Dementia

Alzheimer’s Disease Defined

Alzheimer’s disease is the most common form of dementia.  Older adults often live in fear of the diagnosis.  One of  the most difficult duties of a psychologist is to inform family members a loved one has Alzheimer’s disease.  It is a death sentence without any firm termination.  The condemned is blithely unaware, while the caretakers assume a huge burden.

There are many facets of this disease, and likely even more misconceptions.  In my opinion, to call Alzheimer’s a “disease” is a misnomer.  Normal aging includes erosion of the neocortex and hippocampal areas of the brain.  Once the degree of cortical damage reaches roughly thirty percent, then the unlucky person exhibits symptoms of a senile dementia of the Alzheimer’s type.  The professional literature abbreviates this as SDAT.  The neurodegenerative changes are not unusual or pathological.  If one lives to 80 years of age, without any cognitive impairment, they will still possess neuritic plaques and neurofibrillary tangles.  This is an aspect of normal age-related cognitive decline.  The presence of a pathological memory impairment is associated with the degree of cortical atrophy, not with some exogenous disease process.

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 a 20 and a 90 year old.  Another difference is called “source amnesia.”  Your 85 year old father may forget to do a task, or forget that they had learned something, but will recall when prompted.  In the early stages of a SDAT, the patient will sometimes remember verbal or visual information with a cue, yet be completely baffled as to where they acquired the information.  In more advanced stages of a SDAT, one can teach these patients procedure rules.  They can be taught a card game, for example, yet be totally amnestic as to who taught them the game, and will even deny they know anything about how to play the game.

Two early symptoms of SDAT that goes unnoticed is decreased social interest and poor planning ability.  As the disease begins to take hold, the spouse of a dementia victim will almost always notice a decrease in their willingness to visit with friends and family.  It is often misdiagnosed as a clinical depression or chronic fatigue.  Even more subtle are deficits of planning.  The sequencing of new behaviors to accomplish a goal is impaired even in the early stages.  Many people confuse this with old routines acquired over a lifetime, which are extremely resistant to the disease.  It is very apparent when on tries to have them plan something new, something they have not done before.  While in training, a patient of mine was due to go home to live independently by themselves.  I noticed his helplessness when trying to take apart and put together a broken electric shaver.  He ignored all discharge planning to the exclusion of the shaver, which he could not put together after disassembling.  This patient would have returned to the hospital within a month or two, dehydrated and malnourished.  He did well at an ALF for many years.

The last subtle symptom of early SDAT is a lack of self-awareness.  People who suffer with SDAT are not aware of their memory impairment, diminished social interest and poor planning.  They always answer “fine” when questioned regarding their memory.  Nearly all normal aging persons remark that their memory is terrible!  I consider this to be an extremely important diagnostic indicator of a SDAT.  If your 80 year old husband or wife maintains their memory is normal, and you notice some of the symptoms I’ve mentioned, then I would consider a consult with a neuropsychologist.

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.

Multi-Infarct 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.

The Caretaker Versus  the Doctor

It is not unusual for me to deliver a particular admonishment to family and patients.  Sometimes people need a simple reminder; others need a figurative beating about the head and shoulders.  This warning is critical to the care of the people we love.  The essence of the advice is this-function as a caretaker rather than as a doctor when treating a loved one.

The definition of a human being invariably dwells on our fragile and temporary existence.  The most primitive of tribal cultures always includes a medicine man to counter this fragility.  Whether the setting is composed of desert nomads or slick urbanites, people consult specialists that smooth and extend their existence.  Once the specialist is consulted, patients arrive at their own decisions regarding treatment.  The specialist consulted may be termed an internist or shaman, yet both are healers that direct our behavior in pursuit of health.  The mission of all health specialists is to provide specific directions for others to follow.  Whether the treatment is eagle feathers or a new drug, the aim is to cure sickness and extend human life.  Neither the shaman or internist provide day-to-day physical or emotional care.

Most family members of ailing patients want to be as helpful as possible, and this is where the trouble begins.  Caregivers may cajole or force a loved one to comply with the directions of the health specialist, and find themselves ostracized by the one they are seeking to help.  There is no guarantee that the behaviors proscribed by the health specialist may cure or even be helpful.  Most long-term follow-up studies of actual patient compliance hover around five percent after one year.  Stated another way, ninety-five percent of people do not follow doctor’s orders.  Most people take more or less drugs than proscribed, and rarely comply with non-drug behaviors suggested by the physician.  The caretaker who is frustrated with their loved one’s lack of compliance are very likely to be poorly compliant themselves.  It’s good advice for the other guy.

All doctors can be replaced, though all caretakers are not replaceable.  Parents often comment that “I’m just a mother or father” when confronting disease in their children.  This often gives voice to the parent’s sense of helplessness and feelings of inferiority to the specialist.  The response I frequently employ is, “There are many doctors, but you are the only mother there will ever be.”  The emotional support of a mother, father, husband and wife are indispensable and irreplaceable.  Strangers may provide excellent physical care, but their actions do not have the emotional importance of close relations.  Occasionally I will turn the phrase around, stating to the parent, “I’m just the doctor, you’re the parent.”  It is an effort to reinforce the importance of the caregiver’s emotional support.

Even if you are a health care provider, do not fulfill that role with your loved ones.  There is no shortage of opinions regarding our health, but there is always a shortage of love and support when the chips are down.  Nagging a loved one into compliance with the doctor is more likely to result in bitter feelings than better health.  Such nagging may be taken as a need to control, rather than the need to see the patient regain their health.  As a parent, best friend or spouse, remember that the relations built over a lifetime cannot be replaced by a stranger-no matter how educated and skilled.  The non-specific factor in all forms of recovery is love and support.  Leave the specifics to the specialists.

The Use of 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.
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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 a 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.

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.

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 that cognitive 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 increasescognitive 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 as cognitive 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.

Delirium

Delirium is a term that has gained acceptance within the medical community.  Twenty years ago, a clinician could be maligned for using the term in a clinical setting.  Many providers consider it a popsy, imprecise, if not inappropriate term.  Delirium is actually a precise clinical term that may have profound consequences for the afflicted.  It is a cognitive state in which the person is unable to focus their immediate attention.

Schizophrenics are often incorrectly labelled as being in a delirium.  Their stream of thought is bizarre and often not pertinent to the immediate situation.  While their attention is reduced by the automatic thoughts, schizophrenics are rarely delirious.  Similarly, people who suffer with mania or are highly anxious may be labelled with a delirium, but this is also a rare situation.  While automatic and unwanted thoughts decrease their attention, these unfortunate individuals are still able to focus their attention at a reduced level.

Individuals suffering with a delirium have an impairment of immediate attention.  The attentional deficit far surpasses that observed in people with an Attention-deficit Disorder, which is typically a disorder of sustained attention-not immediate attention.  It is not a dream world, since this presupposes the sustained attention to be consistently unrealistic.  It is an acute condition that is typically caused by a metabolic or an infectious process.  Delirium is more a sign of medical illness than psychological distress.  A person immersed in a delirium may incur increasing organic damage the longer they remain in this state.  Urinary infections, severe dehydration, head injury, stroke and an elevated intracranial pressure may produce a state of delirium.  Psychoactive drug use and allergic reactions may also produce a state of delirium.  Alcohol and tranquilizer withdrawal are two of the more common causes of delirium.

A simple test for delirium is to ask the person to repeat numbers of increasing length.  The ability to repeat five digits accurately generally indicates functional immediate attention.  A limit of four digits is borderline functional, and these individuals often manifest problems with independent living.  A person suffering with a delirium is usually unable to repeat more than two digits before their attention shifts.  Commonly, the examiner will be unable to teach the simple rules for the digit repetition task.  The delirium renders the assessment of higher order cognitive functions impossible, since the person is unable to focus on the task instructions sufficiently.

Managing a person suffering with a delirium is best accomplished with a smile.  Since their attention is too impoverished to comprehend well, the patient will tend to focus on the examiner’s facial expression.  Gentle physical guidance is almost always required, secondary to the poor aural comprehension.  The main task of the caregiver is to protect the person from accidental harm until medical services can intervene.  It is not suggested to wait for the delirium to pass, since there may be increasing organic damage without the appropriate treatment for the underlying condition.  Even if the caregiver knows that severe dehydration if causing the delirium, convincing the person to drink voluntarily is nearly impossible.  If a person was able to understand the caregiver’s concern and act accordingly, this would be proof enough that the person is not in a state of delirium.

No matter how skilled the caregiver, delirium presents an emergency that requires coordinated medical care.  A highly skilled caregiver is apt to know their limitations and seek timely medical intervention.  Less skilled caregivers may wait for the condition to pass.  Even worse, the caregiver may perceive the patient’s delirium as a personal commentary on their skill as a caregiver.  Be a skilled caregiver and seek medical intervention as soon as possible.

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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