The lecture was at UCSD medical school by Gary W. Small, M.D, that focused on his latest book, "The Alzheimer's Prevention Program: Keep Your Brain Healthy for the Rest of Your Life." Here is the video, of his hour long presentation. When you watch it you will probably will be charmed by his candor, friendliness and erudition-- as I was initially
The man does have a comedic touch that conveys a sense of humility in spite of his high standing in his field of medicine. Seeing the word "Prevention" in the title of his book, knowing there is none for this disease, aroused my suspicion, and started the analysis that this essay elaborates on, and is a part of my article in the Septermber 2013 issue of "The Humanist," magazine. He justifies towards the end of his lecture the use this word in the book's title by saying that by his program postponing onset, if you die before getting the disease it will have been "prevented." That's may be valid, but only if there were actual evidence that his program does delay onset of the disease, along with the lifespan of the patient. He admits that he doesn't have a cure- which is different from prevention, but does not withdraw the claim of the title. With a friendly uncritical audience, not only is this inapplicable word accepted, but insidiously it begins to change the general meaning of the word, "prevent."
This book title is doing violence not only to the reality of the current clinical course of this disease, but to our language itself. "Prevent" and "postpone" as these links demonstrate do not overlap with common synonyms. Even if his claim to postpone were true, it would not constitute prevention. But language is always in flux, and Dr. Small's misuse of this word will have the effect of legitimizing this distortion in claims for the myriad panaceas for everything for "preventing" cancer to autism. A precise word is thus distorted in the service of confusing the public for self gain.
Dr. Small starts by acknowledging the vast number of studies that are reported every week, and then goes on to feature those that support his case, often accentuating the word "significant" to describe the positive effect. Those who have taken a statistics course will know that such technical significance is not necessarily meaningful, as the word generally connotes. The studies are even less meaningful when culled to present a narrative, rather than evaluated in the context of all other research of the same treatment.
With this slight of hand he asserts various conclusions, such as that Omega 3 fish oil is one of the four ways to "prevent" dementia. He ignores the consensus from various disinterested sources such as the National Institute of Health that states
"Impact on cognitive function: The quantity and strength of evidence is inadequate to conclude that omega-3 fatty acids protect cognitive function with aging or the incidence or clinical progression of dementia (including Alzheimer's disease), multiple sclerosis, and other neurological diseases."
He adds recommendations for being physically active, eating healthy and having friendships--something few would argue are not good things in themselves. Unfortunately, friendships are not available for purchase, and are built on affiliations and personal attributes that most covet, but some have not acquired.
It's important to point out that if this talk, and the book, had been written by just anyone, even a medical doctor with minimal credentials, I wouldn't have written this essay; but it was by someone who is the head of the Aging Institute of an esteemed university, UCLA. Thus his words transcend his personal opinion, as it represents to many frightened people the real chance of actually preventing a dreaded disease. It also raises the bar of what level of distortion is acceptable for others who would make unrealistic promises for self gain.
For people who are diagnosed with Alzheimers, his equating of simplistic mnemonic memory techniques with brain health is not only unfunny, but cruel. Dr. Small even talks about his success in convincing a man to take up walking, perhaps to tell the audience that little things can help. The people in the audience laughed with him, and why not, as he made it sound oh so easy. If you accepted his conflating "memory devices" with "brain health" which will then prevent dementia- some slippery word play that you had to listen to carefully to catch-
Dr. Small (at 32 minutes of the video) describes one study of "cognitive and physical successful aging" that showed it was only one third determined by genetics. He did have a slide up referencing ...."lower risk for dementia" so it's fair to say this was what the audience would infer he was referring to. This must be contrasted with This statement from a comprehensive survey of 179 studies on this question, where the genetic cause is evaluated by tracing family members by degree of shared genome.
Regardless of the individual parameter estimates obtained from these studies, the ultimate conclusion is unifying and support a significant genetic component for AD estimated at 60–80%.
Dr Gary Small, understates the actual extensive evidence of the genetic cause of this illness by about half. Such inaccuracies support the potential value of mental exercises--a program of which he has licensed- in postponing the onset of Alzheimers in spite of scant evidence of their effectiveness. His explanation of the pharmaceutical Aricept (at 30 minutes into his lecture) , is a clear distortion of the actual effect. He has a chart that shows that the slight increase in cognition only drops when it is discontinued, which is not the case, as within 18 months there is no residual benefit. This could not have been understood by those who viewed his presentation. The Alzheimers Association describes here his assertion as the myth that, "There are treatments available to stop the progression of Alzheimer's disease"
Reality: At this time, there is no treatment to cure, delay or stop the progression of Alzheimer's disease. FDA-approved drugs temporarily slow worsening of symptoms for about 6 to 12 months, on average, for about half of the individuals who take them.
This explains the attitude that I brought to writing this, knowing that my Mother and those in her ward, many of whom spent their last years in frightened confusion, were not responsible for their condition. And also knowing that it is the physician's interest group that wants the earliest manifestations of memory loss to be diagnosed as a disease so they can have this vast source of the worried well to treat, and to bill.--which was the focus of my The Humanist article referenced above.
Dr. Small's down to earth expertise ensures no one will challenge his book or this presentation to non professionals. He has little concern that anyone will bring up the most definitive surveys of research that evaluates his program's validity. This major study done by the National Institute of Health in 2010, is an example of such studies, with this conclusion:
Nevertheless, there remain important and formidable challenges in conducting research on these diseases, particularly in the area of prevention. Currently, firm conclusions cannot be drawn about the association of any modifiable risk factor with cognitive decline or Alzheimer’s disease. Highly reliable consensus-based diagnostic criteria for cognitive decline, mild cognitive impairment, and Alzheimer’s disease are lacking, and available criteria have not been uniformly applied. Evidence is insufficient to support the use of pharmaceutical agents or dietary supplements to prevent cognitive decline or Alzheimer’s disease.
The problem of MCI diagnosis proliferation is actually worse than I described, as I found out only after I had written this essay. It turns out that Dr. Small gave a version of this lecture as a main speaker at the 2013 Psychiatric Association Conference, as described in this article on Medscape, a website directed to those in the medical profession. As of this writing there are about eighty comments mostly from psychiatrists. None have chosen to state an objection to the the misleading and inaccurate aspects of his presentation that I describe here.
Having trust in the integrity and skill of our personal physicians provides a palpable sense of security and well-being for many, especially when faced with disease or injury. It is perhaps natural to resist accepting the implications of this kind of seemingly self serving distortion, especially when it is not only by one individual, Dr. Small, but tacitly ratified by an entire specialty. Psychiatry, with extensive impact on defining normalcy, deviance and individual responsibility, has a unique impact on cultural values beyond the medical setting that must be subjected to critical analysis commensurate with this social impact.
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*see MCI or CRS, why the name of a decline of memory matters.
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