Alzheimer’s ABC’s: Cognitive Changes II
Cognitive Changes in AD: Apathy and Delusion
In the last post we considered the cognitive change of depression, and how it can affect those with Alzheimer’s disease (AD), as well as some tips to help discern between pure depression and AD.
Today we’ll consider other cognitive change often seen along with AD – apathy and delusion.
Some AD patients develop frustration, agitation or combativeness, which can be extremely difficult to treat and manage (if you are a caregiver for an AD patient with these symptoms, you are all too aware of the strain this can create). Sometimes change in personality with agitated features can be an early manifestation of AD so pay close attention to this. (more…)
Add comment March 8, 2010
Alzheimer’s ABC’s: Cognitive Changes
Cognitive Changes in AD
In the first three posts of this series we explored how to identify and understand many symptoms of early Alzheimer’s disease (AD), as well as how to use them to build a historical timeline. These posts provide a good foundation for moving forward in our basic understanding of AD.
In this post we move into the topic of cognitive changes associated with early AD, and include an exercise you can try with your loved ones at home.
Early Alzheimer’s or Depression?
Twenty percent of people with Alzheimer’s disease (AD) also develop depression, so it is not uncommon for a person with AD to also be depressed. However, I see a number of patients who present with symptoms of AD, when the patient is simply depressed with no real sign of AD. So an individual could show apparent symptoms of AD and be in one of following groups: 1. they actually have AD, 2. they have both AD and are depressed or 3. they are experiencing pure depression with no associated AD.
Since people with depression sometimes complain very bitterly of memory difficulties, it’s very important from a clinical standpoint to distinguish between early AD and pure depression. (more…)
2 comments February 24, 2010
Alzheimer’s ABC’s: Understanding Early Warning Signs
In the last post we began to take a closer look at some of the more widely known symptoms of Alzheimer’s disease (AD), as well as to explore the differences between normal aging and cognitive impairment within those symptoms. In this post I am going to provide you a list of areas in your day-to-day life where symptoms of AD appear, to help you better distinguish normal aging from the signs of something more serious.
When I’m evaluating a new patient I try to see if I can develop a scenario of progressive worsening over time. Perhaps two years ago they were experiencing symptoms of forgetfulness and then one year ago they began to repeat themselves (asking the same questions, for example, even when they have already received an answer). This is a typical progression for AD.
I always ask if they have difficulty with balance/coordination, problems with bladder/bowel control, gait disorders – these are usually signs of vascular dementias, not AD, so it’s important to differentiate right up front.
Other symptoms and potential warning areas for people with early AD
Many people with early AD will have trouble with processing tasks such as: the ability to balance a checkbook, pay bills, cook meals (if they did so before). Specifically I delineate between cooking something simple (or in the microwave) and planning/cooking a full meal (meat, vegetable, bread, etc.). Pulling together an entire meal is usually much harder for someone with AD. (more…)
1 comment February 12, 2010
Alzheimer’s ABC’s: Understanding The Symptoms
This is the second post in a blog series by Dr. John Dougherty, intended to simplify and demystify Alzheimer’s disease, and help you better recognize the signs and symptoms.
In the last post we learned that the single most important place to begin our understanding of Alzheimer’s is history. I start the process by building a timeline from symptom onset with the individual (and family members). In the next few posts we’ll take a look at Alzheimer’s symptoms. We begin the list today with some of the more widely known symptoms, but we examine more closely how to distinguish signs of normal aging from those of possible impairment within them
Repeated and persistent signs of forgetfulness
As people age they frequently complain of losing keys, losing a wallet or purse, a checkbook, or some other staple item. With normal aging you may forget where you parked your car after shopping, or you may forget a turn or two in the car but not be lost. You may even go to the pantry, only to forget what you went for, but you can retrace your steps, or think for a moment and recall. The concept of forgetting briefly but then being able to reason out a way to the memory in the mind is very normal.
This is not so for people with AD. Someone with AD may be incapable of remembering where the car is parked, or may find themselves driving with no idea where they are or how to navigate from there. The inability to eventually pull out the recent memory is not normal.
Diminishing success using everyday items
People with AD frequently have trouble operating a microwave (not just adding 30 second increments, but having the ability to set cook time and power, program defrost, etc.). They may also have trouble using kitchen utensils or everyday tools (especially for folks who typically perform household projects with ease).
Someone with worsening symptoms may be putting clean dishes away and have trouble recalling where the dishes are supposed to go. They may have a very difficult time getting the dishes put in the right place.
Memory problems
Problems with memory tend to worsen over the course of a year or so, which is very typical progression for AD. After one year there will be much more difficulty with recent memory and recalling conversations, trouble remembering to tell a spouse of a phone message they took for them, or to recall what was discussed in a call they just had. Recent memories are the key here. Past memories tend to be fully intact for people with AD. They may have no idea what they ate for breakfast but will be able to recount early times in their lives with ease. Anxiety over memory loss can exacerbate these problems.
One of my patients was telling me about a block party they had in their neighborhood. There were some guests coming whom he did not know well and he was very nervous about recalling their names as they arrived. He spent time going over their names and practicing before the party. As guests began to arrive he was very anxious about his performance and ability to introduce people, which naturally made recall more difficult for him. Then he had a glass of wine, relaxed a bit and found he was more fluid in recalling names. This anxiety can complicate the issue for our next symptom as well: word recall.
Word recall
People in the slow progression of cognitive decline often have trouble recalling every day words, or have difficulty selecting the right word to use.
If you are experiencing normal aging, you may see a clock on the wall and recognize that it has hands and numbers, but momentarily lose the word clock. The word clock will eventually come to you, however. You may forget the names of people that you do not see on a regular basis – this can be completely normal. People with normal aging often joke about their memory – they intuitively understand it is not a serious problem.
People with AD have trouble recalling the names of people they do see regularly. They may not be able to eventually pull the word clock out of their memory, no matter how well they can describe the device itself. As mentioned above, anxiety over this issue can be an extenuating factor.
These are some of the very typical early symptoms of AD versus normal aging. In the next post we’ll go into greater detail on symptoms that may not be as well known.
2 comments February 2, 2010
Alzheimer’s ABC’s: Start With Where We’ve Been
This is part of a blog series by Dr. John Dougherty, to simplify and demystify Alzheimer’s disease, and help you better recognize the signs and symptoms.
As the first in a series of posts I’d like to begin my telling you a bit about myself. I’ve been a neurologist for 25 years, and an Alzheimer’s disease (AD) specialist for more than 10 years. As the Director of the Cole Neuroscience Center in Knoxville, TN I currently follow over 2,000 patients with AD in my practice.
I lost my mother, my uncle and my grandmother to Alzheimer’s disease. My mother died in her mid-eighties, and had AD symptoms for almost 15 years prior to her death. My father died at age 90 and had perfectly normal cognition the day of his death. He died suddenly from a ruptured aortic aneurism.
My desire to share my medical knowledge here with you results from my deep abiding passion for understanding the science behind Alzheimer’s disease, as well as my years of caring for those with AD, and the profound impact it has on those beautiful people who care for them.
There are a lot of myths and misunderstandings about dementia, and an overwhelming yet unnecessary fear of it. I’d like to help dispel some of these myths and, for many of you, put your mind at ease, as well as equip you with the knowledge and power to take control of managing your brain health, and keeping your minds sharp for the rest of your lives.
Let’s start with the single most important aspect of understanding Alzheimer’s: HISTORY. It is crucial to take a very careful history as a starting point for assessing cognitive problems. You can do this at home with your loved ones, as it may help you to determine if it’s time to pursue further medical evaluation, or self testing in the privacy of your own home.
When I see a patient for the first time, I ask that as many family members as possible come along to the appointment, and an individualized approach to each patient and family is very important. Not only do we return to the beginning of the cognitive problems, but we build a timeline. I am frank with the patient about what we are assessing: “We’re checking your memory. Let’s see how this goes and then we’ll all discuss in detail.”
First I want to know: “How long ago did symptoms begin?” Usually, if symptoms are mild (by the time they get to my office), they tend to go back about 2 years. “When did the signs of forgetfulness first start (losing keys/wallet/checkbook, or asking the same question over and over, etc.)?”
So this is the first step within the first step of building the timeline: determine the duration (Alzheimer’s disease usually results in progressive cognitive impairment). In the next post we’ll dig much deeper into building the timeline and understanding how to read the signs of the past.
If you have comments, stories or questions please use the comment form here to interact. I’d love to hear from you.
Dr. John Dougherty
Director, Cole Neuroscience Center
Creator, ALZselftest.com
2 comments January 19, 2010
Introduction to ALZselftest by Dr. Dougherty
As a neurologist of 25 years, I have specialized in Alzheimer’s Disease (AD) for the last ten. I currently follow over 2,000 AD patients in my practice and have personally experienced the immense toll that this disease takes on care givers. It was painful watching my own mother suffer with AD for more than 15 years.
When my mother was diagnosed our medical understanding of AD was very different, far more limited than what we know today. At the time (and still to a large extent today), physicians relied on a basic paper-based test called the Mini-Mental Status Evaluation (MMSE), to diagnose people with AD. The MMSE was developed over 30 years ago and has been shown to be less than 70% effective in diagnosing AD.
As our AD knowledge base expanded I began doing more research and in 2002, created the Self Test, an AD screening test which demonstrated 97% accuracy in clinical trials in differentiating between people with cognitive impairment or AD and otherwise healthy individuals. The success of the Self Test offered a much more effective means of screening for AD, but I was dismayed to know that 60% of people with AD are still going undiagnosed in a primary care setting.
There are many reasons for this, including a lack of sufficient health care coverage, difficulty getting primary care physicians to screen for AD before full onset of the disease, resistance by elders to be screened, and many others. This number is not only unacceptable, it is unnecessary.
In 2005 I began working to adapt the Self Test for use as a computer-based screening and in July of 2008, made it available directly to the public so that any individual with age-related memory concerns can access it from the comfort of their own home. Clinical trials have shown the computer-adapted version of the Self Test to be 98% accurate at distinguishing between impaired and healthy individuals. This means the test is VERY good at uncovering early warning signs. I designed the test to be quick, simple, and user-friendly yet highly effective at revealing potential early warning indicators of cognitive impairment.
Unlike the days when my own mother was diagnosed, we now know that there are hundreds of natural ways to prevent or delay onset or worsening of symptoms of AD. In future posts I’ll write more about these options, and will include articles and resources in our newsletter, which you can sign up for here. The key to best utilizing our medical understanding of this disease is to catch it as early as possible.
Let me say that again: *early detection is the key* to combating AD. The sooner you uncover potential warning signs, the sooner you can put into motion the steps to delay it. If we’d had this information when my mother first became ill, I have no doubt we could have radically improved her quality of life, and significantly reduced the burden on the family.
This is why I have brought you this screening test – to empower you as an individual (or caring family member) to identify potential warning signs before AD symptoms are fully active. Armed with this knowledge you can make much better decisions about your future. You have an “Empty” light on your gas gauge for a reason – it tells you that it’s time to fill up. A “warning light” in this screening test is similar, it tells you it’s time to check in with your physician and pay more attention to your cognitive health.
You’ll be able to print your results for further discussion with your physician, and will also have access to a wide range of tools and information we have compiled to better support you. Knowledge IS power and the reason I have made this test available to you is to give you the power to better care for yourself, both today and in the future. I wish you very good health.
Dr. John Dougherty
Director, Cole Neuroscience Center
Knoxville, TN
Add comment January 16, 2010
Give The Gift of Cognitive Health
I had a conversation last week with a trainer for a large Assisted Living Facility corporation. She has the daunting task of re-training the staff of all the facilities in that organization on their approach with residents. In particular, she is working to train them to understand that their approach has a great impact on whether a resident will comply or take part in activities geared towards stimulating their cognition.
We talked about how she struggles to help the staff understand that, while it may seem easier in the short run, doing tasks FOR the residents actually has a negative impact on them long term. It may seem easier to just take a senior by the hand and lead them where they need to go, or to manage their time and take responsibility for when/where they need to be. But doing this causes them to relinquish the responsibility and starts a slow process of atrophy in the cognitive domain associated with that task.
As we talked I was reminded of the time I got my first GPS navigational system in my car. I had just moved to Providence, RI and was taking regular trips into Boston, so the guidance was a huge relief. In an astonishingly short period of time however, I became aware that I had surrendered my right to think for myself while driving. One day the GPS system stopped communicating with the satellites and I suddenly realized that I wasn’t sure where I was or how I got there, much less how to get where I wanted to go next. That was a scary realization of how quickly we relinquish a task when someone else takes over for us.
As a caregiver, friend or family member, when you take over task management for your senior loved one, it may seem quicker and easier at the time, but the long term impact on their cognitive health suffers greatly. Practice a little patience, and know that for every task you allow them to complete, you give them the gift of brain exercise and overall cognitive health. That gift is truly priceless.
Try These Exercises:
- If you routinely drive a senior to the doctor or similar appointment or gathering: next time you get in the car, have them participate in guiding you to your location. Ask them to tell you where you need to turn and when and get them involved in the navigation.
- If you are a caregiver in a facility: rather than taking the resident to the cafeteria, ask them to lead you to it. Make it a game!
- Rather than maintaining their schedule, give your senior a calendar and have them add appointments as they are scheduled and task them with calling or reminding you the day before they need to go somewhere.
- If your loved one watches sports: have them track their favorite team (or a local team) throughout the season, updating the schedule with all wins/losses and stats.
Add comment January 13, 2010
Driving and Alzheimer’s Disease
The caregivers of my patients frequently ask me about the safety of their loved ones getting behind the wheel after receiving a diagnosis of Alzheimer’s Disease (AD). This is a sensitive topic for patients, but a very important one in terms of both safety and liability, as I will discuss here.
First, my own research has recently revealed that driving in moderate and late stage AD is a much larger problem than we first feared, and this is not attributable merely to aging. In fact, we have seen that 16 year old males have a higher incidence of accidents than healthy non-demented individuals over the age of 75. However, in mild cognitive impairment (MCI) and the early stages of AD, we do not see increased accident rates. But as early AD progresses into moderate AD accident rates rise sharply.
I’ve done some research correlating test scores to driving safety and will discuss that more in a later article. For now let me just say that by the time a patient’s MMSE (mini mental status exam) or ALZselftest score is as low as 20, they are at a increased risk of having an accident while driving. Put simply, these people should not be driving.
A complicating factor here is that a portion of AD patients who also have Anosognosia, may believe they are perfectly healthy and see no reason not to drive. I had a very distraught family come in one day and tell me that in spite of all their efforts, they could not get the patient to stop driving. He ended up getting into the back seat of the car, becoming very angry and accusing his family of stealing the steering wheel, yet he was certain he was okay to drive. These are the patients that refuse to give up the keys, exacerbating the problem.
Complicating things for the family is the fact that, according to the legal system, the family could possibly be held liable if their loved one takes the car and gets into an accident. The family could well be sued and held financially responsible.
As a physician, here are the things that I do with my patients, and suggest to others, to help support both the family and the patient, and especially to keep everyone involved safe and protected.
- The healthcare provider should assume responsibility – I always explain to my patients that I am a professional with a lot of experience in this area and, based on their test results I believe that they should not be driving. I attempt to be very fact-based in this delivery, explaining the results of their test scores (MMSE, ALZselftest, etc.) and indicate that they fall into a group with high accident rates.
- Next, I physically write a prescription and hand it to them, instructing them “no driving.” This prescription goes home with them and is placed on the refrigerator, or bathroom mirror, or somewhere they will see it regularly.
- Sometimes I offer my patients a follow up call. This is a buffer to allow them time to get used to the idea, and to give some space to the subject of driving as an option. In the office I tell them if they get home and still feel they need to discuss it, to give me a call back. I’ve made this offer over 500 times and no one has taken me up on it.
- I enable the family to agree with the patient, rather than argue. Family members can say “Hey, we agree with you about driving but, unfortunately the doctor said no, as you can see from this prescription. We cannot go against the doctor.”
- If necessary, I encourage the family to disable the car – often after a couple of weeks the patient will simply stop inquiring about driving.
The best way to both support the patient and ease the stress on the family is for the healthcare provider to assume full responsibility for the decision to take away driving. If you are a caregiver with these concerns, talk to your healthcare provider privately and ask for support in making this decision.
Whatever you do, do not ignore the problem. This is a problem than can and does cost lives. If you doubt your loved ones ability to drive, do not allow it until you can receive further assessment from your physician, and receive professional support for taking driving away. And above all, be sensitive in delivery of this news. Driving is a freedom that is very upsetting to part with and should not be taken lightly. But it should be taken when the patient becomes too impaired. Using these tips, the process should go much more smoothly for everyone involved.
I wish you good health.
Dr. John Dougherty
Director, Cole Neuroscience Center
Add comment January 12, 2010
“There’s Nothing Wrong With Me!” Caring For Loved Ones Unaware Of Their Problem
Anosognosia is a term used to describe a person who is unaware of or denies the existence of their condition or problem. Some researchers estimate 20% of Alzheimer’s Disease (AD) patients suffer from Anosognosia. My own research puts this estimate closer to 50%.
If you have a loved one suffering with Anosognosia you are probably very familiar with this concept, even if you didn’t know the medical term for it. AD patients with Anosognosia will argue with you if you point out deficits in memory or basic functioning. They tend to believe that they can function normally – still manage the finances, for example, when it is apparent to you that their cognitive deficits impair this ability.
AD patients with Anosognosia can be some of the toughest for caregivers to manage, and can create greater stress on loved ones than those without Anosognosia. It may help to remember that this is a medical condition and that special care is needed to manage these individuals. It is often important to ensure that some individuals with Anosoagnosia not drive vehicles, as this can present a dangerous situation.
Since the patient may not recognize the need for medication, creativity is helpful here. For example, I sometimes recommend that caregivers of patients using the anti-cholinesterase patch place the patch on the patient’s back (rather than chest), to keep them from seeing and removing it.
It is frequently best not to argue with patients with Anosognosia when the issues are often of little consequence. Important issues however, should be dealt with firmly and directly, especially when it’s time to explain to them that certain activities are dangerous for them, such as: driving is not safe!
As the caregiver, always remember that patients with Anosognosia have a distorted self-awareness and are not just trying to be difficult.
Add comment January 11, 2010
Mild Cognitive Impairment
Mild Cognitive Impairment, or MCI, has become better understood in recent years. It is broadly considered to be a transitional stage between normal, age-related cognitive changes and dementia. We have learned some key things about individuals with MCI that are very important to understand for long term quality of life. Believe it or not, if you have received a diagnosis of MCI, this is actually very good news. It means that you are one of the few people who have been brave enough to get yourself tested for memory concerns. And because of this, you have learned at the earliest possible stage of some potential future problems. It’s great news because at this stage we have a lot of options for treating you and others like you.
As a physician, I can tell you that almost 8% of people diagnosed with MCI convert to Alzheimer’s Disease (AD) within 1 year. However, 20% of people diagnosed with MCI revert to normal memory within 1 year. So a diagnosis of MCI is not a cause for panic so much as it is a call to action. MCI can be caused by a number of things and it’s very difficult to track down which one caused yours. However, studies of people with MCI who take Cholinesterase Inhibitors (CEIs), such as: Aricept and the Exelon Patch, have shown a slower 12 – 24 month rate of conversion to AD.
While there have been some mixed study results on the use of CEIs, the most recent study in the New England Journal of Medicine provides support for CEI effectiveness up to 24 months. I prescribe CEIs for my MCI patients and continue to see encouraging results. I also suggest that my patients add vitamins, physical and mental exercises to their daily lives, all of which have been shown to slow the progress of AD.
If you have memory related concerns and haven’t been tested, know that *early detection is key*. If you have received a diagnosis of MCI, be aware of your options and continue to monitor your brain function. You can take our own clinical computerized screening test, or you can follow up with your physician for in-office testing. Which ever you choose, make sure you are being followed by a physician, testing yourself regularly to chart your progress and stay informed of all the latest research on how physical and mental exercise, diet and nutrition and other steps can keep your mind sharp and AD at bay. I wish you very good health.
Dr. John Dougherty
Add comment January 9, 2010
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Dr. John Dougherty