Dementia, Sno: "1,5 million people affected in Italy, but the figure is underestimated. Studies are lacking"

Prof. Sorbi: "Residential facilities are few, private, and expensive. It's a social problem." From youth-related dementia to preventable alcohol-related dementia. Trauma and vitamin B1 deficiencies. Focus on language disorders. Expert: "Recognizing disease-related stress? Not easy." The topics at the center of the 62nd National Congress of Neurologists.

Dementia is a slow, progressive decline in mental function, including memory, thinking, judgment, and learning ability. It most often occurs in people over age 65, but can strike earlier.

However, dementia is a disease and not part of normal aging: many people over 100 do not suffer from it. Dementia usually occurs as a brain disorder with no other cause (so-called 'primary brain disorder'), but it can be caused by many diseases.

Among the common causes of dementia is Alzheimer's disease: approximately 50% of older adults with dementia have Alzheimer's disease. This was discussed by Professor Sandro Sorbi, Professor of Neurology at the University of Florence and one of Italy's leading Alzheimer's researchers, at the 62nd National Congress of SNO - Hospital Neurological Sciences, currently underway in Florence.

But how many people in Italy today are affected by dementia? The numbers of the pathology, to date, are based only on estimates. "The last good studies on dementia in our country date back to the end of the 900s. Conducting epidemiological studies is extremely expensive and no one invests in it anymore - said Professor Sorbi - The estimate in Tuscany, where I work, is quite significant: we are talking about about 100 thousand patients affected by dementia.

In Italy, the estimate is instead of about 1,5 million people, but no one has 'counted' them in recent years for the reasons I said. The figure in my opinion is underestimated because it considers the manifest forms, while now research and clinics are increasingly dealing with patients in the very early phase.

This is because future new therapies, already in use in the United States, even if we don't know if they are truly effective, are aimed at 'preclinical' patients, that is, with minimal clinical signs but evidence and testing of the disease. Demographic projections show an arithmetic progression of this indicator, reaching 2051 elderly people for every 280 young people in Italy by 100. Therefore, all chronic diseases, as they are age-related, are on the rise, including dementia.

Dementia mostly occurs in people over 65, but it can also strike earlier. After all, the history of dementia “begins with the young”, since 1906 when the psychiatrist and neuropathologist Alzheimer described the disease for the first time in a 46-year-old woman.

“The first patients with Alzheimer’s studied at the beginning of the 900th century were all relatively young,” said Professor Sorbi. “It is true that the elderly died earlier and did not reach 90 years of age. Today, dementias are diseases with a high incidence throughout life, particularly in adulthood. But in fact, there are juvenile dementias, including the early-onset form of Alzheimer’s disease. Even in this case, however, there are unfortunately few epidemiological studies.”

The most common forms of dementia are degenerative ones, such as Alzheimer's disease, or 'frontotemporal' dementias, degenerative forms that tend to be earlier than Alzheimer's, and dementias associated with parkinsonism. A separate chapter is instead represented by the so-called 'avoidable dementias', in particular three: alcoholic dementia, traumatic dementia and vitamin B1 deficiency dementia.

"The first, alcoholic dementia, exists all over the world including our country. For this reason - said Professor Sorbi - it is recommended that young people do not drink alcohol every day and do so in moderation, because there is a risk of promoting the development of dementia. We remember that the World Health Organization does not set particular limits because the evidence shows that the ideal situation for health is not to consume alcohol at all.

The second is traumatic dementia: small repeated traumas cause degeneration mechanisms that can lead, after years, to dementia. In this regard, the Football Federations of the United States of America and the United Kingdom have banned heading young apprentice players who are under 10 years old. The third avoidable dementia, that caused by vitamin B1 deficiency, is more frequent in the elderly adult population, with poor nutrition and poor absorption”.

Finally, among secondary dementias we must remember vascular dementias, and the risk for these forms can also be reduced with good control of the well-known vascular risk factors, arterial hypertension, hyperlipidemia, diabetes, atrial fibrillation, overweight, and poor physical activity.

But are more men or women affected by dementia? The expert also spoke about this: “The number is higher in women because the incidence increases with age and we know that a greater number of women, compared to men, reach 90 years of age.

As for the percentage, however, it is not very different between the two sexes. Youthful dementias are more frequent in men, because it is among them that alcohol and trauma are more widespread”. Speaking of the first signs of recognition of the pathology, all dementias “start with little”, unfortunately and fortunately: unfortunately for the clinician, fortunately for the patient.

“They start with a defect in one of the cognitive functions, once it was always said with memory, but that is not the case - the neurologist explained - there are fronto-temporal dementias, which begin for example in the frontal lobes, for which the first symptoms can be a change in character, less attention to personal care, a reduced capacity for concentration, attention or planning”.

In addition, there are dementias that begin with language disorders: “In some people, language becomes poor and words are 'lost': these are the typical patients who say 'can you give me that thing?' or 'that thing to do those things', even if memory and orientation are good in the initial stages.

Other patients lose the semantic use of language, so if you say 'corkscrew' they think of a screwdriver, because for them the term falls into the category of tools but they do not identify the object exactly in its precision". And again, there are dementias with a disorder of spatial exploration: "Just recently a patient of mine told me that he saw a sheet of paper on the table, he wanted to take it but he did not understand where it was - Sorbi said - So on one side I see the sheet of paper, on the other I do not understand it, this is because the rear part of the brain that deals with exploring space to tell us what is there tells us badly".

Ours, meanwhile, is a society characterized by a perpetual and frenetic race, with women and men today increasingly breathless. What is the boundary between stress and pathology? Or rather: when should we start to worry if, during a busy day, we forget a word or do something?

"This is a very interesting aspect," the neurologist commented, "also because we increasingly see people in our clinic who tell us they do many things but with increasing difficulty. What we can do is study them: first of all, an extensive neurocognitive evaluation must be done to check whether the evaluation scores are adequate for the subject's level of education, skills and age.

Then the test must be repeated, because a functioning subject must be studied in depth. Since the early 2000s we have identified a new category of 'non-ill' people, with subjective memory disorder, some of whom may be in the initial phase of the disease. We are studying them to try to grasp aspects that can allow us to predict who will develop a disease or not".

Given this premise, it is "very difficult," according to the expert, to identify who is actually at the beginning of an illness or is simply tired and stressed. Among the protective factors against any form of dementia, Professor Sorbi's report further highlighted, is education. "Those who are more educated are at greater risk of having a disease but not of manifesting it, because our brain compensates," he noted. "If the word 'glass' doesn't come to mind, they can say 'goblet.'

I've had 'brilliant' patients—we're talking about high-level international scientists—complain about feeling like they no longer functioned as they used to. The patient in question therefore perceived a minimal defect, but at a very high level: he scored high on neuropsychological tests, but his brain PET scan already showed areas of hypometabolism in the regions initially affected by Alzheimer's disease, and a year later the disease was clinically manifest. In short, he had perceived something that our tests, designed to be applied to the general population, were unable to document.

A problem, this, therefore linked to high education. "But there is another very important element, evident in studies from all over the world: education delays the onset of the clinical disease. I could have the Alzheimer's disease that is already attacking my brain but still be clinically well, while if I had not been educated maybe five years ago I would have already had the first memory problems.

Education - explained the professor - is one of the most proven elements of protection from any form of dementia: what we think is that perhaps it delays the onset, but it could also be that it protects". Other factors that protect are socialization, carrying out a job that gives satisfaction and doing physical activity.

“There is an animal model for the well-being of physical activity,” Sorbi said. “If we put two mice with the same genetic mutation that causes a form of dementia in these animals in two separate cages, and we give one, the 'marathon mouse', a treadmill while the other only gets food, the cognitive disorder comes to the 'lazy' mouse and not to the marathon mouse.”

Finally, Professor Sorbi wanted to underline an ethical but also economic aspect that concerns patients with dementia, but above all their families: “In Italy, residential facilities for patients with dementia are few, almost all private and expensive: for a hospital stay you can spend up to 4-5 thousand euros per month.

There is a municipal and regional contribution that covers only a small part and only those families who have a very low income. It is a significant social problem. As for the ethical aspect, which the families of patients report, also through associations, is that following the patient is delegated to the relatives. But a wife or a son is not necessarily always able or willing to do so. The problem is that, in fact, there is no alternative because there is no adequate organization of assistance for these patients”.