Table of Contents

 

Memory Disorders

 

Mild Cognitive Impairment

 

All of us recognize that it becomes more difficult to recall names, dates, and information as we age—even remembering names of people and info we know so well we can see them, feel them, and describe them.  We can see a person’s face, hear his music, or visualize his roles in films but his name just won’t appear.  These brief lapses are so common that standard jokes about having “senior moments” help cover embarrassment.

 

Delay of recall is a normal consequence of aging especially when, after a brief blank moment, we find the word or name that we are looking for.  However, there is a condition called, Mild Cognitive Impairment (MCI), which causes affected people to have declines in their thinking abilities.  These mild deficits can be precisely measured by sensitive tests.  These problems rarely interfere with a person’s ability to function though there may be complaints of problems with memory, naming, or modest confusion. This is a condition we need to identify as early as possible.  We can identify it with Neuro-Psychological testing performed by specially trained psychologists.

 

Nearly 10% of persons aged 70-79 suffer from MCI and approximately 18% of persons aged 80-89 warrant the diagnosis. Nearly half of those who are given this diagnosis progressively deteriorate and develop a dementia disorder within 5 years. The risk is even greater for persons with an amnestic variant of MCI—meaning they cannot find the word(s) even with hints and cues. Interventions at this stage or even earlier are important to help maintain an individual’s quality of life and independence for as long as possible.

 

Therefore, accurate diagnosis of Mild Cognitive Impairment is imperative and mandated by Medicare to be included in a yearly Wellness Exam. Unfortunately, very few doctors include cognitive screening in their annual physicals despite it being “mandatory.”  It is not enough to simply ask a few questions that test recent memory.

 

So, until you have been tested you might not know whether you have garden variety “senior moments” or Mild Cognitive Impairment.  And it is most important to get this checked every year just as your doctor monitors your blood chemistries, cholesterol, and blood pressure in an annual physical exam.  Medicare now insists upon it and fully covers the cost.  The earlier we catch a problem, the better the odds of stopping it in its tracks–or at least slowing it down and buying time until more effective treatments emerge.

 

Amnesias

 

Amnesias are a particular form of Mild Cognitive Impairment.  People may present with an inability to learn and retain new information without significant problems in other areas.  Such a problem may be an early sign of a developing neurodegenerative disorder or may be a pure disorder that occurs as a result of an hypoxic or anoxic insult to the brain—too little or no oxygen to your brain. Have you climbed to high elevations without proper equipment? Were you exposed to carbon monoxide or other toxic chemicals?  Or did you stop breathing during surgery? Uncommon accidents and experiences do occur, and they can produce amnesias.

 

Medication Induced Memory Problems

 

Anti-depressants and other psychiatric medications, statin drugs used to lower cholesterol, blood pressure pills, and a host of other medications can interfere with normal cognitive function and produce some impairment in memory or word processing.

 

The impairment is reversible but often creates a kind of cost/benefit dilemma for those who take these meds. Would you rather be depressed or anxious or take a couple of extra minutes to remember your favorite musical group’s name? It is crucial to distinguish between real cognitive degeneration and side effect induced cognitive deficits.

 

Lawyers often tell us they are scared to go into court thinking they are going to have a recall gap in front of the judge and jury. But, they would have lots of trouble getting to court if they have panic disorder with agoraphobia. So, it is all about costs vs. benefits and going to a specialist who knows how to minimize side-effects. But, first we have to know that it’s really the meds!

 

The Dementias

 

People seem to get confused about the difference between dementia, Alzheimer’s disease, and senility.  The one thing all these different names share is the fear they instill in people who are aging.  These are the beasts that lurk in the alleys of old age–incurable conditions that steal your memory, your personality, and then your humanity.

 

These words have become tantamount to a death sentences for most people—in fact, they have been associated with fates worse than death.   But, you will find out that much progress has been made, and it is no longer wise to hide from dementia.  Knowledge is power and early knowledge is most powerful.

 

Dementia is a general term that indicates the presence of significant impairments in a person’s thinking and memory abilities.  There are many different types of dementia—Alzheimer’s is the most common form of dementia.  Senility is an outdated term.  Banish it from your vocabulary.  It no longer has any clear meaning.  We are well beyond using this wastebasket term to stand in for every memory problem or disorder.   We can now identify memory disorders much more precisely and with greater understanding of cause and prognosis.

 

The impairments associated with dementia are sufficiently great that they interfere with a person’s quality of life and ability to complete daily activities.  Such impairments must include a person’s learning and memory abilities, and at least one of the following:  expressive language, nonverbal communication, visuoperceptual abilities, and more complex, executive functioning skills (e.g., judgment, planning, organizing, reasoning, and problem-solving).  A dementia can develop from a variety of organic causes and can, in some cases, be somewhat reversible.  At the least, we can often slow the progression of most cases of Alzheimer’s disease especially when we catch it at its earliest stages—including the pre-Alzheimer’s state–Mild Cognitive Impairment, which starts about five years before the disease is clearly visible.

 

Alzheimer’s disease (AD)

 

Presently an estimated 5 million Americans suffer from Alzheimer’s disease, which is the most common form of dementia.  The physical hallmark of the disease lies in the brain itself, hidden from plain sight, and is characterized by sticky, thick, neurofibrillary tangles and neuritic plaques in the brain.  These plaques cause progressive deterioration and malfunction of the cortex—the lobular “cauliflower” portion of the brain that sits on top of the brain stem and is most visible in pictures of the brain as well as in scans.  The cortex is where higher intellectual and memory functions occur.  It is the repository for the complicated learning and emotional centers that make us distinctly human.

 

Alzheimer’s disease is the most common form of dementia, and approximately one in two to three persons age 85 and older have the disease.  By 2030 an estimated 7.7 million Americans are predicted to develop the disease, a greater than 50% increase over today’s estimates.  The disease is graded in stages:  early, moderate, and late (advanced).  Each stage has more disabling symptoms and progressively more psychiatric symptoms.

 

Affected people lose their ability to “read” nonverbal signals from other people and therefore have difficulty relating in a calm, normal manner.  They also lose the ability to accurately perceive or duplicate the shapes and sizes of objects they see (apraxia).  Copying geometric figures or drawing a clock set to a specific time becomes difficult or impossible.

 

People with AD often lose balance and become disoriented in new environments.   Eventually the disease involves more complex mental abilities and is accompanied by psychiatric problems and inability to care for oneself.  Memory fails and disorientation can be severe in any setting.

 

As the disease progresses psychiatric symptoms including depression and psychosis (misperception of reality including delusions and hallucinations) occur—they are very common and are related to brain impairments associated with dementia’s progression.

 

Eventually people with advanced Alzheimer’s can no longer contribute to the simple activities of daily function—dressing, bathing, eating–things we must do to engage in community life.  In fact, the number one reason people are admitted to nursing homes is because they can no longer control their elimination functions or participate in simple activities of daily living.

 

Genetics–familial Alzheimer’s–can account for a very small number of cases, but the greatest risk factor for the disease is simply age.  In fact, there is a new medication that has promise to prevent familial Alzheimer’s from occurring.   A history of head injuries can also increase the chance of developing Alzheimer’s disease.   High blood pressure, high cholesterol, and diabetes are also risk factors.  So, a diet that is healthy for your heart will be healthy for your brain.

 

An individual with no family history of Alzheimer’s has a 15% lifetime risk of developing the disease.  We view Alzheimer’s as a fatal illness with a life expectancy of 8-12 years from beginning to end.  Without treatment, death may come a bit sooner but most importantly, the progression of the illness is far more rapid.  Severe impairments arrive much earlier and the affected person requires a great deal of care simply to get through a day and night.

 

This is another reason why early detection is so important.  The illness can possibly be delayed and new drugs used immediately.  People who have been diagnosed can gain easier access to new medications as well as qualify for clinical trials of medications awaiting FDA approval.  At the very least, existing medications can slow the progression of the disease. The cost of care for a person with moderate and advanced disease is far greater than for someone with MCI or early stage Alzheimer’s.  More importantly, preservation of higher functioning allows more quality relating.

 

The APOE-e4 gene on chromosome 19 is linked to a greater risk of susceptibility for developing late-onset Alzheimer’s, the more common form of the disease that is manifested after the age of 55 and generally associated with old age. APOE-e4 is a variant form of a gene that encodes the production of a protein called apolipoprotein E, which may play a role in repairing connections between brain cells.

 

People with one copy of APOE-e4 have a greater risk of getting Alzheimer’s than people with other forms of the gene, and people with two copies of APOE-e4 have an even greater risk.   Genetic testing is possible but is not done as a standard test because it does not accurately predict whether a single person will or will not develop Alzheimer’s.  It does correlate with increased risk and may be considered as part of an assessment.

 

Vascular Disease

 

This variety of dementia is also known as multi-infarct dementia.  Unlike Alzheimer’s disease which progresses in a straight line downhill course, this type of dementia disorder is associated with a step-wise progression of impairment and is caused by the repeated occurrence of strokes or mini-strokes, resulting in death of small areas of brain.  These areas grow larger as strokes continue and in this way produce neurological, cognitive, and psychological deficits.

 

This type of dementia is typically characterized by more loss in the sub cortex (below the main lobes of the brain) with greater declines in attention, concentration, and speed of thinking.

 

Cortical abilities are generally better preserved than in Alzheimer’s disease.  Abstract thinking, reasoning, and other complex cognitive functions are less impaired.  Approximately 1% of persons age 60 and older develop a vascular dementia; that rate increases to approximately 5% for individuals in the 70-80 group.  Vascular dementia and Alzheimer’s can co-exist.

 

Lewy Body Disease

 

This variety of dementia generally affects sub-cortical areas of the brain and is the second most common form of dementia.  This form of dementia is often associated with symptoms similar to Parkinson’s disease along with other related symptoms including sleep behavior disorders involving dream enactment behavior during sleep.

 

Visual or auditory hallucinations and delusions frequently occur along with falls—the latter caused by faulty visual/spatial perception.  Of interest is that the psychotic symptoms are often made worse by both conventional anti-psychotic medications including the new atypical agents.  By far the most effective medication for these psychotic symptoms is Quetiapine (Seroquel).

 

Considerable variations in cognitive functioning and memory may be seen with this dementia.  Its symptoms and progression are much less uniform than other varieties of dementia, and it can be difficult to diagnose.

 

Fluctuating attention is a core feature of LB Disease, in addition to poor nonverbal perception skills, and visuospatial deficits.  These patients can seem strange and are prone to sudden changes in behavior.  They often have severe psychiatric problems and can be aggressive or even violent since their disturbed perceptions create uncertainty and fear.  Their inability to read non verbal expressions accurately can cause them to perceive others as threats or enemies.

 

Fronto-temporal disorder (FTD)

 

FTD, accounting for up to 20% of dementia cases, typically has an earlier onset than other forms of dementia, and the first signs usually involve personality and/or behavioral changes.   Such changes may include impulsivity, disinhibition—walking around naked, inappropriate sexual advances, social inappropriateness, perseveration, or apathy.  This type of dementia typically targets memory and more complex mental abilities.  The frontal and temporal lobes of the brain progressively deteriorate, while the posterior areas of the brain are spared.

 

Dementia Secondary to Specific Medical Disorders

 

Several kinds of neurological diseases and disorders may precipitate the development of a dementia disorder, including Parkinson’s disease, Huntington’s disease, and Multiple Sclerosis.  Some rare forms of cortical brain atrophy include primary progressive aphasia and semantic dementia (SD).  SD is a progressive neurodegenerative disorder characterized by loss of semantic memory in both verbal and non-verbal functioning. The most common presenting symptoms are in the verbal domain (with loss of word meaning) which becomes noticeable to others.  Of course, these conditions can co-exist with one of the more common forms of dementia.

 

 

More Conditions Diagnosed:

Mood and Anxiety Disorders

Attention and Processing Disorders