This blog post by Dr. Sanjay Gupta (of CNN) is about the low diagnostic accuracy rate of Alzheimer’s Disease. Over 400 brain autopsies were done on Japanese-American men. “Only about half of those who had a diagnosis of Alzheimer’s before death had the brain plaques that signal the disease. The dementia in the other half appeared to have been caused by abnormal protein deposits (known as Lewy bodies), stroke-related tissue death (microinfarcts), cell damage, or some combination thereof.”
Why is an accurate diagnosis important? “Ruling out other forms of dementia may help relatives plan for future care and determine their own risk for Alzheimer’s, for instance. Accurately diagnosing Alzheimer’s is even more critical for research on potential treatments.”
As many of you know, I’m a proponent of brain donation. If anyone wants help making these arrangements, I’m happy to volunteer my time to do this. It can never be too early to make these arrangements. A gentleman with a clinical diagnosis of Dementia with Lewy Bodies died this week. His wife and I made the brain donation arrangements nearly two years ago! She was very thankful that she didn’t have to stress over these arrangements when her husband’s death became imminent or after he died. All went according to plan.
I’ve copied the short blog post below and a link to it. This news article was posted today to an LBD-related online support group.
Paging Dr. Gupta: Blog by Dr. Sanjay Gupta
February 23rd, 2011
Half of Alzheimer’s cases misdiagnosed
Roughly half of the people who are told they have Alzheimer’s disease may in fact have other forms of dementia that produce similar symptoms, according to a new study.
Doctors have known for some time that the confusion and memory loss caused by the brain lesions associated with Alzheimer’s can also be caused by other types of brain changes, such as tissue damage stemming from strokes. The study suggests that it may be even harder than previously thought to identify the source of dementia while a patient is still alive, says lead researcher Lon White, M.D.
“There are at least five different kinds of important lesions which can produce a picture that looks like Alzheimer’s,” says White, a professor of geriatric medicine at the University of Hawaii in Honolulu. “Each of those five kinds of lesions is apparently driven by its own pathologic process, and having one doesn’t protect you from having others. All are independent and all are increasing with age.”
White and his colleagues performed brain autopsies—the only surefire way of diagnosing Alzheimer’s—on more than 400 elderly Japanese-American men. Only about half of those who had a diagnosis of Alzheimer’s before death had the brain plaques that signal the disease. The dementia in the other half appeared to have been caused by abnormal protein deposits (known as Lewy bodies), stroke-related tissue death (microinfarcts), cell damage, or some combination thereof.
The researchers have since completed another 400 or so autopsies with similar results, and will present their findings in April at the annual meeting of the American Academy of Neurology. Unlike studies published in medical journals, these findings are still preliminary and have yet to be thoroughly vetted by other experts in the field.
An Alzheimer’s misdiagnosis doesn’t have immediate consequences for the patient because no treatments exist that can stop the steady progression of the disease. And the drugs that, in some people, help slow Alzheimer’s or make it more tolerable appear to work for other types of dementia, White says.
Patients and their families can nevertheless benefit from an early and accurate diagnosis. Ruling out other forms of dementia may help relatives plan for future care and determine their own risk for Alzheimer’s, for instance.
Accurately diagnosing Alzheimer’s is even more critical for research on potential treatments. Without knowing precisely who has Alzheimer’s, pharmaceutical companies that have been developing new drugs “are not going to be able to see a true assessment of how effective their drug is,” White says.
Some promising advances in diagnosis have been made recently. A study published last year found that spinal fluid tests can predict Alzheimer’s with a high degree of accuracy, and the Food and Drug Administration is currently weighing the approval of a brain scan that uses dye to highlight the plaques characteristic of Alzheimer’s. The reliability of these methods needs to be confirmed, however.
“Everybody knows we need to do a better job of diagnosing,” says Maria Carrillo, Ph.D., the senior director of medical and scientific relations at the Alzheimer’s Association, a research and advocacy organization based in Chicago. “We are all trying to make that diagnosis better, earlier, faster. All of those things are currently under way in terms of research study.”
This news article, written for laypeople, is about how disordered proteins spread from neuron to neuron in Huntington’s Disease, and probably in other diseases as well (such as PD, AD, PSP, and CBD). What seems to be new here is a confirmation that the misfolded protein spends part of its time outside neurons as this “opens up the possibility for therapeutics.”
February 18, 2011
Stanford researchers study how disordered proteins spread from cell to cell, potentially spreading neurodegenerative disease
Misfolded proteins can get into cells and form large aggregates by recruiting normal proteins. These aggregates are associated with neurodegenerative diseases. Stanford biology Professor Ron Kopito has found that the protein linked to Huntington’s can spread from one cell to another. His research may explain how these diseases spread through our brains, an understanding that might lead to the development of drugs to target the misfolded proteins.
By Sandeep Ravindran
One bad apple is all it takes to spoil the barrel. And one misfolded protein may be all that’s necessary to corrupt other proteins, forming large aggregations linked to several incurable neurodegenerative diseases such as Huntington’s, Parkinson’s and Alzheimer’s.
Stanford biology Professor Ron Kopito has shown that the mutant, misfolded protein responsible for Huntington’s disease can move from cell to cell, recruiting normal proteins and forming aggregations in each cell it visits.
Knowing that this protein spends part of its time outside cells “opens up the possibility for therapeutics,” he said. Kopito studies how such misfolded proteins get across a cell’s membrane and into its cytoplasm, where they can interact with normal proteins. He is also investigating how these proteins move between neuronal cells.
The ability of these proteins to move from one cell to another could explain the way Huntington’s disease spreads through the brain after starting in a specific region. Similar mechanisms may be involved in the progress of Parkinson’s and Alzheimer’s through the brain.
Kopito discussed his research Friday at the annual meeting of the American Association for the Advancement of Science in Washington, D.C.
Not all bad
Not all misfolded proteins are bad. The dogma used to be that all our proteins formed neat, well-folded structures, packed together in complexes with a large number of other proteins, Kopito said. But over the past 20 years, researchers have found that as much as 30 percent of our proteins never fold into stable structures. And even ordered proteins appear to have some disordered parts.
Disordered proteins are important for normal cellular functions. Unlike regular proteins, they interact with only one partner at a time. But they are much more dynamic, capable of several quick interactions with many different proteins. This makes them ideal for a lot of the standard communication that happens within a cell for its normal functioning, Kopito said.
But if some of our proteins are always disordered, how do our cells tell which proteins need to be properly folded, and which don’t? “It’s a big mystery,” said Kopito, and one that he’s studying. This question has implications for how people develop neurodegenerative diseases, all of which appear to be age-related.
Huntington’s disease is caused by a specific mutated protein. But the body makes this mutant protein all a person’s life, so why does that person get the disease in later adulthood? Kopito said it’s because the body’s protective mechanisms stop doing their job as we get older. He said his lab hopes to determine what these mechanisms are.
A bad influence
But it’s clear what happens when these mechanisms stop working – misfolded proteins start recruiting normal versions of the same protein and form large aggregations. The presence of these aggregations in neurons has been closely linked with several neurodegenerative diseases.
Kopito found that the mutant protein associated with Huntington’s disease can leave one cell and enter another one, stirring up trouble in each new cell as it progresses down the line. The spread of the misfolded protein may explain how Huntington’s progresses through the brain.
This disease, like Parkinson’s and Alzheimer’s, starts in one area of the brain and spreads to the rest of it. This is also similar to the spread of prions, the self-replicating proteins implicated in mad cow disease and, in humans, Creutzfeldt-Jakob disease. As the misfolded protein reaches more parts of the brain, it could be responsible for the progressive worsening of these diseases.
Now that we know that these misfolded proteins spend part of their time outside of cells, traveling from one cell to another, new drugs could target them there, Kopito said. This could help prevent or at least block the progression of these diseases.
Kopito is currently working to figure out how misfolded proteins get past cell membranes into cells in the first place. It is only once in the cell’s cytoplasm that these proteins can recruit others. So these studies could help find ways to keep these mischief-makers away from the normal proteins.
He is also collaborating with biology Professor Liqun Luo to track these proteins between cells in the well-mapped fruit fly nervous system. In the future, Kopito said he hopes to link his cell biology work to disease pathology in order to understand the role misfolded proteins play in human disease.
Sandeep Ravindran is a science-writing intern at the Stanford News Service.
Despite the fact that this is a publication of the Lewy Body Dementia Association (LBDA), much of this publication applies to those with all neurodegenerative disorders, not just Lewy body dementia (LBD). Very little of this publication is specific to LBD — really only the mentions of LBD symptoms (including hallucinations and delusions) are specific to LBD.
A new webpage was posted a week ago to the LBDA’s website (lbda.org); it addresses the role of palliative and hospice care. Here’s a link to the webpage and the text from it.
The Role of Palliative and Hospice Care in Lewy Body Dementia Lewy Body Dementia Association February 14, 2011
What is Palliative Care?
The Clinical Course of Lewy Body Dementia
What is Hospice Care?
Comparison of the Features of Palliative and Hospice Care
What to Ask When Choosing a Hospice?
Additional Resources and Reading
Lewy Body Dementia (LBD) is a progressive neurodegenerative disease with cognitive, motor, sleep, and behavioral symptoms. Because these symptoms are similar to those of Alzheimer’s and Parkinson’s disease, it can take some time to correctly diagnose LBD. Once the diagnosis has been made, families go through a process of adjustment as they come to understand more about LBD symptoms and treatments and as they try to anticipate what the future will hold. Because there is no cure, it is important for families and physicians to focus on helping people with LBD maintain the highest possible quality of life. In addition, families need emotional support and guidance in their roles as caregivers and advocates. Palliative care and hospice programs have an important place in helping families to achieve these goals.
What is Palliative Care?
The goal of palliative medicine is to improve quality of life by relieving the symptoms of disease. Accepting palliative care services does not mean that someone has given up hope of a cure. Instead, it signifies recognition that the quality of one’s life is as important as its duration. Generally speaking, palliative care can benefit people of any age at any stage of illness, whether that illness is curable, chronic, or life-threatening. For example, patients with cancer, multiple sclerosis, or emphysema can be helped by palliative care. It is important to note that patients can receive palliative care while actively pursuing curative treatment for their conditions. In the early and middle stages of LBD palliative care can be handled by the individual’s regular primary care physician and specialists. All LBD symptoms, such as constipation, sleep disorders, and behavioral problems, should be evaluated for their impact on the quality of life of the person with LBD and the primary family caregiver.
Palliative care has an especially important role in LBD because, by default, all current treatments focus on ameliorating symptoms rather than achieving a cure. And because of the multi-system nature of LBD, physicians from different specialties may be providing clinical care for the person with LBD; palliative care providers can coordinate the care provided by multiple physicians and help patients and caregivers express their feelings about which symptoms should be given priority. Another important aspect of palliative care is developing ongoing dialogue between the patient, family, and palliative care providers about whether interventions such as feeding tubes should be used as LBD progresses. Palliative care encourages early discussions about the creation of living wills and advanced healthcare directives.
Palliative care is available in a variety of settings including hospital-based programs as well as programs in skilled nursing and assisted living facilities. For patients who live at home, palliative medicine clinics also provide care on an out-patient basis. Palliative care providers work in concert with the primary care and specialist physicians who treat patients’ LBD and any other conditions they have. The palliative medicine specialist works with a team that typically includes nurses, social workers, physical therapists, dieticians, and pharmacists. The goals of this team are to provide:
* Relief from troubling symptoms
* Assistance in medical decision making
* Emotional and spiritual support
* Care coordination
Using a team-based approach incorporates multiple perspectives on patient care; facilitates communication amongst all health care providers; and creates an effective structure for problem solving. To find a palliative medicine specialist, ask a physician or local hospital for a referral or consult the American Board of Hospice and Palliative Medicine’s website though the link provided in the Resources section at the end of this article.
Many types of health insurance cover the costs of palliative care. Although neither Medicare nor Medicaid recognize the term “palliative care,” these programs do cover some palliative care medications and treatments as they do other medical care. The palliative care provider will bill Medicare Part B or Medicaid, but the patient or family may be responsible for co-payments or other fees. Ask the palliative care provider about these fees and ask for a fee schedule before beginning to receive care. Similarly, many private health insurers and managed care plans as well as long-term care plans provide some coverage for palliative care. Before beginning palliative care, ask the insurer about the extent of coverage provided.
The Clinical Course of Lewy Body Dementia
The way in which LBD progresses varies from person to person. Some people experience a gradual worsening of LBD symptoms, while others experience periods of more rapid decline. Often LBD cognitive and behavioral symptoms worsen temporarily, because of pain, infection or other medical problem, but may improve once the problem is resolved. And while some LBD treatments may lesson certain symptoms for a period, there is no cure for LBD. The average duration of LBD (from the time of diagnosis to death) is 5 to 7 years.
The initial symptoms of LBD can vary by the individual, and may include either visual hallucinations, acting out dreams or other sleep disturbances, cognitive impairment, or parkinsonian motor signs (these signs include tremor, rigidity, and problems with balance and movement). In general, the symptoms of LBD get worse as the disease progresses over a period of years, but there may be times when symptoms suddenly become much worse or mental abilities may fluctuate unpredictably. Medications that have anticholinergic or antipsychotic properties should be used cautiously, if at all, and may cause sudden and sometimes severe deterioration. In the later stages of the disease, people with LBD are not able to do the basic self-care activities such as bathing, dressing, or toileting and often have increasing difficulties with movement that can affect walking, talking, and swallowing. These more severe problems also make it more difficult for the person with LBD to communicate or participate in activities and may cause weight loss, aspiration pneumonia, or falls that result in broken hips or wrists. When a person with LBD needs constant care to meet their basic needs (like feeding and toileting) and their quality of life is greatly reduced, it is an appropriate time to consider a hospice program.
What is Hospice Care?
A great deal of overlap exists in the ways in which palliative care and hospice care are organized and provided, as outlined in the table below. The primary difference is that hospice programs are intended for people who are in the later stages of an incurable illness that has progressed to the point where providing basic supportive care and measures to ensure comfort take precedence over treatments that attempt to slow disease progression. The goal of hospice care, like palliative care in general, is to offer relief from pain and other symptoms for the patients, while providing emotional support to patients and their families.
Comparison of the Features of Palliative and Hospice Care
Goal Palliative Care: Pain relief and symptom control; Emotional support Hospice Care: Same
Curative treatments Palliative Care: Curative treatments continue as long as individual desires Hospice Care: Curative treatments cease
Eligibility restrictions Palliative Care: None Hospice Care: Physician must certify that individual is unlikely to live more than 6 months
Team Palliative Care: Palliative care doctor; Primary care and specialist physicians; Nurses; Physical therapists; Dieticians; Social workers; Pharmacists Hospice Care: Same as Palliative Care team plus: Home health aides; Chaplains; Volunteers
Interventions Palliative Care: Interventions to alleviate pain and symptoms Hospice Care: Interventions to alleviate pain and symptoms, may be more aggressive
Coverage Palliative Care: Medicare Part B; Medicaid; Most private health insurance; Patient/family responsible for co-payments, deductibles, or other fees Hospice Care: Medicare Part A; Medicaid covers in 45 states; Most private health insurance; Patient/family responsible for small co-payments
While there are no restrictions on who can receive palliative care, hospice care has some eligibility restrictions. The patient’s doctor and the hospice’s medical director must certify that the individual has a terminal illness and has six months or less to live if the illness is allowed to run its course. To receive Medicare’s hospice benefit the patient also must be eligible for Medicare Part A, agree to choose hospice care instead of regular Medicare benefits to treat the terminal illness, and receive care from a Medicare-approved hospice program.
Like palliative care, hospice care teams consist of specially-trained nurses, physicians, social workers, physical therapists, dieticians, and pharmacists. However, the hospice team will also usually include chaplains and volunteers. In addition, a home health aide may come to assist with bathing, dressing, or feeding. Most hospice care is provided in the patient’s home. However, there are hospice programs located in many assisted living and skilled nursing facilities as well as hospital-based and residential programs.
The interventions provided by the hospice team are similar to those previously described for palliative care, but they focus more on keeping the person comfortable in the later stages of their disease. For example, hospice nurses will teach family members how to provide comfort feeding for individuals who have difficulty swallowing, a common symptom in late-stage LBD. Also, hospice physicians may suggest periods of palliative sedation for individuals with LDB who suffer from severe hallucinations or delusions and are severely agitated and cannot sleep.
Hospice care is covered under the Medicare program. If an individual has Medicare Part A, then he or she is entitled to receive hospice services. The way in which hospice services are arranged and paid for under Medicare is more like
a managed care plan than traditional fee-for-service Medicare. This can cause some confusion about what the Medicare hospice benefit will and will not cover. When a person elects to receive Medicare’s hospice benefit and is admitted to a Medicare-approved hospice program, that program receives a fixed payment for each day of that person’s care (a per diem). In return, the hospice program must provide all the care needed for that person’s terminal illness. This includes:
* Physician services
* Nursing care
* Medical equipment (such as a hospital bed or wheelchair)
* Medical supplies
* Medication to control pain or other symptoms
* Hospice aide and homemaker services
* Physical and occupational therapy
* Speech-language pathology services
* Social worker services
* Dietary counseling
* Grief and loss counseling
* Short-term inpatient care (if pain or other symptoms cannot be controlled at home)
* Short-term respite care (up to 5 days at a time)
Out-of-pocket costs for hospice under Medicare are minimal. There is a $5 copayment for each prescription medication and, if inpatient respite care is needed, there is a charge of 5 percent of the Medicare-approved cost of the stay.
Medicare does not permit hospice programs to pay for some services including:
* Treatments to cure terminal illness
* Prescription medications to cure terminal illness
* Care from a hospice provider that was not arranged by the hospice care team
* Room and board in a nursing home, assisted living facility, or residential hospice
* Emergency room or inpatient hospital care or transportation in an ambulance unless these services have been arranged by the hospice team or are unrelated to the terminal illness
If individuals need care for other health problems that are not related to their terminal illness, then this care is not paid for out of the hospice payment but is covered by their regular Medicare benefit. Individuals may continue to see their regular primary care physician and other health care providers for conditions unrelated to their terminal diagnosis (a podiatrist, for example).
Hospice care also is covered by most private insurance carriers, but check the plan’s benefits to determine the extent of coverage available. As of December 2010, hospice care is covered by 45 of the 50 state Medicaid programs. Unfortunately, states are under tremendous pressure to control their Medicaid costs and several states have dropped hospice coverage from their Medicaid
plans within the last year. Individuals should check with their state’s Medicaid program to find out if it covers hospice services. If an individual decides that he or she no longer want hospice care or does not like a hospice program, that person may dis-enroll or switch to a different hospice program at any time for any reason without penalty.
What to Ask When Choosing a Hospice?
There are many hospice programs available — large and small, for-profit and not-for-profit, those with a religious affiliation and those without. Selecting an appropriate program will take some research. Here are some questions to ask:
* Is the hospice run as a for-profit or not-for-profit business?
* Does the hospice belong to the National Hospice and Palliative Care Organization?
* Does the hospice have experience with LBD patients?
* Does the hospice have experience dealing with patients who have severe delirium or hallucinations?
* Does the hospice have a full-time physician on staff who can be reached for emergencies at night and on weekends and holidays?
* Is the hospice “open- access” — that is will the hospice provide all services and medications that a patient requires for pain control and symptom relief?
* Does the hospice have access to an inpatient hospital in the event that the patient’s symptoms cannot be adequately handled at home?
* Will the hospice covered all the medications that your loved one is currently receiving (provide a list)? What about atypical antipsychotics (which can be quite expensive)?
* What types of bereavement services does the hospice provide (just written pamphlets or individual/group counseling as well)?
LBD places a tremendous burden on families. Palliative and hospice care helps individuals with LBD to maintain the highest possible quality of life and it provides families emotional support as they cope with their loved ones’
progressively debilitating illness. Now widely available and affordable palliative and hospice care are much needed resources for individuals and families affected by LBD.
Additional Resources and Reading
American Academy of Hospice and Palliative Medicine — locate a palliative medicine physician in your state: http://www.palliativedoctors.org
HospiceDirectory.org- locate a hospice program by state or zip code: http://www.hospicedirectory.org
The Hospice Foundation’s Hospice Information Center — lists caregiver’s tools and a reading list: http://www.hospicefoundation.org/
Centers for Medicare and Medicaid Services — Describes Medicare’s hospice benefits in detail:
Caring.com – useful resources about all aspects of caregiving including end-of-life care: http://www.caring.com
The Alzheimer’s Reading Room has a nice summary of German research published last week that appears to show “that the toxic effect of tau protein is largely eliminated when the corresponding tau gene is switched off” in mice with a human tau gene. This suggests that the progression of Alzheimer’s Disease may be reversible. Here’s the summary:
The really important discovery here, however, is that the progression of Alzheimer’s disease can be reversed in principle – at least at an early stage of the illness before too many neurons have been destroyed…
Tau Induced Memory Loss in Alzheimer’s is Reversible
Friday, February 18, 2011
Alzheimer’s Reading Room
Amyloid-beta and tau protein deposits in the brain are characteristic features of Alzheimer disease. The effect on the hippocampus, the area of the brain that plays a central role in learning and memory, is particularly severe. However, it appears that the toxic effect of tau protein is largely eliminated when the corresponding tau gene is switched off.
Researchers from the Max Planck Research Unit for Structural Molecular Biology at DESY in Hamburg have succeeded in demonstrating that once the gene is deactivated, mice with a human tau gene, which previously presented symptoms of dementia, regain their ability to learn and remember, and that the synapses of the mice also reappear in part.
The scientists are now testing active substances to prevent the formation of tau deposits in mice. This may help to reverse memory loss in the early stages of Alzheimer disease – in part, at least. Journal of Neuroscience, February 16, 2011.
Whereas aggregated amyloid-beta protein forms insoluble clumps between the neurons, the tau protein accumulates inside them. Tau protein stabilises the tube-shaped fibers of the cytoskeleton, known as microtubules, which provide the “rails” for cellular transport.
In Alzheimer disease, excess phosphate groups cause the tau protein to malfunction and form clumps (the ‘neurofibrillary tangles’). As a result, nutrient transport breaks down and the neurons and their synapses die off. This process is accompanied by the initial stage of memory loss.
Together with colleagues from Leuven, Hamburg and Erlangen, Eva and Eckhard Mandelkow’s team from the Max Planck Research Unit for Structural Molecular Biology generated regulatable transgenic mice with two different human tau gene variants that can be switched on and off again: one group was given a form of the protein that cannot become entangled (anti-aggregant), and a second was provided with the code for the strongly aggregating protein variant (pro-aggregant). The mice with the first form developed no Alzheimer symptoms; the rodents that were given the pro-aggregant tau developed the disease.
The scientists measured the mice’s memory loss with the help of a swimming test: the healthy mice quickly learn how to find a life-saving platform located under the surface of the water in a water basin.
In contrast, the transgenic animals, which have the additional pro-aggregant tau gene paddle aimlessly around the basin until they accidentally stumble on the platform; they require over four times more time to do this than their healthy counterparts.
However, if the mutated toxic tau gene is switched off again, the mice learn to reach “dry land” with ease just a few weeks later. As a control, the mice with the anti-aggregant form of tau have no defects in learning, just as normal non-transgenic mice.
Surprising tissue results
Tissue tests showed that, as expected, no tau clumps had formed in the brains of the first group of mice expressing anti-aggregant tau.
In the second group – the mice suffering from Alzheimer’s – co-aggregates from human tau and “mouse tau” were formed – against expectations, because tau protein from mice does not usually aggregate.
“Even more astonishingly, weeks after the additional gene had been switched off, the aggregated human tau had dissolved again. However, the ‘mouse tau’ remained clumped. Despite this, the mice were able to learn and remember again,” says Eckhard Mandelkow. More precise tests revealed that new synapses had actually formed in their brains.
The scientists concluded from this that mutated or pathological tau can alter healthy tau. It appears that pro-aggregant tau can act similar to a crystal nucleus – once it has started to clump up, it drags neighboring “healthy” tau into the clumps as well. This is what makes the process so toxic to the neurons.
“The really important discovery here, however, is that the progression of Alzheimer’s disease can be reversed in principle – at least at an early stage of the illness before too many neurons have been destroyed,” explains Eva Mandelkow who, together with her husband, will be awarded the Potamkin Prize 2011 for Alzheimer’s disease research, which is sponsored by the American Academy of Neurology.
The aggregation of tau proteins, however, cannot simply be switched off in humans the way it can in the transgenic mice. Nevertheless, special substances exist that could dissolve the tau aggregates. By screening 200,000 substances, the Hamburg researchers have already identified several classes of active substances that could re-convert the tau aggregates into soluble tau. These are now being tested on animals.
Tau-induced Defects in Synaptic Plasticity, Learning and Memory are reversible in Transgenic Mice after Switching off the Toxic Tau Mutant
Astrid Sydow, Ann Van der Jeugd, Fang Zheng, Tariq Ahmed, Detlef Balschun, Olga Petrova, Dagmar Drexler, Lepu Zhou, Gabriele Rune, Eckhard Mandelkow, Rudi D’Hooge, Christian Alzheimer, Eva-Maria Mandelkow
Journal of Neuroscience, February 16, 2011
There’s a good article in the latest issue of Neurology Now magazine on the treatment of drooling in neurological disorders. Dr. Robert Miller (a neurologist at Stanford and at the ALS center at CPMC San Francisco) is quoted in the article as saying: “We tend to think that since some of these [neurologic] conditions are incurable, they’re also untreatable. That’s a big mistake. We have many treatments—for the breathing issues, the nutritional issues, treatments that slow the progression of disease, and yes, treatments for drooling.”
The article mentions the medication glycopyrrolate (brand name=Robinul). Generally speaking, caution should be exercised when giving an anticholinergic medication such as Robinul to someone to dementia (as there may already be a lack of acetylcholine in the brain of someone with dementia).
EYE ON THERAPY
Dealing with Drooling
Getting rid of excess saliva goes high-tech.
by Amy Paturel, MS, MPH
February/March 2011; Volume 7(1); Pp 38,40
When 61-year-old Deborah Clark first experienced trouble swallowing, she didn’t think much of it. But six months later, when she began having symptoms like slurred speech and difficulty projecting her voice, she visited a neurologist. Diagnosed with amyotrophic lateral sclerosis (ALS, also called Lou Gehrig’s disease) in February 2008, Clark quickly discovered how integral the muscles in her mouth were to her quality of life. Not only did she have difficulty speaking, but she also experienced excess saliva pooling in her mouth. At its worst, Clark found herself changing clothes up to four times a day because she had drooled down the front of her shirt.
“I was reluctant to be in public or around strangers—especially when a meal was involved,” says Clark. “People were always offering me tissues to control the drooling. It was embarrassing.”
Drooling, or sialorrhea, can be a major problem for people with neurologic conditions ranging from Parkinson’s disease and cerebral palsy to certain types of stroke and ALS. People with these conditions may not have the brain control to coordinate muscle movements in the face and mouth.
“Any condition that affects the muscles and nerves of the bulbar area (the swallowing mechanism) could cause increased drooling,” says Steven Bachrach, M.D., co-director of the Cerebral Palsy Program for Alfred I. duPont Hospital for Children in Wilmington, DE. And if you’re not swallowing your saliva, it tends to pool and accumulate in the mouth, and then it starts overflowing.
Beyond the obvious social implications of incessant drooling, the overflow of saliva in the mouth can irritate tissues around the lips and even cause aspiration pneumonia, a serious condition where people breathe fluid (or other foreign materials) from the mouth into the lungs. But with recent advances in everything from oral medication to botulinum toxin injections, people have more options than ever to control sialorrhea.
Speech and swallowing therapy is a great option for people who are mildly impaired and highly motivated to control their drooling. Most neurologists will advise patients to investigate this approach before considering invasive procedures. Through a series of sessions, therapists teach patients a variety of techniques to improve the safety of swallowing and minimize the risks of aspiration.
“There’s a lot that a swallowing therapist can do in this area,” says Robert Miller, M.D., professor of neurology at Stanford University and director of the Forbes Norris ALS Research Center at the California Pacific Medical Center in San Francisco. “If you tuck in your chin when you’re swallowing, for example, you’ll open up the airway, making it easier for fluid and food to go down.”
Even just becoming more aware of when and how you swallow can be effective. With regular training, people can learn to swallow more efficiently and get rid of excess saliva. Unfortunately, none of these techniques actually dries up the spit. If that’s your goal, medications or surgery are your best bets.
When less invasive methods have failed, the next approach is medication, usually anti-cholinergic medications. This class of drugs is used for everything from seasickness to overactive bladder. But with dry mouth as one of the main side effects, anti-cholinergics have become a useful tool to control drooling. In fact, studies investigating glycopyrrolate (the most commonly prescribed medication for drooling) consistently find the drug reduces drooling for up to 95 percent of patients who try it.
“One of the biggest challenges was that glycopyrrolate was only available in tablet form, so it was hard to adjust the dose to very small amounts,” says Dr. Bachrach. But in January 2011, the Food and Drug Administration approved a liquid form of the drug, which will make it easier to take and easier to dose.
When Clark started taking glycopyrrolate, her drooling improved within a matter of days. Initially she took one tablet three times a day, but eventually she needed four tablets daily to experience the same effects. Over time, even four tablets didn’t reduce her drooling to an acceptable level.
“Even if the drugs do work initially, receptors on the cells and within the salivary glands change, so patients may end up requiring higher and higher doses to get the same result—and then they get side effects,” says Scott Brietzke, M.D., M.P.H., director of pediatric otolaryngology at the Walter Reed Army Medical Center in Washington D.C. While dry mouth is the most common side effect, some people also experience constipation, urinary retention, and cognitive side effects such as confusion and memory impairment.
If the anti-cholinergics stop working—or the side effects are intolerable—some physicians prescribe amitriptyline, an anti-depressant that dries up saliva. A bonus: amitriptyline improves sleep, which is often disrupted in patients with ALS, multiple sclerosis, and other neurologic disorders.
If meds can’t control drooling, botulinum toxin is another option. Using an ultrasound-guided approach, the physician injects the drug into the major salivary glands to paralyze the muscles that normally squeeze out saliva. In one study of 131 patients, published in the medical journal Archives of Otolaryngology Head and Neck Surgery in 2010, botulinum toxin injections in the submandibular glands (the two glands located in the lower jaw that produce most of the saliva) reduced drooling and improved quality of life among patients who received injections. Two months after the injections, nearly 50 percent of patients experienced significant improvement, with effects beginning to taper off at the eight-month mark.
Clark started with just two shots into the salivary glands on either side of her face. Within a week, her drooling had dissipated more than it had with glycopyrrolate alone, and the effects lasted for three months. On the heels of this success, Clark’s physician gradually increased her dose to a total of six shots (three on each side).
“With six shots, the results were much more dramatic,” says Clark. “I have very little drooling and the only side effect is dry mouth, which is easier to deal with than drooling.” After the last round of botulinum toxin, Clark discontinued the glycopyrrolate without any noticeable difference.
Studies suggest that combined injections in both the parotid glands (which are located in the cheeks) and submandibular glands are slightly more effective than injections into the submandibular glands alone. And after repeated injections, there have been some reports that the salivary glands actually stop working, resulting in a permanent reduction in drooling. “You can’t count on that,” says Dr. Bachrach, “but it does happen in some patients.”
For other people, though, botulinum toxin is just a trial procedure to determine whether surgery will be effective. “Botulinum toxin deactivates those major glands, so we can see if that helps the patient with either the social problem or aspiration,” says Dr. Brietzke. “If there’s significant improvement, then we can consider a potentially irreversible procedure, such as tying off the ducts or removing the glands.”
Surgical treatment for drooling may be even more effective than injections, without subjecting people to recurrent treatments. Studies show that people who have surgery are generally happy with the results. Unfortunately, there are a variety of approaches and little consensus about which ones work best. The most straightforward procedure involves the submandibular glands: Rerouting the ducts from these glands to the back of the mouth makes it easier to swallow saliva. Alternatively, surgeons can reroute the ducts from the parotid glands or remove the submandibular glands altogether.
“The evidence we have suggests that intra-oral procedures (like tying off the four ducts in the mouth) may not be as successful,” says Dr. Brietzke. According to a study he co-authored in Archives of Otolaryngology Head and Neck Surgery in 2009, removal of the submandibular glands and parotid duct rerouting appear to have the highest success rates at 87.8 percent while the success rates for tying off the four ducts varied wildly from 31 to 100 percent.
“The biggest downside is that surgery is not reversible,” says Dr. Bachrach. “Once you’ve tied off the ducts, or removed the glands altogether, you can’t undo that.” So while you can go from drooling to dry, you can’t go back. And dry mouth has its own set of complications.
Even so, treating symptoms like drooling still gets short shrift from some health care providers.
“We tend to think that since some of these [neurologic] conditions are incurable, they’re also untreatable,” says Dr. Miller. “That’s a big mistake. We have many treatments—for the breathing issues, the nutritional issues, treatments that slow the progression of disease, and yes, treatments for drooling.”
For Clark, that treatment has been invaluable. Today, she no longer carries a napkin with her at all times, she doesn’t shy away from social events, even with strangers, and her shirt stays dry throughout the day. “I’m very happy with the results,” she says.