Interview with Stephen Bartels M.D., Past- President of the American Association for Geriatric Psychiatry
Share:
Topic: Alzheimer's & Depression
Beck: Hi Dr. Bartels. I certainly appreciate your time today. I am honored to again speak with you on issues relating to Alzheimer's and Depression, I know you are an extraordinarily busy person and I am very appreciative of your time.
Bartels: Thank you Dr. Beck. It's an honor to work with you again too.
Beck: If you don't mind, I'd like to tell the readers about a few of the positions you currently hold, and have recently held... You're currently an associate professor of psychiatry at Dartmouth Medical School and you're also the past-president of the American Association for Geriatric Psychiatry. You're the current chair of the Geriatric Mental Health Foundation. In addition, you're the co-director of the Geriatric Fellowship Program and you're the medical director of the Division of Behavioral Health for the State of New Hampshire and you're the Director of the Aging Services Research center at the New Hampshire-Dartmouth Psychiatric Research Center. Over the last year (2003) you were the "Expert Consultant" to the sub-committee on Older Adults for the President's Commission on mental health. Wow!
Bartels: Yes, that sounds about right.
Beck: We know that some 28 million people in the U.S.A. have hearing loss. 14% of those with hearing loss are between 45 and 64 years, about 23% of individuals between the ages of 65 and 74 years have hearing loss and about 1 out of 3 people over 75 years have hearing loss. So given that, Dr. Bartels, before we get specifically into Alzheimer's and depression, can you tell me your general observations regarding hearing impaired seniors?
Bartels: Certainly. Many of the individuals we see have hearing loss. As you just stated, the rate of hearing loss increases with age. Seniors have a greater incidence of hearing loss, and so we often see the same patients in our office and the audiology office. Sensory isolation, whether it is visual or auditory can be highly problematic. It may make the person more easily agitated or confused, and of course hearing loss exacerbates social isolation and depression. Hearing loss can make the management and diagnosis of Alzheimer's even more problematic - particularly if the hearing loss is undetected, or if the patient is in denial regarding their hearing loss. Of course, there are probably patients who have hearing loss, yet they are suspect for geriatric psychiatric issues - because the hearing loss is not known! In other words, maybe the patient appears to have psychiatric issues occurring to the casual or professional observer - but perhaps some of those behaviors are attributable to hearing loss. So the bottom line is yes, hearing loss is an issue we deal with regularly and it does impact our management of patients.
Beck: Thank you. Would you please give me a "working definition" of Alzheimer's?
Bartels: Sure. Alzheimer's is the single most common form of dementia and/or memory loss (besides neuro-degenerative disease) and again, like hearing loss, it increases significantly with age. The statistics are that 40 percent of the USA population over 85 years of age develop Alzheimer's, so you could say it's at epidemic proportions right now. Alzheimer's is a progressive degenerative dementia characterized in the early stage by short-term memory deficits, and later with short and long-term memory deficits, aphasia, apraxia, disorientation and severe functional deficits. The underlying pathology includes cortical nerve cell destruction with characteristic amyloid plaques and neurofibrillary tangles.
Beck: Dr. Bartels, what are the earliest signs and symptoms of Alzheimer's please?
Bartels: All of us might have forgetfulness related to names, and that's actually pretty common and normal in some respects. But when we see people forgetting names of their family members, or forgetting appointments, misplacing things at an increasing rate...these are all signs of something we now call MCI - Mild Cognitive Impairment. We know that MCI is an early sign of Alzheimer's for a number of people.
Beck: Are there genetic predispositions for Alzheimer's?
Bartels: Yes, there can be. There are at least five different genes that have been associated with Alzheimer's. For example, familial Alzheimer's is relatively uncommon, it occurs to people at about age 45 to 50, and it is very malignant. It is associated with chromosomes 14 and 21. As you know, chromosome 21 is associated with Down's Syndrome, and interestingly, 100 percent of the people with Down's Syndrome eventually get Alzheimer's. Other chromosomes include numbers 1, 12, and 19. It appears that the most common form of Alzheimer's that generally occurs after the age of 60 is associated with chromosome 19.
Beck: Very good. Dr. Bartels, what are the treatment options for Alzheimer's?
Bartels: Treatment options vary. Major treatments include use of particular agents which help reduce the rate of symptomatic memory decline. We have used cholinesterase inhibitors successfully to help increase acetylcholine in the brain and make the decline of memory over time, less significant. It does not appear to change the underlying course of the illness, but it helps to preserve memory for a longer period of time, allowing people to function better for a little longer. Over the past several months a new agent that is being prescribed in addition to cholinesterase inhibitors is memantine, this works differently and helps decrease cellular damage associated with Alzheimer's by blocking the cellular destructive action of the chemical glutamate. We also recommend vitamin E and folic acid as they have a potential role in decreasing the amount of decline and damage. Of course, psycho-social treatment, the support of family members in managing the decline is certainly useful and very important. So basically there are many opportunities and alternatives to help these patients, and like most things, early intervention is the most useful.
Beck: Is denial by the patient a big factor in Alzheimer's diagnosis?
Bartels: It can be. For patients whose career and livelihood is based on their intellect, it's very depressing and frustrating to become forgetful. For others, in the middle stage of Alzheimer's they may not realize how bad their memory has become and indeed, they may even say... "My memory is not that bad." That typically comes out when the family starts talking about a nursing home. So yes, denial can be an issue but it depends on the individual and their stage of disease, but no, it's not necessarily a hallmark of Alzheimer's per se.
Beck: Dr. Bartels, I hate to mention this, but president Reagan is probably the best known late stage Alzheimer's patient. Is there any effective treatment option for someone in a situation similar to President Reagan?
Bartels: Tough call. I certainly haven't seen him personally and I really cannot say specifically. However, both cholinesterase inhibitors and memantine have FDA indications for moderate and severe Alzheimer's dementia. Regarding treatment in late stages, these decisions are largely driven by the presence or absence of a response and the specific clinical situation. The jury is still out on the effectiveness of these agents in the latest stage of the illness. In addition to pharmacological interventions; behavioral and environmental interventions are important. For example, modifying the environment to provide cues and appropriate levels of stimulation, and having familiar people around as much as possible can be helpful. Also, some 30 to 40 percent of all Alzheimer's patients develop hallucinations and delusions or depression. These secondary symptoms are treatable, and so it's important to test for these things because if they're present, they probably can be treated.
Beck: Is Alzheimer's more a frontal lobe disorder, or more generally present throughout the brain?
Bartels: Alzheimer's is present and ravages the whole brain, essentially through the cortical grey matter, and of course throughout the hippocampus, where memory lives. Some Alzheimer's patients demonstrate apraxia and some might have aphasias, but the variation is tremendous. Of course as time goes on and the disease progresses, virtually all Alzheimer's patients will develop expressive and receptive aphasia.
Beck: If you don't mind, let's switch topics. Would you please discuss the clinical definition of depression, and the signs and symptoms to be aware of there too?
Bartels: Yes, certainly. The definition of major depression is a disorder in which people have feelings of hopelessness, helplessness and worthlessness. This is different from sadness and it's different from bereavement. Depression usually occurs with physical symptoms too, such as loss of appetite, difficulty sleeping, poor energy, loss of libido, and increased agitation. So people with major depression tend to have a functional impairment associated with the disorder.
Beck: What can you tell me about the prevalence of major depression?
Bartels: There are several types of depression, but in particular, if we're speaking about major depression, it's probably about 5 percent of the geriatric population, though rates are considerably higher for older persons in nursing homes or hospitals.
Beck: And the signs and symptoms of depression to be on the look out for?
Bartels: Persistence of a sad, or low mood for beyond two to three weeks, social withdrawal, and perhaps difficulty sleeping. It varies, but those would be the major things to look for.
Beck: Dr. Bartels, is there a genetic pre-disposition for depression?
Bartels: There certainly can be. We know that people who have recurrent depression are more likely to have first degree relatives, meaning within their direct family, who also may have depressive illness. Certainly manic depressive illness, also known as bipolar disorder, has a significant genetic predisposition. Importantly, not all depressions are genetic, although there can be a familial component.
Beck: What about treatment options for depression?
Bartels: There are many treatments. The treatment ranges from anti-depressants to problem solving therapy (PST), also known as brief cognitive behavioral therapy (CBT). Both of these therapies have evidence-based literature supporting their use. In general, preferred pharmacological treatments are with the SSRIs (selective serotonin reuptake inhibitors) or the newer non-SSRI agents. The older tricyclics such as amitriptiline (elavil) or sinequan (doxepin) are contraindicated due to anitcholinergic and cardiovascular side effects.
Beck: Thank you so much for allowing me so much of your time. It really has been enlightening, and I think it will be very useful for many of the readers too.
Bartels: You're welcome, it's been a pleasure speaking with you.
Bartels: Thank you Dr. Beck. It's an honor to work with you again too.
Beck: If you don't mind, I'd like to tell the readers about a few of the positions you currently hold, and have recently held... You're currently an associate professor of psychiatry at Dartmouth Medical School and you're also the past-president of the American Association for Geriatric Psychiatry. You're the current chair of the Geriatric Mental Health Foundation. In addition, you're the co-director of the Geriatric Fellowship Program and you're the medical director of the Division of Behavioral Health for the State of New Hampshire and you're the Director of the Aging Services Research center at the New Hampshire-Dartmouth Psychiatric Research Center. Over the last year (2003) you were the "Expert Consultant" to the sub-committee on Older Adults for the President's Commission on mental health. Wow!
Bartels: Yes, that sounds about right.
Beck: We know that some 28 million people in the U.S.A. have hearing loss. 14% of those with hearing loss are between 45 and 64 years, about 23% of individuals between the ages of 65 and 74 years have hearing loss and about 1 out of 3 people over 75 years have hearing loss. So given that, Dr. Bartels, before we get specifically into Alzheimer's and depression, can you tell me your general observations regarding hearing impaired seniors?
Bartels: Certainly. Many of the individuals we see have hearing loss. As you just stated, the rate of hearing loss increases with age. Seniors have a greater incidence of hearing loss, and so we often see the same patients in our office and the audiology office. Sensory isolation, whether it is visual or auditory can be highly problematic. It may make the person more easily agitated or confused, and of course hearing loss exacerbates social isolation and depression. Hearing loss can make the management and diagnosis of Alzheimer's even more problematic - particularly if the hearing loss is undetected, or if the patient is in denial regarding their hearing loss. Of course, there are probably patients who have hearing loss, yet they are suspect for geriatric psychiatric issues - because the hearing loss is not known! In other words, maybe the patient appears to have psychiatric issues occurring to the casual or professional observer - but perhaps some of those behaviors are attributable to hearing loss. So the bottom line is yes, hearing loss is an issue we deal with regularly and it does impact our management of patients.
Beck: Thank you. Would you please give me a "working definition" of Alzheimer's?
Bartels: Sure. Alzheimer's is the single most common form of dementia and/or memory loss (besides neuro-degenerative disease) and again, like hearing loss, it increases significantly with age. The statistics are that 40 percent of the USA population over 85 years of age develop Alzheimer's, so you could say it's at epidemic proportions right now. Alzheimer's is a progressive degenerative dementia characterized in the early stage by short-term memory deficits, and later with short and long-term memory deficits, aphasia, apraxia, disorientation and severe functional deficits. The underlying pathology includes cortical nerve cell destruction with characteristic amyloid plaques and neurofibrillary tangles.
Beck: Dr. Bartels, what are the earliest signs and symptoms of Alzheimer's please?
Bartels: All of us might have forgetfulness related to names, and that's actually pretty common and normal in some respects. But when we see people forgetting names of their family members, or forgetting appointments, misplacing things at an increasing rate...these are all signs of something we now call MCI - Mild Cognitive Impairment. We know that MCI is an early sign of Alzheimer's for a number of people.
Beck: Are there genetic predispositions for Alzheimer's?
Bartels: Yes, there can be. There are at least five different genes that have been associated with Alzheimer's. For example, familial Alzheimer's is relatively uncommon, it occurs to people at about age 45 to 50, and it is very malignant. It is associated with chromosomes 14 and 21. As you know, chromosome 21 is associated with Down's Syndrome, and interestingly, 100 percent of the people with Down's Syndrome eventually get Alzheimer's. Other chromosomes include numbers 1, 12, and 19. It appears that the most common form of Alzheimer's that generally occurs after the age of 60 is associated with chromosome 19.
Beck: Very good. Dr. Bartels, what are the treatment options for Alzheimer's?
Bartels: Treatment options vary. Major treatments include use of particular agents which help reduce the rate of symptomatic memory decline. We have used cholinesterase inhibitors successfully to help increase acetylcholine in the brain and make the decline of memory over time, less significant. It does not appear to change the underlying course of the illness, but it helps to preserve memory for a longer period of time, allowing people to function better for a little longer. Over the past several months a new agent that is being prescribed in addition to cholinesterase inhibitors is memantine, this works differently and helps decrease cellular damage associated with Alzheimer's by blocking the cellular destructive action of the chemical glutamate. We also recommend vitamin E and folic acid as they have a potential role in decreasing the amount of decline and damage. Of course, psycho-social treatment, the support of family members in managing the decline is certainly useful and very important. So basically there are many opportunities and alternatives to help these patients, and like most things, early intervention is the most useful.
Beck: Is denial by the patient a big factor in Alzheimer's diagnosis?
Bartels: It can be. For patients whose career and livelihood is based on their intellect, it's very depressing and frustrating to become forgetful. For others, in the middle stage of Alzheimer's they may not realize how bad their memory has become and indeed, they may even say... "My memory is not that bad." That typically comes out when the family starts talking about a nursing home. So yes, denial can be an issue but it depends on the individual and their stage of disease, but no, it's not necessarily a hallmark of Alzheimer's per se.
Beck: Dr. Bartels, I hate to mention this, but president Reagan is probably the best known late stage Alzheimer's patient. Is there any effective treatment option for someone in a situation similar to President Reagan?
Bartels: Tough call. I certainly haven't seen him personally and I really cannot say specifically. However, both cholinesterase inhibitors and memantine have FDA indications for moderate and severe Alzheimer's dementia. Regarding treatment in late stages, these decisions are largely driven by the presence or absence of a response and the specific clinical situation. The jury is still out on the effectiveness of these agents in the latest stage of the illness. In addition to pharmacological interventions; behavioral and environmental interventions are important. For example, modifying the environment to provide cues and appropriate levels of stimulation, and having familiar people around as much as possible can be helpful. Also, some 30 to 40 percent of all Alzheimer's patients develop hallucinations and delusions or depression. These secondary symptoms are treatable, and so it's important to test for these things because if they're present, they probably can be treated.
Beck: Is Alzheimer's more a frontal lobe disorder, or more generally present throughout the brain?
Bartels: Alzheimer's is present and ravages the whole brain, essentially through the cortical grey matter, and of course throughout the hippocampus, where memory lives. Some Alzheimer's patients demonstrate apraxia and some might have aphasias, but the variation is tremendous. Of course as time goes on and the disease progresses, virtually all Alzheimer's patients will develop expressive and receptive aphasia.
Beck: If you don't mind, let's switch topics. Would you please discuss the clinical definition of depression, and the signs and symptoms to be aware of there too?
Bartels: Yes, certainly. The definition of major depression is a disorder in which people have feelings of hopelessness, helplessness and worthlessness. This is different from sadness and it's different from bereavement. Depression usually occurs with physical symptoms too, such as loss of appetite, difficulty sleeping, poor energy, loss of libido, and increased agitation. So people with major depression tend to have a functional impairment associated with the disorder.
Beck: What can you tell me about the prevalence of major depression?
Bartels: There are several types of depression, but in particular, if we're speaking about major depression, it's probably about 5 percent of the geriatric population, though rates are considerably higher for older persons in nursing homes or hospitals.
Beck: And the signs and symptoms of depression to be on the look out for?
Bartels: Persistence of a sad, or low mood for beyond two to three weeks, social withdrawal, and perhaps difficulty sleeping. It varies, but those would be the major things to look for.
Beck: Dr. Bartels, is there a genetic pre-disposition for depression?
Bartels: There certainly can be. We know that people who have recurrent depression are more likely to have first degree relatives, meaning within their direct family, who also may have depressive illness. Certainly manic depressive illness, also known as bipolar disorder, has a significant genetic predisposition. Importantly, not all depressions are genetic, although there can be a familial component.
Beck: What about treatment options for depression?
Bartels: There are many treatments. The treatment ranges from anti-depressants to problem solving therapy (PST), also known as brief cognitive behavioral therapy (CBT). Both of these therapies have evidence-based literature supporting their use. In general, preferred pharmacological treatments are with the SSRIs (selective serotonin reuptake inhibitors) or the newer non-SSRI agents. The older tricyclics such as amitriptiline (elavil) or sinequan (doxepin) are contraindicated due to anitcholinergic and cardiovascular side effects.
Beck: Thank you so much for allowing me so much of your time. It really has been enlightening, and I think it will be very useful for many of the readers too.
Bartels: You're welcome, it's been a pleasure speaking with you.
