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Wertman E. Essential New Complexity-Based Themes for Patient-Centered Diagnosis and Treatment of Dementia and Predementia in Older People: Multimorbidity and Multilevel Phenomenology. J Clin Med 2024; 13:4202. [PMID: 39064242 PMCID: PMC11277671 DOI: 10.3390/jcm13144202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/28/2024] Open
Abstract
Dementia is a highly prevalent condition with devastating clinical and socioeconomic sequela. It is expected to triple in prevalence by 2050. No treatment is currently known to be effective. Symptomatic late-onset dementia and predementia (SLODP) affects 95% of patients with the syndrome. In contrast to trials of pharmacological prevention, no treatment is suggested to remediate or cure these symptomatic patients. SLODP but not young onset dementia is intensely associated with multimorbidity (MUM), including brain-perturbating conditions (BPCs). Recent studies showed that MUM/BPCs have a major role in the pathogenesis of SLODP. Fortunately, most MUM/BPCs are medically treatable, and thus, their treatment may modify and improve SLODP, relieving suffering and reducing its clinical and socioeconomic threats. Regrettably, the complex system features of SLODP impede the diagnosis and treatment of the potentially remediable conditions (PRCs) associated with them, mainly due to failure of pattern recognition and a flawed diagnostic workup. We suggest incorporating two SLODP-specific conceptual themes into the diagnostic workup: MUM/BPC and multilevel phenomenological themes. By doing so, we were able to improve the diagnostic accuracy of SLODP components and optimize detecting and favorably treating PRCs. These revolutionary concepts and their implications for remediability and other parameters are discussed in the paper.
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Affiliation(s)
- Eli Wertman
- Department of Neurology, Hadassah University Hospital, The Hebrew University, Jerusalem 9190500, Israel;
- Section of Neuropsychology, Department of Psychology, The Hebrew University, Jerusalem 9190500, Israel
- Or’ad: Organization for Cognitive and Behavioral Changes in the Elderly, Jerusalem 9458118, Israel
- Merhav Neuropsychogeriatric Clinics, Nehalim 4995000, Israel
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Gossard TR, Teigen LN, Yoo S, Timm PC, Jagielski J, Bibi N, Feemster JC, Steele T, Carvalho DZ, Junna MR, Lipford MC, Tippmann Peikert M, LeClair-Visonneau L, McCarter SJ, Boeve BF, Silber MH, Hirsch J, Sharp RR, St. Louis EK. Patient values and preferences regarding prognostic counseling in isolated REM sleep behavior disorder. Sleep 2023; 46:zsac244. [PMID: 36259668 PMCID: PMC9832520 DOI: 10.1093/sleep/zsac244] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/19/2022] [Indexed: 11/27/2022] Open
Abstract
STUDY OBJECTIVES Isolated REM sleep behavior disorder (iRBD) carries a high lifetime risk for phenoconversion to a defined neurodegenerative disease (NDD) including Parkinson disease, dementia with Lewy bodies, and multiple system atrophy. We aimed to examine iRBD patient values and preferences regarding prognostic counseling. METHODS One hundred thirteen iRBD patient participants enrolled in the Mayo Clinic iRBD Patient Registry were sent an email survey concerning their values and preferences concerning NDD prognostic counseling and their experiences following diagnosis with iRBD. RESULTS Of 81 respondents (71.7% response rate), the majority were men (74.0%) with an average age of 65.7 (±9.7) years. Responses indicated a strong preference toward receiving prognostic information about possible future NDD development. 92.5% of respondents felt knowledge concerning personal NDD risk was important, while 87.6% indicated prognostic discussions were important to maintaining trust in their physician. 95.7% indicated a desire for more information, while only 4.3% desired less information regarding their NDD prognostic risk. Most respondents strongly agreed that prognostic information was important to discuss with their family and friends and inform future life planning, and most expressed interest in learning more about future neuroprotective therapies and symptomatic treatments for parkinsonism and dementia. CONCLUSIONS Most iRBD patients indicated strong preferences for disclosure of NDD prognostic risk and indicated that prognostic information was important for family discussions and future life planning. Future broader surveys and qualitative studies of clinic-based and ultimately community dwelling iRBD patients' values and preferences are needed to guide appropriately tailored and individualized prognostic counseling approaches following iRBD diagnosis.
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Affiliation(s)
- Thomas R Gossard
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
| | - Luke N Teigen
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
| | - Seeley Yoo
- Mayo Center for Sleep Medicine, Minnesota, USA
| | - Paul C Timm
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
| | | | - Noor Bibi
- Mayo Center for Sleep Medicine, Minnesota, USA
| | - John C Feemster
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
- Neurology, Minnesota, USA
| | - Tyler Steele
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
- Neurology, Minnesota, USA
| | - Diego Z Carvalho
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
| | | | - Melissa C Lipford
- Mayo Center for Sleep Medicine, Minnesota, USA
- Neurology, Minnesota, USA
| | - Maja Tippmann Peikert
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
- Neurology, Minnesota, USA
| | | | | | | | - Michael H Silber
- Mayo Center for Sleep Medicine, Minnesota, USA
- Neurology, Minnesota, USA
| | - Jessica Hirsch
- Biomedical Ethics, Mayo Clinic and Foundation, Rochester, Minnesota, USA
| | - Richard R Sharp
- Biomedical Ethics, Mayo Clinic and Foundation, Rochester, Minnesota, USA
| | - Erik K St. Louis
- Mayo Center for Sleep Medicine, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Minnesota, USA
- Departments of Medicine, Minnesota, USA
- Neurology, Minnesota, USA
- Mayo Clinic Health System Southwest Wisconsin, La Crosse, Wisconsin, USA
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van der Schaar J, Visser LNC, Bouwman FH, Ket JCF, Scheltens P, Bredenoord AL, van der Flier WM. Considerations regarding a diagnosis of Alzheimer's disease before dementia: a systematic review. Alzheimers Res Ther 2022; 14:31. [PMID: 35144684 PMCID: PMC8829985 DOI: 10.1186/s13195-022-00971-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The NIA-AA research framework proposes a purely biological definition of Alzheimer's disease (AD). This implies that AD can be diagnosed based on biomarker abnormalities, irrespective of clinical manifestation. While this brings opportunities, it also raises challenges. We aimed to provide an overview of considerations regarding the disclosure of AD pathology before the onset of dementia. METHODS A systematic literature review was conducted and reported according to PRISMA guidelines. We searched PubMed, Embase, APA PsycINFO, and Web of Science Core Collection (on 10 December 2020) for references on conveying AD biomarker results to individuals without dementia. Our query combined variations on the terms Alzheimer's disease, disclosure, or diagnosis, preclinical or prodromal, and biomarkers. Two reviewers independently screened the resulting 6860 titles and abstracts for eligibility and examined 162 full-text records for relevance. We included theoretical articles in English, on communicating amyloid and/or tau results to individuals with mild cognitive impairment, subjective cognitive decline, or normal cognition. MAXQDA-software was used for inductive data analysis. RESULTS We included 27 publications. From these, we extracted 26 unique considerations, which we grouped according to their primary relevance to a clinical, personal, or societal context. Clinical considerations included (lack of) validity, utility, and disclosure protocols. Personal considerations covered psychological and behavioral implications, as well as the right to (not) know. Finally, societal considerations comprised the risk of misconception, stigmatization, and discrimination. Overall, views were heterogeneous and often contradictory, with emphasis on harmful effects. CONCLUSIONS We found 26 diverse and opposing considerations, related to a clinical, personal, or societal context, which are relevant to diagnosing AD before dementia. The theoretical literature tended to focus on adverse impact and rely on common morality, while the motivation for and implications of biomarker testing are deeply personal. Our findings provide a starting point for clinicians to discuss biomarker-based diagnosis with their patients, which will become even more relevant in light of the conditional approval of a first disease-modifying drug for AD.
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Affiliation(s)
- Jetske van der Schaar
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands.
| | - Leonie N C Visser
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands.,Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Femke H Bouwman
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | | | - Philip Scheltens
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | - Annelien L Bredenoord
- Erasmus School of Philosophy, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Wiesje M van der Flier
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands.,Department of Epidemiology & Data Sciences, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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Ursin F, Timmermann C, Steger F. Ethical Implications of Alzheimer's Disease Prediction in Asymptomatic Individuals through Artificial Intelligence. Diagnostics (Basel) 2021; 11:diagnostics11030440. [PMID: 33806501 PMCID: PMC7998766 DOI: 10.3390/diagnostics11030440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/09/2021] [Accepted: 02/25/2021] [Indexed: 11/25/2022] Open
Abstract
Biomarker-based predictive tests for subjectively asymptomatic Alzheimer’s disease (AD) are utilized in research today. Novel applications of artificial intelligence (AI) promise to predict the onset of AD several years in advance without determining biomarker thresholds. Until now, little attention has been paid to the new ethical challenges that AI brings to the early diagnosis in asymptomatic individuals, beyond contributing to research purposes, when we still lack adequate treatment. The aim of this paper is to explore the ethical arguments put forward for AI aided AD prediction in subjectively asymptomatic individuals and their ethical implications. The ethical assessment is based on a systematic literature search. Thematic analysis was conducted inductively of 18 included publications. The ethical framework includes the principles of autonomy, beneficence, non-maleficence, and justice. Reasons for offering predictive tests to asymptomatic individuals are the right to know, a positive balance of the risk-benefit assessment, and the opportunity for future planning. Reasons against are the lack of disease modifying treatment, the accuracy and explicability of AI aided prediction, the right not to know, and threats to social rights. We conclude that there are serious ethical concerns in offering early diagnosis to asymptomatic individuals and the issues raised by the application of AI add to the already known issues. Nevertheless, pre-symptomatic testing should only be offered on request to avoid inflicted harm. We recommend developing training for physicians in communicating AI aided prediction.
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Carpiniello B, Wasserman D. European Psychiatric Association policy paper on ethical aspects in communication with patients and their families. Eur Psychiatry 2020; 63:e36. [PMID: 33289623 PMCID: PMC7355125 DOI: 10.1192/j.eurpsy.2020.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment. METHODS On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified. RESULTS The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, "dual roles" enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided. CONCLUSIONS Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions.
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Affiliation(s)
- Bernardo Carpiniello
- Department of Medical Science and Public Health, Psychiatric Unit, University Hospital Cagliari, Cagliari, Italy
| | - Danuta Wasserman
- National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) LIME, Karolinska Institutet-CHIS, Stockholm, Sweden
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Zhang K, Yang Q, Fan Z, Zhao J, Li H. Platelet-driven formation of interface peptide nano-network biosensor enabling a non-invasive means for early detection of Alzheimer's disease. Biosens Bioelectron 2019; 145:111701. [PMID: 31541786 DOI: 10.1016/j.bios.2019.111701] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/27/2022]
Abstract
Soft material fabricated with DNA origami or peptide cross-linking technique may be promising theranostic platforms in the future; however, their naturally occurring counterparts, such as the peptide aggregates in the neurodegenerative diseases, constitute an increasingly burdensome issue of public health. Thus, a design of artificial peptide nano-network biosensor is conceived, in an attempt to combat the natural pathological peptides, by mimicking their pathogenesis process. Specifically, periphery platelet can secrete A-beta and induce its cross-linking & aggregation to form a surface peptide nano-network, resulting in large numbers of poly-tyrosine strands being covalently trapped in the network to serve as an efficient signal amplifier, through the electrochemical oxidation of tyrosine. This method is sensitive and quantitative in the range of normal and pathological periphery platelet distribution and can effectively discriminate Alzheimer's disease (AD) patients based on the detected potential neurodegenerative activity of platelet. These results may point to some future perspective of this method in the early screening of AD.
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Affiliation(s)
- Kai Zhang
- Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu, 214063, China.
| | - Qianlu Yang
- Department of Biochemistry and Molecular Biology, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Zhenqiang Fan
- Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu, 214063, China; Key Laboratory of Flexible Electronics (KLOFE) & Institute of Advanced Materials (IAM), Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing Tech University (NanjingTech), 30 South Puzhu Road, Nanjing, 211816, PR China
| | - Jianfeng Zhao
- Key Laboratory of Flexible Electronics (KLOFE) & Institute of Advanced Materials (IAM), Jiangsu National Synergetic Innovation Center for Advanced Materials (SICAM), Nanjing Tech University (NanjingTech), 30 South Puzhu Road, Nanjing, 211816, PR China
| | - Hao Li
- School of Biological Science and Technology, University of Jinan, No. 106 Jiwei Road, Jinan, Shandong, 250022, China.
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Tigano V, Cascini GL, Sanchez-Castañeda C, Péran P, Sabatini U. Neuroimaging and Neurolaw: Drawing the Future of Aging. Front Endocrinol (Lausanne) 2019; 10:217. [PMID: 31024455 PMCID: PMC6463811 DOI: 10.3389/fendo.2019.00217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/18/2019] [Indexed: 11/13/2022] Open
Abstract
Human brain-aging is a complex, multidimensional phenomenon. Knowledge of the numerous aspects that revolve around it is therefore essential if not only the medical issues, but also the social, psychological, and legal issues related to this phenomenon are to be managed correctly. In the coming decades, it will be necessary to find solutions to the management of the progressive aging of the population so as to increase the number of individuals that achieve successful aging. The aim of this article is to provide a current overview of the physiopathology of brain aging and of the role and perspectives of neuroimaging in this context. The progressive development of neuroimaging has opened new perspectives in clinical and basic research and it has modified the concept of brain aging. Neuroimaging will play an increasingly important role in the definition of the individual's brain aging in every phase of the physiological and pathological process. However, when the process involved in age-related brain cognitive diseases is being investigated, factors that might affect this process on a clinical and behavioral level (genetic susceptibility, risks factors, endocrine changes) cannot be ignored but must, on the contrary, be integrated into a neuroimaging evaluation to ensure a correct and global management, and they are therefore discussed in this article. Neuroimaging appears important to the correct management of age-related brain cognitive diseases not only within a medical perspective, but also legal, according to a wider approach based on development of relationship between neuroscience and law. The term neurolaw, the neologism born from the relationship between these two disciplines, is an emerging field of study, that deals with various issues in the impact of neurosciences on individual rights. Neuroimaging, enhancing the detection of physiological and pathological brain aging, could give an important contribution to the field of neurolaw in elderly where the full control of cognitive and volitional functions is necessary to maintain a whole series of rights linked to legal capacity. For this reason, in order to provide the clinician and researcher with a broad view of the brain-aging process, the role of neurolaw will be introduced into the brain-aging context.
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Affiliation(s)
- Vincenzo Tigano
- Department of Juridical, Historical, Economic and Social Sciences, University of Magna Graecia, Catanzaro, Italy
| | - Giuseppe Lucio Cascini
- Department of Experimental and Clinical Medicine, University of Magna Graecia, Catanzaro, Italy
| | | | - Patrice Péran
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Umberto Sabatini
- Department of Medical and Surgical Sciences, University of Magna Graecia, Catanzaro, Italy
- *Correspondence: Umberto Sabatini
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Abstract
SUMMARYAlzheimer's disease pathology accumulates years before the onset of clinical symptoms and has been termed ‘preclinical dementia’. Biomarkers have been developed to detect this pathology – namely, brain amyloid deposition and markers of neurodegeneration. In this article we describe these biomarkers and review the evidence for their clinical use in predicting risk both in the cognitively ‘normal’ and in those who already have established cognitive decline. We also discuss the limitations and ethical considerations of these tests and consider whether we should start incorporating Alzheimer's disease biomarkers into clinical practice. We find that, because many cognitively healthy people will have Alzheimer's pathology, and it is not clear whether this does help predict future risk of Alzheimer's disease, diagnosing preclinical dementia carries numerous ethical implications and is currently not being advocated outside research settings.LEARNING OBJECTIVES•Understand the concepts of preclinical and prodromal Alzheimer's disease and the use of biomarkers in this context•Analyse the supporting evidence for the use of biomarkers in prodromal and preclinical dementia•Apply this information to everyday clinical practiceDECLARATION OF INTERESTJ. C. H. works in the Research Institute for the Care of Older People (RICE), which undertakes clinical drug trials for drug companies. He is a sub-investigator on a number of trials (some of which involve neuroimaging and biomarkers) and principal investigator and chief investigator on two trials (neither of which involves biomarkers). All of these trials concern Alzheimer's disease or dementia. He does not receive any direct personal payment from the trials: the payment goes to RICE, which does, however, fund almost half of his post. RICE is an independent charity and separate from the University of Bristol.
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Molecular imaging in dementia: Past, present, and future. Alzheimers Dement 2018; 14:1522-1552. [DOI: 10.1016/j.jalz.2018.06.2855] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 06/02/2018] [Accepted: 06/03/2018] [Indexed: 12/14/2022]
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