Austin J Clin Neurol 2015;2(5): 1048.
Baycrest Geriatric Health Care System, University of Toronto, Canada
*Corresponding author: Michael Gordon, Medical Program Director and co-director Ethics Program, Baycrest Geriatric Health Care System, University of Toronto, Toronto, Canada
Received: March 09, 2015; Accepted: May 01, 2015; Published: May 16, 2015
If one depended on the popular media to form opinions about medical conditions you might come to the conclusion that Alzheimer’s disease and other causes of dementia are the new plague, and that at least western civilizations will be brought to their knees economically and health care system-wise because of the “hoards” of those living with dementia who will overwhelm our societies. The positive aspect of organizations such as the Alzheimer Societies in virtually all western countries bringing knowledge to the public and to policy makers, is sometimes countermanded by what at times seems to be a mixture of public hysteria and media crises generation as the statistics enumerates those with the disease entities and those at risk of developing the conditions that fall under the umbrella of the dementia diagnosis.
The potential impact from the clinical, social, economic and ethical perspectives was highlighted in a recent book by that describes what in essence is the “perfect storm” of confluence of the increase in the aged population, the apparent increase in the prevalence of dementia (which in many ways merely mirrors the first population age increase) and the popularization of the ethically principled autonomy movement, which has resulted in the legalization of assistance in dying with Canada being the most recent western country in which the prohibition on assisted suicide was overturned by the Canadian Supreme Court.
Challenges exist of course at the macro level as each society tries to cope with many aspects of the health and well-being of their populations. With each apparent epidemic the dire warnings come out and everyone mobilizes for “the worst”. I recall as a young teenager when polio was rampant in the United States that we were warned about congregating in groups or swimming in the neighbourhood swimming pools which during the summer months in Brooklyn was quite an imposition during the very hot and humid days that were common in the early 1950’s. The newsreels in the movies often showed clips of large arena sized rooms filled with iron lungs, tending to the many thousands of afflicted children. Who among the ordinary public or even public policy officials would imagine that within a few years, polio outbreaks would be a thing of the past as the Salk vaccine became available in 1955 and mass inoculations began with astounding results . The iron lungs became historic curiosities within a few years. How ironic that contemporary anti-vaxxers seem to have forgotten or just ignore the lessons of history as they make outrageous claims against the practice of universal vaccination.
While the future results of research into the aetiology and possible treatments of all the components of dementia syndromes are sought, at least we in the front-line of medical practice can greatly assist our patients and families come to terms with the various stages of clinical dementia, in terms of proper assessments, holistic approaches to therapy which looks at the living situations of those with the syndromes, the family and other support systems and good planning for the future as the course of the condition progresses. Whether the few potentially helpful symptomatically useful drugs such as the cholinesterase inhibitors might be of value is part of that important role that physicians should ponder seriously and provide the proper clinical and epidemiological perspective on this class of drugs, being neither erroneously nihilistic or excessively optimistic about the potential benefit in any given patient.
As part of the current process of planning as an individual with preferably appropriate professional guidance, the process of advance care planning should be carefully considered as part of the total process in the same way that most people are careful to formulate their wills; yet we know that many unfortunately do not. With all the recent focus on what is now called advance care planning (ACP) in the medical, legal and social work literature, it is important for people especially middle-aged and older people to understand what is at stake. Using the old terminology of a “living well” there has been a transformation from what used to be a few words in a document somewhere or as a conversation with the family member likely to be the SDM that for example the parent “would not want any heroics” if they develop a terminal illness.
The reality is that is no longer enough to help those empowered to make such decisions on your behalf. The new world of medicine has many things that can be done that are no longer considered “heroics” but just part of contemporary every day medicine. So a number of suggestions are in order: 1) make sure an SDM (Substitute Decision- Maker or Proxy) can honestly and emotionally carry out one’s wishes; 2) try to be specific about those life-prolonging interventions that for sure would not be wanted-such as a permanent feeding tube if the subject in question is not conscious enough to appreciate food or one’s loved ones; 3) make sure in addition to writing a document, having the conversation with the advance directive’s contents and intention with those who are appointed as one’s SDM; 4) obtaining advice from a trusted doctor and lawyer as what might be wanted to include and how to frame a document if one is desired to be written.
Within all the research that is mostly directed to earlier and early diagnosis with bio-markers and cognitive screening tests, there is good news that should not be ignored. There is a growing body of evidence that supports the contention that the same life-style modifications that have been espoused for cardio-vascular disease for decades seems to be at least as effective in decreasing the incidence of dementia-syndromes. A recent study published in the Lancet  supports the observation that telling our patients and the general public that improved life style to decrease vascular risk factors can be instrumental in decreasing the risk of dementia-syndromes can potentially part of the solution to a societal in addition to an individual problem and change the perception of a “coming plague” to another medical challenge to address and then overcome.
With persistence and careful analysis and investigations in many domains, it is possible that one day in the not-too-distant future, Alzheimer’s disease and other dementias will decrease in prevalence so that like polio-myelitis will be a condition of distant past rather than a terrifying present.