused with normal forgetfulness. Observing a downward trend in cognitive function is the most important element.
“If I am becoming more forgetful than I was before, that’s a concern,” Cooper says. “It’s usually going to be forgetfulness and loss of memory for recent things – I forgot a conversation, or I repeat myself more often.”
Cooper notes that many family members who see him with concerns about a relative say that he or she can clearly remember events from childhood but can’t recall actions from earlier in the same day. “That’s still consistent with Alzheimer’s disease. It really is a problem with learning new information. That’s why, early on, it’s our short-term memory that’s affected,” he explains.
Other behaviors to monitor include misplacing belongings, struggling to come up with words, and getting lost in familiar surroundings, Cooper says.
“If I think that I’m having problems with memory, there’s a good chance that I’m OK,” he continues. “If my family thinks I have a problem, and I think they’re crazy and I’m doing fine, that’s when I should be more worried about it. It sounds silly to say this, but if I have a memory disorder, I don’t really remember that I don’t remember.”
Cooper will make a diagnosis of Alzheimer’s or related dementia by starting with interviews with relatives or friends of the patient as well as a general neurological exam that takes around one minute. He then moves on to measuring orientation, language, and memory.
“I’d say that 95 percent of the time, you’ll have the answer by that point,” he confirms. “We will do some additional testing, we’ll do some blood work to rule out things like thyroid disease or vitamin B-12 deficiency, and we’ll do a scan of the brain – a MRI if we can, and what we’re doing there is ruling out things like a stroke or tumor.”
If a patient is diagnosed with Alzheimer’s, Cooper says the individual and his or her family will be counseled to prepare for the significant changes in daily life that lie ahead. Resources are available at neurological centers such as Norton Healthcare in Louisville to educate families on how to best care for a loved one with dementia, he says, and nonprofits such as the Alzheimer’s Association also provide essential support.
3) A recent report from a leading medical journal found that 40 percent of Alzheimer’s disease cases worldwide are preventable, and new medications are being developed that show promise.
According to Cooper, this paper released by the Lancet Commission identified several risk factors that can be controlled on an individual basis, such as regulating blood pressure and glucose levels, increasing exercise, getting eight hours of sleep a day, and avoiding smoking. Communities and governments can also enact policies to decrease environmental risk factors such as air pollution on a broad scale.
“We don’t have definitive proof that we can do A, B, and C and prevent this disease, but we’re getting close,” Cooper says.
In terms of genetic influence, Cooper explains that having a first-degree relative (a parent or sibling) with the disease doubles an individual’s risk level for developing Alzheimer’s. However, having relatives from the extended family with Alzheimer’s has not been found to correlate to higher risk, he adds.
Women are at higher risk for Alzheimer’s, according to Cooper, but scientists don’t know why. He says recent studies also show African Americans are at double the risk and Hispanics are at 1.5 times the risk of developing the disease. Research indicates the increased risk is not due to genetics, but rather higher rates of diabetes, hypertension and other conditions mentioned above among these populations. Cooper says these groups are also more affected by social determinants of health such as poverty and pollution.
For many years, treating Alzheimer’s disease focused on slowing the decline of memory and function loss by prescribing medications that Cooper calls cognitive enhancers. Those are modestly effective, but Cooper says that pharmaceutical innovations are forging a “new era” in treatment.
“We have medications, and more coming, that get at what we think is the root cause (of Alzheimer’s),” he explains. “So if the root cause is amyloids, medications that remove amyloids ought to make a difference. And we now have a recent medication, lecanemab, and there’s another one that will probably be available in January called donanemab. These are monoclonal antibodies, which are given through an IV. They go to the brain, attach to an amyloid, and remove it from the brain.”
Cooper says that so far, using lecanemab appears to slow down progression of Alzheimer’s disease by about 30 percent. “Some of the newer medications that are in studies, there is a suggestion that if we start the right patient very early on, the benefit may be even more than that,” he adds. “So it’s not reversing the disease, it’s not curing the disease, but it’s the first step we have where, at least to me, convincingly it’s slowing the progression of the disease.”
In the future, Cooper hopes he and fellow neurologists will be able to effectively screen for amyloid in patients with no signs of dementia, and if the protein is found in the brain, then start them on a drug such as lecanemab in order to prevent full-onset Alzheimer’s from occurring.
“That would be the dream,” he says. “We’re doing studies to try to get there. I can’t say we’re there today, but I hope we get there.”
