Alzheimer's treatment offers return to normalcy

SANTA ANA, Calif. — It should have been much too late for retired obstetrician Marvin Sando to tour the Ronald Reagan Library.

According to medical benchmarks, the 76-year-old would no longer be able to dress himself for the spring weather, use the public restroom or walk through the presidential jet that transported one of his favorite statesmen.

But on this March day in Simi Valley, he dined at the foot of Air Force One and bought a copy of "Reagan, In His Own Hand" in the gift shop.

As he toured, Sando thought of Reagan's slow fade into Alzheimer's disease, a descent that could have been his.

In 2002, Sando found himself forgetting conversations, books and people. Like the late president he so admires, Sando was diagnosed with the degenerative brain disease that destroys neurons, tissues, memories and independence.

Nearly five years later, on a regimen of medication, he is virtually symptom-free, confirmed by scores on memory tests, images in brain scans and the ease of his everyday life.

"Every day when I take that little pill, I think of how lucky I am to be here," said Sando, who lives in Newport Beach, Calif. "I'm enjoying every day."

Sando's neurologist, William Rodman Shankle, who is both respected and discounted by his peers, cautions that Sando isn't cured.

But as his patient travels with his wife, drives to Mass and plays with his grandchildren, Shankle believes he represents the future of Alzheimer's disease.

"You can't get any more dramatic than completely reverting to normal," Shankle said.

Sando's journey into Alzheimer's disease began with a book.

He retired from his Riverside obstetrics-gynecology practice in 1999 after a 37-year career that included delivering four of his own grandchildren. He and his wife, Pauline, moved to Newport Beach eager for family time, long walks and reading.

But a few years into retirement, Pauline noticed some strange changes in her husband. Sando, who once added rows of numbers in his head, struggled with calculations.

A voracious reader who juggled five or six books at a time, Sando could no longer follow when he turned to his place in a book.

The Sandos found themselves sitting in Dr. Shankle's office after receiving a referral from a physician friend.

Neurologist Shankle, a 52-year-old statistician and researcher, keeps a model of the brain on his desk and iconic black-and-white photos of Marilyn Monroe on the wall. The pictures were taken by a deceased Alzheimer's patient who once worked for the New York Times.

At their first appointment in October 2002, Shankle gave Sando a memory test he developed that involves word repetition to test memory storage in different parts of the brain. Sando remembered seven out of 10 words, but only those at the end of the list, suggesting that he was relying on attention span rather than short-term memory.

But was it Alzheimer's or normal aging?

Blood work and an MRI came back normal, excluding other causes of memory loss. Next, a PET scan showed normal brain function everywhere but in the hippocampus, where Alzheimer's begins. That, combined with his memory test score, left Shankle 95 percent certain that Sando had Alzheimer's.

First discovered in 1906, Alzheimer's disease is the sixth-leading cause of death for Americans over 65. But in the new millennium, a handful of expensive medications have become commonly used for slowing the progression of the disease. But studies have indicated small improvements in patients, which may delay their entry into a nursing home, but will not restore intellectual losses.

Shankle said that's because most patients aren't diagnosed early enough to fully benefit.

He started Sando on Exelon, a drug approved by the Food and Drug Administration in 2000 that stops the breakdown of a chemical transmitter in the brain. Shankle also directed Sando to make lifestyle changes: mandatory daily walks, a glass of wine only on rare occasions, and Sudoku instead of crossword puzzles to give his mind a new challenge.

Within a few months, Sando's memory test score improved to 100 percent. A PET scan at five months revealed much more activity in the memory storage parts of his brain.

Pauline didn't need to see test results to be convinced.

"He was back to reading his five books again and adding up everything," she said.

But Shankle knew there would be skeptics who would doubt the diagnosis. So he came up with an experiment. He asked Sando if he would consider going off Exelon for three weeks so they could see what would happen. Because of his medical background, Sando agreed without reservation.

Sando's word score dropped to six out of 10 and he struggled to track his books again. Once Sando went back on the medication, his function returned.

But Dr. Wesson Ashford, senior research scientist at the Stanford VA Alzheimer's Research Center, said the brain becomes dependent on medication, so function plunges if the drug is stopped. He also cautioned that the medications have side effects and risks.

As for the Sando case, Ashford said he respects Shankle's work in early detection, but noted that extensive studies must be done before drawing any conclusions.

"Some people may get more benefit than others do," said Ashford, a geriatric psychiatrist. "You can't make claims until you do large double-blind studies. You can't base your treatment recommendations on one patient."