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Rachel Pierce

December 10, 2015


RC 2001-181
Major Issues Essay
Pre-screening for Alzheimers Disease
Doctors recommend women start getting annual mammograms around
age 40, because it is a preventative measure that is taken in order to
hopefully catch cancer early enough to treat it effectively. One would think
this would also be the case with a disease such as Alzheimers, but it
currently is not. Primary care physicians do not provide screening for early
detection of the disease unless the patient is showing symptoms; which by
that time it is probably already too late for the patient to be treated
effectively. This is currently a very controversial topic for doctors, researchers
and patients. The article Should older adults be screened for dementia?
makes an excellent point of this. Health professionals and the public accept
screening for breast cancer, cervical cancer, colorectal cancer, diabetes,
hypertension, high cholesterol, obesity, osteoporosis, and even for
depression, provided treatment can be offered and current US government
announcements advise that Medicare covers the screening costs for all of
these conditions. However, screening for dementia, the most disabling
common condition of later life, is currently left to chance. (Should older
adults be screened for dementia?) I think this is a very important point. The
authors of this article make it very clear that pre screening should be a
necessary practice.

Alzheimers disease is a degenerative brain disease that, as of right


now, is incurable. It is the most common type of dementia, and early
symptoms include difficulty remembering recent conversations, names and
events, and sometimes depression. Later symptoms include impaired
communication, disorientation, poor judgment, confusion, behavior changes,
and eventually, difficulty speaking, walking and swallowing. Although
research has revealed a great deal about Alzheimers, much is yet to be
discovered about the precise biologic changes that cause Alzheimers, why it
progresses more quickly in some than in others, and how the disease can be
prevented, slowed or stopped. (2015 Alzheimers Disease Facts and Figures)
However, researchers believe that early detection will be crucial to
prevention and slowing of the disease. Research on early detection has
grown significantly in the last ten years. Before, the criteria for testing was
evident signs of memory loss; but now that more is known about how the
disease can occur years before the symptoms begin to show, the new
proposed criteria for testing will accommodate to that fact.
Millions of Americans have Alzheimers disease and other dementias.
The number of Americans with Alzheimers disease and other dementias will
grow each year as the size and proportion of the U.S. population age 65 and
older continue to increase. The number will escalate rapidly in coming years
as the baby boom generation ages. (2015 Alzheimers Disease Facts and
Figures) This is a growing problem, and according to tests and studies
conducted by the Alzheimers Association, about half of the estimated 5

million Americans with Alzheimers were probably not told they have it by a
physician.
The latest advance in Alzheimer's diagnosis came this year, when the
U.S. Food and Drug Administration gave its approval to a radioactive dye that
can be used to determine whether the protein of Alzheimer's disease is
accumulating in the brain, says Dr. Jeffrey Cummings, a neurologist and
researcher and director of the Cleveland Clinic Lou Ruvo Center for Brain
Health. (reviewjournal.com) The radioactive dye binds to amyloid plaque that
accumulates in the brain of a person with Alzheimer's. Then, a PET scan is
conducted, and the presence, or absence, of the plaque is revealed.
(reviewjournal.com) With these new tests, clinical trials can begin using a
person who is not showing symptoms in their daily lives yet, but their brain
scans show that there are already abnormalities presenting; this would allow
access to very early stages of the disease, and new research and
information. If no amyloid plaque is found, that can rule out Alzheimers,
which will allow further testing for a different dementia-related disease. This
is important because with other certain types of dementia, Alzheimers
medications actually worsen the conditions. "So it's the interaction between
what the scan tells us and the clinical examination. That's why the doctor is
still important here," Cummings continues. "And that, of course, is why we
have to teach the medical community how to use this scan, because you
could easily get a positive scan and say, 'You have Alzheimer's disease,' and
we don't think that. We think there's a lot of uncertainty in what's going to

happen to that person." (reviewjournal.com) That is why it is important that


primary care doctors are better educated on the exact signs of Alzheimers,
not just dementia in general.
Another important advance in early detection research is use of
biomarkers. A biomarker is something that can be measured to accurately
and reliably indicate the presence of disease. An example of a biomarker is
fasting blood glucose (blood sugar) level, which indicates the presence of
diabetes if it is 126 mg/dL or higher. (Alzheimers and Dementia Testing for
Earlier Diagnosis) There are several different potential biomarkers that are
being studied for their ability to indicate the early symptoms of the disease.
Some of these include beta-amyloid and tau level in cerebrospinal fluid and
brain changes, which are detectable by different types of imaging. Beta
amyloid plaques are formed when protein pieces clump together. It is a sticky
substance that gradually builds up in the brain and can be very damaging by
blocking cell-to-cell signaling. The tau protein tangles up inside the brain and
destroys cell transports made of proteins. The tau is normally there to keep
the protein straight like tracks, for food and other important molecules to
travel on. However, when it begins to twist and collapse it forms tangles,
which cause the tracks to become weak and disintegrate; therefore inhibiting
food and nutrients from traveling through cells, causing them to eventually
die. (alz.org/braintour)
However, there is a downside to this argument. Researchers such as
Dr. Jeffery Cummings, a neurologist and researcher and director of the

Cleveland Clinic Lou Ruvo Center for Brain Health, are strongly
recommending patients who do not show any symptoms to not get screened,
because if they have no symptoms they cannot be treated for anything. "At
this point, we don't have any medicine we know of to take in advance to
prevent the disease, I would not recommend getting a test just to know."
(reviewjournal.com) Getting a test just for curiositys sake could be
extremely expensive. For some people, however, who know they have a
family history of the disease, knowing ahead of time could be very beneficial
in the long run. For example, knowing it might be a part of your future would
allow you to be prepared to seek treatments as soon as you do recognize
that you are showing symptoms, as well as have a plan in place for at home
care, or clinical care for when the time comes. On the negative side,
however, getting screened ahead of time and being labeled as someone who
might possibly develop the disease could be detrimental to a career or other
opportunities. For example, an employer might be less willing to hire
someone and provide them with insurance benefits if they know he or she is
more likely to develop a life threatening disease within the next ten years or
so. Other complications have also come about; such as the fact that the test
costs about $4,400, which would not be covered by medical insurance or
Medicare.
According to the article A Review of the Evidence for and against
Screening for Alzheimer Disease in Primary Care, there are three keys to
successful treatments: early detection, the use of currently approved

medicines to provide symptomatic treatment, and the development of new


medicines to slow and eventually stop disease progression. Routine
screening is one strategy that could be used to help fight under-diagnosis of
Alzheimers disease; because a little less than half of patients are underdiagnosed. This mistake usually occurs in the primary care setting because
patients are not typically showing symptoms at that point. At the time this
article was written in 2005, there had been some recent initiatives taken,
such as legislation being signed by President Bush that made memory
screening more accessible, and a Welcome to Medicare physical exam,
which some argued should have included a memory screen. A lot of
questions are raised when it comes to figuring out who should be screened
as well. This article suggests that patients over 65 be screened annually;
other patients who have a family history should also be screened even if
younger than 65, and any patients who are having cognitive complaints
should get screened as well. The contrasting views in this article were things
like the inaccuracy of the screening tests, and biases for age, education, or
ethnicity. Until studies demonstrate that screening provides better
outcomes for patients with Alzheimers disease, endorsement is premature.
(A Review of the Evidence for and against Screening for Alzheimer Disease in
Primary Care) In my opinion, this might make sense at first, but if there is no
endorsement for early detection screening in primary care, then the patients
condition would probably already be too progressed for a doctor or scientist
to be able to utilize them for any type of valuable research, because there

was no way of knowing the patient had the disease in the first place.
Although it may be a costly expenditure, I think in the long run it would
greatly benefit Alzheimers research. If we can somehow find the means to
make early detection screening a common practice in primary care, it would
give researchers the grounds they need to perform experiments on patients
whose minds are not already completely degenerated; which could do
wonders for the research.
Overall, I think both sides of the argument have valid points. However,
I think early detection screening will be a key factor in making more progress
in the research for Alzheimers. "A big problem in Alzheimer's disease and
research is that we're not catching people early enough, Cummings says,
"There are hundreds of thousands of people out there that have symptoms.
(reviewjournal.com) This is clearly a prevailing problem in the United States,
and the statistics show that it will only continue to get worse in the years to
come.

Works Cited
"2015 Alzheimers Disease Facts and Figures." Alz.org. Web. 2 Nov. 2015.
<https://www.alz.org/facts/downloads/facts_figures_2015.pdf>.
"Alzheimer's & Dementia Testing Advances | Research Center | Alzheimer's
Association." Alzheimer's Association. Web. 9 Nov. 2015.
<http://www.alz.org/research/science/earlier_alzheimers_diagnosis.asp
>.
Ashford, J. Wesson, Soo Borson, and Ruth O'Hara. "Should Older Adults Be
Screened for Dementia?" Sciencedirect.com. Elsevier, 1 Apr. 2006.
Web. 24 Nov. 2015.
<http://www.sciencedirect.com/science/article/pii/S1552526006000458
>.
Brain Tangles - Alzheimer's Association." Alzheimer's Brain Tangles Alzheimer's Association. Web. 9 Nov. 2015.
<https://www.alz.org/braintour/tangles.asp>.
Solomon, Paul, and Cynthia Murphy. "Should We Screen for Alzheimer's
Disease? A Review of the Evidence for and against Screening for
Alzheimer's Disease in Primary Care Practice." Wncln.org. Web. 18 Nov.
2015. <http://0eds.a.ebscohost.com.wncln.wncln.org/eds/pdfviewer/pdfviewer?
sid=c88eb7d1-82c1-4074-89db2158eade8cd9@sessionmgr4005&vid=1&hid=4211>.
"TOUGH TESTS: Why Get Screened for Alzheimer's When There Is No Cure?"
Las Vegas Review-Journal. 12 Dec. 2012. Web. 2 Nov. 2015.
<http://www.reviewjournal.com/life/health/tough-tests-why-getscreened-alzheimers-when-there-no-cure>.