Alzheimer’s disease starts two decades prior to first symptoms
Medical Director of the Center for Brain and Neurocare, Maryland, USA, Dr. Ruwani Gunawardane delivering a lecture on AD stresses the importance of prevention
The guest lecture on Monday (April 1) was wide and varied covering a major public health concern in the world which is causing much worry not only to doctors but also people.
Delivered at the Sri Lanka Medical Association (SLMA), even though the topic was ‘Early Diagnosis of Alzheimer’s Disease (AD) Bio-markers’, Dr. Ruwani Gunawardane, Medical Director of the Center for Brain and Neurocare, Maryland, United States of America, taking precious time off her holiday in Sri Lanka, covered numerous aspects of this debilitating disease including vital pointers on prevention.
Cautioning that the disease starts two decades prior to the first symptom, she reiterated that the journey begins in the late 40s…….“So if you are trying to prevent dementia at the age of 60 like me, I’m 62 now or patients who are in their 70s and late 70s, it’s too late.”
Prevention is the best, said Dr. Gunawardane, looking at the different stages of a person’s life. Understanding risk factors for
AD include:
In early life – lower education
In mid-life – hearing loss, traumatic brain injury, hypertension, ethanol (alcohol) and obesity
In later life – smoking, depression, social isolation, physical inactivity, air pollution and diabetes
This Neurologist questioned as to how many times doctors see patients having hearing loss in mid-life but do not attend to correcting this deficit? It is important to let patients know when they have hearing loss and this needs to be treated, because this is one of the very important risk factors to developing AD.
Next she moved onto patients with traumatic brain injury, underscoring the importance of putting these patients on cognitive stimulating exercises and getting them involved in modern activities.
With regard to hypertension, she said that she makes sure that her patients come to the clinic with a blood pressure diary. She looks at their systolic and diastolic blood pressure and their blood pressure fluctuations, whether they are taking their medications and getting themselves routinely monitored.
Dr. Gunawardane dealt with a scenario common to Sri Lanka – assuming that their blood pressure is normal after being on medication a while, they think they do not need medication. This is why their compliance in taking their blood pressure medication has to be checked.
“It’s really important to tell these patients about increased risk, small vessel ischaemic disease (changes to the small blood vessels in the brain), how important it is to treat hypertension, not only to prevent strokes and cardiovascular and kidney disease, but also dementia,” she said.
What about obesity, she asked, elaborating that it is on the rise in America because of patients’ inactivity, diet problems and more sedentary lifestyle.
“We notice that obesity also increases the risk for AD. Just telling patients to lose weight is not going to work. When asked, patients would say they go for vigorous walks twice a week. But twice a week is not adequate. Tell patients, we eat our meals every day and brush our teeth every day, so this too should be routine. Your exercise should be routine in your daily programme. Encouraging patients to exercise first thing in the morning I think is beneficial, because as the day goes along, they have worked and they are too tired to exercise,” she said, pointing out that exercise should not be three or five days, but every single day.
Dr. Gunawardane also looked at the need for healthy nutrition, what is called a Mediterranean diet replete with fruits and vegetables and some fish, but avoiding red meat and saturated fats; putting a stop to smoking; treatment for depression and anxiety; and dealing with sleeping issues.
“Treating depression and anxiety can prevent patients going on to have AD,” she said, mentioning how depression and anxiety are often not addressed. However, depression and anxiety are “important and reversible risk factors, as the patient will then be much better with memory issues.”
With regard to sleep, she said that it is during deep sleep that neurotoxic products are excreted. Fragmented sleep and sleep deprivation are important causes of AD.
Expressing grave concerns with regard to diabetes, Dr. Gunawardane said that it is a “great” risk factor for AD. Therefore, it is vital to make sure that diabetic patients have extremely good diabetic control.
She also cited examples of a typical presentation
of AD in young patients in their 40s or 50s, coming with word-finding problems which is called primary progressive aphasia (which leaves a person unable to communicate effectively). There could also be patients presenting with disorientation – getting lost in their own house or visual disturbances, which could also be primary progressive aphasia which is a variant of AD.
There are also cases where a young patient would come with a seeming psychiatric problem, but this could be a behavioural variant of frontal lobe presentation of AD, she said.
Her detailed one-hour presentation in summary included: Hallmarks of AD pathology; Amyloid Cascade Hypothesis; Variation in AD pathology and distribution of biomarkers; Therapeutics under investigation; and Monoclonal antibodies targeting amyloid plaques farthest along in development.