Dementia

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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To quote from my article for August 2011,  “It is clear that anesthetic agents may be neurotoxic for some and more so after 60.”  This statement was predicated on findings from that time suggesting that undergoing general anesthesia may cause cognitive decline especially in the elderly.  Delirium and postoperative cognitive decline are the two most common untoward effects of surgery.  Delirium is transient and obvious but may last days to weeks.  Postoperative cognitive decline is a more long lasting condition, often subtle at first. But not so fast, understanding is a process that evolves over time and must integrate new information as it becomes available.  A new study (Mayo Clinic Proceedings, May 2013) states that there is no association between anesthesia and dementia.  The data were obtained from medical records on nearly 2000 cases.  Results were based on individuals that […]

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I keep hoping for more useful research on treatments and management techniques that may potentially benefit those with memory loss and their caregivers.  There are three recent studies that caught my attention as examples of movement in the right direction. First, “The effect of stimulation therapy and donepezil on cognitive function in Alzheimer’s disease” (BMC Neurology, 2012, 12, 59).  The study compared the effects of stimulation therapy, treatment with donepezil (Aricept), or to combined treatment during the first year after diagnosis with mild to moderate Alzheimer’s disease.  Stimulation therapy consisted of multiple elements including physical activity (e.g., dancing, walking, fitness training), as well as cognitive and social activities (e.g., reading, listening to music, crossword puzzles, reminiscence) for at least 30 minutes each day 5 times per week.  Donepezil (or placebo) was started at 5 mg and increased after four weeks […]

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“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 […]

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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. Those in […]

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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 […]

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Two recent headlines caught my attention. “Eating berries linked to delay in cognitive decline” (Annals of Neurology, 2012, April 25) and “Coffee may ward off progression to dementia” (Journal of Alzheimer’s Disease, 2012, 30, 559-572). I drink blueberry flavored coffee each morning. Does this give me double the protection? The first study demonstrated that higher consumption of either blueberries or strawberries “slowed memory decline by up to 2.5 years. The study, Nurses’ Health study, had a very large sample size, 16,010, with an average age of 74. Cognitive function was assessed every two years between 1995 and 2001. “Protective” associations were found for women who ate 1 or more servings of blueberries per week or ate 2 or more servings of strawberries per week. On the surface the findings look encouraging. But the rub comes with some of the details. […]

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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 […]

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Alzheimer’s disease unfolds over the course of decades. In the early stages (as discussed in part one), the afflicted person displays increasing loss of short-term memory and becomes increasingly disengaged from activities. Higher level, complex skills such as doing a checkbook and using a computer become more of a challenge. Older, overlearned skills work well whereas learning new skills or habits become increasingly difficult. Rehabilitation is self-generated if started early. If memory loss becomes severe enough to meet the criteria for dementia, rehabilitation must be accomplished by others (e.g., family, home care, or facilities) as independence is lost. The goal of treatment and rehabilitation is not to restore memory but rather to increasingly mold the environment to take advantage of learned habits and skills and keep the person with memory loss engaged and active. Competence no longer matters. What matters […]

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Alzheimer’s disease is often misunderstood. These misunderstandings create a false sense of fear and futility. We are bombarded by new studies that are often contradictory. We are inundated with “alternative” treatments that are supported by anecdotal testimony and clever marketing. We live in a time of reductionist medicine that promises cures and preventative lifestyles but can’t deliver on all of its promises. We can treat chronic diseases: diabetes, certain cancers, heart disease, and chronic pain. Alzheimer’s is a chronic disease that is also easier to manage and treat if caught early. The key is to identify small changes early and, as with any chronic disease, focus on life style and proactive planning. 1. Alzheimer’s unfolds over the course of decades. There is a great deal of time to plan treatment strategies that work. Plan to have a good life even […]

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