Posts tagged: senile dementia

Memory Meds

Dr. Holzmacher's Business LogoIt 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.

A Question of Alzheimer’s

Business Logo for Psychological and Neuropsychological IssuesThere 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.  As always, comments from any interested party are welcome.

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