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Update on Alzheimer's research.

The past 10 years have seen an almost explosive growth in scientific understanding of Alzheimer's disease. Fueled by generous Federal government funding, scientists have identified specific brain changes associated with the disease and are now exploring how and why they occur and, most importantly, how they might be stopped. Every few months seems to herald a new discovery--and new questions -- that, to the non-scientist, can be bewildering in their biological detail. Recently Nursing Homes asked Peter V. Rabins, MD, Professor of Psychiatry at Johns Hopkins Medical Institutions, authority on Alzheimer's disease and co-author with Nancy Mace of the caregiver's bible, "The 36-Hour Day," to explain the research effort, and to put it into meaningful context for nursing home staffers who confront the ravages of Alzheimer's every day. The questions were posed by Editor Richard L. Peck.

Peck: How would you characterize the current Alzheimer's research effort?

Dr. Rabins: There has been a tremendous growth in biological understanding of the disease during the past five years, and there has also been progress on several fronts. Setting the biology aside for a moment, we have seen just in the past year or two a growth in understanding by the general population, and in particular policymakers, that Alzheimer's is not just memory loss, but carries with it behavioral dysfunction that poses major problems for patients and caregivers alike. This is not news to caregivers, but now it can be said that policymakers -- those who generate funding for Alzheimer's research and support -- understand it too. That is a major change, and an important one for the future.

Other recent events include the development of good evidence that environmental modification can benefit Alzheimer's patients and a growing understanding that medications -- at least so far -- have only modest effectiveness at best.

Peck: Let's get back to those in a moment, but first, what have been some of the key biological developments?

Dr. Rabins: It is now widely recognized that some cases of Alzheimer's do have a genetic component. Specific abnormalities have been identified on three chromosomes. This supports the idea that people with first-degree relatives who have, or had, the disorder are at greater risk for developing the disease. There is also fair evidence by now that head trauma increases the risk of Alzheimer's, and that aging is, in itself, a risk factor.

One of the major recent discoveries is that the brain itself attempts to repair damage to nerve cells. This is something that no one believed for a hundred years until fairly recently. This discovery has prompted major interest in nerve growth factors and how they might be employed in treating Alzheimer's. Human trials are underway, though it will likely be years before they produce results. Also, there is controversy over whether the nerve self-repair that has been observed is a response to the disease or, in fact, a contributor to the disease. Is this an abnormal repair effort that only makes the disease worse? We don't know at this point.

Peck: What about the famous plaques and tangles that have been found in Alzheimer's brains?

Dr. Rabins: These are the two basic abnormalities that have been found. The plaques consist of a protein called amyloid, which is surrounded by dying nerve endings. We have learned in the past few years that everyone has the genes to produce amyloid, but some people seem unable to break it down properly. There have been studies of cholesterol metabolism that indicate that some people have difficulty breaking down all proteins properly, and the hypothesis is that the difficulty in breaking down proteins, including beta amyloid, is the cause of Alzheimer's. Several groups are studying this.

The "tangles" you refer to are twisted fibers that appear to be located in nerve cells specifically in brains afflicted by Alzheimer's. Even though they are specific to Alzheimer's, less attention has been focused on these in recent years than on other findings, and so we really don't know much about how or why they form, or whether they're a cause or an effect of the disease.

Peck: Before you mentioned the "modest effectiveness" of drug therapy. Would you amplify on that?

Dr. Rabins: A drug called tacrine has raised interest of late. It has been shown to delay progression of Alzheimer's by as much as six months. It it still too early to say whether tacrine will modify the long-term course of the disease or resolve its symptoms. Other than this, there has been no drug as yet that has shown direct effectiveness of any significance on the disease.

Other, more standard medications have been found to be useful in some cases. For example, if the patient is upset by hallucinations or is acting out dangerously, hitting people and so forth, the antipsychotics such as haloperidol and thioridazine may be useful. Antidepressants are effective in managing the depression that occurs commonly in the early and mid-stages of the disease, although with these patients environmental stimulation with activities and other types of support are probably a more appropriate first choice.

Interestingly, there is some uncertainty as to whether depression does or does not occur in the late stages of Alzheimer's. It is possible that it does occur and may underlie some of the behavioral disorders, but the diagnosis is very difficult to make in people with memory disorders.

One general statement about medications: All medications used in the nursing home have the potential of affecting memory. If there is sudden memory loss, that is good reason to review all the patient's medications.

Peck: Everyone has heard the pros and cons of aluminum as an environmental risk factor for Alzheimer's. What do you think?

Dr. Rabins: There is controversy about that, but so far there is little direct evidence that it's causal. It's probably too soon yet to give up your pots and pans or underarm deodorant.

Peck: Until research comes up with something substantial in treating or preventing Alzheimer's, what are the key considerations in its management today?

Dr. Rabins: As I mentioned, we know now that the patient's personal environment has a major effect on the clinical manifestation of Alzheimer's, both the physical surroundings and interpersonal relationships. My own bias is that interpersonal relationships are the most important factor of all. How the nurse or nursing assistant relates to the patient poses the greatest potential benefit or the most negative risks of any component of treatment. We need to learn what the good ones do, and teach it to others.

To me, the most successful aides are the ones who are most flexible and adaptable to the patient's needs. Some patients need a lot of direct care, others rebel against this. The good aide knows how to discriminate among these and respond accordingly. They're also good at explaining to the patient everything they do as they do it.

Peck: The thinking that physical environment is important to Alzheimer's patients underlies much of the recent movement toward special care units. Any thoughts about those?

Dr. Rabins: They have both benefits and drawbacks. The benefits are that you can have an experienced, well-trained staff focusing on these patients, and you can design the environment to minimize their risks. A drawback is that you need relatively heavy staffing to manage these high-care patients, and there is some risk of burnout, compared to facilities that mix these patients in with those requiring less intensive care. Another potential drawback is that these patients get sicker together. You may start out with a very active program and then see patients continue to drop out because their physical needs are intensifying. That leads to another controversy: Should these patients be allowed to "age in place?" Or is there a point when they should be returned to the more typical nursing facility to deal with their physical needs? I favor the latter, but the jury is still out on that.
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Title Annotation:interview with Johns Hopkins professor of psychiatry Peter V. Rabins on Alzheimer's disease research
Author:Peck, Richard L.
Publication:Nursing Homes
Article Type:Interview
Date:May 1, 1994
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