March 2015

The Medicine

by Karen Hitchcock

The dementia cure

Do we change our behaviour or wait for a medical breakthrough?

Mrs Finch was sent to the hospital by her nursing home after she punched an attendant. Prior to the incident she’d apparently been a model inmate. She was delirious, probably due to an infection, though she didn’t look terribly unwell. She sat on the side of her bed, hissing any time we came near her. “She won’t let me do her vitals,” a nurse said. The other nurse had just fled, crying, after Mrs Finch called her fat. I stood at the end of the bed watching her, monitoring her respiratory rate, seeing if I could detect cellulitis or an ulcer on her exposed skin. She turned, narrowed her eyes, pointed her finger at me and said, “Have you seen how you look? … Well, have you?” She lowered her finger and shook her head. “You used to be so pretty … and now look at you … You’re disgusting. You’re nothing but a dirty, disgusting, drug addict, you are.”

“I know,” I said. “It’s terrible. I’m sorry.”

She nodded, satisfied. “And so you should be …” She pointed at the beds opposite her where two patients lay staring at the ceiling. “And look at what you’ve done to them. Look at them … look at what you’ve done …”

I looked. I could see what she meant, though they’d both be fine in a day or so. She turned back to me, her talon my way once again. “And you know the worst part of it? You meant it.

I’m not scared of developing dementia. It’s bound to happen: all my great-aunts lived through the last years of their 90s with it. They weren’t unhappy. They remained perfectly content – chipper, even. Their children’s and grandchildren’s feelings were another matter: grief, as ever, trailing love. I’m not scared, but I’m doing everything I can to avoid it, or delay it. Drink coffee. Exercise. Eat vegetables. Study. Read. Love. Leave the house periodically.

Everyone in the developed world is living longer. Doctors congratulate themselves, governments tell us to tighten our belts. In the next decade the number of people in Australia with dementia is expected to reach 400,000, and we’re all waiting for the medical breakthrough. The promise of cures for non-communicable diseases captures our imaginations and leads to large funding for biomedical research programs. Funding research is a good thing, except when it focuses on drug development and marginalises action to prevent and delay. And when it comes to the heterogeneous group of syndromes known collectively as dementia, it seems there is no medical breakthrough on the horizon. Years of research have focused on the “amyloid hypothesis”, the idea that the plaques found on autopsy in the brains of most people who die with Alzheimer-type dementia are the cause of the cognitive decline. However, one third of elderly people with a brain full of plaques have no symptoms of dementia at all. Two thirds of people receiving a diagnosis of “early dementia” based on current screening tests don’t have it and never will. Claims made for some heavily promoted dementia drugs – that they slow progression and mitigate symptoms – are almost completely unfounded. In trials they increase a person’s score on a 70-point scale by 2.8 points, which translates to far less change than social and behavioural supports would bring.

In 2010 a group of researchers, led by Karen Ritchie, published an epidemiological study in the British Medical Journal outlining measures to reduce dementia incidence should no cure be found. They identified four modifiable risk factors for the development of dementia: depression, inadequate fruit and vegetable consumption, diabetes and “crystallised intelligence” – a measure of lifetime intellectual activity and cultural exposure. They concluded that improving these factors was likely to have a huge impact on reducing the incidence of dementia, outweighing even genetics.

An editorial that ran alongside this article urged the reader to remember that the results “may help to identify people at increased risk of developing dementia, but it is too early to call for prevention programs that target these specific factors”.

Given the two editorialists’ attitude to the health of the population, I was interested to read in their conflict-of-interest statements that in the past two years they’d received honorariums from drug companies for “research”, “lectures” and “speaking engagements”.

Around the time the article went to press, one of the companies supporting these editors had a “dementia-curing” drug named bapineuzumab entering human-testing phases. The drug removed plaques from the brain. Unfortunately, in the following years this plaque removal was shown to have no impact on cognitive impairment, and the drug (which would have been prohibitively expensive) caused brain swelling and meningitis in some trial participants.

Medicine and society have entered into a folie à deux regarding medicine’s importance in gigantic population ills. We believe that genetics and pills and enzymes bring us health. We wait for the dementia cure (the obesity cure, the diabetes cure) rather than changing our society to decrease incidence and severity. We slash social welfare programs and access to GPs and ignore the downstream effect this will have on future generations.

To reduce non-communicable diseases, the actions we need to take are societal: make it easier for people to move more and eat well, strengthen education, promote community participation and meaningful work. Our collective delusion is that we can have all the benefits such a society would bring without the structural supports necessary to bring it into being, that we can attain health by inventing and buying drugs.

It is hard to know which is the more utopian vision: magic pills or a society serious about prevention. 

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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