The World Alzheimer Report of 2011 reported that we do not
know the benefits of screening and early diagnosis of dementia. We all assume
that people should be checked early for dementia, but we do not know whether
there is an advantage to be diagnosed with the disease. There are definitely
negative repercussions—losing your driving license, right to conduct
professional duties, enter into financial agreements, and sometimes even the
right to conduct your own affairs. It seems that once you get diagnosed with
dementia then you are left to fend on your own with your loved ones if you have
any.
There is a disconnect between diagnoses—the identification
of the disease—and prognosis—forecasting the progression of the disease and
suggested treatment, therapy or support services. In the field of dementia, as
with other diseases especially cancer, there lies an expectation that an early
detection brings better outcomes: You live longer with less pain. But the
reality is very different. New emerging research shows that our ambition to
help dementia patients because of an early diagnosis is failing miserably.
In a French study in 2015, Clément Pimouguet and his
colleagues reported that people with dementia who had consulted a specialist at
the start of their disease, died earlier than those who only saw their general
practitioner (GP) or did nothing. Sadly they found that there was no difference
between participants who visited their GP and those who went without any
clinical care. Although those that went
to see a specialist had much faster functional decline, their thinking ability
was not much different from the other group. Why would seeing a specialist
increase your likelihood of dying?
The lack of follow-up by the specialist was one of the
reasons given for the higher rate of death. In 2017 Paula Rochon and Jeremy Matlow and colleagues in Toronto,
Ontario, reported that half of 2,998 nursing home residents with dementia were
still getting questionable medication in their last year of life. These medications might have had some benefit
at the early stages of the disease but definitely have negative affect on the
wellbeing of these confused patients. That a third of the residents did not see
a specialist in the last year of life suggests that the medication was
prescribed earlier on in the diagnosis and had not been reviewed since. Regular
medication reviews will help to curtail unnecessary prescriptions.
It is likely therefore that too much and inappropriate
medication is a culprit. In France only the specialist can prescribe drugs and
this study found that half were prescribed antidementia drugs (46.2%); while
the rest 12% prescribed antipsychotic drugs, 28% anxiolytic drugs, and 9% took
psychostimulant. It is only when the diagnosis of dementia was vascular
dementia and where some fo these drugs are not to be prescribed that seeing a
specialist was found to be beneficial. Amelie Bruandet with the university of
Lille, France and her colleagues found that with vascular dementia the shorter
the delay between first symptoms and first visit, the longer patients survived.
It could be due to medication, specialist do not prescribe medications that are
killing dementia patients earlier.
It seems that we do not have any medication for dementia
that is both effective and safe. In fact, all evidence points to dementia
medication as being ineffective and in most cases dangerous. A conclusion that
was arrived at by a 2014 study by two Dartmouth professors Steven Woloshin and
Lisa Schwartz reporting for Consumer Reports. In addition to their
costs—ranging on average $177-$400 a month—there was not one drug that they
could recommend. Not one drug.
The logical assessment would be that since physicians have
no medication to provide patients with dementia then following the Hippocratic
Oath and “first, do no harm,” no medication should be prescribed. But a 2015 study of elderly patients showed
that anticholinergic medications given to patients with dementia—including
antimuscarinics, tricyclic antidepressants, and first-generation
antihistamines—are associated with an increased risk for dementia. Drugs being
prescribed have an established evidence to increase dementia. Sometimes this
dangerous medication is given for non-life-threatening disease such as
overactive bladder. Christian Meyer from the University Medical Center
Hamburg–Eppendorf in Germany, and his colleagues reported that more than
one-quarter of older Americans with overactive bladder are given a prescription
for oxybutynin, and one-third are given a refill, despite the established link
between this drug and cognitive dysfunction in the elderly. In a 2015 survey of
Medicare patients with dementia more than one in four were being prescribed
"potentially inappropriate" anticholinergics.
The overuse of prescription of medication among older
patients is ageist. We need to address this final bastion of stereotyping. We
know that younger people with a similar disease are more likely to get therapy.
But there is another negative consequence of this lack of knowledge. Physicians
become shy at making prognoses. Although diagnosis is relatively easily, they
can easily say it is Alzheimer’s disease or Vascular dementia without any
liability issue, and most do despite evidence that they are likely to be
wrong. The patient is seriously sick, we
can all see that. But once physicians start to define a timeline or sequence of
how the disease will enfold, then they become exposed not only to the patient,
but more importantly to the patient’s family, their medical institutional and
legal liability.
In a short paper, Sonali Wilborn, and Navdeep Grewal, with
Seasons Hospice and Palliative Care, Madison Heights, Michigan USA found that
predicting mortality using current prognostic guidelines, fails in
approximately a third of Alzheimer’s patients. Nicholas Christakis, a hospice
physician takes it much further. He rightly laments the neglect of prognosis in
medicine. Making a prognosis is messy and inaccurate. In 2000, he reports a
study where only one in five timelines were accurate in forecasting death, more
than half were over-optimistic while one in six were over-pessimistic. Being
over-optimistic ensures that patients delay too long in sorting out their
affairs.
The symbol of medicine is the rod of Asclepius—which has a
snake coiled around a cane. It is carried by the Greek god Asclepius, a deity
associated with healing and medicine. It is often confused with the caduceus
which has a very different meaning.
The caduceus—depicting two snakes wrapped around a winged
rod—is carried by Mercury the mythical messenger of the gods. Mercury is the
guide of the dead and protector of merchants, shepherds, gamblers, liars, and
thieves. In dementia care we might be confusing both the symbol and the objectives
becoming the protectors of big pharma: merchants, gamblers, liars, and thieves.
The abuse of older patients with dementia remains an unwritten chapter in the
low point of medicine.
© USA Copyrighted 2017 Mario D. Garrett
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Bombois, S., Maurage, C. A., Deramecourt, V., Lebert, F., ... & Pasquier,
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Pimouguet, C., Delva, F.,
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Rait, G., Walters, K.,
Bottomley, C., Petersen, I., Iliffe, S., & Nazareth, I. (2010). Survival of
people with clinical diagnosis of dementia in primary care: cohort study. Bmj,
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© USA Copyrighted 2017 Mario D. Garrett
