Committed to memory

The elderly Indian population is increasing due to improved lifespan. Dementia, which impairs mental processes, affects millions and is often referred to as a hidden epidemic. Currently, an estimated 8.8 million Indians over the age of 60 have dementia. By 2050, people over 60 are predicted to make up 19.1 per cent of the population. Globally, there are 50 million people with dementia, with ten million new diagnoses every year.

Alzheimer’s dementia is the most common cause of dementia, affecting memory, thinking, reasoning, judgement, and comprehension. The irreversible decline in intellectual and physical functioning places a significant burden on both
families and society.

Prevalence of dementia in India

Changes in the brain, leading to dementia, start at least a decade before the clinical symptoms appear.

Research indicates that Alzheimer’s dementia can develop over 20-30 years.

Brain imaging and post-mortem studies have revealed that factors such as the deposition of amyloid and tau proteins and loss of grey matter collectively contribute to dementia.

The Indian population has a high prevalence of diabetes, hypertension, and obesity, which increases the risks of both Alzheimer’s and vascular dementia. 

Dr Ratnavalli Ellajoysula, a senior dementia neurologist specialist who probably initiated the first memory clinic in India, notes that the incidence of dementia in India is similar to that in the West. However, detection rates vary between urban and rural areas. Dr Sridhar Vaitheswaran, assistant director and consultant psychiatrist at Dementia Care in SCARF (DEMCARES) Chennai, attributes the lower detection rates in India to literacy levels, social inequalities, and limited access to healthcare.

Diagnosis

The diagnosis of Alzheimer’s dementia is primarily based on clinical criteria. The standard workup includes neuropsychological tests and an assessment of daily activities. However, since these tests are often adopted from Western settings, they may not fully capture the cultural diversity of a country like India. Dr Ratnavalli emphasises the need for an inclusive approach to ensure these tests and questionnaires are valid across different languages and cultural contexts. Imaging tests such as MRI and PET scans are done as part of investigations.

Biomarkers

Traditionally, understanding Alzheimer’s disease relied on studying patient symptoms and diseased brain tissues. With proximity to the brain, the fluid surrounding the brain called Ccerebrospinal Fluid (CSF) has been used to diagnose dementia.

But now, scientists have looked at analysing biomarkers (a molecule that is a sign of abnormality) in the blood to make that diagnosis. “We have good blood tests for heart, kidney, liver, inflammation, and blood disorders. Diagnosing Alzheimer’s dementia through a single blood test is a monumental step forward,” says Professor Henrik Zetterberg from UCL Queen Square Institute of Neurology, London, and the University of Gothenburg. As a world expert on biomarkers, Professor Zetterberg focuses on how these biomarkers enable the early diagnosis and detection of diseases before symptoms manifest. Identifying a biomarker that can detect the disease in its earliest stages can help slow or prevent its progression and monitor its course. His team has developed an ultrasensitive test to measure a protein called p-tau 217.

Dr Ashvini Keshavan, a consultant neurologist from UCL Queen Square Institute of Neurology, is co-leading a trial to demonstrate its utility in the real world in the setting of UK memory clinics. The trial’s intervention is disclosing the plasma p-tau 217 results to the patient and clinician (which will be given to 50 per cent of people). The trial will find out whether the p-tau 217 result makes a difference in how many are diagnosed with Alzheimer’s dementia and the care they receive.

Plasma p-tau 217 is known to increase in individuals with no symptoms who are developing brain amyloid pathology, but only a third of them eventually develop symptomatic Alzheimer’s dementia; Dr Ashvini cautions the test should not be offered to people who do not have symptoms suggestive of Alzheimer’s dementia.

Professor T Govindaraju and his team, Alzheimer’s researchers from the Jawaharlal Nehru Centre for Advanced Scientific Research (JNCASR), Bengaluru, have developed a biomarker probe called VNIR AD that targets the Abeta amyloid plaques in the brain. It can be administered and followed by a near-infrared (NIR) and PET scan for diagnosis.

Treatment

A class of acetylcholinesterase inhibitor drugs prevents an enzyme from breaking down acetylcholine in the brain, aiding nerve cell communication. Donepezil, rivastigmine, and galantamine are used to treat symptoms of mild to moderate Alzheimer’s disease. Additionally, two drugs are being used in early Alzheimer’s disease — Lecanemab and Donanemab, to clear the brain of amyloid, which is currently unavailable in India.

After a decade of research, Prof Govindaraju’s team have discovered a small molecule drug candidate, TGR63, for Alzheimer’s disease. TGR63 significantly reduces amyloid burden and reverses cognitive decline in animal models. It has been picked up for clinical trials by a pharma company.

Non-pharmacological options

Dementia India Alliance (DIA) has launched India’s first comprehensive expert-led online memory clinic for the elderly, focusing on assisting families in creating person-centred care plans. Dr Radha Murthy, the president of DIA, highlights various non-pharmacological treatment options, such as cognitive stimulation therapy and social interaction, which encourage patients with dementia to engage in structured activities to stimulate thinking, concentration, and memory.

Regular physical exercise has been shown to slow cognitive decline. Additionally, creating dementia-friendly environments at home by reducing clutter, improving lighting, using appropriate signage to identify rooms and objects, and establishing consistent daily routines helps patients navigate their surroundings safely and manage their daily activities better.

Cogworks is a novel intervention enrichment programme for healthy elders and dementia patients in Bengaluru. The Cognitive Neurology Clinic started the first of its kind in India. It uses art, movement therapy, puzzles, and brain games
to slow dementia.

Prevention

Studies from the Netherlands Institute of Neuroscience have shown that certain individual brains are resilient in removing toxic proteins associated with the development of Alzheimer’s dementia, a phenomenon still under active investigation. “Adhering to brain health right from childhood and adolescence and adapting based on abilities over the ages can help reduce the risk for dementia immensely,” opines Dr Sridhar. From an Indian perspective, diagnosing and treating hypertension and diabetes is the best intervention. Dr Ratnavalli stresses the importance of adopting healthy lifestyles early, recommending that individuals in their 20s engage in regular reading, reduce social media usage, maintain good sleep hygiene with 6-8 hours of sleep, and quit smoking and alcohol. She opines that prevention is an excellent real-world strategy for dementia, as it is more cost-effective for a low-income country like India. Both experts agree that developing brain reserve through mindful activities, healthy social interactions, and regular meditation is beneficial for preventing dementia.

Those interested in the benefits offered by DemClinic, can log on to www.demclinic.com or call 85 85 990 990 for assessments, care plans, or training on helping persons with dementia.

Address these modifiable risk factors

• Less exposure to
information
• Hypertension
• Hearing loss
• Smoking
• Obesity
• Depression
• Physical
inactivity
• Diabetes
• Social isolation
• Excessive alcohol
consumption
• Head injury
• Air pollution
• Loss of vision
• High HDL cholesterol

(The author is a consultant haemato-oncologist with a special interest in stem cell transplantation at Royal Wolverhampton NHS Trust, UK. He can be reached at [e-mail].)