Does Detection Outpace Treatment Options for Alzheimer’s disease?
A headline in The New York Times (November 16, 2012) announced that “For Alzheimer’s, detection advances outpace treatment options.” We are given the example of a family who sought out a new brain scan technology that is heralded as a diagnostic breakthrough for detecting Alzheimer’s disease. These scans show plaques in the brain. Plaques, in turn, are composed of deposits of amyloid proteins in the brain that are associated with Alzheimer’s disease.
These scans are currently available at over 300 hospitals throughout the country. But there are a number of dilemmas resulting from this technology and its use.
Are we creating a tautology between Alzheimer’s disease and plaques? A tautology is a logical fallacy that constrains our thinking by circular reasoning. Alzheimer’s is plaques and plaques are Alzheimer’s. The real issue is diagnosing dementia, which is disability from cognitive decline. Two cases from the article are to this point. In one case, a person with Parkinson’s disease was given a scan and found to have plaques. The conclusion seemed to be that he had Alzheimer’s all along but may he not have had both pathologies?
Another case presented was of a person who had a clinical diagnosis of Alzheimer’s disease based on genotyping, brain atrophy, and memory testing. When he was scanned there were no plaques and his neurologist told him he didn’t have Alzheimer’s. Was he falsely relieved? Alzheimer’s disease is more than the accumulation of plaques. Will he become demented?
Autopsy does not provide for a definitive diagnosis of Alzheimer’s disease. First, autopsy diagnosis is based on the density of plaques and tangles. As many as 30% of sampled populations have the pathology on Alzheimer’s, based on autopsy, but do not have clinical symptoms. Is this Alzheimer’s disease? What can he do now?
The FDA requires that radiologists interpreting the scan have no information about the patient. This is a blinding procedure that is used in research trials. Does this break the integrity of clinical medicine? Are we so sure of our belief that amyloids are the essence of Alzheimer’s disease? I think not.
In earlier articles we covered the failure of amyloid altering strategies and medications to work. Indeed, the medications tried so far have not helped and have, in some cases, caused worsening of symptoms. I can see that the outcome of having the scans will lead to the use of these medications decades before symptoms develop. But will this cause undo harm? Are amyloids necessary for normal brain function? What about the tangles?
The scans are very expensive and are not covered by insurance. One center charges $3,750 for a scan. Furthermore, employers and insurance companies are prohibited from discrimination based on genetic testing. But the law does not cover scans. Having a scan may jeopardize employment and lead to denial of long-term care.
I feel that we are getting ahead of our science. As I have often discussed we do have effective treatments that are available now. They are not primarily medical. Indeed, do treatment options outpace detection?
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