“Monday Musings” for Monday Feb 1, 2016
Volume V!, No. 5/265
On the Brain and Behaviour, Part V
Editor’s Note: This is part V of a six part series on Brain and Behaviour. In Part I, January 4, 2016, the general topography and physiology of the brain was discussed. In Part II, Monday January 11, the topic of Epigenetics was explored. In Part III, January 18, the emergence of ‘Age of Mind’, the marriage between psychoanalysis and neurosciences was examined. Part IV, Monday January 25, we offered an example of such marriage in the form of a book review to enhance our understanding of what lies in the future of the union of psychoanalysis and neuroscience. Today, Part V and next Monday, Part VI, we conclude the series by offering clinical examples of two dreaded brain diseases, namely Alzheimer’s and Parkinson’s Disease.
Alzheimer’s Disease, The Latest
By Assad Meymandi, MD, PhD, DSc (Hon)*
It has been a whirlwind of a week. The World Association of Alzheimer’s Disease has been meeting in Washington DC. Alzheimer’s Disease is a heartbreaker. Some reflections, but first a bit of history:
Alzheimer’s disease is the most common form of dementia (forgetfulness/inability to recall) that afflicts more than 100 million worldwide, and five million in America. The dementia-causing brain disorder is named for its discoverer, German psychiatrist and neuropathologist, Aloysius (Alois) Alzheimer (1864-1915). The first case of Alzheimer’s disease was of course presented in the form of a scientific paper to the Conference of Southwest German psychiatrists in Tubingen, Germany, on November 4, 1906.
Dr. Alzheimer discovered little bits of goo, starch like substance, the chemical composition of which we now know to be amyloid, accumulated around the nerve cells (neurons) in the brain. These bits grow and coalesce into bigger pieces called plaques and later on neurofibrillary tangles, all of which disrupt the works of the brain which are primarily memory, intellectual functions, such as thinking and communication. As the result, nerve cells die (are choked to death) and the brain literally shrinks in volume. The patient with Alzheimer’s disease experiences loss of memory both for recent and distance events, as well as deficit in perception, mental processes, cognition and comprehension in a progressively worsening mode until the patient dies. Alzheimer’s disease is a slow but major killer. In mid to later stages, the Alzheimer’s patients do not even remember or recognize their children and other close members of the family.
Alzheimer’s disease is brutal. It robs the afflicted of experiencing joy, communication, and connection with life. The patient turns into a zombie. Most important loss is loss of dignity and nobility of the soul preceded by urinary and fecal incontinence. We now have five million Americans suffering from this disease (worldwide over 100 million). It is more prevalent in women because of female hormonal and body chemistry. There may be accompanying mood disorder such as depression; or behavior disorder such a s violence; and thought disorder such as paranoia and delusions.
Interpersonal relationship, let’s say between a husband and wife is based on ability to talk (communication). And talking is about memories of the past, plan for the future and enjoyment of here and now. After attending a party, we chit chat about whom we saw at the party and who said what…And plan for the future, trips, vacations, grandchildren, etc. With Alzheimer’s all this is taken away in a brutal and irreversible manner. Conversations are reduced to asking and answering the same questions limited in scope and variety, repeatedly, randomly and aimlessly. The “conversation”/exercise soon becomes exhausting. In Alzheimer’s disease, meaningful communication, the central alchemy of relation and love, is one of the first things to disappear.
Diagnosis and treatment:
Diagnosis is through neuropsychological testing, mental status examination and brain scans. Besides magnetic resonance imaging (MRI), we now have other radiological instruments such as positron emission tomography (PET scan) and functional MRI (fMRI) that not only visually demonstrate existence of the plagues and the amyloid bits, but can measure the physiological function of the brain. It is now well known that Alzheimer’s related changes in the brain begin 10-15 years or more before people show signs of detectable memory loss. Scientists at University of Pittsburgh and the Johns Hopkins University have developed a BIOCARD which study and predict onset of the disease in volunteers through long term monitoring and testing. Therefore, treatment is primarily through brain exercise, reading, memorizing, classical music, doing crossword puzzle, Sudoku puzzle, physical exercise and activities, staying socially active, interactive, and engaged.
In the past few decades, we have had a number of chemicals, among them Aricept and Namenda. These drugs are designed to fight the progression of the disease and bring symptom relief. In essence they slow down the deterioration of the brain, but, unfortunately, not very successfully. More recently, a new group of drugs–the Zumab family of drugs—have been introduced with the promise that they attack the plaques directly by dissolving and removing them from the brain. They belong to a group of chemicals called monoclonal antibodies. Their expected function is to just like a chemical vacuum cleaner get in the brain and sweep away the goo, the plaques and the neurofibrillary tangles. The Zumabs supposedly are those chemical vacuum cleaners. The first one of these drugs Bapineuzumab which is still in trial has not shown glorious results. The fuss last week in Washington, DC was over another drug from the same family, Solanezumab, a drug made by Eli Lilly & Co. The first clinical trial of the drug is near completion, and the preliminary results offer some promise. More and bigger clinical trials are on the way. Now, critics, pharma pundits and stock market analysts alike, are awaiting with bated breath the results from Solanezumab- the second antibody-based vaccine drug marketed by Eli Lilly, currently in clinical trials. The hopes and dreams of a worldwide population of nearly 100 million (and growing) people with AD rides on these trials. A lot of money rides on these trials, too, given that the number of people with AD is steadily growing. The profits for any company that comes up with a reasonable drug for AD would be unimaginable. With all the hype in last week’s global conference on Alzheimer’s Disease, it remains unclear how solanezumab will fare in subsequent clinical trials. Hot on the heels of the failed bapineuzumab trials, the solanezumab trials carry the burden of possible failure and extra scrutiny.
Personal Thoughts Not Only As A Practicing Psychiatrist, Teacher, But As A Care Giver:
It is a distinct privilege to care for a beloved afflicted with Alzheimer’s. The opportunity to be exposed to deeper strata of love is unique and instructive. One learns patience, compassion, and care—feeling for—the victim with relentless constancy. There is nothing like experiential learning…However, personally, I believe that with the American ingenuity, and the vast resources of a mature capitalist society at our disposal, we will find a cure for Alzheimer’s. Remember in 1981 when the first case of auto-immuno-deficiency syndrome (AIDS) was diagnosed. In the 80s and 90s, tens of thousands died because of AIDS. Well, again this past week, at another scientific meeting re: AIDS, the speakers including our own Myron Cohen of UNC School of Medicine and Health, were talking about not only control of AIDS and minimizing mortality but curing AIDS. We are today with Alzheimer’s where we were with AIDS in the mid-1980s.
I am reminded of St Thomas Aquinas (1205-1275) view of science: “Believing is good. Knowing is better.” What a privilege to be alive today, especially in America, and enjoy the experience of explosion of knowledge.
*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, Life Member, American Medical Association; Life Member, Southern Medical Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012).