Life and Memory Center

“Alzheimer’s epidemic puts advisers – and their practices – at risk” (InvestmentNews.com, February 26, 2013).  “Clients with Alzheimer’s pose “scary” legal risks” (InvestmentNews.com, February 13, 2012).  “Money woes can be early clue to Alzheimer’s” (New York Times, October 2010).  The worry has been there for some time.  The problem of risk management is as clear as is the solution.

 Alzheimer’s disease unfolds over the course of 30 or so years, progresses slowly, and does not produce disability until well advanced.  Progressive dementias unfold like reverse development.   First in, last out.   We learn walking and talking very early.  Managing technology and complex decision-making comes much later.  It’s no wonder that complex decision-making, like investing and managing money and legal decisions, are the first signs of decline.  It appears to sneak up on us – but it does not.

Alzheimer’s disease gives adequate warning to allow developing a proactive plan that gets ahead of changes and unfolds based on feedback from objective data and self-determination – just like long-term investment strategies and advanced directives.  It seems to me that the solution is obvious.  We must quit waiting for a medical diagnosis as that puts us in a reactive rather than a proactive stance..  The problem early on is progressive and measurable short-term memory decline.  A brain scan or a memory screening, a MMSE, does not detect memory change.  Memory change is not a medical problem.

Memory is not solely the domain of medicine.  All professionals (i.e., financial, legal, medical) have an obligation to their clients to help them monitor their own memory with objective and quantifiable assessments.  As we gather data to set up financial and/or legal estate planning, we owe it to our clients to begin memory assessment as part of the program from the start.  We must help clients make their decisions fully informed of how well their memory is working.  We need to help them be proactive and act in their own best interests before decline becomes more than just forgetfulness.

I have been working with Tony Curatolo, Ciccarelli Advisory Services, to develop a plan to better serve his and my clients.  As we discussed the many complex issues of detecting decline, it became clear that neuropsychologists are reluctant to discuss money matters and financial advisors are reluctant to discuss memory.  We both need to change our practices as our clients are the ones who are getting short changed.

Next week I will outline a simple, proactive plan that may serve as a model.

“The research is out there that you can cure all of it by diet!” Not so fast.  One of the most popular theories of aging is that aging results from accumulation of damage from oxidative stress – destruction of tissues by free radicals.  Hence oxidation creates havoc on cells over time and causes tissues and organs to age as a result.  The theory suggests that consuming antioxidants is the key to anti-aging and curing disease.

Last March, I wrote an article based on several findings that puzzled me. “There are small but consistent findings that vitamins and supplements may cause harm – even use of a multivitamin in those who are well nourished may slightly increase the risk of premature death.”  Additionally, taking more than 400 IUs of vitamin E may pose health risks including premature death.  Vitamin A may increase the risk of hip fracture in postmenopausal women and high doses of vitamin A are potentially toxic.  Folic acid supplementation may increase the risk of premature death.  Vitamin B-6 – doses of greater than 100 mgs can cause nerve damage.  Vitamin B-3 (niacin) – high doses of niacin can lower cholesterol but may also damage the liver.

An article, “The Myth of Antioxidants” by Melinda Wenner Moyer (Scientific American, February, 2013, pp. 62-67) clarified my confusion.  In an experimental test of the antioxidant theory conducted by David Gems, roundworms were genetically modified so that naturally occurring antioxidants were deactivated.  Sure enough, the mutation caused free radicals to rise dramatically.  According to the free radical theory, these worms should have a shortened life expectancy when compared to their normal counterparts.   “Contrary to Gem’s expectations, however, the mutant worms did not die prematurely.  Instead they lived just as long as normal worms did” (p 64).

Ms. Moyer goes on to present several additional studies that contradict the oxidative stress theory of aging.  She also reports two studies in humans where antioxidant vitamins increased the risk of death.  First, antioxidants (beta-carotene and retinol) were associated with an increased rate of death from lung cancer.  Second, a review of a large number of studies of vitamins concluded that beta-carotene, vitamin A, and vitamin E are associated with increased risk of death.  Additionally, exercise reduces the effects of aging despite the fact that it produces free radicals.

Like the amyloid theory of Alzheimer’s disease, the antioxidant theory of aging is too simplistic.  Both the American Heart Association and the American Diabetes Association have cautioned against taking antioxidant supplements unless you have a vitamin deficiency.  Be cautious of taking supplements – even vitamins and minerals – without consulting with your physician first.

Reserve today by calling 239-262-6577 for the Naples event or 239-495-2242 for the Bonita Springs event.  Alternatively, you can email ciccarelli@cas-Naples-FL.com

Invite_-_Memory_Wellness

I received a recent e-mail that asked me to stop putting “such doom & gloom out there.”  I was surprised that my views are perceived as “doom and gloom.”   The writer of the e-mail states “The research is out there that you can cure all of it by diet!”  If  only it were that simple.

Alzheimer’s disease is not caused by faulty diet.  Indeed, no one really knows what causes Alzheimer’s disease.  Eating more healthy foods and portion control are a part of any good wellness plan.  The best current advice from research of Alzheimer’s disease is to focus on fruits, vegetables, and fish.  But eating such a diet will not cure all of our ills.  There is no simple solution.  There is no magic supplement or food.  And isn’t it a form of blaming the victim to be so simplistic?

The bad news about Alzheimer’s disease is that there is no cure in sight.  We still don’t understand the biology well enough yet to develop a preventative strategy.  So far, well-conducted, prospective research has been disappointing regarding supplements, foods, and anti-inflammatory agents.  You can do all of the “right” things and still become demented.

The good news is there too.  By 2050 only 15% of those over 65 will have a diagnosis of Alzheimer’s disease. That is a substantial number of people but does not approach the numbers affected by heart disease, cancer, or stroke (by far, the leading causes of death are still heart disease and cancer – Alzheimer’s disease is number 6 on the list).  Alzheimer’s disease develops over a period of decades and comes on very slowly.  Many will develop Alzheimer’s disease and not become demented (i.e., disabled by it).  This means that you can be proactive and make the course much better for you and your family with advanced planning.  You can manage  better by aggressively monitoring and treating changes in short-term memory over time.

I don’t want to belabor points that I often make.  There are no guarantees, no simple strategies.   We now clearly know that brain health is related to cardiovascular health and cognitive stimulation.  Attend rigorously to cardiovascular health to reduce some of the wear and tear from aging.  Manage blood pressure and blood sugars.  Eat more healthy foods.  Feed your interests and passions.  Above all else, stay in good physical shape.

I am a very practical person.   The realities of everyday life and the needs of my forgetful clients keep my focus on short-term memory.    Short-term memory is the ability to learn new information and works by the One Minute Rule (entries in the calendar, Post-It notes, alarms, taking notes).  It is not like a muscle.  You can’t exercise it to make it better.  Short-term memory is essential to any program of memory improvement or maintenance.  Managing short-term memory is necessary but not sufficient for treating Alzheimer’s disease.

But memory is much richer than just short-term memory.  Whereas short-term memory adds more threads and details to the tapestry of memory, long-term memory is the evolving tapestry of color, dimension, and passion that adds quality to life – even for those who are forgetful.

Long-term memory does work like a muscle.  The more you use it the better it gets (as long as short-term memory keeps working) but strengthening it does not help short-term memory.  Long-term memory holds routines (e.g., dressing, reading, doing crossword puzzles, using a computer), the core of personal history (e.g., birth date, social security number, date of my wedding), knowledge, expertise, and self – the essence of who I am.  It is the source of alertness and passion.

Long-term memory works well into and is the mainstay for treatment of Alzheimer’s disease. As short-term memory weakens, we rely more and more on long-term memory to sustain and enrich life.

Sadly, art has largely been neglected in memory research.  We are so infatuated by computers and technology that we lose sight of the power of the arts to provide mental stimulation and engagement.  Why aren’t there studies comparing the relative merits of playing the piano, listening to a live symphony, painting, sculpting, or creating a memoir to computer programs and brain exercises?  The arts build brain circuits and stimulate the brain as well as do computer programs or crossword puzzles.  The arts feed passions in those with Alzheimer’s disease as well as in those who have normal memory.

I was especially moved by an 80-year-old client who came to me sobbing “I am so depressed because I am demented.”  I asked her for details.  The retirement community where she resides purchased a computer program to “enhance the mental fitness” of their residents.  She had religiously used the program for a month and was unable to improve and was still forgetful.  The failure was devastating.  She did have mild Alzheimer’s disease but still was able reside in her apartment.

As we pursued possible solutions, I asked what she loves to do.  She loved participating in programs and events at the Phil and the museum.   She didn’t understand that feeding these interests also strengthened her brain.  The treatment was simple and effective.  Stop doing the computer program and step up time at the Phil.  She was so relieved.

There are so many examples: the resident in a skilled nursing home who came to life with music, the 97 year old who didn’t know who I was after several meetings but still played concert level piano ….   Don’t neglect the arts when you put together your brain stimulation/fitness program.

Placement in a memory care or skilled nursing unit is a very difficult and gut wrenching 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 either their spouse or one of their children.  However, there may come a time when a caregiver can no longer safely manage alone at home.

The most typical reasons for placement are behavioral problems (e.g., wandering, aggression, delusions, hallucinations), incontinence, refusal of personal care, and/or caregiver illness or stress.  Unfortunately, placement is usually secondary to a crisis rather than a planned extension of care.  Placement is better executed as part of a palliative and safe memory care plan rather than a reaction to a crisis.  The objective is to continue to engage in a comfortable and stimulating life despite increasing loss of ability, as lost abilities can no longer be restored.

When I work with a couple early in the disease process (stage 2 or 3) we devise a long-term plan to pursue in case there is further decline.  We devise a strategy for monitoring and adjusting care that gradually transfers decision making over the course of several years, as that is the typical course of dementias like Alzheimer’s disease.  As decline progresses there is a transition from self-care to needing various types of external support. Using outside resources such as companions and aids is a natural component of any good plan and helps both the person with the decline as well as the caregiver function better and allows adaptation to external supports for care.

When external care and companions are an integral component of caregiving all along, placement is often less traumatic as there is no single caregiver or place of care.  When placement is desired, it may help to place in steps rather than all at once.  For example, getting involved in lunch and activities at the facility while still at home softens the change for all involved.  Because proactive transitions are slower, familiarity can be established with the new environment and staff before moving in. The major factor to consider in choosing a facility is personalized programming that keeps resident engaged rather than passive.  Even persons with middle stage dementia need stimulation; so care needs to be active.  Care needs to emphasize productivity rather than competence.

Finally, these decisions are best made with the help of a knowledgeable and skilled professional who can compassionately guide all through this difficult process.  There are many excellent ways to monitor the changes in cognitive decline with the intention of helping all involved be more proactively rather than reactively responding to decline.  It is critical to have placement done with support for both the person who has declined and those who are intimately involved in their care.

One of the most difficult lessons for those who are caregivers for persons with Alzheimer’s disease or other dementias to learn is to not fight futile battles.  The mind over matter strategy does not work.  We are used to being persistent to teach or learn new things and used to the benefits of practice in learning new behaviors, skills, or information.  These practices offer diminishing returns as the memory loss progresses.  Caregiving – whether in a facility or at home – needs to be built around what still works and needs to increasingly involve external prompts to initiate even retained skills.

Let’s consider some examples of strategies that were helpful to several of my clients.  The intention was to reduce frustration, errors, and conflict as well as to improve stimulation for persons in early to middle stage dementia.

1. Those in early to middle dementia have lost the capacity for making financial, legal, or medical decisions.  They can neither provide reliable self-report and nor report back what they are told to do.  For example, the forgetful person needs an advocate to provide accurate history or symptoms during medical appointments.  He or she cannot complete paperwork for medical or other decision-making events.  All medical as well as legal and financial appointments must be made and attended by the primary caregiver or a knowledgeable representative.
2. Those in early to middle dementia often have progressive decline in standards of dress and grooming.  They need at least supervision (sometimes prompts) to maintain ADLs.  The forgetful person may need daily assistance with caring for his teeth and gums, shaving, bathing, choice of clothing, and prompts to change to clean cloths.  Standards such as how many showers per week or whether it is really important to shave each day need to be considered in the light of which battles are worth the energy to fight.  How many showers a week are really necessary?  Do clothes have to match well?
3. Those in early to middle dementia have significant decline in judgment as well as monitoring the passage of time and are at risk of getting lost on outings.  They should not attend group outings without a one-on-one companion.
4. Those in early to middle dementia need stimulation via routine and regularity. Forgetful persons need to be engaged in the familiar not the new.  They need activities that focus on productivity rather than competence and short-term memory.  If the forgetful person can still play the piano, make the opportunity available each day and guide them to the piano with an invitation.  If he or she enjoys movies, going to lunch, playing bridge, doing art, or playing golf, invite don’t ask.  It’s better to say, “Let’s go to a movie” rather than asking, “Do you want to go to a movie?”
5. Caregivers for those in early to middle dementia need support and guidance.  Don’t go it alone.

I hope this gives caregivers some ideas that reduce power struggles that they cannot win.  Managing those with dementias can often go much more peacefully if caregivers choose battles carefully and don’t make unrealistic demands on either the person with memory loss or themselves.

What have we learned about memory disorders and Alzheimer’s disease over the past year?

1.  Despite the increasing pressure to use PET scans to diagnose Alzheimer’s disease the results may be misleading.  About two thirds of community dwelling participants were misdiagnosed with Alzheimer’s disease based on positron emission tomography scan readings using amyloid-specific tracers. We need to be cautious about using brain scans to make a diagnosis of Alzheimer’s disease. Studies used to make the case for the accuracy of scans have so far only used highly selected participants – a sampling bias that may distort results.

2.  Janssen released results from trials on a compound named bapibrzumab, which is a monoclonal antibody that is meant to decrease amyloid production thereby modifying the progression of Alzheimer’s disease.  The 18-month trial in patients with mild to moderate disease was stopped because of ineffectiveness of the compound.  This adds to the growing number of disappointing studies employing amyloid lowering strategies to treat Alzheimer’s disease.

3.  Medications such as Aricept and Namenda continue to work in moderate to severe Alzheimer’s disease. Continued treatment with Aricept or Namenda maintained skills better than those who were taken off these medications nearly a year later.  Those who switched from Aricept to Namenda were also better than those switched to a placebo.  The combination of Aricept and Namenda was no better than either alone.

4.  Alzheimer’s disease unfolds over the course of decades.  The Dominantly Inherited Alzheimer’s Network study of these high-risk individuals completed numerous baseline and clinical/cognitive assessments on those enrolled in their data bank.  The following timeline emerged:

1)     Concentrations of amyloid and tau proteins were elevated 25 years before the onset of symptoms in carriers.

2)     Siblings without the mutant gene had no detected change in these markers.

3)     Imaging studies detected amyloid and tau deposition in the brain 15 years before symptoms.

4)     Memory loss and cerebral hypometabolism were detected 10 years before symptoms.

5)     Changes in the Mini-Mental State scores were not seen until 5 years before expected symptom onset.

5.  Memory training helps recovery after heart surgery. Memory training consists of use of external memory support (a specific application of the One Minute Rule) and attention training (computer speed games). Recovering patients who completed memory training showed enhanced memory as well as improved reaction times.

6.  High levels of physical activity reduce brain atrophy and white matter damage.  Interestingly, leisure activity and stimulation do not alter brain volume or white matter disease.

Bottom line: we need to broaden our thinking.  Amyloids are not the necessary cause of Alzheimer’s disease, which develops and progresses over the course of at least 2-3 decades.  Other treatment approaches need to be evaluated – including nondrug treatments.  The current medications do not quit working and should be continued once started.  Memory evaluation, adopting the One Minute Rule, and physical conditioning are our best bets for maintaining our brains as we age and should be a part of wellness at least as early as middle age.

You make careless errors.  You are easily distractible, have poor concentration, and are forgetful.  You are disorganized and often misplace items.  You interrupt others, are easily frustrated, and have poor follow through on what you start.  These symptoms interfere with your ability to work or engage in activities you enjoy.  Do you suffer from Attention Deficit Disorder or do you have early Alzheimer’s disease?  Or do you have something else?

I have several cases a year where I am consulted by someone with these symptoms and asked about both the diagnoses and what to do to help. If you are older than 15 and the symptoms are new (were not present before the age of 12), you don’t have Attention Deficit Disorder and are very unlikely to have Alzheimer’s disease.

If you are between 30 and 60, you probably do not have Alzheimer’s disease, other causes of these symptoms must be considered.  You need to be assessed for conditions like diabetes, thyroid disorder, hormone imbalances, sleep disorders, etc.  You also need assessment for Adult Attention Deficit disorder, depression, anxiety, bipolar disorder, and substance use disorder.  As you age beyond 60 these symptoms are more likely to reflect neurological disorders such as Alzheimer’s disease.

Both Attention Deficit Disorder (ADD) and early Alzheimer’s disease (AD) are memory disorders based on subjective complaints.  However, the mechanics of the memory loss are different.  In ADD, the problem is inattentiveness and distractibility.  The conflict is in working memory (multitasking and sustaining attention).  The memory failure in AD is that storage does not occur.  It is like the save command for your computer fails.  You are fine with what is already stored – long-term memory – but you are impaired when life requires you to cope with something new – short-term memory.

The One Minute Rule (anything given less than one minute of thought will fade from your memory) will help in either case but for different reasons (hear Dr. Beckwith by going to www3.gotomeeting.com/register/891165934).  In ADD part of the fix is to slow down input, increase attention, and reduce interference.  This fix will help in the future as long as short-term memory (the hippocampus) continues to function well.  In early onset AD, this strategy allows the inefficient hippocampus to have more time to work.  It also allows those so afflicted more time to build effective compensatory strategies.

The other similarity between ADD and AD is impairment of executive functions.  In both disorders there are often weaknesses in the areas of organizing, sequencing, prioritizing, planning, making decisions, and holding information in memory.  In both disorders the solution is therapy that teaches effective organizational strategies, reduces anxiety and self-defeating thoughts, improves planning and decision-making.

The primary difference is that in ADD the target of intervention is the afflicted individual as the skills and new habits are sustained.  In AD there will be a degrading of skills over time.  Therefore, treatment strategies need to include family and significant others who will progressively become more involved in managing situations as memory and executive functions erode.

We are clearly a society that relies on the use medications and drugs.  Look in your medicine cabinet.  How many medications do you find?  Aspirin?  Acid blockers?  Allergy medications?  Blood pressure medications?  Antidepressants?  Anti-anxiety drugs?  Do you drink coffee or caffeinated sodas?  Do you drink alcohol?  Drug use is pervasive.

Indeed, we have become so enamored with drugs that we often forget that many human problems are better treated with nonpharmacological methods.   Furthermore, aging increases drug accumulation over time and increases the risk of toxicity from medications and drugs.  A single class of medications; psychotropics that are used to manage conditions like anxiety, depression, and lack of sleep; is used by as many as 40-50% of those who are aged, by some estimates.  The use of psychotropics is greater among the aged than the young despite the fact that mental illness is much less likely in the elderly than in the young.  Additionally, more than 50% of the elderly take psychotropics for 6 months or longer).

Psychotropic drugs (and alcohol) impair cognitive (e.g., memory, induce confusion) and motor (e.g., induce falls, slow thinking and reaction time) in everyone.  These effects as well as delirium are more likely as we age.   A recent study raises questions regarding the impact of use of psychotropics on the prevalence of motor vehicle accidents.

We have known for some time that use of medications like Valium/diazepam, Klonopin/clonazepam, Xanax/alprazolam, Ativan/lorazepam increase the risk of accidents while driving.  These are the class of medications known as benzodiazepines.  Long acting benzodiazepines (e.g., Valium, Klonopin) were believed to be more problematic than short acting (e.g., Xanax, Ativan) and those given for anxiety were believed to be problematic while those given for sleep (e.g., Restoril/temazepam) were not seen as increasing driving risk.

A new study (British Journal of Clinical Pharmacology, 2012, September 12) reveals that anyone taking benzodiazepines (long acting, short acting anxiolytics or hypnotics), antidepressants (either older generation like Elavil/amitriptyline or newer generation like Prozac/fluoxetine), or hypnotics such as Ambien/zolpidem (called “Z” drugs) is at increased risk for motor vehicle accidents.  Interestingly, there was no significant increase in motor vehicle accidents for those taking antipsychotic drugs (either older generation medications like Haldol/haloperidol or newer generation medications like Seroquel/quetiapine.

There is no simple solution to this problem.  Psychotropic medications are useful in managing distress.  However, we have to assess the risks and benefits from these medications better.  We need to consider several questions related to use of medications in driving in particular but for our lives in general.  Are many of the bad effects of psychotropics due to an interaction with alcohol?  Alcohol potentiates the effects of these medications and many drink when taking them.  We may underestimate the effects of prescribed medications as consumers because they are given by prescription and therefore must be “safe.”   We have not addressed the effects of multiple medications or their chronic use.

Psychotropic medications reduce anxiety and depression and help induce sleep.  However, they don’t teach skills or coping behaviors.  We need to realize that better living takes more than altering our chemistry.  Better living requires effort, planning, and constant learning.

Join Dr. Beckwith for a free webinar sponsored by Ciccarelli Advisory Services on December 11 at 3:30.  Call (239) 262-6577 or e-mail ciccarelli@cas-naplesfl.com to register.