Current memory clinics, what we do, what we’ve been doing for the past decades, is diagnosing patients who already have cognitive impairment, issuing a prognosis which is telling them whether their cognitive impairment will progress and at what rate it will progress, putting in place what treatment is available and rehabilitation, psychoeducation, and social support. This is the setup that works for patients who already have cognitive impairment...
Current memory clinics, what we do, what we’ve been doing for the past decades, is diagnosing patients who already have cognitive impairment, issuing a prognosis which is telling them whether their cognitive impairment will progress and at what rate it will progress, putting in place what treatment is available and rehabilitation, psychoeducation, and social support. This is the setup that works for patients who already have cognitive impairment. But the field is quickly moving towards prevention, towards secondary prevention, which is preventing the development of cognitive impairment in those persons who are at high risk but who do not yet have cognitive impairment. And this requires a radically different set of skills. First of all, you don’t do diagnosis because there’s no disease to diagnose. There are risk factors. You have to detect the risk factors. And the problem with risk factors is that you can have one, two, three, four, five, ten. With diagnosis, you in general, you have one disease, you may have two if you’re very, very unlucky, but that’s it. With risk factors you have a number of them and the risk associated with this risk factor is different. There’s weak risk factors, there’s very strong risk factors for cognitive impairment. So you have to know the weight of each risk factor in order to stratify patients into those with low risk, intermediate risk, high risk, and prioritize interventions on the risk factors.
And the other challenge is communicating the risk factors to patients. Communicating a diagnosis, it’s challenging, but it’s comparatively easy because either you have the disease or you don’t. You cannot have half Alzheimer’s disease. Either you have Alzheimer’s or you don’t. Risk factors are different. Of course you can have, or not have risk factors, but risk factors are about probabilities. They do not tell you that you have a condition. They tell you that you have higher risk of developing a condition. So what’s the risk? You have the challenge is communicating the concept of risk, which is radically different from communicating a disease, which is you have or you don’t have the condition.
And then there’s risk reduction interventions to put in place. And we have a number of strategies here. Multi-domain interventions, FINGER-like, there may be probiotic-based interventions, there may be drug-based interventions for secondary prevention in the future. And then there’s cognitive enhancement which is something different from the reduction of risk and that’s related to a request that comes from patients. Patients with subjective cognitive decline who are at risk of cognitive impairment and dementia, they want to decrease the risk, but they also ask that their cognitive performance may function better than at the present time. So the challenge is improving cognitive performance in someone whose cognitive performance is within normal limits. And there’s a number of techniques that might allow to do so. For instance, transcranial electrical stimulation.
There’s a set of skills and capabilities that are required for secondary prevention of dementia and Alzheimer’s disease that are not part of the armamentarium of current memory clinics and this is what our paper is about.
