Beck: Hi Dr. Bartels. I certainly appreciate your time today. I am honored to again speak with you on issues relating to Alzheimers and Depression, I know you are an extraordinarily busy person and I am very appreciative of your time.
Bartels: Thank you Dr. Beck. Its an honor to work with you again too.
Beck: If you dont mind, Id like to tell the readers about a few of the positions you currently hold, and have recently held Youre currently an associate professor of psychiatry at Dartmouth Medical School and youre also the past-president of the American Association for Geriatric Psychiatry. Youre the current chair of the Geriatric Mental Health Foundation. 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. Over the last year (2003) you were the Expert Consultant to the sub-committee on Older Adults for the Presidents Commission on mental health. Wow!
Bartels: Yes, that sounds about right.
Beck: We know that some 28 million people in the U.S.A. have hearing loss. 14% of those with hearing loss are between 45 and 64 years, about 23% of individuals between the ages of 65 and 74 years have hearing loss and about 1 out of 3 people over 75 years have hearing loss. So given that, Dr. Bartels, before we get specifically into Alzheimers and depression, can you tell me your general observations regarding hearing impaired seniors?
Bartels: Certainly. Many of the individuals we see have hearing loss. As you just stated, the rate of hearing loss increases with age. Seniors have a greater incidence of hearing loss, and so we often see the same patients in our office and the audiology office. Sensory isolation, whether it is visual or auditory can be highly 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, or if the patient is in denial regarding their hearing loss. 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.
Beck: Thank you. Would you please give me a working definition of Alzheimers?
Bartels: Sure. Alzheimers is the single most common form of dementia and/or memory loss (besides neuro-degenerative disease) and again, like hearing loss, it increases significantly with age. The statistics are that 40 percent of the USA population over 85 years of age develop Alzheimers, so you could say its at epidemic proportions right now. Alzheimers 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.
Beck: Dr. Bartels, what are the earliest signs and symptoms of Alzheimers please?
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 know that MCI is an early sign of Alzheimers for a number of people.
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 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 numbers 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.
Beck: Very good. Dr. Bartels, what are the treatment options for Alzheimers?
Bartels: Treatment options vary. 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. It does not appear to change the underlying course of the illness, but it helps to preserve memory for a longer period of time, allowing people to function better for a little longer. Over the past several months a new agent that is being prescribed in addition to cholinesterase inhibitors is memantine, this works differently and helps decrease cellular damage associated with Alzheimers by blocking the cellular destructive action of the chemical glutamate. 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.
Beck: Is denial by the patient a big factor in Alzheimers diagnosis?
Bartels: It can be. For patients whose career and livelihood is based on their intellect, its very depressing and frustrating to 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. That typically 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 of disease, but no, its not necessarily a hallmark of Alzheimers per se.
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 a situation similar to President Reagan?
Bartels: Tough call. I certainly havent seen him personally and I really cannot say specifically. However, both cholinesterase inhibitors and memantine have FDA indications for moderate and severe Alzheimers dementia. Regarding treatment in late stages, these decisions are largely driven by the presence or absence of a response and the specific clinical situation. The jury is still out on the effectiveness of these agents in the latest stage of the illness. In addition to pharmacological interventions; behavioral and environmental interventions are important. For example, modifying the environment to provide cues and appropriate levels of stimulation, and having familiar people around as much as possible can be helpful. Also, some 30 to 40 percent of all Alzheimers patients develop hallucinations and delusions or depression. These secondary symptoms are treatable, and so its important to test for these things because if theyre present, they probably can be treated.
Beck: Is Alzheimers more a frontal lobe disorder, or more generally present throughout the brain?
Bartels: Alzheimers is present and ravages the whole brain, essentially through the cortical grey matter, and of course throughout the hippocampus, where memory lives. Some Alzheimers patients demonstrate apraxia and some might have aphasias, but the variation is tremendous. Of course as time goes on and the disease progresses, virtually all Alzheimers patients will develop expressive and receptive aphasia.
Beck: 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.
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 for older persons in nursing homes or hospitals.
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.
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 known as bipolar disorder, has a significant genetic predisposition. Importantly, not all depressions are genetic, although there can be a familial component.
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 their use. In general, preferred pharmacological treatments are with the SSRIs (selective serotonin reuptake inhibitors) or the newer non-SSRI agents. The older tricyclics such as amitriptiline (elavil) or sinequan (doxepin) are contraindicated due to anitcholinergic and cardiovascular side effects.
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.
