“This research, as well as comparative effectiveness studies on the use of the usual approach to care as compared with a palliative care approach, could inform public policy.”
—Laura Sassano
Suggested Reading
Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538.
Sachs GA. Dying from dementia. N Engl J Med. 2009;361(16):1595-1596.
[Sidebar] Late-Life Dementia: A DIfferent Perspective
Late-life dementia may no longer be considered synonymous with Alzheimer’s disease, according to Majid Fotuhi, MD, PhD, and colleagues. Most recent clinicopathologic studies have found that only a small proportion of individuals older than 80 with cognitive impairment have pure Alzheimer pathology, and most patients have coexisting abnormalities, reported Dr. Fotuhi’s group in the December Nature Reviews Neurology. Dr. Fotuhi is Director of the Center for Memory and Brain Health at the Sandra and Malcolm Berman Brain & Spine Institute and Assistant Professor of Neurology at Johns Hopkins University School of Medicine in Baltimore.
Dr. Fotuhi’s team proposes a broad view that integrates brain function, cardiovascular function, and neuroplasticity, to account for the eventual development of cognitive impairment in late life. They highlight the dynamic interaction between genetically determined processes that are nonreversible (eg, apolipoprotein genotype), and the environmental processes that are potentially reversible (eg, vascular risk factors). “This model, which we have termed the ‘dynamic polygon hypothesis,’ departs from a primary focus on plaques and tangles.” Dr. Fotuhi’s group noted that the primary focus on Alzheimer’s disease pathology to account for late-life dementia is superseded by understanding potentially modifiable processes.
“According to the dynamic polygon hypothesis, a balance of positive and negative genetic factors seems to affect the brain throughout early life and midlife to determine the degree of cognitive agility or impairment in late life,” the researchers stated. These factors increase or decrease cerebral blood flow, oxidative stress, inflammation, insulin-signaling components, size and frequency of infarcts, and concentrations of growth factors, cortisol, or other hormones.” Although brain imaging and other advances in neuroscience have increased the understanding of the aging brain, “More research is required before specific recommendations to prevent late-life dementia can be formulated,” Dr. Fotuhi’s group concluded.
—Laura Sassano