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  • Dr. Karen Lynch: The Doctor Is In

The Doctor Is In

Dr. Karen Lynch answers questions from a recent Womens Health Initiative, sponsored by the Cape Cod Healthcare Foundation

Attendee: Does Alzheimer’s skip a generation?

Dr. Lynch: Yes and no. In the less than 1% of cases that are definitely genetic (that we currently have discovered genes for), i.e. under 65 years of age or early onset, they are dominant and tend to be passed on through each generation. The other genes (more common) that are found in Alzheimer’s cases simply increase the risk of Alzheimer’s in a patient but not definitely cause it (see question 5 below for more details). If anyone has come across “23 and me” (genetic send out testing commercially available to look at genealogy and lineage) they send back results such as “you are 6 times more likely to have restless leg syndrome, 5 times more likely to have colitis “. So, it puts you at a slightly higher risk, however you may have the gene and not display the disease. Hence why it certainly skips generations and can be hard to pinpoint why one case with the gene (APOe) displays it more than another – environment probably plays a role.

Attendee: Since we only use 20% of our brain, can we re-wire what we have left?

Dr. Lynch: There are ways that patients can help optimize parts of the brain less affected by dementia (for example the creative centers of the brain which rely less on the memory areas). However, as this is an illness of older people, as you age your ability to “re-learn” or induce/improve neuronal plasticity (re-wire) becomes less effective. The nature of this illness also means that eventually many more areas of brain will become involved as it progresses – however if you work at learning and participate in cognitive programs such as ones that can be found at many memory disorders/cognitive rehabs across the Cape, memory and function can be optimized thus often slowing progression and maintaining function.

Attendee: Is the genetic testing for AD expensive/complicated?

Dr. Lynch: This often depends on your insurance. The testing is not complicated and can be done through outside labs, but Medicare does not cover this testing. Overall, it is a small minority of patients who have genetic tests usually if they are young, or have a strong history and/or if they specifically request it. It obviously can have huge emotional implications for children of the patient should tests be positive, thus counselling is often advised.

Attendee: Adult Day Health Programs: VNA in Sandwich; JML in Falmouth; both great resources for families with AD.

Dr. Lynch: Yes - both great and highly recommended.

Attendee: How frequently is the Alzheimer’s gene found in children if one parent has the disease?

Dr. Lynch: I can’t give a figure on this as most patients with Alzheimer’s don’t get genetic testing – by far most of it is sporadic i.e. just occurs without a genetic basis. A clear inherited pattern exists in approximately 10% of cases, however over the years and with research, we believe that this figure is likely higher; probably in the region of 1/3 of cases have some genetic basis. The difficulty lies in undiscovered genes, which is why research is so important in understanding this disease.
There is a SMALL proportion (less than 1% that it pass through each generation – a dominant gene, and this occurs in those under 65 (early onset). These mutations are in 3 genes that make proteins (APP, Presenilin 1 and 2). The other genetic test is for those patients that have an INCREASED risk of AD – Having a particular “codon” or allele on your genetic make-up called APOEε4 allele increases the risk of the disease by three times in heterozygotes (those with one copy) and by fifteen times in homozygotes (those with 2 copies). A majority of Alzheimer’s patients that do want testing, and receive it, usually possess 1 or 2 of this allele. Finding this allele in a patient however doesn’t tell me much about a child or how many if any copies they have. Like many human diseases, environmental effects and genetic modifiers result in incomplete penetrance through generations. This makes it impossible to predict if a child of a patient is at risk, if the allele is found. They would need to have testing, which usually is not advised if they are not symptomatic.

The main thing to consider is the children in this, as it can leave them in a huge dilemma, anxiety and fear if mom or dad has the gene. In some cases a parent with the gene is also left with a decision in that should they keep it to themselves (not wanting to worry anyone), or should they tell the family and be open and honest about the risk. It’s an extremely difficult decision.

Attendee: Is there any correlation between having severe migraines and dementia later in life?

Dr. Lynch: No correlation to this. Uncontrolled migraines can cause “white spots” on the brain, along the same lines as developing freckles if exposed to sun. These spots are probably mild inflammation that occurs with regular migraine. Lots of studies have been done on this as it is such a common disorder and we see these white spots on the brain all the time in people suffering from migraines. However they have not been shown to affect cognition and not linked to dementia, that we are aware of at this time. With the number of migraines if there was a link , we would most definitely see much more dementia cases than we are and more women (as women are X3 times more likely to have migraines), but that isn’t the case.

Attendee: What are must do’s for reversing dementia?

Dr. Lynch: Unfortunately there is no way to reverse this disease. Medications slow the progression. However some areas I stress to patients who might be worried about memory loss as they age, and for those who already have early signs of mild memory loss, include exercise, omega 3 fatty acids, being engaged in activities – social, physical or a hobby, flavonoids (tea), cutting out excessive alcohol intake, vitamin D supplements, recognizing mood issues and addressing them sooner rather than later – depression can often mimic dementia.

Attendee: What type of prescription drugs put one at higher risk?

Dr. Lynch: No drug or prescription medication has been shown to cause dementia to date that we are aware of. A type of Parkinson’s dementia was caused by illicit drug use in the 70s - PCP. There may be data in the future regarding other drug use as studies come out.

Attendee: What is meant by acute medications? Is long term use of propananal dangerous (3x daily 2 mg)

Dr. Lynch: Acute are medications used when migraine starts. Right away and usually on an as needed basis. These are usually oral in tablets or dissolvable, nasal spray or injection if patients have vomiting.

Propranolol is relatively safe overall for migraines. In young women and older patients, I closely watch blood pressure and heart rate as this can predispose to fainting or syncope in this group of patients. In diabetes propranolol can effect sugar levels/glycemic control. If it’s effective and you tolerate it well with no reason to stop it, then keep on it.

Attendee: What are infectious disorders?

Dr. Lynch: Viruses, AIDs, syphilis, Lyme disease, CJD, more rarely fungal infections and parasitic infections. There is some data that the common viruses that we see causing cold sores (HSV1), genital herpes (HSV2) and CMV could be linked to increased risk of dementia in later life. Studies are very small and not conclusive as these viruses are so common in the general population and with a relatively prevalent disease such as dementia it may be more of an observation not causative. There is also a body of work on the possibility of “a virus” causing dementia.

Attendee: Lewy Body dementia…more explanation, please.

Dr. Lynch: It’s the 3rd most common type of dementia – after AD and vascular with about 1.5 million in the US. People with Lewy body dementia have the same progressive decline in their memory and ability to think as AD cases; however they will often fluctuate from one moment to the next, seeming more alert at times. Visual hallucinations (seeing things that aren't there) and delusions (believing something that is not true) are quite prominent in these cases. Patients often resemble Parkinson's disease hence it can sometimes be misdiagnosed initially, however they respond poorly to medications for Parkinson’s. There is no specific treatment for dementia with Lewy bodies, so patients are treated with the same medications we use for Alzheimer’s.

Attendee: Is there a “typical “profile of women who have migraines?

Dr. Lynch: This is a fun question! Conscientious, intelligent, straight A’s, creative/artistic (Van Gogh), light sleepers, aware of environment and people around them, feelings often can get hurt, cold feet and hands and skip breakfast! You find many migraine sufferers in med school!

Attendee: Are migraines hereditary? Husband/2 daughters have them.

Dr. Lynch: Yes - well known to be genetic.

Attendee: How is the Botox administered for migraine?

Dr. Lynch: 31 injections are given by a very small needle (same used for cosmetic purposes), by a neurologist trained in this (I do not recommend this done by someone who has not been trained to administer it for migraines as it is given to specific sites established through rigorous studies). Botox is given into muscles around the face, posterior head, neck and shoulders. It usually takes 15 minutes and is given every 12 weeks.

Attendee: Do cosmetic injections help with migraines?

Dr. Lynch: Yes and no – this was how Botox for migraine therapy was found to be a potential treatment after a physician in California found that his female patients who had migraines and who were getting cosmetic Botox had improvement in their pain. Botox for chronic migraine follows different injection paradigm/areas (31 injections in sites around the head, posterior neck and shoulders). Cosmetic Botox is obviously limited to muscles causing furrows for example and is out of pocket. Botox for chronic migraine is FDA approved and the only treatment approved for chronic migraine.

Attendee: Thoughts on acupuncture and headaches?

Dr. Lynch: See below – works very well in many cases

Attendee: Is acupuncture a good way to deal with migraines?

Dr. Lynch: Yes in certain patients – must be comfortable with the technique and open to holistic approach. Its great for most chronic pain issues too – neuropathy included. Probably in part a placebo effect. I advise at least 2 sessions to be tried before deciding its benefits – one session often not enough.

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