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Senior Moments

May 17, 2012 By:
Dr. Todd H. Goldberg, Special Sections Feature
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Alzheimer’s disease and diabetes are two of the most familiar and feared diseases mainly affecting seniors — and justifiably so, as they are the fifth and sixth leading causes of death, respectively, in this country.

But advances in research and treatment are making both conditions more manageable and the outlook more hopeful.

Alzheimer’s disease, a well- known cause of memory impairment in aging, remains one of the most-feared problems in geriatric medicine. Although Alzheimer’s was only “discovered” about 100 years ago, it is probably not a newly occurring condition, only a newly recognized or understood condition.

Certainly throughout history, people became old, feeble and confused, but they were just called “senile.” And most people didn’t live to be very old, so the problems of senility were uncommon and not all that important.

Only in the past 40 years did doctors realize that most “senile” old people really had the same disease that had been reported in 1907 by German psychiatrist Alois Alzheimer.
Typically since then, it has been felt that the majority of persons with what is now called “senile dementia” have Alzheimer’s, and the rest have strokes (vascular dementia) or other miscellaneous brain diseases. True (pathological) AD consists of abnormal deposits called “plaques and tangles” as seen by Dr. Alzheimer in brain cells, which only can be diagnosed with certainty with an autopsy of the brain.

Although there is still no cure, several drugs have been available to treat the symptoms of Alzheimer’s and related dementias since the late 1990s. These include Aricept, Exelon, Razadyne, which are FDA approved for mild to moderate Alzheimer’s; and Namenda, which is approved for moderate to severe Alzheimer’s.

All these drugs work by regulating the brain chemicals involved in learning and memory that are affected in Alzheimer’s, but only improve the condition or slow the deterioration by a modest amount at best.

Active research is pursuing early diagnosis and more advanced means of arresting or curing the disease, aimed at preventing and eliminating the plaques and tangles that seem to cause the brain damage in Alzheimer’s. New diagnostic criteria supported by the National Institutes of Health and the Alzheimer’s Association were issued in 2011 to aid in more accurate diagnosis.

But, unfortunately as of this time, no major new drugs or treatments for Alzheimer’s have been approved by the FDA since Namenda in 2003. Several other anticipated new treatments have not been successful so far.

However the NIH, the Alzheimer’s Association and many universities and organizations are actively advancing research on Alzheimer’s, and there is optimism that more definitive diagnostic tests, treatments and cures will eventually be found.

Giving additional hope for the future, on Jan. 4, 2011, President Barack Obama signed into law the National Alzheimer’s Project Act (NAPA), requiring the Secretary of the U.S. Department of Health and Human Services to establish the National Alzheimer’s Project to:
• Create and maintain an integrated national plan to overcome Alzheimer’s disease;
• Coordinate Alzheimer’s disease research and services across all federal agencies;
• Accelerate the development of treatments for Alzheimer’s with the hope of achieving a more effective treatment by the year 2025;
• Improve early diagnosis and coordination of care and treatment of Alzheimer’s disease;
• Improve outcomes for ethnic and racial minority populations that are at higher risk;
• Coordinate with international bodies to fight Alzheimer’s globally.

The law also establishes the Advisory Council on Alzheimer’s Research, Care, and Services and requires the Secretary of Health and Human Services, in collaboration with the Advisory Council, to create and maintain a national plan to overcome Alzheimer’s disease. The first draft of this National Alzheimer’s Plan was released by the federal government on Feb. 22, 2012.
Part of the plan includes the just-concluded “Alzheimer’s Research Summit,” held at the NIH in Bethesda, Md.

Currently about 5.4 million Americans are believed to have Alzheimer’s (5 to 10 percent of all individuals over 65), and the number is projected to increase to about 15 million by the year 2050, at a nation cost of $1 trillion.
Further information about Alzheimer’s may be found on the websites of the Alzheimer’s Association (www.alz.org) and the National Institute on Aging (www.nia.nih.gov/alzheimers).

Sweeter success?

What about diabetes and its treatment and possible cure?

Unlike the situation with Alzheimer’s, for which the prognosis remains guarded, there are many successful new treatments for diabetes being developed and marketed all the time.
Diabetes, technically called diabetes mellitus (from a Latin word meaning sugary sweet) is a well-known glandular disease in which blood sugar builds up to harmful levels because the body under-produces or is resistant to the hormone insulin, which originates in the pancreas and controls metabolism of sugar.

The cause is not 100 percent clear but is partly genetic and partly related to obesity and to acquired damage to the pancreas.

There are two main forms of diabetes, Type I (usually juvenile onset and requiring insulin), and Type II (usually adult onset and often less severe and manageable, with diet and oral medications though insulin may still be eventually required).

Diabetes is extremely common, with about 26 million individuals, 8 percent of the population of the United States, being afflicted, according to American Diabetes Association figures.
The rate of diabetes increases with age, including more than 25 percent of adults over 65. The direct and indirect costs of diabetes care and disability were estimated at $174 to 218 billion as of 2007. (For many other interesting statistics on diabetes, see the National Diabetes Fact Sheet 2011 at: www.cdc.gov/diabetes/pubs/
pdf/ndfs_2011.pdf.)

If diabetes is not properly diagnosed and treated, blood sugar (glucose) rises, causing many complications. Glucose is a normal fuel for the body and as such some is needed but too much is toxic. Over the long term, excess sugar causes well-known severe problems such as heart attacks, poor circulation, kidney and eye damage, and nerve damage (neuropathy).

Accordingly, diabetes is among the leading causes of limb amputation, kidney failure requiring dialysis, visual impairment and blindness. Immediate symptoms of uncontrolled blood sugar can include excessive thirst and urination, blurry vision, fatigue, hunger and weight loss.

Slowly developing chronic diabetes may not cause any obvious symptoms at first but can be easily detected by a blood test. According to the American Diabetes Association, all adults, even if seemingly healthy, should have their blood sugar tested at least every few years. A glycated hemoglobin (Hb A1C) level of 6.5 percent or greater, or a fasting blood glucose level of 126 mcg/dl or more is considered diagnostic of diabetes. Normal blood sugar is considered to be below 110, and levels of 110-125 are labeled borderline or “pre-diabetes.”

Unlike with Alzheim­er’s, there are fortunately many effective treatment options for diabetes that greatly reduce though do not totally eliminate the complications.

Since obesity is often a contributor to diabetes and elevated blood sugar, diet and exercise alone may improve the condition. Diabetic patients are often given diets which are restricted in sugar and carbohydrates, which may help but may be difficult and frustrating to follow.

Most patients with a significant degree of diabetes will need medications. Many oral medications are available by prescription, including such drugs as glipizide (Glucotrol), metformin (Glucophage), pioglitazone (Actos), nateglinide (Starlix), and sitagliptin (Januvia). A combination of drugs and diet will often adequately control the blood sugar in Type II diabetes, but over time the disease is progressive and often insulin shots will eventually be required.

Type I diabetics always require insulin. Insulin used to be derived from animals (beef and pork) but is now manufactured synthetically, and there are a number of different types of insulin, short-acting, long-acting, and in combination. The newer insulins are felt to be much more safe and effective than older beef and pork insulins.

Although no one likes needles, insulin is actually by far the most effective treatment for diabetes and should not be feared. Almost everyone with diabetes can be controlled with an appropriate amount of insulin; however frequent blood testing may be required to keep the sugar properly regulated.
Insulin is generally injected once or twice a day subcutaneously, with a small painless needle just below the skin. There are many easy to use “pens” for injections nowadays, eliminating the need to draw up and measure insulin from a vial.

Some well-monitored and motivated patients will benefit from a continuously running implanted “insulin pump.” Pancreatic transplants and artificial pancreas implants to “cure” diabetes are still in the process of active research.

Studies have also shown that obesity surgery (gastric banding and bypasses, etc.) can sometimes cure a person’s diabetes.

Everyone with diabetes should see a primary care physician or other provider such as a nurse practitioner regularly, and many diabetics will also benefit from seeing an endocrinology specialist, especially if their diabetes is not easily controlled, or high-tech treatments such as insulin pumps are used.

Diabetic education and support groups are also very helpful to patients, as living with and controlling diabetes can be complicated and stressful.

With appropriate support and treatment, however, most diabetics can achieve good control of their condition and lead long and productive lives.

There are far too many details on diabetes diets and treatments to cover in a brief article. For more extensive information, go to: the American Diabetes Association (www.diabetes.org), or the National Institute of Health’s Pub Med Medical Encyclopedia (www.ncbi.nlm.nih. gov/pubmedhealth/PMH0002194).

If you or a loved one is suffering from Alzheimer’s or diabetes, get regular medical care, have hope and try to still enjoy life as much as you can!

Dr. Todd H. Goldberg, formerly geriatrics fellowship director at Philadelphia Geriatric Center and Einstein Medical Center in Philadelphia, is now associate professor and director of geriatrics at West Virginia University/Charles­ton Area Medical Center in Charles­ton, W. Va.

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