Life and Memory Center

A headline in The New York Times (November 16, 2012) announced that “For Alzheimer’s, detection advances outpace treatment options.”  We are given the example of a family who sought out a new brain scan technology that is heralded as a diagnostic breakthrough for detecting Alzheimer’s disease.   These scans show plaques in the brain.  Plaques, in turn, are composed of deposits of amyloid proteins in the brain that are associated with Alzheimer’s disease.

These scans are currently available at over 300 hospitals throughout the country.  But there are a number of dilemmas resulting from this technology and its use.

Are we creating a tautology between Alzheimer’s disease and plaques?  A tautology is a logical fallacy that constrains our thinking by circular reasoning.  Alzheimer’s is plaques and plaques are Alzheimer’s.  The real issue is diagnosing dementia, which is disability from cognitive decline.  Two cases from the article are to this point.  In one case, a person with Parkinson’s disease was given a scan and found to have plaques.  The conclusion seemed to be that he had Alzheimer’s all along but may he not have had both pathologies?

Another case presented was of a person who had a clinical diagnosis of Alzheimer’s disease based on genotyping, brain atrophy, and memory testing.  When he was scanned there were no plaques and his neurologist told him he didn’t have Alzheimer’s.  Was he falsely relieved?  Alzheimer’s disease is more than the accumulation of plaques.  Will he become demented?

Autopsy does not provide for a definitive diagnosis of Alzheimer’s disease.  First, autopsy diagnosis is based on the density of plaques and tangles.   As many as 30% of sampled populations have the pathology on Alzheimer’s, based on autopsy, but do not have clinical symptoms.  Is this Alzheimer’s disease?  What can he do now?

The FDA requires that radiologists interpreting the scan have no information about the patient.  This is a blinding procedure that is used in research trials.  Does this break the integrity of clinical medicine?  Are we so sure of our belief that amyloids are the essence of Alzheimer’s disease?  I think not.

In earlier articles we covered the failure of amyloid altering strategies and medications to work.  Indeed, the medications tried so far have not helped and have, in some cases, caused worsening of symptoms.  I can see that the outcome of having the scans will lead to the use of these medications decades before symptoms develop.  But will this cause undo harm?  Are amyloids necessary for normal brain function?  What about the tangles?

The scans are very expensive and are not covered by insurance.  One center charges $3,750 for a scan.  Furthermore, employers and insurance companies are prohibited from discrimination based on genetic testing.  But the law does not cover scans.  Having a scan may jeopardize employment and lead to denial of long-term care.

I feel that we are getting ahead of our science.  As I have often discussed we do have effective treatments that are available now.  They are not primarily medical.  Indeed, do treatment options outpace detection?

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.

I am in the same boat as everyone else who is aging.   I am trying to plan for the best outcome.   My profession does not protect me from either the physical or mental changes that come with getting older.  During my last physical, my physician, Kathleen Wilson, gently reminded me that I am not being aggressive enough with my personal wellness program.  I have been managing hypertension since I was 35.   I have Type II diabetes in my family and mildly elevated blood sugars.  These factors and age increase my risk for cognitive decline (I hope that if I decline it will not be severe enough that I become demented) as I grow older.

As part of my wellness, I take an aspirin each day, exercise, and stay engaged in professional and leisure activities.  A couple of recent studies encourage me that I am on the right track.  First, what about taking the aspirin, acetylsalicylic acid (ASA, for short)?  There is clear evidence that taking aspirin reduces my risk of stroke and heart disease.  But does taking aspirin reduce my risk for dementia?

Until now there have been no studies for guidance.  Four hundred eighty nine women (I hope the same findings apply to men) ranging in age from 70-92 (British Medical Journal, October 2012) completed assessment of social, physical, and cognitive health.  Those who took low dose aspirin, 75-160 mg, at the beginning of the study declined less than those who did not take aspirin.  This benefit remained regardless of age, Mini Mental State Score, APOE genotype, cardiovascular risk score, and use of other NSAIDS.

Interestingly, taking aspirin did not reduce the risk of becoming demented despite helping reduce cognitive decline.  This finding goes to the point I often make.  Some memory loss is not the same as dementia and not everyone with cognitive decline becomes demented and disabled.  I will keep taking my aspirin each day.

What about exercising?  With hypertension (and if I progress to diabetes), I am at greater risk of increased brain atrophy and increased white matter damage.  Does my exercise plan help?  How much time do I need to put into exercise?  A study (Neurology, 2012, 79, 1802-1808) of about 700 with a mean age of about 70 (close to my age) higher levels of physical activity were associated with both less atrophy and less white matter damage.  Interestingly, there was no association between leisure activity and stimulation and brain volume or white matter disease.  It may be that those who are willing to be in these studies are those who already seek stimulation and engagement.

Another study (Preventative Medicine 2012, September 7) does not directly address the issue of cognitive function.  There is evidence that about 150 minutes of exercise per week (about 2.5 hours) improves cardiovascular health and reduces the risk for diabetes.  The new study of 7,674 adults adds that 2.5 to 7.5 hours of exercise per week reduces stress, anxiety, and depression.  Those who exercised less than 2.5 hours or more than 7.5 hours report greater stress, anxiety and depression.  I aim at a minimum of 40 minutes at least 4 days a week (160 minutes).  I am a long way from overdoing it but I will persist.

One way to understand progressive changes resulting from dementia is to compare them to the changes that occur as a result of human development.  Dementia unfolds as reverse development.  As a general rule, those skills we learn later in life (e.g., managing investments, complex technology, doing a checkbook, and writing poetry) decline earlier than those learn earlier in life (e.g., toileting, dressing, and language).  The major difference is that as we develop from infancy, we constantly learn new skills and information.  The opposite is true for most dementias.  Learning new skills becomes increasingly difficult or impossible.   Those who are demented must be managed based on skills that are already there and those skills progressively deteriorate.  Dementia is a backward moving target.

The good news is that we can learn a lot about managing dementia by understanding and using principles of good parenting (once we better resolve the personal conflict/sadness that we must parent our spouse or parent).  There are several general ways to approach either caregiving or parenting that work.  Despite the loss of short-term memory, those who are demented usually respond to consistent contingencies and environments structured around their interests and preserved skills.

Catch them being good.  Praise behavior that is desired.  There is a strong tendency to parent and to give care by nagging or punishing.  When someone you care for is doing something that you desire such as taking a shower, sitting quietly or engaged in a desired activity while you get the checkbook done, praise him or her.  Spend the effort when things are good to provide a smile or a hug.

Ignore unwanted behaviors if they do no harm.  Ignore stories with the facts all-wrong or that are repeated, there is no benefit to being correct when there is no harm.  Learn to ignore embarrassing and inconvenient behaviors that do no harm.  It is more important for someone with cognitive decline to be productive and engaged than competent.

Children do not make a mess by intention.  Nor do those who are demented.  If they try to make coffee and it turns out poorly, try to determine if this task has become too hard and beyond current skills.  You would not explain to a two year old what they couldn’t yet understand.  The same holds true for communicating to someone who is demented.  Communication works best with simple one step requests, prompts, and modeling.

Plan and direct time.  Structure activity based on retained competence that does not require short-term memory.  Unstructured situations are often the source of difficult or inappropriate behaviors.  Keep those with cognitive impairment engaged.

Use time out.  If a behavior such as anger is elicited, leave for a short time and return.  Don’t go toe to toe.  If the memory loss is great enough, he or she will often forget what they were angry about and you can start anew – if you have been able to stay calm.

Take care of yourself.  You cannot be either a parent or a caregiver 24-7.   If you fall apart or become ill, you both lose.  You will be a better parent or caregiver if you also manage to tend to your needs with the same dedication that you provide to those for whom you care.

I have had a number of clients who have sought out advice after coronary artery by-pass surgery. They, their spouse, or their children often report that everything was fine mentally until after the surgery. I often see these clients within the first year after surgery. The concern is always the same. Mom, dad, my husband or my wife has physically recovered from the surgery but now has memory problems they did not have prior to the surgery.

A recent study (Journal of Behavior Medicine, 2012, 35, 557-568) provided memory training to patients recovering from coronary artery by-pass surgery. They assessed cognition by neuropsychological evaluation one week, one month, three months, and four months after surgery. 65% of patients displayed memory deficits one month after surgery and 41% continued to have deficits after 4 weeks. Memory training focused on use of external memory support (a specific application of the One Minute Rule) and attention training (computer speed games) provided between six and eight weeks after surgery.

The study group consisted of 44 participants (all had Mini-Mental State scores above 24 – above the cut off for dementia) who were randomly assigned to either a treatment or a control group. Each participant underwent 8 training sessions of 50 minutes duration. Those who completed the training showed significant enhancement of memory as well as faster reaction times on an attentional test than did those who received no training.

Although this study addressed cognitive decline after heart surgery as this is an especially high-risk group, the issue of cognitive decline is not restricted to heart surgery. The risk is present after any surgery. Estimates are that postoperative cognitive decline occurs in 35% of those under 40, 56% of those 40-59, and 69% of those 60 and older at one week after surgery. By three months the rates decline to about 7% in those under 40, 13% in those 40-59, and 24% of those 60 and older.

Other risk factors include cardiopulmonary bypass surgery, duration of anesthesia, respiratory complications, infection, history of alcohol abuse, and a second surgery. Heart surgery produces greater risk for produce postoperative cognitive decline at one week after surgery but is no different from other surgeries (e.g., hip replacement, knee replacement) at three months. Hip or knee replacement produces similar rates of postoperative cognitive decline with either regional or general anesthesia.

The point is that adding memory training as an essential component for all post-surgery rehabilitation can at least partly mitigate the risk of cognitive problems after surgery. The training should probably start about two to four weeks after surgery (to give some time for post-operative delirium to clear). The training focuses on practical techniques and enhancing alertness. A few sessions can be very effective and may reduce the long-term outcome after surgery for all of us “elders.”

Last July I discussed the differences between delirium and dementia. To review, by the dictionary a delirium is “an acute mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinations.” By the same dictionary dementia is “usually progressive condition marked by deteriorated cognitive functioning with emotional apathy.” The critical thing to know is that a delirium has a sudden onset and is reversible in time. A dementia often has a gradual onset and is irreversible.

A new study (Archives of Internal Medicine, 2012, August 20 online) demonstrated that there are enduring effects of hospital-acquired delirium in patients with Alzheimer’s disease. The rate of decline is about two times faster in those who developed an in-hospital delirium when compared to those who do not. Delirium is thought of as a transient condition that clears and returns affected persons to their baseline level of cognition. These researchers followed patients with Alzheimer’s disease for 5 years after hospitalization. Those who developed delirium declined more quickly. The delirium may be transient but the risk for more rapid decline is not.

The effects of delirium have also been seen in surgical and intensive care patients whether demented or not. The authors of the study suggest that delirium should be handled as a medical emergency. Hospital staffs need to be better trained to recognize delirium so they can be proactive rather than reactive (reach for tranquilizes). Current estimates are that 56% of hospitalized Alzheimer’s patients will develop a delirium but fewer than 30% of the deliriums are recognized. We need to do better.

Early identification of delirium and interventions with high-risk patients is essential to better care. There are several non-pharmacological treatments that may help. These interventions include reorientation (to time, place, and reason for hospitalization), therapeutic activities (PT, OT, and stimulation), early mobility (get them moving as soon as it is safe), exposure to direct light rather than darkness, presence of familiar people/objects (e.g., family, pictures, reassuring videos), and hydration.

We should not sit back and wait for delirium to set in. Rather we need to develop protocols for assessment and implementation of interventions that reduce or prevent delirium. Treatment is best when it removes offending medications and focuses on environmental modifications. Finally, include family. They often do not understand what is happening and need support so they can better manage their emotions in a difficult and stressful time. Family modeling calmness is essential to better outcome.

I was talking with staff from the Alzheimer’s Support Network in Naples after Minder’s Keepers (a memory loss support group for families dealing with early signs of memory loss) about frequently asked questions. They often get asked how do I find out whether I have Alzheimer’s disease? Who do I see first? What should an evaluation consist of?

First, diagnosis of Alzheimer’s disease can be done by either licensed medical personnel such as a physician or nurse practitioner or by a licensed psychologist, usually a neuropsychologist. Where you go first depends on both your insurance coverage and your comfort level. If you have government run Medicare you can see ether a physician or a neuropsychologist first at your own discretion. If you have Medicare replacement or other insurance, check with your carrier first to see what their requirements are. The best evaluation consists of both medical and neuropsychological assessment so you should ultimately do both.

The medical side of the evaluation usually consists of an interview that addresses your concerns, memory screening (usually the 30-item Mini Mental state
Exam), a physical/neurological exam, blood work, and an imaging study. The objective of the medical evaluation is to describe your physical functioning. The interview will cover concerns, medical history, medications, etc. The neurological exam will describe motor (e.g., reflexes, gait) and sensory (sense of smell, visual fields) functions. Blood work describes relevant biology (blood sugars, immune function, thyroid function, etc.). Imaging (MRI, CT scan) provides a picture of your brain to see if there are pathologies such as stroke, bleeds, and tumors.

The medical assessment is necessary to provide answers to questions like are the changes that concern you due to the effects of a head injury. Alternatively, have you had a stroke? Do you have Parkinson’s disease? Are you diabetic? Is your thyroid over or under active? Do you have a vitamin deficiency? These tests allow inferences about whether there are treatable causes of memory loss and confusion. The information obtained also helps with differential diagnosis of conditions like vascular disease, head injury, Lewy body disease, Parkinson’s disease, frontotemporal disease, and Alzheimer’s disease.

But even the most thorough medical evaluation does not address the most critical treatment issue. What are your strengths and weaknesses and how do you use your strengths to compensate for your weaknesses? What still works? A neuropsychological evaluation should focus on what your brain can do. What still works in your memory? How is your ability to make decisions? Can you still reason effectively? Can you use appliances? Treatment plans are best made based on what still works not on what doesn’t work well any longer. The most important part of a neuropsychological evaluation is the feedback.

A thorough evaluation takes time. Family should be included in all phases of evaluation. Feedback should include provide hope, understanding, and defectiveness rather than just a diagnosis. As Alzheimer’s disease unfolds over the course of decade, evaluation is a process that unfolds over time. The first evaluation provides a baseline to work from.

I was talking with staff from the Alzheimer’s Support Network in Naples after Minder’s Keepers (a memory loss support group for families dealing with early signs of memory loss) about frequently asked questions. They often get asked how do I find out whether I have Alzheimer’s disease? Who do I see first? What should an evaluation consist of?

First, diagnosis of Alzheimer’s disease can be done by either licensed medical personnel such as a physician or nurse practitioner or by a licensed psychologist, usually a neuropsychologist. Where you go first depends on both your insurance coverage and your comfort level. If you have government run Medicare you can see ether a physician or a neuropsychologist first at your own discretion. If you have Medicare replacement or other insurance, check with your carrier first to see what their requirements are. The best evaluation consists of both medical and neuropsychological assessment so you should ultimately do both.

The medical side of the evaluation usually consists of an interview that addresses your concerns, memory screening (usually the 30-item Mini Mental state
Exam), a physical/neurological exam, blood work, and an imaging study. The objective of the medical evaluation is to describe your physical functioning. The interview will cover concerns, medical history, medications, etc. The neurological exam will describe motor (e.g., reflexes, gait) and sensory (sense of smell, visual fields) functions. Blood work describes relevant biology (blood sugars, immune function, thyroid function, etc.). Imaging (MRI, CT scan) provides a picture of your brain to see if there are pathologies such as stroke, bleeds, and tumors.

The medical assessment is necessary to provide answers to questions like are the changes that concern you due to the effects of a head injury. Alternatively, have you had a stroke? Do you have Parkinson’s disease? Are you diabetic? Is your thyroid over or under active? Do you have a vitamin deficiency? These tests allow inferences about whether there are treatable causes of memory loss and confusion. The information obtained also helps with differential diagnosis of conditions like vascular disease, head injury, Lewy body disease, Parkinson’s disease, frontotemporal disease, and Alzheimer’s disease.

But even the most thorough medical evaluation does not address the most critical treatment issue. What are your strengths and weaknesses and how do you use your strengths to compensate for your weaknesses? What still works? A neuropsychological evaluation should focus on what your brain can do. What still works in your memory? How is your ability to make decisions? Can you still reason effectively? Can you use appliances? Treatment plans are best made based on what still works not on what doesn’t work well any longer. The most important part of a neuropsychological evaluation is the feedback.

A thorough evaluation takes time. Family should be included in all phases of evaluation. Feedback should include provide hope, understanding, and defectiveness rather than just a diagnosis. As Alzheimer’s disease unfolds over the course of decade, evaluation is a process that unfolds over time. The first evaluation provides a baseline to work from.

There is a long standing debate in psychology and medicine regarding what defines our physical traits (e.g., height), skills (e.g., memory) and personality (e.g., temperament). Which is more important genes or environment? We usually think of the impact of this question for early experience. Do we place emphasis on genes (nature) or on parenting/schooling (nurture)?

The most hotly debated topic in this arena is intelligence. Is intelligence inherited or is intelligence built from experience? Research estimates for heritability of intelligence range from 40% to 80% depending on factors such as socioeconomic class, age, and design of study. In other words, intelligence is determined by the interaction of genes and environment. Both are important. The practical implication of this is that ability is not fixed but rather is modifiable within limits. Early interventions (e.g., quality of teaching, decrease class size, memory training) with children and young adults can raise intellectual ability and performance.

We also need to keep this interaction between genetics and environment in mind as we age. There is such a sense of hopelessness about treating Alzheimer’s disease. I often hear professional as well as lay persons say “I don’t want to know as there’s nothing that can be done.” Fortunately, we don’t take the same approach to education. The overall heritability of late onset Alzheimer’s disease is about 50% (67% for identical twins and 22% for siblings). Genetics is not destiny.

We are so focused on genetics and microbiology that we often lose sight of the nurture side of the equation. Take for example the search for biomarkers (e.g., blood tests, cerebrospinal fluid analysis, and brain imaging) to detect Alzheimer’s disease. We treat cognitive (e.g., memory tests) and functional measures (e.g., adaptive skills) as if they are less important than the underlying biology. The interaction of genetic and environmental history determines function. Both are important. No matter what the biology, function and adaptive skills dictate which actual treatments (nurture) will be helpful.

Furthermore, it is becoming increasingly clear that cognitive and functional assessments out perform biomarkers in predicting and treating Alzheimer’s and related diseases (Archives of General Psychiatry, 2011, 68, 961-969). The most important determinant of how well you can live and how independent you can be is the ways your brain functions. What are the strengths and weaknesses in your ability? How can you use your strengths to compensate for your weaknesses? These are the questions addressed by neuropsychological evaluations.

Treatment for Alzheimer’s disease is built around assessment just as are educational programs. IQ scores (genetics) do not fully determine how well you will do in the education system or how well you will live life. Your adaptive skills determine how you will do as you age. Neuropsychological evaluations are best used to direct life plans as we age and to help us focus on the nurturing and adjusting skills as we age.