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Memory Loss: Should You Be Concerned and Where to Go
by Lory Bright-Long, MD
As the population ages the mass media has paid more attention to issues affecting those in mid and late life. We see advertisements for nutritional supplements, incontinence protection, and vitamins. There also has been an increase in the coverage of the research of Alzheimer's Disease and related dementias. We are left with the daily question, is the forgetfulness I am experiencing the harbinger of a dementia such as Alzheimer's Disease?
As the human brain ages there are natural changes in the brain chemicals which are responsible for the retrieval of memories. The difference between this "Age-Associated Memory Loss" and dementia is the impact upon usual social and work performance. But, are these changes the start?
Although dementia is typically defined as a decline in memory and functional decline, there are other features that may be a part of the over all picture. There may be changes in language skills such as a loss of vocabulary, ease of speech, and naming of common items. The individual may experience change in organizational abilities, spatial orientation, mathematical calculations, mood, and personality. Dementia has many causes. A thorough medical evaluation may uncover causes that may be reversed or improved. Drugs, singularly or in combination, depression, infections, thyroid dysfunction, vitamin deficiencies are all examples of cause that, when discovered, can be treated and reversed. Dementia associated with stroke, Parkinson Disease, Lewy Body Disease, Huntington Chorea, Pick's Disease, and Alzheimer's Disease at this point may not be able to be reversed but the care of the individual may be optimized as to prevent premature institutionalization or caregiver burn-out.
Alzheimer's Disease is the largest single cause of dementia in the United States in persons over the age of 65. Over the age of 85, the incidence of Alzheimer's Disease may be as high as 50%. The current numbers have over 4 million American affected, costing $100 billion per year. The highest risk factor is age, even though not every one develops a dementia over the age of 65. (The percentage of those over the age of 65 is thought to be 15% for all dementias.) A family history of the disease, head trauma, and certain genetic changes are also now known to be associated with Alzheimer's Disease.
A physician with specific training in geriatrics and dementia care is the best resource for the diagnosis and ongoing management of Alzheimer's Disease and related dementias. Because of the associated mood, personality, and behavioral problems, a geriatric psychiatrist may be of particular assistance to the individual and their family. Diagnosing the condition includes a medical history from the patient and family, a physical examination, and a standardized mental status examination including memory performance and other abilities. Laboratory tests to discover anemia, electrolyte imbalance, thyroid changes, vitamin deficits, central nervous system infections such as syphilis and Lyme disease are recommended. A CAT scan of the head or a MRI to look for structural changes (as in a stroke, tumor, or injury) may also be helpful in the diagnostic process. More intensive neuropsychological testing or neurologic testing such as spinal taps (to diagnose infections or central nervous system disease such as multiple sclerosis) may be ordered when there are unusual symptoms, early onset, or rapid changes.
Once a diagnosis is made, the physician has to provide follow-up for the treatment of the symptoms of the dementia, the management of the associated mood and behavioral symptoms, and the support of the family. At present there are only two medications approved by the FDA for the treatment of Alzheimer's Disease. The first drug on the market was COGNEX, associated with gastrointestinal side effects and the need to monitor liver function tests. The next medication is ARICEPT that is fairly well tolerated but does have some gastrointestinal and cardiovascular side effects that must be followed by the physician. Both of these medications increase the amount of acetylcholine in the brain. This brain chemical is associated with memory and higher functioning of the brain. Increasing this brain chemical (called a neurotransmitter) has been the primary focus of research over the past two decades. There are also active research studies throughout the country trying to answer whether the use of anti-inflammatory drugs, estrogens, Vitamin E, and Ginkgo biloba may be useful in the treatment of or prevention of the disease onset and progression. Drugs to stimulate nerve growth in the central nervous system are also being studied but may be many years away from actual use. The other area of active research is the genetics of Alzheimer's Disease. Trying to develop tests to look for genetic markers or certain proteins in the body is of major interest to dementia researchers. At present there is a particular genetic marker call APO E which may be used to identify those at high risk for developing Alzheimer's Disease, however, it is not recognized as a diagnostic tests for all those with memory problems.
The management of depression, anxiety, agitation, aggression, wandering, sleep disturbance, hallucinations, and delusions is important to the over all well being of the individual but also the ability of the caregiver to cope with the disease. A psychiatrist is uniquely qualified to address these dementia-related symptoms with both behavioral interventions and the medications that are often used. The management of depression, anxiety, and physical symptoms is possible and helps the caregiver utilize the community resources available. By using antidepressant, antianxiety, and antipsychotic medications, the psychiatrist may be able to alleviate symptoms that interfere with daily functioning. Medications must be used in partnership with modifying the person's environment. Providing a regular routine and making sure that there is daily exercise and activity help with anxiety and wandering. Using signs, notes, seeking out adult day programs and others to act as companions may be very useful in addressing general restlessness, frustration, and sleep disturbance.
The first step in dealing with dementia is to learn as much about it as possible, there are excellent references to guide the caregiver:
Mace NL, Rabins PV. The 36-Hour Day. A Family Guide to Caring for Persons with Alzheimer's Disease, Related Dementing Illnesses and Memory Loss in Later Life. Revised Edition. Baltimore, MD: The Johns Hopkins University Press; 1991. Ph: 410-516-6900.
Hamdy RC. Alzheimer's Disease: A Handbook for Caregivers. St. Louis, MO: Mosby -Year Book Inc; 1993. Ph: 314-872-8370.
Levin NJ. How to Care for Your Parents: A Handbook for Adult Children. Harbor, WA: Storm King Press; 1993. Ph: 206-378-3910.
Smith KS. Caring for Your Aging Parents: A Sourcebook of Timesaving Techniques and Tips. (for caregivers living at a distance). San Luis Obispo, CA: American Source Books/Impact Publishers, PO Box 1094; 1992. Ph 800-246-7228.
National Resource: Alzheimer's Disease and Related Disorders Association, 919 North Michigan Ave., Suite 1000, Chicago, IL. 60611-1676. Ph: 312-335-8700. Publication Line: 800-272-3900. On-line: www.alz.org
Local Resource: Long Island Chapter of the Alzheimer's Disease and Related Disorders Association, 66 South Street, Patchogue, NY 11772-3520; Suffolk 516-289-6335; FAX: 516-289-6453; Nassau 516-935-1033.
Long Island Alzheimer Foundation, 5 Channel Drive, Port Washington, NY 11050; Ph: 516-767-6856; FAX: 516-767-6864. On-line: www.liaf.org
Caregiver News, 271 Cedar Lane, East Meadow, NY 11554-2720, Ph 516-481-6682, FAX: 516-486-7820.
ABOUT THE AUTHOR:
Lory Bright-Long, MD, is a geriatric psychiatrist practicing exclusively in nursing homes on Long Island. She is a graduate of Medical College of Ohio and completed her Psychiatry Residency at Stony Brook University Hospital. After completing a Geriatric Psychiatry Fellowship in conjunction with Stony Brook and the Office of Mental Health, she joined the Stony Brook faculty. Since 1996, she has directed the Kipp Pavilion for Special Dementia Care at St. Johnland Nursing Center in Kings Park, New York. She participated in the American Psychiatric Association's development of Practice Guidelines for Alzheimer's Disease and Related Dementias and was a co-author of a manual for psychiatric care in nursing homes published in 1999.