Tuesday, April 26, 2011

New Guidelines for Diagnosing Alzheimer’s

“Expert Panels” convened by the National Institute on Aging and the Alzheimer’s Association have offered new guidelines for diagnosis which include earlier stages of the disease. The new guidelines establish three stages: early brain changes, mild cognitive impairment and full-blown Alzheimer's. The new guidelines are being published in Alzheimer's and Dementia: The Journal of the Alzheimer's Association.

The question now being hotly debated is whether these new guidelines are positive and helpful, broadening awareness that the effects of brain aging take place over a wide spectrum, or whether they reinforce the clinically-unproven argument that all persons diagnosed with MCI will inevitably convert to Alzheimer’s. For example, Debbie Benczkowski, head of the Alzheimer’s Society of Canada, fears that if these guidelines are accepted in Canada they will label and stigmatize people as Alzheimer’s sufferers who will never develop the disease.

But Danny George argues that there may be important hidden benefits from the new guidelines because they place AD in a continuum: "Metaphorically, the notion of a continuum moves us away from the “you have it or you don’t” mentality that has for decades separated persons with the unified condition of “AD (mild, moderate & severe)” from the rest of us who live in fear of acquiring “it”. Instead of categorical “boxes” we are now presented with a continuum featuring differing degrees of severity. Generally speaking, the DSM-V seems to be drifting more towards continuum based classification of conditions (as evidenced by conditions such as autism spectrum disorders and others)."

Clearly this debate will need some time to unfold; the new guidelines offer both potential risks and rewards. If the number of persons diagnosed with AD suddenly doubles to include many persons with no clear signs of memory loss or cognitive decline, will that lead to these persons being stigmatized? Or will it have the opposite effect? Will it bring wider understanding that we are all living within a continuum of brain changes as we age, and therefore those experiencing AD (or other dementias) do not exist on the other side of a hard line between those who "have it" and those who do not? One can hope for the latter, but we need to be very careful not to permit the former.

Tuesday, April 5, 2011

Subjective Cognitive Impairment

“One-quarter to one-half of community-dwelling older adults report subjective cognitive complaints, such as forgetfulness and word-finding difficulties.” So report Abhilash Desai, MD, and Lauren Schwarz, PhD, in an article published in Current Psychiatry. Desai and Schwarz differentiate Subjective Cognitive Impairment (SCI) from Mild Cognitive Impairment (MCI) because in the former there is no supporting objective evidence from neuropsychological testing or evidence of functional decline.

But these are not merely the “worried well.” Persons reporting SCI are 4.5 times more likely to develop MCI or dementia within seven years than those who report no such concerns. Which is to say that a significant number of older adults are aware that “something is not right” long before clinical diagnosis of their condition becomes possible.

It makes for a confusing stew, not just of cognitive conditions among older adults, but of perceptions of these conditions. There are persons journeying into dementia. There are persons with MCI. And there are persons experiencing “healthy aging” and the changes in memory function that almost universally attend it (“senior moments,” misplaced keys, etc.), some of whom worry about these lapses, some of whom accept them without concern, and some of whom deny them ferociously. Those who are aware of these changes and concerned about them now have a term they can claim: SCI.

For some but not all, Desai and Schwarz suggest, SCI will be a precursor to MCI, which in turn may or may not convert to Alzheimer’s disease or another dementia. For others, it may indicate nothing more than anxiety about developing dementia or a general tendency to worry. Even as clinical categories of memory loss and cognitive decline become more rigidly defined in some circles, the lived experience of older adults appears to speak more of many shades of grey. There are those who are clearly experiencing cognitive loss who yet remain happy, engaged and fulfilled (the “pleasantly confused,” as one friend put it). There are those whose cognitive health is well within the “normal” range who yet become crippled by fear and anxiety over small lapses in memory. And there are many, many folks who fall somewhere in between.

Diagnostic categories are certainly valuable, and early diagnosis of AD and other dementias will play an increasingly important role, not only in allowing earlier (and hopefully more effective) pharmacological intervention, but also in motivating persons to make lifestyle changes that may slow the rate of progression and almost certainly will make for a higher quality of overall life. But there is growing evidence that fixed, rigid categories will never be able to encompass the wide range of lived experiences of aging. As we age, whatever our cognitive state, we all require the same things to flourish as fully as possible: love, laughter, joy, friendship, meaning and purpose. All of these things are fully possible within dementia, but all of them can be easily undermined by fear and anxiety. One is tempted to quote Churchill: the real enemy in the journey of aging is not cognitive loss, it is fear itself.