Life and Memory Center

We constantly read about the need for mental stimulation to enhance the efficiency of our brains. The current catch word is “neural plasticity.”

This process involves the elaboration of brain function by activity. We learn to speak, to walk, to ski, to golf because of our brain’s innate ability to learn from experience. This is true for those of all ages. Indeed one of the essential ingredients in treating progressive memory loss is keeping engaged in doing and learning. The subject doesn’t matter. It is in the doing that counts.

This principle even applies to those with “early Alzheimer’s disease” or “mild cognitive impairment.” The key to successful treatment of dementias — keep engaged.

No matter what stage of memory loss, human beings need to be active in the world. They need stimulation for their brain as much as the rest of us. The challenge is that short-term memory loss may limit doing things they enjoy on their own. Hence we have developed treatments through residential, day care, and home-based programs.

For example, participants at well run residential and day care programs for the memory impaired are provided with “palliative” memory rehabilitation through engagement therapy. In essence, this therapy keeps those with memory loss engaged in joyful and stimulating activities such as walking, socializing, thinking (e.g., word games, watching movies, art therapy, music therapy) that fit their interests as well as their level of memory and skill. The key to this treatment is to start these programs early when memory and other cognitive skills are working relatively well.

I have always felt that we need some newer programs for those who are very early in progressive memory loss. We need to set routines that keep stimulation going in the face of increasing passivity and forgetfulness. I call this concept day care without walls. The concept is simple. If you love to fish, keep fishing. If you love ballet, keep going to the ballet. The range of activities is limitless: movies, lunch, concerts, museums, art, exercise. This works even better when stimulation is done in small groups.

There is a new program, CompanionPlus, that has been developed along this idea. Participants are carefully selected and go out in small groups of three or four persons to do activities of common interest. Their first outing was a group of three who went to a Twins game last spring. Others are golfing or sailing again. Still others are going in small groups to supervised exercise. The intent of the program is to give life back to those who are more mildly memory impaired and to provide respite for caregivers who are trying to do it all. It allows a proactive plan for staying ahead of progressive decline. For more information about CompanionPlus, call (239) 566-2815.

I have believed for years that Alzheimer’s disease and related disorders are present for decades before a medical diagnosis can be made. A newly published study confirms my belief.

The study focused on healthy, independently living persons 40 years or older who were cognitively normal. Nearly 80 percent of the participants expressed concerns about decline in their memory (“Worriers”); the rest reported that they felt they had normal memory (“Nonworriers”).

The two groups were similar in education and ratio of men to women. The average age of participants was about 65. Interestingly, all participants did very well on the Mini-Mental State Exam. The exam is very commonly used in research and clinical practice to screen for dementia and memory loss and has a perfect score of 30 points. Participants average score was 29 (a score that can lead to false reassurance).

Nearly half of the participants declined cognitively by the end of the study after 7 years. A greater proportion of the worriers (54.2 percent) declined than the nonworriers (14.9 percent). Eighty percent of worriers were diagnosed with Mild Cognitive Impairment (objective decline in memory on rigorous testing). In short, cognitive decline occurs many years (as many as two decades) before there is a decline serious enough to be labeled as dementia (severe enough that independently living is not safe).

The investigators suggest that these findings raise the “possibility of preventative research.” I feel the findings tell us so much more. First, current medical screenings are not adequate. By the time that one is losing even a point on the Mini-Mental State Exam, changes may have been occurring for several years.

Second, your intuitions about your memory are good. If you think there are changes, get a rigorous evaluation to establish a baseline and make memory evaluations as common as physical exams. Be as proactive about your memory as you are with monitoring blood sugars or blood pressure.

Third, you don’t have to wait until the medical world finds a treatment. Treatment begins with the use of external memory supports and management of life style. We don’t wait until we are 80 to start saving for retirement but we wait until we have substantial changes to address our memory.

Treat changes (whether they be senior moments or more) in memory early. Use your calendar well. Get a digital watch for orientation. Put everything in its place. Make a plan to stay involved in your passions. Quit trying to remember. Plan on how you will remember. Don’t wait until you forget that you forget.

Type 2 diabetes mellitus is associated with accelerated cognitive decline in the elderly. This includes increased risk for mild cognitive impairment (often seen as short-term memory loss that is either subjective or confirmed by rigorous memory tests) as well as dementia (moderate to severe short-term memory loss that causes a lack of independence).

A recent study indicated that type 2 diabetes also accelerated the rate at which those with mild cognitive impairment progress to a diagnosis of dementia. The dementia may be either caused by Alzheimer’s disease, vascular disease or both.

Individuals with both mild cognitive impairment and diabetes are at greater risk of becoming more seriously and cognitively impaired over time. As is true of most studies, the studied population consisted of mostly whites of European decent and the design of the study was retrospective or epidemiological. As there are nearly 6 million cases of type 2 diabetes in the U.S., it is important for those at risk to remain proactive as managing the risk of developing type 2 may also reduce the risk of becoming demented.

Attend to risk factors for type 2 diabetes. Risk factors include a family history of diabetes; being older than 45; hypertension; metabolic syndrome; “good” cholesterol less than 35 mg/dl and/or triglycerides greater than 250 mg/dl; history of gestational diabetes; polycystic ovary syndrome; inactive (exercise less than three times per week); and ethnicity (black, Hispanic/Latino, Native American, or Asian).

If you have any of these risk factors, monitor blood sugars. But don’t also forget to monitor memory. Those with changes in memory who develop type 2 diabetes are at great risk of cognitive decline.

But don’t wait for a diagnosis. If you have these risk factors there are many life style choices you can make now. First, get moving. Increase your aerobic exercise to the point where you are exercising 5-6 days a week for at least 30 minutes. This is probably the most important element for maintaining cardiovascular and brain health. Second, eat well most of the time. Eat mostly fruits and vegetables with smaller portions of meats (no larger than a deck of cards).

Finally, don’t forget your memory. Use external memory aids liberally. If you have any concerns, get a memory evaluation. Stay ahead of changes in your blood sugars as well as your memory.

The short answer is no. There are two tests of which I am aware that have received some press. One is a take home test and the other is a genetic test.

First, there is a scratch and sniff test. The test is simple; you buy a kit and scratch to see if your sense of smell is adequate. This test is based on the findings that many people with Alzheimer’s disease have noted changes in the senses of taste and smell. This stems from the fact that the short-term memory circuits (i.e., the hippocampus) are next to the brain circuits for taste and smell (i.e., rhinal cortex).

Often pathology (e.g., head injury, Alzheimer’s disease) in this region of the brain also may affect the abilities to learn new things, to smell, and/or taste. However, there are many factors other than brain disease that can affect taste and smell such as smoking, sinus infections and tumors. Therefore, this home test is not diagnostic for Alzheimer’s disease.

The most known genetic risk for Alzheimer’s disease is the “Apolipoprotein” gene. There are three forms (alleles) of this gene — E2, E3 and E4. You obtain one of these gene types from each of your parents. You may have any of a number of combinations such as E4/E4, E4/E3, E4/E2, and so on. Research has associated the E4 genotype with higher risk of developing late-onset Alzheimer’s disease and the E2 genotype with lower risk.

But association does not mean cause and effect. Having the Apolipoprotein E4 is not a genetic time bomb. You may have two E4s and not get Alzheimer’s disease and you may have two E2s and get the disease. This genotyping is a research tool but is clearly not diagnostic or predictive in individual cases. This is a susceptibility gene that may contribute to late onset Alzheimer’s disease. It is not a deterministic gene.

The greatest risk factor for developing Alzheimer’s disease remains age. If you live to be 85 or older, you have approximately a 50 percent chance of being diagnosed with Alzheimer’s disease. There is no reliable biological marker for determining who will get Alzheimer’s disease. If you have any risk factors (e.g., age, family history, head injury, late onset depression) your best protection is to have routine memory evaluations (not screenings but rather thorough memory testing) to track your short-term memory just as you monitor cholesterol or blood sugars with annual physicals. The best, most effective treatment for Alzheimer’s disease is tracking and managing short-term memory and staying engaged in life.

Does cardiovascular disease cause Alzheimer’s disease? There is no definitive answer to this question yet. However, there is good circumstantial evidence that heart and vascular risk factors are associated with memory loss and Alzheimer’s disease.

Studies have been consistent in showing an association of cardiovascular disease with impaired cognitive function and with Alzheimer’s disease. But whether this is a result of common risk factors or whether cardiovascular disease directly influences the pathology of Alzheimer’s disease is not clear.

One relatively strong risk factor for both Alzheimer’s disease and for heart disease is having the E4 form of the Apolipoprotein gene. We discussed this last week and the link here may be that E4 influences cholesterol and hence adds to cardiovascular disease. The other strongly related cardiovascular risk factor that is associated with Alzheimer’s disease is type 2 diabetes. Diabetes often causes vascular damage. Additionally, high levels of insulin may increase the risk of cognitive impairment.

Weaker links exist between cognitive decline, hypertension and high cholesterol. The relationship to hypertension is very complex with high blood pressure in middle age being correlated with increased risk of Alzheimer’s disease in later life but the association of hypertension in later life is not clear. Findings from studies addressing the effects of treatment with antihypertensive drugs are mixed. In the case of cholesterol, it appears that high low density lipoproteins and low high density lipoproteins may increase the risk of dementia.

Despite much press and considerable marketing, the association of Alzheimer’s disease with inflammation and antioxidant vitamins is not very convincing. Indeed, short term use of vitamin supplements (less than 10 years) does not protect against cognitive impairment. However, long term use (more than 15 years) may be neuroprotective.

The one dietary substance that has shown promise as a neuroprotective agent is alcohol. Drinking moderate amounts of alcohol (up to 13 drinks per week) has consistently been associated with better cognitive function. The decreased risk appears to hold for all types of alcohol: beer, wine and liquor. However, there is a clear dose effect here in that there is increased risk of cognitive decline associated with three or more drinks per day.

The good news here is that lifestyle modifications may decrease cardiovascular disease and, in turn, reduce the risk for or the severity of cognitive decline later in life. The findings from the studies on blood pressure suggest that lifestyle choices in midlife may have a great deal of impact on later cognitive function. But keep in mind that we are discussing overall risk factors and not cause and effect.

There are no guarantees but I am hedging my bet on exercise, eating a heart healthy diet most of the time, drinking some alcohol each week, not smoking, as well as monitoring blood pressure, blood sugars and cholesterol.

There are effective treatments for Alzheimer’s disease. Don’t wait for the magic elixir that may never come. The first thing to go is short-term memory.

Treatment involves first understanding the changes in your memory and whether they are different from changes due to aging. A thorough memory assessment should help you understand, in detail, the strengths and weaknesses of your memory. Do you remember better visual or verbal information? Do you benefit from hints to improve your memory? Even if you cannot recall new information, are you able to recognize it? Are your other brain skills still sharp? Answers to these questions will help you decide on the strategies that will work best for you.

Use external memory supports. For example, if you are struggling with arithmetic but can still do a checkbook, you may wish to use a calculator and “carbon copy” checkbooks. If you are having trouble remembering appointments or activities that you enjoy, mark them in your calendar and check it often. If finding your way is a problem, draw schematic maps to help you navigate. Build good memory habits. Get organized. Don’t use scattered notes. Use a bound notebook to help track your “to do” lists and tear out pages that are no longer of use. Make sure that everything has a place and put everything in its place.

Aggressively manage blood pressure, cholesterol and diabetes. Get adequate rest. Use alcohol judiciously. Stop smoking. Take only necessary medications at correct doses. Exercise nearly every day. Consider doing both aerobic (e.g., walking, treadmill, cycling) and resistance training (use weights). Eat fish at least twice a week. Manage your stress. Structure your time to build in relaxation each day. Decide what things are of interest to you (e.g., gardening, pets, art, crafts, sporting events, volunteer activities) and be sure to get and stay involved. Keep active with friends and family.

Involve others (i.e., a family member, a friend, or a skillful companion) in your program. For example, if you love to golf, plan for someone to help initiate the outings. If you garden, do it with someone else who will keep doing it with you as your skills change. At some point, someone else may need to track and initiate your program for you. But if you set up the best fit for your interests and talents early and use liberal external supports (including other people), you will be able to enjoy your life well into the changes that occur with your memory. There is so much you can do to help yourself if you start early and involve others in your plans.

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 doing 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 changing clothes.

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. It is not a state of being.

Dementia is caused by a loss of skills (i.e., brain function). There are many possible causes of dementia. For example, many who develop a progressive form of dementia have a heavy burden of amyloid plaques and tau tangles. When this is the cause of the decline the condition is referred to as Alzheimer’s disease. In short, dementia is the general term for decline and Alzheimer’s disease is the cause of the decline.

There are many other causes that can produce dementias. For example, when strokes cause 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, makes judgments, interacts in socially appropriate ways, expresses oneself) decline, the diagnosis would be a frontotemporal dementia. Progressive loss of expressive language is diagnosed as a semantic dementia. There is a dementia sometimes associated with Parkinson’s disease.

There is another rather common dementia caused by Lewy bodies called diffuse Lewy body disease. These conditions (as well as others) are all irreversible declines in ability. Some of the conditions are progressive (meaning they get worse over time) whereas others may be develop suddenly then stabilize over time (such as 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, there is a recovery to 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 inability to function. These possibilities need to be evaluated in anyone showing decline. Any condition that resolves with time or treatment should not be referred to as a dementia. Dementia should be reserved for decline that cannot be resolved.

People come to me to determine if they have significant changes in memory. However, memory is a multifaceted series of skills — for example, knowing how to drive, knowing your birth date, knowing a body of facts, knowing how to get places, etc.

The most critical type of memory to the understanding of most dementias is short-term memory. Short-term memory is not a time but rather a process whereby new experiences or information are stored for later use.

For example, someone with a good short-term memory can read a book once and recite all of the facts. Someone with an average short-term memory may need to review the material a few times. Someone with a poor short term-memory may have to review the information 50 times. Short-term memory loss is the hallmark feature of Alzheimer’s disease.

We owe much of our knowledge of short-term memory to Henry Molaison, who died about a year ago at age 82. Molaison developed seizures as a boy. They worsened after an accident where he was knocked down by a bicycle and may have suffered a concussion. By the age of 26, he was so overwhelmed with seizures that he consented to surgery that had never before been done on a human being. He had the hippocampus from each side of his brain removed. The good news was that the surgery controlled the seizures. The bad news was that the surgery severely impaired his ability to learn new information.

Molaison loved to talk to people but within a few minutes after a conversation he would tell the same story again without remembering that he has just told it. Each time he met or re-met an acquaintance, it was as if it was the first time. When asked who the president of the United States was, he would always reply “Eisenhower.”

He appears to have had the feeling throughout his life that he was awakening from a dream. He was able to learn some new skills such as puzzles which he became better at with practice. But each time he was shown the puzzle he would state that he had never seen it before. In short, he had a severe deficit in learning new information.

If this all sounds familiar to those who live with someone with short-term memory loss caused by Alzheimer’s disease, stroke, head injury, etc., it is because this is the same process and brain structure that is affected in those conditions. The challenge in living with or working with someone with these kinds of dementias is that they, like Molaison, literally live in the moment. They cannot go back to the past 5 minutes and they cannot anticipate the future. It is like being stuck in a single frame of a movie. Treatment involves making those moments joyful with skills they already have.