Alzheimer's Disease- Why So Hard to Diagnose?

Alzheimer's disease (AD) should be simple to diagnose, right? How hard can it be for a doctor to decide if memory loss is a normal part of aging, or if it is severe enough to "count" as Alzheimer's? Well, if diseases only occurred one at a time, it might be simple. Unfortunately, as old Texas doc's say, when you itch, it's possible you've got ticks AND fleas. I find in family medicine, it's rare we see any disease state by itself, and Alzheimer's is no exception.

Many different issues can affect memory. Depression and/or anxiety very frequently preoccupy the brain so much that short term memory loss can be a predominant issue. Low thyroid levels can decrease memory. B12 deficiency is another cause. The list of medications that can affect memory seems to be growing each year as well.

When my mother first noticed significant memory issues at the age of 61, she was convinced she had Alzheimer's. I literally laughed when she told me her concerns...We had no family history of early or even late onset dementia. She had recently started a medication known for impairing memory (Digoxin.) As her medical workup progressed, I was relieved to find out she had not only that medication as a possible cause, but literally every cause I listed above- B12 deficiency, hypothyroidism and depression. I felt confident that as we addressed each of these problems, her memory would improve. In many cases, that would have been true, but unfortunately for Mom, she did indeed have underlying Alzheimer's, which took roughly another two years to fully decipher.

If you are concerned about memory loss, please make an appointment with your family physician to address your concerns. Head to the Alzheimer's Association website and review the 10 Warning Signs of Alzheimer's. Until those biomarkers for AD become more refined, physicians will not have a quick or simple answer, but a thorough history and exam, combined with possible neuropsychiatric testing, will take us a long way in the right direction.

BOTTOM LINE: Memory loss can have many different causes, and these causes can and frequently do overlap.

Alzheimer's Biomarkers- What ARE They?

In yesterday's post about the new Alzheimer Disease (AD) guidelines, I talked about how Alzheimer's biomarkers represent hope for future early diagnosis and treatment of AD. But what the heck ARE biomarkers? Today I will clarify...

Biomarkers - short for biological markers-are any naturally occurring substances in the body that reliably predict or indicate a disease. Cholesterol, for example, can be considered a biomarker for heart disease. We know when cholesterol levels are very high, it is likely that plaques of cholesterol could be building up in the heart arteries, making it more likely that that person could have a heart attack. In the case of Alzheimer's disease, the pathological changes in the brain involve the buildup of certain types of protein around the nerve cells in the brain, as well as degeneration and breakdown of other nerve cells. The combination of these two problems makes it hard for the brain to function correctly, as messages can't be passed effectively from one part of the brain to another.

Biomarkers for AD include beta-amyloid protein (that builds up in plaques) and tau protein, which is part of "neurofibrillary tangles"- clusters of protein that block nerve conduction. Right now, these proteins must be measured in spinal fluid, which means the patient must have a spinal tap (aka. lumbar puncture) which involves a needle in your back near your spinal cord. The hope is that measuring levels of these proteins in blood or urine may also prove to be accurate predictors of AD, so the more invasive procedure is not needed.

Not all of today's biomarkers require spinal fluid. Genetic testing for APOE-e4, as well as other genes that increase risk for AD, can be done by a simple blood test. Additionally, imaging of the brain using MRI and PET scans can provide valuable information as well.

Unfortunately, the diagnosis of Alzheimer's disease is not black and white, even with use of biomarkers and the new guidelines. I'll delve more into the challenges of diagnosis tomorrow.

BOTTOM LINE: Biomarkers for Alzheimer's include blood tests, spinal fluid tests and brain imaging, and these procedures are primarily restricted to research settings in 2011.

Breaking News about ALZHEIMER's

Over 5.4 million Americans suffer from Alzheimer's dementia (AD), and we believe that an equal number of people are in the early, yet UNdiagnosed stages of Alzheimer's. If you don't know someone affected yet, you will soon. My mother battled AD for over a decade, so I have a very personal face for this disease. For the first time in nearly three decades, there are new criteria for the diagnosis of this challenging disease. What's new?

Now there are THREE stages, with the first stage existing before there is any memory loss, called PRE-Clinical AD. This is based on research settings ONLY, where levels of biomarkers can be measured. The second stage is Mild Cognitive Impairment (MCI), where there are early memory and other cognitive changes, but these developments do not significantly impair the person's ability to perform daily tasks. The final stage is Dementia, where there are not only memory, orientation and judgement difficulties, but they are to a level that affects the patient's daily life.

Biomarkers represent a very exciting FUTURE for Alzheimer's disease research and treatment. Right now, these tests are not readily available to those of us in private practice, and even if they were, we have not established solid reference points to allow for accurate interpretation of the data. The importance is THIS- just like we can measure and treat cholesterol levels BEFORE someone has a heart attack, or see rising blood sugars before full diabetes, elevated AD biomarkers may warn us of impending AD. Obviously, the next step is then to develop medications that will PREVENT the full development of dementia, if they are started during the earliest stage.

We're making progress! Go to the Alzheimer Association website and see how you can help make a difference.

BOTTOM LINE: We are learning more and more about the early stages of Alzheimer's disease, and biomarkers represent an exciting new diagnostic tool...but they are still ONLY IN RESEARCH protocols.

The Secret to a Successful Exercise Program

Here in Austin, the temperature is already climbing into the upper 80's, so our swimsuit season has officially arrived. Unfortunately, most of us still have a bit of "winter fat" on us that we'd like to shed. If you have kids, it's easy to get caught up in the end of school year rush and push aside your own health priorities. After all, who's got the time?

Let me encourage you to MAKE the time. Make exercise a DAILY habit- just like brushing your teeth. Take away the whole "am I going to exercise today" dilemma. If you got out of bed, YES, some form of exercise will happen today. Period. You don't have to have an elaborate work out plan that consumes an extra hour simply to get to and from the gym! If you have the time, grab that gym bag, but if not, START MOVING. The "BEST" exercise is the plan you will follow every day. Extend that dog walk and make it two miles in a half hour; pull the clothes off the treadmill or exercise bike and hop on it to watch your favorite show; pull out your favorite exercise DVD or flip channels till you find a new one.

What's the secret to exercising every day? Do it FIRST THING in the morning, and don't give yourself a "choice" to hit snooze. Let me assure you, when my alarm goes off at 5:00am, I do NOT leap out of bed with a smile on my lips and a song in my heart! I grumble to myself, moaning and groaning a bit while I throw on weather appropriate clothes, leash the dog, and head out the door. That being said, by the time I reach the top of the first hill, I'm pleased with myself for getting out there, and I feel energized and ready to take on the day by the time I hit the shower.

BOTTOM LINE: START EVERY DAY with 30 minutes of exercise, and you'll stop worrying about whether or not you can "fit" exercise into your schedule!

Confirmed Contagious: Silent Herpes

The current issue of JAMA, the Journal of the American Medical Association, includes an important study: Genital Shedding of Herpes Simplex Virus Among Symptomatic and Asymptomatic Persons With HSV-2 Infection. We know that the vast majority of people who are infected with genital herpes are UNAWARE that they have this disease, so it is critically important to know whether someone who has disease, but doesn't KNOW it, can still pass that disease on to a partner. How can infected people not know?

First of all, not all herpes infections are obvious. The classic herpes lesion is a painful cluster of blisters sitting on a bright red base. However, these blisters may not be visible, especially on a woman, since they can be hidden up inside the vagina. Additionally, many people have very mild symptoms, such as intermittent burning, itch, or discomfort with intercourse. If you are not checked for herpes with a specific antibody blood test, both you and your medical provider can easily miss this diagnosis!

Back to the research...This study was done on roughly 500 patients, both men & women, all of whom tested positive for Herpes Simplex Type 2 (HSV-2) by a blood test, though only 82% were already aware that they had herpes symptoms. Those that did know they were infected averaged 4 break outs per year, and had ~8 years history of having the disease. Every participant swabbed their genital area daily, regardless of symptoms. None of the patients were allowed to take anti-viral medications during the trial.

The results? Yes, people who experienced obvious herpes lesions shed MORE virus- translation, they were potentially infectious to partners. However, here is the important part: People who only knew that they had herpes because of the positive blood test STILL SHED VIRUS (meaning were infectious to others) 10% of the time, and the amount of virus present was the same quantity in people aware or unaware of their lesions.

BOTTOM LINE: This study again confirms that you are infectious to other people if you have a positive blood test for herpes, whether or not you have any symptoms. GET TESTED, and be sure your PARTNER GETS TESTED, too!

Teen Pregnancy- New CDC Report has Good News & Bad News

The CDC released "Vital Signs: Teen Pregnancy" this week, which looks at teenage pregnancy statistics over the last two decades. On the plus side, the total national teen birth rate in the United States was the lowest we have recorded, down, in fact, by 37% from 1991. Unfortunately, we still had over 400,000 teenage births, which is 4% of female teens aged 15-19, and the annual estimated cost of teen childbearing is- gulp- over $9 BILLION. The USA birth rate is up to 9 times higher than most other developed countries.

Please note, my fellow southerners (Texas, Oklahoma, Arkansas, New Mexico and Mississippi), that we have the very WORST rates of teenage pregnancy in the country: >60/1000 females vs. <20/1000 for the best states, up in New England. Not something to boast about...

Today, and every day, 1,100 teenage girls will give birth in the US. That's 1 out of 10 new mothers. The cycle continues as 1/3 of kids born to teenage moms become teenage parents themselves. Not surprising, only half of teenage moms earn their high school diplomas- even by age 22.

The media is still portraying teen motherhood and sex in general as glamorous, fun, and enticing, which is far from the truth. Unpaid bills, screaming kids and exhausted parents are more the rule. We are slowly creeping in the right direction, but we've got much work to do to effectively educate our kids.

BOTTOM LINE: America has embarrassingly high rates of teenage pregnancy, costing our nation billions of dollars and heartache. We can do better.

Social Media Impact- from Disney to Facebook

The Journal of Pediatrics recently published a timely clinical report—The Impact of Social Media on Children, Adolescents, and Families. Kids are entering social media at earlier ages, logging on to Disney websites such as Club Penguin. Soon they progress to websites intended for more mature audiences, such as Facebook and Youtube. Once again, we need to be aware of a desensitization process- this time, in the parents! We are used to our kids being ON the computer, and may not be watching closely enough as they evolve beyond cartoons characters. The minimum age on Facebook is 13, but that doesn't mean all teens should have free rein on FB without supervision.

The report noted that up to 20% of teens log on to their favorite social media site 10 times per day. Most teens have smart phones that allow them constant access. Ever notice how few teens use their phones...to make PHONE CALLS? Cell phones are cameras and instruments to TEXT or IM (instant message). The significance is that a good chunk of teens emotional and social development is occurring through these screen communications.

There are absolute advantages to the social media for youth, including anonymous access to health education that they might not otherwise seek- depression, anxiety, and sexually transmitted disease, for example. This report did not offer shocking news, but is an excellent reminder for parents to stop, look and listen to our kids' social media. And I mean that- go on the sites, read what your child and their friends are saying, and follow up with real live conversation with your kids. BTW, this is a great time to remind everyone that the total recommended daily screen time (ALL screens, big and small) is LESS THAN 2 HOURS, and yet most youth are surpassing 6 or more hours.

BOTTOM LINE: Recognize the role social media is playing in your child's development, and play an active role in setting time and boundary (privacy setting) limits.