Prof. Dr. Lutz Frölich
Head of the department for Geriatric Psychiatry at the Central Institute of Mental Health (ZI) Mannheim
Interview of December 19, 2008 with Dr. Birgit Teichmann
Alzheimer’s Disease begins gradually and almost undetectable. Often one does not find the car in the parking lot or repeatedly misplaces important objects like the house keys. Additionally one suffers from amnesic aphasia (Word-finding difficulty) and difficulty in areal and chronological orientation. Also the people concerned are irritable and less resilient but long term stress and geriatric depression can also lead to similar symptoms.
How does one or his relatives recognize that he suffers from dementia even though some symptoms can be the result of stress or the normal aging process of the brain?
That is true, those are difficult decisions for individual cases. The bottom line with the Alzheimer’s disease is that the dysmnesia (disturbance of memory) is the central point. Ultimately the most important is the feedback, also from relatives. If they say: “Goodness, I have been telling you this for the third-fourth time”. Things repeat themselves, the forgetfulness repeats itself in the daily routine. The question if it is Alzheimer’s disease can only be determined through a good, special medical examination. Especially at the early stages the symptoms are inconclusive, particularly in classification to depression. Different dementias to the Alzheimer’s disease have often a personality change or a deceleration more distinctive than the forgetfulness. In addition to a special medical diagnosis, it is recommendable to visit a memory assessment clinic if one is nearby. Through additional clinical examination, through neuropsychological tests and machine-aided examination procedures a clarification is possible.
At the early stages of the Alzheimer’s Disease, do the persons concerned recognize that something is wrong with them or are the relatives more attentive?
That is very differential, lately it has been indentified that the patients themselves have own experiences of the disease and are not just passively subordinated, without realisation. Most patients complain about forgetfulness, they realize that something has changed. But in most cases they refer their symptoms to the normal aging process and do not think that it can be a form of a disease. Foremost it is still the confusion of the term and also of the age stereotypes: In old age everything gets worse, gets less, and it has not raised the awareness of the population that the life impeded forgetfulness is a disease and not the normal aging process.
How is Alzheimer’s disease diagnosed to differentiate it from other forms of dementias?
Through good clinical examination, neuropsychological tests and a series of laboratory and instrumental examinations. When it is diagnosed that is a form of dementia, then it has to be determined what the cause of this dementia syndrome is. New scientific tests have been introduced consistently and first examination results show that it can be clearly differentiated between healthy people and Alzheimer patients. The problem with the first, very promising results is, that the conclusions were drawn from a distinct examined population. In comparison there are very healthy people, at comparable age of course, and so on but otherwise without any further physical diseases, without ambiguous results, so that it is not a comparison group by experience. This group goes into comparison with clearly diagnosed Alzheimer patients. If this test is going to be reliable in general practice, is going to show by large multi-centrical examinations with a very diverse natured control-population, thus healthy, sick physically sick and so on. And of course especially in the cases in which it was not possible to classify the individual diseases. Of course at first one is scientifically excited to see such procedures and results but it is still a long way until it is released into practice similar to the pharmaceutical development.
How does the therapy work presently?
The therapy is affected by 10 years of neurotransmitter based therapy approach, which actually apply to the last progression of the biological-molecular changes of the brain. For the treatment of Alzheimer’s disease it particularly changes the neurotransmitter Acetylcholin and Glutamate in a certain way, so that this leads to a better function of the tissue.
All innovative medication that has been developed in the last 5 years have not been successful. Meaning all methods which apply more to the etiology of the disease and more to the initially damaging agents. Through the outstanding findings of the fundamental research of the development of Alzheimer’s disease, there has been new therapeutically useful mechanisms detected, e.g. on the level of the anti-amyloid strategies, e.g. on the metabolized enzymes for the beta-peptides to the immunity appendage against deposit and also the development of the toxic peptides. There are currently a number of clinical tests with innovative substances in different stages of development, so there is hope that in a few years, more effective treatment will be available to what is presently provided.
So that means, the therapy and medication is not particularly effective at the moment?
Moderately affective but overall convincing. Even after critical assessment of the individual benefits, the approved medication is useful to the patient. So the time of the therapeutical nihilism is surely over. More of a problem these days is the non acceptance of the medication by doctors and patients who are still under the preconception to confuse age with disease and therefore do not see the necessity of treatment for dementia. In single cases it is also difficult to recognize slow deterioration or a standstill of symptoms over a longer period of time, as a successful therapy. The medication is an option for the patient and his relatives to “take a breath” for a longer period of time but it will not lead to a decrease of the symptoms.
And not a cure?
Certainly not a cure!
If Alzheimer’s disease is not curable, what is the point of early diagnosis? To assure a longer quality of life?
The medical science of our time is naturally and primarily confronted with not curable diseases, all widespread diseases are really incurable. There are a few answers to your question. First, it is always good to have clarity of a situation and for the mature patient it is a great plus to have the ability to determine their own destiny. Secondly, through the explanation of the diagnosis – and the clinical experience is very clear on that- it leads to a decrease of stress in the system of the family. That eases the use of own resources of the patient. The whole treatment, medication, consultation and information about the disease, stabilises the situation of the patient and his family and assures not only a better quality of life, but especially a better functioning of everyday life. At last, after an early diagnosis there are specifically useful risk-modifications, which might delay the progress of symptoms. So what is usually recommended for risky patients without symptoms, namely real prevention and risk minimisation, might also play a role in the stage of the disease. To name physical activity or mental and psycho-social activation, which all enhance the everyday functions. And of course the treatment of so called co-morbidities, diseases that are on their own damaging to the brain can decrease the mental performance especially in relation to the Alzheimer’s disease. The consumption of alcohol, Diabetes Mellitus, high blood pressure, dysfunction of the lipometabolism to name a few. I believe there are many reasons to conduct real early diagnosis and foremost early intervention.
You mentioned prevention. How can one protect himself from Alzheimer’s disease?
There are a few brain specific approaches which have a neurobiological plausibility, namely the promotion of synaptic plasticity. Those are physical movement, social interaction, mental activity alongside of course general preventive behaviour which has to do with the disease, and also damages the brain. To mention primary the cardiovascular risk factors. Unfortunately the overall situation is unclear. There are very conclusive epidemiological studies which show the risk and protection factors but the absence of intervention studies which prove the positive effect of a treatment with these factors on healthy, elderly people or risk groups. If the influence on these risk factors really lead to an adjustment of the appearance of Alzheimer’s disease, needs to be determined.
What do you think about the intake of statins, Omega 3 fatty acids or other matters of prevention?
At the moment there are corresponding clinical studies, we ourselves have a germany-wide study on the effect of statins at light, cognitive disorder. There are currently two international studies on the relevance of omega 3 fatty acids on such risk populations. The results we will see in a few years. So at the moment we only have clues that these substances can be helpful but no evidence that they are really effective.
Finally a few practical tips: When someone notices something wrong with him, does he go to the family doctor to clarify the problem? Does he go to one of the memory assessment clinics? What are the possible ways?
The medical landscape in Germany is very variable. In our region we are very fortunate to have a few good memory assessment clinics which are specialised with the detection of light forgetfulness as well as in Heidelberg and Mannheim at the Central Institute. But foremost the family doctor is the first contact. There a family doctors who intensively concern themselves with the disease, who will listen and send the patients onto a specialist if the case is indistinct. But there are still many doctors who are not open minded to this subject and do not have the knowledge in this area so that the patient often has to fight his way through the health system. One should encourage people not to accept the decrease of the mental ability, it is normal age, but to clarify these problems. Often it does not have to be Alzheimer’s disease and one is relieved of the concern
Personal Data
Lutz Frölich was born in 1956 in Neumünster. He studied medicine in Kiel, Heidelberg and also at the University of Kentucky, Lexington, KY, USA. His occupational activities brought him to Heidelberg, Würzburg and Frankfurt. Since 2003 Lutz Frölich is head of the department for Geriatric Psychiatry at the Central Institute of Mental Health (ZI) in Mannheim. The scientific emphasis of his work lies in the development and evaluation of new therapies for dementia, the research of clinical process, neuropsychological and diagnostic procedures for dementia as well as functional-imaging methods for psychiatric, age related diseases. Lutz Frölich is married and has two children. In his leisure time you will find him at the tennis court or sailing- most of the time at his favourite place- Mani on the Peleponnes in Greece.
