Life and Memory Center

A part of any good memory evaluation needs to address practical skills in addition to a thorough work up for treatable causes of memory loss and a thorough testing of cognitive skills. These questions take many forms and should be asked of both the person being assessed as well as someone who knows him or her well such as a spouse. Why ask an informant? Simply because the person with memory decline may forget that they forget. This is a major problem in early detection as forgetfulness extends to one’s own deficits.

The best way to describe the changes that reflect Alzheimer’s disease is “first in last out.” This means that skills such as complex reasoning and problem-solving change much earlier in the course of the disease than personal care and orientation skills. With the current diagnostic push to identify Alzheimer’s disease earlier and earlier, we need tools that are able to differentiate normal changes from aging, those that involve slowing and reduced efficiency. Aging slows and reduces the efficiency of memory; it does not in itself cause memory loss. The earliest changes are not detected through simple screenings.

My concern arises from a study reporting that four questions (from a set of 21 questions in a questionnaire) are all that may be needed to identify a form of Mild Cognitive Impairment which may be the first stage of Alzheimer’s disease in some. The questions include:

1. Does the client repeat questions/statements in the same day?
2. Does the client have trouble remembering the date, year, and/or time?
3. Does the client have trouble managing finances?
4. Does the client have a decreased sense of direction?

The article goes on to state that “tests need to be short, easy to administer, and easy for clinicians to understand.” But here is the rub. Screening questions are not tests. There are too few items. Asking the client alone doesn’t work in many cases as they aren’t aware of changes. The intention is to find something a primary care clinician can use easily and reliably. How much can you really accomplish in a 20 minute visit (the normal time a physician has with each client)?

If we are going to detect Alzheimer’s disease earlier in its course we need to spend time and effort. The simple questions above reflect changes in mild Alzheimer’s disease, (changes in functional skills) not the changes in Mild Cognitive Impairment (no changes in functional skills). The questionnaire that I use has 60 items that reflect major functional areas (e. g., managing finances, meal preparation, use of appliances) as well as areas of concern that do not yet reflect functional changes (are you concerned about your memory, is your spouse?).

Changes need to be detected while you have control to improve your own outcome. It feels to me that there is a push to get people in clinical trials sooner at the cost of diagnosing someone with Alzheimer’s disease who does not. Until medical treatments are reliably available the goal should be to help clients and spouses who need more aggressive treatment of memory and planning for the future.

I have had several questions asked of me this week that are based on recent news about Alzheimer’s disease and cognitive decline. First, in response to my article on nicotine “Is Nicotine a New Treatment for Alzheimer’s Disease” (January 31), I was asked “Should I start smoking again?” The question arose in response to the recent finding that the nicotine patch may be helpful to those with mild cognitive decline or Alzheimer’s disease. The answer is clearly no. A study published in the Archives of General Psychiatry (February 6, 2012) links smoking to cognitive decline – especially in men. Smoking delivers a multitude of chemicals in addition to nicotine as well as carcinogens. The nicotine patch delivers only nicotine.

Another client asked “Should I be giving coconut oil to my husband [he has significant dementia]?” She gave me an article that she read on the internet which claimed that taking coconut oil reversed dementia. The article is based on an anecdotal case study and the claim was that a caregiver gave her demented husband coconut oil and he was able to read again, talk on the phone again, run again, and do yard work again. As impressive as the case is, it is founded on one person not several. We also don’t know details of diagnosis and course. I have had several of my clients try coconut oil (also anecdotal) to no avail. No one is hiding potential treatments from the public. There just aren’t any substances, medical or supplements, that have been shown to be effective in well designed studies. Aricept, Exelon, Razadyne, and Namenda are the best options we have at the preset time.

Finally, “What do you think about the new report that deep brain stimulation strengthens memory?” The research (New England Journal of Medicine, February 9, 2012) reports on the effects of deep brain stimulation used to treat serious epilepsy. Stimulation of a region (the entorhinal cortex) of the brain near the hippocampus (the area of the brain that allows new information to be stored into long-term memory) improved memory. The study was small as there were only 7 patients. The memory system studied was spatial memory (patients played the role of taxi drivers). The researchers speculated that they hoped that this would be helpful in improving memory is Alzheimer’s patients. But they also point out that these findings may not generalize to other diseases. Furthermore, the treatment requires brain surgery. It’s way too early to be counting on “neuroprosthetic” devices.

Memory loss can sneak up on families. Those with early and mild decline changes are adept at coping. Furthermore, others don’t notice until changes are more dramatic. You can even fool yourself. For example, you notice a “senior moment” and ask your friends and they often report the same problems. But how do you know a senior moment from beginning memory loss? The overlap between normal changes of aging and mild memory loss is substantial.

There is a push for early detection of dementia including the addition of memory screening as part of Medicare’s annual wellness program. The problem is that the recommendations don’t go far enough for two reasons. First, the screenings are too superficial to find truly early changes. Consider a screening consisting of telling someone three random words that they are to recall later. The words are followed by the task of drawing the face of a clock with all of the numbers. Then make the time set the time to be something like “ten minutes after eleven.” By the time you are forgetting words on such an easy task, you have lost your advantage to be proactive, often by years.

Second, the objective should not be to detect dementia. By the time the condition is severe enough to be called dementia, you are no longer in control. Alzheimer’s disease takes decades to unfold and in the earliest changes cannot be detected by screenings like described above. Your physician can’t tell by talking to you. You do not yet have the warning signs of Alzheimer’s disease. The problem is that a progressive decline like Alzheimer’s disease usually starts with increasing problems with short-term memory (i.e., the ability to learn something new). Habits, routines, and long term memory work just fine. You must be challenged to show the changes and three or even ten words are not enough.

The good news is that early detection of memory loss is easy. As with cancer we should not wait too long to determine if there might be a problem. The good news is that there are tests – memory tests – that work just like blood work. They measure strength of memory. They don’t hurt – no one has yet fainted on me. You cannot pass or fail. There are at least two ways to examine the brain. Take a picture of what it looks like by having an MRI or CT scan. That’s all well and good but I am more concerned about what my brain can do than what it looks like. The second way to examine a brain is to do a memory test which allows direct measurement of what the brain can do. Don’t wait for dementia to set in. Get your memory evaluated now. There is so much you can do if you act early and make memory evaluation (not screening) part of your wellness program.

Mental stimulation enhances the efficiency of our brain. For example, if I am feeling a little sluggish it often helps to go on a short walk or go to a movie or a concert. The brain is built to respond to change and stimulation. This is true for those with normal memory as well as those with memory loss. Indeed, an essential ingredient of any treatment plan for those with progressive memory loss such as Alzheimer’s disease is to keep them engaged. The activity doesn’t matter. It is in the doing that counts.

Participants at well run residential and day care programs for the memory impaired are provided with “palliative” memory rehabilitation through engagement therapy. In essence, therapy allows those with memory loss to remain engaged in joyful and stimulating activities such as walking, socializing, thinking (e.g., word games, watching movies, art therapy, music therapy) that fit their interests and retained abilities. The key is to start these programs early when memory and other cognitive skills are working relatively well.

Day care programs are usually at a specific location where participants gather in a room(s) and engage in activities run by a staff member. Naples has a number of excellent programs (Millennium House, Ardent Manor, and The Care Club). However, they are limited by the need to be in a place like a “senior center.” Not everyone needs this kind of setting and not everyone does well in group activities.

I called for the development of day care without walls. The concept is simple. If you love to fish, keep fishing. If you love ballet, keep going to the ballet. The range of activities is limitless: movies, lunch, concerts, museums, art, exercise …. This can be done one-on-one or with small groups of 2-4 participants.

Jim Moran created CompanionPlus (239-566-2815) to meet this need in 2009. Participants are carefully selected and go out individually or in small groups to do activities of common interest. Their first outing was a group of three who went to a Twins game. Others have enjoyed golfing or lunch. Still others may go for supervised exercise. At this point most use the program for one-on-one outings in a safe, relaxed, friendly environment.

I had a chance to catch up with Jim and asked what types of activities seem to work best? “Activities with movement, such as golf, biking, tennis, walks on the beach are ideal because those types of activities enhance body, mind and spirit. Also, lunch, movies and ball games are popular. Just being out is the most important aspect of the program. Not only does the participant benefit but also family members and caregivers also benefit, they need their time to relax and recharge too.”

Jim remains enthusiastic about his experiences. He said “It’s been very gratifying.” Caregivers have said “we both really needed that” to stating that “we have been sent by divine intervention.” “I had one wife call and tell me her husband needed to get out with the Roosters’”. “I knew exactly what she meant. It’s important for men [or women] spend time with male [female] friends in activities they enjoy.”

The nicotine patch may present a treatment for Mild Cognitive Impairment and early Alzheimer’s disease. This study is new but the idea is old and there are other studies. Before you run off and ask for the patch or chew nicotine gum, let’s put this in the context of current medical treatment.

The only FDA approved treatments for Mild Cognitive Impairment and Alzheimer’s disease are medications known as cholinesterase inhibitors (Namenda is not approved for early changes and works through an entirely different neurotransmitter). These medications have been available since 1993. They work by increasing the amount of the neurotransmitter acetylcholine in the brain. Acetylcholine has important actions on cognitive functions such as attention and some forms of memory. It is one of the neurotransmitters that act on the frontal cortex, amygdala, and hippocampus – structures very important to attention, planning, reasoning, memory, and emotion.

There are four medications available that work by this mechanism: Tacrine (not used because of side effects), Aricept (available in generic form as donepezil), Exelon (rivastigmine in generic form and available as either oral medication or a patch), or Razadyne (galantamine in generic form and available as standard or extended release forms). All three work by increasing acetylcholine.

Choosing which medication is based on convenience and tolerability. There are no proven clinical differences in efficacy. Side effects are similar. It would be convenient if acetylcholine only acted in the brain. However, it also acts elsewhere. For example, it medicates the activity of the gastrointestinal system producing in some symptoms such as loss of appetite, loss of weight, heartburn, nausea, or worse. Acetylcholine also works to regulate neuromuscular (can cause unwanted movement or cramps) and cardiac function (can cause low heart rate and fainting). There are more side effects but the good news if that as many as 70% who take these medications will tolerate them. The only way to know is to swallow the pill and be followed closely by your physician. They help many with progressive disorders such as Alzheimer’s disease function much better for longer.

Where does nicotine fit in? Nicotine also makes acetylcholine more available but by a different mechanism of action. In other words it may do the same thing as cholinesterase inhibitors but also may produce the same risks. The studies so far available are comparing nicotine to a placebo. My question is how does it compare to any of the cholinesterase inhibitors? They are much more widely studied than nicotine in progressive memory loss. I eagerly await the needed studies that may help guide us in making informed choices.

Jan. 30 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Foxfire Country Club,
Davis Blvd; Kings Way, Time: 6pm-social hr, 6:30 dinner, 7:15-talk Contact: Carol Hollenbeck 261-8520

and also
January 31, 2012 Where: Naples Healthcare Assoc., Hilton Ballroom When: 4:30 pm-6:30 pm Contact: Pearl at Naples H.C Assoc. 596-1111

Feb 2, 2012 : Managing your Memory Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Minor League Club @ Cub @ Pelican Bay When: 11:30 – 1:30 Contact: Mike Kelly 908-233-2263

Feb. 8, 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Naples Center When: 1:30-3pm Contact: John Guerra (FGCU) 287-5196

Feb. 9, 2012: Assessing and Treating Progressive Memory Loss Where: Naples United Church of Christ When: 2pm Contact: Dr. Greg Smith 595-3550

Feb. 15, 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Bonita Bay Club Fitness Center When: 1-2 Contact: Mayra Newborn, 495-1937/ mayran@bonitabayclub.net

February 20, 2012: Memory Workshop Complementary book, Complementary Workbook Where: At Premier Conference Room, Naples When: 2-5 Contact: 591-6226 for reservations, Fee $100 x1 and $150 x2

February 29, 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain Where: Glenview at Pelican Bay When: 1-3 Contact: Michael Souland-591-0011

One headline reads “Dementia’s first signs appear long before old age, study finds.” (Bloomberg) Alternatively, another headline reads that “Cognitive decline can start at age 45.” (Medscape). These differing interpretations are the leads for two “alerts” I follow to try to keep up with current topics related to memory and aging. In both cases, the actual data are the same and come from a recent article published in The British Medical Journal.

The headlines are based on a large, prospectively designed longitudinal study of more than 7,000 volunteers aged 45-70. Each participant (ranging in age from 45 – 70) underwent cognitive assessment three times during ten years. Overall scores on tests of memory and reasoning declined during the ten years. Only scores on tests of vocabulary remained stable.

On face value these findings appear to be worrisome. However, on closer inspection, the changes were small for men and women between the ages of 45-49 (3.6%). As might be expected, the decline was greater in those aged 65-70 years (a drop of 7.4% for women and 9.6% for men). These are not dramatic changes even in the older participants (some of whom may have actually been in the early stages of decline).

It’s important to realize that not all individuals declined. The percentages are based on averages which mean some declined more and some less than the average – and some improved their scores. Furthermore, there were over 7,000 enrolled in the study. That means that small changes can be statistically significant. But this begs the question of whether small changes like these are important. The risk from such large studies is that trivial effects can be over interpreted as being of practical importance.

To equate these changes – even for the older participants – with “dementia’s first signs” is clearly not justified by the findings. Dementia marks a severe decline that compromises independence. Dementia is not the same as changes that result from normal aging. It seems clear to me that we are justified in saying that tending to cognitive abilities and brain function needs to start in middle age or earlier. But to say the first signs of dementia start at 45 is needlessly alarming. We are not destined to become demented and it is not downhill for all of us after 45.

Many are more fearful of a diagnosis Alzheimer’s than a diagnosis of cancer. However, cancer is much more fatal (cancer is the second leading cause of death in the United States; Alzheimer’s disease is the sixth). This fear stems from a misunderstanding of Alzheimer’s disease and leads many to fear memory assessment.

Alzheimer’s disease unfolds over the course of decades; it does not occur suddenly. There are seven stages of decline in Alzheimer’s disease but current diagnostic standards often don’t identify those with problems until stage 4. Not everyone with Alzheimer’s disease becomes demented and disabled. Not everyone who becomes demented has Alzheimer’s disease. Memory loss is the hallmark feature of Alzheimer’s disease but not everyone with memory loss will have Alzheimer’s disease or become demented. During the early stages of Alzheimer’s disease and memory loss, there is so much that you can do.

The first step in gaining control of your future is to monitor your memory. Whether you prefer the concept of prevention or the concept of wellness, assessment is the key to taking proactive action. You see a dietician to learn more healthy eating patterns. You consult with a physical therapist or trainer to develop exercise routines. You consult with your physician to monitor many elements of your biology such as blood pressure, cardiovascular function, blood sugars, thyroid function, whether you are adequately taking vitamins such as B and D. You do screening tests for many cancers (breast, cervical, skin, and prostate). But you fear and avoid memory assessment as an integral part of your wellness program.

What’s involved in a memory assessment? It doesn’t hurt. You cannot pass or fail any more than you can pass your blood tests. A memory assessment is best administered by a memory expert. The main focus is assessing short-term memory (ability to learn new information) and associated skills such as language, judgment, and reasoning. Assessment evaluates abilities of different parts of your brain. Assessment should be an integral component of annual evaluations.

Be proactive with your memory. Make memory part of your wellness program. Assess and monitor your memory over time. Use external memory supports such as calendars and take away spots. Seek stimulation that uses your mind to learn and master things in which you are interested. Exercise, as it is probably the best overall thing you can do for your memory. Eat more healthy foods by adding more vegetables and fruits to your diet. Be social as those who are isolated are more at risk for memory loss.

It’s that time of the year again. The top ten lists of the year are out to help us recall the year. It triggers both year and life review and stimulates our long term memory of where we have been, where we are, and where we are going. Seneca said it well. “It’s not that we have a short time to live, but that we waste a lot of it.” This of course comes with end of the year resolutions that often amount to trying to do better next year.

I often remark during my talks that the most grievous memory error is “trying to remember.” Instead, plan on how you will remember. Good intentions often fall short when a well placed post-it note would serve us well. It’s the same for New Year’s resolutions. A resolution needs to be a planned act. For example, if you want to get healthier in the 2012, make a plan to remember to exercise consistently. Get out your new calendar and mark out four times a week to exercise for the entire year. Let life then fill in around this goal.

I am pleased to say that I took my own advice last year. I now have an office manager, Beth, to do the many things I was not keeping up with: returning phone calls, scheduling appointments, etc. I hope this has made everyone less frustrated with trying to contact me. Dr. Steve Saldukas completed training with me and is now available to assist with assessments and treatment. All of this has made my life less stressful and caused less frustration for those who wanted to contact or make appointments with me. My resolution for 2012 is to create a system to keep up with e-mails as I get behind and sometimes forget which ones I have done.

The idea of a resolution is simple. A resolution should be a plan that you execute during the New Year. Choose your most important goal and mark your calendar now. This all reminds me of the concept from one of my favorite movies, “What About Bob?” The idea is to take “baby steps.” Think small. Be concrete and specific in setting your plan. And don’t forget to mark it in your 2012 calendar. You can build on it later.

What are the warning signs that the stress of caregiving may be beyond the normal and that you need help?

1. Easily lose patience
2. Easily anger
3. Experience a loss of energy
4. Lose sleep but not from providing care
5. Appetite changes
6. Provide care 24/7
7. Find no joy in any aspect of your life
8. Have frequent crying spells
9. Feel a constant sense of depression, anguish, and despair
10. Don’t think you can go on much longer.
11. Don’t know to whom to turn
12. Use drugs or alcohol to get by

If you check most or all of these feelings, you are likely depressed in a clinical sense. There are many support groups, clinicians, and organizations that will provide help and guidance. Asking for help is not a sign of weakness. If you have considered suicide or homicide, call now.

It’s normal to be stressed by stressful situations. And caregiving for progressive neurological conditions is one of the most challenging stressors I have seen during my 30+ years as a psychologist. As a caregiver you need to understand that it is not only ok but also necessary to sometimes put yourself first. It is okay to make mistakes and become frustrated, impatient, and angry. Whatever you feel is ok. And it is ok to ask for advice and help from others.

Caregiving requires attention to both the needs and feelings of the person giving as well as the person receiving the care. Treatment of dementing conditions needs to address both the needs of the person with loss of memory as well as the needs of the caregiver from the start. Both should be actively involved in all phases of assessment and treatment. The focus of treatment needs to include those who will provide the care.

Caregiving requires effort to take a more positive approach to the task. Don’t forget to care for yourself. Don’t make a mountain out of a molehill. It’s ok to become overwhelmed and frustrated. A bad morning does not have to spoil the whole day. Learn from your mistakes without punishing yourself. Accept offers from family or friends to help with care. Accept offers to go out with friends. “I can’t” really means that what you have to do or face is hard. You don’t have to do everything alone. Get exercise and do something relaxing for yourself each day.