Having an appointment with Mercè Boada to talk about Alzheimer’s means receiving a master class in biology, research, and patient care. A lesson wrapped in empathy, optimism and passion. Neurologist, co-founder, vice president and medical director of the Ace Alzheimer Center Barcelona foundation, Boada received the gold medal for scientific merit from Barcelona City Council a few months ago for her work: she is one of the leading experts in Europe in the study of the disease. Alzheimer’s and defends global care for sick people.
Every year about 40,000 new cases of Alzheimer’s are diagnosed in Spain, and more than 50% of mild cases are still undiagnosed, according to the Spanish Society of Neurology (SEN). Although it is not a normal characteristic of aging, the most important known risk factor is increasing age, and most people with Alzheimer’s are over 65 years old. Boada speaks to La Vanguardia to talk about the state of the art regarding drugs, early detection and coping with the diagnosis.
A person arrives at their center, with the feeling that something is happening in their cognitive capacity and memory…
They believe they have lost memory and their self-perception is more subtle than any diagnostic method. They have that feeling of “something is wrong with me”, “I don’t have such good language”. Nowadays we are very alert when patients inform us of this; 10 years ago it was attributed to age, fatigue, stress… It is good for us that the world in which we live justifies that feeling, when the reality is that the person is not well.
Is it a mistake for the primary care doctor to respond that memory losses are “things of age”?
Yes, of course it is a mistake. Researchers from a working group published their recommendations focused on dementia and aging in 2020 in The Lancet. They detected what can lead us to dementia, in the long term. There are 12 situations that, if we control them, we could prevent 40% of dementias – Alzheimer’s, among them, the most prevalent.
Which are?
Schooling and a good educational level, obesity, smoking, diabetes, hypertension… Lifestyle helps control many diseases, such as diabetes, which can lead to other pathologies. There are other very social factors, such as the feeling of loneliness, the tendency to depression… Also craniocerebral trauma (which is prevented by wearing a helmet), environmental pollution… Some factors, then, depend on the equity of public policies. so that we have good health.
What would you say is the most effective, in our power, to prevent the development of the disease?
Talk, read, go to the movies, read, comment, walk, have emotional relationships, we have to love each other, we can’t be alone… Pets help, we talk to them, they are faithful friends who accompany us. Walking is important, maintaining physical activity, swimming, Nordic walking… This is how endorphins and serotonin are generated. This is life.
High levels of omega-3 fatty acids in the blood are associated with a lower risk of Alzheimer’s, according to the largest population study developed in this field, co-led by the Hospital del Mar. Its authors recommend eating, for example, oily fish or walnuts.
It is not just oily fish, but it is true that it is very healthy because it contains many trace elements and a lot of omega-3. What we should do is eat a balanced diet, eat a diet with all types of fish, but also with red pepper, beans, broccoli… And at the same time, with little butter (preferably olive oil). They are the basic guidelines of the Mediterranean diet, which helps, but does not cure, of course. What you can’t do is have industrial pastries for breakfast and processed hamburgers for dinner.
Can intermittent fasting protect the brain from cognitive decline, as some studies suggest?
There are not yet solid enough studies to confirm this, but it is possible that it will go well. The Lipididiet study, very well prepared, is based on taking nutrients with a lot of omega-3, vitamins and minerals (zinc, copper, magnesium, vitamin D) and some type of other components. All these elements together make brain interconnection protected. The product that is purchased in pharmacies is Fortasyn Connect, it is a compound of nutrients that help maintain cognitive capacity. It didn’t work in people with Alzheimer’s, but in people who started with symptoms, the patients improved. The goodness or excellence of this study is that it was done with people over 70 years old, with a normal life, and they were followed for three years. Those who did not take the compound tended to lose more cognitive ability. I could eat everything that contains the drug, therefore a derived message is that I must follow a good diet.
In some people, prevention does not work; they have a hereditary component that predisposes them to the disease…
There are people who, even living a simple life and following all prevention guidelines, will develop Alzheimer’s because they have a genetic mutation, and their children will also inherit it with a 50% chance. There are also cases of sporadic Alzheimer’s: no one has it in the family, but one person develops it. We investigate the differences and equalities between those who have developed the disease and those who have not, to develop drugs.
Can anyone undergo a genetic test to find out if they have a higher risk of suffering from Alzheimer’s?
Yes, the one with the greatest risk factor is protein E, which is linked to the transport of cholesterol and fats. If a person inherits one E4 allele from the father, and one from the mother, he has a higher risk of developing Alzheimer’s. From a scientific point of view, I would like everyone to be able to undergo a genetic test like this at the age of 30 or 40. This would give us millions of pieces of data, I could find a component so robust that it tells me that for sure you will or will not develop the disease.
At home, what are the first signs or manifestations that can be noticed and can be related to the disease?
That the person does things badly, or worse than before. There are activities of daily life that we minimize because we have done them all our lives, but that are actually very important. An example that I always give: a woman who runs the house is an executive woman, it is like running a company: she prepares breakfasts, thinks about what is there, plans the meals, goes shopping to buy for x diners… This is an executive function: You can modify what you planned to do, based on the prices of each day, improvise and change plans. If before the person was not dazed or overwhelmed and now he is, it may be a sign. There are patients who express: “I go to the market and I don’t know how to shop.” The early symptoms of Alzheimer’s are extremely subtle.
When do we have to go to the doctor?
At the first moment we realize it. If you wake up one day and have a puncture in your chest, you think you may have a myocardial infarction, and you go to the doctor. It is the same with losses of cognitive capacity. In primary school, attention to these first symptoms has changed a lot, it is quality medical care, with great knowledge. The primary care has gone from sending us very advanced patients, for whom we hardly even needed to test, to sending patients in very early stages of the disease. At the first subtle signs of lack of memory, you must undergo an MOT.
How is the diagnosis of Alzheimer’s reached? What tests are done?
The first thing is to listen to the patients’ stories about what they notice happening to them. We must be attentive to see the social image of that person: what they did, what they did, what level of education they have, what economic level… See what degree of executive function they had and have, how their cognitive development has been. We have learned that each function is located in a part of the brain: memory, language, brain behavior… With neuropsychology we design a test or questions to record or inspect a specific area of ??cognitive function, these are the cognitive domains. Sometimes only one of them is affected.
What is different about a brain with Alzheimer’s?
We say that Alzheimer’s has two biological signatures or hallmarks, which is the presence of the beta amyloid protein and the tau protein. They are two proteins that change their structure, they fold poorly. Which of these two triggers the deposit of the other and what synergies do they have? There is no brain with Alzheimer’s that only has beta or beta and tau, but the brain is full of other proteins and other cells, and over time, or triggered by a genetic cause, many other pathologies appear, such as cardiovascular disease. Diabetes or hypertension are neurovascular diseases, they influence the development of Alzheimer’s, for example.
Studying the gait of those with memory or language problems can help determine the risk of Alzheimer’s, according to a study published in the Journal of Alzheimer’s Disease Reports. Is that so?
Yes, areas of flexibility and balance can be affected. When we are old we walk worse, we are not as agile to get out of a car or get up from a chair and swing. Balancing is one of the characteristics of neurodegenerative diseases focused on the motor component, such as Parkinson’s.
Will the future of diagnostics be a blood test?
Yes, it will go this way. The route of early diagnosis will come through blood samples. Research groups are trying to see if with a drop of blood they can observe what they see in the cerebrospinal fluid—which bathes the brain and is the most reliable translator of what happens in the organ. We will look for the mark of these proteins that signal Alzheimer’s. We are constantly looking for and analyzing signs that may be external signs of the disease, that something is wrong with the brain.
Can artificial intelligence help with early diagnosis? Is it already being applied?
Artificial Intelligence or new technology (itech), or both combined, can offer data that a short time ago, and even now, seemed implausible. We can detect, very early, spontaneous language alternations that could be the very early signs of a cognitive disorder that will lead to Alzheimer’s or other diseases. Now platforms are being designed to granulate language, motion sensors to analyze how a person gets up from a chair…
From the first symptoms, how many years can an Alzheimer’s patient still be good?
Many. We have 200 people—whom I thank for their collaboration—some of them complained of symptoms, but they were fine. We have been following them with MRIs, we have seen their amyloid beta, we have done some neuropsychology batteries… The result is that there are people who have been coming for 8 years and are still fine; others have lost a little (mild cognitive impairment), and in these eight years none has gone into dementia. These people should follow what The Lancet Commission recommends, take care of themselves.
Will we soon have a drug or cure for Alzheimer’s?
Yes, but this is a successful disease, we have learned a lot about the brain and its mechanisms, what is called epigenetics. Alzheimer’s is not a disease that depends on just one gene, but many of them interact with each other, each with a specific function. There are groups of genes that generate the risk of developing Alzheimer’s, and others that can protect.
In the United States, a drug is prescribed, Leqembi, which has shown a decrease in cognitive deterioration… What effects does it have and what risks?
This drug fights beta amyloid, the misfolding protein. To prescribe it, it must be proven that the patient has this protein in their brain. It has been proven that it controls the evolution of the disease by 25 or 27%. Academic and scientific voices know that it is little, and it is true that the costs are high, who will pay for it? Sometimes making a decision involves having a few perspectives. Additionally, those who take it may be at greater risk of cerebral edema. When we have it here, the prescription may be different due to these possible adverse effects.
What would you say to families with a recent diagnosis of Alzheimer’s?
I advise understanding the disease, knowing that memory loss leads to behavioral changes. Patients realize that they are breaking down, and it is normal for them to have a bad mood, they become stubborn, they want to be right… Families must be explained that sometimes they must close their eyes, hoping that the patient’s bad moment will pass. . I recommend that they go to a day center, just as they would take a child to school because that is where they will grow, learn and build a future; Alzheimer’s patients maintain abilities to learn and relate. If we are at home accompanied and sick, we will get very tired. Families believe that they are abandoning their relatives with Alzheimer’s when, in reality, if they take him to a day center, they are taking him to the best school that he needs.
