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Thursday, December 1, 2011

Why Am I Reading This?



            Before we answer that question, I want to you to read and remember these 4 words.

APPLE            MR. JOHNSON        CHARITY                  TUNNEL

            Moving on. Now your second task, before I let you go is to:  DRAW A CLOCK THAT SAYS 11:15 am.

            The question I would like to discuss in this essay is:  When is poor and declining memory significant?  As we each experience it, do we also need to worry about Alzheimer’s disease? Fortunately, the answer is mostly NOT. But let me explain.

            We’ll start with consideration of a case that was recently described in the New England Journal of Medicine (1):  A 77-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep tract of appointments and recent telephone calls. The process has been insidious. She lives independently in the community and drives a car. She pays her own bills and maintains good hygiene and an attractive appearance.
            This case is an example of what is called “mild cognitive impairment.” To put this into perspective it is worth noting that only 1% of all elderly patients will be fortunate enough to experience NO cognitive decline. For the rest of us, we have to expect some. In fact, 10-20% of us who are over the age of 65 will experience this same condition—mild cognitive impairment.  The good news is that, of this 10-20%, only 10% will go on to develop Alzheimer’s disease.  As we get even older, among persons aged 70-89, 11%  will experience mild cognitive impairment; 4.9% will develop Alzheimer’s disease.
            A more recent New England Journal of Medicine published another case, one that I feel can lift some our anxieties if we are among the unfortunate few who develop Alzheimer’s disease.(2) Here is Michael Donohue’s story.
            "At the age of 69, a year after retiring from his practice as a Minneapolis trial lawyer, Mike Donohue noticed his driving skills deteriorating. His wife persuaded him to undergo a simulated driving examination. 'I flunked it miserably,' he recalls. Donohue consulted his physician, underwent tests, and learned that he had early Alzheimer's disease. His doctor told him, 'Take this medication, call me in a year, and call the Alzheimer's Association.'"
    Try to imagine for a moment your reaction to both this information and this manner of care.
    Fortunately, this patient did not resign himself to such implied pessimism. He called the Alzheimer's Association's local office. He volunteered there, where he met other people with early-stage disease, helped to launch some programs for them, and now, 5 years later, serves on an advisory committee about services for people with newly diagnosed Alzheimer's disease and their family. Recently, he and several friends with the condition entered a new program where they’ll serve as mentors for others with a new Alzheimer's diagnosis.
    'There's a great loneliness out there, Donohue says. 'It comes from the stereotype that we’re all drooling in a corner,' even though most people living with the diseases are in community settings rather than nursing homes. 'My cognition remains good, and until recently my memory remained reasonably good. These friendships are so important to me.' 
One of  the pieces of major good news amid the spreading epidemic of Alzheimer’s disease is that we are having larger numbers of people survive and function well with a meaningful social life. The modern Alzheimer’s disease is not the end of the road. This is a more important fact than that research so far has failed to identify any medications that truly make a big difference for persons with Alzheimer’s.

Let’s return to our original point. There is mild cognitive impairment and there is Alzheimer’s disease. Where in this spectrum , for the 99% of us not destined to have no cognitive impairment at all, do we fit in with our ordinary failings of memory. What do you forget?  Here are some typical examples.

         Difficulty with word finding (we all do this)
         Difficulty with recalling names (most of us do this at least some of the time)
         Forgetting why you went into a room (we all do this)
         Forgetting where you put something (we all do this)
         Forgetting appointments (this is a little bit more severe forgetfulness)
         Forgetting telephone calls (this is a little bit more severe forgetfulness)
         Forgetting recent events that you participated in (this is quite severe forgetfulness)

So assume you or I are doing at least the first four items a lot. What does it mean? Are they going to take us away in the morning? Fortunately not. The lesson here is that this is the new normal. When 99% of the population repeatedly encounter this kind of experience, on a statistical basis, it is clearly normal behavior.
So, when should I worry?
There are some simple cues.
First of all, if you’re aware enough to be concerned about how memory may be interfering with your overall function, you probably don’t have Alzheimer’s. It is characteristic of the global cognitive defects in Alzheimer’s that the patient is not explicitly aware of the number and nature of the defects and the degree of impairment. Patient’s with Alzheimer’s don’t go on their own to the doctor to ask about their memory. Friends or family members bring them and the friends or family members ask the questions about memory and provide the behavioral details. On the other hand, patients with mild cognitive impairment frequently go to the doctor to express their concern about their slow decline from their peak mental performance. The question they ask the doctor is, “Is this anything to worry about, Doc?”  If the patient is asking this question, then the doctor can generally be very comfortable in say, “Nope. This is just part of the new you (and me, I might add).”
Remember the little tasks I asked you to do right at the beginning of this essay. This would be a good time to take a look at the clock you drew. If you drew a clock with a full closed circle, 2 hands, one longer than the other, centered in the middle of the clock, 12 digits, each at least in the appropriate quadrant, and had the hands at the right time, you’re good. You don’t have Alzheimer’s disease.                                                         

Figures 1 and 2: This clock passes the test. All the other clocks below do not.

Why can we say this? It is because Alzheimer’s disease affects more than simple memory. One of its prominent effects is impairment or destruction of our sense of space, which is what, is tested with the clock test. The inability to pass this test is one of the earliest signs of Alzheimer’s disease. It’s one you can use yourself for someone about whom you may be concerned. (Just ask them to draw a clock that shows 11:15 a.m.) Generally, as long as all the little cognitive defects are only in the area of memory, and not in the realm of visuospatial sense, motor skills, or coordination, that the worst we are talking about is mild cognitive impairment, which all your friends have too. So don’t feel so bad.
Another way to recognize whether it is more than just mild cognitive impairment is to think about how you function in your life. Can you adequately do all your routine daily tasks? People with mild cognitive impairment can, no matter how irritated they may be at forgetting some of the details. People with Alzheimer’s can’t. They just can’t.
Here are some of the tasks that patients with Alzheimer’s often cannot do:

1.      Write checks, pay bills, keep financial records
2.      Put together tax records, business records, or personal papers
3.      Shop alone for clothes, household necessities, or groceries
4.      Play a game of skill or work on a hobby
5.      Heat water, make a cup of coffee, or remember to turn off the stove
6.      Keep track of current events
7.      Pay attention to a TV program, book, or magazine and report the story
8.      Remember appointments, special family events, holidays, or medications
9.      Drive out of the neighborhood safely in a car, or plan how to use a bus system.

So, if you’re currently doing all these functions OK, you have nothing to worry about at this time. You still, however, will forget things.
OK. So now you’re at the point of accepting that you have some memory lapses and probably have mild cognitive impairment. What do you do about it? First, don’t worry so much about it. Second, become proactive. There’s a lot you can do.
The first proactive step is to get active. Exercise prevents cognitive impairment and a host of other problems too. "Recent epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining cognitive health. This was studied in more than 2800 female health professionals over the age of 65 with at least 3 vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile.  A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit." (3)
      My recommendation, following the US national exercise recommendation, is to engage in at least 150 minutes of exercise, at least brisk walking, each week—broken up in any way you want to do it.
Second, do mental exercises regularly. In a recent comprehensive review of all studies of various kinds of mental exercises “The data showed statistically significant improvements at the end of training on 44% of objective measures of memory and statistically significant improvements after treatment were obtained on 49% of subjective measures of memory, quality of life, or mood.” (4)
And, of course, I am going to recommend eating healthy—5 servings of fruits and vegetables a day, lots of grains, small (4 oz) portions of red meat, and a regular multiple vitamin with calcium and vitamin D.  All this is with a view to keep your BMI (body mass index) below 30.
            Of course, you’re not going to smoke because smoking leads to narrowed blood vessels, and, if you care about your memory, you want your precious little brain cells to get every ounce of circulation they can.
            Finally, carry out a plan for some time spent relaxing every day. Relaxing can be going for a quiet walk, time with a pet, reading, dancing, reading the Bible, watching a good movie  (no sex, no violence, no commercials), of doing something creative—gardening, painting, writing, interior design, refurbishing an old car, whatever gets you in your groove. Memory cells like it when you relax and turn off all the other chatter and clutter of your daily life.
Actually, this advice is rather simple. You’ve heard it before. It’s no more than the Formula for Health. Give it a try!

By the way, if you can still remember     APPLE           MR. JOHNSON        CHARITY
TUNNEL, you’re doing pretty good.

Colin Kopes-Kerr, MD
December 1, 2011

1. Petersen RC. Mild Cognitive Impairment. New England Journal of Medicine 2011; 364: 2227-34.
2. Okie S. Confronting Alzheimer’s Disease. New England Journal of Medicine 2011; 365: 12: 1069-72.
3. Middleton LE et al. Activity energy expenditure and incident cognitive impairment in older adults. Archives of Internal Medicine 2011; 171(14): 1251-7.
4. Jean L et al. Cognitive intervention programs for individuals with mild cognitive impairment: Systematic review of the literature. American Journal of Geriatric Psychiatry 2010; 1

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