Turning The Brain Back Ten Years And Slowing The Decline

I first found out about this list of so-called “Influential Doctors“ in the USA Today newspaper and did not finish the article before I became aware of two powerful realities: 1. This list does not sound like it will help people who need a doctor, but more likely it will benefit someone else in the health care industry.  2. Nobody compiling a list of influential doctors is going to add me because I’m a professional pain in the rear-end of the other doctors on the list.

It sounds like one of those times when somebody is making money from patients pockets by marketing drugs or services, via insurance companies or drug companies. 

Hello “parasite!”  Hello person-making-money-from-sick-people without adding “value” to healing them.

Hmmmm …. who could be behind this? Marketing? Pharmaceutical marketing?

Pretty transparent stuff.  Let us look a little closer at what is going on.

This “Influential Doctors” database is written up in the newspaper subsequent to two interviews with Alzheimer’s experts.

The first interview is with Ron Peterson, “a leading researcher” who runs Mayo Clinic center, talking about the way to diagnose Alzheimer’s.  The article labels this “a problem critical to solve.” 

Somebody gives this doctor a title as “a leading researcher” (where? In the US?  In his specialty?  In the Mayo Clinic?)”

And the project they are working on is labeled “a problem critical to solve.”

Please don’t think I’m unsympathetic to what is generically called “Alzheimer’s” — broadly applied to diminished cognitive function at any age.  I’ve worked with it extensively and consider it a very serious consideration for everybody who expects to live to a ripe old age.

My pet peeve is with the usage of labels.

Labels.  Every mature adult has a decline in cognitive ability.  We measure it starting at 30 or so when people start forgetting where they parked their car at the mall.  I have learned recently that in Japan it is considered to start at 20 or so.

We know that people who are genetically “chosen” to be more likely to get a more rapid decline exist, and we can test for this genetically. Insurance has never paid for this test — to my knowledge — although the test is not extremely expensive (a few hundred bucks for an admittedly imperfect but reasonably predictive result).

The fancy, impressive medical term is apolipoprotein E allele testing.  I have offered this test to plenty of patients, and never found a single one who actually followed through on it.

What Alzheimer’s means, when it is diagnosed, is that attention, memory and some other things we group into “cognitive functions” are slipping away faster and more acutely.  So we get the prescription drugs, which are not without risk — headaches, confusion, dizzyniess, fatigue and sometimes hallucinations –and sometimes the drugs work, but sometimes they don’t.

When the patient continues to decline and becomes psychotic and/or aggressive, the next line of medications given is usually antipsychotics.

Ironically, the main risk from these medicines (besides cerebrovascular events and movement disorders) is –cognitive decline.

Alzheimer’s is largely preventable, or at least it can  be delayed enough so that the patient ends up dying from something else first.

I know I don’t qualify for it as a diagnosis, but I am not going to sit around waiting until I meet this set of criteria, if I ever do.  Everyone who discusses this issue with me usually gets my favorite quote from the poet Dylan Thomas:“Do not go gentle into that good night; rage, rage against the dying of the light.”

Age can be fought, with both efficacy and panache, with everything from new activity menus to over the counter supplements.  We all have cognitive decline to fight, and there are lots of reasons, from traumatic brain injury to prescription medications, that cognitive loss is a problem — a big social problem.

The USA Today article also included a brief interview with Dr. Julie Schneider of the Rush Alzheimer’s center in Chicago.  Patient are referred to her because their doctors are unsure of the diagnosis.

AAAAUUUGGGHHH!!!!

Doctors today seem notoriously bad at diagnosis.  That probably accounts for the popularity of the TV series “House, MD.” Every episode of that show for the past six years has been a race to find a correct diagnosis — while plowing through a dozen or so wrong diagnoses.

The most common question I get from a new patient is “Why didn’t my last doctor (or all my other doctors) know that/find that out/tell me that?” And then they tell me I am a real-life Dr. House.  (Except I’m nice and touchy-feely instead of crochety and sarcastic).

This reminds me of my beloved brother-in-law of blessed memory.  He was a man in the mold of a young John Wayne — a macho, rugged man who loved re-enacting frontier life and portraying a mountain man.  His hobbies included shooting guns, sharpening large knives, and throwing tomahawks at targets.

But the last time I saw him, he was a shadow of himself, dying from colon cancer.  His chemotherapy had caused him great pain and anguish (as if the cancer had not provided enough) and I offered him some alternative treatments that — if not able to actually cure the cancer — could ease his pain and help the horrible side-effects of his treatment.

He declined.  He said he figured he was getting along pretty well, since his doctor told him he was coming along about as they expected.

As far as I could figure, that meant that he was dying according to schedule. 

He trusted his doctor and declined any other treatment as graciously as he could, leaving my husband and me feeling devestated.  He lived his last days stoicly, as John Wayne did in the movie where he died defending The Alamo.  He died right on schedule and the doctors must have thought they had another success.

I never cared about his progression (or was it a digression?).  The doctors tracked the stages of his illness and charted various vital signs and blood tests.  Their only worry was to keep him alive as long as they could — not to make him better or to make the quality of the rest of his short life any better.

Jump forward a few years to today — when we have “influential doctors” who have to do cross-cultural tests to see when a label of Alzheimer’s is appropriate appropriate to hang on a patient.

I trained in an era when a “real” diagnosis of Alzheimer’s could be made only by brain biopsy (I did some) or autopsy.  I can tell you, after seeing the pathology (microscope slices from suffering brains) several times, the difference between what we call Alzheimer’s and what we call cognitive loss for age is only one of degrees.  The lesions, the brain changes, are exactly the same.

I have worked with some cracker jack neuropsychologists who can diagnose the intensity of a cognitive loss for age — that is, tell the difference between aging and “Alzheimer’s — with pencil and paper tests.  Luckily we don’t see too many examples of honest-to-goodness Alzheimer’s as Alois Alzheimer first described it, in the mid-fifties.

It’s not pretty and it’s extremely incapacitating.

There are great prevention programs available.  My personal regimen is wildly effective, and I’m staking my most valuable resource (my razor-sharp mind) on a bunch of supplements and “brain games” validated by scientists.  My mental workout is tough stuff, but my brain stem cells are working overtime replacing those dead cells and re-establishing neural pathways that might have gotten tangled or lost.

Of course I have given elements of such a program to my patients, although I can’t say who listens and does what I say unless they stay in my care.

But I’m mostly aware of results when I’m looking out for Number One.  My brain; according to my self-tests, it is getting younger — something which amuses me no end.

I will not sit around and wait for a diagnosis, nor rely on treatment.  I “rage against the dying of the light” every day, every chance I get. 

Every patient is more like their doctor than different.  In the case of mental illnesses (I still consider Alzheimer’s under that moniker) us doctors and treating personnel, we live twenty or thirty years longer than our patients.

That is not fair.  Patients have to ask us what we are doing, at least.  They have to get informed, try harder, realize they may be serving a system, not themselves.

I suppose that when the diagnosis is made, people get more home health care and other kinds of benefits, but with an implied prognosis that things won’t get much better.  I am sure that somebody gets something.  I am also sure that the gold standard that people really want is clarity of diagnostic criteria to justify the prescription of the drugs, or else there would not be pharmaceutical folks working on the list.

I had not been a doctor for very long — as a matter of fact I was still a student — when I assimilated the concept of “working diagnosis.” You get to know people better sometimes; you may have to, as a physician, before you can tell if they really fit criteria.  You try to find truth.  I have surely tried, and there have been times it did not work.

In the Qforma list, it sounds — at least from these most influential doctors — as if we are looking for meeting of diagnostic criteria, and as if the reason for doing this has something to do with pharmaceutical marketing, which seems to be financing the research both of these “influential” doctors are doing.  They are part of institutions, and one could argue it is part of their jobs.

I have a strong memory, early in my professorial career, at a Midwestern university of a particular patient. He was in his early twenties and living on the streets.  He ended up in my clinic because he couldn’t get treatment anywhere else — he no money, no insurance and didn’t qualify for any of the welfare programs.

His symptoms were pretty generic –treatment-resistant depression with a little paranoid psychosis. I did a neurological exam but I could not get a phone call back from the neurological clinic.  They refused to see him because nobody would pay.

Given his homelessness and age and his grab-bag of symptoms, everyone assumed his problem was drugs.  That wasn’t a diagnosis — just a stereotype to put a label on his peculiarities.

It was an older nurse who took my hand and walked me to the front desk of the neurology department.  They asked me for the diagnosis.  She motioned to me that I should be quiet.  I thought diagnoses were, well, a doctor thing, but she was old and mad and powerful so I shut up.  She said his diagnosis was “rule out muscular dystrophy” and he was given a clinic appointment immediately.

As soon as we got out of that office I told her there was nothing — I mean nothing — wrong with his muscles.

She told me “If we say there is, he is one of Jerry’s kids, and if he is one of Jerry’s kids, they will pay for the workup.  So you are going to shut up and they probably won’t even bother telling the chief you are a rotten neurologist, because they think all psychiatrists are rotten neurologists, but this is the only way this workup is going to get done.”

Okay, so they are diagnosing, and that is their pressure and their choice.  Doctors covering their tushies, looking for data to justify insurance payments for drugs.  I cannot read this group, and what these people say, any other way.

Look, I had an Alzheimer’s type patient recently, in her 80s, recent decline.  With nothing but supplements, daughter told me I had “rolled back her life” ten years and she was gardening, going out with groups, and having a grand old time.  Another daughter insisted on insurance and mainstream medicine, removed my supplements, and gave prescription drugs.  Within a week the patient had declined and was messing her pants.  She had gone from winning at canasta to wearing diapers.

Of course, the daughter who had consulted me and trusted me was heartbroken, and we mourned together.  But finances being what they are, this is what life is like.

You won’t find me on any “influential” list.  Like most of the profession I was once proud of, these folks have become parasites on needy and hurting people.

I can’t be “influential” — I’m considered a renegade doctor.

And PROUD of it!