Alzheimer’s Disease (AD) affects approximately 6 million Americans and is the seventh leading cause of death in the US. Currently there is no cure for AD, nor a means to prevent the progression of AD. As such, understanding the biomarkers associated with and how they relate to AD progression is critical in understanding how to diagnose and care for individuals with AD. Additionally, understanding these biomarkers is paramount in research associated with prevention/modification of AD symptoms (Weller & Budson, 2018). The most prevalent biomarkers related to AD are Beta-amyloid (β-amyloid) plaque, Tau neurofibrillary tangles (Tau), Apolipoprotein A (Apoe), anatomic structural changes, and cognitive functional changes (Weller & Budson, 2018). Furthermore, these biomarkers can distinguish AD into 3 stages: a presymptomatic stage, mild cognitive impairment (MCI), and a symptomatic stage. Interestingly, these biomarkers seem to begin accumulating far before cognitive symptoms become apparent (Albert et al., 2011). The differentiation of these stages is an interesting topic to think about with respect to decision making (Briggs et al., 2016).
Before exploring the idea of therapeutic intervention (part 2 maybe next), I think it is important to understand the ethical dilemma when caring for, and treating those with AD. As noted, the disease can be differentiated into 3 stages: Normal, MCI, and Dementia. Normal refers to individuals that have biomarkers associated with AD, but do not have any cognitive implications relative to their age (Albert et al., 2011). MCI refers to those with AD pathology and a level of cognitive impairment not normal for their age (Albert et al., 2011). The dementia stage refers to a decline in function through three areas: cognition, function, and mood/behavior (Weller & Budson, 2018). The dilemma with diagnosis of MCI and of dementia is that it relies on interviews, informants for the patient, and neurophysiological testing together versus one singular (subjective) test (Weller & Budson, 2018). Additionally, a patient with MCI could be cognitively aware of what is being discussed/administered during these tests, but at later stages of the disease, the patient is likely unable to provide input on treatment thereby putting the burden on the caretaker/caregiver to decide what's right for the individual. Moreover, there are drugs available to mediate cognitive symptoms associated with AD, but who should decide whether to administer them those in late stages of AD (Briggs et al., 2016). Furthermore, how should one assess the efficacy of said medication if an individual is unable to provide information related to their symptoms? I think the ethical question becomes: at what point during this disease’s progression should providers rely on a caretaker versus the patient themselves with regards to decision making. Understanding and using biomarkers associated with AD could allow individuals to discuss these options before cognitive decline, but this intrinsically relies on being tested for biomarkers (somewhat regularly). A series of tests not often implemented without concern to do so.
References
Briggs, R., Kennelly, S. P., & O’Neill, D. (2016). Drug treatments in Alzheimer’s disease. Clinical Medicine, 16(3), 247–253. https://doi.org/10.7861/clinmedicine.16-3-247
This article was very interesting and poses several follow-up ethical questions! The Mayo Clinic utilizes biomarker testing for patients already diagnosed with mild cognitive impairment or dementia. The addition of biomarker testing increases diagnostic accuracy above the 70% or 80% level achieved through traditional clinical and cognitive assessments for Alzheimer's. Patients can use this additional information in order to make the best decisions for their future. Things get a little more complicated when advocating to check biomarkers prior to being diagnosed with mild cognitive impairment or dementia. The presence of these biomarkers in the absence of a diagnosis does not constitute a diagnosis of Alzheimer's.
ReplyDeleteEisai Inc. (2022). AHEAD 3-45 Study: A Placebo-Controlled, Double-Blind, Parallel-Treatment Arm, 216 Week Study to Evaluate Efficacy and Safety of Treatment With BAN2401 in Subjects With Preclinical Alzheimer’s Disease and Elevated Amyloid (A45 Trial) and in Subjects With Early Preclinical Alzheimer’s Disease and Intermediate Amyloid (A3 Trial) (Clinical Trial Registration No. NCT04468659). clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT04468659
Hey Spencer, this article was super interesting and brought up ideas I haven't considered before. The idea of patient consent and decision making can be a difficult topic but you explained it very well. It seems like a good idea that individuals at risk (Normal stage) for Alzheimers should talk with their provider about a care plan for when they enter the later stages of the disease. This would take pressure off the care taker and may also allow the patient to feel more in control of their future. This of course only applies to individuals who know they are at risk or have undergone testing. However, what would be the psychological implication of this plan? It seems very morbid to ask someone about their end of life plan, would it cause more damage then benefit? It would surely make the caretakers job easier as they would have to make less decisions, but would it increase depression and hopelessness in an individual who may not even get the disease? It is most definitely a hard decision to make.
ReplyDeletehttps://www.apa.org/topics/aging-older-adults/end-of-life-decisions
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731514/