Memory Disorders

Memory Disorders, or I can’t Remember Sh__!

Memory Disorders, like “learning disabilities”, is not a term you will find in the “Diagnostic & Statistical Manual of Mental Disorders.”  Neither term is found in either edition.  This is the guide used by many American insurance companies for procedure codes and diagnostic criteria.  “Memory Disorder” is an oft used term by professionals and laypeople alike.  It is likely most people are trying to describe difficulty recalling verbal or visual information, in the absence of another cognitive impairment.  The DSM system refers to memory disorders as an “Amnestic Disorder.”

It is good to rule out a medical factor affecting a person’s ability to think; that is their cognition.  The official diagnostic nomenclature is an “Amnestic Syndrome (due to a general medical condition)”.  The first thing to realize is that a memory impairment caused by a medical condition is generally of rapid onset and dramatic.  Trauma to the central nervous system is the most common cause.  Viral and bacterial infections of the brain may cause mild to profound memory impairments as well.  The damaging factor does not have to originate in the central nervous system.  Low oxygen saturation in the blood and bodily dehydration are common causes of a memory impairment secondary to a medical condition.  Specific vitamin deficiencies may cause memory impairment, as well as unwanted reactions to many medications.  Most of these medical conditions also reduce attention, vigilance, and orientation to one’s environment.  Perhaps the most difficult to detect are sub-clinical vitamin deficiencies and dehydration that test within the average range, but produce a measurable decline in cognitive performance.

What should we expect from our memories in the first place?  By the age of 50, we all begin to have a reduced ability to find names for things, and difficulty recalling verbal information without some prompt or context.  Many people call this the CRS Syndrome; alternately entitled “can’t remember sh–.”  The differential diagnosis is the recognition memory of the person.  Utilizing memory tests with a recognition component reduces the gulf between chronological ages.  It is also necessary to utilize tests that have been normalized on different age groups.  These tests attempt to make a level playing field between different ages.  The differential diagnosis between normal aging and a dementia should be performed by a trained professional.

If you believe you have a memory impairment, consider consulting a neuropsychologist.  They will administer tests normed for your specific age, and often education as well.  Do not consider yourself diagnosed based upon a test in a magazine or on the internet.  Memory is built upon other cognitive skills, such that verbal or visual memory should not be assessed in isolation.

Many people confuse poor immediate attention as a memory impairment.  It is likely at the root of many medical causes of an “Amnestic Disorder.”  The ability to sustain one’s attention over time is called “vigilance”.  If a person has poor immediate attention, they will have difficulty encoding new verbal and visual information.  If, after a delay, the person can recall the same small amount of information, then attention is likely a greater factor then memory.  It is also difficult for the attention impaired to chunk (organize) information for greater recall.

The initial step in the diagnosis of a “memory disorder” is to administer tests to determine if the disorder exists.  If the disorder exists, then consider ruling out medical factors causing the poor visual and/or verbal memory functioning.  If no medical factors can be determined, then the next step is remediation.  Immediate attention is the most proven remediable skill.  The remaining treatments are largely compensatory strategies to build on the patient’s cognitive strengths.

Thanks You for the Memories

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.

What’s Up with Mommy?

What’s up with Mom?  We moved her into a new apartment over the weekend, and she is not like anything or anyone I’ve seen before.  She is so confused she has forgotten to eat; sitting and staring for hours, or up at night and wondering the hallways.  All the children take shifts supervising her, but the situation does not appear to be resolving.  It tears me up to see her like this.  What is worse, the our family is splitting down the middle; some favor keeping her in the apartment no matter what arises, and the rest believe she should be in a nursing home.  I don’t know where to turn.

This is a paraphrased narrative that I have heard literally hundreds of times.  Neurologists of old called this the “Monday Morning Disease.”  It refers to family that did not notice a loved one becoming senile until some change in their environment produced confusion.  Most families will report changes in the patient’s behavior over a one to two year period prior to an incident, only they did not ascribe them to a senile dementia of the Alzheimer’s type.

One of the earliest symptoms of Alzheimer’s to escape the notice of others is a deficit of planning.  It is not as noticeable as memory or attention deficits, yet it causes profound functional impairment.  As long as the dementia victim relies on old well-learned behavioral routines, there is minimal trouble living independently.  Once a person’s daily behaviors are upset by a move, they must develop new functional behaviors that accomplish goals necessary to live; for example, shopping for food.  In a new environment, the person lacks clues to their old behaviors, and so are at a complete loss for where to go and what to do.  Many cognitive scientists (fancy term for psychologist) conceptualize humans as planning machines.  As you read this post, you may also be thinking of what you are going to do next, and you may even formalize the steps to accomplish this goal.  Children burst with plans for what they will do after school.  Do not mistake deficient planning for a lack of energy or optimism.  Planning is a necessary cognitive skill for survival, and it is one of the earliest functions to decline in a senile dementia.

Another early cognitive deficit is a decline of mental flexibility.  This is not to be confused with someone who is easygoing and complaint with the wishes of others.  Cognitive flexibility refers to a person’s ability to switch between mental sets; for example, glancing at a drawing and putting together a model.  It is a necessary skill we all employ every day to accomplish tasks with greater efficiency and accuracy.  It is evident while doing the dishes and answering the telephone, alternating between tasks at work, and making conversation while driving.  When this skill declines, the person is noticed to be performing behaviors that are out of character with the situation.  In my residency, the team was to discharge a patient to independent living when I noticed he had taken apart his shaver and laid it across his bed.  The patient missed several physical therapy sessions due to his insistence he had to fix the shaver.  The shaver was busted, but he could not conceive of working alternately on the shaver and his ambulation.  He became obsessed (stimulus bound) to the shaver; neglecting more important goals that he had to accomplish.  While it may appear as a failure to prioritize his goals, this unfortunate man could not accomplish the main goal because he was stimulus bound to an unimportant goal.

The early deficits of a senile dementia are subtle, yet as real and damaging to an independent existence as the deficits of verbal and visual memory.  The latter deficits are well known to the average person.  Memory skills are the main determinant of Alzheimer’s Disease in most people’s minds.  Actually, verbal and visual memory may be functional well into the disease, and these “executive” deficits of planning and flexibility may be crippling at an earlier stage of the disease.  In terms of planning the future for someone with a known or suspected senile dementia, the family should take these symptoms into account.  It reduces the probability of a Monday morning surprise.

Memory Drugs

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.

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.

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