The good news on Alzheimer's: Better ways to diagnose it. Drug trials offer promise.
Although my grandmother received a diagnosis of Alzheimer's disease in her 80s, my family was never sure that's what she had.
She certainly suffered from dementia: She was able to recall childhood memories but couldn't remember what she had had for lunch. But dementia and Alzheimer's are not synonymous. Back then, the only way to look for the telltale Alzheimer's plaques — deposits of the protein fragment beta amyloid that accumulate in the spaces between nerve cells — was through an autopsy, which we didn't do.
Over the past 15 years, researchers have developed a greater understanding of how the disease works. We now have more accurate ways of diagnosing Alzheimer's and are moving closer to developing drugs to directly attack the disease. Much of this work is still in the early stages, but experts are growing more hopeful about dealing with the debilitating disease, which currently has no cure.
Now, for example, we no longer have to rely on autopsies to confirm the existence of Alzheimer's plaques. In a major advance last year, the Food and Drug Administration approved a method that uses a radioactive dye, known commercially as Amyvid, to light up amyloid plaques in a PET scan.
The FDA approved Amyvid to rule out Alzheimer's when the scan is negative and to confirm the presence of plaques when positive, but that does not necessarily indicate the disease is present. However, some doctors are using the scans to confirm the disease, which experts say is misdiagnosed up to a quarter of the time. Paul Aisen, director of the Alzheimer's Disease Cooperative Study at University of California at San Diego, calls Amyvid an "enormous advance" because a positive scan, combined with his clinical diagnosis, means he can tell patients and their families the disease is "present, not probable."
However, the scans are not available everywhere, cost $3,000 to $4,000 and are not covered by Medicare or other insurers.
Still, says John Morris, a neurologist at Washington University School of Medicine in St. Louis, "families want to know." A few of his patients have paid for the test out of pocket. "They want to put a name on it, to deal with it, even if there isn't a curative therapy for it."
Most physicians are using the scans only to help confirm or rule out Alzheimer's in complex cases. Other imaging tests being developed track another sign of Alzheimer's in the brain, tangles of a protein called tau. By identifying cases at much earlier stages, such tests may change how experimental treatments for the disease get tested.
All five current Alzheimer's drugs, including Aricept and Exelon, have limited effectiveness. They treat the symptoms of cognitive impairment by attempting to rebalance the scrambled chemical signals in the brain. But according to the Alzheimer's Association, they typically stave off cognitive decline for less than a year and only in about half of the patients who take them.
"We have drugs that try to make the brain work better in the face of the disease, but they don't treat the underlying disease process," says Reisa Sperling, director of the Center for Alzheimer's Research and Treatment at Brigham and Women's Hospital in Boston.
Efforts to make more effective treatments have been challenging. Morris says eight drugs aimed at slowing or removing the buildup of amyloid plaques have failed to pass the clinical trials needed for drug approval in the past 13 years. Those failures probably reflect "too little, too late," experts say, because the drugs were tested on patients who already exhibited Alzheimer's dementia, now thought to be the final stage of the disease.
Abnormal accumulation of amyloid is now suspected to begin 10 or even 20 years before cognitive symptoms appear. So researchers and drug companies are shifting their testing to patients who show no signs of the disease but who are likely to develop it. Those patients will be identified either using scans to detect plaque or through genetic screening.
For a trial later this year, Sperling and her team will recruit 1,000 people who exhibit no cognitive dysfunction but whose Amyvid scans show amyloid accumulation. The trial will test whether giving patients an antibody drug called solanezumab, which binds to and mops up the soluble form of amyloid, will slow the onset of cognitive decline. "Hopefully, we'll very much change the curve of the very early cognitive decline," Sperling says.
Along similar lines, Morris and colleagues at the Dominantly Inherited Alzheimer Network (DIAN), an international research partnership of scientists, will be testing two drugs in the rare set of patients who are genetically predisposed to developing early-onset Alzheimer's, typically in their mid-40s. This will be the first trial to test whether amyloid-attacking drugs can slow or stop the progression of Alzheimer's in patients destined to develop it. Last month, the U.S. National Institutes of Health announced $45 million in funding for DIAN and other early intervention trials.
It's a hopeful step for treating a disease whose pervasiveness is growing. About 5 million people in the United States have Alzheimer's, and that number is expected to escalate. "By our 90s, most of us are going to have it," Aisen says.
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In Financial Inclusion, Indonesian Policies and Banks Found Wanting
Category Commentary, Opinion
Tags: Indonesia government subsidies, savings
(JG Illustration)
The direct relationship between financial inclusion and economic growth and development is well accepted globally. But when it comes to financial inclusion in Indonesia, there is quite a long way to go.
The concept of financial inclusion not only embraces access to credit and loans for all, it also means access to bank accounts, insurance products and, equally importantly, financial education.
Financial exclusion has a major impact on the lives of the poor. In the absence of proper storage facilities like a savings deposit bank account, whatever little savings they are able to gather become vulnerable to theft and natural disasters, like floods for instance. A lack of access to bank accounts means poor Indonesians end up paying extra charges, resulting in an unnecessary extra financial burden on them. The poverty-financial exclusion cycle is a vicious one and needs to be broken.
Financial education would provide a big boost to people with scarce funds, enabling them to better utilize their money. Access to formal banking infrastructure would also save people from exorbitant and unreasonable interest rates, ranging up to 50 percent and more, that must be paid to informal lenders.
In addition to being a burden for the most deprived members of society, the existing state of financial exclusion has numerous disadvantages for banking and financial institutions and the government.
On the government's part, given the shift toward efficiency and a move toward direct, targeted and even cash subsidies, it would make a great deal of sense for more people to have access to formal banking and for bank accounts to receive these subsidies.
In terms of the socioeconomic impact, the opportunities are huge and the room for improvement colossal. According to World Bank statistics, in the year 2011 only 3 percent of Indonesia's population above 15 years of age used a formal bank account for receiving government payments. With financial inclusiveness and formal bank accounts for more people, it would not only make the subsidy transfer easier and smoother, but also more effective and efficient.
Besides the substantial advantage of better monitoring of government subsidy spending, access to more precise data from the banking institutions would assist in the process of poverty-targeted policy making.
Banks themselves need to start viewing the push for financial inclusion as an opportunity and not an obligation. The success of the micro-lending and micro-credit institutions in Indonesia, as evident from the decently high loan repayment rates, has provided us with sufficient proof regarding the credit worthiness of those neglected by established banking institutions. It has also reinforced the scope for profitability for the banks.
It is high time for the banks to move beyond just lending and see the financially excluded as their next big wave of customers.
In addition to a dismal rate of banking penetration and financial inclusion, inefficiency is a major cause of concern for financial intermediaries in Indonesia.
It is extremely ironic that although based on average return on equity Indonesian banks constantly rank as the most profitable in the world, they are amongst the least efficient.
As a result of the highest net interest margin (NIM) in Southeast Asia, the difference between the lending interest rate and the deposit interest rate, which stands at an average of 12 percent for all the Indonesian banks and 7 percent for the big five, banks are able to make huge profits at the expense of their customers.
At the same time, Indonesian banks are the least efficient in the region, with the ratio of operating expenses to assets standing at 2.5-4 percent, according to the Boston Consulting Group. This figure stands at 2 percent and 1 percent for Malaysia and Singapore respectively. Once Indonesia's low banking penetration rate of 20 percent, as measured by the percentage of the population with formal bank accounts, is factored in, it becomes self-evident where the real problem lies.
If the banks can get their act together and manage to improve their efficiency, they can make a push for improving banking infrastructure in the rural and remote areas and still maintain their profitability. Simultaneously, bringing their NIM in line with other regional economies might not be such a bad thing and would definitely be a big help in the push for financial inclusiveness.
The gains to be made from greater financial inclusion and losses from the existing financial exclusion are clear. The role of the government and banking institutions in providing an impetus for financial inclusiveness is also very clear cut. What is missing is the will.
The banks need to become more efficient and competitive, which would help them bring down the interest rates on loans and capitalize on this exceptional opportunity to profitably tap into a large base of people with deposits to offer. The government and the central bank need to provide suitable legal and institutional frameworks for the banks to work in and also provide enough safeguards to protect the vulnerable against fraud. Government agencies should also bear the responsibility for collecting demographic information and data regarding potential customers to facilitate the banks in their work.
The drive for financial inclusiveness and banking reforms can be a complete game changer for the poor in Indonesia. But it won't succeed without political will.
Mukul Raheja (mukul@strategic-asia.com) is a researcher at consultancy Strategic Asia.