Life and Memory Center

A recent report in the journal Brain indicates that ratings from family and friends better predict early signs of memory decline than do traditional medical screenings that are so commonly given to detect and monitor those with possible Alzheimer’s disease or other brain disorders that may be progressive. The questionnaire used in the study is called the Ascertain Dementia 8 and takes only about two minutes to complete. The Ascertain Dementia 8 provides a low cost screen to detect those who need more thorough follow-up evaluation to determine the causes of noted problems.

This study is a reminder that a thorough evaluation for memory disorders requires both technical evaluation such as neuropsychological and medical tests and a thorough history. A good history is obtained not only from self-report (which can be tricky if you forget that you forget) but also from the report of someone who knows you well. I have talked to so many frustrated family members who have not been included in the evaluation process. For years a critical element of my evaluations has been to include family members from the start. The results of family reports have been invaluable both for diagnoses and treatment planning.

Here are some of the 60 items that I use during my interview:
• Is repetitive
• Trouble remembering recent conversations
• Trouble remembering recent events
• Trouble remembering appointments
• Trouble using tools or appliances
• Frequently misplaces objects
• Trouble discussing current events or areas of interest
• Change in sense of smell or taste
• Trouble performing tasks that require many steps such as balancing a checkbook or cooking a meal
• Trouble finding his or her way around unfamiliar places
• Increasing difficulty with finding the words to express what he or she wants to say
• Appears more passive and less responsive
• More irritable than usual
• A family member is concerned

If you can answer yes to two or more of these items for your spouse, parent, or friend, encourage them to seek an appointment with a memory expert and insist on being part of the process. Positive answers do not mean that the cause is Alzheimer’s disease but they do mean that further evaluation is needed. Be proactive. Catch the changes early when there is so much you can do to help.

Alzheimer’s disease is a complicated condition that comes on very slowly over the course of many years.  The first signs may be quite subtle.  The course is irregular with periods of lucid thought interrupted by fluctuations in memory or thinking that are similar to the changes in memory efficiency that happen as a consequence of aging.  This makes early detection of those who develop Alzheimer’s quite difficult and gives rise to a number of beliefs that lead to the attitude that there is nothing you can do.

“Aging is a disease.”  Aging is not a disease state that needs treatment.  Many age quite well and have productive fruitful lives into their 90s or even early 100s.  Take for example my wife’s 96 year old aunt who still safely drives, lives alone and is still a whiz at playing cards or the judge who still works at age 102.

“Memory loss is a consequence of aging.”  Aging does not lead to memory loss.  Memory loss is a consequence of abnormal changes in brain structure, illness, and or accidents.  Aging makes memory like other skills less efficient but if does not destroy memory.

“There is a medication on the horizon that will cure Alzheimer’s.”  Indeed, despite the impressive advances in medicine, there are few real cures for diseases.  We have come a long way in hygiene and immunizations that have allowed control of many diseases but these advances are not cures.  For example, we can better manage diabetes with the discovery of insulin, but being able to replace insulin does not cure diabetes.  The failure of Lily’s medication should give us pause to consider that there will not be a simple cure for Alzheimer’s.

“The objective of evaluation is to predict Alzheimer’s disease.”  We still don’t know what causes Alzheimer’s.  Abnormal proteins called amyloids are associated with the classical plaques that define Alzheimer’s but we still have not resolved whether Alzheimer’s causes the plaques or the plaques cause Alzheimer’s. Furthermore, the almost single minded focus on plaques ignores the other hallmark characteristic of Alzheimer’s called tangles.  It’s is clear that the most common early sign of Alzheimer’s is changes in short-term memory.  We have well developed and standardized ways to measure memory but instead ignore these advancements and continue to seek out “biological markers” for Alzheimer’s.  The objective during evaluation should be to focus on memory and cognitive skills.  If we wait for a medical diagnosis of Alzheimer’s we lose years of valuable time that could be productively spent working around progressive changes in memory.

“There is no treatment for Alzheimer’s.”  The treatment for early stage Alzheimer’s requires focusing on your short-term memory and making a proactive plan to manage if your short-term memory declines in the future.  There are three components to treatment.  First, use short-term memory aids liberally.  Second, learn memory skills that you might need in the future and implement them before you need them.  Third, make a plan for how to stay engaged in the things you love to do.

I was recently moderating a support group for families caring for a parent or sibling with Alzheimer’s disease. One of the participants was 60 years old and after some discussion of her mother she turned and asked: “What about me?” She is noticing changes in her memory and concerned as was her 39 year old daughter sitting next to her. She reported no clear memory deficits but was worrying about her future and whether her current memory concerns were normal for her age, a result of the stress of caregiving, or signs that she may one day develop Alzheimer’s disease. I am hearing this question more and more.

Clearly, there is an increased risk for developing Alzheimer’s if someone in your family is diagnosed with the disease. For example, I recall a retired physician who sought evaluation as he was one of seven children and each of his siblings had Alzheimer’s. He was having clear decline in his short-term memory but otherwise doing well cognitively. We put together a proactive plan to protect his future. However, the genetic link is not always this clear. There is no established genetic test for Alzheimer’s disease. Furthermore, the majority of those diagnosed with Alzheimer’s do not have a family history of the disease. To make things even muddier, I once assessed a 65 year old identical twin whose sister was in a skilled nursing home with Alzheimer’s. The well sister had an excellent memory. If it were all genetics, she would be in the bed next to her sister. Despite all of the advances in genetics, the greatest risk factor for developing Alzheimer’s remains age.

The good news is that Alzheimer’s takes at least 15-20 years to unfold. You have lots of time to plan for how to handle possible changes if they occur sometime in the future. This plan needs to be written and included as part of advanced directives. The plan needs to cover anticipated needs and decisions like driving, assisted living, transfer of financial decisions. Additionally, start life style enhancements but realize there are no guarantees. The clearest directive is to exercise; don’t smoke; drink alcohol in moderation; eat a diet that is heavy in fruits, vegetables, vegetable oils, and fish; and stay intellectually and socially engaged.

The other good news is that Alzheimer’s starts with a reduction in short-term memory – the ability to learn and retain new information. These changes progress slowly and begin years before a diagnosis of Alzheimer’s disease can be made. There is so much you can do about your short–term memory if you don’t wait until you forget that you forget. Not everyone with poor short-term memory will develop Alzheimer’s but the risk is considerably higher for those that do. We think nothing of routine medical evaluations for various diseases like diabetes, cancer, hypertension, heart disease, and thyroid disease but we don’t consider having routine memory evaluations (screenings are insensitive to mild changes in memory). There is so much you can do if you know you are vulnerable. If you have a family history of Alzheimer’s, start with a thorough memory evaluation that allows you to plan and be proactive with your memory and life style.

The New York Times (August 29, 2010) is running a series called “The Vanishing Mind” with the most recent installment titled “Years Latter; No Magic Bullet Against Alzheimer’s.”  The article is based on the conclusions reached by a “jury” of 15 medical scientists along with scientists at Duke University with no vested interests in Alzheimer’s research.  The National Institutes of Health convened this “court” to objectively evaluate the quality of research findings addressing the prevention of Alzheimer’s disease.  These studies covered all of the bases: exercise, mental stimulation, healthy diet, social engagement, nutritional supplements, anti-inflammatory drugs, drugs lowering cholesterol, amount of education, being married, and being a loner.  Last week’s article reviewed the conclusions of the panel and discussed the issue of standards of scientific proof. This article focuses on the meanings of prevention in medicine.

Consider the notion of prevention.  The dictionary definition of prevention is “to keep from happening” or “to hold back.”  The medical definition is not as precise.  There are several levels of prevention in the medical sense including health promotion, early detection, and reducing complications.  Prevention according to medical usage ranges from hand washing, immunizations, screening tests, hygiene, and pest control to  smoking cessation, reducing alcohol consumption, using seat belts, taking drugs to lower cholesterol, using condoms for sex.  We do not need cause and effect evidence (high or medium quality scientific evidence) to engage in many of these behaviors.  Correlational data are adequate to guide us in making many of choices we must to lead a better life.

What about the evidence that interventions may reduce the risk of Alzheimer’s disease.  We have more confidence in interventions that manage as compared to prevent Alzheimer’s.  But this is also true for such diseases as diabetes, cancer, and Parkinson’s.  Correlational studies have brought us a long ways toward better choices, earlier detection, better management, and possibly slowing the progression of these ailments.  I believe the same is true for managing Alzheimer’s disease.  The tone of the Times’ article continues to contribute to the attitude of many that early detection of risk for Alzheimer’s disease is a futile enterprise as “there is nothing that you can do.”  Despite lacking magic bullets against Alzheimer’s or definite scientific evidence, there is clearly so much you can do and there are many good studies providing converging evidence of effective interventions.

So what do we know about managing Alzheimer’s disease based on current evidence?  First, having the E4 variant of the ApoE gene or using combination hormones as hormone replacement therapy for women increases your risk for developing Alzheimer’s.  Second, that being depressed, never married, having little social support, having a head injury, or smoking may increase your risk of developing Alzheimer’s.  Third, there are positive and proactive interventions you can include in your life style.  Eat a diet rich in fruits, vegetables, fish and olive oil; become more educated if you have a choice; condition your body; and stay cognitively and socially engaged.  These choices may decrease your “risk of developing” Alzheimer’s.  This is good news.  Despite the fact that there are no guarantees, there are things you can do to help yourself or someone you love.  Furthermore, doing these things improves the quality of your life no matter whether you develop Alzheimer’s or not.