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We Need Health Care, Not Disease Care

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President Obama was correct when he stated that the United States has a disease care rather than a health care system. Our approach to the treatment of Alzheimer's dementia is a prime example of this fact. As a consequence of this approach, a perfect storm that could lay waste to the American health care system is brewing in the confluence of increasing health care costs, an ageing population, and a looming epidemic of Alzheimer's dementia.

The emotional and human costs of Alzheimer's dementia are enormous. However, the dollar costs of caring for the increasing numbers of elderly Americans expected to develop Alzheimer's dementia over the next 30 years will decimate the personal savings of millions of families, exhaust Medicare, and likely be the final straw that breaks our health care system. The only means to escape this catastrophe is to initiate a program of education and preventative medicine to stop or at least delay the development of dementia among our ageing citizens.

Some 5 million Americans are currently suffering from Alzheimer's dementia. This number is expected to double by 2020, and double again by 2040. Medicare payments for the care of patients with dementia were over $91 billion in 2005, and will grow to over $160 billion by 2010, or roughly a third of projected Medicare expenditures for that year. An additional $94 billion is lost annually in unpaid services performed by care giving family members. The stress and strain placed upon families and caregivers costs society yet another $36 billion a year due to absenteeism and losses in productivity.

Some of the increased incidence of Alzheimer's Dementia is due to demographic changes. About 98 percent of cases of dementia occur in people over the age of 65, and because of improvements in food production and health care, more Americans are living beyond this age. However, most of this epidemic is due to unhealthy changes in modern lifestyles. The risk of dementia grows when an individual suffers diabetes, heart disease, obesity, major depression, and other major health problems. The numbers of people being diagnosed with such conditions are exploding and, along with dementia, growth rates of these illnesses are reaching epidemic proportions. Some losses in cognitive function that occur with age are unavoidable, and some people are genetically predisposed to dementia of one type or another. However, there is compelling evidence that by improving our diet, reducing stress, exercising our minds and bodies, and staying socially active, most of us can avoid or at least delay the development of dementia.

At present, the standard of care is to give expensive medications that cannot be prescribed until the disease has progressed to the mild or moderate stage, at which time no medication can have a significant effect on the course of the illness. The effects are at best temporary and palliative at a cost of roughly $2,000 per patient per year. By 2020, this may amount to nearly $20 billion a year in dementia medication costs. Care on a specialized dementia unit over the final years of illness may cost $200,000 per patient. If current trends persist, we will not be able to afford disease care for the millions of Americans that are likely to be suffering dementia in the next decades.

Instead, we must work to prevent the epidemic of dementia by promoting good health. Preventative measures must start with people in their forties and fifties, as pathological changes tend to occur in the brain ten years or more before changes in cognitive function and behavior are seen. We must educate the American people to the fact that Alzheimer's dementia is not a natural part of ageing, but that often it can be delayed or avoided entirely through healthy diet, exercise, achieving an ideal weight, reducing stress, cultivating mental health, maintaining good dental health, remaining intellectually and socially active, and avoiding the bad habits and environmental contaminants that increase the risk of dementia. It is no coincidence that dietary changes that can be made to reduce the risk of heart disease and diabetes can also reduce the risk of dementia. Such changes include reduction in saturated fats, sugars and simple carbohydrates, along with increases in good fats, such as olive oil and fish oils. Indeed, many of the same pathological processes that such dietary changes address, such as inflammation, high blood sugar, oxidative damage, high cholesterol, and atherosclerosis, can lead to dementia as well as to diabetes and heart disease. We must embrace the notion of food as medicine. Evidence shows health benefits from eating fish, vegetables, chocolate, blueberries, garlic, and other spices. Recent studies even suggest that the spice, turmeric, consumed in fiery curry dishes may reduce the risk of dementia.

Our health care system must provide basic medical care to monitor the risk factors for dementia and other major health problems. This can be done economically by enlisting the services of more nurse practitioners and physician assistants to perform these basic screening tasks, and by initiating outreach programs to provide this care where people work, shop, and purchase their medications. The expertise of physicians can be reserved to treat the more difficult problems found. In lieu of steps taken to prevent the decline of health in our country, and to address disease in a wholistic, comprehensive manner, the question of whether health insurance should be public or private is moot, as neither will be able to manage the enormous costs of treating dementia if the epidemic progresses as predicted.

Scott D. Mendelson, M.D., Ph.D. is the author of the new book "Beyond Alzheimer's: How to Avoid the Modern Epidemic of Dementia," and works as a Consult Liaison Psychiatrist at the Roseburg VA Medical Center in Roseburg, Oregon.

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