A Potential Solution to the Alzheimer’s Problem

by Guy McKhann, M.D.

December 8, 2017

This is a column from Dana's print publication, Brain in the News.

A new report from the Rand Corporation raises a question about Alzheimer’s disease we don’t often address ahead of time: How we are going to deliver therapy to the millions of patients who require it? It is estimated that five million Americans carry the diagnosis of Alzheimer’s disease at present time. There are also a large number of people with early changes in cognitive function, the so-called MCI (minimal cognitive impairment) group, who are also candidates for therapy. What are the steps that need to take place to bring therapies to these people?

First comes evaluation, followed by choice of therapy (there may be more than one). This is usually carried out at clinical centers, and is often a collaboration between industry and academia. These clinical trials are often small studies aimed at safety and efficacy. When the chosen drug or intervention is applied to larger populations, other side effects may be discerned. When the medication is being made available to thousands—if not millions—of people, the production and monitoring of the medication becomes a unique problem.

The next step is monitoring the subjects receiving the therapy. That entails selecting the symptoms that define diagnosis and determining which therapeutic responses will follow. Alzheimer’s is a progressive, life-long disease. Once a patient is introduced to a successful therapy, it is unlikely he or she will stop, other than to begin a different, more effective therapy. Someone needs to be responsible for monitoring this.

In the present system, who carries out these therapeutic evaluations? Neurologists, psychiatrists, geriatricians, and general practitioners provide medical services. Even combining these specialties would not provide nearly enough experts to handle the large population receiving therapy.

One possibility is to develop a non-M.D. cadre of people trained to deliver and evaluate medicines. This is already being done on a smaller scale in specialty areas. For example, here at Johns Hopkins, we have a clinic dedicated to ALS, largely run by an exceptional nurse practitioner, Lora Clawson. Lora has been doing this for years, and knows more about the disease than any M.D. in our group. She has also been the point person in several clinical trials. Others, many others, like Lora, could play similar roles in the treatment of Alzheimer’s.


Training non-M.D. Cadres

Michael C. Patterson

1/5/2018 11:02:38 AM

Guy, Thank you for calling attention to the challenge of delivering brain health treatment to the millions of people who will be at risk for dementia in the years ahead. The first step towards effectively addressing this question may be to clarify what “treatment” actually means. Efforts to control or ameliorate the pathology once it has taken hold will, of course, be a critical aspect of any treatment plan. But a comprehensive approach - one that has any chance of diminishing the predicted epidemic - must also focus on prevention and address the root causes of accelerated cognitive decline and dementia. Given the incredible complexity of dementia, this comprehensive treatment approach will involve a hierarchy of coordinated intervention. The most basic foundation of this hierarchy will be behavior change and lifestyle modifications that target modifiable risk factors. Successive levels will include: • Treatment and management of co-morbidities, • Environmental detoxification and • Management of metabolic and hormonal imbalances. • The last resort, the final level, would be pharmacological treatments, if they can be developed. Diverse teams of practitioners (MDs and non-MDs) will, as you suggest, be required to deliver this hierarchy of interventions. Medical clinicians and MDs are well positioned to address the more technical levels of the intervention hierarchy that involve sophisticated diagnoses and precise treatment regimens. But, the foundational level of lifestyle modification requires sets of specialized skills that some MDs may not possess or simply do not have time to fully deploy. Individualized behavior modification treatments could be delivered more effectively by specially trained social workers and counselors or by health and wellness coaches. These professionals are likely to possess the skills needed to motivate people to adopt and sustain brain healthy behaviors. They could form that critical front-line cadre of non-MD practitioners that you are looking for. How would such a cadre be developed? This potent and intriguing idea presents a number of challenges. We would need: (1) a standard set of effective and easily administered behavior-change protocols that can be measured, modified and monitored, (2) a system to train this cadre of counselors, and (3) a viable distribution system established before the training even begins. And, finally, (4) there must be a viable funding model to support the entire effort. After AARP’s national “Staying Sharp” program was discontinued in 2009, Roger Anunsen and I founded MINDRAMP Consulting to continue the important work promoting brain health. Our mission has been to translate cutting edge brain science into practical programs that help people keep their minds sharp at all ages. Our work has culminated in the development of a prototype train-the-trainer program to teach non-MD counselors how to deliver a comprehensive set of behavior change protocols. MINDRAMP is now partnering with a for-profit wellness counseling company to address the challenges of distribution and funding. We hope to begin testing this model in early 2018. We also hope that our experiences will help to stimulate the development and testing of other innovative approaches to delivering much needed education, interventions and treatment protocols to prevent cognitive decline and dementia. We have no doubt that your “non-MD cadre” of exceptional professions are out there and will be inspired by your potential solution. Like Lora Clawson, they’ve been working in their specialty areas for years. With proper guidance and the right tools, they are perfectly placed to help people start making brain healthy choices.