“In a tremendously hopeful moment .” This is how Dr. Juan Fortea defines the point at which the research on azheimer is located , a neurodegenerative disorder that despite being prescribed for the first time 115 years ago continues to pose a major challenge for science. In June, the US FDA (Food and Drug Administration) approved the first treatment capable of modifying key pathophysiological processes of the disease and, although its clinical benefit has yet to be determined, this specialist advocates not focusing on the controversial but in the “paradigm shift” that drugs such as aducanumab will entail.
The also coordinator of the Behavior and Dementia Study Group of the Spanish Neurology Society (SEN) also warns that while the future goes through biological treatments like that, the Spanish health system is far from being prepared to supply them when the time comes. “There is no other disease so serious, with so much socioeconomic impact and such lethality that it has such great disparities in our country in terms of diagnosis, treatment and management,” he warns in an interview with 20 minutes in the framework of this Tuesday of World Health Day. Alzheimer’s.
Where are we in the Alzheimer’s investigation? In a tremendously hopeful moment. For the first time it is beginning to be seen that in the coming years we may have treatments that modify the course of the disease. They will be biological treatments that will suppose a change of paradigm and more than ever we have to insist on the importance of being prepared for that change.
What has been failing so far? Why are the causes not known and therefore a remedy is not found? Indeed we come from years of failure. Until the FDA approval of aducanumab, the last treatment had been approved in 2003. These continuing failures exemplify the gaps in knowledge of the ultimate causes of the disease but also distort that enormous progress has been made in understanding its pathophysiology. The advancement of biomarkers to diagnose Alzheimer’s and understand its course, even in asymptomatic stages, is unparalleled.
What have these advances led to? This has led to the fact that now, without any doubts, we can modify some key pathophysiological aspects. Aducanumab and other medications have modified brain amyloid deposition. There are still doubts about whether the withdrawal of the amyloid induced by aducanumab has a clinical significance, and hence all the controversy that has arisen around it, but we know better the pathophysiology of the disease, we can influence it and aducanumab is not an isolated drug. It is the spearhead of a series of biological treatments for which there is hope.
So do you value this new drug positively? I have not said that it is clearly positive. What I would not like is that the doubts that everyone recognizes downplay the fact that his arrival is going to mean a paradigm shift. Alzheimer’s is the structural epidemic of the 21st century. No other disease so serious, with so much socioeconomic impact and so much fatality, has such great disparities in our country in terms of diagnosis, treatment and management. Depending on which hospital you have a specialist or another can see you, there are no specialized routes … Even if we dispelled doubts about aducanumab and it were free, the system would not be prepared to supply it.
What is wrong? To give aducanumab it will be essential, first, the widespread use of biomarkers, which unfortunately in Spain are only performed in a minority of patients when we know that they increase diagnostic reliability and that an early diagnosis improves the prognosis. It would also require day hospitals for its intravenous infusion, much more specialized personnel, several resonances a year … All of this is far from being generalized and it is not easy to implement. There is no reflection on the fact that the health system is not prepared for the revolution that biological treatments are going to bring and that it is going to be very stressed. Because beyond aducanumab, any drug that is going to come is going to be similar.
“There are many modifiable factors that can help prevent disease.”
Is it being worked on or will the bull catch us? Unfortunately I think we are closer to the latter. There has been progress but there are many things that we could do and are not doing. For example, the National Alzheimer’s Plan is still pending, a demand from family associations and doctors for a long time. It is said that it has been approved but has not been associated with an economic endowment for which he is born dead. This plan should recognize the challenge that dementia will pose in this century and encourage the allocation of resources to address needs that are not just medical. Because Alzheimer’s is a multidemensional disease with a tremendous family and social outlook.
What advances have there been in diagnostic tests? We have known for many years of markers that worked very well but were tremendously expensive. They cost more than 1,400 euros per patient. There were others that required lumbar punctures and as this was minimally invasive and uncomfortable, they also presented complexities. But for two or three years we have plasma markers that are beginning to work very well. And this can radically change the path of patients and the screening of the population for cognitive impairment. This is a young disease that manifests itself in old men. Its pathophysiological process begins twenty years earlier. On the one hand it can be scary but it is a very important window of opportunity. The ideal would be to be able to give treatments not only when there is a significant memory loss but before and that is where we have to walk.
Is keeping the mind active important when someone is diagnosed with the disease especially early?Much. Is demonstrated. And not enough emphasis has been put on it. Alzheimer’s is increasing a lot because the population is aging a lot, but a 70-year-old person now has a lower risk of having dementia than he did 50. This is what is called the age-adjusted incidence or prevalence and it is going down. Better life habits, better care and general socioeconomic improvement are reducing Alzheimer’s, showing that a percentage of cases are preventable. Improvements in risk factors such as cardiovascular problems, hypertension, diabetes, tobacco … also help prevent dementias. And physical and mental activity is equally basic. There are many modifiable factors that can help prevent the disease.
Daniel de Jorge Aguinaga and his mother, Marivi, sick with Alzheimer’s.
Caregivers, between delivery and wear: “My father dedicated himself to my mother until he had no strength”
When should one be concerned? The sensation of memory lapses is very frequent. Attentional failures, such as going to a room and not knowing what you have gone to, is shown to be due to the fact that you were thinking about other things. What worries us is episodic memory: forgetting what we have done over the weekend, medical appointments, relevant events … And it is especially worrisome when the companion notices these deficits but the patient does not. A very paradoxical thing comes into question called lack of awareness of the disease. It has the positive side that patients suffer much less, but it poses difficulties in planning care with them.
Some information suggests that Covid could accelerate the symptoms of Alzheimer’s . Is there a relationship between the two diseases? It is the great fear. The Covidit has been devastating for these patients on multiple levels. First, because the vast majority of deaths have occurred in residences and the vast majority of people in residences have dementia. We are not aware that the coronavirus has fundamentally killed Alzheimer’s patients disproportionately. The second impact is that the residences have been locked up, which has been a tremendous isolation. And then indeed, major acute inflammations are associated with accelerations of degenerative processes and there is a doubt as to whether Covid can trigger or accelerate the pathophysiological processes of Alzheimer’s. But for this, which is being studied a lot, we lack perspective.