Dementia

It is increasingly clear that becoming demented as we age is more than just Alzheimer’s disease. There may be few if any “pure” cases of Alzheimer’s disease. It may be the added wear and tear from added medical burdens in conjunction with the pathology of Alzheimer’s that leads to dementia. We already test for factors such as B12 deficiency, thyroid deficiency, and acute infections as they may impact cognitive function and are treatable conditions. However, we ignore many diseases that may take a toll on brain function and cognition. We are just coming to terms that such events as surgery, treatment of cancer, sleep apnea, and repeated head injuries have short and long term effects on cognition. The cumulative load is too much for biological and psychological compensation with time and aging. One often-ignored disease is lung disease such as […]

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I have been specialized in memory and memory disorders such as Alzheimer’s disease and related disorders for a quarter of a century. Interestingly, in all that time I have read very little about Dr. Alois Alzheimer (6/14/1864 – 12/19/1915). Engelhardt and de Mota Gomes wrote a recent article (“Alzheimer’s 100 anniversary of death and his contribution to a better understanding of senile dementia,” 2015, Arquivos De Neouro-Psiquiatria, 73, 159-162 PMID 25742587) in honor of the upcoming 100th anniversary of his death that helped me put Dr. Alzheimer in a broader context. It’s important to understand that the concept of “senile dementia” dates back thousands of years. Both Aristotle and Plato held the belief that old age is linked to inevitable memory failure. The concept of mental stimulation as neuroprotective is also not new. Cicero believed that keeping mentally active prevented […]

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There are retirement stories both ways. Some have a long and rewarding retirement. Others seem to decline either physically or mentally shortly after retirement. The fear is that by retiring, one becomes disengaged and cognitive impairment sets in. After all, educational attainment, social engagement, exercise, challenging work, and bilingualism are “neuroprotective so they decrease the risk” of such problems as Alzheimer’s disease. Of course, the conundrum is that we cannot determine cause as there is no study that disentangles whether time of retirement is a result or the cause of cognitive decline. This is further complicated by the fact that Alzheimer’s disease unfolds over the course of decades with subtle onset. But what does the research tell us? There are a few studies that indicate that there is a correlation, an association between retirement and the risk of developing dementia. […]

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What is a neuropsychological evaluation, what good is it, and how is it best done? Let’s start by making a distinction between testing and evaluation. Tests are rigid, standardized, formal measuring tools to determine things like mastery of information, placement in school programs, and outcomes for clinical trials of drugs. The test administrator needs to be consistent, neutral, not help, and not give feedback that may influence the results. Many neuropsychologists administer “tests.” On the other hand, an evaluation is more flexible. The interaction is less formal and can be modified to meet the needs and personalities of those needing evaluation. For example, memory evaluations start by observing whether the client is on time. Did he or she remember the paperwork? Can he or she find the office? Find their insurance cards? Know their birthdate? Remember a list of words? […]

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Alzheimer’s disease and other progressive dementias are not the only cause of cognitive impairment. It is commonly known that as the heart goes, so goes the brain. An estimated 5 million Americans suffer from heart failure and this number is expected to double over the next 40 years (“Heart failure and cognitive dysfunction,” International Journal of Cardiology, 2014, 178, 12-23, PMID 25464210). Cognitive impairment is common in those with heart failure with a prevalence ranging from 25% to 75% with greater degree of heart failure associated with higher levels of cognitive impairment. Those in heart failure with a left ventricular ejection fraction of less than 45% are especially prone to cognitive impairment that is at least mild. Cognitive impairment may involve any one or all of several brain functions. These include attention, memory, executive function, language, speed of thinking, and/or […]

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Alzheimer’s disease does not develop suddenly. It emerges over the course of decades. There is a history of short-term memory loss that often dates back a decade before more obvious symptoms arise. Onset is subtle. How many of us have had senior moments? How do we know if they are benign or the hallmark of progressive cognitive decline? Changes are complex and differ across individuals depending on the region of the brain that is affected. One way to make sense of these complicated pathways is to have a category that reflects significant changes in memory that fall short of a dementia. The solution has been to create a category – diagnosis if you like – for individuals who have memory changes but are not demented. This is Mild Cognitive Impairment (MCI) (“Mild cognitive impairment and mild dementia: a clinical perspective,” […]

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There has been a long standing debate about whether undergoing anesthesia can trigger dementia (see article by Roni Jacobson in Scientific American, October, 2014). Despite large, well-publicized studies claiming there is no significant association between anesthesia and dementia, there are too many cases to dismiss the phenomenon as coincidence. The cases appear to be statistical outliers in that they are not the norm. However, that does not make them any less real just infrequent. What is widely accepted is that a portion of those who undergo general anesthesia experience what is called “postoperative cognitive decline.” This marked by lapses of memory and attention (mild to severe delirium) that lasts from a few hours to a few weeks before it clears. Most who experience anesthesia do not show these effects for more than a very brief time and do not go […]

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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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We often get so focused on Alzheimer’s disease that we neglect other causes of memory loss and cognitive dysfunction.  Stroke is the second most likely cause of cognitive dysfunction after Alzheimer’s disease in the elderly.  Furthermore, there is a complex interaction between cerebrovascular health and Alzheimer’s disease.  Post-stroke cognitive impairment may affect several domains of cognitive abilities such as attention (tracking the moment), memory (recalling new information and/or details of personal history), language (expressive and/or receptive speech), orientation (for time, place, and/or person), and executive functions (planning. judgment, reasoning, and/or social graces).  The effects of stroke may be temporary (e.g., TIA) or persisting depending on the size of the lesion and timing of treatment.  The effects may be severe (e.g., cause dementia) or mild (e.g., cause mild cognitive impairment) and may affect single skills or multiple skills. There are three […]

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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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