In our ongoing effort to meet both mandates of “Connections”, informing readers about RGP services and promoting wellness by providing information on matters relevant to aging and health, following is an article by Dr. Christopher Frank.

Treating Alzheimer’s Disease: Hope for the Future

Alzheimer’s dementia is a common and feared diagnosis in older Canadians. The 1996 Canadian Study on Health and Aging, found that approximately 10% of people over age 65 have some degree of dementia. Of these, approximately 65% will have Alzheimer’s disease. This condition usually presents with short-term memory problems but also effects other areas of thinking such as personality, language, and planning skills. In the next century, Alzheimer’s disease (AD) will become an increasingly common problem as the population ages and as a result there has been an increased interest in drug treatments for Alzheimer’s disease. There are some new medications available or soon to appear on the market that hold out some hope for patients and their families.

This article will review the effectiveness of a few of the treatments currently available for Alzheimer’s disease. It is important to use reliable sources of information about drug treatments for AD or any other type of dementia. The Internet is full of reports about treatments and many of the claims are unproven. The Alzheimer’s Society remains a good source for information, either by visiting their office or by visiting their excellent website. It is worth being wary of some of the claims being made about treatments, particularly when the information source has a financial interest!

Aricept (generic name: donepezil)

This medication was introduced in Ontario in 1998, but was only recently included on the Ontario Drug Benefit Plan. Alzheimer’s seems to be associated with low brain levels of the chemical acetylcholine and donepezil works by preventing the breakdown of acetylcholine. Donepezil is safer and better tolerated than older medications that worked in the same way.

There have been well-designed studies done looking at the safety and effectiveness of donepezil. Overall, it seems that the drug does not alter the course of Alzheimer’s disease itself but is helpful by slowing down the progress of dementia. The medication has been shown to slow the disease by only 3-5 months but this short time can be very important for caregivers. Some patients may get a very significant improvement but most patients will get mild but helpful improvements. These improvements may include greater interest in previous activities such as reading, or the person may regain some of their previous personality traits. The benefits may last longer than previously thought and it is now suggested to keep people on donepezil, who are benefiting, for a year before stopping it. Unfortunately, many people get a rapid decline in cognition once the drug is stopped and they may not get the same benefit if it is restarted.

As mentioned, this medication is now partially covered by the ODB plan. In order to qualify patients must have been on donepezil for at least 60 days already and must have some clear evidence of improvement. The prescribing physicians must show this using the cognitive testing tool called the Mini Mental Status Exam, and this test must show mild to moderate levels of dementia. After one year, the Mental Status Test must be done again for coverage to continue.

It is very important that patients and families remember that donepezil is not a cure and that its effects are often small and are time-limited also. Expecting miracles will only lead to disappointment. However, donepezil may be helpful in delaying the need for institutional care and may provide some help for caregivers in the difficult task of caring for a loved one with Alzheimer’s. Other drugs that work in the same way are due out on the market in the next few years and it is hoped that these may be more helpful.

Ginkgo Biloba

Interest in the use of Ginkgo for the treatment and prevention of dementia is very high. However, there have not been many English-language studies done to look at its effectiveness. Studies have shown modest improvement in cognitive scores but have also had high rates of subjects who dropped out of the studies. Given concerns about the quality of the evidence, a group of Canadian experts recently suggested that there was insufficient evidence to support or advise against the use of Ginkgo for treatment of Alzheimer’s. If patients decide to try Ginkgo, it is important that they use a brand containing the preparation called EgB 761,as this has been the most studied formulation. It is also important to note that there is no good evidence to suggest that EgB 761 helps to prevent dementia.

Vitamin E

Vitamin E may be helpful for Alzheimer’s disease because it acts as an antioxidant in the body. However, there has only been one well-designed trial to study its effectiveness. In this study, a large dose (2000 IU) was used and was found to increase the length of time it took for patients to develop severe Alzheimer’s. Unfortunately, there were some concerns about the design of the study and as a result it is not possible to strongly suggest the use of Vitamin E.

Prevention

From this discussion, it is apparent that the medication treatments available for Alzheimer’s are limited. It is hoped that new medications will offer more hope in the future. In the meantime, work is being done to see how to prevent Alzheimer's and at the moment these suggestions may be helpful:

· Maintain a high level of intellectual activity

· Avoid head injury (e.g. wear a bike helmet!)

· Lower your risk factors for heart disease and stroke

· Consider estrogen replacement for women

· Anti-inflammatory medications

Estrogen and anti-inflammatories, such as ibuprofen, have not been studied in clinical trials but seem to put people at lower risk in other types of studies. At the moment, the risk of side effects from anti-inflammatories is too high to recommend their regular use to prevent AD. Better research on these medications is expected in the next few years so we can better advise on prevention of Alzheimer’s.

If you have any questions or would like further information about this subject, please contact your local Alzheimer Society or visit the Alzheimer Canada website www.alzheimer.ca.