Nearly seven million Americans over 65 had Alzheimer’s dementia in 2023, according to figures from the US Alzheimer’s Association (USAZ).
USAZ estimates this accounts for one in nine of the total population in this age group, a figure that rises sharply as people get older with one third of those over the age of 85 having some form of the disease.
According to Swiss Re’s 2023, ‘Future of life expectancy’ report, Alzheimer’s accounts for up to 80% of the total number of dementia sufferers, a group that the firm predicts will expand in size as societies age.
Despite over $40bn of cumulative private expenditure on clinical stage Alzheimer’s treatment R&D being invested since 1995 results so far have been slight.
The US Food and Drug Administration (FDA) has approved acetylcholinesterase inhibitors such as donepezil, rivastigmine, galantamine and memantine which only aim to reduce cognitive decline and don’t halt progression of the disease.
There are treatments which are intended to halt the disease’s progress, but treating the root cause has thus far proven difficult.
“The challenge at the moment, is that there is little available which treats the underlying condition in Alzheimer’s disease,” says Dr. Prachi Patkee, Life & Health R&D Analyst at Swiss Re and one of the report’s authors.
“This often means that by the time somebody gets this diagnosis they are symptomatic, and the disease has really cemented itself within their brain. It almost requires a miracle drug to undo the damage,” Patkee adds.
But what actually is Alzheimer’s?
“The neuropathological hallmarks of Alzheimer’s are a consequence of the abnormal aggregation of two different proteins, amyloid which causes plaques, and tau which leads to neurofibrillary tangles on the brain.
“Ultimately these changes result in neuronal loss which impacts cognition and functioning,” says Patkee.
According to Patkee, medications, such as acetylcholinesterase inhibitors, can’t reverse the disease, but are attempts to improve quality of life by improving the day-to-day functioning and providing symptomatic relief.
“It’s trying to treat the symptoms such as memory loss but does not address the underlying cause,” she says.
The complex pathophysiology of Alzheimer’s presents challenges for breakthroughs in curative treatments and extending life expectancy says Dr Logan DuBose, Resident Physician at The George Washington University Hospital and co-founder of Olera, a tech platform for old age care provision.
DuBose says the problems start with how to diagnose Alzheimer’s.
“While we do test for beta amyloid plaques to differentiate markers on a biophysical level that distinguish this sort of Alzheimer’s, we don’t make that distinction in common clinical practice only in very thorough research.”
There are two additional barriers to diagnosing Alzheimer’s, says DuBose. Sufferers have low insight over their condition which typically means a carer needs to bring symptoms to a doctor’s attention.
“The second red herring is called spotlighting. People perform when the spotlight is on them. Alzheimer’s sufferers are very intelligent individuals. It’s just they’re a little slower. They know their stage and they will play to the spotlight. Their low insight over their condition means they can deny having it and they are able to fool a clinician on a 15-to-20-minute visit.”
There is some cause for optimism, however. Patkee says that while the current generation of medicines may fall short it does demonstrate progress towards finding effective treatments.
“We’re on the right path in terms of finding a way to treat Alzheimer’s and there is something in scope in a field where previously there was nothing.”
Development of Alzheimer’s treatments is still at the early stages and Patkee says that even if drugs which clear the underlying pathology develop, it will be 10 to 15 years before medications which slow down the speed at which Alzheimer’s develops appear.
She instead points to other developments which could improve the disease’s treatment.
“Diagnosing Alzheimer’s earlier would help us give someone a better quality of life.”
Patkee adds focusing on an individual’s underlying health would be worthwhile in potentially reducing the risks faced by Alzheimer’s sufferers. This includes factors such as a positive metabolic health profile including a controlled diet and weight, the absence of high blood pressure, cholesterol levels and smoking.
“Maintaining a healthy physical lifestyle and mental wellbeing ultimately helps to keep you living longer and healthier, ensuring that you avoid developing other comorbidities such as diabetes or cardiovascular disease which add to the potential burden that may result in an Alzheimer’s diagnosis. At this stage, that’s the best that an individual can do for themselves,” she says.
DuBose echoes Patkee’s thoughts and says that while there is a large expectation around potential breakthroughs in Alzheimer’s treatments, a more productive approach would be to look at patients’ overall wellness.
“Everybody’s talking about these expensive medicines that are being tested like they are the answer but the proper treatment for Alzheimer’s is a good environment.
“It’s social activity and wellness. It’s exercising and meaningful relationships. It’s sun during the day and dark during the night. It’s good food, not poor food. It’s no alcohol or drugs. It’s really basic stuff.”
USAZ hosts an annual event called the ‘Race to end Alzheimer’s’, which aims to raise enough money to fund research which will eliminate the disease but DuBose says that improving support networks for Alzheimer’s sufferers could bring more tangible benefits.
“Ending Alzheimer’s is a nice idea but it’s just not a realistic goal. We instead need to focus all of our efforts in developing the social infrastructure.
“This would help to address the Alzheimer’s situation, that isn’t to say that therapeutics should be ignored, but instead, as much money, if not more, should be put into our long-term care infrastructure, because that’s where we’re going to start extending life,” says DuBose.
