Alzheimer’s Disease

Alzheimer’s Disease-What the Caregiver Needs to Know

If you suspect a loved one has a dementia, a progressive deterioration of memory and other cognitive skills, please consider these recommendations.

The primary consideration in all such circumstances is the safety of the loved one.  There may be months of time between calling a specialist and receiving an appointment; perhaps longer before a meaningful diagnosis is achieved and treatment is initiated.  As I have pointed out many times, there is no guarantee of treatment effectiveness.  Even after treatment, your loved one may still suffer with the same symptoms, or worse, the initial treatment appears to cause a decline in the patient’s condition.  It is this last group that calls my office in the most desperate fashion.  Typically, the decline is not from practitioner incompetence, but poor standardized treatment protocols for victims of senile dementia.  The focus is almost exclusively on medications for memory, and these come with a host of side-effects that may be worse than the symptoms for which you sought treatment.  Unfortunately, in the last twenty years of assessing victims of senile dementia, I have not witnessed an institutionalized patient regain functionality through the use of  memory boosting medications.  As a caregiver of a dementia victim, do not believe that memory medications will slow or halt the progression of Alzheimer’s Disease.

Knowing that it may be months until meaningful help arrives, consider a few simple steps to make your loved one safer in their home.  The risk of fires and falls are preeminent.  I strongly suggest unplugging stoves anytime someone is inattentive or actually confused.  This includes barbecues and working fireplaces.  Microwave ovens are generally safer, since they will usually blow a fuse before starting a fire, but you may want to observe the loved one’s actual use of the device before making that determination.  Smoking in bed is almost a cliche, but it is a very real danger, and all confused people should be supervised while smoking.  Matches or lighters should never be in their possession.

Falls are the bane of every caregiver, and the source of most nursing home admissions.  Kitchens and bathrooms are the big culprits, with sharp corners and hard surfaces everywhere.  A consult with a physical therapist is an excellent early intervention to determine your loved one’s ability to safely ambulate.  As with all behavior, past behavior is the greatest predictor of future behavior.  If your mother has fallen twice in their home, it is likely that a third will occur.  The interval between falls is very important.  If you as a caregiver notice a doubling or trebling of fall occurrences, than consider rapid follow-up with a physician to rule out common causes of weakness and imbalance.  Here again, consulting with a physical therapist is very important.  The use of an assistive device for ambulation is not always straight forward.  Consider the charitable act of giving the demented person a walker for balance.  Unless trained on how to use the walker over a number of sessions, the walker may increase the number of falls.  Negotiating transitions between floor surfaces and maintaining a forward upward gaze is critical to the use of a walker, and it is not always self-evident.

What if your loved one’s ambulation is so good they are wandering away from home?  This is an intolerable situation from a safety standpoint.  If the person is confused, simply putting curtains over the door will decrease exit seeking, but not entirely prevent the same.  Installing double dead bolts will keep the person inside, but may seal their fate if a fire is started.  The best solution, and most expensive, is to purchase an alarm placed on the patient’s body and corresponding sensors placed on every door.  Please keep in mind that this only is effective if someone is able to respond to the alarm in under five minutes, or the patient is unaware how to remove the bodily alarm.  Even in the nonverbal seventh stage of a senile dementia, I have witnessed these poor people remove alarm bracelets from arms and ankles, as they have no idea as to the purpose of the alarm.  The only iron-clad way to keep a demented person safe from exit seeking is to have eyes on them 24 hours a day-7 days a week.

There is no realistic method to keep a demented person completely safe.  Even in facilities dedicated to the treatment and maintenance of the terminally demented, falls and exit seeking are a fact of everyday life.  All a caregiver can do is try their best.  Please avoid trying so hard that sheer exhaustion nullifies your effectiveness as a caregiver.

Thanks for the Memories, Babe

Thanks for the Memories.  This was a song made famous by “Les Brown and his Band of Renown.”  In the 1960’s and 70’s I recall Bob Hope specials on television with Les Brown conducting his signature song.  I was of course a neonate at the time, so my recollection depends upon the generosity of my elders.  Unfortunately, truth be told, I recall these TV specials from childhood and early adolescence.  I was indifferent to his music at the time,  yet I still recall Les Brown’s name and can hum his tune.  What purpose could there be in retaining this trivial information?

Consider memory as a storage house of our five senses.  Smell is strangely the most powerful initiator of old memories, with hearing, touch, taste and vision not far behind.  The greater the interconnection of the senses, the greater the chance of the memory being retained and recalled.  For example, reading about building a model airplane is easily forgotten.  Reading then watching someone else build the plane solidifies the memory.  Actually assisting someone else build the plane after reading and watching further enhances recall and subsequent successful performance.  The auditory memory channel was strengthened by the visual, and locked into place by the motor/tactile.  Each sensory channel leading into the storehouse is strengthened by repetition.  It appears that repetition across days is better at storage than repetition across minutes, or even hours.  Consolidation of memory during sleep may be a factor, but this has yet to be proven.  Two hours of effort-full practice a day over ten years typically leads to mastering nearly any skill.  Like a road or river, the greater flow produces a larger pathway.

“Les Brown & his Band of Renown” were televised every six months to a year; deepening this auditory and verbal memory pathway.  These TV specials were viewed by the whole family, associating other auditory, tactile and visual information with the events.  Not only did the TV specials reflect my personal history, but the unique time in history that served as a backdrop for these specials.  The war in Vietnam took center stage at the time.  Episodic memory refers to the storage and recall of personal events-laughing with the family.  Semantic recall refers to the storage and recall of events that are outside of oneself-the Vietnam war.  Writing an autobiography requires precise episodic recall, whereas playing Jeopardy requires excellent semantic recall.  There is obviously some blurring between these two categories, yet people who suffer with deficits strictly in the episodic or semantic mode are well known.  It is likely that my  recall of the TV specials was enhanced by interconnected personal and historical memories of the events.

Perhaps retaining the memory of “Les Brown and his Band of Renown” was not so trivial after all.  In order to commit any type of information to memory, the use of multiple senses over several days will increase the amount and strength of memory storage.  Linking personal with extra-personal events further solidifies memories into long-term storage.  Memories that remain strong over many years expose their importance.  Many people want to forget strong memories.  Perhaps listening to their call across the years is wiser than ignoring their pleas.

Memory Medications

It was a bit shocking. The wife remarked on the comments of her husband’s neurologist.  He was rumored to malign memory enhancing drugs used in the treatment of Alzheimer’s Disease.  He was of the opinion that this class of drugs benefited the drug companies more than the victims of a senile dementia.  The wife was understandably confused by the disparity between the opinion of the neurologist and the claims of the drug companies.  The shock was the public admission of what many physicians voice in private.

Over the last ten years, most patients I’ve evaluated with a change in mental status, due to any cause, have already been prescribed memory enhancing medications.  The drug companies caution that these drugs should be limited to the victims of a senile dementia of the Alzheimer’s type.  It is very common to observe these drugs used in the treatment of stroke and head injuries.  Is this a good thing?

Unfortunately, this clinician has never witnessed a significant increase of verbal memory performance as a consequence of these medications.  This experience applies both to the preferred use of these drugs in the treatment of Alzheimer’s, as well as off-label use of memory enhancing medications.  It is not intended as a blanket condemnation, rather it reflects the lack of statistically significant benefit displayed on well-normed tests of verbal memory.  There may be many people who have a significant increase of verbal memory with the use of these drugs, but none of these responders have been evaluated by this clinician.  Memory enhancing drugs that boost the neurotransmitter acetylcholine may display increased agitation, weight loss, and even chronic nausea with vomiting.  These reactions are fortunately not universal.  This clinician has witnessed the resolution of these symptoms many times after a reduction or discontinuation of the medication.  Personal experience of medication that affects glutamate levels in the brain is that they are neither very harmful or helpful in the treatment of moderate to severe Alzheimer’s Disease.

Given the modest benefits advanced by the drug companies, and the lack of personal observation as to their effectiveness, it may not come as a shock that I rarely recommend memory enhancers.  Family members are often convinced of their benefit based upon commercial advertising.  I have never witnessed a family member request memory enhancers based upon their personal experience, or the experience of a close friend.  This is not to say that memory enhancers never have beneficial effects, just not in this clinician’s limited experience.  Much of the public and even some physicians are highly influenced by these drug advertisements.

The latter stages of Alzheimer’s Disease are often fraught with weight loss and agitation.  Victims of a senile dementia become too inattentive to sit through a whole meal, requiring frequent prompts and even hand feeding to keep up their body weight.  By the middle stages of Alzheimer’s, the loss of other cognitive functions largely negates a mild increase in verbal memory.  These mid-stage patients would still have trouble with planning, praxis, attention, judgment, flexibility, etceteras.  Even a significant increase in verbal memory would not return these victims to an independent lifestyle.   Memory enhancing drugs that commonly produce symptoms of weight loss and agitation should be used with obvious caution.

This clinician’s advice is to proceed with, you guessed it, caution.  Consider having a neuropsychologist perform pre and post testing to measure any significant increase in verbal memory as a consequence of these medications.  If there is not a significant increase in verbal memory after a six week trial, consider requesting the attending physician to reduce and eventually discontinue the medication.  If an acetylcholine boosting medication is utilized, and the patient develops weight loss and agitation, work with the physician to determine if the symptoms are secondary to the memory medication.  Senile dementia of the Alzheimer’s type is a horrid disease that can cripple an entire family.  Pills without a clear benefit should be considered as a risk to the patient over time; possibly creating undesired symptoms and interacting with other medications in an unpredictable fashion.  I strongly suggest to formulate conclusions based upon observation-not advertising.

When to Seek a Nursing Home for your Loved One

When is it the correct time to seek the assistance of a nursing home?  This is a monumental decision.   An initial hurdle is the public perception of nursing homes.  It is the place to go when one is ready to die.  This remains true for some, but much less than even twenty years ago.  Over half the patients admitted to Florida nursing homes leave in a better condition than when they were admitted.  Increasingly, nursing homes are fulfilling the duties of hospitals.  Most rehabilitation is now conducted in nursing homes, rather than hospitals and free standing rehab centers.  Rehabilitation is a general term for physical, occupational and speech therapy services.  In the state of Florida it would be fair to say that emergencies are evaluated at the hospital, but most of the long-term treatment occurs in the nursing home.

In the most general terms, seek nursing home treatment for a loved one when you are no longer able to care for them at home.  This statement sounds a bit obvious, but it is not obvious in practice.  Most people in the United States wait too long before seeking treatment for a loved one with Alzheimer’s Disease.  I will repeat that statement.  Most people wait too long for nursing home treatment.  This fly’s in the face of world opinion that American’s are quick to institutionalize the elderly.  Over the last twenty years, I have treated hundreds of patients whose only crime was to care for a demented loved one until they were physically and emotionally exhausted.  I have witnessed dozens of families form three shifts to care for an elderly parent twenty four hours a day, seven days a week.

An especially poignant example is a family aftercare group.  A woman tearfully described the guilt she experienced placing her mother in the nursing home.  She had cared for her severely demented mother for nearly twenty years; seriously impacting her marriage and career.  Like so many, she found herself in the unpleasant and awkward position of changing her mother’s dirty diapers.  At the time of her mother’s admission, she was over one hundred years old, and required total care for bathing, dressing and toileting.  Her tears became torrential when others in the group reflected the depth of her devotion and sacrifice.  The situation was not unusual, it was the support she received from peers of her own age that etched the story into memory.

Another misconception is that demented elderly patients will decline rapidly in the nursing home.  It is may be awkward for family members to admit their loved one has mentally and physically improved in the nursing home.  It is easier to coordinate physician care in the nursing home.  On an outpatient basis, physicians rarely have a coordinated picture of the total clinical situation.  Said another way, Dr. A may unfortunately not be aware of what Dr. B has prescribed.  Dr. B may not be aware there is a Dr. A. .  In the nursing home, there is a master medication record, and this record is often reviewed by pharmacists to catch possible drug interactions-or just plain errors.  The nearly universal lack of coordinated outpatient care leads to many preventable iatrogenic hospital and nursing home admissions.  A potentially positive aspect of nursing home care is the increased socialization.  So many widowed and single elderly become extremely isolated, and this lack of socialization may be destructive to their mental and emotional functioning.  Family members are often surprised to the degree their loved one’s spirits have brightened in the nursing home.

A general rule of caring for a loved one is to not exhaust yourself in the process.  Once exhausted, a caretaker is largely worthless to the patient and themselves.  You will not be doing anyone a favor by working yourself to death.  Do not be deceived that nursing home placement is a sign of personal failure, or that keeping a loved one in their home will slow the disease.  Consider adult day care if you are becoming exhausted caring for a person with a progressive dementia.  Once the loved one experiences falls, becomes aggressive or escapes from the home, have them evaluated as soon as possible.  Please visit local nursing homes and develop a relationship with the ones that appear most promising.  Do not wait to evaluate institutions until the patient has an emergency-typically a fall.  Please listen to close others who tell you to lighten the workload.  We only know ourselves through the eyes of others.  A happy nursing home visitor will likely do more for the patient’s spirits than a depleted caretaker cleaning another diaper.

A Question of Alzheimer’s Disease

There is a single question that may accurately and reliably differentiate between dementia and normal aging.  Not only is this question  potentially able to discriminate between normal senility and dementia, it may prove a powerful method to differentiate Alzheimer’s Disease from other types of dementia.

Here is the question.  How is your memory?

Perhaps this appears too simple to be elegant.  As with any rule to describe complex phenomenon, the rule only has power within specific boundaries.  For example, Newtonian physics is so powerful that it largely accounts for the success of NASA’s space program.  Newtonian physics loses most of its predictive power when the object is going very fast, or is very small.  This in no way renders Isaac Newton’s mechanics useless, rather his worldly physics is extremely useful within certain parameters.  If the observer loses sight of these parameters, then the power of the system may suffer.  A rule that holds true for all phenomenon is compelling, but it may come at the expense of explaining anything in the particular.

The boundaries that are important for this rule are predicated on the functioning of the person before dementia is suspected.  When a person is questioned regarding the status of their memory, this directly calls upon their level of self-awareness.  The awareness of self appears to be well correlated to intelligence, but again within specific parameters.  If one questions a person with mild mental retardation regarding a cognitive skill, they will likely have some idea of the meaning, but their responses will not be very accurate in relation to informants.  Questioning someone with moderate mental retardation will reveal that they do not understand abstract concepts regarding cognition.  Once low average intelligence is reached, self-awareness is typically functional.  There is a lack of evidence indicating that self-awareness increases with above average intelligence.  It may increase, but research that converges on this conclusion is lacking.  A general rule offered is that self-awareness is likely normal until intelligence falls below the average range.  As with any cognitive skill, self-awareness may be significantly greater or lesser than one’s Full Scale IQ, but it will likely be well correlated across thousands of individuals.

The other boundary that needs to be considered is age.  It is unlikely that this question has much utility before the age of 75.  Purely as an artifact of testing thousands of patients, it is rare for someone before the age of 70 to complain about their memory.  By the age of 80, most non-demented patients of average intelligence complain about their memory.  People in their 80’s are self-aware that their memory has declined, which is realistic and insightful.  The ability to name common objects and freely recall verbal information starts to decline in our 50’s, and is very evident to ourselves and others by the late 70’s.  In addition, people who age well are typically irritated by their inability to recall and generate names for people and objects.  Even in the early stages of a senile dementia, the victim is not bothered by their poor performance, and they frequently generate external causes for their inability to name or recall.

The next time you speak with someone in their 80’s who is constantly bemoaning their memory, let them know their cognition is likely just fine!  Conversely, the next aged person with whom you speak reporting an excellent memory should be a cause for concern.  If this person is college educated and held a middle-class job, then be very concerned.  If the person is suspected to be below average in terms of education and vocation, then the answer to this question is less revealing.  Also remember that this question is less able to discriminate between normal aging and Alzheimer’s in those younger than 75.  There are many causes of poor verbal memory throughout our lifespan, but the early degradation of self-awareness is nearly unique to Alzheimer’s Disease.  This is likely the source of the question’s utility and power.

Whether it is termed the “dementia question” or the “Holzmacher paradigm” is less important than future research into the uses of this questions for clinical practice.  This single brief question may offer physicians a procedure to accurately make dementia referrals, as well as provide a simple way for caretakers to make treatment decisions.  The greatest difficulty with the question is that it appears too simplistic to be meaningful, let alone useful.  Perhaps Friar Ockham was correct, amongst competing explanations, the simplest solutions are most satisfactory.  If anyone knows of a simpler method to reliably differentiate between normal aging and Alzheimer’s Disease, please write as soon as possible.  It is hoped that clinicians will weigh in on this proposal, as my razor may have removed a bit too much.

Dementia: is it Clean or Dirty?

Is it possible to find someone with a “clean” dementia?  While this sounds like a misnomer, it is intended to describe people who suffer with a specific dementing pathology, and no other complications are known to exist.  It is a form of progressive cognitive deterioration that corresponds perfectly with its diagnostic category.  Only symptoms of this particular dementia are present, uncontaminated by other forms of physical or mental illness.  Hypothetically, such a “clean” dementia should readily conform to existing treatment protocols.  When a patient consults a neuropsychologist, they expect some sort of diagnosis with treatment recommendations, and not “well, it might be this, or it might be that.”  Families often vacillate between different factors to explain the changes in behavior and cognition, such that they expect definitive answers from a professional.  It is not unusual for the patient to become agitated when the doctor invariably, stereotypically, calls for more tests before they can arrive at a definitive diagnosis.  Why can’t we just do our job?

Here is where I frustrate my audience by reporting that diagnoses are rarely simple and clear cut, and that it’s typically a disservice to the patient to arrive at a quick and dirty diagnosis.  For example, a new patient came into the office yesterday with an old severe closed head injury.  This person exhibited classic signs of a severe traumatic brain injury.  Their personality and mental functioning were permanently altered in a way that is very consistent with the pathology of TBI that I was taught in school.  The easiest route is to dazzle the family with my knowledge of traumatic brain injury, make some behavioral and medication recommendations, and then sit back until they return in two weeks.  During the course of the interview with the family and patient, it became apparent that the patient endured a cerebral vascular accident immediately subsequent to the closed head injury.  Unfortunately, this is not an uncommon occurrence after severe closed head injury, though rare in mild to moderate injuries without a period of coma.  There are aspects of the patient’s balance and overall ambulation that would be uncommon in a “clean” closed head injury.  While the patient is walking in a functional manner, they often trip and fall into objects.  Weakness in one of their arms makes it difficult to perform tasks that require two hands.  Functional impairment from the stroke is as or more important than the impairment secondary to the closed head injury.  Formulating recommendations based on one or the other diagnosis would be unsafe and unwise.  Only by thinking in terms of the patient’s holistic or overall functioning would I be able to make their life safer and more stimulating.  Stated another way, diagnoses are typically less important than the obvious difficulties the patient confronts in their environment every day.

How is a physician able to prescribe the correct medication without the correct diagnosis?  Since the Food and Drug Administration does not allow direct comparison between drugs, physicians cannot be confident that they are using the single best medication for a given illness.  While certain medications are believed by professionals to be better for organic conditions than psychiatric conditions, there is only modest support in the research for using one medication over the other.  The best clinicians tend to prescribe by side-effect; that is there are many medications that claim to do the same thing, but the risk of unwanted and possibly deleterious effects of any given medication are uppermost in their mind.  For example, the physician is weighing the benefit of two tranquilizers.  The med they typically prescribe for most neurologically intact patients causes memory and attentional impairments, and the other tranquilizer is known to have few cognitive side-effects, but may cause trouble with ambulation.  Most of us, physician or not, would avoid using the first medication in someone recovering from a closed head injury, and avoid the second for someone recovering from a stroke or movement disorder.  While this appears to make good sense, and even smacks of common sense, one has to keep in mind that common sense is anything but common.

The common sense approach to treatment of damage to the central nervous system is driven by symptoms and their expression in the patient’s unique environment.  A diagnosis helps alleviate the anxiety of family members and the insurance industry, but in isolation, does little to assist the patient.  Medications prescribed for their main effect rather than by their side-effect may help in one area and cause problems in another, rendering little to no net gain for the patient.  Clinicians that need to find neat categories and rapid solutions will please the family shopping for confidence more that the family looking for real gains.  Lastly, even the best of treatment protocols needs adjustment.  People change over time, and the cognitively impaired are no exception.  Any intervention that has positive results for a year or more should be considered a success-even if there is a subsequent decline.  Consider periodic adjustments to behavioral and medication protocols to be necessary and expected.

To answer the initial question, it is rare, indeed, to find a “clean” dementia.  Even if the initial stages of the dementia are uncomplicated and according to protocol, the illness rarely remains so orderly for its entire course.  Patients and family members often gain confidence from hurried and decisive experts; tending to view their curt behavior as a sign of social importance.  A clinician who is unsure and vacillating about treatment options exudes less confidence to others, but may ultimately be the most concerned and helpful.

Vascular Dementia

Vascular dementia is a progressive loss of cognitive skills over time, secondary to a blockage or rupture of a blood vessel in the brain.  This term used to be called “multi-infarct dementia”, and other classification systems refer to it as an “arteriosclerotic dementia.”  The primary form is atherosclerosis, in which the plaques of fatty deposits form in the innermost layer of the cerebral artery.  It is almost exclusively a problem of the older adult.  Very young children are prone to arteriovenous malformations, which are congenital defects of the cerebral vascular system.  Most of these AVM’s are located in the brain stem, and do not result in the sort of symptoms observed in the older adult.

The primary deficit of multiple strokes is an impairment of memory.  The impairment may be the ability to recall old information or learn new information.  It is rare that someone forgets old information, yet learns new information at an average level.  The most common scenario is a decreased ability to retain new information, with increasing impairment of long-term personal information that declines with every subsequent stroke.  The specific deficit regarding loss of old personal information is called “episodic memory”, and it may be affected in isolation of other memory impairments.  A specific deficit of this type of memory is exceedingly rare, such that an impairment of new learning is much more common.

Vascular dementia is not limited to memory impairment alone.  The diagnostic criteria stipulates that a patient must have a memory impairment, as well as one other cognitive deficit, in order to be appropriately diagnosed with “Vascular Dementia”.  The most common cognitive impairment from stroke is difficulty with motor control; not just unilateral paralysis, but an impaired ability to carry out motor routines, despite a functional motor system.  Many stroke victims have difficultly recognizing and utilizing objects, despite having an intact sensory system.  Lastly, many stroke suffers have difficulty switching between mental tasks, making plans, and organizing the steps necessary to accomplish a plan.

Patients with a vascular dementia are impaired in work and/or social functioning.  If one performs well at work and socially, despite having multiple strokes, the diagnosis of “Vascular Dementia” would not be appropriate.  Usually, there are hard neurological signs of the multiple strokes; e.g., unilateral paralysis, gait disturbance (difficulty walking), unilateral weakness and lesions that appear on brain images.  It is also common to suffer with a delirium in the acute phase, which is an altered mental state where a person is incapable of focusing their attention. Immediate attention is often impaired after a stroke, but tends to resolve over several months.

Psychological problems are common after suffering one or more strokes.  It is not common to have delusions of persecution or grandiosity after a stroke.  Some forms of progressive dementia affecting the right prefrontal-temporal area exhibit delusions as an early symptom of the disease.  Neglect of the right or left visual space should not be mistaken for a delusion.  It is frequently the case that the patient suffered with a Delusional Disorder prior to the onset of the stroke.  The most common psychological symptom of “Vascular Dementia” is depression.  The depression may arise from difficulty with psychological adjustment to their declined condition, or a general psychomotor retardation without any awareness as to their own psychological condition.  This takes the form of a significantly reduced reaction time, both simple and complex.  The person appears chronically fatigued, laconic, and wanting to be left alone.  This type of depression is often deemed to be “organic” in nature.

The neuropsychological treatment of “Vascular Dementia” is to first determine the exact nature of the deficits through testing.  If the patient is experiencing psychological symptoms of depression or delusions, the clinician must determine if the patient is aware of their abnormal state.  For example, psychotherapy is appropriate for an adjustment problem in a self-aware person, but inappropriate for a severely depressed person with no awareness of their symptoms.  Neuropsychologists use the patient’s remaining cognitive strengths to compensate for their deficits.

Cognitive Reserve

Cognitive reserve is a term often used in neuropsychology.  It is invoked to explain the differences in functioning between people with a similar level of dementia.  One person at the fourth level of a senile dementia may be able to live independently, yet another person at this level may require supervision.  Current research suggests thatcognitive reserve is not related to human brain size or circumference of the head.  It is related, however, to years of education and the level of one’s physical activity.

Education has been extensively studied for its influence on the incidence of Alzheimer’s Disease.  Large studies on Alzheimer’s risk factors have been performed around the world, and years of education is consistently an important variable.  The greater the years of education, the lower the incidence of Alzheimer’s Disease.  Though it may actually reflect the intelligence of the person, these huge studies rarely obtain IQ scores on thousands of subjects.  Educational attainment is a number that is much easier to acquire than an intelligence quotient, which takes approximately two hours to measure.  Currently, a person’s educational attainment is the single most valuable estimate of dementia risk.

Exercise is another factor that appears to lower the risk of dementia and increase cognitive reserve.  It lacks the practical appeal of education’s influence on cognitive reserve.  Why would straining one’s heart and muscles lead to better cognition?  As mentioned in the Lifestyle section of this website, exercise has a significant impact on the cognitive performance of children.  It is associated with improved academic performance.  For the elderly, exercise is an important aide to stroke recovery. Exercise reduces geriatric memory loss, reduces the risk of Alzheimer’s Disease by 45% (Walsh, 2011), and reduces the risk of other dementing conditions as well.  Exercise programs of one to three months offer significant cognitive benefits, but those lasting more than six months are more beneficial.  The benefits are even more significant if the exercise lasts more than thirty minutes, and combines both aerobic and strength training components.

Cognitive reserve is definitely not related to the conjecture that most humans use only ten percent of their brain.  This statement is absurd, both academically and evolutionarily.  Watch a child sticking out their tongue while drawing a novel figure.  They are using one hundred percent of their brain capacity.  The brain’s subconscious processing of streaming data is far more than ten percent.  This is neglecting the intentional conscious processing of sensory data that occurs throughout our waking lives.  Evoluntionarily, neurons are the most expensive kind of cells.  They use ten times the energy of a muscle cell by volume.  Mother nature distributes brain cells in a very jealous fashion, and it requires a very high return on investment to make them worthwhile.

It appears that education and exercise are two variables that increases cognitive reserve.  The whole notion of cognitive reserve is a bit sloppy, as it is vague explanation for a complex phenomenon.  As researchers learn more about dementia risk factors, the term may die a natural death.  For example, innate intelligence or a specific type of cognitive activity may underlay the differences in functioning between a similar level of dementia.   Subsequent research may define specific factors explaining the variance that is now broadly labelled ascognitive reserve.  Perhaps the dementia tests themselves are biased towards those with less education, falsely classifying the level of dementia in those with more education.  It is too early to tell.  Much like the use of “dark matter” in astronomy to explain the inexplicable, “cognitive reserve” serves as a patch to bridge this gap in knowledge.  Perhaps it should be called “dark cognition,” as a nod to our friends in astronomy.

Mild Cognitive Impairment

Mild Cognitive Impairment seems less threatening than its predecessors; such as “organic brain syndrome” and “minimal brain dysfunction.”  It sounds more benign than terms that contain the word “brain.”  Mild Cognitive Impairment is not an actual diagnostic code, but it is a term used by researchers and clinicians.  MCI reflects cognitive changes in the elderly that exceeds normal aging, yet does not meet the diagnostic criteria for Alzheimer’s Disease.  It is important to note that people diagnosed with MCI have retained their ability to perform all activities of daily living in an independent fashion.

Mild cognitive impairment has received much attention from the research community in recent years.  The interest is focused on what percentage of those with MCI actually convert to Alzheimer’s Disease.  This is not merely splitting hairs, as it would be a great asset to know which people in this group will actually manifest Alzheimer’s Disease.  Early diagnosis will allow more time for caretakers to plan and prepare.  An early diagnosis may also avoid surprises that utilize the emergency room and/or local law enforcement.

Current estimates of those that convert from MCI to AD are under twenty percent, but the percentage varies wildly within this restricted range.  Most suspected of MCI are brought to the attention of professionals due to a decrease in verbal memory.  Fewer are referred, in this clinician’s experience, from an onset of unusual behaviors.  This is important, because many progressive dementia’s initially present with a change in behavior prior to the onset of measurable cognitive deficit(s).  Measurable is highlighted because these people may actually exhibit a cognitive decline, but it may not be detectable by the current neuropsychological tests in use.  Current lab tests and medical imaging are ineffective at diagnosing MCI, as they are ineffective at diagnosing Alzheimer’s Disease.

There are no particular medications or class of medications that could be recommended for the treatment of mild cognitive impairment.  As with Alzheimer’s Disease, exercise and keeping mentally active are likely helpful.  The beauty of mental and physical exercise is that even if it does not prevent the onset of AD, at least the person will still retain some benefit.  The early data suggests that effortful cognitive activity is more important than the passive variety.  For example, watching TV is a passive activity and completing a crossword is an effortful activity.

Once the diagnosis has been established, it is recommended to visit the neuropsychologist at least yearly.  Only a neuropsychologist will be able to accurately measure any change in cognitive skills, and differentiate the change from the effects of normal aging.  Remember that over eighty percent of people with mild cognitive impairment never manifest a progressive dementia.  The unfortunate remainder will require ongoing neuropsychological monitoring and behavioral planning.  Report any change in mental or physical functioning to the neuropsychologist and attending physician, as they are in a better position to know what is significant.  Nearly all people with mild cognitive impairment will profit from set routines and compensatory strategies.  Even though MCI sounds less threatening than its previous designations, it is still wise to monitor the disorder and treat symptoms as they arise.

Is Alzheimer’s a Disease?

Is Alzheimer’s Disease truly a disease?  The word “disease” is defined as an “abnormal condition or illness” in the dictionary, and Wikipedia describes disease as “an abnormal condition affecting the body of an organism.”  The word shared in common between these definitions is “abnormal.”  What is labeled as “normal” or ” abnormal” is not a trivial distinction.  It encompasses much of the training I received towards becoming a clinical psychologist.  For something to be regarded as “normal” it must be observed to be the typical/common state of affairs.  This rests on the assumption that people are accurately and reliably able to distinguish between what is common and what is exceptional.  Where does one draw the line between the average and the exceptional?

Consider shoe sizes.  My feet are a size 12, and about 5% of males share this large size.  A size 12 foot is not the average for a male, but it is not uncommon.  The same size foot in a female is not average and it is fortunatelyuncommon.  What is considered or measured to be the average is highly dependent on the group being considered.  The deviation of my foot size from the human average increases when compared to females, Asians, and pygmy tribesmen-no relation is expressed or implied.  Though my feet are abnormal, they function quite well notwithstanding!  The notion of “normal” is an interval centered about the average of the population under consideration.  The notions of “normal” and “average” only have meaning in light of the specific population(s) being considered.  A statistical analysis may discover that male shoe sizes between 6 and 10 are within the “normal” range, whereas sizes less than 6 or over 10 are labeled “abnormal.”  The term “abnormal” should not be equated with the word “dysfunctional.”  An IQ of 130 is certainly abnormal, but definitely not dysfunctional.  These terms only have real meaning when nested within specific groups, defined by measurable functional outcomes that are evaluated over a finite period of time.

So is a senile dementia of the Alzheimer’s type really a disease?  The quickest answer is that the biological process of Alzheimer’s is not a disease, but the end result of the process could be termed a disease.  All humans acquire neuritic plaques and neurofibrillary tangles as we cross the age 50 boundary.  Correspondingly, free verbal recall and naming decline with so-called normal aging.  The tangles and plaques are the organic hallmarks of Alzheimer’s Disease.  Less mentioned is that these tangles and plaques increasingly infest the brains of all middle-aged humans.  It is largely a question of degree.

Once the neurofibrillary tangles and neuritic plaques encompass about 30% of the cerebral cortex (brain’s outer coating of gray cells), the unfortunate person will exhibit the early symptoms of Alzheimer’s Disease.  Less than 30% of the cortical area manifests as “normal” cognitive decline, and over 30% of the cortex affected results in symptoms of early AD.  The organic pathology of AD is undifferentiated from normal aging until it is observed to cause functional impairment.  Even though the organic pathology is “normal,” the uncommon extent of the pathology and the unusual decline of mental skills could be termed a “disease.”  Similarly, all humans lose critical neurons that help us modulate and initiate motor movements as we age.  If more than 60% of these dopamine producing neurons are lost during our lifetime, we will exhibit the symptoms of Parkinson’s Disease.  Generally, under a 60% loss of the dopaminergic neurons will result in “normal” age-related tremors.  Once again the natural process of aging is labeled as a disease if its manifestation is unusually powerful and negative.  In the near future, I will address what people can do to minimize their chance of becoming “abnormal” in their old age.

Aging and Lifestyle

There is an increasing amount of evidence that a person’s lifestyle is critical to successful aging.  It is hypothesized that ongoing participation in lifestyle activities may confer some resistance to cognitive decline in the older adult.  A longitudinal study was recently performed that appeared to consolidate this hypothesis.  Small et al. (2011) used data from the Victoria Longitudinal Study that followed approximately five hundred subjects for twelve years.  The study authors compared three lifestyle factors with three neuropsychological factors across this time period.  The three lifestyle factors were comprised of fitness, cognitive activities and social activities that require “complex cognitive functioning.”  The three neuropsychological factors were verbal speed and two types of verbal memory.  The study participants varied in age from fifty-five to ninety-four.  While the neuropsychological measures were administered by professionals, the lifestyle and health questionnaires depended on the subject’s self-report.  This is important to note, since the study lacked an objective assessment of lifestyle or health.  Ninety year old test subjects were asked to recall detailed aspects of their health and lifestyle, and the power of the study depended on the accuracy of their self-report.

The study found that preserved verbal speed was associated with preserved physical, cognitive and social activity.  The authors discovered that cognition and lifestyle activity were dual coupled.  This means that the factors worked both ways.  Verbal speed predicted lifestyle activities, and lifestyle activities predicted verbal speed.  The results of the memory measures were less coupled than verbal speed.  Memory for stories was dual coupled with physical activity, but not cognitive or social activity.  For example, increased cognitive activity predicted increased story recall, but the reverse did not hold true.  Conversely, better story recall predicted increased social activity, but increased social activity was not associated with better story recall.  Memory for word lists was not correlated with physical activity, whatsoever.  Increased cognitive activity was predictive of better word list recall, and proficient word recall was predictive of increased social activity, but the reverse did not hold true for either.  Generally, the study authors discovered that a decline in cognitive ability preceded a decrease in social activity.  This artifact is the opposite of many studies that have demonstrated increased levels of lifestyle activity improving overall cognitive performance.  The current authors suggest that impaired cognition causes decreased lifestyle activity, rather than decreased lifestyle activity producing the decline in mental functioning.

As mentioned, it is important to consider the affect of self-report in this study.  Both health and overall activity level were measured by self-report of the participants.  It is also important to consider that most older adults are not proficient at reciting their medical history, and very few can list their medications accurately.  Do not forget the natural tendency for people to please the examiner.  Questionnaires completed by test subjects invariably reveal the nature of the study; at the very least there are clues to the desired response.  Additionally, accurate self-appraisal declines over time.  The self-awareness of a fifty-five year old person is generally greater than an eighty year old.  For example, an eighty year old test subject is more apt to make temporal errors than a fifty-five year old subject.  Combined with the natural tendency to please the examiner, the eighty year old is likely to report more social and physical activity than they actually experience.  The current study may actually have measured the change in self-awareness with age, rather than the influence of lifestyle activity levels on cognitive performance.  Since the variable of self-awareness was not controlled in the study, the ability to draw a conclusion was tarnished.

The reader needs to be rather sophisticated and thorough when interpreting scientific articles.  The objections to the current study do not invalidate the results.   The reliance on self-report reduces the study’s power to predict whether lifestyle affects cognition or cognition influences lifestyle.  As with most psychological phenomenon, there is a dynamic interplay between overall lifestyle activity and cognitive functioning.  The early onset of Alzheimer’s Disease directly lowers the social interest of the afflicted.  Reducing environmental stimulation, at any age, will have negative affects on cognition.  It is not surprising that isolating one component of the interaction collapses the dynamic interplay.  Statistics is limited in this way, as one variable is examined while others are considered invariable, or held as invariable for purpose(s) of the study.  Lifestyle and cognition possess so many variables that an immense effort must be made to reduce the uncontrolled factors.  If the study authors used an informant to crosscheck health and lifestyle data, the predictive power of the study would be much greater.  Commonly, the cost in money and time becomes prohibitive.  The current study used data obtained over a twelve year period, such that informants had to be utilized at the inception of the research.  To add the use of informants later in the study would produce two studies, and the data cannot be compared once the methodology is changed.  Keep in mind that there is no such thing as the perfect study.  The most important part of a research article is not the results, but the limitations that influence the results.

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