Life and Memory Center

Depression has been associated with dementia. For example, the Framingham study followed 949 men and women (average age was 79) for 17 years. There was a 50% increased risk of developing a dementia in those reporting symptoms of depression during the study. Similar findings are evident from the Baltimore Longitudinal study of aging.

Depression robs motivation and enjoyment, drives poor self-esteem, adds to the discomfort of pain, and produces social isolation. Depression also distorts memory. In very severe depressions, one is so focused on inner feelings of despair that there are few memory resources left to process information from their surroundings. As if this weren’t enough, people who develop a depression in later life are more at risk of experiencing cognitive decline.

There are four explanations for the association of depression and cognitive decline. First, depression is a symptom of dementia. Second, depression may be a reaction to the loss of memory. Third, depression is a unique risk factor for developing dementia. Fourth, the apathy and loss of engagement or the blunted affect often seen in dementia may be mistaken for depression. Often antidepressant medications are used to treat the depression associated with dementia but until recently their effectiveness has been assumed rather than tested.

A study in Lancet (July 2011) raises questions regarding the effectiveness of the commonly used antidepressants Zoloft (sertraline) and Remeron (mirtazapine) in treating depression in patients with Alzheimer’s disease. Neither medication was more effective than a placebo and both increased unwanted side effects (GI distress for Zoloft and sedation for Remeron). Another study in the British Medical Journal (August 2011) indicates a significant association between adverse outcomes (e.g., stroke, falls, seizures, and mortality) for antidepressant use (including SSRIs, which may fare a bit worse than older tricyclic antidepressants but better than medications such as Remeron, Trazodone, and Effexor) in those over 65.

These findings indicate that use of antidepressants must be carefully considered for those with a diagnosis of dementia or milder forms of cognitive decline and closely monitored in anyone over 65 (include thorough memory evaluation which should assess mood issues). Adverse effects appear more often during the first month of use and weekly monitoring by a professional is essential. A limitation of the study is that it did not address the issues of agitation or aggressiveness. There is clinical lore that antidepressants may calm agitation and aggressiveness that is part of some with dementia. This treatment effect was not addressed and needs to be empirically resolved.

Alternatively, don’t reach for the medications too quickly in the treatment of depression. A first approach in those with cognitive decline may be to treat the depression with nonmedical interventions first and then add medications if needed. Start with cognitive therapy that addresses the lack of worth. Include a plan for exercise and socialization immediately. Whether the issue is apathy or depression, the treatment needs to follow a plan that promotes and structures re-engagement. The idea is to get activated even though you don’t want to.

The American Heart Association and the American Stroke Association have issued a 42 page statement regarding the vascular contributions to cognitive impairment and dementia that was published in the July issue of Stroke. Although Alzheimer’s disease has received the most attention vascular changes make significant contributions to cognitive decline and should be routinely addressed in clinical practice.

The statement suggests a new term, “vascular cognitive impairment,” to incorporate the varied cognitive disorders associated with stroke ranging from mild cognitive disorders through dementia. Don’t be confused by the introduction of a new term as accumulating evidence indicates that vascular factors also play a role in neurodegenerative cognitive disorders such as Alzheimer’s disease that develops latter in life and the recommendations below apply to all of us. Two criteria are needed to diagnose vascular cognitive impairment: (1) neuropsychological evaluation to demonstrate cognitive decline and (2) presence of stroke by history or neuroimaging (e.g., MRI, CT scan).

Stroke and heart disease are risk factors for both vascular cognitive impairment and Alzheimer’s disease. Hypertension, high cholesterol, diet, tobacco use, and sedentary life style play a causal role in cognitive decline. Many have summarized the relationship as “what’s good for the heart is good for the brain.” The hope is that detection and managing these factors may reduce the cognitive impairment that some experience as they age.

The committee makes numerous recommendations based on current scientific evidence that may reduce cognitive decline with age:
 Stop smoking
 Be moderate in using alcohol
 Exercise and manage weight (being either too skinny or being greatly overweight may increase risk)
 Eat a “Mediterranean” type diet
 Fish oil may be helpful via either eating fish or using supplements
 Aricept (donepezil) is useful to treat vascular cognitive impairment as well as Alzheimer’s disease
 Razadyne (galantamine) is beneficial for those with mixed vascular and Alzheimer’s disease

There are also a number of factors that do not appear to be helpful in treating or managing risk of vascular cognitive impairment based on current scientific evidence:
 Use of antioxidants and B vitamins have not proven useful
 Vitamin supplementation does not appear to enhance cognitive function even when homocysteine is lowered and vitamins’ usefulness in those without vitamin deficiencies has not been established.
 The evidence for usefulness of vitamin D for vascular cognitive impairment is mixed and limited to date
 The effectiveness of antiaggregant therapy (blood thinners) for vascular cognitive impairment is not well established. This is not to be confused with the helpfulness of these medications for treating stroke.
 Rivastigmine (Exelon) and Namenda have not yet been shown to be useful in vascular cognitive impairment.

Dr. Beckwith will present a three hour workshop (fee $100 per person/$150 per couple with limited seating) in Naples on August 8 (call 591-6226 to register).

One of the most frequent questions I am asked is “What is the difference between Alzheimer’s disease and dementia?” Dementia is a general term that is often misunderstood. Dementia refers to mental deterioration to the point that one can no longer do higher level mental tasks like balancing a checkbook, using a computer, or preparing a meal. In more severe forms of dementia, one may no longer be able to tend to personal needs such as bathing, toileting, or dressing. In other words, dementia refers to mental decline where one can no longer function independently (i.e., needs at least some level of external care). Dementia refers to the severity of the mental deterioration.

Dementia is caused by a loss of skills that used to work well (e.g., finding your way around, paying bills, dressing). There are many possible causes of dementia. For example, the most frequent cause of dementia stems from a heavy burden of abnormal proteins named amyloid (i.e., plaques) and tau (i.e., tangles) that interferes with brain functions. When these proteins are the cause of the decline the condition is diagnosed as Alzheimer’s disease. Dementia is the general term for decline and Alzheimer’s disease is one of many possible causes of decline known as primary progressive dementia.

There are many causes of dementia other than Alzheimer’s disease. For example, when stroke causes the decline, the diagnosis would be vascular dementia. When a head injury causes the decline, the diagnosis would be dementia due to traumatic brain injury. If the frontal lobes (the part of the brain that plans and judge, interacts in socially appropriate ways, expresses oneself) decline the diagnosis would be a frontotemporal dementia. Progressive loss of expressive language is diagnosed as a primary progressive aphasia. There is a progressive dementia in some with Parkinson’s disease. There is another rather common progressive dementia caused by Lewy bodies called diffuse Lewy body disease. These conditions (as well as others) are all irreversible declines in ability. Some dementias are progressive (meaning they get worse over time) whereas others may be develop suddenly then stabilize or even improve over time (such as those caused by a stroke or a brain injury).

We often hear of so called “treatable dementias.” This is a poor choice of words. The term dementia should refer to irreversible conditions. There are some medical conditions that may cause temporary mental deterioration. With appropriate treatment or over time, there is a recovery to normal or near normal. Medical conditions such as thyroid disorder, metabolic disorders, certain vitamin deficiencies, tumors, severe depression, normal pressure hydrocephalus (if discovered and treated early enough), reactions to medications, untreated sleep apnea, “brain fog” from chemotherapy, acute illnesses (e.g., urinary tract infections, high fever) may cause temporary (may last hours to days to weeks) inability to function. These possibilities need to be evaluated in anyone showing decline.

In short, dementia is an irreversible and severe decline of mental abilities that interferes with independence. If properly managed, those with dementia can have a good quality of life.

Dr. Beckwith will present “Engagement Therapy for Memory Loss” on July 27 sponsored by Arden Courts in Fort Myers (call 454-1277 to register) and a three hour workshop (fee $100 per person/$150 per couple with limited seating) in Naples on August 8 (call 591-6226 to register).

Mild memory loss always presents diagnostic and treatment dilemmas. The actual prevalence of Alzheimer’s disease (a major cause of memory loss) changes with age so that it is 1.4% during the late 60s, 2.8% during the early 70s, 5.6% during the late 70s, 11.1% during the early 80s, and jumps to as high as 50% after 85. It is safe to conclude that age trumps all other risk factors if we live past 85.

There are many putative risk factors that may cause memory loss and may also slightly raise the risk of developing Alzheimer’s disease: cardiovascular disease, cerebrovascular disease, high cholesterol, peripheral artery disease, elevated homocysteine, low folate, diabetes, smoking, midlife obesity, short men, adult onset depression, family history, and head injury. The greater the number of risk factors, the greater the risk.

Head injury has received increased attention in recent years because of the increased risk of developing dementia in those who engage in certain sports such as football, boxing, and soccer (I find it sad that we monitor cognitive and memory function for those who play college and professional football but not the rest of us). Moderate to severe head injury often produces clear and enduring deficits in those affected. The most controversial form of head injury is what is called “mild” traumatic brain injury. This is defined as suffering a blow to the head which induces confusion or disorientation, loss of consciousness of 30 minutes or less, and/or post-traumatic amnesia for less than 24 hours.

Most of those suffering from a single mild traumatic brain injury (the risk increases for multiple mild head injuries or concussions) will fully recover. However, an estimated 15% will not have a complete recovery. Furthermore, there is an increased risk for Alzheimer’s disease or frontotemporal dementia in those with head injury. There are no clear estimates of the percentage increase in risk.

Among current hypotheses to explain the increased risk of dementia in those with brain injuries are that head injury speeds up the onset of dementia in those already predisposed and/or that head injury increases the level of beta amyloid (as does stroke) which is the pathology underlying development of plaques. There are overlapping complaints for those with head injury and early Alzheimer’s disease and Mild Cognitive Impairment: memory complaints, slowed thinking, and decision making and problem solving deficits. In mild brain injury the memory deficits respond well to external supports and the problem solving deficits occur early. In Alzheimer’s disease the memory deficits are more severe and problem solving comes as the pathology increases.

Treatment is similar for early stage Alzheimer’s disease and for mild brain injury. Thorough assessment of memory and thinking for a baseline as well as monitoring over time and treatment is essential. Both require a proactive approach that treats working and short-term memory. Treatment needs to be practical and focus on developing memory skills, compensation strategies, family support, and planning for the future in case there will be progressive decline.

Dr. Beckwith will present “Engagement Therapy for Memory Loss” on July 27 sponsored by Arden Courts in Fort Myers (call 454-1277 to register) and a three hour workshop (fee $100 per person/$150 per couple with limited seating) in Naples on August 8 (call 591-6226 to register).

Sleep apnea is characterized by reductions or pauses (10 seconds or more) in breathing during sleep. Sleep apnea is more common in men than women before age 50 and the same after age 50. It is more common with obesity (maybe as high as 70%), heart disease (30-50%), and stroke (60%). Estimates suggest that only 10% of those with sleep apnea receive treatment. Untreated sleep apnea is associated with increased accidents at work and while driving.

Sleep apnea induces daytime fatigue and sleepiness, headache upon awakening, and insomnia. It also affects mental functions including poor concentration, impaired attention, and poor memory. It contributes to irritability and anxiety. Those with sleep apnea may exibit loud snoring and abrupt awakenings with shortness of breath. If you have this constellation of symptoms, consult your doctor who may order a sleep study to definitively diagnose sleep apnea.

There are also long term risks resulting from untreated sleep apnea. These include exacerbation of hypertension, heart disease, heart attack, stroke, or disturbances of heart rhythms.

The memory loss from sleep apnea may result from atrophy of the mammillary bodies, which are involved in recognition memory (a different kind of memory loss than that found in Alzheimer’s disease which affects the hippocampus and short term memory). Mammillary bodies are bilateral structures of the limbic system and are involved in attention, memory, and emotion. Imaging studies have demonstrated shrinkage of the mammillary bodies in those with moderate to severe sleep apnea. The atrophy is believed to be caused by the repeated drops in oxygen.

Fortunately, sleep apnea is treatable. The most common treatment is to use a machine that provides continuous positive airway pressure (hence the name CPAP) via a face mask that is worn while sleeping. A recent study demonstrated that using this device for about 6 hours per night improved scores on tests of memory, decision making, and attention after 18 months of treatment when compared to baseline scores before using the apparatus. Participants in the study also reported improved quality of life.

Treating sleep apnea is not a cure all for memory loss and the type and severity of the memory loss is different from that associated with dementing conditions. Sleep apnea should be considered in cases of mild memory loss. Treatment involves using the CPAP device, weight loss, and avoidance or limited use of alcohol, tranquilizers, and sleep aids (all of which also impair memory).

Caregiving takes an enormous emotional and physical toll even when it is a labor of love and/or obligation. In the case of caring for someone with progressive memory loss, a spouse or child often has to parent their partner or parent. This sets up a natural and sad antagonism. The caregiver must set limits and enforce rules (nag and be bossy) and the care receiver isn’t aware that they need the guidance as they forget that they forget and resent and resist rather than appreciate the efforts on their behalf.

Take for example the case of a caregiver (partner or child) who is caring for her very forgetful but very bright husband/father. He is so forgetful that he cannot monitor how much money he spends in any given month and is prone to overspend. His partner/daughter has to put him on a budget (remove credit cards and take over the finances) so he has money to continue to live in his home. He is understandably angry and resentful. She is sad, anxious, hurt, and guilty. Furthermore, he forgets to take his medications despite an organized pill box and this must be managed by others. Finally, there is the issue of whether he is still safe to drive and needs a driving evaluation. He is irate, she is tearful and overwhelmed. Once all of these issues are resolved and he gets over his anger and used to the new structure, things will settle down – in time.

These conflicts take their toll on both caregiver and care receiver and create many gut wrenching dilemmas. Treatment must be sensitive to both parties. We often neglect caregivers in the formula as they may be prone to refuse assistance as they don’t want to burden others. The most effective caregiving is accomplished by balancing the needs of the one you love and your own needs. Treatment is simple to state but difficult to implement. Try some of these strategies but remember nothing works every time.

• With severe short-term memory loss you cannot say something often enough for it to sink in. You must do what needs to be done without expecting understanding or gratitude. Keep discussions short – no longer than 15 minutes – and try to not take the anger personally.
• Pick your battles. If the issue is not critical don’t go toe to toe.
• Get assistance in working through issues by talking to an experienced memory expert or support group. They don’t have all the answers but may help you plan strategies and provide support in difficult situations.
• Expect your agreements to be forgotten and give time for the anger to settle.
• Go for a walk. Short walks can be very restorative and help you to settle down.
• Do something you like such as going to a movie, concert, shopping, out to lunch with a friend. You need to defuse your stress if you are a caregiver.
• You will have some bad times/days no matter what you do. Caregiving and receiving is hard.
• Get a pet. They are great listeners.
• Exercise daily for at least 30 minutes.