Inadequate support given to DLB families, especially around the time of diagnosis

One key finding of the study described in this email is the value of in-person LBD-specific support groups! It seems at the time of diagnosis, physicians should encourage families to seek out LBD-specific support and information about coping with certain symptoms, especially hallucinations, fluctuating cognition, and sleep disorders. Of course, these symptoms are regularly discussed at our LBD-specific support group meetings.

This journal article out of the UK is based on 125 responses to an online survey about Dementia with Lewy Bodies. The majority of the respondents were caregivers. Some were those with DLB.

The conclusions were: “People with DLB and their family members are currently inadequately supported at diagnosis. There is a need to address information needs related to symptomology, medication and prognosis, including provision of emotional and instrumental social support.”

The symptom about which the most respondents said there needed to be more info and support was hallucinations. The authors noted that: “Hallucinations can be more problematic to others than to those experiencing them, with 85% of caregivers finding visual hallucinations very stressful or moderately stressful compared with 45% of patients.”

The next symptoms where respondents felt more need for info and support were fluctuating cognition and sleep issues.

The article made several other points worth considering:

  • “People with DLB have significantly more depressive symptoms, and their quality of life rated by their caregivers is much worse than for people with AD.”
  • “24% of caregivers for people with DLB (6% for AD) rated their cared for person’s health state at a level which a general population sample rated as worse than death.” Wow!
  • “[Caregivers] of people with DLB report more stress compared with AD and vascular dementia, with daytime somnolence, one feature of cognitive fluctuations commonly seen in DLB, particularly associated with increased stress.”
  • “Online resources…do not offer the emotional and instrumental social support from peers…”
  • “The current lack of DLB specific support groups excludes access to the benefits of emotional and instrumental social support from peers. Whilst some dementia information is generic to all dementia types, specialist information about the physiological aspects of DLB, including how to cope effectively with DLB-related symptomology, and associated somatic and mental health comorbidities are rarely addressed.”
  • “Poor community awareness and the lower incidence of DLB compared to AD often means that caregivers experience social isolation, which may explain the high proportion (80%) who wanted information about what strategies others in their position found helpful.”

Here’s the abstract:

International Psychogeriatrics. 2015 Sep 2:1-7. [Epub ahead of print]
Support and information needs following a diagnosis of dementia with Lewy bodies.
Killen A, Flynn D, De Brún A, O’Brien N, O’Brien J, Thomas AJ, McKeith I, Taylor JP.

Abstract
BACKGROUND:
There is a lack of knowledge regarding the information and support needs of people with dementia with Lewy bodies (DLB) and their families around the time of diagnosis.

METHODS:
A volunteer sample of patients with DLB and their family members completed a web survey hosted by the UK based Lewy Body Society in May 2014. This focused on past experiences of information and support received and what information and support needs would have been beneficial at the time of diagnosis.

RESULTS:
One hundred and twenty five adults responded to the survey. The majority were first degree relatives or spouses of people with DLB (n = 107%, 86%). Approximately 50% (n = 61) reported they had not received any tangible support at diagnosis. Thirteen categories of information needs were identified.

CONCLUSIONS:
People with DLB and their family members are currently inadequately supported at diagnosis. There is a need to address information needs related to symptomology, medication and prognosis, including provision of emotional and instrumental social support. Seeking the views of recipients of information and support is important in ensuring relevance and appropriateness prior to the development of interventions to improve the knowledge and coping skills of people with DLB and caregivers.

PMID: 26328546 (see pubmed.gov for this abstract; enter in the PubMed ID #)

Alzheimer’s Australia – Overview of LBD

In this Australian overview of Lewy Body Dementia, the term “Lewy Body Disease” is used.  My personal preference is to use the term “Lewy Body Dementia” as it refers to both Dementia with Lewy Bodies and Parkinson’s Disease Dementia.  Medical researchers use the term “Lewy Body Disease” to refer to Parkinson’s Disease.  This Australian overview seems to be use the term “Lewy Body Disease” to refer to Dementia with Lewy Bodies.

Other than that, I think this is a short-and-sweet overview of LBD.

Big news- MSA seems transmissable, LBD does not, etc.

Though this email is of most interest to the MSA folks in our support group, I’m sending this to everyone as it may be that similar findings will be made with PSP and CBD.  I’ve added a note near the bottom of this email; it seems that these findings don’t apply to LBD.  …  Also, I want to note upfront that this ground-breaking research is made possible through generous people donating their brains.

My email inbox exploded this afternoon — first Candy, then Jen, then Denise, and then several others.  There was big news today (Monday, 8-31-15) about MSA research.

Prions are “infectious proteins” that spread in the brain like a virus or bacteria.  The Nobel Prize-winning discoverer of prions is Stanley Prusiner at UCSF.  The most well-known human prion disease is Creutzfeldt-Jakob Disease (CJD), a very rare disorder involving PrP prions.  The most well-known animal prion disease is made cow disease.  Suggestions have been made over the last several years that perhaps Alzheimer’s or Parkinson’s is caused by prions.

Two weeks ago and today (in two separate papers), Dr. Prusiner and a team of researchers reported that “multiple system atrophy (MSA) is caused by a…human prion composed of the alpha-synuclein protein.”  This is all over the news today.

Here’s a link to NPR’s All Things Considered’s discussion of this research today:

Scientists Discover New Disease Caused By Prion Protein
www.npr.org/2015/08/31/436377464/scientists-discover-new-disease-caused-by-prion-protein

The 3.5-minute radio segment notes that MSA may be transmissible from person to person!  (There’s no transcript posted yet of this radio story.)

Here’s a related part of the UCSF press release on the public health aspect of this research:

“The discovery that alpha-synuclein prions can transmit MSA raises a public health concern about treatments and research that involve contact with brain tissue from neurodegeneration patients, because standard disinfection techniques that kill microbes do not eliminate the PrP prions that cause CJD. Whether the same challenges hold for alpha-synuclein prions in MSA remains to be determined. … The authors write that clinicians and researchers should adopt much more stringent safety protocols when dealing with tissue from patients with MSA and other neurodegenerative diseases, many of which they believe may also be caused by prions. For instance, MSA is frequently initially diagnosed as Parkinson’s disease, which is often treated with deep-brain stimulation. The disease could potentially be transmitted to other patients if deep-brain stimulation equipment is reused. … [The] researchers stress that there is no apparent risk of infection by MSA prions outside of specialized medical or research settings.”

This makes me wonder if some people who had PD and got deep brain stimulation (DBS) surgery, actually acquired MSA from the surgical instruments used during DBS.  That’s alarming to consider.

This excerpt from the UCSF press release explains how the discovery was made:

“The new work has its origins in experiments conducted in Prusiner’s lab in 2013, showing that samples of brain tissue from two human MSA patients were able to transmit the disease to a mouse model for Parkinson’s disease, expressing a mutant human alpha-synuclein gene. To confirm this finding, Prusiner and colleagues expanded this experiment to include tissue samples from a dozen more MSA victims from tissue banks on three continents…  The results were the same: When exposed to human MSA tissue, the mice developed neurodegeneration. In addition, the team found that the brains of infected mice contained abnormally high levels of insoluble human alpha-synuclein, and that infected mouse brain tissue could itself spread the disease to other mice.”

Note that this research was made possible only through the generosity of those who donated their brains!

You can read the full UCSF press release here:

www.ucsf.edu/news/2015/08/131416/new-type-prion-may-cause-transmit-neurodegeneration

And you can read the abstract for the Prusiner article here:

www.pnas.org/content/early/2015/08/27/1514475112.abstract

What does this mean for LBD?  Both Lewy Body Dementia and Parkinson’s Disease are also disorders of alpha-synuclein protein.  If I’m understanding the full Prusiner paper accurately, researchers also tried to get human Parkinson’s Disease  tissue from six brain donors to transmit PD to transgenic mice.  None of the mice developed Parkinson’s Disease.  It would seem that the “strain” (or variant) of alpha-synuclein that causes PD is different from the transmissable strain that causes MSA.

(Actually, four patients were diagnosed with “Lewy body disease” or Parkinson’s Disease.  And two patients were diagnosed with “diffuse Lewy bodies,” which is Lewy body dementia.)

Not sure where we go from here!  Fortunately we are right at the center of prion disease research with UCSF.  I think lots of MSA researchers are going to be changing their strategies as a result.  And probably PSP and CBD researchers will want to investigate if these disorders are transmissable as well.

Robin

Spinal fluid biomarker research – PSP v. MSA v. PD, and which PDers will develop LBD?

There was an interesting – but hard to understand (at least for me!) – paper published a couple of weeks ago in JAMA Neurology, an important journal.  A lot of the worldwide research community is focused on biomarkers.  If we could give someone a blood test (or a spinal tap, in the case of this paper) to determine if the person had PD, PSP, or MSA, that would be groundbreaking.  And it might be helpful to know which of those who have PD will eventually develop dementia (or Lewy Body Dementia in particular).

In this paper, Swedish researchers looked at cerebrospinal fluid (CSF) of 128 people with Parkinson’s Disease (PD), Progressive Supranuclear Palsy (PSP), and Multiple System Atrophy (MSA) over a 5-9 year period.  None of the 128 had dementia.  CSF of 30 older healthy controls was also examined.

Here’s an (understandable) excerpt from a useful summary of the paper on Alzforum, posted last Friday:

“Scientists…report a combination of useful candidates in the cerebrospinal fluid (CSF) that may help [differentiate these diseases and predict who will decline cognitively]. One biomarker in particular, neurofilament light chain (NFL), a neuronal cytoskeleton protein, best distinguished PSP from PD. In helping predict which patients with PD would become demented, NFL joined two other proteins: Aβ42 and heart fatty acid–binding protein (HFABP), which helps carry fatty acids to the mitochondria for oxidization. All in all, the results propose useful diagnostic biomarkers for these diseases and may offer clues to their pathophysiology. … No single biomarker or combination separated MSA from PD.”

In the study, 35 percent of the PD patients developed dementia over the five to nine years of participation.  This seemed to be a high conversion rate to dementia for John Growdon, a neurologist at Mass General in Boston.  He said:

“‘To be able to predict with some certainty who’s on the path to dementia and who’s not is a very important finding,’ he told Alzforum. If these results can be reproduced, it could mean that Aβ-lowering therapeutics for Alzheimer’s disease (AD) will be applicable to the PDD group. It would be useful to compare these biomarkers in other disorders that might also cause diagnostic confusion, such as AD and dementia with Lewy bodies, he said.”

For what it’s worth, Dr. Growdon described this as a “very important study.”

Here’s a link to the Alzforum post, if you’d like to read more:

www.alzforum.org/news/research-news/biomarkers-differentiate-parkinsonian-diseases-and-forecast-decline

I’ve copied the abstract below.

Robin

—————————————————————

Abstract

JAMA Neurology. 2015 Aug 10.

Cerebrospinal Fluid Patterns and the Risk of Future Dementia in Early, Incident Parkinson Disease.
Bäckström DC, Eriksson Domellöf M, Linder J, Olsson B, Öhrfelt A, Trupp M, Zetterberg H, Blennow K, Forsgren L.

Importance:
Alterations in cerebrospinal fluid (CSF) have been found in Parkinson disease (PD) and in PD dementia (PDD), but the prognostic importance of such changes is not well known. In vivo biomarkers for disease processes in PD are important for future development of disease-modifying therapies.

Objective:
To assess the diagnostic and prognostic value of a panel of CSF biomarkers in patients with early PD and related disorders.

Design, Setting, and Participants:
Regional population-based, prospective cohort study of idiopathic parkinsonism that included patients diagnosed between January 1, 2004, and April 30, 2009, by a movement disorder team at a university hospital that represented the only neurology clinic in the region. Participants were 128 nondemented patients with new-onset parkinsonism (104 with PD, 11 with multiple system atrophy, and 13 with progressive supranuclear palsy) who were followed up for 5 to 9 years. At baseline, CSF from 30 healthy control participants was obtained for comparison.

Main Outcomes and Measures:
Cerebrospinal fluid concentrations of neurofilament light chain protein, Aβ1-42, total tau, phosphorylated tau, α-synuclein, and heart fatty acid-binding protein were quantified by 2 blinded measurements (at baseline and after 1 year). Follow-up included an extensive neuropsychological assessment. As PD outcome variables, mild cognitive impairment and incident PDD were diagnosed based on published criteria.

Results:
Among the 128 study participants, the 104 patients with early PD had a different CSF pattern compared with the 13 patients with progressive supranuclear palsy (baseline area under the receiver operating characteristic curve, 0.87; P < .0001) and the 30 control participants (baseline area under the receiver operating characteristic curve, 0.69; P = .0021). A CSF biomarker pattern associated with the development of PDD was observed. In PD, high neurofilament light chain protein, low Aβ1-42, and high heart fatty acid-binding protein at baseline were related to future PDD as analyzed by Cox proportional hazards regression models. Combined, these early biomarkers predicted PDD with high accuracy (hazard ratio, 11.8; 95% CI, 3.3-42.1; P = .0001) after adjusting for possible confounders.

Conclusions and Relevance:
The analyzed CSF biomarkers have potential usefulness as a diagnostic tool in patients with parkinsonism. In PD, high neurofilament light chain protein, low Aβ1-42, and high heart fatty acid-binding protein were related to future PDD, providing new insights into the etiology of PDD.

PubMed ID#:  26258692

Exercise and dementia (research updates from Alzforum)

This post may be of general interest since many of us are dealing with dementia or will be dealing with dementia at some point in our lives.

At the recent Alzheimer’s Association International Conference in Washington DC (mid-July), a lot of research was presented on exercise.  The Alzforum has two good summaries of the research.

The first summary is here:

alzforum.org/news/conference-coverage/exercise-boosts-cognition-symptomatic-disease

The first summary examines research into whether Alzheimer’s disease can be tempered by aerobic exercise and whether dementia can be avoided through exercise:

“Speakers…presented new evidence that regular aerobic exercise can help people in prodromal disease stages maintain their cognition, while for those with full-blown dementia it relieves neuropsychiatric symptoms. Some studies provided hints that exercise can also hone thinking at the dementia stage, but only if the participants reach moderate intensity heart rates during their workout. Exactly how exercise helps the brain is still not known, but several talks reported better cerebral blood flow and improved structural and functional connectivity in exercisers, and even some signs that six months or more of physical activity can slow pathology.  Researchers agreed that the duration and intensity of an exercise intervention are crucial to determining its effects. For aerobic exercise in particular, the field is standardizing methods and narrowing in on the appropriate dose to prescribe. Some believe supervised exercise classes could become part of the standard of care for people with cognitive problems. … Researchers have few doubts now that exercise protects normal older adults against brain decline.”

(prodromal = before symptoms appear)

The second summary is here:

alzforum.org/news/conference-coverage/can-exercise-slow-progression-alzheimers-pathology

The second summary explores research into whether exercise can slow the progression of a neurodegenerative process:

“Overall, the findings indicated that working out enhances vascular brain health and connectivity, implying a direct benefit to brain structure and function. Data were mixed on whether exercise slows the progression of underlying Alzheimer’s pathology, however. One six-month study of moderate aerobic exercise reported a drop in cerebrospinal fluid tau in cognitively impaired people, but a shorter intervention failed to budge brain amyloid in people with AD. In general, speakers agreed that the cognitive boost from exercise likely comes from diverse benefits on several different aspects of brain function, something that would be hard to match pharmacologically.”

Both summaries are worth reading if exercise research is of interest.

While this may be a good day to go to the gym, this is probably not a good day to exercise outdoors.

Stay cool,
Robin