When Lapses Are Not Just Signs of Aging

Who hasn’t struggled occasionally to come up with a desired word or the name of someone near and dear? I was still in my 40s when one day the first name of my stepmother of 30-odd years suddenly escaped me. I had to introduce her to a friend as “Mrs. Brody.”

But for millions of Americans with a neurological condition called mild cognitive impairment, lapses in word-finding and name recall are often common, along with other challenges like remembering appointments, difficulty paying bills or losing one’s train of thought in the middle of a conversation.

Though not as severe as full-blown Alzheimer’s disease or other forms of dementia, mild cognitive impairment is often a portent of these mind-robbing disorders. Dr. Barry Reisberg, professor of psychiatry at New York University School of Medicine, who in 1982 described the seven stages of Alzheimer’s disease, calls the milder disorder Stage 3, a condition of subtle deficits in cognitive function that nonetheless allow most people to live independently and participate in normal activities.

One of Dr. Reisberg’s patients is a typical example. In the two and a half years since her diagnosis of mild cognitive impairment at age 78, the woman learned to use the subway, piloted an airplane for the first time (with an instructor) and continued to enjoy vacations and family visits. But she also paid some of the same bills twice and spends hours shuffling papers.

Dr. Ronald C. Petersen, a neurologist at the Mayo Clinic College of Medicine in Rochester, Minn., described mild cognitive impairment as “an intermediate state of cognitive function,” somewhere between the changes seen normally as people age and the severe deficits associated with dementia.

While most people experience a gradual cognitive decline as they get older (only about one in 100 lives long without cognitive loss), others experience more extreme changes in cognitive function, the neurologist wrote in The New England Journal of Medicine in June. In population-based studies, mild cognitive impairment has been found in 10 percent to 20 percent of people older than 65, he noted.

Dr. Petersen described two “subtypes” of the condition, amnestic and nonamnestic, that have different trajectories. The more common amnestic type is associated with significant memory problems, and within 5 to 10 years usually — but not always — progresses to full-blown Alzheimer’s disease, he said in an interview.
“Subtle forgetfulness, such as misplacing objects and having difficulty recalling words, can plague persons as they age and probably represents normal aging,” he wrote. “The memory loss that occurs in persons with amnestic mild cognitive impairment is more prominent. Typically, they start to forget important information that they previously would have remembered easily, such as appointments, telephone conversations or recent events that would normally interest them,” like the outcome of a ballgame would a sports fan.
The forgetfulness is often obvious to those who are affected and to people close to them, but not to casual observers.

The less common nonamnestic type, which is associated with difficulty making decisions, finding the right words, multitasking, visual-spatial tasks and navigating, can be a forerunner of other kinds of dementia, Dr. Petersen said.

In general, Dr. Reisberg said, “mild cognitive impairment lasts about seven years before it begins to interfere with the activities of daily life.”

The Correct Diagnosis

Distinguishing mild cognitive impairment from the effects of normal aging can be challenging. Typically, new patients take a short test of mental status, provide a thorough medical history and are checked for conditions that may be reversible causes of impaired cognition. Problems like depression, medication side effects, vitamin B12 deficiency or an underactive thyroid can mimic the symptoms of mild cognitive impairment.
Other tests, like an M.R.I. or CT scan of the brain, can look for evidence of a stroke, brain tumor or leaky blood vessel that may be impairing brain function.
It is natural, Dr. Petersen said, for patients and their families to want to know whether and how quickly the disorder might progress. While patients decline by about 10 percent each year, on average, certain factors are associated with more rapid progression. Among these are the presence of a gene called APOE e4, more common among patients with Alzheimer’s disease; a reduced hippocampus, a region of the brain important to memory; and a low metabolic rate in the temporal and parietal regions of the brain.
Amyloid plaques in the brain, while a hallmark of Alzheimer’s disease and a predictor of progression, have also been found at autopsy in people with perfectly normal cognitive function.

Preserving Cognitive Function

Despite a number of clinical trials that tested various medications, no drug to treat mild cognitive impairment has been approved by the Food and Drug Administration. But experts like Dr. Reisberg and Dr. Petersen suggest several approaches that may slow the decline in cognitive function.
Although studies did not show that medications like donepezil (brand name Aricept) and memantine (Namenda), both used to treat Alzheimer’s disease, change the ultimate course of mild cognitive impairment, Dr. Reisberg said they can be useful temporary treatments that may stabilize patients for a few years.
Although the drugs are not approved for this condition, licensed physicians can prescribe approved medications “off label.” “Clinicians have to work with what we have,” Dr. Reisberg said.
There are people who think they are having memory problems, but tests do not show anything definitive. Some may be in Stage 1 of Alzheimer’s disease, Dr. Reisberg said, and perhaps could benefit from early treatment with the drugs.

It is also important to reduce cardiovascular risk factors like smoking, elevated cholesterol and high blood pressure; keep blood sugar at normal levels; minimize stress (which in animal studies can cause the hippocampus to shrink); and avoid anticholinergic drugs that can interfere with brain chemicals important to memory. These include Demerol to treat pain, Detrol to treat a leaky bladder, tricyclic antidepressants, Valium, and over-the-counter medications with Benadryl (diphenhydramine), like Tylenol PM, Dr. Petersen said.

Some cognitive rehabilitation exercises, like computer games that enhance focus, may be helpful, Dr. Petersen said, but there have been few good studies to demonstrate a benefit. Compensatory techniques, like taking notes, creating mnemonics and making structured schedules, can be useful aids, he added.
But most promising is regular physical exercise, which in animal studies was found to reduce the accumulation of amyloid in the brain. An Australian study in patients with memory problems showed that brisk walking for 150 minutes a week improved cognitive function.

By JANE E. BRODY

New York Times

YAAA! Young Advocates for the Alzheimer's Association Meeting & Social

PLEASE NOTE THE NEW LOCATION! Our next meeting is August 9th from 6-8pm in Phoenix. Please see below for more details and we will see you there! ~ Suzette

Applebees Neighborhood Grill & Bar

2547 N 44th St (just South of Thomas Rd)

Phoenix, AZ

YAAA!, Young Advocates for the Alzheimer's Association, will be having Monthly meetings every 2nd Tuesday of the month from 6:00-7:00 pm followed by a supportive social from 7:00 - 8:00 pm. Young adults 18-39 are welcome to attend! We will be reviewing current federal and state priorities of the Alzheimer's Association as well as any advocacy done by our YAAA! members for the previous month.

After the meeting we invite everyone to stay for our supportive social from 7:00 to 8:00pm to further bond with members, prospective members or just enjoy drink and food specials for happy hour! Please calendar this for future reference and let me know when you can make it. I am looking forward to seeing everyone!

YAAA! Facebook page: www.facebook.com/DSWYAAA

Alzheimer's management from diagnosis to late stage

With the aging of the population, the incidence and prevalence of Alzheimer's disease (AD), already the most common type of dementia, are projected to rise. A diagnosis of AD has implications for ongoing care across all settings and providers—whether you are the primary-care provider (PCP) and made the diagnosis, assuming the care of a new patient with AD, or a consultant asked to provide input for a chronic problem of someone with AD. A diagnosis of AD adds to the complexity and cost of care. This article focuses on post-diagnostic care and is based on the 2008 report from the California Workgroup on Guidelines for Alzheimer's Disease Management.1


Because it is a slowly progressive neurodegenerative condition that may continue for a decade or more after diagnosis, management of AD must change over time. The majority of patients with AD (and their caregivers) receive their medical care from PCPs.2 PCPs are key to ensuring the care provided is appropriate to the patient's needs and situation. 

Assessment


Appropriate treatment plans and goals that meet all of a patient's needs require ongoing comprehensive assessment of the patient, the family, and the living situation. This assessment should include daily functioning, cognitive status, comorbid medical conditions, behavioral symptoms, medications (prescription and OTC), living arrangement and safety, and need for palliative and/or end-of-life care. The use of standardized instruments to assess function, cognition (Table 1), and behavior (Table 2) can help the PCP monitor changes.

Longitudinal monitoring of disease progression and response to therapy, along with regular health maintenance examinations, are essential.3,4 The frequency of visits depends on a number of factors, including the patient's clinical status, likely rate of change, current treatment plan, need for any specific monitoring of treatment effects, and the reliability and skills of the patient's caregivers and support system. Assessment should occur at least every six months or any time there is a sudden change in behavior or increase in the rate of decline. 


It is essential that assessment also include identification of the primary caregiver and the adequacy of family and other support systems. Assessment of the caregiver should include knowledge, social support, health status (including psychiatric symptomatology), and ethnic and cultural issues.5 Family caregivers are central to the PCP's assessment and care of the person with AD.6 Therefore, establishing and maintaining a relationship with caregivers is crucial in the ongoing care of patients with AD.7 This relationship is most important as the disease progresses into the moderate and severe stages, at which time family members who oversee day-to-day care and implement and monitor treatment become the real managers.8 





Beginning at the time of diagnosis and continuing throughout the course of the disease, ongoing assessment of a patient's decision-making capacity is essential. Capacity assessment is decision-specific, with more complex decisions requiring higher cognitive function than simpler decisions.9 Since patients with AD experience decreasing cognition and will eventually lose all decision-making ability, identification of a surrogate decision maker early in the course of the disease is important. In the beginning stages of AD, patients typically retain their decision-making capacity and are able to appoint a surrogate decision-maker for the time in the future when they will no longer retain this capacity.10 In addition, identification of the patient's and family's culture, values, primary language, and literacy level is necessary to assure that an appropriate treatment plan is developed and can be carried out.


Treatment


In addition to monitoring function and cognitive decline, ongoing regular management of general health and other medical conditions is essential to the care of the patient with AD. Management goals and interventions need to be appropriate to the patient's (if capable) and family's preferences and modified as the disease progresses. When prescribing medications (whether for AD, associated behaviors, or other comorbid conditions), it is important to assess the ability of the patient and family member or caregiver to adhere to the regimen. Medications should be reviewed with attention to discontinuing nonessential medication, simplifying the dosing schedule, and using aids (e.g., pillboxes). 


Appropriate treatment of comorbid medical conditions is crucial and may require extra vigilance and adjustment depending on where the AD patient is in the course of the illness. The degree of cognitive impairment impacts the ability to manage other chronic and acute medical conditions, and the appropriate management of these other conditions can impact both cognition and function in AD. Whenever a new treatment or intervention is considered or a change in the current treatment is anticipated, the health-care provider must assess the patient's and the caregiver's ability to understand and participate in the decision-making process.11 


Schedule a meeting with every patient and his or her family about the use of FDA-approved medications for the treatment of cognitive decline. The currently available cholinesterase inhibitors (i.e., donepezil, galantamine, rivastigmine) all work by blocking acetylcholinesterase. These medications have similar efficacy and side effects. Patients and family members must be given realistic expectations about the medications, which are aimed at slowing—not reversing—cognitive decline. 




Reports from clinical trials and meta-analyses of individual agents and the class of acetylcholinesterase inhibitors demonstrate a small, statistically significant benefit in cognition, activities of daily living, and behavior over a period of six to 18 months.12-15 GI side effects, primarily nausea or diarrhea, occur in 10%-15% of patients and may require discontinuation of the treatment. Rivastigmine is available in a patch form, which makes it more tolerable. Patients with bradycardia or bradyarrhythmias have an increased risk for syncope or dizziness with cholinesterase inhibitors.12 Treatment with one of these agents should be started on diagnosis or after six months' duration of AD symptoms. Evaluation for adverse drug reaction should occur after two to four weeks of treatment. Reassess effectiveness every six months. 


Memantine, an N-methyl D-aspartate receptor antagonist widely used in Europe, is currently approved for use in the United States for moderate AD. Memantine has also been shown to have a small effect on cognition, function, and behavior.16 Use this medication either alone or in conjunction with an acetylcholinesterase agent. 


At this time there is insufficient evidence to support the recommendation of other pharmacologic treatments for patients with AD. Studies of antioxidant therapy with vitamin E,17,18 ginkgo biloba,19 estrogen,20,21 and nonsteroidal anti-inflammatory agents22 have failed to demonstrate any clear benefit in preventing or postponing cognitive decline or affecting function or behavior.


Behavioral symptoms and mood disorders are common in people with AD as well as their caregivers, affecting up to 90% of patients at some time during the illness.23 These include a broad spectrum of symptoms (e.g., apathy, wandering, agitation, verbal and physical aggression, and psychosis) that can vary from intermittent and mildly annoying to life-threatening. Behavioral symptoms in AD patients are among the most difficult aspects of care for patients, caregivers, and health-care providers. There is agreement that except in emergency situations, nonpharmacologic strategies are the preferred treatment approach for behavioral problems.24,25 This should include such approaches as environmental modification, task simplification, appropriate activities, and physical exercise. Consider psychotropic medication only when nonpharmacologic approaches have been exhausted and have failed to reduce agitation or improve behavioral symptoms. The use of psychotropic medications is controversial, and no agents are currently approved by the FDA for use in people with AD or other dementias. If used, medication should be targeted to a specific behavior, for narrowly specified and predetermined goals, with close monitoring for side effects and drug interactions.26,27 Start with a low dose, and increase slowly until the behavior improves or adverse effects emerge.3


Education and support


Education and support services for AD patients and their families are critical for effective long-term management of this progressive disease. Medical care must be integrated with education that connects patients and caregivers to support organizations. Patients and caregivers should be provided with linguistically and culturally appropriate educational materials and referrals to community resources, including support groups, legal counseling, financial resources, respite care and counseling, and consultation on care needs and options. 


Discuss the diagnosis, progression, treatment choices, and goals of AD care in a manner that is consistent with the patient's and family's values, preferences, culture, education, and ability. This discussion should occur at the time of initial diagnosis and recur periodically throughout the course of the disease. If feasible, encourage patients to complete an advance directive with identification of surrogates for making medical and legal decisions along with statements of their care preferences. 


Caregiver assessment, education, and community referral have been shown to lead to improved well-being and enhanced quality of life for the caregiver as well as the recipient.28,29 This counseling is often beyond the scope and time of a routine office visit and may require an additional appointment. At a minimum, providers should be familiar with agencies and services in their community that can provide assistance and routinely and repeatedly refer families and caregivers.


Legal considerations


Since cognitive decline over time will deprive the patient with AD of the ability to think clearly, major legal and financial decisions should be addressed early in the course of the disease, while the patient is still capable. Health-care providers occupy a unique position of trust and influence that provides an ideal opportunity to discuss the importance of basic legal and financial planning. 


A capacity evaluation may be required before a patient's chosen surrogate or substitute decision-maker can be authorized to act on his or her behalf. Utilize a structured approach to the assessment of capacity with attention to the relevant criteria for the kind of decisions being required of the patient. Depending on the state, a capacity declaration is usually required when one or more clinicians consider conservatorship of a patient with AD. 


AD patients are at increased risk for abuse and neglect.30 Because of their cognitive and functional decline, it is particularly challenging to obtain information about potential abuse from these patients. Providers need to actively monitor for evidence and report all suspicions of abuse to the proper authorities. Abuse can take many forms, including physical, sexual, and financial. Abuse may also involve neglect, isolation, abandonment, or abduction. Monitoring requires that the provider be alert to both the patient's and the caregiver's circumstances. In addition, be aware that the patient's behavior may be a reaction to a disturbing or dangerous situation in his or her environment.31 


The cognitive, visuospatial, and other impairments associated with AD increase the risks associated with driving. In some states, the diagnosis of dementia in a licensed driver requires automatic reporting. Patients with moderate or severe AD should not drive.32 In patients with mild or early disease, careful consideration of the ability to safely operate a motor vehicle is required.22





SPECIAL CONSIDERATIONS


Early-stage AD


Improved recognition of signs of cognitive decline has led to earlier diagnosis of AD. This is resulting in a growing population of early-stage individuals who are able to benefit from active involvement, education, and support interventions. Patients in the early stages of AD have unique concerns that need to be recognized and addressed. These individuals should be involved in planning their own care. Discussions about the implications of the diagnosis with respect to work and family may require more frequent medical visits and/or referral to community resources. Clinicians need to be able to provide patients in early-stage AD with recommendations that promote continued functioning, assist with independence, and maintain cognitive health (including physical exercise, stimulation, and social support). Support groups specifically for individuals with early-stage AD and their caregivers are being developed in many communities to address the special concerns and needs of this population.


End-of-life care


The course of AD is one of slow, gradual decline. As the dementia worsens and the ability to understand treatment options and participate in decision making declines, care should shift to a focus on relief of discomfort. The advisability of routine screening tests, hospitalization, and invasive procedures should be made based on a previously discussed care plan, patient wishes, and severity of the dementia. As the end of the patient's life nears, emphasize options that maximize comfort and avoid futile treatments that may not provide relief and could prolong the dying process. Generally, tube feeding is not recommended for patients with severe dementia.33 Consider referral to hospice sooner rather than later to provide the patient and family optimal support. 


A diagnosis of AD is often the beginning of a long period of decline in cognition and function that is frequently accompanied by behavioral changes. These changes can be challenging for everyone, including health-care providers. Evidence-based recommendations for ongoing assessment, treatment, education, support, and legal considerations enable clinicians to better meet the needs of patients and assist families and caregivers over the course of the disease.

Dr. Segal-Gidan is director of the Rancho/University of Southern California Alzheimer's Disease Research Center in Los Angeles. She has no relationships to disclose relating to the content of this article.


References


1. California Workgroup on Guidelines for Alzheimer's Disease Management. Guideline for Alzheimer's Disease Management. Available at www.caalz.org/PDF_files/Guideline-FullReport-CA.pdf.


2. Landefield CS, Callahan CM, Woolard N. General internal medicine and geriatrics: building a foundation to improve the training of general intern­ists in the care of older adults. Ann Intern Med. 2003;139:609-614.


3. APA Work Group on Alzheimer's Disease and Other Dementias, Rabins PV, Blacker D, et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007;164(12 Suppl):5-56.


4. Hogan DB, Bailey P, Carswell A, et al. Management of mild to moderate Alzheimer's disease and dementia. Alzheimers Dement. 2007;3:355-384. 


5. Dunkin JJ, Anderson-Hanley C. Dementia caregiver burden: a review of the literature and guidelines for assessment and intervention. Neurology. 1998;51:S53-S60.


6. National Institute for Health and Clinical Excellence (2006). Dementia: supporting people with dementia and their carers. Available at www.nice.org.uk/nicemedia/live/10998/30321/30321.pdf.


7. Bultman DC, Svarstad BI. Effects of physician communication style on client medication beliefs and adherence with antidepressant treatment. Patient Educ Couns. 2000;40:173-185.


8. Barrett JJ, Haley WE, Powers RE. Alzheimer's disease patients and their caregivers. Medical care issues for the primary care physician. South Med J. 1996;89:1-9. 


9. Karalwish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16:91-98. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2717553/.


10. KL Braun KL, JH Pietsch JH, PL Blanchette, eds. Cultural Issues in End-of-Life Decision Making, Thousand Oaks, Calif.: Sage Publications; 2000:31.


11. Larson EB. Management of Alzheimer's disease in a primary care setting. Am J Geriatr Psychiatry. 1998;6(2 Suppl 1):S34-40.


12. Birks J, Harvey RJ. Donepezil for dementia due to Alzheimer's disease. Cochrane Database Syst Rev. 2006;1:CD001190. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001190/frame.html.


13. Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006;1:CD005593. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005593/frame.html.


14. Winblad B, Cummings J, Andreasen N, et al. A six-month double-blind, randomized, placebo-controlled study of a transdermal patch in Alzheimer's disease - rivastigmine patch versus capsule. Int J Geriatr Psychiatry. 2007;22:456-467.


15. Loy C, Schneider L. Galantamine for Alzheimer's disease and mild cognitive impairment. Cochrane Database Syst Rev. 2006;1:CD001747. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001747/frame.html.


16. McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev. 2006;2:CD003154. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003154/frame.html.


17. Sano M, Ernesto C, Thomas RG, et al. A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer's disease. The Alzheimer's Disease Cooperative Study. N Engl J Med. 1997;336:1216-1222. 


18. Doody RS, Stevens JC, Beck C, et al. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:1154-1166. Available at www.neurology.org/cgi/content/full/56/9/1154.


19. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev. 2007;2:CD003120. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles
/CD003120/frame.html.


20. Hogervorst E, Yaffe K, Richards M, Huppert FA. Hormone replacement therapy to maintain cognitive function in women with dementia. Cochrane Database Syst Rev. 2009;1:CD003799. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003799/frame.html.


21. Shumaker SA, Legault C, Rapp SR, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled trial. JAMA. 2003;289:2651-2662. Available at jama.ama-assn.org/cgi/content/full/289/20/2651.


22. Tabet N, Feldmand H. Ibuprofen for Alzheimer's disease. Cochrane Database Syst Rev. 2003;2:CD004031. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004031/frame.html.


23. De Deyn PP, Katz IR, Brodaty H, at al. Management of agitation, aggression, and psychosis associated with dementia: a pooled analysis including three randomized, placebo-controlled double-blind trials in nursing home residents treated with risperidone. Clin Neurol Neurosurg. 2005;107:497-508.


24. Ayalon L, Gum AM, Feliciano L, Areán PA. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Arch Intern Med. 2006;166:2182-2188. Available at archinte.ama-assn.org/cgi/content/full/166/20/2182.


25. Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. Am J Geriatr Psychiatry. 2001;9:361-381.


26. Lyketsos CG, Colenda CC, Beck C, et al. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry. 2006;14:561-572.


27. Gambert SR. Alzheimer's disease for the primary care physician. Compr Ther. 1997;23:174-178.


28. Feil DG, MacLean C, Sultzer D. Quality indicators for the care of dementia in vulnerable elders. J Am Geriatr Soc. 2007;55 Suppl 2:S293-301.


29. Logsdon RG, McCurry SM, Teri L. Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Psychol Aging. 2007;22:28-36.


30. Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48:205-208.


31. Warshaw G, Gwyther L, Phillip L, Koff T. Alzheimer's Disease: An Overview of Primary Care. Tucson, Ariz.: University of Arizona Health Sciences Center Press; 1995.


32. Dubinsky RM, Stein AC, Lyons K. Practice parameter: risk of driving and Alzheimer's disease (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2000;54:2205-2211. Available at www.neurology.org/cgi/content/full/54/12/2205.


33. Volicer L. Medical issues in late-stage dementia. Alzheimers Care Q. 2005;6:29-34.


By Freddi Segal-Gidan, PA, PhD

Tips on Alzheimer's Wandering Why it Happens and What to do

Wandering is among the most unsettling and even terrifying behaviors people with Alzheimer's display. Often poorly clad, they leave safety at random hours and strike out into unknown territory, for no apparent reason. But this seemingly aimless activity usually does have a reason. It's often an attempt to communicate after language skills have been lost.

Alzheimer's caregivers ask if I am worried that my mother might wander away from me and get lost. Wandering is one of the more widely known behaviors of people suffering from Alzheimer’s disease.

I am not worried about my mother wandering at this time because she can't walk very far. I can say I would be very worried at this stage if she could walk.

I can't remember how many people emailed me and were lamenting that there loved one wanted to "go home." When you hear this you really need to start paying attention. The patient could make a break for it at any time.

"Going home" is an elusive term. It could mean back home to where they last lived, or home to the place were they were born. In many of the stories about wandering the patient takes off to a place they once lived that brings back fond memories.

It isn't easy to find a person suffering from Alzheimer's once they "take off." They don't wander logically. Sometimes it is like looking for a needle in a haystack.

One of the most fascinating stories of wandering I read was about a woman that wandered way from her home in Frederick, Maryland at night on foot.

To find the missing elderly woman the Frederick police had to use 50 to 60 police and civilians, and four civilian K-9 search and rescue groups.

The woman was missing for more then 8 hours in temperatures that dropped as low as 20 degrees. She was finally located "huddled up" on a property adjacent to her home. Go figure.

Another man wandered from a Denver, Colorado suburb to San Diego,California. He was lost for three days. How did he do it? He walked down to the corner and took public transportation to the Greyhound bus station. He then took a series of buses to San Diego.

Alzheimer's: Understand and control wandering

Find out why people with Alzheimer's wander and what you can do to keep them safe.

  

Alzheimer's disease can erase a person's memory of once-familiar surroundings and make adaptation to new surroundings extremely difficult. As a result, people with Alzheimer's sometimes wander away from their homes or care centers and turn up — frightened and disoriented — far from where they started, long after they disappeared.

Wandering is among the most unsettling and even terrifying behaviors people with Alzheimer's display. Often poorly clad, they leave safety at random hours and strike out into unknown territory, for no apparent reason. But this seemingly aimless activity usually does have a reason. It's often an attempt to communicate after language skills have been lost.

Wandering may communicate something as simple as "I'm feeling lost," or "I feel as though I've lost something." It can also signal such basic needs as hunger and thirst, the need to void, or the need for exercise or rest.

Other causes of wandering:

Too much stimulation, such as multiple conversations in the background or even the noise of pots and pans in the kitchen, can trigger wandering. Because brain processes slow down as a result of Alzheimer's disease, the person may become overwhelmed by all the sounds and start pacing or trying to get away.

Wandering also may be related to:

• Medication side effects  
• Memory loss and disorientation
• Attempts to express emotions, such as fear, isolation, loneliness or loss
• Curiosity
• Restlessness or boredom
• Stimuli that trigger memories or routines, such as the sight of coats and boots next to a door, a signal that it's time to go outdoors
• Being in a new situation or environment
• Tips to prevent wandering

Although it may be impossible to completely prevent wandering, changes in the environment can be helpful. For example, a woman who was a busy homemaker throughout her life may be less likely to become bored and wander if a basket of towels is available for her to fold.

People with Alzheimer's often forget where they are. They may have difficulty finding the bathroom, bedroom or kitchen. Some people need to explore their immediate environment periodically to reorient themselves.

Posting descriptive photographs on the doors to various rooms, including a photo of the individual on the door to his or her own room, can help with navigation inside the home. Offering a snack, a glass of water or use of the bathroom may help identify a need being expressed by wandering. Sometimes the wandering person is looking for family members or something familiar. In such cases, providing a family photo album and sharing reminiscences may help.

Watch for patterns

If wandering occurs at the same time every day, it may be linked to a lifelong routine. For instance, a woman who tries to leave the nursing home every day at 5 p.m. may believe she's going home from work.

This belief could be reinforced if she sees nursing home personnel leaving at that time. A planned activity at that hour, or arranging for staff to exit through a different door at the end of their shift, could provide a distraction and prevent the wandering behavior.

Make a safer environment

If wandering isn't associated with distress or a physical need, you may want to focus simply on providing a safe place for walking or exploration.

Living spaces will be safer after you remove throw rugs, electrical cords, and other potential trip-and-fall hazards. Rearranging furniture to clear space can help. Childproof doorknobs or latches mounted high on doors help prevent wandering outside. Sometimes a stop sign on an exit door is enough.

Rooms that are off-limits pose a different problem. Camouflaging a door with paint or wallpaper to match the surrounding wall may short-circuit a compulsion to wander into such rooms. Night lights and gates at stairwells can be used to protect night wanderers.

Help ensure a safe return

The Alzheimer's Association's Safe Return program is designed to help identify people who wander and return them to their caregiver. Caregivers who pay a registration fee receive:

• An identification bracelet
• Name labels for clothing
• Identification cards for wallet or purse
• Registration in a national database with emergency contact information
• A 24-hour toll-free number to report someone who is lost

You can register someone by filling out a form online at the Alzheimer's Association's Web page or by calling (888) 572-8566.

Source Mayo Clinic

By Bob DeMarco

Alzheimer's Reading Room

Should Mom Still Be Driving?

By Heather Frenette, RN, MSN, CMC

Whether or not an elderly person should be driving is a question I am frequently asked. It is a very touchy subject and most children do not want to force the issue with their parents. Getting a drivers license is a rite of passage that most teenagers look forward to. Having to give up that license can be very difficult. It affects a person’s independence. When a person has to surrender their driver’s license, they suddenly are dependent on others to get around. Going to the grocery store, going to the doctor and even going out with friends can become difficult without transportation.


There are several warning signs to look if you are concerned about a loved one’s safety behind the wheel. If you notice any of the following 17 warning signs, it is time to evaluate whether your loved one should continue driving.

1. signaling incorrectly

2. trouble making turns

3. changing lanes improperly

4. confusion at highway exits

5. difficulty parking

6. stopping inappropriately in traffic

7. confusing the brake and gas pedals

8. driving too fast or slow

9. hitting curbs

10. failing to notice stop signs or traffic lights

11. reacting slowly to traffic situations

12. failing to anticipate potential dangers

13. getting lost in familiar places

14. scrapes or dents on car, house, garage, etc.

15. traffic violations

16. near-misses

17. accidents

There are several options for driving evaluation. One option is to have an evaluation through a driving evaluation center. Although there are companies that offer these services, many of these programs are offered through larger rehabilitation centers as well. Another option is to have a physician write a letter to the Department of Motor Vehicles (DMV) expressing their concern about their patient’s driving ability. Once the DMV receives this letter, they will send out a letter to your loved one either revoking their license or requesting them to come in for a written test and/or an on the road driving test. Successful completion of the testing is necessary for the license to remain valid.

It can be hard for family members to address the topic of driving safety with their loved one. Involving the primary care physician in this process can be helpful because it takes the role away from the family. Another option is to consult with a Geriatric Care Manager. Care Managers are typically well versed in the resources to evaluate driving and can facilitate not only the testing, but also put a plan in place to address the need for transportation once the person stops driving. Again, involving an independent third party takes the pressure off the family and takes some of the emotion out of the situation.

Addressing driving concerns with your loved one can be stressful and very difficult. It is an emotional topic with significant consequences. Having a plan to both evaluate your loved one’s driving and to accommodate their transportation needs if they stop driving will help make this difficult task somewhat easier.

Alzheimer's I Want You to Know What I Know

Sometimes I write about how my mother went down hill fast, or did she? At 85 she was still walking long distances with me in New York. At 87 she couldn't walk a block. I found out later that she had stopped walking to the pool, she was bascially reduced to sitting around most of the day. Didn't know it. Nobody saw a problem.

I was living in New York and Reston, Va working away. The sound of my mother's feet and the way she complained constantly on the phone were already bothering me. These were new and different behaviors.

I thought something was wrong, but everyone seemed to think she was just "getting old". It seemed like a reasonable explanation, and I guess I was eager to accept this conclusion. I didn't have a clue about what was happening, so why not "old". It might have stayed that way if my stomach wasn't bothering me, and if I wasn't worried every time I thought about mom.

I know more now then I did back in those days. I now realize that my mother was deteriorating slowly over a long period of time. There were plenty of signs. Hindsight 20/20.

I continue to wonder about how things might have been. I wonder what if I had gotten my mother's memory tested the minute I felt concerned. I wonder if she had gotten on the combination of Aricept and Namenda early, what effect would they have had on my mother. Where would she be today?

I am never going to know the answers to those questions.

Now I spend time wondering how I can get the word out about mild cognitive impairment -- often the precursor to Alzheimer's dementia. The point at which a person starts to lose their memory faster than a person that is just getting "old".

The finding of the study below suggest that the memory and thinking abilities of person suffering from mild cognitive impairment declined two times as fast every year as the abilities of those without any cognitive problems. Thinking ability and memory in subjects with Alzheimer's disease declined four times as fast as in those without any cognitive problems.

"There persists the idea that some decline in memory is typical" with age. -- Robert Wilson

No doubt, memory does decline with age.

Here is my advice. If you have a parent or grandparent that starts to evidence new and different behaviors like meanness, worries about money, forgetfulness, gets lost while driving, or starts scrapping their feet on the ground -- get their memory checked.

If your stomach starts bothering you and you think there could be someone wrong with a parent or grandparent, don't assume they are getting old. Stomach bothering you? Pay attention. It is trying to tell you something -- get their memory checked.

If you have a parent or grandparent over 70 years of age -- get their memory checked every two years. People get physicals don't they? How about a brain physical? A memory test.

Alzheimer's dementia is ugly. You probably agree with that statement. But, if you haven't experienced Alzheimer's personally -- from the front row -- you can't imagine how ugly. No -- possible -- way.

There are treatments, not cures, available for Alzheimer's disease. They work very well for some people. We have people on this list that swear that the combination of Aricept and Namenda made a big difference in quality of life.

If you get worried about someone you love -- take action.

If its Alzheimer's, someone is going to have to assume the caregiver responsibility. The sooner you act the better the quality of life for the patient and the caregiver. The caregiver could be you.

Trust me, I know.

By Bob DeMarco, Alzheimer's Reading Room

Exercise associated with preventing, improving Mild Cognitive Impairment

Moderate physical activity performed in midlife or later appears to be associated with a reduced risk of mild cognitive impairment, whereas a six-month high-intensity aerobic exercise program may improve cognitive function in individuals who already have the condition, according to two reports in the January issue of Archives of Neurology, one of the JAMA/Archives journals. Mild cognitive impairment is an intermediate state between the normal thinking, learning and memory changes that occur with age and dementia, according to background information in one of the articles. Each year, 10 percent to 15 percent of individuals with mild cognitive impairment will develop dementia, as compared with 1 percent to 2 percent of the general population. Previous studies in animals and humans have suggested that exercise may improve cognitive function.

In one article, Laura D. Baker, Ph.D., of the University of Washington School of Medicine and Veterans Affairs Puget Sound Health Care System, Seattle, and colleagues report the results of a randomized, controlled clinical trial involving 33 adults with mild cognitive impairment (17 women, average age 70). A group of 23 were randomly assigned to an aerobic exercise group and exercised at high intensity levels under the supervision of a trainer for 45 to 60 minutes per day, four days per week. The control group of 10 individuals performed supervised stretching exercises according to the same schedule but kept their heart rate low. Fitness testing, body fat analysis, blood tests of metabolic markers and cognitive functions were assessed before, during and after the six-month trial.

A total of 29 participants completed the study. Overall, the patients in the high-intensity aerobic exercise group experienced improved cognitive function compared with those in the control group. These effects were more pronounced in women than in men, despite similar increases in fitness. The sex differences may be related to the metabolic effects of exercise, as changes to the body's use and production of insulin, glucose and the stress hormone cortisol differed in men and women.

"Aerobic exercise is a cost-effective practice that is associated with numerous physical benefits. The results of this study suggest that exercise also provides a cognitive benefit for some adults with mild cognitive impairment," the authors conclude. "Six months of a behavioral intervention involving regular intervals of increased heart rate was sufficient to improve cognitive performance for an at-risk group without the cost and adverse effects associated with most pharmaceutical therapies."

In another report, Yonas E. Geda, M.D., M.Sc., and colleagues at Mayo Clinic, Rochester, Minn., studied 1,324 individuals without dementia who were part of the Mayo Clinic Study of Aging. Participants completed a physical exercise questionnaire between 2006 and 2008. They were then assessed by an expert consensus panel, who classified each as having normal cognition or mild cognitive impairment.

A total of 198 participants (median or midpoint age, 83 years) were determined to have mild cognitive impairment and 1,126 (median age 80) had normal cognition. Those who reported performing moderate exercise—such as brisk walking, aerobics, yoga, strength training or swimming—during midlife or late life were less likely to have mild cognitive impairment. Midlife moderate exercise was associated with 39 percent reduction in the odds of developing the condition, and moderate exercise in late life was associated with a 32 percent reduction. The findings were consistent among men and women.

Light exercise (such as bowling, slow dancing or golfing with a cart) or vigorous exercise (including jogging, skiing and racquetball) were not independently associated with reduced risk for mild cognitive impairment.

Physical exercise may protect against mild cognitive impairment via the production of nerve-protecting compounds, greater blood flow to the brain, improved development and survival of neurons and the decreased risk of heart and blood vessel diseases, the authors note. "A second possibility is that physical exercise may be a marker for a healthy lifestyle," they write. "A subject who engages in regular physical exercise may also show the same type of discipline in dietary habits, accident prevention, adherence to preventive intervention, compliance with medical care and similar health-promoting behaviors."

Future study is needed to confirm whether exercise is associated with the decreased risk of mild cognitive impairment and provide additional information on cause and effect relationships, they conclude.

By e! Science News
Source: JAMA and Archives Journals

Missed and Delayed Diagnosis of Dementia in Primary Care: Prevalence and Contributing Factors

Dementia is a growing public health problem for which early detection may be beneficial. Currently, the diagnosis of dementia in primary care is dependent mostly on clinical suspicion on the basis of patient symptoms or caregivers' concerns and is prone to be missed or delayed. We conducted a systematic review of the literature to ascertain the prevalence and contributing factors for missed and delayed dementia diagnoses in primary care. Prevalence of missed and delayed diagnosis was estimated by abstracting quantitative data from studies of diagnostic sensitivity among primary care providers. Possible predictors and contributory factors were determined from the text of quantitative and qualitative studies of patient, caregiver, provider, and system-related barriers. Overall estimates of diagnostic sensitivity varied among studies and seemed to be in part a function of dementia severity, degree of patient impairment, dementia subtype, and frequency of patient-provider contact. Major contributory factors included problems with attitudes and patient-provider communication, educational deficits, and system resource constraints. The true prevalence of missed and delayed diagnoses of dementia is unknown but seems to be high. Until the case for dementia screening becomes more compelling, efforts to promote timely detection should focus on removing barriers to diagnosis.

By Bradford, Andrea MA; Kunik, Mark E. MD; Schulz, Paul MD; Williams, Susan P. MD; Singh, Hardeep MD, MPH

Huge wave of dementia cases coming, warns report

By CTV.ca News Staff

So many Canadians are expected to develop Alzheimer's disease and dementia in the next 30 years that a new case will develop every two minutes unless preventive measures are taken, a new report says.

The report, released Monday by the Alzheimer Society, says the prevalence of dementia will more than double in the next 30 years.

By 2038, almost three per cent of Canada's population will be affected by dementia, and about 257,800 new cases will be diagnosed per year.

Today, dementia costs Canada about $15 billion a year; those costs could soon increase by 10-fold.

"If nothing changes, this sharp increase in the number of people living with dementia will mean that by 2038, the total costs associated with dementia will reach $153 billion a year," David Harvey, principal spokesperson for the Alzheimer Society project called "Rising Tide: The Impact of Dementia on Canadian Society," said in a statement.

That amounts to a cumulative total of $872 billion over the 30-year period.

Much of the increase in cases can be attributed to the "greying" of Canada. With Canadians living longer and baby boomers aging, there is expected to be a spike in many chronic diseases that come with age, such as heart disease, arthritis and cancer.

But the expected rising rates of dementia are not just about demographics; poor lifestyles also play a role.

It's been well documented that regular physical and mental exercise can delay the onset of dementia, which includes Alzheimer's disease and other progressive diseases that destroy brain cells. For that reason, the report recommends that all Canadians over 65 without dementia increase their physical activity by 50 per cent.
"Prevention is where we need to be starting," Harvey told Canada AM.

"We know that healthy eating and active living are antidotes to dementia."

The "Rising Tide" report calls on government to fund more health promotion to remind Canadians of the benefits of a healthy lifestyle.

"This intervention would reduce the number of people diagnosed with dementia, resulting in a reduction in the pressure on long-term care facilities, community care services and informal caregivers," the report says.

Need for national strategy

Just as important, Harvey says, is the need for Canada's health care system to adapt to accommodate the projected rise in dementia cases.

"Dementia is one of the leading cases of disability amongst older people," Harvey said, noting that the flood of dementia expected in the next 30 years could overwhelm emergency rooms and hospitals.

His group's report calls for more support for informal caregivers -- generally, family members -- who tend to be the ones who care for patients with dementia in the early stages of the disease.
"There are services that can be put in place to support caregivers, and also economic and financial support for caregivers," he said.

By also providing caregivers with skill-building and support programs, caregivers struggling with the overwhelming emotional and financial hardships of providing care may feel better equipped to care for their loved one.

That could go far to delay admission of patients into long-term care facilities, thereby lessening the burden on the health care system.

The report also suggests assigning "system navigators" to each newly diagnosed dementia patient and their caregivers. These case managers would help families navigate the health system to find the right social services for their loved one depending on their stage of dementia.
Some facts about dementia:

The symptoms of dementia include a gradual and continuing decline of memory, changes in judgment or reasoning, mood and behaviour, and an inability to perform familiar tasks.
Dementia can strike adults at any age, but has traditionally been diagnosed in people over 65. However, symptoms start much earlier, and an increasing number of people are being diagnosed in their 50s and early 60s.

Age is the number one risk factor for dementia

Alzheimer's disease, the most common form of dementia, accounts for approximately 64 per cent of all dementias in Canada.

Other related dementias include Vascular Dementia, Frontotemporal Dementia, Creutzfeldt-Jakob Disease and Lewy body Dementia.

There is no known cure for dementia. However, some medications can delay progression of the disease.

Researchers are confident that within five to seven years, there will be treatments that attack the disease process itself, not just the symptoms.

How to decide if your family needs a geriatric-care manager

By Anya Martin

DECATUR, Ga. (MarketWatch) -- The holidays should be a joyful time of homecoming for families, but sometimes those visits also reveal that elderly parents are more frail or more forgetful than before. Discoveries like these may suggest that it's time to consult a geriatric-care manager.

When Nancy Gratzel's mother had a sudden change in her health requiring placement in a nursing home, Gratzel and her four siblings found themselves overwhelmed by the complex paperwork to qualify for Medicaid coverage. So they turned to Stephen Mielach, a geriatric-care manager based in their community of Toms River, N.J.

"It's a very cumbersome process because you have to find all your parents' documents and follow the trail of their money over the past five years," Gratzel said. "I decided that my time constraints didn't allow me to attend to that. I commute to work, have long work days, and all my siblings are married with children and very active."

Now Mielach also shares a power of attorney with Gratzel to assist her 88-year-old father, now living on his own, with bill-paying -- a task that his wife used to perform exclusively. Her father appreciated the help and began to look forward to Mielach's visits, she said.

"To me, that was a good use of my parents' money which we were going to have to spend anyway [to meet Medicaid qualifications]," Gratzel said. "It afforded me the opportunity to direct my energy towards nicer things, helping my mom adjust to the facility and my dad to living at home alone. They had been married 67 years."

While most seniors and their families do not go so far as to assign power of attorney to geriatric-care managers, members of this growing profession can assist not just with money matters but also with navigating the often complicated decisions about what care is best for mom, dad or another relative.

Sometimes they help resolve a short-term challenge such as Mielach did initially for Gratzel's mother or they may provide assistance over a period of months or years. Sample tasks range from vetting home health aides to assessing whether a senior is able to remain at home or needs to relocate to an assisted-living community or nursing home. They may also accompany seniors to medical appointments and ensure they receive the prescribed follow-up such as lab tests and radiology scans or find contractors and coordinate bids for home repairs, for instance.

Or when a senior has no spouse or children, a geriatric-care manager may take on even more responsibilities to fill that void.

"For people who have family, I become the expert in the family," Mielach said. "For those with no family, I become family for hire."

Boomers' aging parents spur demand

The profession of geriatric-care manager has been around for decades but really has taken off in the past 10 years as the baby boomers increasingly became long-distance caretakers of elderly parents, said Joyce Gray, a Philadelphia-based certified geriatric-care manager who serves on the board of the National Association of Professional Geriatric Care Managers, the industry's trade association. The group's membership has grown from 50 to 2,000 since its 1985 founding.
"There are a lot more older people who don't have someone locally to look after them," Gray said. "The baby boomers also are more used to paying for services and expecting high quality and results."

Another change Gray has noticed is that more people are contacting her proactively rather than in the middle of a crisis such as a broken hip or an Alzheimer's diagnosis, she said.
A decade ago, Ron Fatoullah, a New York-based certified elder law attorney, rarely recommended that his clients consult a geriatric-care manager. Now he refers at least one-third to see one, if only to validate that seniors and their family are making the appropriate care and financial decisions for their health and happiness.

"I have to know that my client is placed in the right facility, and if they're going to be at home, that it's the proper environment with all the safety features they need," Fatoullah said. "The care management assessment heavily dictates how I do my legal work."

In the case of Gratzel's mother, all family members agreed she needed nursing home care. However, geriatric-care managers also can be valuable third-party referees, providing an impartial viewpoint to siblings or children and a parent with different opinions about what is best for the senior, Fatoullah said.

"I've seen a reluctance among seniors to want any care, and if a child mentions it, the parent may bite the child's head off," he added. "But some geriatric-care managers are very good with seniors and letting them know in a constructive way that they do need care."

A background in nursing or social work

Most geriatric-care managers come to the profession from nursing, social work or a handful of other fields related to geriatrics or long-term care, according to NAPGCM.

Before launching his geriatric-care management practice 20 years ago, Mielach, a licensed clinical social worker, was director of social work at a hospital. During that time, he became an expert in tracking down relatives of seniors who were admitted to the hospital and did not have obvious family members. Those responsibilities eventually led to him becoming a court-appointed guardian when no relatives could be found, and he realized that he enjoyed not just the detective work but the chance to improve people's lives.

Mielach even accompanied one New Jersey woman with dementia across the country to move into a New Mexico assisted-living community near close friends.

He also sometimes serves as a health proxy, a legal status which allows him to make medical decisions based on a previous consultation as to the seniors wishes, he said. In a recent example, a client of 12 years had a stroke which robbed her not just of mobility but the ability to speak, and Mielach had to inform the EMS team that she did not want to be taken to the hospital.
"I always go into detail about what values you have so if a situation comes up, I can make decisions consistent with your values," Mielach said. "But in 20 years of doing this, I have never been so confident that someone did not want treatment as with this woman."

Geriatric-case managers typically charge by the hour, and rates vary from $80-$200/hour depending on location, Gray said. Most also charge an initial assessment fee ranging from $300-$800, she added.

Some geriatric-care managers may also agree to a lump sum for a particular service. For example, Mielach charges between $1,000 to $5,000 to research and prepare a Medicaid application, depending on the complexity involved.

While health insurance policies do not cover care-management services, some long-term-care policies do.

How to find a care manager

In the past, finding a geriatric-care manager was very much through word-of-mouth referrals, and asking a hospital discharge planner, psychiatrist or elder law attorney for suggestions in your community is still one good way to start, Gray said.

Another option is to consult NAPGCM's nationwide directory at its Web site, http://www.caremanager.org/. As of January 1, 2010, all NAPGCM members are required to have at least one of four professional certifications: Care Manager Certified (CMC), Certified Case Manager (CCM), Certified Social Work Case Manager (C-SWCM) and/or Certified Advanced Social Work Case Manager (C-ASWCM).

One red flag would be care managers who say they got into the field after helping their own relative but don't have much other experience or have not committed the time to get professional training, Gray said.

You should also be sure to ask for references, and most care managers will offer a free 20- to 30-minute telephone interview so families can get a sense of how they work, their fee schedule and whether their personality is a good match, she added.

"It's important to have a sense of trust right from the start that you can work with this person and that your mother, father, aunt, uncle can work with them, too," Gray said.

More questions to ask include whether the geriatric-care manager is part of a solo or group practice and who covers for them if they are away, she added. Are they available 24 hours a day and on weekends, because that is when many falls and other health crises occur?
Finally, don't hire anyone who accepts financial rewards from nursing homes, home health agencies or other providers. Such practices are directly in conflict with NAPGCM's ethical standards and suggest that the geriatric-care manager may not have a seniors best interests at heart, Gray said.

Dementia and How it is Diagnosed

Many of us may from time to time, forget our neighbor’s name or the items to purchase at the grocery store, and we wonder if this is part of normal aging. Your doctor is the best person to speak with regarding these concerns. There are many conditions that are treatable that may be contributing to periodic memory lapses.

Often when we think of dementia we think of Alzheimer’s disease. While Alzheimer’s disease is considered to be the underlying cause of between 60 and 80% of all dementia cases, there are also other conditions that might cause dementia. It is important to know about the other types and causes of dementia because treatment can vary between diseases and early detection can be beneficial in slowing the progression of incurable dementia's.

According to Dr. Harvey Gilbert, MD of the Gilbert Guide, some of the most common types of dementia and their causes are:

1. Vascular Dementia
This type of dementia is the second most common. It is caused by poor blood flow to the brain, depriving brain cells of the nutrients and oxygen they need to function normally. Vascular dementia can be caused by any number of conditions which narrow the blood vessels, including stroke, diabetes and hypertension.

2. Mixed Dementia
Sometimes dementia is caused by more than one medical condition. Most commonly, mixed dementia is caused by both Alzheimer's and vascular disease.

3. Dementia with Lewy Bodies (DLB)
Sometimes called Lewy Body Disease, this type of dementia is characterized by abnormal protein deposits called Lewy bodies that develop in nerve cells in the brain stem. This disrupts the brain’s ability to function normally and impairs cognition and behavior. It can also cause tremors and is often linked with Parkinson’s Disease and dementia. It is not reversible and there is no known cure.

4. Parkinson’s Disease Dementia (PDD)
Parkinson's disease is a chronic, progressive neurological condition, and in its later stages can affect cognitive functioning. Not all people with Parkinson’s disease will develop dementia, however. This type of dementia is also a lewy body dementia. Symptoms include tremors, muscle stiffness and speech problems. Reasoning, memory, speech, and judgment are also usually affected.

5. Frontotemporal Dementia
Pick's disease is the most common and recognized form of frontotemporal dementia. It is a rare disorder which causes damage to brain cells in the frontal and temporal lobes. This affects the individual’s personality significantly, usually resulting in a decline in social skills, along with emotional apathy. Unlike other dementia's, Pick’s disease usually results in behavior and personality changes occurring before memory loss and speech problems.

6. Creutzfeldt-Jacob Dementia (CJD)
A degenerative neurological disorder, CJD is also known as “mad cow disease”. The incidence is very low, occurring in only about one in one million people. There is no cure. Caused by viruses, CJD progresses rapidly, usually over a period of several months. Symptoms include memory loss, speech impairment, confusion, muscle stiffness and twitching, and a general lack of coordination, which makes the individual susceptible to falls. Sometimes blurred vision and hallucinations also occur with this form of dementia.

7. Normal Pressure Hydrocephalus (NPH)
Normal pressure hydrocephalus involves an accumulation of cerebrospinal fluid in the brain's cavities. When this fluid does not drain as it should, the associated build-up results in added pressure on the brain, interfering with the brain’s ability to function normally. Individuals with dementia caused by normal pressure hydrocephalus often experience problems with ambulation, balance and bladder control, as well as cognitive impairments involving speech, problem-solving abilities and memory.

8. Huntington’s Disease
Huntington's disease is an inherited progressive dementia that affects the individual’s cognition, behavior and movement. Symptoms include memory problems, impaired judgment, mood swings, depression and speech problems (especially slurred speech). Delusions and hallucinations may also occur. Individuals with Huntington’s disease may also experience difficulty walking, and uncontrollable jerking movements of the face and body

9. Wernicke-Korsakoff SyndromeWernicke-Korsakoff syndrome is caused by a vitamin B1 (Thiamine)deficiency and often occurs in alcoholics, although it can also result from malnutrition, cancers, abnormally high thyroid hormone levels, long-term dialysis and long-term diuretic therapy (used to treat congestive heart failure). The symptoms include confusion, permanent gaps in memory, and impaired short-term memory. Hallucinations may also occur. If treated early by supplement, this dementia can be reversed.

10. Mild Cognitive Impairment (MCI)
Dementia can be due to illness, medications and a host of other treatable causes. With mild cognitive impairment, an individual will experience memory loss, and sometimes impaired judgment and speech, but they are usually aware of this decline. These problems usually don’t interfere with the normal activities of daily living. Individuals with mild cognitive impairment may also experience behavioral changes that involve depression, anxiety, aggression and emotional apathy. This is often due to the awareness of and frustration related to his or her condition.

With an understanding of the types of dementia, questions begin to arise about how these diseases are diagnosed. What can a patient expect when trying to determine whether he or she has some form of dementia? What can a caregiver expect?

When you initially meet with your doctor, it is important to be honest with them about the symptoms the patient is experiencing, their duration, frequency and rate of progression. The doctor will then review your current health status, family history and medication history. This includes evaluating the patient for depression, substance abuse and nutrition, and other conditions that can cause memory loss, including anemia, vitamin deficiency, diabetes, kidney or liver disease, thyroid disease, infections, cardiovascular and pulmonary problems. The patient also undergoes a physical exam and blood tests. Diagnosing specific diseases causing dementia can be difficult and it may be necessary to ask for a referral to a doctor with expertise in this area. Additional tests that may be used in conjunction with the aforementioned approaches include the Mini Mental State Evaluation (MMSE), the Mini Cog Screen, and Medical Imaging (CT, MRI and PET scans).

The MMSE is an evaluation of the patient’s cognitive status. The patient is required to identify the time, date and place where the test is taking place, be able to count backwards, identify objects previously known to him or her, be able to repeat common phrases, perform basic skills involving math, language use and comprehension, and demonstrate basic motor skills.
The Mini Cog Screen takes only a few minutes to administer, and is used as an initial screening for dementia. The patient is required to identifying three objects in the office, then draw the face of a clock in its entirety from memory, and finally, recall the three items identified earlier.
Finally, medical imaging helps doctors see images of the patient’s brain to determine whether there are any growths, abnormalities or general shrinkage which occurs in Alzheimer’s disease. These medical imaging tests can help improve the accuracy of a dementia diagnosis to 90%.

Once a diagnosis has been made, doctors can help patients to look at various treatment options and can often provide information for caregivers and families about support groups and organizations that can provide them with information about their specific diagnosis. It is recommended that patients and their families try to learn as much as they can about the disease and how it is expected to progress. Organizations like Alzheimer’s Association or the Parkinson's Society can provide valuable information about the disease, its progression and tips on how to slow the progression of the disease and deal with symptoms. These organizations also provide support groups to both the patient and their caregivers to help deal with the blow of a dementia diagnosis. As mentioned earlier, early detection is often key in being able to reverse or slow the progression of many of these diseases. Having a basic understanding of the many dementia's that may occur and how they are diagnosed will be beneficial to physicians and families alike.

If you find that you simply do not know where to begin or how to handle this change in status and what it means for your future, a Geriatric Care Manager can assist you in making plans for the future.

For information on Care Managers in your area go to http://www.caremanager.org/ or for a care manager in Maricopa County click here.

By ElderCaring.ca