HH/Beck: Hi Dr. Bartels. It is a pleasure to meet you and I certainly appreciate your time today. I know you are an extraordinarily busy person.
Bartels: Thank you Dr. Beck. Its an honor to work with you.
HH/Beck: I have an amazing bio-sketch here in front of me, and if you dont mind, Id like to tell the readers about a few of the positions you currently hold. You are currently an associate professor of psychiatry at Dartmouth Medical School and youre also the president of the American Association for Geriatric Psychiatry. In addition, youre the co-director of the Geriatric Fellowship Program and youre the medical director of the Division of Behavioral Health for the State of New Hampshire and youre the Director of the Aging Services Research center at the New Hampshire-Dartmouth Psychiatric Research Center.
Bartels: Yes, that sounds about right.
HH/Beck: Dr. Bartels, before we get into Alzheimers and depression, can you tell me about your observations regarding hearing impaired seniors?
Bartels: Certainly. Many of the individuals we see have hearing loss. As you know, the rate of hearing loss increases with age. Naturally, seniors have a greater incidence of hearing loss, and so we often see the same patients in our office as are seen in the audiology office. Sensory isolation, whether it is visual or auditory can be very problematic. It may make the person more easily agitated or confused, and of course hearing loss exacerbates social isolation and depression. Hearing loss can make the management and diagnosis of Alzheimers even more problematic particularly if the hearing loss is undetected! Of course, there are probably patients who have hearing loss, yet they are suspect for geriatric psychiatric issues because the hearing loss is not known! In other words, maybe the patient appears to have psychiatric issues occurring to the casual or professional observer but perhaps some of those behaviors are attributable to hearing loss. So the bottom line is yes, hearing loss is an issue we deal with regularly and it does impact our management of patients.
HH/Beck: Can you please give me a working clinical definition of Alzheimers?
Bartels: Sure. Alzheimers is the single most common form of dementia and/or memory loss (besides neuro-degenerative disease) and it increases significantly with age. The statistics are that 40 percent of the USA population over the age of 85 years develop Alzheimers, so you could say it is at epidemic proportions right now. Alzhemiers is a progressive degenerative dementia characterized in the early stage by short-term memory deficits, and later with short and long-term memory deficits, aphasia, apraxia, disorientation and severe functional deficits. The underlying pathology includes cortical nerve cell destruction with characteristic amyloid plaques and neurofibrillary tangles.
HH/Beck: Dr. Bartels, what are the earliest signs and symptoms?
Bartels: All of us might have forgetfulness related to names, and thats actually pretty common and normal in some respects. But when we see people forgetting names of their family members, or forgetting appointments, misplacing things at an increasing ratethese are all signs of something we now call MCI Mild Cognitive Impairment. We think that MCI is probably an early sign of Alzheimers for a number of people.
HH/Beck: Are there genetic predispositions for Alzheimers?
Bartels: Yes, there can be. There are at least five different genes that have been associated with Alzheimers. For example, familial Alzheimers is relatively uncommon, it occurs to people at about age 45 to 50, and it is very malignant. It is associated with associated with chromosomes 14 and 21. As you know, chromosome 21 is associated with Downs Syndrome, and interestingly, 100 percent of the people with Downs Syndrome eventually get Alzheimers. Other chromosomes include chromosomes, 1, 12, and 19. It appears that the most common form of Alzheimers that generally occurs after the age of 60 is associated with chromosome 19.
HH/Beck: Very good. Dr. Bartels, what are the treatment options for Alzheimers at this time?
Bartels: Treatment options vary. The major treatments include use of particular agents which help reduce the rate of symptomatic memory decline. We have used cholinesterase inhibitors successfully to help increase acetylcholine in the brain and make the decline of memory over time, less significant. Of course it does not change the course of the illness, but it helps to preserve a little more memory for a little longer period of time, sp people function better for a little longer. We also recommend vitamin E and folic acid as they have a potential role in decreasing the amount of decline and damage. Of course, psycho-social treatment, the support of family members in managing the decline is certainly useful and very important. So basically there are many opportunities and alternatives to help these patients, and like most things, early intervention is the most useful.
HH/Beck: Is denial by the patient a big factor in Alzheimers diagnosis?
Bartels: It can be. For those patients whose career and livelihood is based on their intellect, it is very depressing and frustrating that they have become forgetful. For others, in the middle stage of Alzheimers they may not realize how bad their memory has become and indeed, they may even say. My memory is not that bad, which comes out when the family starts talking about a nursing home. So yes, denial can be an issue but it depends on the individual and their stage, but its not necessarily a hallmark of Alzheimers per se.
HH/Beck: Dr. Bartels, I hate to mention this, but president Reagan is probably the best known late stage Alzheimers patient. Is there any effective treatment option for someone in that condition?
Bartels: Tough call. I certainly havent seen him personally and so I really cannot say specifically. But in general, pharmacologic treatment is really more for early and middle stage patients. Of course it varies, but that is generally true. The jury is still out on late stage pharmaceutical options. I think maybe the best option for President Reagan is behavioral treatment, keeping him comfortable and having familiar people around him as much as is possible. Also, some 30 to 40 percent of all Alzheimers patients develop hallucinations and delusions or depression. These secondary symptoms are indeed treatable, and so it is important to test for these things and if theyre present they probably can be treated.
HH/Beck: Is Alzheimers more a frontal lobe disorder, or more generally present throughout the brain?
Bartels: Alzheimers is present and ravages the whole brain, through the cortical grey matter, and of course throughout the hippocampus, where memory lives. Some Alzheimers patients will demonstrate apraxia and some might have aphasias, but the variation is tremendous. Of course as time goes on and the disease worsens, virtually all will develop expressive and receptive aphasia.
HH/Beck: OK, thank you very much. If you dont mind, lets switch topics. Would you please discuss the clinical definition of depression, and the signs and symptoms to be aware of there too?
Bartels: Yes, certainly. The definition of major depression is a disorder in which people have feelings of hopelessness, helplessness and worthlessness. This is different from sadness, and its different from bereavement. Depression usually occurs with physical symptoms too, such as loss of appetite, difficulty sleeping, poor energy, loss of libido, and increased agitation. So people with major depression tend to have a functional impairment associated with the disorder.
HH/Beck: What can you tell me about the prevalence of major depression?
Bartels: There are several types of depression, but in particular, if were speaking about major depression, its probably about 5 percent of the geriatric population, though rates are considerably higher in older persons who are in nursing homes or hospitals.
HH/Beck: And the signs and symptoms of depression to be on the look out for?
Bartels: Persistence of a sad, or low mood for beyond two to three weeks, social withdrawal, and perhaps difficulty sleeping. It varies, but those would be the major things to look for.
HH/Beck: Dr. Bartels, is there a genetic pre-disposition for depression?
Bartels: There certainly can be. We know that people who have recurrent depression are more likely to have first degree relatives, meaning within their direct family, who also may have depressive illness. Certainly manic depressive illness, also know as bipolar disorder, has a significant genetic predisposition. Importantly, I want to state clearly that not all depressions are genetic, although there can certainly be a familial component.
HH/Beck: What about treatment options for depression?
Bartels: There are many treatments. The treatment ranges from anti-depressants to problem solving therapy (PST), also known as brief cognitive behavioral therapy (CBT). Both of these therapies have evidence-based literature supporting its use. In general, preferred pharmacological treatments are with the SSRIs (selective serotonin reuptake inhibitors) or the newer non-SSSRI agents. The older tricyclics such as amitriptiline (elavil) or sinequan (doxepin) are contraindicated due to anitcholinergic and cardiovascular side effects.
HH/Beck: Thank you so much for allowing me so much of your time. It really has been enlightening, and I think it will be very useful for many of the readers too.
Bartels: Youre welcome, its been a pleasure speaking with you.
