Abstract
A recently presented concept of Alzheimer disease (AD) is based on a primarily ischemic (rather than degenerative) type of brain disease. Etiologically, this new concept is presumed to be related to the human upright gait along with individual predisposition.
The proposed treatment—head-down therapy (HDT)—is the centerpoint of this presentation: a simple and generally accessible type of therapy, with monitoring by neuropsychological questioning, electroencephalography, and transcranial Doppler. As a treatment of AD (limited to stage 1), HDT is expected to be helpful. It is possible, however, that its prophylactic use may be of even greater importance.
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INTRODUCTION
The concept of Alzheimer Disease (AD) as a primarily ischemic disorder (without true vascular disease) has opened the door for therapeutic action. 1 The primary ischemia causing AD might be a price to be paid for our upright gait: in predisposed persons as early as age 40 years (with a prevalence climbing from 0.4% to 30% at age 80).
Paramount is the strict separation of AD from other types of dementia and, above all, from the dementias associated with cerebrovascular disorder (multi-infarct dementia). Whenever a patient with suspected AD has a history of high blood pressure, coronary disease/myocardial infarction and any type of stroke, the associated dementia is then most unlikely to be of the AD type. Furthermore, nicotinism with its well known cardiac, cerebral and peripheral arterial effects is hardly compatible with AD. To understand AD, understand first its limitations!
THE THERAPEUTIC APPROACH: HEAD-DOWN THERAPY
“Head down!” sums it up. The patient lying on the back, being placed on a tiltable bed with the head below the horizontal. How much lowered? The treatment must be done within the limits of safety and comfort. When the head is lowered between 1 to 5 degrees, the therapeutic sessions of 1 hour duration are likely to be well tolerated. Steeper lowering of the head (5–20 degrees) should be done with reduction of duration.
HEAD-DOWN THERAPY AND STAGE OF DISEASE
Advanced stages of AD are certainly too late for the initiation of head-down therapy (HDT). Once memory is not the only affected function any more and signs of speech disturbance (paraphasias) are becoming prominent, the widespread neuronal loss will make HDT useless.
Is stage 1 of AD therefore the ideal period for HDT? Certainly, as long as the presence of AD is the only criterion. But it is quite possible that HDT will turn out to be even more successful in the prevention of AD in patients with mild or marked cognitive decline yet without evidence of AD. It is quite possible, if not likely, that such prophylactic therapy will find a much greater number of HDT users. The fear of AD has always fostered anxieties in healthy middle-aged persons concerned about their decline of memory—be this within or above normal limits.
Therefore, the use of HDT may spread far beyond the domain of hospitals and similar institutions. In the home setting, it may become a “do-it-yourself” treatment. This may prove to be an effective preventive method, but it must not turn into a mere fad. Using an ordinary bed, with the patient lying on a flat surface, the feet can be lifted to a reasonable height of about 4″ by raising the foot section of the bed, placing its rear posts on blocks of such size.
Will this not amount to veritable chaos in a field where scientific exactitude ought to reign supreme? Of course it will—but as long as the do-it-yourselfers note improvement, one will have to be tolerant. As long as strictly scientific projects are going on in the hospital setting with monitored HDT, the door should remain open for those who, driven by anxieties, rush to the homemade treatment.
At this time—in the absence of data—it is still unknown if HDT is more successful in the prophylaxis than in the treatment of AD.
Hearsay has it that advanced Yoga exercisers who stand on their head every day—a position usually not longer tolerable than 1 minute—never become victims of AD. If this turns out to be more than hearsay—if this is correct—such a strong argument should remove further obstacles on the route to widespread prevention of AD.
THERAPEUTIC SESSIONS WITH MONITORING
In the clinical setting, the treatment should be monitored by the following methods: a) Neuropsychological questioning, b) EEG, and c) Transcranial Doppler. For those experienced in the P300 methodology, that method can be recommended for the monitoring of AD. 2
Neuropsychological questioning
Neuropsychological questioning—ideally done by an experienced clinical neuropsychologist—can be performed in many ways. If familiar with the patient's family situation, names of children and grandchildren, dates of their lives, their schools, their husbands/wives, and information about cousins and other relatives, are quite appropriate. Does the patient know his/her birthday or wedding day? In what town is he now, where did he live before? Then, of course, there are the usual questions about the present president of the USA and his predecessors. Presenting pictures of presidents may reveal a form of agnosia (usually beginning in the second stage of AD, a stage that could be too late for the use of HDT). Whatever is being questioned in the course of a therapeutic session should have been asked before HDT for comparison.
Electroencephalography
In stage 1 of AD, slowing of the EEG gradually increases, starting with a 4–7/sec and some 1.5–3/sec activity over the temporal area. The posterior basic rhythm gradually slows down to 6–8/sec. Temporal slowing may be intermingled with sharp potentials (almost always unassociated with clinical seizures).
In the head-down position, a reduction of slowing should be expected. The use of computerized frequency analysis may or may not provide further informative data.
Transcranial Doppler
In view of suspected major neurocirculatory problems, sonography, transcranial Doppler has been used in recent AD studies by Silvestrini et al. 3 and, in particular, by Ruitenberg et al. 4 who were impressed with the diminished cerebral blood flow velocity. This method has to be warmly recommended.
A new concept—still without data
Without data?!—a horrifying prospect in modern clinical medicine! But the concept had to come first because the reigning concept is flawed and has to be mended.
“Concept before data” is a normal situation for physicists and chemists. Yes, it is true: those scientists smile or even laugh at the total data-dependence in biomedicine. Data will come to prove the new concept right—or wrong. But as long as a concept is based on logical thought, there is nothing to fear.