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From Anti-Alzheimer’s “Magic Bullets” to True Brain Health

If you followed latest headlines surrounding the release of the National Alzheimer’s Plan, you’d probably conclude that the likely solution to maintain lifelong brain health is simple: simply wait until 2025 for a “magic bullet” to be discovered, to cure (or end or prevent) Alzheimer’s disease and aging associated cognitive decline. These kinds of beliefs, often reinforced by doctors and advertising, may explain the billions spent today by pharma companies on discovering new compounds, and by consumers on supplements like ginkgo biloba. But the failures to produce better drugs and conflicts of interest are making many people ask what is wrong with this picture.

We need a new culture of lifelong brain health to empower that 80% of the 38,000 adults over 50 surveyed in the 2010 AARP Member Opinion Survey who indicated “Staying Mentally Sharp” as their top ranked interest and concern, not to mention youth, workers and elders facing cognitive and emotional challenges.

The problem? That the “magic bullet” approach neither does it reflect existing clinical evidence or emerging neuroscientific thinking, nor does it address the lifelong needs and demands of our citizens.

That’s why we need to shake the Etch-A-Sketch and create a new image of the future.

Let’s first draw our true objective: is it to promote mental vitality and collective wisdom or to declare war on Alzheimer’s plaques and tangles? Those are two radically different objectives, leading to very different priorities. For example, let’s imagine the implications of being able to maximize cognitive performance and to delay cognitive decline.

Second, let’s build on what we know today. We know that 30% or more of the population with plaques and tangles do not manifest significant cognitive decline. This is a fact –often explained via the “Cognitive Reserve” theory. It is also a fact (ignored in the report’s presentation and related media coverage) that the most exhaustive systematic evidence review, performed in 2010 under the auspices of NIH, found that nonpharmacological factors (such as physical exercise, cognitive engagement, cognitive training, and Mediterranean diet) seemed to be protective against cognitive decline, whereas “magic pill” interventions (drugs, supplements such as vitamins and gingko biloba) had no such effect.

Third, let’s select the right framework and toolkit. While biomedical research is indeed part of the solution, public health/ education initiatives and technology innovation are equally important. The 2011 SharpBrains Virtual Summit, which brought together more than 260 research, technology and industry innovators in 17 countries, highlighted the need to devote sufficient attention and resources to preventive brain health strategies across the whole lifespan, and the need to bring to market a new generation of reliable and inexpensive assessment and monitoring strategies of cognitive and emotional health – in order to target and deliver those preventive strategies in efficient ways. Innovative public education initiatives, such as Experience Corps and The Intergenerational School, may lead to better cognitive and health outcomes over the long-haul.

It simply makes no sense to put all our eggs in the biomedical basket. Each of this column’s co-authors is producing a different conference in June: Dr. Whitehouse and colleagues on “Healthy Environments Across Generations” (June 7-8, NYC) and Mr. Fernandez on “Optimizing Health via Neuroplasticity, Innovation and Data” (June 7-14th, fully online). There are a number of exciting and complementary approaches to “Staying Mentally Sharp” such as physical exercise, mindfulness meditation, biofeedback, cognitive therapy and training, volunteering…How can consumers make informed and relevant decisions today? And how can they use these reenergized healthy brains to solve challenges like global climate change and economic stagnation?

Sure, more research is better than less, and we hope that the new funded trials will result in useful drugs. But neither policy-makers nor citizens should wait until then to foster and make lifestyle decisions than can maximize cognitive performance across the lifespan.

JFK challenged us not only to go to the moon, but to take proactive care of our physical fitness. Perhaps the time has come for a serious open national conversation on true brain health and how the newly announced Alzheimer’s strategic plan must include healthier and brainer thinking than a war on Alzheimer’s plaques and tangles.

Dr. Peter Whitehouse is a Professor of Neurology at Case Western Reserve University and co-author of The Myth of Alzheimers: what you aren’t being told about today’s most dreaded diagnosis. Alvaro Fernandez, recently named a Young Global Leader by the World Economic Forum, is the co-author of The SharpBrains Guide to Best Fitness, named a Best Book by AARP.

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2 Responses

  1. Bruce Brotter, PhD says:

    We could not agree more with the concerns and argument posed by Dr. Whitehouse. Yes- the NIH report tells us that there is so much that can be helpful to healthy older adults as well as individuals suffering from MCI and early stage AD. And yet, the National Alzheimer’s Project Act (NAPA, new version just released 5/15) does not once mention cognitive therapy or training as an effective intervention, or even mention as an intervention to be funded for further study. Even in the face of the NIH report and countless others (interestingly not listed in the NAPA bibliography) the protective and restorative effects of cognitive training are not discussed.

    Is it possible, as Dr. Whitehouse suggests, that the funding from pharmaceutical companies and the search for the “magic bullet” is resulting in neglect of what we already know and have in the “arsenal” to help our patients struggling with the early effects of Alzheimer’s disease? We think it is, and that a true disservice is being done to patients and families who are in desperate need of help NOW.

    We could not agree more with Dr Whitehouse’s statement that: “It sim­ply makes no sense to put all our eggs in the bio­med­ical bas­ket.” While of course biomedical research should continue, it seems irresponsible to not make every effort to keep the public well-informed regarding effective non-pharmaceutical interventions.

    It is of course our hope that ongoing research will lead to new and improved ways of treating patients with chronic neurologic diseases such as Alzheimer’s, including the possibility of a “magic bullet – cure”. But we also know that in clinical practice, biomedical and psychological or rehabilitative interventions are not mutually exclusive. In fact, study after study in various subspecialties of clinical medicine report the synergistic effects of the two. In the field of cognitive rehab, a March, 2012 review of the literature by Cotelli, et al., makes the case for the benefits of combining biomedical and cognitive rehab interventions in relation to Alzheimer’s patients: ”The studies described above have shown that non-pharmacological intervention can enhance the effect of ChEI treatment.” (Cotelli, 2012)

    So we know from the NIH review and others that cognitive training is an effective treatment for cognitive decline and early stage AD. We also know from the NIH review that the benefits of pharmaceutical approaches showed no such effect. And we now know that adding cognitive training to pharmaceutical intervention “enhances” the effect of medication alone. Still, NAPA does not speak of the practice or funding of cognitive intervention.

    And there is more bad news coming. Despite the NIH report, and despite recommendations of advocates for the Alzheimer’s patient such as the Alzheimer’s Association and the Alzheimer Foundation of America to provide early detection and TREATMENT, one of Medicare’s largest Carriers – NGS – has removed cognitive rehabilitation as an acceptable treatment for memory loss. This ruling most directly impacts upon the early Alzheimer’s (pre-clinical) patient.

    It is important to note that in 2007, NGS reviewed the most current studies of that time, and changed their policy to allow Alzheimer’s patients to benefit from cognitive rehabilitation especially memory training. It is only in 2009/2010 when NGS was reorganized that the decision was reversed. This occurred just at the time that NIH informed us that cognitive training was the only factor associated with a decreased risk of cognitive decline (with a strong degree of scientific strength behind the research). Is it possible that NGS was unaware of the latest research in the field? Is it possible that this pivotal finding was known but ignored?

    The Memory Training Centers of America has requested of NGS that patients suffering from Alzheimer’s disease (as well as other chronic, neurodegenerative diseases) be, again, allowed to receive one of the only interventions that at this point in our history is known to be helpful. This month, the NGS Medical Staff ‘s preliminary response was to reject this request. NGS will not allow cognitive rehab to be applied to neurological diseases such as early Alzheimer’s disease when they demonstrate memory loss and other cognitive dysfunctions. These patients will only be allowed ineffective medication. We are appealing that decision.

    One has to wonder what could possibly be the motivation of Medicare to stop a medically necessary treatment that can relieve or delay the major symptoms of this devastating disease, in the face of the research, and in the absence of a “magic bullet”. With NAPA’s goal of finding that bullet by the year 2025. What are we to tell our patients TODAY, who we know we can help, but from whom Medicare is now withholding treatment?

    Bruce Brotter, PhD, Clinical Director, Memory Training Centers of America

  2. Steve Zanon, Director Proactive Ageing says:

    The latest NIH perspective as summarised by 57 expert speakers and panellists at the recent NIH Alzheimer’s Disease Research Summit, May 2012 is now available. These Research Recommendations will go directly the Health and Human Services Secretary for her consideration toward meeting the research goals set forth in the National Plan to Address Alzheimer’s Disease. Kathleen Sebelius, herself also presented at this Summit – adding her weight to the proceedings.

    Much of the Summit was devoted to biomarkers and drug interventions, however one session (out of a total of 6) covered non-pharmacological interventions. That’s good news in itself. It was also heartening to see that one recommendation from this particular session was to “Initiate rigorously designed clinical trials in asymptomatic and cognitively impaired older adults to establish the effectiveness of physical exercise, cognitive training, and the combination of these interventions for Alzheimer’s disease treatment and prevention.”

    Unfortunately medicines to prevent and/or treat Alzheimer’s are looking a long way off. Two comments from the Summit’s Research Recommendations include ….. “In 2006 PhRMA, the pharmaceutical industry’s advocacy group, reported over 80 therapies in clinical development for AD. To date, none of these therapies has been successful in late-phase clinical trials, with at least 20 failing in Phase III and many more failing in Phase II”. ….. “Alzheimer’s is a highly heterogeneous, multifactorial disorder with a very long prodromal period. There is growing realization that identifying successful interventions for AD will require stratification of patients across multiple criteria”.

    In the future, effective treatment and prevention interventions will likely require a combination of personalised exercise/lifestyle plans and personalised pharmaceutical strategies, with regular re-assessments starting in our 40’s just like we have cholesterol tests and intervention strategies. But for now several lifestyle factors (including physical & mental exercise) starting in mid life or earlier are our best bet for dementia prevention. Doing nothing and hoping for an effective generic Alzheimer’s pharmaceutical treatment in the near future is I believe a risky personal strategy.

    We don’t yet have an assured solution for Alzheimer’s or the other dementias and the evidence to date shows that researchers are struggling with prospective pharmaceutical solutions. So we need to take some responsibility for managing uncertainty – both individually and as a society. As I wrote back in 2010 “with any good risk management strategy our best bet is to diversify risk across several of the most likely factors. The [NIH] ‘Systematic Evidence Review’ clearly identifies the most likely risk factors. We don’t have certainty but we do have direction and I think that is an encouraging message for the public”….. and maybe for responsible governments too.

    Links …..
    – Alzheimer’s Disease Research Summit, May 2012 http://www.nia.nih.gov/newsroom/announcements/2012/05/alzheimers-research-summit-may-14-15-2012
    – Comments on 2010 NIH State-of-the-Science Review http://www.sharpbrains.com/blog/2010/05/14/cognitive-training-identified-as-protective-with-highest-evidence-in-recent-nih-alzheimers-cognitive-decline-prevention-report/

    Steve Zanon, Director Proactive Ageing

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