Life and Memory Center

There is a flurry of articles appearing in both the medical and popular press as many experts are attempting to change the criteria for diagnosing Alzheimer’s disease. The new criteria are based on the “amyloid hypothesis.’ Amyloid is brain protein that sometimes goes awry and is associated with the formation of plaques on neurons. The theory is based on the belief that abnormal amyloids cause Alzheimer’s disease. If this is so, the theory suggests that treatment strategies should be based on arresting or reversing the creation of amyloid plaques. Most current clinical trials of medications for Alzheimer’s disease are based on this hypothesis. By the newly proposed criteria, finding plaque on a PET scan or in cerebrospinal fluids would be cause to diagnose Alzheimer’s disease in persons without memory loss or other symptoms. If adopted, many would be told either that they have or that they are on the way to developing Alzheimer’s disease.

The idea behind this change is to develop treatments before there are symptoms such as memory loss. There is a feeling that the failure of amyloid treatments is due to starting treatments after the disease has developed or progressed too far. Although this is a noble goal, there are a few reasons to be concerned based on current knowledge. First, these decisions are being made based on theory. It is still unclear whether the plaques cause the disease or are a result of the disease. This fact in combination with the failure of amyloid treatments so far to induce clinical improvement is a concern. If amyloids are not the cause of Alzheimer’s disease, we are causing a great deal of anguish for the new cases that would be falsely identified. Second, amyloids are only part of the picture. People with Alzheimer’s disease usually have other pathologies such as tangles caused by a tau protein and vascular damage from mini-strokes. Third, there are a substantial number of people who meet the autopsy criteria (including plaques) for Alzheimer’s disease that have no clinical symptoms.

I feel that we need to be more careful about converting research criteria into clinical diagnostic criteria. The new guidelines are fine for clinical trials based on theory and hope. There will be a large economic and emotional price to pay for these changes. The additional testing is expensive as are the drugs that would be used. But I am even more concerned with the emotional toll. Not every case of memory loss is a result of Alzheimer’s disease (which by current diagnostic criteria involves more than just memory loss). Not all memory loss produces disability. Not all memory loss leads to dementia. There is the security that we derive from being able to label something. If we can put a label on something we have a false sense of understanding it. This is clearly not true for Alzheimer’s disease. We need to focus on functional strengths and weaknesses in abilities rather than diagnostic labels and medical tests. This allows us to treat changes in brain function proactively based on what still works rather than being so focused on what doesn’t work.

Having a better memory is really quite simple. Anything given less than one minute of thought will fade from your memory. We have all known this for years. Consider taking notes at lectures. Notes allow us to think longer about the point we feel is important and they focus our attention. Additionally, taking notes allows us to review the important facts which again give more time to learn and later remember what’s important. In a world filled with massive and multiple sources of information we often ignore the fact that we learn most things well by spending time with the skill or information we want to remember.

The more minutes you spend the better the memory. Indeed, Malcolm Galdwell, author of Outliers, points out that it takes 10,000 hours of practice to become an expert. Think of the multitude of memory systems involved in learning complex tasks. It’s quite a marvel that we can master such complex skills as driving, skiing, bridge, chess, painting, sculpting, writing, or growing orchids. Furthermore, the more time you devote to these activities the better you become at executing them because some of the memory operations involved become automatic.

The One Minute Rule also applies to so many everyday endeavors. How many times have you looked for your car in the parking lot? Often this is a result of ignoring the One Minute Rule. You run from your car to a meeting and want to be on time. You are reviewing who will be at the meeting and what the agenda is. What you don’t do is to stand by your car for a minute and spend the time thinking only of where it is located.

Consider the pervasive frustration with learning new names. Learning new names is a very complex memory skill. Some are very good at this and others have to work at it. But if you want to be better at remembering new names, you must spend the time up front. Repeat the name as you are talking to the person. If you are good at imaging think of a visual association such as trying to remember my name by imaging a duck to represent Bill. When you sit at a table with new acquaintances, make a seating chart on your napkin of the names as they introduce themselves and use their names frequently.

Make notes. The act of making a note makes you think longer about the information. Put a notepad and pen next to every phone and repeat back what you write to the person providing the message. Make a Post-It note to remember to take Kleenex to work and place it on the door going to the garage.

Most memories do not form instantly. Remembering requires time to find, review, understand, and finally to recall. The time we put in pays massive dividends later. Don’t forget the One Minute Rule.

Behavioral problems like aggression, agitation, and hallucinations are common among those with memory loss and dementia. They are often treated with medications as a class called “antipsychotics” or “neuroleptics.” The newer medications in this class include Risperdal, Zyprexa, Geodon, Seroquel, and Abilify. Examples of older medications in this class of drugs include Thorazine, Haldol, and Melleril and are not widely used today. The newer medications are used in about 90% of prescriptions written.

The belief was that these newer (and more expensive) medications are safer and more effective than older medications. However, these assumptions have been challenged by recent research. The overall risk of death from use of these medications is low – about 3%. However these drugs affect heart rhythm and may cause a higher rate of sudden cardiac deaths in vulnerable individuals. This is true for individuals treated with either the older or the newer anti-psychotic medications. Not only did newer medications not offer any advantage over the older medications but the death rates were higher for higher doses of the drugs. Additionally, other recent research has shown that treatment with anti-psychotics (including newer medications) has been associated with weight grain, hyperglycemia (high blood sugars), increased risk for stroke and transient ischemic attacks (TIAs), pneumonia, movement disorders such as tardive dyskinesia, hyperlipidemia (high blood fats), and increased risk for metabolic syndrome. These findings are raising new questions about the relative benefits and costs of the newer as well as the older medications. The FDA now requires warning on the labeling for this class of medications.

When used in low doses (especially in the elderly) and monitored for safety, anti-psychotic medications have a role in management of severe behavioral problems in those with dementia. But these medications should be used with caution and vigilance and only if less problematic medications are tried first and don’t work. Careful cardiac evaluation needs to be done before and after prescribing these medications to better determine the risk versus the benefits of use. Blood sugars, lipids and weight should be monitored prior to and subsequent to prescribing these medications. Family members should be vigilant for over sedation or gait changes. The medications should be carefully discontinued when they are no longer needed. Long-term use should be considered only if the medication effectively helps manage the behavior they were prescribed to help (i.e., there is empirical evidence a treatment effect) and adds to quality of life.

Finally, medications should be used at the lowest dose possible and be only part of treatment. Difficult behaviors also need to be managed through environmental (e.g., keeping people with memory loss engaged) and behavioral control interventions (e.g., calming voice, redirection toward peaceful activity).

The stress of caregiving takes an enormous toll even when it is a labor of love. It is a job that consumes you if you do not take active steps to get away from the constant demands. Being compassionate and caring does not mean total self-sacrifice.

The most effective caregiving is accomplished by balancing the needs of the one you love and your own needs. I often talk with caregivers who are overwhelmed and worn out from their 24 hour/7 day a week job. Caregivers are so invested in the needs of the person with the memory loss that they lose sight of the fact that caregiving demands that you care for yourself as well.

This self neglect is driven by either guilt (“I have to do it myself no matter what the cost”) or because by demands on time (“I don’t have the time”). Clearly you can burn the candle at both ends only for so long without compromising your physical and emotional health. You need time to restore yourself.

The plan is simple. Set your guilt aside and plan something relaxing and restorative each day. Don’t just try to do better; put the plan in your calendar (this time is at least as important as is your next doctor’s appointment).

Decide what you will do (for example, go for a 15-minute walk each day) and make the entries in your calendar for each day in January and February now. Keep two months ahead. The time periods or events don’t have to be long, just frequent. You have enough things you have to do already in your calendar. Schedule time with yourself to do something you want to do. Here are a few suggestions you might consider:

— Get a massage.
— Go for a walk. Short walks can be very restorative.
— Do something you like such as going to a movie, concert, or shopping.
— Treat yourself to a haircut, manicure, or time at a spa.
— Go to lunch or dinner with a friend.
— Take a nap. Improve on your sleep habits.
— Get a pet. They are great listeners.
— Read something escapist like a mystery or gossip magazine.
— Exercise daily for at least 30 minutes.
— Listen to music.

Current research suggests a number of “protective factors” that are associated with better mental skills as we age. These factors include higher educational attainment, higher socioeconomic status, social support, better mental abilities to start with (may be the cause of the education socioeconomic status effect), better lung capacity (an index of fitness and lifestyle), taking a multivitamin, and moderate alcohol use. Note that many of these factors are under your control. There is so much you can do.

The persons that do best as they age work or volunteer, live with someone, rate their health as good to excellent, exercise moderately to vigorously, and do not smoke. If your short-term memory holds, engagement in the world improves memory, reasoning, and speed of thinking. There are no guarantees. However, if you manage the factors you can control, the quality of your time will improve whether you remember what you did or not.

If you make New Year’s resolutions this year, consider doing something for your brain.

— Reduce vascular risk by treating hypertension and high cholesterol.
— If you smoke, quit smoking.
— Exercise most days of the week at least to a moderate intensity.
— Avoid head injuries (e.g., use your seat belt, wear a helmet to cycle)
— Eat a heart healthy diet (many fruit, vegetables, and some fish).
— Manage emotional issues such as stress, anxiety and depression.
— Be social.
— Stay curious and engaged. Read, learn, travel, enjoy. Stay with your passions.

Although aging does not cause memory loss, advancing age is the greatest risk factor for cognitive impairment. This creates a fear of progressive decline such as that caused by dementing conditions like Alzheimer’s disease. Furthermore, we are confronted by many who propose that aging is a disease and the solution lays in “Anti-Aging Medicine.” The notion here is that there are “natural” cures for aging that traditional medicine is hiding from us.

The problem is that creative marketing often hides the facts. As recently as 5 years ago there were a number of supplements that were viewed as essential to slow aging and prevent cardiovascular as well as memory decline. Epidemiological studies demonstrated a clear association between consumption of several herbs, vitamins, anti-inflammatory agents, and hormones (e.g., Gingko Biloba, ibuprofen, estrogen replacement therapy, high dose vitamin E, and vitamin B12) and thinking and the rate of cognitive decline. Hence, the conclusion was reached that these agents “prevent” or slow the progress of Alzheimer’s disease.

During the last five years a number of longitudinal, prospective studies have been published. Participants in these studies are randomly given either the supplement (e.g., vitamin B12, Gingko Biloba, estrogen replacement) or a placebo and followed forward. These studies allow inferences of cause and effect. So far the results have been disappointing.

Take for example the case for replacement of vitamin B12. Many epidemiological studies demonstrated an association between vitamin B deficiency, mental skills, and mood. Lowered levels of vitamin B raised the blood levels of homocysteine (an amino acid). Replacement of B12 lowered homocysteine to “normal” levels. The hypothesis was that replacement of B12 would prevent or delay cognitive decline. The logic was compelling and randomized clinical trials were begun. The results of studies completed to date are clear. Despite the fact that treatment with vitamin B12 returned homocysteine to normal levels, there was no improvement in cognitive function or decline in rates of dementia.

This is not to say that no supplement will help us remember, feel, or think better. Rather the point is that none of the supplements have proven themselves in well designed studies so far completed. Why is this? The logic from epidemiological studies sounds so good and the evidence they provide give us a starting point for investigation. However, epidemiological studies have a bias that cannot be overcome. Those who volunteer for these studies probably already lead healthier lifestyles including a number of factors that may make them different from most of us and there are a multitude of possible causes for any effect that is found. As you decide what supplements you are going to take, be careful to distinguish clever marketing from effective supplements. As with medications, there is no magic bullet.

Dr. Beckwith is a neuropsychologist, speaker, and author of Managing Your Memory: Practical Solutions for Forgetting. He has an office in Naples and can be reached at memoryseminars@aol.com or (239)851-1968.

Have you ever lost your train of thought? Stared into space? Experienced daytime sleepiness? Had disorganized or illogical thoughts? Of course, we all have these experiences. There are days when I am not as focused and days where I am very focused and I’m never at my best by 4:00 in the afternoon as I am in the morning. The clinical term for these lapses is fluctuating consciousness. It should come as no surprise that fluctuating consciousness is more pronounced in dementias. It is startling how lucid a person with Alzheimer’s or Lewy body disease can be one minute and how confused the next.

Fluctuating confusion is a hallmark diagnostic sign of Lewy body disease as it is characteristic of nearly 90% of those with this form of cognitive decline – even before it progresses to the point of dementia. But fluctuating confusion can also be found in a substantial percentage of those with cognitive decline from cerebrovascular disease (e.g., TIAs or strokes) or Alzheimer’s disease, about 40% and 20% of cases, respectively. Early on this symptom appears infrequently but as the decline progresses the inconsistency becomes more frequent.

This is not to say that we should be alarmed at every mental lapse. It is to say that if these lapses are frequent or severe, they deserve appropriate medical and cognitive assessment. If these changes have happened to you or to someone you love, ask two questions. First, do they ever have spontaneous episodes where they appear drowsy but awake or look dazed and are not aware of what is going on? Second, has the level of confusion varied from day to day or week to week with at least two incidents over the past month? How frequent are the episodes (daily, weekly, monthly)? How long do they last (seconds, minutes, or hours)? If answering these questions makes you concerned, seek assessment. Start with a medical evaluation. If there is no medical reason (e.g., sleep apnea, drug or medication use, metabolic disorder, etc.), be sure to get a thorough cognitive assessment.

To put this in another perspective, a recent study of 500 older adults demonstrated that 12% experienced cognitive fluctuations such as daytime somnolence, sleeping more than 2 hours during the day, illogical or disorganized thinking and/or staring spells. Those with mild cognitive decline were nearly five times as likely to report significant episodes of cognitive fluctuations as those with no cognitive decline.

There are early signs that should alert us to the need for memory assessment such as worrying about your memory, a family history of dementia, a past head injury, late life depression, and significant cognitive fluctuations. And for caregivers, these cognitive fluctuations are a part of the reality of a dementia. Take advantage of the lucid moments and try to go with the flow when the confusion is substantial.

Dr. Beckwith is a neuropsychologist, speaker, and author of Managing Your Memory: Practical Solutions for Forgetting. He has an office in Naples and can be reached at memoryseminars@aol.com or (239)851-1968.

What makes us forget? There are a number of factors that make forgetting more likely.  The first step in improving memory is to plan for remembering.  Anticipate where there will be challenges and plan strategies to help.  Here are a few common problems and solutions.

Problem:  Forgetting what someone tells us.

Solution: Take notes.  Mark appointments in your calendar the instant you make them.  Place a note pad and pen by every phone.  Make a grocery list and don’t forget to take it with you.  Record important conversations on tape.

Problem: Difficulty following characters in a novel or learning new facts.

Solution: Inside the front cover of most books is a blank page.  Use the blank page to write the name, a couple of facts, and the page number for each character as they are introduced.  This extra effort will help you remember the character as it focuses your attention.  It is attached to the place you will use it.

Problem: Forgetting where things are placed.

Solution: Everything has a place and everything goes in its place.  It doesn’t matter how inconvenient it is.  It doesn’t matter how tired you are.  Always put your eyeglasses, keys, wallet, etc. in their assigned place.

Problem: Your navigation skills are poor.

Solution: Make schematic maps with landmarks before you drive somewhere.  Keep them simple and don’t forget to look at them backwards before returning home.

Problem: Forgetting to take your medications.

Solution: Make taking the medication part of a routine.  I place my blood pressure pills next to my razor.  Now taking them is part of the routine of shaving.  For those harder to remember afternoon pills, use an alarm.  Put the alarm clock next to the pills.

Problem: Forgetting birthdays or anniversaries.

Solution: Mark the dates in your calendar.  Do it now and do it for the rest of this year.  Don’t forget to mark a few surprise gifts (e.g., flowers) for someone special.

These are but a few examples.  I am sure you can come up with others that better fit your needs.  The solutions are often simple.  We just need to take the time and effort to make better memory plans.

Placement in a memory care or skilled nursing unit is a very difficult decision, one of the most stressful decisions I have ever seen anyone make. Most people suffering from a dementing condition are cared for at home by family members. However, there may come a time when a caregiver can no longer manage alone at home. The most typical causes for placement are behavioral problems (e.g., wandering, aggression, delusions, hallucinations), incontinence, refusal of personal care, or caregiver illness or stress. All of these reasons involve a crisis and are often made when emotional resources are drained.

I have worked with many who see me early in the disease process and we develop a plan that we follow by monitoring and decision making over the course of several years. Care evolves as decline progresses from being able to manage on one’s own to needing various levels and types of external support. This support can be provided by a family member (e.g., spouse or child) or by professional caregivers.  Using outside resources such as companions (CompanionPlus at 370-7130) and aids (there are many good home care agencies) helps both the person with the decline and the caregiver function better for longer at home and allows adaptation to external supports for care.

If use of external care and companions has been part of the process of caregiving all along, placement may be less traumatic. It is also helpful to have the person placed in stages rather than all at once.  For example, getting involved in lunch and activities while still at home softens the change for all involved. This way the changes can be slower and familiarity can be established with the new environment and staff before moving in. This is true for assisted living as well as for placement in more secured care settings such as dementia assisted living or skilled nursing facilities. The major factor to consider in a facility is programming (getting the person out of their room and to activities). Even persons with middle stage dementia need stimulation; so care should be active rather than custodial and emphasize productivity rather than competence.

Finally, these decisions are best made with the help of a knowledgeable and skilled professional. There are many excellent ways to monitor the changes in cognitive decline and help all involved be more proactive. It is also very helpful to have placement made in a supportive context for both the person who has declined and those who are intimately involved in their care.