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By James M. Ellison, MD, MPH
Julianne Moore’s stunning portrayal of a linguistics professor with early onset Alzheimer’s disease in the movie “Still Alice” is sure to increase public awareness of a neuropsychiatric disorder that has become one of the top causes of death in the United States. Five percent of people afflicted with Alzheimer’s show mental deterioration before age 65 and while Alzheimer’s disease is one of the most feared illnesses among our rapidly increasing aging population, newer research findings suggest that we may be thinking about “early onset” and “late onset” in the wrong way.
Recent research into biomarkers leads us to the frightening realization that every case of Alzheimer’s disease is “early onset.” At first glance, this will seem an outrageous statement, but consider what we now know about this disorder.
At least two decades before changes in memory and behavior become apparent to others, in other words as early as our 40’s and 50’s, newer MRI techniques can uncover subtle derangements in the fine structure of brain anatomy caused by the pathological changes that eventually will lead to clinical Alzheimer’s disease. Positron Emission Tomography (PET) incorporating tracers designed to seek out destructive amyloid protein can demonstrate clinically silent destruction of brain cells. Metabolically oriented PET scans can reveal diminished metabolic activity where these proteins accumulate. Volume loss in memory-oriented brain structures such as the hippocampi can be seen as the disease progresses. Subtle cognitive failings, invisible in daily function, are made apparent by sophisticated neuropsychological challenges.
A recent consensus statement from assembled experts warns us that Alzheimer’s “dementia” is best understood as the third and final stage of a disease process that begins with silent neuropsychiatric alterations, progresses through a period of barely detectable cognitive changes, and ends with the inevitable decline of memory and other cognitive faculties, a loss often made more tragic by the emergence of the most distressing behavioral changes.
Despite decades of research performed by a global network of dedicated scientists, there is as yet no cure for Alzheimer’s. Current breakthroughs have raised hopes for the success of disease-modifying therapeutic agents that attack the Alzheimer’s pathology at a fundamental level. Fantastic possibilities emerge daily, most recently the seemingly outlandish prospect of restoring lost memories by repairing damaged synapses in order to reconnect estranged neurons. But ultimately, the best weapon against Alzheimer’s disease, as against many of the most devastating public health threats, will be prevention.
Evidence is amassing to support the value of early detection and intervention through lifestyle modifications that make sense for all of us, whether or not Alzheimer’s disease would lie ahead. These common sense, accessible interventions include attentive management of cognition-damaging illnesses such as diabetes and hypertension, regular and sufficient aerobic activity, dietary modifications emphasizing a Mediterranean-like menu, cognitive stimulation using challenging exercises dosed with adequate intensity, building meaningful relationships with others, cultivating a sense of purpose and self-worth, assuring enough restful and restorative sleep, and incorporating mindfulness practices such as yoga or meditation as a regular component of daily life.
Changes such as these, timely at the onset of a new year, may increase our likelihood of optimal cognitive aging. Prevention, more powerful than palliation, is our best current weapon against this public health enemy.
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James M. Ellison, MD, MPH, is formerly a psychiatrist in the Division of Geriatric Psychiatry at McLean Hospital.