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Video: Increasing Dementia Costs Burns Through 1% of Global GDP: Video

by on September 21, 2010

Sept. 21 (Bloomberg) — Bloomberg’s Pat Wechsler talks with Mark Crumpton and Julie Hyman about the outlook for the global cost of treating Alzheimer’s and other dementias. A report from London-based Alzheimer’s Disease International says treatment will cost 1 percent of the gross domestic product globally this year, with seventy percent of an estimated $604 billion being paid in North America and Western Europe. The global price will exceed $1 trillion annually by 2030 the advocacy group said. (Source: Bloomberg)

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Video: Increasing Dementia Costs Burns Through 1% of Global GDP: Video

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Landmark report reveals massive global cost of Alzheimer’s

by on September 21, 2010

Landmark report reveals massive global cost of Alzheimer’s

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Landmark report reveals massive global cost of Alzheimer’s

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Anthony Tjan: Medical Entrepreneurship: A New Movement to Accelerate Cures

July 12, 2010

There is a new social entrepreneurial movement afoot, which seeks to find cures to some of the world’s most challenging diseases. Medical entrepreneurship is, in my view, the very best hope we have for accelerating the pace of finding medical cures. A good example and arguably the pioneer of this movement is Michael Milken’s Prostate Cancer Foundation. Milken has taken on a decidedly entrepreneurial approach to providing capital and human resources to accelerate the pace of research into cures for cancer, particularly that of the prostate. From 1999 to 2006 we have seen a 25% drop in the death rate for prostrate cancer. There is little doubt that Milken’s leadership has been one of the greatest catalysts in this improvement. Another leader in the movement is Henry McCance, who co-founded the not-for-profit Cure Alzheimer’s Fund, which I first wrote about last year. The Cure Alzheimer’s Fund is another example of a cure accelerator, an organization using a venture approach towards medical research. Out of full disclosure, I recently joined the Cure Alzheimer’s Fund’s advisory board. And while I care deeply about diseases such as Alzheimer’s, I am mostly fascinated and hopeful that a more maverick VC-like business model applied to the search for medical cures will be a better approach to solving some of the big medical challenges we have. The medical research model as we know it today is broken. Why? Three words: insufficient, inefficient, and ineffective. This is both the big problem and the big opportunity for medical entrepreneurship. Today’s model is insufficient because typically 1% or less of the amount spent each year on diseases goes towards cure research, with the balance going to caring for people with the disease. Alzheimer’s, for example, costs our country hundreds of millions of dollars each year, yet we spend just one cent out of every $4.00 available towards a cure. That is an astonishing 400x delta. The story is similar for diabetes and cystic fibrosis. While care is obviously critical, we need more dollars to go to finding the cure — or the country is at great risk of a healthcare-induced bankruptcy. Henry McCance and Professor Bill Sahlman of Harvard Business School recently gave an excellent overview of this at Venture Summit East and I draw on many elements of their talk in this blog post. The current research model is highly inefficient because researchers spend too much time writing grants. By our estimates at the Cure Alzheimer’s Fund, the very best researchers in the field spend up to 30% of their time writing grants, and should they win the grant they may have to wait months or even a year to get the funding. As well-intended and needed are organizations such as NIH (National Institute of Health), there is an embedded trade-off between the robustness of review and the approval of grants to new and innovative projects. Imagine any venture capitalist going to Netscape or Yahoo to validate funding to Google or expecting an entrepreneur to spend a third of his time writing a business plan and then waiting a year for funding. This is the frustration that many of the best researchers in our country feel. Finally, the medical research model is ineffective because it is, by design, risk averse with regard to the projects it pursues. Grant proposals that win funding are usually those that seek out small, incremental discoveries — it is the very nature and policy of the grant making bodies to look for ideas that slowly build on existing knowledge. Breakout ideas are not able to happen under an incrementalist research model. Even worse, as we’ve heard anecdotally from some researchers, some people write grants for questions whose answers are already known. Pioneers of the medical entrepreneurship movement are taking bigger risks on researchers, asking them to focus their energies on the initiatives that have the largest potential impact as opposed to those that would get traditional grant funding. They are also doing so faster. Milken’s Prostate Cancer Foundation, for example, makes awards based on applications that are limited to five pages and has a 90-day turn-around time. FasterCures has become a think tank and resource-sharing center for this new approach. Focus on the big ideas that can lead to the big goal of curing a disease, eliminate bureaucracy, and give smart people more capital, faster, and you have a formula for change. What proof exists that the change is positive? Thousands of lives have been saved by the advances in prostate cancer understanding by medical innovators in that field. The Cure Alzheimer’s Fund was recognized last year by Time Magazine for one of the top ten medical breakthroughs of the year for work that identified over 100 genes associated with the disease. A number of other dynamic organizations, including the Harvard Stem Cell Initiative and the Myelin Foundation are making significant contributions to cures. Across multiple diseases, researchers have been conditioned to make progress with bond-like returns. While some of this is necessary, it cannot be sufficient. As in any portfolio, we cannot maximize returns if we hold all our eggs in one big conservative basket. We need to invest more behind higher risk initiatives that can yield equity-like returns, and hopefully real cures. This article first appeared on Harvard Business Publishing on July 7, 2010.

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Consumer Gene Tests Making Health Claims Need FDA Approval, Official Says

May 14, 2010

By Rob Waters May 14 (Bloomberg) — Gene-test kits that promise to tell consumers their risk of Alzheimer’s disease, breast cancer and numerous illnesses must be approved by regulators whether the tests are sold online or in stores, a U.S. official said. The Food and Drug Administration has grappled with how to regulate a growing number of gene-testing companies in recent years, said Alberto Gutierrez, director of the FDA office that regulates diagnostic tests. The agency now believes developers of the tests are making health claims that must be cleared by the government if their products are to be sold directly to consumers, he said in an interview yesterday. To date, no such test has been approved or rejected by the FDA, he said. This week’s demand for information from closely held Pathway Genomics of San Diego, which planned to sell its test at Walgreen Co. stores starting today, shows the agency is ready to be more muscular in exercising its authority, said Ira Loss, a senior health policy analyst at Washington Analysis LLC. The FDA wants “to make sure the public is protected from tests that aren’t accurate or a lack of counseling,” Loss said in a telephone interview. “You don’t have to think very long to see how people could possibly make poor decisions concerning their future because of a test that doesn’t properly explain things to them.” Pathway had been marketing consumer gene-tests online before agreeing to sell the product at Deerfield, Illinois-based Walgreen, the largest U.S. drugstore chain. The retailer halted plans to start selling the home-use saliva collection kit after the FDA released a letter May 12 telling Pathway the product appears to be a medical device subject to agency review. Pathway Comment A spokesman for Pathway declined to comment after sending a statement that said the company respects Walgreen’s decision and is communicating with the FDA. “Pathway works very diligently to ensure that our business is compliant with all applicable regulations and guidelines,” the statement said. Some gene tests offer guidance on the probability that would-be parents will pass certain genes linked to diseases on to their offspring. The American Society of Human Genetics said such tests may affect the choice of whether or whom a person marries, the decision to have children and whether to have an abortion. Navigenics of Foster City, California, 23andMe of Mountain View, California, and DeCode Genetics Inc. of Reykjavik, Iceland, are among the companies that market genetic tests online. Navigenics was invited by the FDA to provide information about its service in May 2009, and believes it complies with all state and federal regulations, the company said in a statement. Other Makers 23andMe, started in 2006 by Linda Avey and Anne Wojcicki , wife of Sergey Brin , co-founder of Google Inc., declined to comment. Google, the operator of the most popular Internet search engine, has invested at least $6.5 million since 2007 in the company, according to regulatory filings . Pathway’s test kits offer to analyze customers’ genes for three purposes: to predict what each individual’s risk is for diseases ranging from Alzheimer’s to prostate cancer, to assess would-be parents’ probability of passing on health problems to offspring and to evaluate how the test-taker will respond to certain drugs. Pathway’s test kit aim to provide information about how customers’ genes affect their risk for developing 26 health conditions and the likelihood of passing any of 37 inherited conditions to unborn children. It also describes how customer’s genes affect their propensity to respond to such drugs as Bristol-Myers Squibb Co. ’s blood-thinner Plavix as well as cholesterol-lowering statins such as Pfizer Inc. ’s Lipitor. Fictitious Patient A 95-page sample report contains some information about a fictitious patient’s risk of Alzheimer’s disease. “There is no singular test that can definitively diagnose Alzheimer’s disease, but your genetics suggest that you may be vulnerable to having this disease at some point in your life.” That kind of information won’t help people, said Joanne Boughman , executive vice president of the American Society of Human Genetics in Bethesda, Maryland. “For a disease like AD, for which there is no intervention or treatment, that isn’t useful information,” Boughman said. “In fact I would consider it info that could be disturbing or distressing and therefore harmful. “The genetics community has been seeking oversight for more than a decade,” Boughman said in a telephone interview yesterday. To contact the reporter on this story: Rob Waters in San Francisco at rwaters5@bloomberg.net .

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Pfizer, Medivation’s Dimebon Fails to Help Alzheimer’s Patients in Study

March 3, 2010

By Michelle Fay Cortez March 3 (Bloomberg) — Pfizer Inc. and Medivation Inc. said Dimebon, their experimental drug for Alzheimer’s disease, failed to benefit patients in an advanced study. The trial, dubbed Connection, included almost 600 patients with mild to moderate Alzheimer’s disease from across the U.S., Europe and South America. The results counter an earlier study in Russia that found improvement in patients getting Dimebon. Medivation shares fell 68 percent in early trading. The negative results for Dimebon, a 27-year-old hay fever treatment, are the latest setback in efforts to find a way to slow the most common form of dementia in elderly people. It could have generated more than $5 billion in annual sales if it proved effective, said Raghuram Selvaraju, head of health-care research at Hapoalim Securities USA Inc., in New York. “We are surprised and disappointed,” said David Hung , chief executive officer of San Francisco-based Medivation, in a telephone interview. “We’re trying to figure out what happened in the study and decide how to move forward. This is obviously one battle in our war against Alzheimer’s disease.” Medivation plunged $27.26 to $12.99 in trading before the Nasdaq Stock Market opened. Before today, the stock had risen 6.9 percent this year, giving the company a market value of $1.35 billion. Patients on Dimebon didn’t do better than those given placebo in cognition or global functioning after six months, the two main goals of the study. It also failed to show benefits on the study’s secondary objectives, which looked at behavior, mental functioning and the patients’ ability to care for themselves. ‘Worst-Case Scenario’ “We think this was nearly the worst-case scenario, although management will talk about other ‘shots on goal,’” said Michael Yee , an analyst at RBC Capital Markets in San Francisco, in a note to investors today. He rates Medivation stock “sector perform.” The U.S. Food and Drug Administration told the companies that the original Russian study, published in the journal Lancet, would be considered a pivotal trial. Most regulators require positive results from two pivotal trials, typically in the third and final stage of human testing, to win approval. Selvaraju, who considers himself one of the most optimistic analysts on Dimebon, predicted a 40 percent chance of success for the drug before the results were released. There are four other Dimebon studies under way, evaluating the drug in addition to standard treatment in patients with mild-to-moderate and moderate-to-severe disease, Hung said. The company also is testing it in Huntington’s disease, a degenerative neurological disorder that runs in families. Pfizer’s Aricept Alzheimer’s is a progressive disease that starts with mild forgetfulness and eventually robs patients of memories and independence. It afflicts 30 million people worldwide, a number that may exceed 100 million by 2050, according to Alzheimer’s Disease International, an advocacy group based in London. Existing drugs including Aricept from New York-based Pfizer and Tokyo-based Eisai Co. , the leading therapy with $2.5 billion a year in annual sales, temporarily ease symptoms of Alzheimer’s disease. Doctors and patients are looking for novel treatments that slow the progression of the illness, allowing patients to remain in their homes and take care of themselves for longer periods of time. There hasn’t been a new drug for the disease since Namenda, from New York-based Forest Laboratories Inc., was approved in 2003. Almost a dozen drugs in mid- to late-stage testing have failed since then, according to data compiled by Bloomberg. ‘Tough Business’ “Developing treatments for Alzheimer’s disease is a tough business,” said Michael Krensavage , founder of Krensavage Asset Management in New York. “The landscape of Alzheimer’s research is littered with failure. The drugs that are available provide little clinical benefit.” Researchers have announced setbacks with experimental treatments from GlaxoSmithKline Plc, AstraZeneca Plc, Martek Biosciences Corp., Johnson & Johnson, Abbott Laboratories and Myriad Genetics Inc. in the past year. One of the most eagerly anticipated drugs, bapineuzumab from Pfizer and New Brunswick, New Jersey-based Johnson & Johnson, reduced the buildup of amyloid plaque in the brains of patients with Alzheimer’s disease, according to a study published March 1. Patients getting the drug in the trial didn’t show a clear improvement in mental function. Medivation has no products on the market and has recorded losses exceeding $150 million since 2003. Pfizer, which hasn’t brought a new drug to market that generates more than $1 billion a year since the pain pill Lyrica won U.S. clearance in 2004, has pinpointed Alzheimer’s as one of six focuses of research. Prostate-Cancer Drug Medivation also has a prostate cancer drug in development with Japan’s Astellas Pharma Inc. Information on that treatment won’t be available until the second half of 2011, according to RBC’s Yee. Pfizer has eight other compounds in development for Alzheimer’s disease. “We are committed to this area,” said Briggs Morrison , senior vice president of Pfizer’s primary-care development group, in a telephone interview. “We know it’s going to be hard and we know there’s going to occasionally be disappointments like this one. But that doesn’t in any way change our commitment to trying to come up with important treatments for Alzheimer’s disease patients.” To contact the reporter on this story: Michelle Fay Cortez in London at mcortez@bloomberg.net

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Pfizer, Medivation Drug May Help Huntington’s Disease Patients

February 8, 2010

By Shannon Pettypiece Feb. 8 (Bloomberg) — A 27-year-old hay fever treatment being studied by Pfizer Inc. and Medivation Inc. for Alzheimer’s disease may also help patients with Huntington’s disease. The drug, called Dimebon, improved mental functioning and awareness in patients with Huntington’s, a degenerative neurological disorder that runs in families, according to research released today by the Archives of Neurology. The study of 91 patients, which was funded by Medivation, showed minimal side effects, researchers said. The findings are encouraging because there are no treatments for the psychological effects of Huntington’s which affects about 25,000 people in North America, said Karl Kieburtz , lead author of the study and professor of neurology at the University of Rochester in New York. Symptoms of Huntington’s typically start in middle age and include muscle twitching, depression, aggression, loss of orientation and memory. A larger, long-term study will be needed to see if the benefits were from the pill or by chance, Kieburtz said. “It is really a shot in the arm for us,” Keiburtz said in a telephone interview. “There is a suggestion of efficacy and that, along with the fact there had been improvement in cognition in Alzheimer’s patients in a prior trial in Russia, has led us to think there might be something here.” Withstand Stress Scientists believe Dimebon may help Huntington’s patients, as well as those with Alzheimer’s, because of its effect on mitochondria, parts of cells that help convert food into energy, the study said. Previous laboratory findings showed Dimebon improved cells’ function and helps them withstand stress. The study evaluated 91 patients who took either Dimebon or a placebo for three months and was primarily designed to evaluate the pill’s safety. In the study, patients taking Dimebon were more likely to correctly answer questions about what year it was and where they were, count backward, and recall words over a short period of time. The drug didn’t appear to have an impact on a broader assessment that measured motor function, cognition and behavior. It also didn’t show a benefit when researchers measured cognition in the Huntington’s patients using a test developed for Alzheimer’s patients. Medivation, based in San Francisco, and Pfizer of New York are working on a study involving 350 Huntington’s patients for six months that is part of the third and final stage of testing required to get U.S. regulatory approval. Results from a separate late-stage study in Alzheimer’s patients are expected to be released in the first half of this year. Russian Company Medivation acquired Dimebon, which has been used since 1983 to treat hay fever in the former Soviet Union, from a company formed by Sergey Bachurin, a researcher at the Institute of Psychologically Active Compounds, in Chemogolovka, Russia. The drug was first identified as a candidate to protect neurons when the Russian Academy of Science, in Chernogolovka, Russia, started in the early 1990s to screen libraries of compounds for their ability to block a key brain receptor. Belief in the drug was bolstered when researchers found it improved learning in brain-damaged rodents. To contact the reporters on this story: Shannon Pettypiece in New York at spettypiece@bloomberg.net ;

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Cocktail of Alzheimer’s Therapies More Effective Than 1 Treatment in Study

January 6, 2010

By Meg Tirrell Jan. 6 (Bloomberg) — Alzheimer’s disease may be better treated with a cocktail of therapies that limit production of plaque that impairs the brain rather than with one treatment alone, a study in mice suggests. The combination approach preserved memory with few side effects, something individual treatment methods haven’t been able to do as well, researchers at Johns Hopkins University School of Medicine said in a report published today in the journal Science Translational Medicine . There’s no cure yet for Alzheimer’s , a disease that attacks the brain and causes memory loss that can devolve into severe cognitive decline. It affects an estimated 30 million people worldwide and was the sixth-leading cause of death in the U.S. in 2007, according to the Centers for Disease Control and Prevention in Atlanta. Scientists suspect Alzheimer’s may be caused by a protein called amyloid beta , generated by two enzymes that drugmakers have been targeting individually with experimental treatments. “The idea is if you can identify compounds or drugs that inhibit these enzymes, you’ll be able to slow down the progression of the disease,” said Philip Wong, a professor in the pathology and neuroscience departments at Baltimore-based Johns Hopkins who was a senior author of the study. “One of the major issues is side effects.” Two enzymes known to spur formation of amyloid beta that afflicts brain function are beta-secretase and gamma-secretase, both targets in Wong’s study of mice. Drugs in Development Drugmakers such as Eli Lilly & Co. , GlaxoSmithKline Plc , Pfizer Inc. and Bristol-Myers Squibb Co. are working on Alzheimer’s treatments that aim to inhibit either the beta- or gamma-secretase enzyme, Wong said. Lilly’s semagacestat, a gamma-secretase inhibitor, is in the final stage of human trials generally required for U.S. approval, the company said in December. The idea of targeting both enzymes simultaneously is “completely novel,” Wong said. Drugs will have to be approved for use individually before they would be able to be combined, making the prospect of human testing with a potential cocktail years away, he said. Completely blocking either of the enzymes can cause side effects such as skin cancer, schizophrenia-like symptoms and shortened lifespan, Wong said. Partially inhibiting them, though, cut the side effects and still helped reduce plaque production, said Wong. Combined Attack Using that information, the researchers looked at what would happen if both enzymes were simultaneously limited without being blocked entirely. The scientists found the combination more effectively reduced plaque build-up without the side effects in mice, according to the report. “It suggests this would be a terrific therapeutic strategy,” Wong said. “Eventually the combination of these two drugs as a cocktail would prove to be most efficacious.” To model how the drugs might work, the researchers altered mice genetically to carry the Alzheimer’s gene. One group had reductions in both enzymes, one a reduction in gamma-secretase, and one a reduction in beta-secretase. A fourth Alzheimer’s group was left alone, and a fifth group — the control — consisted of normal mice without the gene. The researchers used a maze set in water to chart how well the different groups were able to remember directions, and found that mice with reductions in both enzymes performed “nearly as well” as the control group, while others did poorly, Wong said. “You don’t need to hit these enzymes too hard,” Wong said. “If you can show some efficacy without the side effects, you can begin to combine the two inhibitors.” To contact the reporter on this story: Meg Tirrell in New York at mtirrell@bloomberg.net .

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Sleepless Nights May Cause Alzheimer’s Disease as Protein Builds in Brain

September 24, 2009

By Pat Wechsler Sept. 24 (Bloomberg) — Sleepless nights may lead to the development of Alzheimer’s disease over time, a study of mice suggests. Rodents forced to stay awake showed a buildup in their brains of a protein associated with the development of Alzheimer’s in humans, said lead study author Jae-Eun Kang. The research was published today in the journal Science . Kang said additional research in humans may explore whether chronic sleep loss in young and middle-age adults increases the risk of Alzheimer’s disease later in life. About 5.3 million Americans have Alzheimer’s, according to the Chicago-based Alzheimer’s Association advocacy group. There is no cure. Drugs sold in the U.S. can ease symptoms for about a year. “The hope would be to show that treating sleep problems in humans is important not just for the immediate effect of having a normal life, but also for the long-term effect of having a healthier brain,” said Kang, a post-doctoral researcher at Washington University in St. Louis, in a telephone interview. Proteins called beta amyloid accumulating in brain fluids is “a critical event” in the progression of Alzheimer’s, the study said. In a healthy brain, the protein is produced by the neurons and secreted into brain fluid. As Alzheimer’s develops over time, clumps of the protein stick together, forming plaques that erode brain function. Forced to Stay Awake The study tested two groups of mice for levels of the protein and found that it increased during waking hours and decreased when they slept. Protein levels also rose when the animals were forced to stay awake or when they were given injections of orexin, a molecule implicated in many sleep disorders, according to the study. When the mice were allowed to follow their normal sleep patterns, protein levels declined. Over 24 hours, mice typically sleep about 70 percent of the time, spread over several short spurts. In the three-week study, mice were forced out of this pattern and required to stay awake for six consecutive hours. The number of people worldwide with the disease could reach 115.4 million by 2050, according to a report released Sept. 21 by Alzheimer’s Disease International, an advocacy group based in London. The first symptom of Alzheimer’s may be mild forgetfulness. As the condition progresses, it begins to interfere with patients’ lives as they forget how to brush their teeth, change their clothes, or recognize once-familiar people. Eventually they require constant care, according to the National Institute on Aging in Bethesda, Maryland. Alzheimer’s destroys brain cells progressively, making it difficult for patients to think, remember and function. The condition is still only definitively diagnosed at autopsy, when amyloid protein plaques in the brain can be seen. The study was paid for in part by the U.S. National Institutes of Health in Bethesda, and Eli Lilly & Co., based in Indianapolis. To contact the reporter on this story: Pat Wechsler in New York at pwechsler@bloomberg.net .

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Alzheimer’s, Dementia Rise Faster Than Expected in `Emergency,’ Study Says

September 21, 2009

By Elizabeth Lopatto Sept. 21 (Bloomberg) — Alzheimer’s disease and other dementias will afflict 35.6 million people in 2010, about 10 percent more than previously estimated because of a higher number of cases in developing countries than doctors realized, researchers said. The number of dementia sufferers may almost double every 20 years to 115.4 million in 2050, researchers at Alzheimer’s Disease International said in a report. The report’s authors had previously projected lower numbers in a 2005 article in the Lancet. Companies such as Johnson & Johnson , Eli Lilly & Co ., Baxter International Inc . and Bristol-Myers Squibb Co. are developing treatments to target the disease. The report recommends that the World Health Organization declare dementia a health priority, and that countries including the U.S. develop a plan for dealing with the greater numbers of dementia patients. “People, the government, the community need to understand that these numbers are an emergency,” said Daisy Acosta, the chairwoman of the London-based Alzheimer’s patients advocacy group. Lower and middle-income countries have the fastest increase in prevalence in the next 20 years, the report said. The poorest countries in Latin America will see the biggest increases of 134 to 146 percent. The new numbers are due to better data available since there weren’t many studies of Latin America, Africa, Russia, the Middle East, and Indonesia, the report said. Care Costs Rising Alzheimer’s disease and other dementias cost $315 billion a year, according to an estimate from Sweden’s Karolinska Institute cited by the paper. Dementia care costs are rising fastest in low and middle income countries, where per capita income is $11,905 or less, the report found. Patients and their families currently have few options. The drugs approved in the U.S. to treat Alzheimer’s ease symptoms for 6 to 12 months at most, according to the Alzheimer’s Association. If U.S. health officials and the WHO develop plans for dealing with the increase of dementia, other countries will follow suit, Acosta said. It has been difficult to get attention from global health organizations, because they often focus on reducing deaths rather than on treating disability, said Alzheimer’s Association Chief Executive Officer Harry Johns. “The very fact that people are older works against them,” Johns said. Many Alzheimer’s patients have spouses or children who provide their care, quitting their jobs to do so, he said. Between 15 percent and 32 percent of caregivers develop depression, as a result of the strains of providing for the needs of Alzheimer’s patients. WHO Priority “We already think dementia is a priority within WHO,” said Tarun Dua, a medical officer at the WHO’s department of mental health and substance abuse. WHO included Alzheimer’s disease as a priority condition when it launched the Mental Health Gap Action Program in October 2008 to bolster care for a range of ailments including mental health, neurology and substance abuse, she said. “The burden of these disorders is very high and the resources are scarce, especially in low and middle income countries,” Dua said in a telephone interview. About 5.2 million people in the U.S. have Alzheimer’s disease, according to the Chicago-based Alzheimer’s association. The first symptom of Alzheimer’s may be mild forgetfulness. As the condition progresses, it begins to interfere with patients’ lives as they forget how to brush their teeth, change their clothes, or recognize once-familiar people. “We’ll be spending the equivalent of the stimulus package every two years if we don’t address this,” Johns said. To contact the reporter on this story: Elizabeth Lopatto in New York at elopatto@bloomberg.net .

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