Dr Claire Steves is both a geriatrician as well as a gerontologist and is the principal investigator for ageing and frailty at the Department of Twin Research, researching health and fitness in older people. As a geriatrician, Claire specialises in dementia and delirium and focuses on people with complex problems that require specialist approaches to treatment.
September 21st marks World Alzheimer’s Day. We caught up with DTR researcher Dr Claire Steves to find out about early stage Alzheimer’s disease and her research into cognitive decline.
Many people are familiar with Alzheimer’s, but perhaps more so with the advanced stages of the disease. As a geriatrician you see patients in the earlier stages of Alzheimer’s – what are the symptoms?
When I see patients for the first time one of the most common things I find is that a relative has noticed they might keep repeating themselves a lot, saying the same thing over and over. It’s recent memory that goes first; perhaps they also can’t remember what they’ve had for dinner or can’t keep track of the TV. In contrast, memory of past events can be very good.
A common test we use is to show images of slightly less common things such as a camel or a rhinoceros. A person with early stage Alzheimer’s wouldn’t be able to name them.
Are there any challenges in diagnosing Alzheimer’s disease in its early stages?
Yes, it can be tricky: one issue is that when someone first goes to their GP with early symptoms they’ve probably been slowly developing Alzheimer’s for years. The real problem is that it can be hard to determine whether they do have Alzheimer’s or whether there’s something else going on. Do they have stress or anxiety, or some other medical condition, or might it be normal decline with age?
We can do detailed tests that look at how someone creates new memories by asking them to remember an item and its location. Joining these two things seems to predict Alzheimer’s early on. We can also use imaging or even take spinal fluid (a lumbar puncture) to look at the amounts of different proteins in the fluid around the brain.
One thing that’s often overlooked is delirium in older people who are have another illness. People with delirium become confused and maybe hallucinate. It can be very distressing for patients, family and carers and can be a real risk for falls or hitting out. We know that people who have delirium are more at risk of cognitive decline. We also know that we can prevent delirium by being careful with how we treat patients in hospital – it’s an unmet need. I follow these patients up when they’re better to see if they might have early stage Alzheimer’s.
Are there any treatments available to people with early stage Alzheimer’s?
The biggest thing that makes a difference is to understand what’s happening and find ways to cope with it in daily life, with help from family members or carers.
There are drugs for early Alzheimer’s called acetylcholinesterase inhibitors, which are very helpful in some people. They can increase the time people are independent for, which is really important. Unfortunately they don’t change the overall outcome of the disease and some people can experience side effects, such as minor dreams, hallucinations, or nausea – we always do a trial period before starting longer-term treatment.
Getting a diagnosis is vital in giving people the right treatment. It’s usually older people who get Alzheimer’s and they often have other health issues, so it’s important that everyone is aware there’s a memory issue. Often, someone will have been going to, for example, a heart clinic for years and no one realises they might have dementia – if they’ve not been taking their medications properly their heart disease then gets worse. That’s what my job as a geriatrician is about – thinking about the whole picture.
The biggest thing that makes a difference [to Alzheimer’s patients] is to understand what’s happening and find ways to cope with it in daily life…
What is the prognosis following early diagnosis?
This varies a lot and depends on other health issues a person may have; there’s no one size fits all. Some people can progress very slowly and really improve with drugs and support, whereas others may deteriorate much quicker.
Some research suggests modern drugs might be able to reverse Alzheimer’s. In the next 5-10 years, we’ll probably see more and more research into this; we need to know whether it’s safe.
A lot of your research involves studying twins in the TwinsUK cohort – what are you trying to find out?
Since my PhD I’ve been researching how learning and memory change as we get older – I’m interested in what might predict changes in cognition.
Right now I’m looking at how gut microbes might affect cognition. It’s possible that gut microbes may change the amount of inflammation in the body which could affect the brain and immune cells called microglia. If this happens, it might worsen dementia. This isn’t to say gut microbes might cause dementia on their own, but they could be part of the bigger picture of how it develops and progresses.
[Twins are] a very accessible way for people to understand the age-old dilemma of nature vs nurture.
How does studying twins help?
There are lots of benefits to studying twins. People really identify with why it’s useful to study twins – they’re a unique natural experiment. The public are also fascinated by identical genetics and it’s a very accessible way for people to understand the age-old dilemma of nature vs nurture.
Identical twins are brilliant for looking at the effect of the environment and lifestyle. We often check research results we find in all our twins using the identical twins. Identical twins are also great when we want to test something, like a dietary supplement. We can carry out much smaller scale studies in twins, as there is less genetic diversity.
For our twins, it’s an enjoyable way for them to take part in research as they come in to the department together – it’s a social thing.
What’s the most interesting thing you’ve found out about cognitive decline from studying twins?
The biggest thing I’ve found is that if you’re physically fitter you have much better cognitive change over time. We looked at changes in the twins over a ten-year period and found that your brain is much less likely to decline if you’re fitter. You may even be able to improve your cognition.
What do you think the long term impact of your research on cognitive ageing will be?
What we’re working towards at the moment is trying to understand what kind of changes people can make to their gut microbes that might improve inflammation and improve cognitive ageing. We have plans to study this, which would be very exciting.
The other thing is that it’s really important to get the message out to the public that keeping physically active is the best way to reduce cognitive ageing, the risk of Alzheimer’s and a whole range of other things. This is a really important message for those people who perhaps aren’t bothered so much by weight, but really care about their brain!
For more information about Alzheimer’s disease, and how to access support, take a look at the Alzheimer’s Society’s website.