Life and Memory Center

We all hope to remain in the first stage of Alzheimer’s disease, Normal. This is the time during our life when we are free of objective as well as functional decline. This is the stage where senior moments are just senior moments. This is the stage when the efficiency of your memory slows along with everything else. You may need more external memory supports and you may not be able to multitask as well as in the past but you are fully competent and self-directed. If given a rigorous memory evaluation, you will do as well as you ever did. This stage may last all of your life but there are no guarantees. Fifty percent of those living beyond age 85 may not show signs of Alzheimer’s disease.

Forgetfulness is the second stage of Alzheimer’s disease. Forgetfulness shows up in one of several ways. First, it may present as worry about your own memory. At least 50% of persons over 65 worry about their memory. Nearly half of those who express worry declined after 7 years. In short, cognitive decline occurs as many as two decades before there is a decline serious enough to be dementia. Second, Forgetfulness may present as poorer than expected performance on a rigorous memory test. Forgetful persons are still competent and self-directed. They need to develop and liberally use external memory supports and make plans in case there is a progression in the future. There is no estimated time course for this stage.

Early confusion is the third stage of Alzheimer’s disease. Confusion becomes apparent during complex tasks. Balancing the checkbook takes much longer than in the past. Work performance declines and retirement should be considered. The ability to organized events declines. Mastering new complex skills (e.g., computer, a new language) may be difficult at best. The need for external memory supports is imperative as is planning in case of future decline. Issues such as managing your own investments or even the checkbook need to be considered. This stage may last as long as 7 years in those who will decline further.

Late confusion is the fourth state of Alzheimer’s disease. Forgetting is much more dramatic (may forget a recent visit from family, may get lost while driving, may not be able to shop for food, or may forget to pay some of the bills). The ability to perform complex actives such as managing personal finances or preparing meals may be impaired. Despite the confusion, a person at this stage can survive independently and is not demented. The person at this stage clearly forgets that he or she forgets. They may appear apathetic and withdraw from interests and socialization. The need for caregiving begins if all is to run more smoothly in the future. The person in the late Confusional stage may no longer be competent or self-directed. This stage may last about two years.

The progression of Alzheimer’s disease unfolds over the course of decades. We lose valuable time by ignoring changes in memory and waiting for a medical diagnosis to take action. By the time current medical screenings detect significant decline we have lost years of valuable time and quality of life. We are too conservative about rigorously evaluating memory but appropriately careful about making a medical diagnosis such as Alzheimer’s disease. By treating Alzheimer’s disease as a medical rather than a memory problem, we miss the opportunity to get ahead of the changes and directly treat memory while the mind still works well. We lose the opportunity to build skills we will need to protect our family and ourselves.

The unfolding of early Alzheimer’s disease overlaps with normal aging. This process can be described in alternative ways. One way of viewing the changes that occur in Alzheimer’s disease is to think of progressive decline as reverse development. Development and aging progress over the course of decades with basic skills like sitting up and walking occurring early. Language unfolds over the course of many years with increasing complexity added each year through at least adolescence. During early development we learn by means of tasks, tools, and projects that actively engage us with the world. We learn to do basic skills early and only later do we add the complexity such as travel, financial planning and management. We move from the simple to the complex, from the concrete to the abstract, from mere productivity to competence. These changes were well described by Marie Montessori who developed educational strategies that can be equally effective at the beginning as well as at the end of life. Her methods require only engagement with the world. They do not rely on memory or competency.

Alzheimer’s disease progresses in reverse. It shows as declining ability to perform complex tasks such as using computers, financial planning, and complex thinking. Early on the changes are very subtle, there is fluctuation in performance, and complex thinking is compromised. At this stage, it is very difficult to distinguish from the slowing that normally occurs from aging. You can’t run as fast or think as fast as you did when you were 20.

But now is also the time when you are most in control and can be proactive about your future. Take action and formulate advanced directives. Start with a thorough evaluation of your life style, your desires, your plans for the future, and your memory. Advanced directives need to do much more than provide a living will and a durable power of attorney. Set the course for your future as you grow older. Build skills based on the passions that you want to protect as long as possible as well as on your ability to learn remember. And finally include plans to stay engaged in the world even if your memory declines sometime in the future.

“Money Woes Can Be an Early Clue to Alzheimer’s.” This is an attention grabbing headline from the November 4th edition of the New York Times. The point of the article is to inform that complex decision-making may be the first sign of Alzheimer’s that catches attention. We often dismiss mild memory loss as another senior moment rather than a call to action. The changes are so small that complex problem solving is ignored. I once had a client who received attention only after he bought his plane ticket to pick up the $17 million he had won from the publisher’s clearing house.

The dilemma is to determine competency. This is a very complex legal issue that faces families, medical professional, financial advisors, and attorneys alike. Financial decisions have important impact on not only the person with Alzheimer’s disease but also their partners. Current legal and medical tests of competency are too insensitive to be of much use as they only become effective after a problem occurs. Some financial institutions are using the Min-Mental State Exam for screenings but the problems they are trying to head off may occur with perfect scores on this insensitive screening device.

It seems to me that we throw out the logic that we use to make financial decisions when it comes to memory. Financial planning requires us to make decisions based on long-term trends and needs. We have to decide early in life how long we will likely live, what life style we aspire to, our balance between present and future needs and desires, and how to best protect our family. We have to make informed guesses and periodically review and update the plan based on periodic assessments and consultations with financial experts. We even approach heath care with the same proactive periodic assessments, review, and alteration of plans based on data regarding how our bodies are working. Again we make informed decisions that are proactive in nature with our physician as our health expert.

But we don’t apply the same process to our memory and judgment. Most are not aware of the risks and what to do about them. Most don’t come close to doing what they need to do to protect their memory against possible cognitive decline. We miss so many opportunities to protect our future because we fear confronting the facts about memory and judgment. Our present philosophy is wait for memory to start failing before we do something about it. We hope that we can exercise or engage in challenging activities to ward off changes. We hope for a magic drug that will cure Alzheimer’s. We listen to those who continue to say there is nothing you can do.

This solution is to treat memory as you do your finances and health. Track your memory with the help of a memory expert as you do your retirement accounts and your physical health. Start when your memory works well and establish a baseline to track changes in memory and judgment over time. Start when you are in control and issues of competence have not changed. Make a plan for how major decisions will unfold given that your memory keeps working fine and an additional plan in case your memory starts declining. Include family in the assessments and planning. Next week we will focus on the outline of the time course of changes and how to plan at various stages of adequate as well as declining memory.

Alcohol as a psychotropic agent acts as a sedative, a tranquilizer, an anti-anxiety agent, or a hypnotic as it is a central nervous system depressant. As such, it diminishes environmental awareness, reduces responsiveness to external stimulation, impairs cognitive functioning, hinders coordination, and reduces physical activity. At high doses it induces sedation, lethargy, amnesia, antiseizure activity, and anesthesia. Next to caffeine, alcohol is the second most widely used psychoactive substance in the world.

The health-related impact of alcohol consumption can vary depending of the amount and chronic use with its consumption. Heavy ingestion of alcohol over time can lead to a variety of serious physiological and neurological disorders (e.g., vitamin and mineral deficiencies, liver damage, destruction of nerve cells that can induce a dementia, pancreatitis, chronic gastritis, and certain cancers such as tongue, mouth, throat, voice box, liver, stomach, intestinal, breast). Drinking more than five drinks per day (about 10 ounces) can damage the heart muscle and result in possible heart failure and increase one’s the risk of ischemic stroke.

Alcohol use by the elderly leads to a rate of hospitalization that is similar to rate of hospitalization for heart attacks. Elderly have higher sensitivity to alcohol and metabolize in more slowly. Drinking alcohol can contribute to congestive heart failure and hip fractures. Indeed, 1 in 10 Medicare beneficiaries reports unhealthy drinking patterns that are associated with higher education, higher income, being male, younger age, smoking, and self-reported depressive symptoms.

One the other hand, long-term ingestion of low-to-moderate amounts (2-4 ounces per day) of alcohol does not appear to produce dramatic physiological, psychological, or behavioral changes. In fact, low-to-moderate doses of alcohol appear to reduce the risk of coronary artery disease and reduce the incidence of ischemic strokes probably by increasing high-density lipoprotein, decreasing low-density lipoprotein, and the aspirin-like decrease in platelet aggregation. So is alcohol protective against cognitive decline? Are low-to-moderate amounts of alcohol a health supplement?

Two recent studies address this issue. One published in the journal Neurology suggested that moderate drinking slows progression of dementia more that abstinence. The other study published in the American Journal of Epidemiology found no association between low-to-moderate consumption of alcohol and rate of cognitive decline. Fortunately, the second study provides guidance in sorting out this issue. The authors make the point that abstainers in most studies include both those who have rarely or never drank much and former drinkers (who tend to be less healthy than moderate drinkers). Their abstainers did not include former drinkers. If these findings are confirmed, there is neither harm nor benefit from low-to-moderate consumption of alcohol on the risk of cognitive decline. It’s not unhealthy to abstain.

What I take from this is that drinking 4 oz or less of alcohol per day is neither a poison nor a healthy dietary supplement. Low-to-moderate consumption of alcohol has no effect on the risk for cognitive decline whereas greater consumption increases risk for many ailments including dementia. I also wonder whether the cardiovascular benefits of abstaining from alcohol may also be the result of including former drinkers in the abstaining group.

Please click on link for more information on my November 16th talk:
Beckwith_-_November_16th

An opinion presented in the New York Times by Sandra Day O’Connor, Stanley Prusiner, and Ken Dychtwald (October 28, 2010) presents a plan on “How to resist the coming wave of fatal dementia.” They present sobering facts to make their case. Alzheimer’s is 100% incurable and 100% fatal (100% of us will die but most will not die with Alzheimer’s). There are 5 million cases of Alzheimer’s in the United States today and there will be an estimated 13.5 million cases by 2050. They remind us of the rush of baby boomers that start on January 1st. Further, they state that we cannot avoid Alzheimer’s by medical checkups, exercise, being social, or engaging in stimulating mental activities. Finally, they bemoan the lack of medications that are presently helpful and the limits of the effectiveness of the medications to reverse the degenerative changes.

They propose the solution is to set a national agenda of “stopping Alzheimer’s by 2020” and compare the process to the race in the 60s to be the first country to land a man on the moon by the end of the decade. They hope to change Alzheimer’s to a “former diseases like typhoid, polio, and childhood cancer.” All of this begs the question of whether we can eradicate a medical disorder by force of will and money. I was at a conference in 1990 where researchers promised a cure for Alzheimer’s by 2000. Finding an effective cure for Alzheimer’s disease is a much more complex problem than landing a rocket on the moon. If we don’t know the cause of Alzheimer’s, how can we realistically set a time table for drug development?

I propose that we spend more resources on treatments that help now. Alzheimer’s disease starts decades before we can detect it by current medical tests. The best model for developing a treatment strategy may be diabetes. Those at risk of diabetes don’t wait for a diagnosis to start education and treatment. Like Alzheimer’s the onset of diabetes is slow and progressive. Like Alzheimer’s there is no cure for diabetes. Like diabetes we need to be proactive and work with changes in life style and education to better manage the course of Alzheimer’s disease. We need to research and develop strategies for early interventions when the changes are mild and diagnostically uncertain.

Let’s further develop assessment and education programs for those with high risk (e.g., family history, head injury, over age 65) that are based on fact and hope rather than fear. These programs need to help everyone understand that the essence of treatment is that certain skills/habits must be learned before short term memory becomes too impaired to learn them. It all starts with a thorough memory assessment that does more than diagnose. Assessment should help families to develop plans that focus on the skills they need to learn. These plans need to include groups like the Alzheimer’s Support Network’s (262-8388) Minder’s Keepers which is designed for those with very mild memory decline rather than Alzheimer’s disease. They also need to direct families to creative treatment programs such as CompanionPlus (370-7130) that focus on those that do not need traditional day care programs.

My wife recently treated herself to an I-Phone and MacBook Pro computer. She has extended her memory to the internet allowing her to explore ideas, places, and events. She has access to applications (“apps”) that allow her to calculate, argue, plan, and daydream. She can also use these devices as memory collaborators. She can track as well as have auditory reminders for appointments. She can pay bills, organize her life, and record events (pictures and videos) that we want to remember. She is delighted. Her I-Phone and computer work for her in the words of David Chalmers as an “extended mind.”

Smart phones and computers serve as memory collaborators for many individuals as well as organizations. They have replaced paper calendars and people whose job it is to remind those for whom they work. On the one hand, they allow us to multitask better. On the other hand, they force us to multitask more often. The Achilles’ heel of memory is multitasking. For example, consider remembering to pick up milk on the way home from work tonight or take a medication at 4PM. Now I can be sure to remember by setting a smart phone to chime at the time I will leave work or at 4:00 and remind me to pick up milk or take my medication. These are examples of the upside. However, smart phones also add to my memory load as now I can constantly be reminded of a new e-mail by a different chime. There have become so many interruptions of my train of thought. I don’t answer my phone when I am with a client or in the middle of a talk.

Computers are thought by some to extend our working memory to make our mind and memory more efficient. Working memory is roughly the human memory system that multitasks. Maggie Jackson (Distracted, 2009) describes our working memory as similar to the news headline crawl which is “constantly updated, never more than a snippet, and no looking back.” But memory is based on more than unlimited access to new information. With the advent of computers and smart phones we can now create and have instant access to information at a rate that far exceeds our ability to find, review, understand, and recall the information. We live in what Richard Wurtman (Information Anxiety, 2001) named the age of information anxiety.

Computers and smart phones are good. They are very helpful forms of mind and memory collaboration. Indeed, I am getting close to obtaining some kind of smart phone to help me keep up better as I still use a paper calendar. As an expert on human memory my concern is that the newly developing technology presents a risk. Human memory evolved thousands of years ago and is not structured around information technology. Maggie Jackson stated my fear best. “The way we live is eroding our capacity for deep, sustained, perceptive attention – the building block of intimacy, wisdom, and cultural progress.” Let’s not forget a corollary the one minute rule that underlies human memory: anything given less than at least one minute of focused thought will fade from memory.

I’m presenting a seminar titled, “Remembering What Not to Forget” this Tuesday, October 19th at 10 am. It will be held at the Renaissance Academy at the Atrium in Fort Myers. Call 425-3276 for reservations and directions.

People often remind each other of appointments, words, what to buy, and names. For example, at work there are administrative assistants whose job it is to remember for and remind others. These memory collaborators serve as the backbone of organizations. At home, partners are our memory collaborators. So often my wife helps me find words for which I am searching, reminds me of appointments, helps me recall times I have enjoyed, and what to pick up at the grocery store. She also reduces my memory load by managing the checkbook and finances. As with many married couples it is a symphony of collaborative efforts that makes both of our lives easier as neither of us has to remember everything on our own.

For those with memory disorders, the need for memory collaboration is no longer a convenience but becomes a necessity. As memory disorders progress, there is an increasing need of external support for memory, especially for those who forget that they forget. Those with partners will do much better than those who live alone. With mild memory loss, the partner becomes the source of reminders for appointments, sending birthday cards, or taking medications but routines such as chores or going to play golf remain. As memory increasingly fails, the partner becomes more and more important (but not necessarily appreciated) for remembering. They need to be sure the bills are paid, that the checkbook is correctly balanced, that the laundry is done, etc. In more advanced stages of memory loss, the partner has to help remember when it is time to attend to personal care such as when to shower or when to change clothes.

It’s no wonder that partners of those with memory disorders are often tired, frustrated, and stressed. They have to increasingly remember for two in addition to the myriad of tasks they have to take over such as shopping, the checkbook, or driving for those who cannot. The collaboration becomes one sided. I recall so clearly the frustration of a husband who brought his wife to see me about back pain that kept her in bed for an extra several hours each morning. By the time they saw me in the afternoon her pain had subsided. He asked her to describe the pain to me and she merely said, “What pain?”

We need to keep the collaborating spouse in mind when working with those with memory loss. For medical appointments self-report is no longer reliable. Assessments need to include the partner as an active participant in all phases. The partner also needs to understand the outcome of assessments and be included in treatment planning and execution. Finally, the partner also needs attention, guidance, support, understanding, and training. Treatment of memory disorders is a collaborative process that must engage all partners.