Q&A: Treating patients with Alzheimer’s and their caregivers
Alzheimer’s and Brain Awareness Month is annually observed in June to raise awareness for the disease that currently affects more than 5 million Americans, and may potentially rise as high as 16 million by 2050, according to the Alzheimer’s Association.
In the United States, more than 15 million people provide unpaid care for individuals with Alzheimer’s or another dementia and 35% of these caregivers report that their health has deteriorated due to care responsibilities, according to the association.
In recognition of Alzheimer’s and Brain Awareness Month, Healio Internal Medicine spoke with Laura Mosqueda, MD, chair and professor of family medicine at the Keck School of Medicine of the University of Southern California, and Christopher M. Callahan, MD, director of Indiana University Center for Aging Research, about the risk factors and treatment options that PCPs need to be aware of to identify and care for patients with the disease, as well as concerns regarding caregivers.
Question: What are the risk factors associated with Alzheimer’s? Who should clinicians screen for the disease?
Mosqueda: Risk factors include ones we can’t control (such as genetics) along with ones we can control (such as a sedentary lifestyle, social isolation and smoking). People who have a history of serious head injury are at increased risk especially in combination with particular genetic factors.
African-Americans and Latinos have higher rates of dementia compared to whites.
All older adults should be screened for memory loss; the older we get, the more likely it is that we have a memory problem. About one in nine people older than 65 years have Alzheimer’s disease and one in three people older than 85 years have this illness.
Callahan: The number one risk factor for Alzheimer’s disease is advancing age. This risk factor far outweighs any other known risk factor. In some respects, this reality offers an unusual lens by which to consider risk. This is true because you have to successfully survive your fifth and sixth decade (not die from other common causes such as cancer or heart disease) in order to be exposed to the higher risk of dementia in your seventh or eighth decade. Low educational attainment is also considered an important risk factor for dementia and this may be true because higher levels of education provide for a higher level of functional reserve. Some families have an increased risk of early onset dementia and this led to the observation of genetic risks. Other considered risk factors are similar to those for other vascular diseases, including smoking, diabetes, high lipid levels, and hypertension.
Q: Are there effective methods clinicians can recommend to high-risk patients to prevent onset of the disease?
Mosqueda: The same types of things that are good for your heart are good for your brain: regular physical exercise, controlling high BP and cholesterol, and a healthy diet (such as the Mediterranean diet) are all helpful. It is also important to avoid head injuries, particularly in certain individuals with a genetic predisposition to Alzheimer’s disease.
There is evidence that brain training (activities that challenge your brain such as word puzzles) can improve some aspects of memory but we don’t know if they impact one’s likelihood of developing dementia.
Callahan: According to the National Institute on Aging, there are no treatments or other methods known to prevent the onset of Alzheimer’s disease. However, many such approaches are currently under evaluation or have shown promising early results. Examples include changes in diet, exercise, cognitive training, control of vascular risk factors and continued engagement in meaningful activities. These are typically viewed as the same lifestyle behaviors recommended to prevent or mitigate heart disease and other chronic conditions. The National Institute on Aging website, as well as the Alzheimer’s Association website, offer clinical support to providers as well as educational materials for patient and families concerned about Alzheimer’s disease and related dementias.
Q: What are the treatment options for Alzheimer’s that PCPs need to be aware of?
Mosqueda: While there are several medications that are available for the “treatment” of Alzheimer’s disease, they help some people a little bit. Occasionally a person has a big improvement when a medication is started, but this is not typical. More importantly, the PCP looks for treatable illnesses that may make the person with Alzheimer’s worse than they need to be. For example, low thyroid is an easily treatable illness that may make a person with Alzheimer’s get worse at a more rapid rate. People with Alzheimer’s who also suffer from depression can have the depression treated and function at a much higher level even though they still have the disease. Much of the treatment is focused on the family and/or caregiver, as we know that these people have high rates of emotional and physical stress due to the caregiving they provide.
Callahan: The first and foremost actions that the PCP can take are to make an accurate diagnosis, reveal this diagnosis to the patient and their family and identify a family caregiver who will be the PCP’s partner in providing care. Many persons with dementia live 5 to 10 years with their disease and die of conditions other than the dementia. Over time the caregiver hones their skills in helping to care for the person with dementia at home. Earlier in the disease, this will include issues of driving and home safety and advanced directives. As the condition progresses, this will include education and support for managing wandering, agitation, or repetitive behaviors. The PCP has an important role in helping to link the family with available community resources like the Area Agency on Aging or the local chapter of the Alzheimer’s Association. Medication management offers limited, but important benefits for some patients.
Q: What should PCPs keep in mind about caregiver concerns?
Mosqueda: Caregivers are dealing with a variety of issues, from the mundane to the philosophical. Getting help at home, deciding if/when a new medical problem may have arisen, handling difficult behaviors, and managing the finances are a few of the many challenges faced by caregivers. When a person is diagnosed with Alzheimer’s, the “patient” becomes the whole family. PCPs should be aware that the physical and emotional health of the caregiver must be attended to along with that of the person with Alzheimer’s. There are many supports in the community such as the Alzheimer’s Association, Adult Day Care programs, and a variety of support groups. The stress and strain of caregiving can take a powerful toll on a person, but there are also joys that can accompany the role: joy, satisfaction, and meaning can also be found along the way.
Callahan: Caregivers would like to be recognized as the key partner in providing care to their loved one with Alzheimer’s disease. Although the person with dementia should always be included in visits, caregivers should also be invited to be an active participant in clinic visits and decision-making. Given the limited treatment options, most of the day-to-day care in the home over a period of 5 to 10 years will be provided by family caregivers and community-based support organizations.
Q: Are there any other factors that PCPs need to consider when treating a patient with Alzheimer’s?
Callahan: Persons with Alzheimer’s disease and even older adults with mild cognitive impairment are often targets of financial fraud and abuse. Unfortunately, the perpetrators can be around the world, in the neighborhood, or in the family. Many communities include attorneys with expertise in elder law that may help PCPs sort the wide variety of concerns that might arise. However, an early preventive service is for PCPs to alert persons with dementia and their families that they are vulnerable.
Disclosures: Callahan reports no relevant financial disclosures.