In 1983, the year I was born, what do you think the mainstay of treatment for a heart attack was? Well according to a medical textbook published the year before, the standard of care was bed-rest, pain killers and little else. Surprising isn't it? Well I'm glad to say that in cardiology things have come a long way since.
In my early days as a doctor it was commonplace to fix a drip of a clot-busting medication for those with a severe heart attack. Today though if you have a severe heart attack you'll most likely be whisked off to the nearest cardiac centre where a cardiologist with a bunch of catheters and wires will suck out, break open and squash the clot like a chimney sweep. New experimental therapies are on the way too, including a blackberry-like structure full of nanoparticles. Full of clot busting drugs they burst open delivering them to exactly to where their needed. Clever stuff!
I was reminded about the success story of modern heart attack treatment whilst sitting in a darkened hospital seminar room; a meeting of neurologists. We were talking about dementia, specifically Alzheimer's disease where those affected gradually loose their thinking abilities, memories and personality until they can no longer recognise their loved ones. Dementia, of which Alzheimer's is the most common, is a tragic and distressing illness and unfortunately it's becoming far more common. By the year 2025 over 1 million people in the UK are expected to have some form of dementia and that's a big social problem too since it is thought to have cost the UK over £23 billion a year in 2012. The risk increases with age and since we're all living longer more of us will be affected by thinking problems. In part this is due to better treatment for things like heart attacks and cancer and as overall mortality falls in the Western world, neurological disorders and Alzheimer’s increases. One way or another we need to get to grips with the problem.
There is a diagram presented at most dementia meetings. Its a hypothetical model of what happens to a patient with Alzheimer's Disease. The graph is made up of various curves each representing something that we can use to track the progression of the illness; from levels of protein in the spinal fluid to brain imaging and tests of thinking in the clinic. The curves look like giant elongated s-shapes drawn one after another and each document the progression of Alzheimer's over time. The proteins accumulate first then the brain starts to shrink followed by worsening of cognition and quality of life. The usual estimate is about a ten year lag between the protein accumulation and development of dementia.
That's 10 years that we could be doing something to treat those who are in the early stages of the disease! Currently there is no evidence that screening for dementia will help; our tests are not good enough yet and currently there is little we can do even if we do find it. Only by addressing these two issues can we make real headway in tackling this new epidemic. If we can identify those at risk for or who have the early signs of a dementing illness then we have a shot at using a protective treatment. Those treatments do not yet exist and that's the second challenge.
If we can recognise that people have dementia and develop treatments that, if not cure then delay the onset how would we benefit? This thought experiment has been played out in numbers by the American Alzheimers Association. If a breakthrough treatment that could delay the onset of Alzheimer's by just five years was available by 2015 then 1.6 million Americans aged 65 and over would be spared the indignity of living with dementia. Costs would reduce immediately and by 2020 $50 billion would be saved by reducing costs from a projected $240 to $190 billion.
What about slowing the onset of the condition? A breakthrough treatment here would paradoxically increase those with dementia as more would survive. Those survivors however would have a less severe illness and have better quality of life for a longer time. Again a cost saving to the tune of $40 billion by 2020 would mean more funding for other areas of healthcare and research.
There is no doubt that in the year that my first child is born treatments for dementia will look as bleak as bed-rest for heart attacks in 1983. However before his 30th birthday I hope he can look back at dementia, just like I did for heart attacks, and say 'we've come a long way since then'. My biggest wish though is that I will be with him, free from dementia, so I can tell him all about how we did it.