The New Modesty

No Big Breakthroughs in Dementia Research, but Some Improvements in Treatment

Editorial to accompany the article: “Non-pharmacological treatment in people with cognitive impairment—results from the randomized controlled German Day Care Study” by Melanie Straubmeier et al. in this issue of Deutsches Ärzteblatt International

It is more than a quarter century ago that optimistic molecular biologists let us know us that the mystery that is Alzheimer’s disease was going to be unravelled within a matter of months (1). They predicted that treatments were going to be developed rapidly and that Alzheimer’s, which was threatening to become mankind’s new plague, was going to be defeated once and for all. With hindsight we now know that the path to knowledge has been rather more laborious and slow than anticipated. We have learnt and understood a great deal about the mechanisms of neurodegenerative disorders, but none of our newly gained insights has actually brought about innovation or changed routine therapeutic practice.

Therapeutic successes still limited

The diagnostic evaluation of Alzheimer’s disease has progressed immensely. The in vivo exposure of amyloid plaques and pathological fibrils on positron emission tomography or relevant analyses of cerebrospinal fluid have made postmortem examination for the ultimate diagnosis less important. But standard medication therapy using acetylcholinesterase inhibitors and memantine still constitutes the gold standard for treating Alzheimer’s disease, although these substances have intermittently been considered to constitute an unsatisfactory provisional solution on the way to etiology-oriented therapy, and the clinical relevance of their effectiveness has been the subject of ongoing controversy.

There is no doubt that in the past decades, society has focused on dementias to an increasing degree. This is certainly also thanks to reports of progress in basic research and diagnostic methods. More modest therapeutic approaches have been subject to scientific validation; these do not have any mechanism of action that is etiology-oriented, but they offer support to us in dealing with, motivating, and accompanying patients and their families, and are therefore valuable aids.

Effective interventions for everyday life

Relevant therapeutic suggestions have been summarized under labels such as cognitive approaches, occupational therapy, physical activity, and creative therapy. In studies, these have shown partly positive results, but effect sizes were small (2). The present study (3) fits into exactly this context. It included patients with mild cognitive impairment or mild and moderate dementia. All patients lived in their own homes and spent one or more days each week in a day-care center. The intervention (called by its German acronym MAKS)—which involved motor skills, practicalities of everyday life, cognitive skills, and social skills—consists of several modules that were always offered in the same sequence for 2 hours each. The intervention was part of the program at the day-care center; there is an instruction book/manual, and, according to the authors, staff are easily able to learn it with the relevant training. The intervention does not impose any rules on the day-care centers in terms of further planning or procedures, which is likely to improve its acceptance. The intervention sticks closely to what patients would usually expect from a day-care center.

The study is of a high methodological standard, in as far as that is possible in studies that are close to reality. Single blinding was naturally the only option in terms of the fact that those who collected the data were not involved in administering the therapeutic measure and remained unaware of the allocation of patients to the intervention group or control group. The results indicate that patients’ ability to perform had stabilized; the intervention was not expected to lead to a specific improvement of cognitive skills. The authors point out the high external validity of the intervention; furthermore, its effectiveness had already been shown in nursing homes. A positive effect was seen where the intervention had been delivered for a period of one year (4).

Reactivation of dormant reserves

Why is this intervention so important? It isn’t only simple and straightforward, but it can also be delivered in a setting that already exists and whose statutory funding has for a long time been guaranteed thanks to Germany’s statutory long-term care insurance. It does not require complex preliminary work, great expenditure, structural building changes, or highly specialized therapists. It potentially reaches the crucial and largest proportion of the target population, since in Germany, most people with mild dementia or mild cognitive impairments live in their own homes and are able to access day-care centers. It may be assumed that the intervention enables participants to summon up dormant reserves. As it is unlikely to affect the disease process, its effectiveness is probably temporary.

The authors have contributed to making available a simple, effective therapeutic method that fits in with the everyday running of a day-care center, which will also improve the acceptance of the centers. The selection of day-care centers is not usually within the area of competence of physicians in private practice. A relevant therapeutic orientation could, however, lead to a situation where doctors collaborate with those day-care centers that have implemented a therapeutic service whose effectiveness is confirmed.

The study (3) does not represent a breakthrough in dementia research, but it is a helpful add-on to our therapeutic offering. It also shows clearly how limited our options still are and are certain to remain for a long time—in view of the unmet need for etiologically based therapy. We have become modest in our expectations.

Conflict of interest statement

The author declares that no conflict of interest exists.

Translated from the original German by Birte Twisselmann, PhD.

Corresponding author
Prof. Dr. med. Hermann-Josef Gertz
Universitätsklinikum Leipzig
Liebigstr. 18
04103 Leipzig, Germany

Cite this as:
Gertz HJ: The new modesty—no big breakthroughs in dementia research, but some improvements in treatment. Dtsch Arztebl Int 2017; 114: 813–4.
DOI: 10.3238/arztebl.2017.0813

References

1. Henderson AS, Henderson JH (eds.): Etiology of dementia of Alzheimer‘s type. Chichester: Wiley 1988.

2. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. S3 Leitlinie: Demenzen. www.awmf.org/uploads/tx_szleitlinien/038–013l_S3-Demenzen-2016–07.pdf (last accessed on 14 November 2017).

3. Straubmeier M, Behrndt EM, Seidl H, Özbe D, Luttenberger K, Gräßel E: Non-pharmacological treatment in people with cognitive impairment—results from the randomized controlled German Day Care Study. Dtsch Arztebl Int 2017; 114: 815–21

4. Gräßel E, Stemmer R, Eichenseer B, et al.: Non-pharmacological, multicomponent group therapy in patients with degenerative dementia: a 12-month randomized, controlled trial. BMC Med 2011; 9: 129