Status: 18.10.2023, 17:00 PM
By: Susanne Sasse
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1.8 million people in Germany suffer from dementia. Now, a new drug is giving us hope. Alzheimer's expert Dr. Jürgen Herzog explains.
Munich-based Alzheimer's expert Dr. Jürgen Herzog explains the new opportunities for dementia patients. Dementia is the progressive loss of mental abilities. There are various signs by which the disease can be recognized early. If you want to counteract this and slow down its progression, you should start early and involve the patient in the process. Unfortunately, things often go differently. Mostly worse – as in the case of Inge Maier (name changed). The 83-year-old woman from Munich cries when she talks about her diagnosis from two years ago, so much did she feel offended by the behavior of a family doctor. "The doctor only talked to my husband, not a word to me," says the elderly woman. A bad start for the treatment, which in itself can do a lot of good. This is because the course of dementia can be influenced by 40 percent, explains Dr. Jürgen Herzog. The neurologist is Medical Director of the Schön Clinic Munich Schwabing and an expert in the field of dementia. Even as a young doctor, he conducted research on this topic at the University Hospital Großhadern.
"The progress in the fight against dementia is enormous," says neurologist and dementia expert Dr. Jürgen Herzog. He works as Medical Director of the Schön Clinic Schwabing in Munich. © Markus Götzfried
He could understand the deep insult of Inge Maier, who had the feeling that her husband and the doctor were only talking about her when making the diagnosis, but not with her, says Dr. Herzog, who also heads the day clinic for dementia at the Schwabing Schön-Klinikum. "Such behaviour only unsettles patients who already suffer from impaired memory function and fuels unpleasant mistrust. It is important to treat them with dignity."
Well-founded and early diagnosis soon possible with a simple blood test
"Today, it is possible to determine much earlier whether an incipient dementia is present – and also to be able to say much more precisely what form it is and how far it has progressed," says neurologist Dr. Herzog. Today, imaging techniques such as magnetic resonance imaging can be used to detect dementia in its early stages. For this purpose, the brain areas that are responsible for memory performance are measured. With this method, it is possible to predict with 70 percent accuracy whether Alzheimer's dementia will occur in the next three years in older people who already suffer from mild mental impairment.
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Even earlier, i.e. before deposits and changes in the brain become visible, Alzheimer's dementia can be detected in the cerebrospinal fluid that surrounds the spinal cord and brain. It is measured whether and how many breakdown products of disease-causing proteins are in it. In order to obtain cerebrospinal fluid, a so-called lumbar puncture is required. To do this, the doctor inserts a thin needle, usually between the fourth and fifth lumbar vertebrae.
From 2024, there could also be a blood test for early detection, in which biomarkers of the disease-causing proteins are also detected, explains Dr. Herzog. This blood test, if approved in Germany in 2024, could replace lumbar puncture.
In addition, there are new nuclear medicine diagnostic techniques, explains Dr. Jürgen Herzog: "With them, dementia can be detected at an extremely early stage." For this purpose, patients are injected with a radioactively labelled substance. This then attaches itself to the disease-causing proteins beta-amyloid and tau and thus marks them. This test costs between 1500 and 1800 euros, the costs are often covered by the health insurance companies.
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Great hope for antibody drugs: Can they finally cure dementia?
For decades, despite all the efforts of science, it seemed impossible to stop the destructive processes that take place in the brain in Alzheimer's disease. The problem is not only deposits in the brain, so-called plaques, but also the fact that these deposits cause nerve cells to die, explains Dr. Jürgen Herzog. Now, however, there are antibodies that dissolve the plaques in the brain. So far, they have only been approved in the USA, but from 2024 antibody therapy with the active ingredient lecanemab will also be approved in Germany. This is expected to significantly slow down the progression of the disease and could be a turning point in the fight against Alzheimer's, says Dr. Herzog. But presumably more patients are hopeful than actually have a chance of treatment, the Alzheimer's expert summarizes. "Of the 1.8 million Alzheimer's patients in Germany, I estimate that only about ten percent are eligible for treatment with lecanemab."
To explain, lecanemab is an antibody that is administered via infusions and targets harmful protein deposits in the brain called amyloid plaques. These amyloid plaques consist primarily of beta-amyloid proteins. If these plaques have already caused a lot of damage to the brain and caused many nerve cells to die, it is no longer of much use to dissolve the deposits, explains Dr. Herzog. "After all, the dead nerve cells are still lost." In this respect, lecanemab is only effective in patients with Alzheimer's disease at an early stage. In one study, it slowed the progression of the disease by 27 percent. But there's another point: "You have to take into account the fact that the treatment has side effects," says Dr. Herzog. Thus, the drug causes temporary swelling and microbleeding in the brain. Their long-term consequences have not yet been researched.
Protein deposits between nerve cells (plaques) are partly responsible for Alzheimer's symptoms. Antibodies could effectively fight these plaques in the future. © Juan Gaertner/dpa
In general, however, the Alzheimer's expert has high hopes that science will develop further drugs that have an even more positive effect on the course of Alzheimer's, he says. Two proteins, the so-called amyloid and the tau protein, play a major role in the progression of Alzheimer's. There are various approaches to stop their devastating effects – and experiments on mice have repeatedly shown success. Some substances are already being tested in human clinical trials at university hospitals in the USA and Germany.
These therapies mitigate dementia
"Although 60 percent of the dementia function in the brain cannot be changed, 40 percent of the risk can be influenced," says Dr. Herzog. "Because you can already have an effect on 40 percent, i.e. almost half, and mitigate the process here."
Drugs such as rivastigmine and donepezil, among others, are used for this purpose, explains Dr. Herzog. To explain: In dementia, nerve cells in the brain are destroyed. Both drugs ensure that more messenger substances are present in order to reach the less numerous nerve cells with more messenger substances. They therefore improve the function of the excitation conductions in the brain and thus strengthen the ability to remember and think. "In the best case, this can ease the course of dementia for one to two years," says Dr. Herzog. The drugs work as follows: Rivastigmine blocks the proteins that break down achetylcholine. Achetylcholine is the substance that activates nerve cells in the brain. Donezepil slows down degradation. In this respect, both remedies ensure that there is more substance in the brain that transmits impulses.
There are other rules that can be used to protect and strengthen people with dementia. Firstly, a fixed daily structure can also have a positive influence on the course of dementia. "Above all, you have to realize that a person in whose brain nerve cells are pathologically dying is of course no longer as resilient and flexible as a healthy person," says Dr. Herzog. Since patients can no longer react as flexibly to unforeseen events, it means enormous stress for them. "If, for example, they get off the subway one stop too early, then they are completely lost," explains Dr. Herzog. One of the most important things is therefore a fixed daily structure that gives patients orientation and security. "For example, if patients prepare their breakfast every day at the same time and in the same way, they can often do so even when the disease is well advanced."
In order to slow down dementia, its side effects must also be treated
In addition, it is very important to treat pain or depressive symptoms, for example, says Dr. Herzog. Since people with dementia often react very strongly to medication, even small doses are often sufficient. In the case of his patient Inge Maier, the neurologist is currently in the process of treating the trembling of her hands, which has recently occurred. She also receives medicine for her sadness – because if she feels better, it also influences the course of dementia. The therapies also seem to be working – at least Inge Maier says she is doing well. Hopefully for a long time to come.
This article only contains general information on the respective health topic and is therefore not intended for self-diagnosis, treatment or medication. It is in no way a substitute for a visit to the doctor. Unfortunately, our editorial team is not allowed to answer individual questions about clinical pictures.