The cholinesterase inhibitors like Aricept (i.e., donepezil) have been available for treatment of dementias such as Alzheimer’s disease since the mid 1990s. It is clear that long term use of these medications slows the progression of Alzheimer’s disease (in those who tolerate them) and that discontinuing the medication after extended use produces a more rapid decline even in those so impaired that they are in skilled nursing facilities. Despite these findings, the cholinesterase inhibitors are often maligned, not used, or discontinued too soon because they do not produce dramatic effects and do not stop or reverse decline. One way to determine the efficacy of these medications is to determine if treatment reduces the burden that caregivers express (“Effects on caregiver burden of donepezil hydrochloride dosage increase to 10 mg in patients with Alzheimer’s disease,” Nakamura et al. Patient Preference and […]

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Benzodiazepines are widely used to treat anxiety and/or insomnia. They include medications like Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam) that are used for anxiety and Restoril (temazepam) and Halcion (triazolam) that are used to help induce sleep. Benzodiazepines may also be separated into those that are long acting (e.g., Valium and Klonopin) and those that are short acting (e.g., Xanax and Halcion). Long acting medications tend to remain in the body for extended periods of time (e.g., days) whereas short acting medications remain in the body for hours – hence you need to take the medication more than once a day to maintain effects. Benzodiazepines are probably most effectively used as short-term management of anxiety and insomnia. As with any medication, there are trade offs that must be considered by both prescribers and consumers. First, there are […]

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I had the pleasure of being invited to observe a workshop by Teepa Snow (http://www.TeepaSnow.com).  The event was hosted by the Alzheimer’s Support Network and, to my great pleasure, was attended by staff from diverse facilities and organizations that provide dementia care.  Teepa is a very skillful and talented presenter/trainer.  Her focus was on doing.  She presented conceptual training in the form of role-plays of many challenges we face when trying to get into the world of someone who is demented.  Her teaching style focused on doing rather than saying.  She challenged but always coached participants into a success by offering specific prompts and modeling.  Caregiving is not an intellectual exercise but is a hands on, participatory activity. Teepa’s message is clear.  You must provide person-centered care to be effective in caring for those with severe cognitive decline.  We often […]

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The “amyloid hypothesis” of Alzheimer’s disease postulates that Alzheimer’s is caused by the accumulation of a protein named beta-amyloid that produces the “gunky” deposits called plaques in the brain.  Despite the evidence that this is not the root cause (may be an effect of the brain changes in Alzheimer’s rather than a cause), the theory has become scientific orthodoxy, dogma and accepted on faith rather than evidence.  It has dominated research aimed at slowing or reversing Alzheimer’s disease leaving little funding for other approaches.  But there is a kink in the armor.  There is accumulating evidence that treating amyloids is not the solution.  For example, six new drugs that decrease beta-amyloid reached phase II and III clinical trials in 2012.  Three of the studies were discontinued because concerns about safety or lack of efficacy.    Furthermore, we know that the brains […]

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How does caregiving unfold over time?  Diseases such as Alzheimer’s disease evolve over time – usually decades.  The person who is forgetful can manage early changes in memory.  But as the disease progresses, there is an increasing need for external guidance, prompts, and caregiving as the problems extend beyond just forgetfulness.  There are seven general stages of memory loss per the global deterioration scale.  The following presents general needs for care at each stage. Stage one – normal.  This is the stage that we all hope to stay.  There are the typical “senior moments.”  No caregiving is needed. Stage two – forgetfulness.  In this stage there is minor consistent forgetfulness and the person in this stage is typically aware that there are changes.  There may be an incident or pattern that raises minor concerns.  There is no need for caregiving […]

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There is treatment for Alzheimer’s disease.  Realistically, Alzheimer’s gives ample time to be proactive.  It is a slowly progressive neurological disease that unfolds over the course of several decades. Treatment involves being proactive rather than reactive.  These are the steps we all need to take beginning now. Assessment.  We all have wellness plans that are managed through annual physicals with our physicians.  We need to include annual memory assessment by a memory expert as a part of this plan.  The assessment should, at the minimum, thoroughly assess short-term memory by means of a challenging, standardized memory test and be administered by a memory expert. Treat short-term memory before it changes.  We seem to lose track of the fact that we took notes in school to manage short-term memory.  It never worked like a muscle.  It takes time, focus, and effort […]

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Caffeine appears to enhance memory consolidation according to a study published in Nature Neuroscience (“Post-study caffeine administration enhances memory consolidation in humans,” 2014, 17, 201-203).  But before you down an extra cup of coffee or an extra diet Coke, consider the details of the study.  The subjects were 160 young adults who reported they consume little caffeine each week – < 500 mg, which is less than the equivalent 2-3 cups of coffee per week.  Furthermore, they consumed caffeine pills not coffee.  Participants studied 200 pictures, swallowed the caffeine pill, and returned the next day for a surprise memory test.  Those who had the caffeine were better able to discriminate items similar to those actually seen from different items – familiarity not memory as most of us think of it. Let’s break down this result.  First, there were three doses […]

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Initially, I was excited to see a review article titled, “Efficacy and safety of cognitive enhancers for patients with mild cognitive impairment: a systematic review and meta-analysis” (Canadian Medical Association Journal, 2013, September 16).   However, I was disappointed after carefully reading the paper.  I had hoped to gain insight into whether cognitive enhancing medications (Aricept/donepezil, Exelon/rivastigmine, and Razadyne/galantamine – there were no cognitive data for Namenda) help those with Mild Cognitive Impairment but there are too few studies with too many limitations to get a clear answer to the question of benefits. Mild Cognitive Impairment is usually characterized by mild memory/cognitive deficits in those without functional decline in everyday skills.  These are persons who do not meet the criteria for Alzheimer’s disease but are clearly at greater risk of obtaining the diagnosis in the future.  The question is whether treating […]

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I have had a number of clients over the years that have come to me with concerns about their memory that seemed just fine.  For example, there was the 82-year-old woman who was a Smith College graduate in physics.  I evaluated her four times over the course of ten years.   On the first evaluation, she tested among the highest I have ever seen – including short-term memory.  However, on each of four subsequent evaluations, her short-term memory scores declined even though the word list was the same.  She obviously was aware of changes before testing could detect decline. Clients such as this are referred to as the “worried well.”  Professionals dismiss them as if they are not aware of their own bodies.  I find this particularly disturbing as progressive neurological conditions such as Multiple Sclerosis, Parkinson’s disease, and Alzheimer’s disease […]

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Alzheimer’s disease unfolds over the course of decades.  Despite the intensive search, there are no accurate and reliable biological markers for Alzheimer’s disease.  Diagnosis is based on a combination of factors including details of course and history gathered from the person who has memory loss as well as family and/or friends.   There must also be a medical work up searching for treatable causes of memory loss such as thyroid function, status of diabetes, anemia, and imaging studies.  The standard of care also requires cognitive evaluation to map out strengths and weaknesses and stage the disease.  Finally, diagnosis requires clinical judgment. There is a push for a new set of criteria that diagnoses Alzheimer’s disease into three stages and is based on the fact that Alzheimer’s disease begins well before symptoms emerge (Practical Neurology, 2013, March/April, 34-35)).  The first stage is […]

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