Life and Memory Center

I finally got around to reading a book that one of my clients gave me a couple of years ago – My Stroke of Insight by Jill Bolte Taylor, 2006, Plume: New York, http://www.drjilltaylor.com. Dr. Taylor is a Neuroanatomist who had a stroke on December 10, 1996 when in her mid 30s. There are two types of stroke. One is caused by blockage (infarction) of blood vessels in the brain, the other caused by bleeding (hemorrhage). Hers was the latter caused by the rupturing of an abnormal blood vessel structure, ateriovenous malformation, which she didn’t realize she had until it bled. Her recovery took 8 years – don’t believe the 6 month rule. The stroke left her completely disabled – unable to walk, talk, read, write or recall much of her life.

Although the book is an excellent, approachable, personal, and philosophical treatise on stroke and recovery from the inside out by an accomplished neuroscientist, I was most moved by her succinct summary of how to approach the neurologically impaired whether victims of stroke, head injury, retardation, or dementia. These insights are summarized in detail in Appendix B of her book. What follows is my selective listing of some of her most important considerations that we all (especially professionals) need to keep in awareness when working with those with brain injuries.

1. “I am not stupid.”
2. “Come close, speak slowly, and enunciate clearly.”
3. “Be as patient with me the twentieth [or one hundredth] time you teach me something as you were the first.”
4. “Take your time.”
5. “Be aware of what your body language and facial expressions are communicating to me.”
6. “Make eye contact with me.”
7. “Please don’t raise your voice – I am not deaf. I’m wounded.”
8. “Honor the healing power of sleep.”
9. “Use age-[retained skill] appropriate … educational toys [objects] and books to … [engage] me”
10. “Teach me with monkey-see, monkey-do behavior.” Liberally use prompts, modeling, and gestures.
11. “Trust that I am trying – just not with your [or my past] skill level or on your schedule.”
12. “Ask me multiple- choice questions. Avoid yes/no questions.” Invite me to do things rather than asking “Do you want to ….”
13. “Do not assess my cognitive ability by how fast I can think [or respond].”
14. “Speak to me directly, not about me to others.”
15. “Break all actions down into smaller steps of action.”
16. “Look for obstacles that prevent me from succeeding on a task.”
17. “Celebrate all of my successes.”
18. “Focus on what I can do rather than bemoan what I cannot do.”
19. “Introduce me to my old life. Don’t assume that because I cannot play like I used to play that I won’t continue to enjoy music or an instrument, etc.”
20. “Love me for who I am today. Don’t hold me to being the person I was before. I have a different brain now.”

“As the twig is bent, so is the tree inclined.” We have long believed that experience and stimulation in early life determines social and intellectual behavior. Indeed, Freud presented theories that personality is largely formed by the age of five. We have broadened our views since then but it is clear that the young brain is malleable, capable of neuroplasticity, based on experience, e.g., John Paul Scott, Early Experience And The Organization Of Behavior way back in 1968.

What about the effects of enrichment on the brain? Rosensweig, Bennet and Diamond performed their classic experiments with rats back in the early 70s. Animals were raised in either a standard, “impoverished,” environment or an “enriched” environment that provided objects to explore and interact with. The brains of enriched rats were thicker and denser than those of impoverished rats. Hence, circumstances in the environment determine brain complexity and we now have programs such as Head Start for the young.

But when it came to the old, the belief was quite different. Whereas early experience had a primacy the old brain was described as declining and not thought to be capable of neuroplasticity. “You can’t teach an old dog new tricks.” Fortunately, we are breaking out of this dogma but old stereotypes are hard to change. The most recent evidence comes from a European study that demonstrated that an enriched environment directly impacts the hippocampus. The hippocampus is a critical brain circuit regulating the formulation of new memories and regulation of emotions. As an aging man with a shrinking hippocampus, I need to take this to heart.

The study demonstrated that enriching the environment produced new innervation within the hippocampus as well as establishing distant connections to other brain regions. The effect persisted even after the enrichment was no longer present. Furthermore, exercise also increases hippocampal neurons. These effects probably don’t alter the course of dementia but they have important implications for the changes in cognition that go with aging.

Finally, naps are beneficial to the brain and learning. Volunteers learned word pairings. Half watched a DVD after learning, half took a nap. The group that took a nap recalled the pairings five times better than those who watched the DVD. In short, the nap reduced forgetting. Brain activity in the hippocampus was thought to explain this effect.

So you can teach an old dog new tricks. As we have known for some time, the best way to deal with the changes of aging are to stay stimulated by enriching activities (e.g., hobbies, reading, beautifying home and garden, getting out into nature, meeting people, engaging in art/music, and studying things of interest). Exercise regularly. And take a nap after learning. Your hippocampus will love it.

We have known for quite some time that women are more likely to develop Alzheimer’s disease than men. The obvious inference is that women live longer than men, on average (the current average age of death for women is 81 and men 76). Given that age is the biggest risk factor for Alzheimer’s disease, women are more likely to live long enough to show symptoms than men.

But many studies have adjusted for age and it is clear that age is not the cause of this sex difference. Indeed, the risk for Alzheimer’s disease is twice that for women than men aged 70-79 but the same for those 80 and older. There is no clear explanation for this relationship.

Despite having a greater risk for Alzheimer’s disease, another interesting sex difference in memory is that healthy woman typically do better than healthy men on recalling lists of words as evidenced by the age norms for memory tests. A recent study from the Mayo Clinic adds an interesting complication (“Age, sex, and APOE4 effects on memory, brain structure and beta amyloid across the adult life span, 2015, JAMA Neurology, March 16, http://archneur.jamanetwork.com/article.aspx?articleid=2193880).

The study focused on 1246 (1209 aged 50 to 95, 37 aged 30-49) participants in a longitudinal study of aging and memory. All were cognitively “normal.” The variables assessed included, age, sex, APOE4 (the “risk gene” for Alzheimer’s disease), hippocampal volume (the short-term memory structure in the brain that is associated with memory loss), and amyloid (a current marker for Alzheimer’s disease based on PET scan results).

The findings:
1) Memory worsened between 30 and the 90s – as we all suspected.
2) Hippocampal volume reduced between 30 and 60s and reduced faster after the 60s – presumably the source of the memory inefficiency.
3) There was little amyloid until after age 70 – suggesting that the memory loss of aging was not related to Alzheimer’s disease.
4) The memory loss was greater for men than women after age 40.
5) Hippocampal volume was less in men than women especially beyond age 60.
6) There was no sex difference for amyloids – the findings do not appear to be related to the development of Alzheimer’s disease.
7) APOE status was unrelated to hippocampal volume, memory, or sex at any age.
8) After age 70 those with APOE4 displayed more amyloid than those with E2 or E3.
Obviously the relationship between dementia and sex is complicated. However, these results do fly in the face of the belief that memory loss in older adults is always a sign of Alzheimer’s disease. The best conclusion at this time is that the memory inefficiencies associated with normal aging are different from the memory loss associated with Alzheimer’s disease.

I have been specialized in memory and memory disorders such as Alzheimer’s disease and related disorders for a quarter of a century. Interestingly, in all that time I have read very little about Dr. Alois Alzheimer (6/14/1864 – 12/19/1915). Engelhardt and de Mota Gomes wrote a recent article (“Alzheimer’s 100 anniversary of death and his contribution to a better understanding of senile dementia,” 2015, Arquivos De Neouro-Psiquiatria, 73, 159-162 PMID 25742587) in honor of the upcoming 100th anniversary of his death that helped me put Dr. Alzheimer in a broader context.

It’s important to understand that the concept of “senile dementia” dates back thousands of years. Both Aristotle and Plato held the belief that old age is linked to inevitable memory failure. The concept of mental stimulation as neuroprotective is also not new. Cicero believed that keeping mentally active prevented or delayed mental decline that he believed comes with age. Cullen defined senile dementia as “a decay in perception and memory” in the 18th century. Phillip Pinel, the great reformer of asylums, set the stage for not only more humane treatment but also increased empirical and pathological observation of those with mental disorders as the brain was increasingly viewed as cause of mental disorders. This has burgeoned into he current explosion of neuroscience and biological reductionism.

Aloysius Alzheimer was instrumental in transforming senile dementia into a brain disorder that is subject to scientific study. He was born in Marktbriet, Bavaria. He obtained his MD from Wurburg University in 1887. He was married with three children but widowed after 7 years. During his career he worked as what would now be known as a biological psychiatrist at hospitals in Frankfurt, Heidelberg, Munich, and Breslau. He had a long friendship and collaboration with Emil Kraepelin, the founder of modern scientific psychiatry, psychopharmacology, and psychiatric genetics.

Although his contribution to biological psychiatry was quit broad, his most famous case was Auguste Deter who was 51 in 1901. Her first symptom was jealousy toward her husband followed by memory decline, disorientation, aphasia, apraxia, agnosia, paraphrasing, and persecutory delusions. Alzheimer studied her for 5 months and later followed her until her death in 1906 at age 55. He was the first to describe “thick bundles of neurofibrils” now known at tangles along with “miliari foci of peculiar substance” now known as plaques based on post-mortem autopsy of her brain. He presented a paper at a Psychiatric Congress in 1906 and published his findings in 1907, which led Kraepelin to coin the name Alzheimer’s disease for this condition in his famous Textbook of Psychiatry in the 1910 edition.

Alzheimer died in 1915 of “renal and respiratory failure” at the age of 51.

There are retirement stories both ways. Some have a long and rewarding retirement. Others seem to decline either physically or mentally shortly after retirement. The fear is that by retiring, one becomes disengaged and cognitive impairment sets in. After all, educational attainment, social engagement, exercise, challenging work, and bilingualism are “neuroprotective so they decrease the risk” of such problems as Alzheimer’s disease. Of course, the conundrum is that we cannot determine cause as there is no study that disentangles whether time of retirement is a result or the cause of cognitive decline. This is further complicated by the fact that Alzheimer’s disease unfolds over the course of decades with subtle onset.

But what does the research tell us? There are a few studies that indicate that there is a correlation, an association between retirement and the risk of developing dementia. The findings are often quoted as a delay in onset of Alzheimer’s disease for each year retirement is delayed. One study suggests a delay of 0.13 years for each year that retirement is put off. This begs several questions like are we talking delays after 65, 60? The most recent study was conducted in connection with the European Alzheimer’s imitative (“Retirement age and the age of onset of Alzheimer’s disease, PloS One, 2015, 10, e0115036, PMID 25714815).

The study was based on an epidemiological study in Europe of 815 patients with Alzheimer’s disease. The database included age at retirement (excluded anyone leaving work before age 50) and age of onset of Alzheimer’s disease. Both age of symptom onset and age of diagnoses were considered. Several possible confounding factors were considered in the analysis: gender, level of education, income, complexity of job, as well as medical variables like hypertension, diabetes, depression, and stroke. Average age of retirement in this study was about 61.

Overall, later retirement age was associated with both delays in age of onset of symptoms (average = 74.9) and age at diagnosis (average = 77.1). This association held even when considering only those who retired before age 65. However, there was no significant association for those who retired before age 65 and developed Alzheimer’s disease ten years or more after retirement indicting that some of those who retired early did so because of symptoms interfering with work performance. The results were not associated with gender, income, medical conditions, occupation, or education.

In conclusion, there is an association between age of retirement and the age of onset of Alzheimer’s disease. However, whether early retirement speeds up the onset of Alzheimer’s disease is unresolved. It is clear that developing cognitive impairment can speed up the age of retirement. I find these data a relief as I an in the early stages of retirement and, so far, seem to be cognitively able.

“Music is ubiquitous in our lives” (Turn off the music! Music impairs visual association memory performance in older adults, 2015, The Gerontologist). It’s present while we are driving, studying, working, shopping, and dining. I often feel that when I’m out and about, I am barraged by music and background TV. Further adding to my frustration is the fact that others are choosing what I have to hear as well as how loud it is.

What is the impact of this noise on cognition and memory? Does it facilitate conversations at diner? Does background music help concentration? Does it help or impair memory? Does it release stress? There is evidence that background music enhances performance on simple tasks like naming as many animals as you can in one minute – called fluency. Then there is the controversial “Mozart Effect.” In the original study listening to Mozart’s sonata for two pianos improved spatial reasoning in college students. It didn’t take long to extrapolate this finding to inferring that listening to Mozart, maybe all classical music, increased intelligence. Later research was unable to confirm this effect.

The study of interest to us assessed the effect of background music on associative memory. The task required learning to associate names with faces and later recognition of which name went with which face. Subjects were younger (aged 18-30) versus older (aged 60-75) healthy adults who had no signs of memory disorder. Each participant was also screened and found not to have significant hearing impairment.

There were three conditions for this study. One group had silence while learning and recalling the task, a control condition. A second heard “musical rain,” computer generated sounds that were not structured like music, anther control. The experimental group heard instrumental background music that was unfamiliar to them as lyrics would be clearly distracting.

The findings were clear. The younger participants were better at this memory task than the older subjects. More relevant to the question addressed, background music as well as “musical rain” similarly impaired memory in the older participants. Interestingly, all participants found the music distracting and preferred silence during learning and remembering. In short, background music as well as “musical rain” was distracting to all and detrimental to the old.

Of course, using familiar music may have produced different results as unfamiliar music draws attention and therefore would likely be more distracting – a question for future research. This becomes more of a problem as we age in that we have a more difficult time multitasking. This limits our ability to ignore irrelevant background when we are engaged in complex cognitive operations.

The implication seems clear to me. Turn off the background music and noise if you need to think or learn – especially if you are past middle age or have any sign of cognitive decline or hearing loss.

What is a neuropsychological evaluation, what good is it, and how is it best done? Let’s start by making a distinction between testing and evaluation. Tests are rigid, standardized, formal measuring tools to determine things like mastery of information, placement in school programs, and outcomes for clinical trials of drugs. The test administrator needs to be consistent, neutral, not help, and not give feedback that may influence the results. Many neuropsychologists administer “tests.”

On the other hand, an evaluation is more flexible. The interaction is less formal and can be modified to meet the needs and personalities of those needing evaluation. For example, memory evaluations start by observing whether the client is on time. Did he or she remember the paperwork? Can he or she find the office? Find their insurance cards? Know their birthdate? Remember a list of words? Evaluation can be more relaxed, friendly. The intention is to put the client at ease. After all, in forensic work the client may want to look as bad as possible. However, no one wants to look demented. Cheating and exaggeration are unlikely.

Neuropsychological evaluation is like blood work – but no one has ever fainted on me. The question addressed is that one has a set of brain skills that have served them well throughout life. The intent is to determine if those skills are holding or declining. Skills may include memory, thinking, problem solving, attention, judgment, using language, nonverbal problem solving. This is the stuff of independence and competence. When well done, the results describe strengths and weaknesses in a way that informs treatment of any deficiencies and takes advantages of strengths. The results inform caregivers of what they are managing and how to help compensate for weaknesses. The results scale the severity of the problem and serve as tracking devices to determine patterns over time and effects of treatments.

I feel strongly that family members should be part of the process. After all, if someone forgets that they forget they can’t tell you what you need to know. Indeed, not including family in the evaluation of memory is a formula for making mistakes that lead to incorrect treatment plans or incorrect assessment of severity of the problem. Furthermore, family members should sit in on the “testing.” That way they better see what they are dealing with. The assessment is part of the treatment and for memory disorders this is a family issue. Being there also enhances feedback, which should be in detail and understandable. Assessment is a teaching device for family members as well as clients with memory concerns.

Diagnosis is a minor part of the process. It informs physicians of treatment parameters. But neuropsychological assessment can be so much more. It is a human interaction. Clients and family deserve to understand not only the findings but also the implications as well as practical guidance of how to deal with often-difficult issues. Assessments should help understanding of how to have a good life despite memory loss as well as to inform decision-making.

It seems that there is a mass sense of awaiting the magic bullet – the medication or the supplement – which we can take to make neurological disease go away. I hear so often how disappointed my audience is when I honestly say there is no magic potion available nor is there one that I can see on the horizon. We have come to expect medicine to offer a cure for Alzheimer’s or Parkinson’s disease just as it can offer antibiotics for certain infections or analgesics that make a migraine go away.

However, if we actually understand how the brain functions, there are treatments right under our nose. I recently read Norman Doidge’s article in the Wall Street Journal (February 7/8, 2015) “Brain, Heal Thyself” with great interest. He points out how our evolving metaphors of the brain, despite having immense heuristic value, have constrained our thinking about treatment of brain diseases.

The French philosopher Rene Descartes proposed an early model. He proposed the brain functioned as a machine. His model was further refined by the added proposition based on the brain’s electrical nature that the brain consists of circuits that have specific roles. Of course, this evolved into the current metaphors of the brain as a computer. These models limit our thinking as the focus on “hardware” and “software” that make the brain inflexible and mechanical. It is something to manipulate from the outside via a chemical or a surgery.

But the brain is anything but static. The brain is a fluid, dynamic organ that defines and constantly redefines itself from birth. The brain creates and refines its skills, microcircuitry, from experiences. It learns. It elaborates skills and parts it uses and it weakens those not needed or used. Consider the miracle of language. We learn language by experience without effort in our early years when all languages are possible. The brain is not fixed but rather it is flexible and evolving. It elaborates itself by use and wastes away by underuse.

Mr. Doidge discusses some interesting implications of this understanding for treating neurological disease. For example, Alzheimer’s disease can be understood as a progressive loss of the brain’s plasticity. It has diminishing returns of benefits from experience. As Alzheimer’s disease unfolds over decades and only becomes disabling at the end of its course, it is treated by lifestyle interventions like found in a recent epidemiological study. The results indicated that the “risk of dementia” is reduced by healthy eating, maintaining normal weight, limited alcohol, not smoking, walking at least the equivalent of 2 miles a day. These interventions appear to mitigate some of the decline attributed to normal or abnormal aging.

Consider also the frustrations of those with Parkinson/s disease that Doidge describes as the “tightening noose.” Fast walking helps motor function in Parkinson/s disease. But the rub is that this becomes increasingly difficult as the disease progresses so those afflicted back off on walking fast further adds to the disability by “learned nonuse.” Also, there is a disengagement of rhythmicity of motor execution in Parkinson/s disease. This may explain why walking on treadmill or dancing to music helps as these activities aid rhythms and help increase speed.

All of this is encouraging. We can treat neurologic disease as well as balance changes from aging by taking advantage of the brain’s natural placidity. We need to better understand these treatments, quit waiting for the magic bullet, buying unproven computer games, and take advantage of the brain’s natural ability to manage itself.

It’s not just those who have memory disorders that want to remember better. In everyday life, at school, or at work we rely on memory to stay engaged, advance, and track information. Seems so simple. It is not. Ever try to remember which movies you have seen over the last 6 months? What books have you read (who wrote them? Details for discussion?)? What you have to do at 3:00? Here are some strategies that help.

1. Read physical books. Reading is reading, right? Apparently not. Turns out that reading a physical book leads to better memory than reading on an electronic reader. Also, taking written notes leads to better learning than transcribing notes on a computer or tablet. When I don’t care if I remember (like for reading just for fun novels), I read electronically. If I am reading to remember, I read hard copy as active notes seem to work better than highlighting functions on electronic readers.
2. Being married. Two memories are better than one. Additionally there can be division of memory labor. Pamela remembers some things better than I and I remember some things better than her. Together we construct a more complete memory of our past and present.
3. Write things down. The act of writing – especially elaborative writing – locks in memory better than single quick experiences or information that are not pondered. Even better, try to teach someone else what you want to remember. Being able to convey information beyond the self creates better understanding as well as better future recall.
4. Walk through the woods or on the beach. A recent study compared the recall of new learning between a group of participants that walked around in a forest to a group who walked around in an urban environment. The persons who walked in the forest did better on a later memory test.
5. Make associations. The best way to learn new information is to associate it with something you already know. Make a story. Draw a sketch. Associate the information with a song. Mark Twain used to walk a familiar route on his estate as he learned new speeches.
6. Review. Takes notes. Review notes often over increasing intervals. Quiz yourself.
7. Don’t ignore the One Minute Rule. This is the old science of mnemonics. The more time, effort, and thought you put into something, the better you understand and remember it.

There are multiple memory systems in the brain. Each has its own organization and structure as well as unique role in our adaptively managing the world about us. I most often discuss short-term and long-term memory as these are so critical for our understanding of senior moments as well as common memory disorders. Short-term memory is the systems that allow new learning and is like the save command in a computer. Long-term memory is autobiographical information, knowledge, habits, sense of self and is like the hard drive of a computer.

Working memory is the memory system that manages the complex inputs we are constantly bombarded with from within (thoughts, feelings) and without. It consists of awareness, near awareness, and rapid decision-making. It is constantly juggling multiple inputs and deciding what to attend to, what to process further, and what to ignore. It is the desktop on a computer, it is the processor on the computer, and it is your active involvement with deciding what to do with all of the possible information and tasks available to you on a computer.

Working memory is a limited capacity system. It is part like the sport light of attention, constantly screening out distraction and focusing on what is import in the moment and in the near future. It allows us to follow conversation. It allows us to hold a phone number long enough to dial it. It allows us to know what we have to do at 3:00. It’s the system that allows us to do mental arithmetic.

Working memory switches from one task to another rapidly and slows more with each demand placed on it. We cannot do two things as quickly as one. Furthermore, as with most skills it slows and becomes less efficient as we age. We are able to juggle fewer things less efficiently, which adds to senior moments.

Hence it becomes essential as we age to actively optimize working memory by spending our cognitive resources and energy more wisely, another manifestation of the One Minute Rule. Here are some suggestions that will help:
1. Reduce and manage stress. Being distressed and overwhelmed takes resources away from working memory. Practice relaxation as a skill, increase mindfulness.
2. Stay fit. A conditioned body optimizes brain function.
3. Become an “expert.” The more we practice a skill or a talent, the more elaborate the brain circuitry underlying the skill, the greater the associations, and the more automatic the execution and the less we need to use working memory. This applies to learning athletic skills, creating knowledge, doing crossword puzzles, playing Bridge, doing art, as well as playing a musical instrument.
4. Get enough rest. Working memory slows when we are tired. Do cognitively demanding work when you are alert and rested.
5. Realize that many drugs (e.g., alcohol) and medications (benzodiazepines, pain medications) compromise working memory.
6. Limit interference (turn off the ringer on the phone) and unnecessary multitasking as much as possible.