According to new data reported at the 2017 Alzheimer’s Association International Conference (AAIC 2017) in London, multiple regions of the United States have been revealed as neurology “deserts” due to a projected chronic shortage of neurologists, and a rapid rise in Alzheimer’s disease and other dementia cases. The research further shows that, due to the projected burden, additional resources, training and education are necessary for primary care physicians and caregivers.
Using population health data from the Centers for Medicare and Medicaid Services, Neurocern, Inc. developed an Alzheimer’s Disease and Related Disorders Neurology Desert Index (ANDI), defined as the projected ratio of neurologists per 10,000 dementia patients. Results showed a great disparity in ANDI values between states by the year 2025. Twenty states, including Kentucky, were identified as dementia neurology “deserts” with a current dementia population of 1,638,800, which is projected to reach 2,068,000 by 2025.
Wyoming, North Dakota, South Carolina, South Dakota, and Oklahoma were revealed as the five states with the most significant projected gap between the available neurology workforce and the health needs of people with Alzheimer’s and other dementias in 2025.
“Our data highlights the importance of neurology education for clinicians, enabling them to have a more positive impact on people with dementia and their families,” said Dr. Anitha Rao, co-founder of Neurocern, Inc. “We should see these ‘deserts’ as opportunities for innovation, collaboration and progress.”
Neurocern Inc. in their research concludes that primary care providers and other licensed clinicians in dementia neurology “desert” states may require additional training and education to make up for the projected lack of neurologists.
“This intriguing study highlights several issues, including the clear inequality that exists across the United States in distribution of health resources and specialist knowledge to diagnose and treat brain diseases, such as Alzheimer’s,” said Beth Kallmyer, MSW, Vice President of Constituent Services at the Alzheimer’s Association.
“In many places, people do not have easy access to specialists, for a variety of reasons. But you may not need a neurologist in every case,” Kallmyer said. “With the right training and tools, primary care physicians can effectively diagnose and treat Alzheimer’s disease. The Alzheimer’s Association is working to arm primary care physicians with the tools they need to manage an increased case load, as well as care planning guidance.” The Alzheimer’s Association’s care planning toolkit for cognitive impairment is available at http://www.alz.org/careplanning/
The National Plan to Address Alzheimer’s Disease states that high-quality care requires an adequate supply of culturally competent professionals with appropriate skills, including direct care workers, community health and social workers, primary care providers and specialists. Among other things, the Plan calls for: “develop[ing] a health care workforce that maximizes individual and family engagement and improves health outcomes for older adults by integrating geriatrics with primary care. Special emphasis is on providing the primary care workforce with the knowledge and skills to care for older adults.”
While the U.S. Congress has recently provided additional funding for Alzheimer’s research at the National Institutes of Health (NIH), the commitment falls far short of the need. Congress must continue its commitment to Alzheimer’s and other dementias by increasing funding for Alzheimer’s research by at least an additional $414 million in fiscal year 2018.
Neurocern, Inc. is an aging and caregiving technology startup that empowers caregivers with limited resources by creating custom care solutions to improve the quality of life of their loved one. The women-led company aims to transform the way families manage Alzheimer’s disease and other aging and mental health conditions for patients living at home.
A series of studies reported at the 2017 Alzheimer’s Association International Conference in London confirm racial inequities in numbers of people with Alzheimer’s disease and other dementias–even after age 90–and also point to growing evidence that early life stress and neighborhood conditions contribute to dementia risk in late life.
One new study in Wisconsin found that a single major stressful event in early life is equal to four years of cognitive aging, and African Americans are most at risk – on average, they experience over 60 percent more of such events than non-Hispanic Whites over their lifetimes.
A second study conducted by a health plan in Northern California found that African Americans born in states with the highest levels of infant mortality had 40 percent increased risk of dementia compared to African Americans not from those states, and 80 percent increased risk compared to Whites not from those states. Other studies reported at AAIC 2017 found:
- Racial disparities in the risk for new cases of dementia previously observed in the younger elderly continue into the oldest-old (age 90+), which is the fastest-growing segment of the population. Researchers found oldest-old African Americans and Latinos had the highest incidence rates compared to Asian Americans and Whites – matching the overall patterns of racial/ethnic disparities in dementia seen in younger elderly. This is the first time different ethnicities in this older population group have been studied for risk of incident dementia.
- Neighborhood disadvantage may contribute to observed disparities in prevalence of dementia.
Stressful Experiences
Prevalence of Alzheimer’s disease and cognitive impairment is rising, and the greatest burden seems to be falling disproportionately on historically disadvantaged communities. Despite substantial evidence for racial disparities in later life cognitive health, specific causes remain unclear and the cognitive impact of lifelong adversity is underexplored.
Megan Zuelsdorff, PhD, at the University of Wisconsin School of Medicine and Public Health, and colleagues examined the impact of lifetime stressful experiences on cognition as part of the Wisconsin Registry for Alzheimer’s Prevention (WRAP) Study. The study population included a total of 1,320 adults – African American (n=82) and non-Hispanic white (n=1,232); the goal was to understand how stressful experiences – such as being fired from a job, the death of a child, growing up with a parent who abused alcohol or drugs, or experiencing combat – impacted cognition differently in these two groups.
Average age, years of education, and APOE?4 status did not differ by race. Stressful experiences included educational difficulties, interpersonal conflicts, financial insecurity, legal/justice system issues, serious health events and psychosocial/physical trauma. Participants answered a questionnaire about stressful experiences and completed cognitive tests that measured memory and problem-solving abilities. Researchers stratified the sample by race and looked at stress-cognition relationships within African American and white subgroups.
A greater number of stressful events was associated with poorer late-life cognitive function for all study participants. Even within a relatively small, highly educated sample, African Americans experienced over 60 percent more stressful events than non-Hispanic Whites during their lifetimes, and these experiences were linked to poorer memory and thinking skills in older age. The researchers determined that, in African Americans, each stressful experience was equivalent to approximately four years of cognitive aging.
Early Life Conditions
High infant mortality rates are a marker of adverse social and physical conditions, and birth in areas with high infant mortality rates are associated with a variety of poor health outcomes. Yet, is unknown if birth in states with high infant mortality impacts dementia risk.
Paola Gilsanz, ScD, of the University of California, San Francisco, and Kaiser Permanente Division of Research, and colleagues looked at race specific infant mortality rates in 1928 of the birth states of more than 6,200 members of the Kaiser Permanente Northern California health system. Members born in the 10 states with highest rates of infant mortality for their race were categorized as being born in high infant mortality states. They linked this information with medical records to see if people born in high infant mortality states were at greater risk of dementia. They found that:
- 1928 rates of infant mortality were much higher among African Americans (up to 277 deaths/1,000 live births) compared to Whites (up to 129 deaths/1,000 live births).
- African Americans born in a state with a high infant mortality rate had a 40 percent higher risk than African Americans born in states without high infant mortality rates, even after taking into account education, high blood pressure in midlife, body mass index, stroke, and diabetes.
- African Americans born in high infant mortality states had almost 80 percent greater risk of dementia even after accounting for education and health risk factors, compared to Whites born outside high infant mortality states.
- Being born in a high infant mortality state was not associated with dementia risk among Whites.
Disadvantaged Neighborhoods
Disadvantaged neighborhoods often pose barriers for accessing healthy foods, safe exercise options, toxin-free environments, and other factors that impact health. It is known that living in a disadvantaged neighborhood increases risk of diabetes, cancer, and early death, and that moving to less disadvantaged settings improves health.
Amy Kind, MD, PhD, of the University of Wisconsin School of Medicine and Public Health and colleagues used data from 1,479 people enrolled in WRAP. The scientists found the level of socioeconomic neighborhood disadvantage for each study participant using the Area Deprivation Index (ADI) score, which incorporates indicators of poverty, education, housing, and employment.
The researchers examined whether patterns of cognitive function and protein biomarkers (n=153 with spinal fluid samples) of Alzheimer’s were found more often in certain neighborhoods than would be expected to occur by chance alone. They found that people in the most disadvantaged neighborhoods had markedly worse cognitive performance in all aspects measured (working memory, immediate memory, speed and flexibility of cognition, and verbal learning), even after adjusting for age and education. They also had disproportionately higher levels of one Alzheimer’s disease biomarker in their spinal fluid (phosphorylated tau).
Kind’s group has quantified ADI scores for more than 50 million neighborhoods across the United States and Puerto Rico; those results could be used to target dementia-focused intervention and research programs to areas of highest need.
While the U.S. Congress has recently provided additional funding for Alzheimer’s research at the National Institutes of Health (NIH), the commitment falls far short of the need. Congress must continue its commitment to the fight against Alzheimer’s and other dementias by increasing funding for Alzheimer’s research by at least an additional $414 million in fiscal year 2018.
Lifestyle, Risk Reduction and More
New research results presented at the Alzheimer’s Association International Conference 2017 (AAIC 2017) deepen our understanding of the risk factors for Alzheimer’s disease and other dementias, and highlight the potential to prevent cognitive decline through lifestyle interventions. Other important data reported at AAIC 2017 included new studies that highlight the impact of race and socioeconomic status on dementia risk, plus advances in diagnostic tools and early detection.
At AAIC 2017, the Alzheimer’s Association announced the launch of the U.S. study to PrOtect through a lifestyle INTErvention to Reduce risk (US POINTER) – a $20 million U.S. two-year clinical trial to test the ability of a multi-dimensional lifestyle intervention to prevent cognitive decline and dementia in 2,500 older adults at increased risk for cognitive decline.
Also at the conference, The Lancet Commission on Dementia Prevention, Intervention and Care reported that more than one-third of global dementia cases may be preventable through addressing lifestyle factors that impact an individual’s risk. They highlighted nine potentially modifiable risk factors at multiple phases across the life-span, not just in old age.
“We are determined to develop and deliver a more-specific recipe for Alzheimer’s risk reduction,” said Maria Carrillo, Ph.D., chief science officer at the Alzheimer’s Association. “We now can effectively prevent or treat heart disease, cancer and HIV/AIDS with combinations of drugs and lifestyle. The same may also be true for Alzheimer’s disease and other dementias in the not too distant future.”
“This will only come through additional, large-scale research trials in diverse populations. The Alzheimer’s Association calls on the U.S. Congress to continue its commitment to Alzheimer’s and other dementias by increasing funding for Alzheimer’s research by at least $414 million in fiscal year 2018,” Carrillo said.
AAIC is the premier annual forum for presentation and discussion of the latest Alzheimer’s and dementia research. Bringing the world closer to breakthroughs in dementia science, AAIC 2017 convened more than 5,000 leading experts and researchers from 64 countries around the world, and featured more than 2,200 scientific presentations.
Large U.S. trial announced to explore benefits of lifestyle interventions on cognitive decline
The U.S. study to PrOtect through a lifestyle INTErvention to Reduce risk (US POINTER) will include physical exercise, nutritional counseling and modification, cognitive and social stimulation, and improved self-management of medical conditions. Recruiting for the study will begin in 2018.
“We now can effectively prevent and treat heart disease with a combination of drugs and lifestyle. The same is true with some cancers; the same with HIV/AIDS. The same may also be true for Alzheimer’s disease in the not too distant future,” said Carrillo. “We must test all options to treat and prevent this horrible disease. The Alzheimer’s Association is extremely proud to launch this clinical trial with our scientific partners.”
More than one-third of global dementia cases may be preventable through lifestyle
The Lancet released the report of its Commission on Dementia Prevention, Intervention and Care at AAIC 2017, finding that more than one-third of global dementia may be preventable through addressing lifestyle factors that impact an individual’s risk. The Lancet Commission brought together 24 international experts to consolidate the advances made in our knowledge of dementia risk factors, treatment and care.
The authors conducted a new review and meta-analysis; they extended current models of dementia risk by including hearing loss and social isolation. They proposed a novel life-course model of dementia risk showing potentially modifiable risk factors at multiple phases across the lifespan. They estimated the potential impact of elimination of the most potent risk factors, finding that roughly 35 percent of dementia cases may be attributable to nine modifiable risk factors:
- Early life – Education to age 15.
- Mid-life – Hypertension; Obesity; Hearing loss.
- Later life – Depression; Diabetes; Physical inactivity; Smoking; Low social contact.
Verbal and sensory skills, and emergency hospitalizations, may predict future cognitive function
Research reported at AAIC 2017 shed light on new and expanded risk factors for cognitive decline and Alzheimer’s. New data suggests associations between cognitive status in older people and verbal skills, hearing loss, and certain types of hospitalization.
Researchers found that people with hearing loss were roughly three times as likely to have mild cognitive impairment compared to those with normal hearing. In a separate study, speech content and fluency of study participants with mild cognitive impairment declined faster than those with normal cognition. If these findings are confirmed, hearing loss and speech pattern changes may be valuable in assessing risk for, or the beginnings of, cognitive decline as we age.
A third study found that older adults may be at higher risk for memory and other cognitive problems after non-elective hospitalizations. These procedures were associated with a roughly 60 percent acceleration in the rate of cognitive decline versus pre-hospital rates. In this study group, elective procedures were not associated with cognitive decline. These findings may have important implications for medical decision-making and care of older adults.
Common sleep problems associated with increased markers of Alzheimer’s risk
Several new research analyses at AAIC 2017 found significant associations between sleep disordered breathing (SDB) and the hallmark brain changes of Alzheimer’s. Researchers found that, in their study populations, obstructive sleep apnea (OSA) was associated with increased brain amyloid deposition, decreased cerebrospinal fluid (CSF) levels of amyloid (which is thought to indicate increased buildup in the brain) and increased tau protein levels. SDB was associated with accelerated accumulation of brain amyloid both in cognitively normal individuals and people with mild cognitive impairment (data from the Alzheimer’s Disease Neuroimaging Initiative). SDB/OSA is a modifiable factor that – with effective treatment – may help lower the risk of cognitive decline and possibly Alzheimer’s. More research is needed to test this idea.
Healthy eating habits may preserve cognitive function and reduce the risk of dementia
Results from four large population-based studies support a connection between good dietary practices and better cognition in old age. A group of U.S. scientists found that, among nearly 6,000 older adults, those who consistently followed diets long known to contribute to good heart health were also more likely to maintain strong cognitive function in old age. Close adherence to the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet and Mediterranean diet was associated with 30 to 35 percent lower risk of cognitive impairment in healthy older adults. Researchers from the Karolinska Institute in Sweden found that people sticking to a Nordic Prudent Dietary Pattern (including non-root vegetables, fruit, fish, poultry and tea) enjoyed better cognitive status. Another study linked unhealthy diet to markers of inflammation, smaller brain volume and worse cognitive performance.
Impact of Amyloid PET on patient management: early results from The IDEAS Study
At AAIC 2017, interim results were presented from the ongoing Imaging Dementia–Evidence for Amyloid Scanning (IDEAS) Study, which is evaluating the utility of brain amyloid PET imaging in a clinical setting. These PET scans are currently not reimbursed by Medicare or private insurance, who have expressed uncertainty about their clinical utility. Researchers reported results assessing changes in patient management (Alzheimer’s and other drugs, and counseling by the physician) in nearly 4,000 IDEAS Study participants, who are Medicare beneficiaries age 65+ with mild cognitive impairment (MCI) or atypical dementia where there are challenges getting a specific clinical diagnosis. After receiving the PET scan results, changes in medical management were seen in 67.8% of MCI patients, and 65.9% of people with dementia. This suggests that amyloid PET may have a substantial impact on patient management. The IDEAS Study is led by the Alzheimer’s Association and managed by the American College of Radiology.
Racial and socioeconomic disparities in dementia risk and incidence
Several studies reported at AAIC 2017 confirm racial inequities in numbers of people with Alzheimer’s disease and other dementias in the U.S. – even after age 90 – and point to growing evidence that stressful life experiences and neighborhood conditions contribute to dementia risk in late life, and disproportionately impact African Americans.
Researchers from Wisconsin found that a single major stressful event in early life may equal four years of cognitive aging, and African Americans are most at risk – on average, they experience over 60 percent more of such events than Whites over their lifetimes.
states with highest infant mortality had 40 percent higher risk of dementia compared to African Americans not from those states, and 80 percent higher risk compared to Whites not from those states.
Racial disparities in the risk for new cases of dementia, previously observed in the younger elderly, continue into the oldest-old – age 90+, which is the fastest-growing segment of the population – according to a new study reported at AAIC 2017. Oldest-old African Americans and Latinos had the highest incidence rates compared to Asian Americans and Whites.
Regional shortages of neurologists – Neurology “Deserts” – revealed across the U.S.
Twenty states in the U.S. have been revealed as neurology “deserts,” due to a projected chronic shortage of neurologists and a rapid rise in Alzheimer’s disease and other dementia cases. Researchers from a digital health startup company created an Alzheimer’s Disease and Related Disorders Neurology Desert Index (ANDI), defined as the ratio of neurologists to Alzheimer’s/dementia population. Wyoming, North Dakota, South Carolina, South Dakota and Oklahoma were revealed as the five states with the most significant projected gap between available neurology workforce and the health needs of people with dementia. With the continued aging of the population, additional resources, training and education are needed for primary care physicians and caregivers, especially in the identified states.
U.S. National Institute on Aging shares inaugural grants on health disparities in Alzheimer’s
At AAIC 2017, the National Institute on Aging (NIA) highlighted new research grants to investigate health disparities in Alzheimer’s. According to the Alzheimer’s Association’s 2017 Alzheimer’s Disease Facts and Figures, African Americans are about twice as likely to have Alzheimer’s as older Whites, and Hispanics are about one-and-a-half times as likely. Yet, these populations are underrepresented in Alzheimer’s and dementia research. According to the NIA, “When [research] cohorts are diverse, new pathways that link environmental, sociocultural, behavioral and biological factors can be identified.”
Promising early study of blood test to detect amyloid
Research has established that there is a connection between Alzheimer’s and the buildup of amyloid protein into plaques in the brain. For a person’s dementia symptoms to be caused by Alzheimer’s, amyloid plaques must be present. Currently, a PET scan or analysis of cerebrospinal fluid can detect amyloid deposition in the brain. However, there is an urgent need for a simpler, less invasive, less expensive test for amyloid, such as a blood test. At the Alzheimer’s Association International Conference 2017, researchers from the Washington University School of Medicine presented promising findings from their investigation of a blood biomarker for amyloid in a small study group, plus a validation sample.
– Kristen Becht is with the Alzheimer’s Association – Greater Kentucky and Southern Indiana Chapter.
