Alzheimer’s disease: A prequel

Alzheimer’s Disease: A Prequel-Part XXIV

This prequel is being written as a reflection following completion of 23 articles on Alzheimer’s disease and poignantly following the death of former President Ronald Reagan after a 10 year battle with Alzheimer’s disease. It is a reflection on the ethical principles of pharmaceutical treatment of Alzheimer’s disease and should not be viewed as a criticism of any of the articles written in this series. It reflects more on the dilemma of treating dementia. We believe the questions asked below need to be answered in all fairness to the people being treated for the disease.

It seems reasonable to assume that any pharmaceutical treatment should not be begun until there is evidence-based medical research that an individual will benefit from the prescribed treatment. Here, we are not talking about standard research protocols, where there are controlled research guidelines for use of drugs on humans, though even here there are ethical considerations that need clarification. Clinical treatment ethically necessitates an acceptable benefit-cost ratio prior to starting the pharmaceutical treatment, especially in those cases that involve long-term drug treatment. There is no question that drug studies look at the safety and efficacy of the pharmaceutical treatment. What is the personal cost of being on a drug for ten years etc.? What are the negative implications of long term therapy?

In dementia, we are faced with a clear dilemma. To date (June 11, 2004), there is no rational based on supposed pathophysiology for early treatment of Alzheimer’s disease. However, there are four drugs approved for treatment of mild to moderate Alzheimer’s disease and one drug for moderate to severe Alzheimer’s. For the most part, these drugs treat symptoms of AD, rather than modifying the effects of the disease. They do nothing to prevent the disease. They are based on a depletion of choline acetyltranferase, which may be a downstream result of the disease. This theory is based for the most part on post-mortem studies of individuals with a late stage of the disease. Newer techniques (PET scan, MRI etc.) hold promise for clearer earlier understanding of the disease process. As far as this author can determine, there is much less data concerning changes in choline acetyltranferase activity at the early stages of the disease. Yet, there are attempts to apply this type of treatment to not only the early stages of AD but also to possible precursors of Alzheimer’s i. e. mild cognitive impairment,. Aside from early onset Alzheimer’s that appears to be genetic in origin, most cases of AD have a range of symptoms that is suggestive not only of genetic origin, but also environmental infarcts. But what are the evolutionary implications of such a disease? If it is more common the older one gets, could this be a meta form of apoptosis?

In some cases the drugs used in treatment of AD retard the progress of certain symptoms/behaviors associated with Alzheimer’s. But what are the effects on those who are not helped, and what price does a person pay biopsychosocially by being on the drug for an extended period of time?

It also seems safe to assume that treatment onset may be different for the targeted goal of the drug therapy, as in general medicine where you may have a vaccine for prevention of the disease given in childhood or drugs given to target symptoms of the disease at the onset of the overt expression of the disease or a different regimen when the disease becomes more serious. Could the same be true of Alzheimer’s disease? Or does one size fit all in this case?

Now to look at another face of this disease: one is faced with a disease that has a 100% mortality rate in the long run. We would assume most of the readers of this prequel are familiar with the effects of AD on the individual. But what of the existential pain felt by the individual and the pain of the caregivers? Do we opt for any kind of treatment, even if we do not know the long-term implications of the treatment or if the downside risks are high? Hope is an essential component of our existence. People want to believe there are pharmaceutical therapies that can prevent their dying a perceived painful death. Medications help in this aspect and should not be sold short. But what of alternative treatments that face an uphill battle in face of the Pharmaceutical Industry?

The story of the treatment of AD is still unfolding. This author hopes that this continuing series of articles will help individuals understand a devastating disease and provide information for them or their caregivers to make informed decisions about their treatment.

For some other articles on Alzheimer's Disease Please see:

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Homes"

Harold Rubin, MS, ABD, CRC, Guest Lecturer
posted June 13, 2004

http://www.therubins.com

To e-mail: hrubin12@nyc.rr.com or rubin@brainlink.com

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Harold Rubin

June 11, 2004