The Future of Preventive Brain Medicine: Breaking Down the Cognition & Alzheimer’s Disease Alphabet Soup

By: Dr. Dharma Singh Khalsa @ Alzheimer's Research & Prevention Foundation

As the pres­i­dent and med­ical direc­tor of the Alzheimer’s Research and Pre­ven­tion Foun­da­tion (ARPF), it’s my job to stay on top of advances in the field of Alzheimer’s research. Recently, a num­ber of arti­cles in the med­ical lit­er­a­ture have caught my atten­tion. They are focused on a par­tic­u­lar ques­tion that con­cerns most Baby Boomers like me: “Is mem­ory loss just a nor­mal part of aging?”
Many of my patients in their fifties, six­ties, and older notice that they occa­sion­ally for­get things like a name, face, or where they put their keys. They won­der whether this behav­ior is nor­mal, or if it is a sign of Alzheimer’s dis­ease. It’s a rea­son­able worry: Alzheimer’s dis­ease is reach­ing epi­demic pro­por­tions and recent sur­veys by the Alzheimer’s Asso­ci­a­tion and oth­ers reveal that it is the Baby Boomers’ biggest health fear.
The answer to that ques­tion used to be, “Yes, we all expe­ri­ence some mem­ory loss as we age. Don’t worry—it’s not Alzheimer’s.” Indeed, it was once thought that a lit­tle mem­ory loss was an expected and accepted part of the nor­mal aging process. There was even a term for it: Age-Associated Mem­ory Impair­ment (AAMI). It included a gen­eral slow­ing of men­tal func­tions such as pro­cess­ing, stor­ing, and recall­ing new infor­ma­tion. It also included a gen­eral decline in the abil­ity to per­form tasks related to cog­ni­tive func­tion such as mem­ory, con­cen­tra­tion, and focus.
But here’s the rub: AAMI was never a clin­i­cal diag­no­sis, even though many physi­cians, lay people—and, yes, even yours truly—thought oth­er­wise. Instead, AAMI is a tech­ni­cal diag­no­sis. It’s made by a psy­cho­me­t­ric test, not by actual clin­i­cal symptoms.
These days, we have a num­ber of other, more accu­rate acronyms to describe the vary­ing states of mem­ory loss—a whole bowl of Alzheimer’s-related alpha­bet soup, if you will. And, unlike AAMI, these labels are based on real clin­i­cal diag­noses. They include:

• No Cog­ni­tive Impair­ment (NCI). This is just what it sounds like: You have no mem­ory issues or complaints.
• Sub­jec­tive Cog­ni­tive Impair­ment (SCI). This means that you feel your mem­ory isn’t work­ing as well as it used to or should—maybe you have trou­ble remem­ber­ing names, num­bers, or words, for example—and you com­plain about it to your doc­tor. Tests, how­ever, show that your mem­ory is normal.
• Mild Cog­ni­tive Impair­ment (MCI). You expe­ri­ence short-term mem­ory loss that is greater than what peo­ple describe with SCI but still doesn’t inter­fere very much with your daily life. Tests may show some abnor­mal­i­ties. MCI is con­sid­ered a seri­ous pro­gres­sive con­di­tion that many experts con­sider an early form of Alzheimer’s disease.
• Alzheimer’s Dis­ease. This is a pro­gres­sive neu­rode­gen­er­a­tive dis­or­der that is incur­able and fatal. It used to be that Alzheimer’s dis­ease could only be diag­nosed after death dur­ing an autopsy, but newer tests, some still inves­ti­ga­tional, can con­firm an Alzheimer’s diag­no­sis much earlier.

That’s a lot of letters—but these new labels aren’t what I want you to take away from this prover­bial soup bowl. The real issue here is not just a name change; it’s a shift in the way we think about mem­ory loss and aging. Indeed, these alpha­bet diag­noses are not sim­ply sta­tic states of mem­ory impair­ment. A grow­ing body of research sug­gests that they are instead points on a con­tin­uum of mem­ory loss that often ends with a diag­no­sis of the dreaded Alzheimer’s dis­ease. Unless prop­erly treated—in my view, with an inte­gra­tive med­ical program—memory loss tends to get worse over time. In my expe­ri­ence, with inte­gra­tive treat­ment, mem­ory loss can be improved and people’s func­tion­al­ity can be pre­served for a much longer time.
But is any mem­ory loss “nor­mal”? I recently asked that same ques­tion of Barry Reis­berg, M.D., Pro­fes­sor of Psy­chi­a­try and Direc­tor of The Aging and Research Cen­ter at New York Uni­ver­sity. Dr. Reis­berg is one of the world’s lead­ing experts on the sub­ject of mem­ory loss and has stud­ied it for decades. His answer: “Mem­ory loss may be nor­ma­tive (aver­age), but that doesn’t mean it’s nor­mal. The real ques­tion is what is pro­gres­sive over time.”
And that brings us back to our alpha­bet soup. In one land­mark study, Dr. Reis­berg and his col­leagues looked at 260 peo­ple, 60 of whom had NCI and 200 of whom had SCI. After 7 years, they dis­cov­ered that mem­ory declined in 7 peo­ple with NCI (15%) and 90 with SCI (54.2%). Of the peo­ple with NCI, 5 devel­oped MCI and 2 devel­oped prob­a­ble Alzheimer’s. On the other hand, of the 90 peo­ple with SCI who pro­gressed, 71 devel­oped MCI and 19 declined all the way to Alzheimer’s.
What this means is that SCI appears to progress to MCI and even to Alzheimer’s dis­ease. Sub­jec­tive or not, even minor mem­ory problems—the kind that many of us typ­i­cally attribute to just “get­ting older”—are not nor­mal and should be taken seri­ously. Con­sider these sta­tis­tics, also from Dr. Reisberg:

• At age 65, 25% to 55% of peo­ple have SCI.
• After 15 years, up to 55% of peo­ple with SCI will have pro­gressed to MCI. (Only 15% of peo­ple with­out SCI will develop MCI.)
• Even more sober­ing, accord­ing to the National Insti­tutes of Health,  about 40% of peo­ple over age 65 who have been diag­nosed with MCI will develop demen­tia within 3 years
• By age 85, an esti­mated 55% of all peo­ple will have Alzheimer’s disease.

Num­bers like these not only drive home the seri­ous news that no mem­ory loss is a nor­mal part of aging, but they also make it clear that we’re on the cusp of what many experts believe will be an epi­demic of Alzheimer’s dis­ease as Baby Boomers con­tinue to age.
I’ve shared infor­ma­tion on ARPF’s web­site about the inte­gra­tive med­ical approach to pre­vent and reverse mem­ory loss. But the fact is that pro­tect­ing against mem­ory loss isn’t just an individual’s respon­si­bil­ity.  They say it takes a vil­lage to raise a child. Well, it takes a vil­lage to sup­port the fight against Alzheimer’s disease—and the types of mem­ory loss that pre­cede it—too.
To that end, in late Novem­ber, U.S. Rep­re­sen­ta­tives Ed Markey and Chris Smith, co-chairs and co-founders of the Bipar­ti­san Con­gres­sional Task­force on Alzheimer’s Dis­ease, out­lined their rec­om­men­da­tions for the National Alzheimer’s Plan, a strat­egy pro­posed for Pres­i­dent Obama’s admin­is­tra­tion to tackle the dis­ease. I heartily agree with many of their sug­ges­tions, which include:

• Increased fund­ing for research. The fed­eral gov­ern­ment spends an astound­ing $130 bil­lion in Medicare and Med­ic­aid pay­ments for the treat­ment of Alzheimer’s dis­ease, and an esti­mated 15 mil­lion care­givers pro­vide some 17 bil­lion hours of unpaid care to loved ones with Alzheimer’s. Yet the National Insti­tutes of Health gives Alzheimer’s dis­ease just $429 mil­lion in annual research fund­ing, com­pared to $6 bil­lion and $3 bil­lion for can­cer and AIDS research, respec­tively. We need to start mak­ing Alzheimer’s dis­ease a top research pri­or­ity, as well as fund inno­v­a­tive screen­ing, pre­ven­tive, and treat­ment approaches.
• Increased resources. Peo­ple with mem­ory loss should receive the best care pos­si­ble. Yet many Alzheimer’s patients and their loved ones do not get the resources they need. This is partly due to insur­ance lim­i­ta­tions: Insur­ance com­pa­nies typ­i­cally cover some diag­nos­tic tests for Alzheimer’s, but tend to curb the amount of time doc­tors can spend with patients. As a result, patients and their care­givers may not get the best infor­ma­tion about the dis­ease or get con­nected to resources to help them man­age it prop­erly. We need to con­tinue to pro­mote early diag­no­sis of mem­ory loss and give patients and their fam­i­lies the sup­port they need.
• Increased pub­lic aware­ness. If the “alpha­bet soup” les­son I’ve shared here comes as big sur­prise, you’re not alone. Many peo­ple are woe­fully mis­in­formed about Alzheimer’s dis­ease and about mem­ory loss in gen­eral. While the ARPF and I do our part to try to edu­cate the pub­lic about opti­mal brain health, we still have a long way to go in spread­ing the mes­sage about symp­toms, diag­no­sis, clin­i­cal tri­als, treat­ment, and resources for patients and care­givers. We espe­cially need to improve the dis­sem­i­na­tion about infor­ma­tion on the cur­rent research proven meth­ods of prevention.

Mem­ory loss isn’t like gray hair or wrin­kles. Con­trary to what many of us used to believe, it is not a nor­mal sign of aging. In my opin­ion, that’s all the more rea­son to make Alzheimer’s disease—and the whole bowl of “alpha­bet soup”—a thing of the past by pri­or­i­tiz­ing pre­ven­tion treat­ment today. Beyond that, we clearly need to move past a “magic bul­let” drug approach mentality.
There is a lot we can do right now to live a brain healthy lifestyle and shar­ing that work with soci­ety is where I’d like to see our focus in the future.