Life and Memory Center

The nicotine patch may present a treatment for Mild Cognitive Impairment and early Alzheimer’s disease. This study is new but the idea is old and there are other studies. Before you run off and ask for the patch or chew nicotine gum, let’s put this in the context of current medical treatment.

The only FDA approved treatments for Mild Cognitive Impairment and Alzheimer’s disease are medications known as cholinesterase inhibitors (Namenda is not approved for early changes and works through an entirely different neurotransmitter). These medications have been available since 1993. They work by increasing the amount of the neurotransmitter acetylcholine in the brain. Acetylcholine has important actions on cognitive functions such as attention and some forms of memory. It is one of the neurotransmitters that act on the frontal cortex, amygdala, and hippocampus – structures very important to attention, planning, reasoning, memory, and emotion.

There are four medications available that work by this mechanism: Tacrine (not used because of side effects), Aricept (available in generic form as donepezil), Exelon (rivastigmine in generic form and available as either oral medication or a patch), or Razadyne (galantamine in generic form and available as standard or extended release forms). All three work by increasing acetylcholine.

Choosing which medication is based on convenience and tolerability. There are no proven clinical differences in efficacy. Side effects are similar. It would be convenient if acetylcholine only acted in the brain. However, it also acts elsewhere. For example, it medicates the activity of the gastrointestinal system producing in some symptoms such as loss of appetite, loss of weight, heartburn, nausea, or worse. Acetylcholine also works to regulate neuromuscular (can cause unwanted movement or cramps) and cardiac function (can cause low heart rate and fainting). There are more side effects but the good news if that as many as 70% who take these medications will tolerate them. The only way to know is to swallow the pill and be followed closely by your physician. They help many with progressive disorders such as Alzheimer’s disease function much better for longer.

Where does nicotine fit in? Nicotine also makes acetylcholine more available but by a different mechanism of action. In other words it may do the same thing as cholinesterase inhibitors but also may produce the same risks. The studies so far available are comparing nicotine to a placebo. My question is how does it compare to any of the cholinesterase inhibitors? They are much more widely studied than nicotine in progressive memory loss. I eagerly await the needed studies that may help guide us in making informed choices.

Jan. 30 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Foxfire Country Club,
Davis Blvd; Kings Way, Time: 6pm-social hr, 6:30 dinner, 7:15-talk Contact: Carol Hollenbeck 261-8520

and also
January 31, 2012 Where: Naples Healthcare Assoc., Hilton Ballroom When: 4:30 pm-6:30 pm Contact: Pearl at Naples H.C Assoc. 596-1111

Feb 2, 2012 : Managing your Memory Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Minor League Club @ Cub @ Pelican Bay When: 11:30 – 1:30 Contact: Mike Kelly 908-233-2263

Feb. 8, 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Naples Center When: 1:30-3pm Contact: John Guerra (FGCU) 287-5196

Feb. 9, 2012: Assessing and Treating Progressive Memory Loss Where: Naples United Church of Christ When: 2pm Contact: Dr. Greg Smith 595-3550

Feb. 15, 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain skills Where: Bonita Bay Club Fitness Center When: 1-2 Contact: Mayra Newborn, 495-1937/ mayran@bonitabayclub.net

February 20, 2012: Memory Workshop Complementary book, Complementary Workbook Where: At Premier Conference Room, Naples When: 2-5 Contact: 591-6226 for reservations, Fee $100 x1 and $150 x2

February 29, 2012: Remembering What not to Forget Description: Aging and memory, Improve memory, Sharpen your brain Where: Glenview at Pelican Bay When: 1-3 Contact: Michael Souland-591-0011

One headline reads “Dementia’s first signs appear long before old age, study finds.” (Bloomberg) Alternatively, another headline reads that “Cognitive decline can start at age 45.” (Medscape). These differing interpretations are the leads for two “alerts” I follow to try to keep up with current topics related to memory and aging. In both cases, the actual data are the same and come from a recent article published in The British Medical Journal.

The headlines are based on a large, prospectively designed longitudinal study of more than 7,000 volunteers aged 45-70. Each participant (ranging in age from 45 – 70) underwent cognitive assessment three times during ten years. Overall scores on tests of memory and reasoning declined during the ten years. Only scores on tests of vocabulary remained stable.

On face value these findings appear to be worrisome. However, on closer inspection, the changes were small for men and women between the ages of 45-49 (3.6%). As might be expected, the decline was greater in those aged 65-70 years (a drop of 7.4% for women and 9.6% for men). These are not dramatic changes even in the older participants (some of whom may have actually been in the early stages of decline).

It’s important to realize that not all individuals declined. The percentages are based on averages which mean some declined more and some less than the average – and some improved their scores. Furthermore, there were over 7,000 enrolled in the study. That means that small changes can be statistically significant. But this begs the question of whether small changes like these are important. The risk from such large studies is that trivial effects can be over interpreted as being of practical importance.

To equate these changes – even for the older participants – with “dementia’s first signs” is clearly not justified by the findings. Dementia marks a severe decline that compromises independence. Dementia is not the same as changes that result from normal aging. It seems clear to me that we are justified in saying that tending to cognitive abilities and brain function needs to start in middle age or earlier. But to say the first signs of dementia start at 45 is needlessly alarming. We are not destined to become demented and it is not downhill for all of us after 45.

Many are more fearful of a diagnosis Alzheimer’s than a diagnosis of cancer. However, cancer is much more fatal (cancer is the second leading cause of death in the United States; Alzheimer’s disease is the sixth). This fear stems from a misunderstanding of Alzheimer’s disease and leads many to fear memory assessment.

Alzheimer’s disease unfolds over the course of decades; it does not occur suddenly. There are seven stages of decline in Alzheimer’s disease but current diagnostic standards often don’t identify those with problems until stage 4. Not everyone with Alzheimer’s disease becomes demented and disabled. Not everyone who becomes demented has Alzheimer’s disease. Memory loss is the hallmark feature of Alzheimer’s disease but not everyone with memory loss will have Alzheimer’s disease or become demented. During the early stages of Alzheimer’s disease and memory loss, there is so much that you can do.

The first step in gaining control of your future is to monitor your memory. Whether you prefer the concept of prevention or the concept of wellness, assessment is the key to taking proactive action. You see a dietician to learn more healthy eating patterns. You consult with a physical therapist or trainer to develop exercise routines. You consult with your physician to monitor many elements of your biology such as blood pressure, cardiovascular function, blood sugars, thyroid function, whether you are adequately taking vitamins such as B and D. You do screening tests for many cancers (breast, cervical, skin, and prostate). But you fear and avoid memory assessment as an integral part of your wellness program.

What’s involved in a memory assessment? It doesn’t hurt. You cannot pass or fail any more than you can pass your blood tests. A memory assessment is best administered by a memory expert. The main focus is assessing short-term memory (ability to learn new information) and associated skills such as language, judgment, and reasoning. Assessment evaluates abilities of different parts of your brain. Assessment should be an integral component of annual evaluations.

Be proactive with your memory. Make memory part of your wellness program. Assess and monitor your memory over time. Use external memory supports such as calendars and take away spots. Seek stimulation that uses your mind to learn and master things in which you are interested. Exercise, as it is probably the best overall thing you can do for your memory. Eat more healthy foods by adding more vegetables and fruits to your diet. Be social as those who are isolated are more at risk for memory loss.

It’s that time of the year again. The top ten lists of the year are out to help us recall the year. It triggers both year and life review and stimulates our long term memory of where we have been, where we are, and where we are going. Seneca said it well. “It’s not that we have a short time to live, but that we waste a lot of it.” This of course comes with end of the year resolutions that often amount to trying to do better next year.

I often remark during my talks that the most grievous memory error is “trying to remember.” Instead, plan on how you will remember. Good intentions often fall short when a well placed post-it note would serve us well. It’s the same for New Year’s resolutions. A resolution needs to be a planned act. For example, if you want to get healthier in the 2012, make a plan to remember to exercise consistently. Get out your new calendar and mark out four times a week to exercise for the entire year. Let life then fill in around this goal.

I am pleased to say that I took my own advice last year. I now have an office manager, Beth, to do the many things I was not keeping up with: returning phone calls, scheduling appointments, etc. I hope this has made everyone less frustrated with trying to contact me. Dr. Steve Saldukas completed training with me and is now available to assist with assessments and treatment. All of this has made my life less stressful and caused less frustration for those who wanted to contact or make appointments with me. My resolution for 2012 is to create a system to keep up with e-mails as I get behind and sometimes forget which ones I have done.

The idea of a resolution is simple. A resolution should be a plan that you execute during the New Year. Choose your most important goal and mark your calendar now. This all reminds me of the concept from one of my favorite movies, “What About Bob?” The idea is to take “baby steps.” Think small. Be concrete and specific in setting your plan. And don’t forget to mark it in your 2012 calendar. You can build on it later.

What are the warning signs that the stress of caregiving may be beyond the normal and that you need help?

1. Easily lose patience
2. Easily anger
3. Experience a loss of energy
4. Lose sleep but not from providing care
5. Appetite changes
6. Provide care 24/7
7. Find no joy in any aspect of your life
8. Have frequent crying spells
9. Feel a constant sense of depression, anguish, and despair
10. Don’t think you can go on much longer.
11. Don’t know to whom to turn
12. Use drugs or alcohol to get by

If you check most or all of these feelings, you are likely depressed in a clinical sense. There are many support groups, clinicians, and organizations that will provide help and guidance. Asking for help is not a sign of weakness. If you have considered suicide or homicide, call now.

It’s normal to be stressed by stressful situations. And caregiving for progressive neurological conditions is one of the most challenging stressors I have seen during my 30+ years as a psychologist. As a caregiver you need to understand that it is not only ok but also necessary to sometimes put yourself first. It is okay to make mistakes and become frustrated, impatient, and angry. Whatever you feel is ok. And it is ok to ask for advice and help from others.

Caregiving requires attention to both the needs and feelings of the person giving as well as the person receiving the care. Treatment of dementing conditions needs to address both the needs of the person with loss of memory as well as the needs of the caregiver from the start. Both should be actively involved in all phases of assessment and treatment. The focus of treatment needs to include those who will provide the care.

Caregiving requires effort to take a more positive approach to the task. Don’t forget to care for yourself. Don’t make a mountain out of a molehill. It’s ok to become overwhelmed and frustrated. A bad morning does not have to spoil the whole day. Learn from your mistakes without punishing yourself. Accept offers from family or friends to help with care. Accept offers to go out with friends. “I can’t” really means that what you have to do or face is hard. You don’t have to do everything alone. Get exercise and do something relaxing for yourself each day.

In the past few weeks I have covered several issues regarding depression. It is clear that being demented does not necessarily cause one to be depressed. Furthermore, being diagnosed with dementia or being placed in a care facility does not necessarily lead to depression. Depression is common but not inevitable outcome for all of us as we age. Medications work in less than half of those who are depressed and are clearly not a panacea. Finally, treating depression requires getting moving despite a lack of motivation.

What about depression in those who care for someone who is demented? Caregiving does not itself cause depression. Many caregivers have never had to deal with these feelings before and are too busy giving care to attend to their own needs and feelings. Statistics provide a wide range of estimates (20 to 60%) suggesting that depression is a common but not inevitable consequence of caregiving. Of course, there is also the issue of how depression is defined and diagnosed that is well beyond the scope of this article.

Let’s agree that we will define “depression” in caregivers as a constellation of feelings rather than a clinical diagnosis. Caring for someone with a dementia is associated with a number of possible feelings including: sadness, anxiety, worry, irritation, impatience, fear, anger, irritation, loneliness, grief, and guilt. Caregiving isolates the caregiver from others and calls for sacrifice of needs and desires. Additionally, being a caregiver is not the outcome we ever expect as a spouse, sibling, or child of someone who we love and care about.

Caregiving for someone with a progressive dementia is a very complex stressor. For Alzheimer’s disease, caregiving averages nearly a decade and may extend out two decades. The onset of Alzheimer’s and many other neurological diseases are subtle and, in the earliest stages, are difficult to tell from the changes of aging (mostly a slowing and loss of efficiency). Progression provides a moving target requiring periodic adjustments both in skills needed to mange deficits (ranges from managing the checkbook to helping with personal care) and feelings that one has in reaction to the changes. Caregivers must manage changes that do not unfold in a linear manner and differ from one person to the next.

In short, caregiving requires difficult and progressive role changes. Parents and children become parents for their spouses or for their parents. The efforts of caregivers are not appreciated – and may even be resented – by those receiving the care. Caregivers may have to confront issues for which they have no training: child-like behavior from an adult, profound forgetfulness, aggression, sexuality, and disinhibition. It’s a wonder that so many cope so well and figure out what to do.

As discussed the past two weeks, depression is frequent in both community dwelling elders and those with dementia. No matter what the source of depression, the most effective treatment for depression is to get activated even though you don’t want to. This is true for the young as well as the elderly and for caregivers as well as care receivers. We have often discussed the benefits of exercise for cognitive skills but there is also considerable evidence suggesting that exercise improves mood.

For example, active people are less depressed on average than inactive people. Furthermore, people who exercise regularly and stop tend to show a decline in mood when compared to those who start or maintain exercise. A recent study randomly assigned depressed adults to an exercise group, a medication group, or a placebo group. Both exercise and medications improved mood compared to the placebo. A year later, those who continued to exercise were less depressed than those who stopped.

Another example of the benefits of exercise is found in diabetics. Diabetics report higher levels of depression than nondiabetics. Furhermore, those who are depressed and at risk of diabetes are more likely to develop diabetes. A twelve week exercise program improved mood in diabetes.

So why is it so hard to exercise when the benefits for cognition and mood are so clear? First, exercise is the antithesis of depression. Depression robs you of motivation and makes everything you do seem futile. Second, exercise takes time to improve mood. You must exercise consistently for 4-6 weeks to see benefits in mood. But it also takes antidepressants 4-6 weeks to improve mood when they work. There is no quick fix. Finally, some push too hard when they start to exercise. This causes discomfort and many don’t continue. Start slow, exercise despite contrary feelings, and be persistent.

How much exercise do you need to improve mood and cognition? Should your exercise plan consist of aerobic or resistance training? The best answer is that it is not clear. My belief is that some combination of both types of exercise is the best plan. Aim at a total time of about 2 and a half hours (that would be 5 days at 30 minutes a day) a week for aerobic training. Add resistance training twice a week. There is evidence that exercising outdoors improves mood more than exercising indoors. Consistency is far more importance than intensity.

It’s close to time for us to make behavioral changes for 2012. I suggest you take out your new calendar and mark your exercise schedule for the first 6 months. For many of us it is better to exercise in the morning as the day begins with a sense of accomplishment. Let the rest of life fill in around exercise. You will improve your mood.

As discussed last week, depression is frequent in both community dwelling elders (by most standards those over 55) and those with dementia. Depression is more likely in dementias due to either vascular disease (strokes) or Lewy body disease than in Alzheimer’s disease (maybe there’s a benefit to short term memory loss). In short, depression is a common but not inevitable outcome for all of us as we age. What are the best treatments for depression? How well do different treatments work for those who are demented as well as for those who are not?

Medications in the class called selective serotonin reuptake inhibitors (SSRIs) such as Lexapro, Prozac, Zoloft, Celexa, and Paxil are the most common medical treatment for depression. However, they are not a panacea – especially in the elderly and those who are demented. A large portion of the elderly obtain only a partial response to medications and fewer than 30% display full remission. Antidepressant medications have an even poorer track record in those with dementias. There is little evidence that they are more effective than placebos in the treatment of depression in Alzheimer’s disease.

Furthermore, there is a negative interaction between use of SSRIs to treat depression and age. Treatment with SSRIs may lead to worsening cognition in those over 75. The reason behind this finding is unclear at present. Is this a result of inaccurate diagnoses? Is it a result of increasing risk of dementia with age? Is it a result of confusing the symptoms of dementia (e.g., apathy, poor initiative, changes in sleep patterns) with those of depression? Is it a negative side effect of the SSRRIs associated with aging?

There is treatment that is effective for depressed elders. Don’t reach for the medications too quickly in the treatment of depression. Adding psychotherapy to use of medications dramatically improves outcome. Use of an SSRI produced 29% treatment response in one study. Adding psychotherapy improved treatment response to 58%. Psychotherapy (broadly defined) is also effective in treating depression in those with Alzheimer’s disease. Effective treatments include: reminiscence, music, cognitive stimulation, conversation, and physical activity.

A first approach to treat depression in the elderly or demented is to start with nonmedical interventions and then add medications if needed. Start with cognitive therapy that addresses the lack of worth. Be sure to also include a treatment plan for increasing exercise and socialization immediately. Whether the issue is apathy or depression, the treatment needs to follow a plan that promotes and structures physical and social re-engagement. The most effective treatment for depression is to get activated even though you don’t want to.

Depression comes in many forms. Mild depression may range from the colloquial use of “I’m having a bad day” to depressive symptoms that are not severe or pervasive enough to meet current diagnostic standards for Major Depressive Disorder (which is more severe and has to persist for at least two weeks). Dysthymia is an enduring but comparatively mild form of depression. Sadly, recent surveys indicate that as many as 40% of community dwelling elders (by most standards those over 55) have some form of depression. This puts those afflicted at greater risk of mortality and suicide as well as poorer quality of life than those who are not depressed.

Does having a diagnosis of dementia increase the prevalence of depression in the elderly? The answer depends on the cause of dementia. The prevalence of depression in dementia due to Alzheimer’s disease is estimated to be between 20-40%. This is true for all stages of Alzheimer’s disease and is slightly lower than for community dwelling elders who are not demented. Depression is more likely to occur with dementias due to either vascular disease (strokes) or Lewy body disease than with Alzheimer’s disease.

What are the mechanisms associated with depression when it occurs in Alzheimer’s disease? One possibility is that genetics determines who will become depressed and who won’t. But genetics explains only about 8% of the variance in studies of Alzheimer’s disease. Furthermore, there is no association between the putative pathology of Alzheimer’s disease (i.e., plaques and tangles at autopsy or amyloids in cerebrospinal fluid) with depression. Interestingly, there is also no association between cerebrovascular disease in those with Alzheimer’s disease and depression.

Does being diagnosed with dementia lead to an increase in depression? Apparently not. A recent prospective study indicated that there was little change in mood during the first 2-3 years after being diagnosed with dementia. Therefore, there is no catastrophic reaction to a diagnosis of dementia. On average, those who were depressed to start stayed depressed and those were not depressed do not become depressed.

Does placement in skilled nursing home of those with moderate to severe dementia make them depressed? Not as much as one would intuitively expect. The prevalence of depression after placement is about 21% (the incidence is about 15%). But if placement induces depression, the depression persists in about 45% of cases. Therefore, depression is not an inevitable outcome of placement (stressful adjustments do not always lead to depression).

Does being depressed make dementia more likely in the elderly? There are several studies indicating that being depressed and over 55 doubles the risk for dementia in the elderly. The largest study involved 280,000 veterans over 55 and concluded that there was two times the risk of dementia in veterans who were depressed when compared to those who weren’t. So depression increased the risk of dementia but dementia does not appear to increase the risk of depression.

In conclusion, contrary to intuitions, being demented does not necessarily cause one to be depressed. Furthermore, being diagnosed with dementia or being placed in a care facility does not necessarily lead to depression. Depression is common but not inevitable outcome for all of us as we age. Next week, what are the treatments for depression? How well do different treatments work for those who are demented as well as for those who are not?