December 11, 2018

The Challenges of Alzheimer’s and Dementia Care

How research is helping health professionals find solutions

 

Unless a new treatment for dementia is discovered soon, an estimated 7.1 million Americans will be living with Alzheimer’s disease by 2025. By 2050, that number will explode to 13.8 million, which could be disastrous for the U.S. healthcare system and devastating for communities across the country.

Research is providing new insights into the disease and its far-reaching effects on patients and families. From targeted medicines to dementia care best practices, health professionals are looking for new solutions to help slow the coming catastrophe.

Adel Aziz, MD

Targeted Treatments Show Some Promise
Pharmaceutical companies have spent millions of dollars to uncover a drug to treat dementia with no success so far. However, Dr. Adel Aziz, neurologist at Riverside Neurology Specialists, says new treatments introduced at this year’s Alzheimer’s Association International Conference show promise at targeting the biochemical causes of dementia.

One treatment, crenezumab, uses antibodies to target beta amyloid protein. A build-up of this protein in the brain is associated with dementia. 

“A phase II trial showed promising effects of clearing the amyloid protein,” says Dr. Aziz. “Measures of cognition improved in several subsets of the study, and 75 percent of the study population saw a clinical benefit.”

Gilbert Snider, MD

Dr. Gilbert Snider, neurologist at Chesapeake Regional Healthcare, also believes the lymphatic system of the brain will play an important role in upcoming research into dementia.

“Up until a few years ago, it was thought the brain didn’t even have a lymphatic system,” says Dr. Snider. “It is a hidden system in which fluid is extruded through microscopic arterioles, filters through the brain, carrying toxins and impurities with it, and is taken up by both the venous system and a recently discovered lymphatic system in the meninges.”

Dr. Snider says the lymphatic system and vascular system of the brain flush away poisons and toxins. But as the vascular system deteriorates with age, it allows more amyloid protein to build up. Since the lymphatic system cannot take on the extra load, it, too, begins to fail, leading to more and more protein. 

One study on mice shows promise for improving the lymphatic system in the brain.

“Vascular endothelial growth factor that is secreted by the blood vessels helps develop the lymphatic system better,” says Dr. Snider. “It can actually reverse dementia in mice if it is administered early in the disease process.”

Earlier Diagnosis for More Effective Treatment
Diagnosing Alzheimer’s disease early may be the real challenge. People with dementia likely have the condition ten to twenty years before the first signs are detected.

“A dementia diagnosis can easily be missed because it usually starts slowly and affects the patient’s personal life,” says Dr. Aziz. “It needs to be detected first by people around the patient and brought to the attention of the primary care physician.”

Even if spotted very early, the disease may have progressed too far in these patients for treatment to be effective. Dr. Aziz believes that’s why so many clinical trials fail in phase III.

“Those studies targeted people who already have Alzheimer’s or dementia,” says Dr. Aziz. “It’s possible that clearing the brain of amyloid proteins won’t make a difference because the damage has already happened. But if we target that protein in earlier stages, when there are no symptoms or symptoms are very mild, these studies may succeed.”

Current methods of diagnosing Alzheimer’s in pre-clinical stages are expensive and difficult. Physicians can spot biomarkers of the disease through a spinal tap or PET scans. Newer PET scans can use tracers that target amyloid proteins, but the tracer has a short life of only 20 minutes. Neither of these tests can be used on a large scale to provide early diagnosis for the millions of Americans who likely already have the condition.

Many researchers are working to create a reliable scale to determine someone’s risk for Alzheimer’s disease. These scales target people between age 40 and 60 who may not have clinical symptoms, but who have the biomarkers for dementia. Someone who may be at high risk for the disease can learn about lifestyle factors that may help them prevent or delay dementia onset.

“There is hope that by targeting this population, we can impact the trajectory of this national catastrophe,” says Dr. Aziz. 

Lifestyle Factors for Prevention
While no medicine can currently prevent Alzheimer’s disease, a heart-healthy lifestyle can benefit the brain and reduce a patient’s risk for dementia. Some studies suggest that age-specific risks for Alzheimer’s disease may actually be falling thanks to control of cardiovascular risk factors.

Managing cardiovascular risk factors such as high blood pressure, high cholesterol, or diabetes are obvious first steps in preventing dementia, along with moderate exercise and a Mediterranean diet. 

But Dr. Snider says other lifestyle factors can also play a role in lowering dementia risk. Socialization and continued learning are key to building up cognitive reserve to help resist the effects of neurological damage.

Quality sleep is also vital for preventing Alzheimer’s disease and dementia, Dr. Snider says, since the lymphatic system works best when you are asleep. If patients suffer from sleep apnea or other sleep disorders, proper treatment may lower their risk for dementia in the future.

Ongoing Care for Changing Needs
Early in the disease, these lifestyle changes may temporarily help reduce or slow symptoms. However, as the disease progresses, patients have growing and changing needs in all aspects of their lives. Dr. Aziz says current healthcare practices are not set up to properly address these needs.

“Dementia is associated with other conditions like depression, risk of falls and medication misuse,” says Dr. Aziz. “We need to introduce Centers of Excellence for Alzheimer’s and Dementia Care and propagate those centers around the county to ensure physicians can address these needs.”

Jacob Almeida, MD

A dementia diagnosis also impacts what medical care a patient should receive. Dr. Jacob Almeida, geriatrician with TPMG Peninsula Internal & Geriatric Medicine, says once patients have an Alzheimer’s diagnosis, all other comorbidities need to be handled in that context.

“Life expectancy is about three to 12 years after diagnosis,” says Dr. Almeida. “The burden of multiple treatments can cause significant harm and decrease longevity. Patients, caregivers and physicians need to discuss goals of care as early in the disease process as possible, so the person with the condition can weigh in on decisions.”

Establishing best practices for dementia care through Centers of Excellence may help improve quality of life for both patients and caregivers.

Care for the Caregiver
Unpaid caregivers, typically a spouse or a child, bear the brunt of care for patients with dementia. These caregivers deliver an estimated $232 billion worth of unpaid care each year and carry a heavy financial, emotional and physical burden when providing care with often little support.

“We have very limited services outside of the home, aside from the Senior Services of Southeastern Virginia and Peninsula Agency on Aging,” says Dr. Almeida. “We also have very few adult daycare or day programs in Hampton Roads that offer respite care.”

Though caregiving at home relieves pressure on the healthcare system, it adds to the growing cost of dementia care. Caregivers may miss work or even quit working completely to provide care for loved ones. They also face significant health concerns as a result of caregiving; 30 to 40 percent of caregivers experience depression, and 35 percent of caregivers report a decline in their health as a result of caring for Alzheimer’s patients.

“Patients do best at home when there is adequate support from family or paid caregivers,” says Dr. Almeida. “But when that burden becomes so great that there is caregiver breakdown and the care of a loved one is impeding on the caregiver’s health, it’s time to consider other options such as assisted living.”

Giovanni Montague-Sneed, MS, RN

Giovanni Montague-Sneed, MS, RN, Senior Vice President of Resident Care at Commonwealth Senior Living, says that earlier referral to residential communities, before a caregiver reaches a point of crisis, better benefits both caregivers and patients.

“When placement in an assisted living community is introduced earlier, the services provided to a resident with Alzheimer’s or dementia can be augmented with specialized memory care services to include specialty trained caregivers, cognitive therapies, programming based on the cognitive function of the individual, expressive art therapy, as well as other plan of care intervention,” says Montague-Sneed. “Supportive living in an assisted living or memory care neighborhood that is fully licensed to care for individuals through all phases of the disease allows the resident to continue to have meaningful relationships with family members and peers as they progress through the disease.”

Montague-Sneed says earlier referral can help patients better participate in their care, whether it is lifestyle changes or music therapy. It also gives both patients and caregivers an opportunity to learn coping skills and improve their communication skills.

“We need to support caregivers and help them understand the dementia process so they don’t wait for their own personal health failures before looking for a residential option for their loved one,” says Montague-Sneed. 

She says families should research care options before that level of care becomes necessary and encourages caregivers to seek out residential options that have specialized dementia care. Some long-term care facilities and nursing homes are equipped to handle acute care needs but may not offer the support that patients with dementia need. Making an early decision about which care environment a patient needs allows families to anticipate future care, involve the patient in the decision, and avoid rushing the decision.

“Researching care options before the need is imminent helps families feel more confident in their decisions and has been found to lessen the need to transfer a loved one after initial placement,” says Montague-Sneed. 

Whether at home or in an assisted living facility, patients with Alzheimer’s disease or dementia need intensive support to stay safe and healthy. With earlier diagnosis and intervention, a focus on prevention, and more support for caregivers, health professionals may be able to ease the demand of dementia care on the healthcare system long enough to avoid a crisis and uncover a more effective treatment.