Comment

What’s the exact problem with the phrase “living well with dementia”?

Shibley Rahman 0 Comments

stock-photo-pink-messy-creative-word-words-quote-quotes-inspirational-scrabble-8451f8e5-00e1-48b2-accf-e87d4d901fd3

Trope is an over-used word. But “living well with dementia” is an over-used trope.

However much you sugar-coat it, there are many aspects to living with dementia for some, including a reduced appetite, having hallucinations, having delusions, potentially strange behaviour such as becoming very disinhibited.

It might be that ‘living well with dementia’ produces no cognitive dissonance for you, in the same way that ‘living well with gangrene’ or ‘living well with scabies’ or ‘living well with necrotising fasciitis’ might. But dementia can be horrible – say if your mum doesn’t recognise you or asks you whether you have any brothers or sisters. To this, the response ‘but it is possible to live well with dementia’ can appear somewhat heartless even to the strongest of souls.

That’s the first thing to say, that my objection to the phrase ‘living well with dementia’ is not that it somehow ‘denies suffering’. And I don’t want to go through for the millionth time the device used ad nauseam that ‘just because we suffer, we are not sufferers’, and bring on the fundraising for (language and stigma) grants for the millionth time.

A rationale for the use of ‘living well with dementia’ is that it is easy to market, for example in fundraising purposes. The official reason is that the use of the phrase mitigates against stigma. This is potentially laudable.

… except when you realise this is an easy thing to claim, but very difficult to measure in any way. Look for example at the never-been-published outcomes of the multi-million £ Dementia Friends experiment.

At worst, “living well with dementia” makes a nice host for cupcakes and speakers from well known corporates on a ‘dementia themed day’.

Meanwhile, back in the real world, when I tell people that my mum has dementia, the reaction is ubiquitously “How awful”. This is not because the campaigning mantra “living well with dementia” has been ineffective, due to my criticism on Twitter for example. It’s because dementia can be an awful condition for the person experiencing it, and the immediate family or friends; unless of course you never get beyond the ‘prodrome’ phrase.

But think about that for a moment.

It would be like someone with pre-renal disease saying that living well with renal disease isn’t that bad, because you don’t have to do dialysis.

Or living well with pre-diabetic disease isn’t that bad either, because your toe hasn’t been amputated.

And so on.

The existence of the same small group of campaigners for dementia who do not exhibit a progressive condition on the face of it might lead to you to believe their diagnoses are ‘none of our business’.

Nobody is asking them to be put under the microscope – except they just appear with remarkable regularity.

But if they are not progressing along a trajectory of symptomatic decline, we need to be very sure about the diagnosis. Whilst they are not holding themselves out to be ‘representative’, the phrase ‘go to group’ for ‘lived experience’ can all too easily trip off the tongue.

This is because there’s only a few of them, and, in their current form, the members of this select group are appearing as if you can ‘live with dementia’ with only very minor adjustments to your lifestyle – since their diagnoses from about 2009 or 2010.

And the effect on skewing samples in public-patient involvement groups can be dangerous, if it’s the same revolving door of patient advocates sitting on panels, doing the “user involvement”, and so on.

It is not in these advocates’ interest to have their diagnoses revised if their symptoms are not getting progressively worse, as the secondary gain from the attention, the book contracts, the conference speeches, is not insignificant.

This could mean potentially that they become trapped with their public personas as ‘having dementia’, and are themselves open to manipulation from people who might wish to make money out of them. This genuinely would be very sad indeed.

The English law firmly believes in the presumption of innocence, and nobody is suggesting for a moment there is any deception. But misdiagnoses do happen all the time, and the significance of the misdiagnoses in this context is not small.

There is so much further to be gained by the wider ‘living well’ narrative which are not so innocent. For example, it could be that if people are living successfully and independently we do not need to be concerned that social care is in such a parlous state.

This is also a subject which does not lend itself to public debate. Doctors are very strictly regulated in the UK, and cannot guess about other people’s diagnoses from afar.

But people who are looking on, who feel their spouses/parents etc. are deteriorating faster than ‘normal’, might blame themselves for not doing a good enough job in caring. After all, ‘caring well’ was actually not stated as a policy goal in the NHS Living well with dementia scheme, which included diagnosing, supporting, living, supporting and dying.

I don’t mind a careful debate, but people I’ve never heard of have trolled me in the social media saying that I do not ‘understand’ dementia, and there is in fact a phase where some people do not decline in performance. Hence, the emphasis becomes you feeling guilty for raising the idea ‘but you don’t look as if you have dementia’ – but the tragedy would be if some of these people in fact do not have dementia but a functional disorder or some non-progressive form of ‘mild cognitive impairment’, a diagnostic category which is hard to take seriously anyway.

We do need to raise attention of why some people cannot live independently, and do need care. These are not the voices of ‘frequent flyers’ in conferences. We need to have a reason why people might want to find a way to prevent the progression of dementia or delay its onset. I don’t think a better shopping experience in the high street is sufficient to support a charity in dementia any more.

 

@dr_shibley

 

Is the drug industry “stopping dementia in its tracks” or in actual fact “running out of steam”?

Shibley Rahman 2 Comments

Sometimes you have to trust people to get on with things.

That’s why headlines saying fracking under homes could go ahead without permission don’t help.

And the reported assimilation of ‘caredata’ into the NHS information “borg”, without clear valid consent, is running into problems.

We cannot sign off every single decision about how each £ is spent in the ‘fight against dementia’ as it’s called. But the issues about care vs cure in dementia is running into the same problems with imbalance in information as fracking and care data. This threatens seriously to undermine trust in policy leaders supposedly working on behalf of us in tackling dementia.

The origins of the phrase “stopping dementia in its tracks” are obscure. Stopping something in its tracks may be somehow related to the phrase “running out of steam” for nineteenth century railway trains “running out of steam”, or coming to a sudden end when travelling. Is the drug industry “stopping dementia in its tracks” or in actual fact “running out of steam”?

To stop something in its tracks, nonetheless, is a popular metaphor, as it tags along with the combattive ‘war’ and ‘fight’ against dementia theme.

Tracks

While there’s been a need to focus on bringing value to lives with dementia, much of the fundraising has involved painfully pointing out the costs. A study conducted by RAND Corp. for the federal government earlier in 2013 found that nearly 15% of people ages 71 or older, or about 3.8 million people, now have dementia. Each case costs $41,000 to $56,000 a year, the study found. By comparison, direct expenses in the same year for heart disease were $102 billion. The study also tried to get a handle on the cost of informal care, which is often provided by family members in their homes. It pegged that cost at a range of $50 billion to $106 billion a year.

In a press release dated 24 January 2014, the Alzheimer’s Society and Alzheimer’s Drug Discovery Foundation (ADDF) are reported in their “Drug Discovery Programme” as offering up to $1.5 million to new research projects which could speed up developing treatments for Alzheimer’s disease (AD) and dementia. It is hoped that international collaboration could help make the hope of finding effective dementia treatments within the next ten years a reality. This call is open for research looking at all forms of dementia including Alzheimer’s disease. This international call for research proposals comes just weeks after the G8 Dementia Summit in London called for more global collaboration in dementia research in order to develop effective treatments by 2025.

It is described in this promotional video as “halting dementia in its tracks”. To “halt something in its tracks” literally means “stop (dead) in something tracks to suddenly it stop moving or doing something”.

A previous research grant from the Alzheimer’s Society looked at fruit flies. It was for Dr Onyinkan Sofola at University College London for £208,277. It started on October 2007 and was completed on September 2010. The researchers developed a fruit-fly model of Alzheimer’s disease where the flies accumulated amyloid, and investigated the involvement of “GSK-3″ on the behaviour of the flies. It was hoped that dialing down GSK-3 in healthy flies also did no harm suggesting this approach could work as a safe therapy for Alzheimer’s disease in humans.

Ahead of the G8 Dementia Summit in London last year (11 December 2013), Professor Simon Lovestone, Institute of Psychiatry, but soon to be at Oxford, set out what he hopes the Summit will achieve, the challenges of developing new therapies for dementia, and the real possibilities of one day preventing this devastating disease. The Summit was supposed to bring together Health Ministers from across the G8, the private sector and key international institutions to advance thinking on dementia research and identify opportunities for more international collaboration, with the ultimate aim of improving life and care for people with dementia and their families.

The G8dementia summit was described as a response thus by the BBC website:

BBC

Drugs currently used to treat Alzheimer’s Disease have limited therapeutic value and do not affect the main neuropathological hallmarks of the disease, i.e., senile plaques and neurofibrillar tangles. Senile plaques are mainly formed of beta-amyloid (Abeta), a 42-aminoacid peptide. Neurofibrillar tangles are composed of paired helical filaments of hyperphosphorylated tau protein.

New, potentially disease-modifying, therapeutic approaches are targeting Abeta and tau protein. Drugs directed against Abeta include active and passive immunisation, that have been found to accelerate Abeta clearance from the brain. The most developmentally advanced monoclonal antibody directly targeting Abeta is bapineuzumab, now being studied in a large Phase III clinical trial.

In the 1980s, the amyloid cascade hypothesis emerged, and it was the most long considered theory. It is based on the β-amyloid overproduction as responsible for the senile plaque formation and for the neurotoxicity that leads to the progressive neuronal death. However, controversial data about if β-amyloid is the cause of the disease or one of the main risk factors for AD are reported.

A further postulated theory at the end of the past century was the tau-based hypothesis. It is based on aberrant tau protein, a microtubule-associated protein that stabilizes the neuronal cytoskeleton, as the origin of Alzheimer’s pathology. There have been two phase IIb clinical trials with two different compounds, tideglusib and methylene blue. Both compounds have reported some positive results in the increase of cognitive level of AD patients after the first treatments on phase IIa clinical trials.

In the meanwhile, intensive research on the physiology and pathology of tau protein leads to the discovery of two kinases responsible for its posttranslational aberrant modifications. After cloning, these kinases were identified more than ten years ago, including the now well-known glycogen synthase kinase 3 (GSK-3).

The excitement of this “GSK3 hypothesis of Alzheimer’s disease” is described here in this paper with Professor Simon Lovestone as last author.

But all may not be as well as it first appears.

GSK-3 inhibition may be associated with significant mechanism-based toxicities, potentially ranging from hypoglycemia to promoting tumour growth. But encouragingly, at therapeutic doses, lithium is estimated to inhibit approximately a 25% of total GSK-3 activity, and this inhibition degree has not been associated with hypoglycemia, increased levels of tumorigenesis, or deaths from cancer. Currently it’s hoped, in pathological conditions, the GSK-3 inhibitor would be able to decrease the upregulation of the enzyme and, in the case that this treatment would slow down the GSK-3 physiological levels, other compensatory mechanisms of action would play the restorative function.

Therapeutic approaches directed against tau protein include inhibitors of glycogen synthase kinase- 3 (GSK-3), the enzyme responsible for tau phosphorylation and tau protein aggregation inhibitors. NP-12, a promising GSK-3 inhibitor, is being tested in a Phase II study, and methylthioninium chloride, a tau protein aggregation inhibitor, has given initial encouraging results in a 50-week study.  Fingers crossed.

Another important challenge for a GSK-3 inhibitor as an AD treatment is its specific brain distribution. The drug needs to cross the blood-brain barrier to exert its action in the regulation of exacerbated GSK-3 brain levels. Usually this is not an easy task for any kind of drug, moreover when oral bioavailability is the preferred administration route for chronic dementia treatment.

And once it gets into the brain, it has to to go to the right parts where GSK-3 needs to be targeted, not absolutely everywhere, it can be argued.

Nonetheless, the enthusiasm about the approach of drug treatments is described on Prof Simon Lovestone’s page for the Alzheimer’s Society.

However, Professor Lovestone’s research group has run into problems when trying to demonstrate their findings in mice, an important step in the research process. The problem is that mice do not naturally develop Alzheimer’s disease, and it is even difficult to experimentally cause Alzheimer’s disease in mice.

We may soon have to face up to the concept, with the current NHS having to do ‘more with less’, and ‘with no money left’, ‘we can’t go on like this’. It would be incredibly wonderful if you could give an individual a medication which could literally ‘stop dementia in its tracks’. But even note the scientific research above is for Alzheimer’s disease, one of the hundred causes of dementia, albeit the most common one. Or we may have to stop this relentless spend on finding the “magic bullet” in its tracks, and think about practical ways of enhancing the quality of life or wellbeing of those currently living with dementia. Nobody reasonable wishes to snuff out hope for prevention or cure of the dementias, but, for a moral debate, the facts have to be on the table and clear. Every money we spend on investigating magic bullets which don’t work could have been spent in giving a person living with dementia adequate signage for his environment, or a ‘memory phone’ with photographs of common contacts. But the drug industry, and the people who work with them, never wish to admit they’re running out of steam.

Would I want to know if I had a dementia?

Shibley Rahman 1 Comment

Brain scan

Would I want to know if I had a dementia?

The background to this is that I am approaching 40.

For the purposes of my response, I’m pretending that I didn’t study it for finals at Cambridge, nor learn about it during my undergraduate postgraduate training/jobs, nor having written papers on it, nor having written a book on it.

However, knowing what I know now sort of affects how I feel about it.

Dementia populations tend to be in two big bits.

One big bit is the 40-55 entry route. The other is the above 60 entry route. So therefore I’m about to hit the first entry route.

I don’t have any family history of any type of dementia.

My intuitive answer is ‘yes’. I’ve always felt in life that it is better to have knowledge, however seemingly unpleasant, so that you can cope with that knowledge. Knowledge is power.

If I had a rare disease where there might be a definitive treatment for my dementia, such as a huge build-up potentially of copper due to a metabolic inherited condition called Wilson’s disease, I’d be yet further be inclined to know about it.

I would of course wish to know about the diagnosis. The last thing I’d want is some medic writing ‘possible dementia’ on the basis of one brain scan, with no other symptoms, definitively in the medical notes, if I didn’t have a dementia. This could lead me to be discriminated against to my detriment in future.

There is a huge number of dementias. My boss at Cambridge reviewed the hundreds of different types of dementia for his chapter on dementia in the current Oxford Textbook of Medicine. Properly investigating a possible dementia, in the right specialist hands, is complicated. Here‘s his superb chapter.

But just because it’s complicated, this doesn’t mean that a diagnosis should be avoided. Analysis can lead to paralysis, especially in medicine.

I very strongly believe that there’s absolutely nobody more important that that person who happens to living with a diagnosis of dementia. That diagnosis can produce a constellation of different thinking symptoms, according to which part of the brain is mainly affected.

I also think we are now appreciating that many people who care for that person also may have substantial needs of their own, whether it’s from an angle of clinical knowledge about the condition, legal or financial advice.

I think though honesty is imperative.

I think we need people including charities to be honest about the limitations and potential benefits in defined contexts about drug treatments for dementia. It’s clearly in the interest of big pharmaceutical companies to offer hope through treatments which may objectively work.

I think we also need to be very open that a diagnosis of dementia isn’t a one path to disaster. There is a huge amount which could and should be done for allowing a person with dementia to live well, and this will impact on the lives of those closest to them.

This might include improving the design of the home, design of the landscape around the home, communities, friends, networks including Twitter, advocacy, better decision-making and control, assistive technology and other innovations.

The National Health Service will need to be re-engineered for persons with a diagnosis of dementia to access the services they need or desire.

Very obviously nobody needs an incorrect ‘label’ of diagnosis. The diagnosis must be made in the right hands, but resources are needed to train medical professionals properly in this throughout the course of their training.

All health professionals – including physicians – need to be aware of non-medical interventions which can benefit the person with dementia. For whatever reason, the awareness of physicians in this regard can be quite poor.

There is no doubt that dementia can be a difficult diagnosis. Not all dementia is Alzheimer’s disease, characterised by symbolic problems in new learning. There are certain things which can mimic dementia for the unaware.

But back to the question – would I rather know? If the diagnosis were correct, yes. But beware of the snake oil salesman, sad to say.