Response to Debate Over Biomarkers for Early Detection of Alzheimer’s Disease
Margaret A. Noel, MD, MemoryCare
Evidence is mounting that beta-amyloid and tau protein biomarkers may become increasingly useful to verify that a person with dementia has an Alzheimer’s component to their pathology. Prior to the onset of clinically diagnosable disease, the same biomarkers may also serve as an indicator of who will be more likely to experience progression along a continuum from mild cognitive impairment due to Alzheimer’s disease to actual Alzheimer’s disease. The press has translated the discussion between some of the most respected researchers in the field of dementia to a promotion of utilizing biomarkers at a community practice level in the immediate future. Reviewing transcripts from the International Conference on Alzheimer’s disease held in July of 2010 (published at the Alzheimer Research Forum’s website) is reassuring to me in my daily practice of caring for people with dementia. Improving accuracy of identifying a disease such as Alzheimer’s in its prodromal (over a decade prior to symptom onset) phase is critical. Intervention prior to destruction of the neurons that permit humans to think, plan, remember, and communicate is indisputably the most effective way to eradicate this devastating disease. The work supporting the high accuracy of these biomarkers is truly exciting but clearly more research is critical before they find a place in prime time practice. This research is deserving of our nation giving it the highest priority for funding.
And if they are right, and additional studies confirm the accuracy of these biomarkers, why might we exercise some caution before establishing the walk-in spinal tap clinic? While the test might be seen as invasive by many primary care providers, such concern is really insignificant if the benefit of the diagnosis warrants the risk of foreknowledge of the disease. In a career spanning 23 years in geriatrics, it is fair to say I’ve cared for upwards of 5000 people in longitudinal fashion with various types of dementia. At MemoryCare, a comprehensive care program for persons with memory disorders and their caregivers, people show up for help all along the continuum of cognitive disorders from diverse educational and occupational backgrounds. Those who seek guidance in what may be labeled the pre-clinical stage may be fearful due to their experience as a caregiver for a loved one with a progressive dementia or are experiencing some normal change in intellectual function as they age and fear it may be a harbinger for a more ominous future. It would be fair to say that the majority of such individuals would agree to testing if it were highly accurate and an effective, affordable treatment for the identified incipient dementia was available. It would also be probable from our experience in a community based clinic that two to five percent of these individuals would be willing to enroll in an investigational trial that might help them if they were in a pre-clinical phase of Alzheimer’s disease. The remainder would and should struggle with the following concerns:
- If I am told I have a 90% risk of suffering a degenerative dementia within the next decade of my life but there is no effective treatment, will the anticipatory grieving process (and one will grieve) over the highly probable loss of mental and functional capacity overshadow the quality of my remaining life?
- How will the insurance industry (long term care and health insurance) utilize the information?
- Will my family members and co-workers begin the process of treating me as “diminished” before I truly have limitations?
- Would being told I do not have the risk markers provide a false sense of assurance that I will live a cognitively intact life as a significant portion of dementia is either mixed or non-Alzheimer’s related?
In the interim, I hope that researchers make haste in exploring biomarkers that will allow testing effective therapies before neurologic destruction takes place possible. But these tests should remain in their hands until such treatments are available and knowledge of our high risk of Alzheimer’s disease is worth the cost of knowing. We currently counsel everyone to live and plan as though they are at high risk of needing help due to cognitive and functional decline if they are blessed with longevity. Nothing has changed in our practice but there is more hope for the future.
Educational Workshop on Dementia Screening in the Primary Care Setting:
To View or copy the screening tools click on the appropriate button:
The AD8 Dementia Screening Interview
The Mini-Cog
The Time and Change Test
A Limited supply of the video recording of the workshop presented by MemoryCare staff physician Dr. Tom Kaluzynski and Misty Haire, RN is available- please call the MemoryCare office at 828-771-2219 to find out if a DVD copy is available and/or if you would like a copy of the materials with a reference list related to the screening tools covered in the workshop.
