Johns Hopkins Health Alerts - Memory

The Potential of Repurposed Drugs to Slow Alzheimer's

Mon, 08 Mar 2010 05:00:00 CST

Nearly all major pharmaceutical companies in the United States are racing to find a cure for Alzheimer’s disease but since the cause of Alzheimer’s disease is still a mystery, scientists aren’t sure where in the brain to aim treatment. In this health alert, Johns Hopkins discusses the potential of new drugs in development, and drugs that target tau protein tangles and inflammation, instead of amyloid plaques.

Attacking amyloid plaques is an important avenue of Alzheimer’s research, but major questions remain. Autopsy studies have revealed that some people with amyloid plaque buildup do not develop Alzheimer’s disease. And so far studies have not been able to show that reducing plaque in the brain leads to cognitive improvement in patients with Alzheimer’s disease.

Many researchers argue that just because these plaques develop with dementia doesn’t mean they cause Alzheimer’s disease symptoms. It’s possible that amyloid plaques are a reaction to brain damage that has already occurred and are merely indicators of cell death. Another possibility: Plaque may work like scar tissue, protecting (not harming) cells damaged by Alzheimer’s.

Many Alzheimer’s disease researchers are targeting other potential causes, like tau protein tangles and inflammation. They’re also investigating drugs that treat other ailments. One potential dementia therapy in this vein is methylthioninium (Rember), a form of which has been used to treat urinary tract infections (among other things) since the 1930s.

Methylthioninium may dissolve and prevent tau tangles -- aberrations that accumulate in the brains of Alzheimer’s disease patients as their disease progresses (like amyloid plaques). Tau protein normally helps keep pathways for brain cell nutrients straight, like train tracks. But in people who have Alzheimer’s disease, the protein tangles up, which prevents nutrients from moving through cells.
According to some preliminary findings, a new form of methylthioninium may have stabilized cognitive decline over 50 weeks in 321 patients with mild to moderate disease. No known clinical trials are underway at this time.

Another repurposed drug is dimebolin (Dimebon), an antihistamine originally marketed in Russia. Researchers hoped it would slow Alzheimer’s disease progression by boosting the energy-producing capacity of brain cells. Patients with Alzheimer’s disease who enrolled in small preliminary trials tolerated the drug well, and cognitive improvements seemed to increase the longer patients stayed on the drug.
Based on this initial Russian work, researchers recruited 598 participants in the U.S., South America, and Europe with mild to moderate Alzheimer’s disease for larger, more definitive Phase III study. After having seen so many “sure hits” come on the scene over the years and then flame out miserably in costly but necessary multi-center Phase III testing, nothing is ever certain except the scientific evidence confirming both the drug’s safety and its ability to truly benefit people with Alzheimer’s disease.

Although many in the Alzheimer’s disease research community held great expectations for Dimebon, all hopes were recently crushed when two late-stage trial results revealed that when compared to placebo Dimebon had no effect whatsoever in treating the cognitive deficits or behavioral problems triggered by Alzheimer’s disease.

Finally, some observational studies have found an association between taking the cholesterol drugs called statins and a reduced risk of developing Alzheimer’s disease. One possible explanation is that lowering cholesterol levels improves blood vessel function in the brain. But several randomized, placebo-controlled clinical trials have found that statins offer no benefit for people who already have Alzheimer’s disease. And the latest clinical trials suggest that these drugs may not protect against the development of Alzheimer’s either.

Living With Alzheimer's: Two Stories From the Front

Mon, 08 Mar 2010 06:00:00 CST

Caring for a loved one with Alzheimer’s is challenging. Here are answers to two questions, asked by Alzheimer’s caregivers to the editors of our Johns Hopkins Memory Bulletin. The subjects: Confusion about place … and symptoms of aphasia.

Q. What do you recommend that I do for my grandfather, who doesn't realize that he is actually home? Gramps worked for the railroad for 48 years and did a lot of traveling during his career. Now that he is 90 and was diagnosed with Alzheimer’s a year ago, he suddenly says that someone should pick him up, along with his luggage, and help him get home. This has been going on for a month, and I don't know how I can convince him and ease his concerns that he is already safe at home. Westport, CT

A. You are describing what doctors refer to as an agnosia, an inability to recognize a familiar object, person, or place despite intact eye function. This symptom can be seen in other brain diseases that affect the parietal lobes of the brain, so it is not only a symptom of Alzheimer's disease but does become common in Alzheimer’s as the illness progresses. This is not merely "forgetting" where one lives; many individuals with this problem can accurately describe the home they live it. Rather, it is an inability of the brain to merge the memory of a place with the perception the person is seeing at that time.

Advice: In my experience, there is no benefit and sometimes harm in repeatedly trying to convince the patient that "this is your house." I think it would be best to distract him by changing the subject, reminiscing about his home, or empathizing with his distress.

Q. My wife was originally diagnosed with early Alzheimer's disease but now the diagnosis has been switched to primary progressive aphasia. I would appreciate your views on diagnosis, prognosis, and treatment possibilities. Via e-mail

A. Primary progressive aphasia, or "PPA," is a condition in which a person has a slowly progressive loss of the ability to communicate through speech. Most individuals who have this condition are found to have fronto-temporal dementia at autopsy but some individuals have the pathology of Alzheimer's disease located only or primarily in the brain's language center.

Advice: Individuals with PPA have marked difficulty finding words and may eventually become unable to generate language through speech. They can often comprehend more than they can express, so if a person gives them 'yes' or 'no' choices for responses, , communication is easier.

Many but not all individuals with PPA are frustrated by their difficulty with language expression; when this is the case, it is often helpful to them to let them know you recognize their frustration.

Update on The Search for an Alzheimer's Cure

Mon, 25 Jan 2010 06:00:00 CST

Alzheimer' s drugs currently on the market can slow the disease, but there is still no cure. Nearly all major pharmaceutical companies in the United States are racing to find one, but since the cause of Alzheimer's is still a mystery, scientists aren't sure where in the brain to aim treatment. In this excerpt from an article in our Health After 50 newsletter, Johns Hopkins discusses therapies in the pipeline that attack amyloid plaques as a way to stall Alzheimer's.

Doctors know that structural changes occur in the brains of Alzheimer 's patients, but researchers are debating a "chicken-or-the-egg" question: Do these neurological abnormalities cause Alzheimer's, or does Alzheimer's cause them?

The answer has dramatic implications for treatment: If the neurological markers that researchers have identified cause Alzheimer's, reversing them may stop Alzheimer's. But if they're merely the result of Alzheimer's, then treating them may not address the root of the problem. It's possible that multiple causes are at play in this complex condition, so there may be more than one way to treat Alzheimer's.

One of these neurological changes is the buildup of amyloid plaques, which are clusters of aberrant proteins found in the brains of all Alzheimer's patients. Many scientists believe going after these plaques will stall dementia. For example …

In 2008, researchers began testing a vaccine, called bapineuzumab. The vaccine did not turn out to be as effective as researchers had hoped, but it was safe and may slow cognitive decline in patients without the APOE ε4 gene (an inherited genetic variant in 30–45% of patients with Alzheimer's disease). Additional trials are under way.

Another new therapy that goes after amyloid plaque is tramiprosate (Alzhemed). This anti-inflammatory drug binds to amyloid fragments before they stick together to form plaque, but as of yet, clinical trials haven't shown the drug slows Alzheimer's.

An alternative tactic against amyloid buildup is targeting the enzymes beta-and gamma-secretase. These enzymes "cut" a large protein known as beta-amyloid precursor protein into toxic fragments that accumulate into plaques. An antienzyme drug currently under investigation, called LY450139, reduced the presence of amyloid in the blood of Alzheimer's patients -- but levels rose again after initial doses. More trials are under way, and the results should come out some time in the next two years.

What now? Families who want access to the most cutting-edge therapies often wonder if they should enroll their relatives with Alzheimer's into clinical trials. One study has shown that trial participants with dementia stay out of nursing homes longer than patients receiving standard care, even when the experimental drugs don't work -- possibly because study participants benefit substantially from the frequent, high-quality medical attention. The bottom line: Since there currently is no cure for Alzheimer's, experimental therapies may be a good bet.

For more information on clinical trials and Alzheimer’s treatment options, contact: Johns Hopkins Alzheimer’s Disease Research Center – 410-502-5164 or http:www.alzresearch.org

Talking About Alzheimer's

Mon, 23 Nov 2009 06:00:00 CST

Many physicians fear that revealing a diagnosis of dementia would only further upset an already troubled patient, but a study from Washington University in St. Louis found quite the opposite. When it comes to a diagnosis of Alzheimer's disease, knowing the truth as soon as possible appears to be the better approach, potentially improving the emotional wellbeing of both patients and their caregivers, the researchers report.

Medical advances have made it possible to diagnose Alzheimer's at very early stages, but a study published in the Journal of the American Geriatrics Society found that about half of all physicians were reluctant to inform patients of an Alzheimer's diagnosis.

The study followed 90 individuals and their caregivers as they came to the Alzheimer's Disease Research Center at Washington University's School of Medicine for an evaluation. Sixty nine percent eventually got a diagnosis of Alzheimer's disease, but no significant changes in depression were noted and anxiety decreased substantially.

"The major finding is that both patients and their families feel relief, not increased anxiety, upon learning the diagnosis," says study co-author John C. Morris, M.D., Director of the Alzheimer's Disease Research Center. This was true regardless of the degree of impairment.

"Nobody wants to hear the diagnosis of Alzheimer's disease, but even that is preferable to recognizing there's a problem and not knowing what it is. At least having the diagnosis allows people to make plans for the future, including treatment as appropriate." One reason an Alzheimer's diagnosis can be comforting to both family members and patients, suggests Carpenter, is that it provides an explanation for what's been going on with the patient. Caregivers, he says, are often quick to attribute symptoms of dementia to the person, rather than the disease, and patients wonder if they are going "crazy."

Bottom line: Knowledge is power, and earlier diagnoses allow for earlier interventions to delay the effects of Alzheimer's and dementia. Medications currently on the market can slightly delay symptoms in some patients and may delay institutionalization. Perhaps more importantly, providing a diagnosis as early as possible gives people a chance to prepare for what is coming. "They know that things are going to get worse rather than better, and they know that there's going to come a time when they're not going to be able to do the things they can do now," says Carpenter. "They can get ready for what's coming, and we can connect them to support services. We can get their family ready, so they'll be better prepared."

The High Cost of Information Overload

Mon, 12 Oct 2009 06:00:00 CDT

The early part of the 21st century may eventually be described by historians as the "era of distraction." Life has speeded up and often we find ourselves trying to do several things at the same time. Unfortunately, we often become distracted, lose focus, and sometimes struggle to complete tasks. In extreme instances -- for example, while driving a car -- a high level of distraction can lead to death.

Multitasking is pervasive in our society, but that does not mean it is a good thing. When you multitask, you may think you are getting a lot done, but there's a cost when the tasks compete for the same (and limited) cognitive resources (e.g., attention, working memory) and draw on the same brain circuitry. This is true, no matter how good you think you are at multitasking. There's just too much competition for the same neural circuits and what you end up with is a compromise. Neither task is performed as well as it is when performed alone.

What are the effects of multitasking in the workplace? Multitasking may actually be counterproductive. It seems that e-mail, instant messaging, cell phones, and personal digital assistants (PDAs), which keep us all connected and allow many of us to do our jobs, can also diminish productivity.

A study by Basex, Inc., a knowledge-management research firm in New York, reported that knowledge workers (people whose work output is mainly informational in nature, e.g., creating documents, reports, studies, inventions, or patents) waste an average of two hours a day due to interruptions from e-mails, co-workers, and cell phones. Recovery time from each interruption can vary but it comes with a stiff price tag for the American economy: $650 billion every year.

How good are you at multitasking? Try this …

Part I:

Take a blank sheet of paper and write on the top: Multitasking is inefficient.

With a stopwatch or a watch with a second hand, start timing how long it takes you to recopy the phrase Multitasking is inefficient.

There is a catch: Every time you write down a letter in the phrase, on a line below the phrase, write down a corresponding number (beginning with 1).

See how long it takes you to write the phrase Multitasking is inefficient and the list of numbers from 1 to 25.

Write down your time for completion at the bottom of the page.

Part II:

Take another blank sheet of paper.

With a stopwatch or a watch with a second hand, start timing how long it takes to write the phrase Multitasking is inefficient.

When you are finished writing the phrase, immediately write down the numbers 1 through 25 on a separate line.

Write down your time for completion at the bottom of the page.

Compare your two times. Don't be surprised to find that it takes you twice as long to complete Part I (when you forced yourself to multitask) than Part II.

Restrict, Reassess, Reconsider, Rechannel, Reassure, Review

Mon, 04 Jan 2010 06:00:00 CST

In their groundbreaking book on Alzheimer's caregiving -- The 36-Hour Day -- Peter Rabins, M.D. (author of the Johns Hopkins Memory White Paper) and Nancy Mace discuss the six R's of managing difficult behavior in people with dementia. Here they are …

People with dementia often exhibit behaviors that are frustrating, embarrassing, and sometimes even dangerous to the caregiver and others. These may include angry outbursts, agitation, aggression, wandering, vocalizations, hoarding or hiding things, and inappropriate sexual behavior.

For many caregivers, these difficult behaviors are the most challenging and exhausting aspect of caring for a person with dementia. Unfortunately, the available medications to treat Alzheimer's disease have little effect on behavioral problems.

Here Dr. Rabins’ six coping strategies:

Dementia Strategy 1 -- Restrict. First, calmly attempt to get the person to stop the behavior, especially if the behavior is potentially dangerous.

Dementia Strategy 2 -- Reassess. Consider what might have provoked the behavior. Could a physical problem (toothache, urinary tract infection, osteoarthritis) be behind the agitation or anger? Is a particular person or the noise level in the room triggering the negative reaction? Could the time of day and fatigue be contributing to the problem?

Dementia Strategy 3 -- Reconsider. Put yourself in the dementia patient's shoes. Try to imagine what it must be like to not understand what is happening to you or to be unable to accomplish a simple task. Consider how frustrating or upsetting the current situation or environment might be for a person with dementia.

Dementia Strategy 4 -- Rechannel. Try to redirect the behavior to a safer, less disruptive activity. For example, if the person constantly disassembles household items, try finding simple unused devices, such as an old telephone or a fishing reel, that can be taken apart and put back together repeatedly. For someone who hoards or hides things, put away valuables and replace them with an array of inexpensive items.

Distraction often works well to curtail disruptive repetitive behaviors and restlessness. For example, try asking the person you're caring for to "help" with simple tasks, such as holding spoons or potholders while you cook.

Dementia Strategy 5 -- Reassure. The demented person's brain injury and the resulting confusion and frustration can lead to anger, anxiety, and outright fear in certain situations. Calmly reassure the person that everything is okay and that you will continue to take care of him or her.

Dementia Strategy 6 -- Review. After an unsettling experience with your loved one, take time to review how you managed the problem and what you might have done differently. Think about what may have triggered the problem, how it might have been avoided, and what you might try the next time a similar situation arises.

It also helps to create a patient-friendly environment. This might include soothing music in the background; pictures, words, or arrows to help orient the person in the house; or a secure place to sit outside or walk in the backyard.

Another Reason to Nap

Mon, 02 Nov 2009 06:00:00 CST

If you enjoy an afternoon nap, here’s good news. A study published in the Journal of Sleep Research suggests that napping may improve your memory. Here’s what the researchers found.

Although memory impairment is common as we age and usually is not a sign of a serious neurological disorder, it can be frustrating and socially embarrassing. The minor memory lapses that occur with age-associated memory impairment can’t be eliminated completely; however, a number of strategies can improve overall memory at any age.

For example, a good night’s sleep has been shown to boost your memory, and now a small study reported in the Journal of Sleep Research (Volume 17, page 3) suggests that even a short daytime nap can help, too.

German researchers conducted two experiments involving 26 university students ages 20 to 29. In the first experiment, the volunteers were asked to memorize 30 adjectives within two minutes and then to recall as many as possible after either a one-hour nap or one hour of waking activities. Each participant was tested in both the napping and waking conditions, and the experiments were repeated one week after the first testing sessions.

The results showed that the students performed significantly better after napping, and their performance was not affected by the time spent in slow-wave sleep (deep sleep). The second experiment tested participants for word recall after no nap, a long nap (35 minutes), and a short nap (six minutes).

Bottom line: The students performed the best after the long nap, but even the very brief nap significantly boosted memory processing compared with no nap at all. It may be that sleep onset itself activates memory consolidation and once the process is triggered it remains effective, even when sleep time is cut short.

Keep Your Friends, Keep Your Memory

Mon, 10 Aug 2009 06:00:00 CDT

Although memory impairment is common as we age and usually is not a sign of a serious neurological disorder, it can be frustrating and socially embarrassing. The minor memory lapses that occur with age-associated memory impairment can't be eliminated completely; however, a number of strategies can improve overall memory at any age.

A recent study in the American Journal of Public Health (Volume 98, page 1221) suggests that having a large social network may preserve cognitive function and stave off dementia among elderly women.

A study of 2,249 women ages 78 and older who were free of dementia at the study's outset were monitored for signs of dementia for four years. To assess the women's cognitive status, the researchers conducted an interview requesting tasks such as counting backwards from 20 to 1 and naming objects and concepts. The women were classified as having dementia, no or minimal impairment, or possible impairment.

To assess the size of the women's active social networks (family and friendship ties), the researchers asked each woman how many relatives/friends she saw or spoke with at least once per month, how many she could ask for help, and how many she could speak with about private matters.

Having a large social network reduced the risk of developing dementia by 26%, even after age, education, presence of depression, and other health conditions were taken into account. However, it is possible that early dementia was not detected in the assessment, and that the very early dementia was responsible for the smaller social network size.

Strong social ties may facilitate better access to health care and healthy behaviors that forestall brain deterioration and other conditions that affect cognitive function.

Rember: The Latest Alzheimer's Drug

Mon, 21 Sep 2009 06:00:00 CDT

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article Rember: The Latest Alzheimer’s Drug is no longer current, and has therefore been removed.

If you would like to read related articles about Alzheimer’s disease or other memory disorders, please go to the Memory Topic page. Thank you.

10 Alzheimer's Treatment Myths Revealed

Mon, 29 Jun 2009 06:00:00 CDT

In this article from an issue of The Johns Hopkins Memory Bulletin, the authors discuss 10 of the most common misunderstandings about Alzheimer's disease treatments.

Myth 1: Dementia is just old age, so it is best to leave the person alone.

Truth: Because dementia, especially Alzheimer's, was traditionally viewed as "senility" or normal aging, physicians and families long held that dementia was untreatable or not worth treating. We now know there are numerous dementia copycats, including depression, vitamin deficiencies, and thyroid problems, that can be improved or even halted through treatment.

Myth 2: Alzheimer's is untreatable.

Truth: Alzheimer's is incurable, but it is not untreatable.

Myth 3: There is no need to start Alzheimer's treatment early -- it's all downhill, anyway.

Truth: Studies suggest that people who start Alzheimer's treatment early usually remain better off than those who start treatment months later. That is why most expert doctors begin treatment right after a person is diagnosed.

Myth 4: Treatment will stop the course of Alzheimer's or bring someone back to normal.

Truth: Unfortunately, the available medicines cannot do this, but they can help people with Alzheimer's to think more clearly and function better and longer than they would have without the medication.

Myth 5: Memory pills should be stopped after a few weeks if there aren't any clear benefits.

Truth: It may take from several months or longer to tell if a memory drug is working.

Myth 6: Drugs for Alzheimer's work only in the early stages, so there is no use treating people in the moderate or severe stages.

Truth: These drugs are effective for treating moderate and severe Alzheimer's. They may help people in the moderate stage even more than those in the early stage. People at every stage should have access to any treatment that helps.

Myth 7: Vaccines and stem cells to cure Alzheimer's will soon be on the market, so let's just wait until they're available.

Truth: It will be years, if ever, before vaccines and stem cell therapies are available for Alzheimer's. To date, researchers have found no experimental treatment that improved thinking and memory better than the four drugs already in use: Aricept, Exelon, Razadyne, and Namenda.

Myth 8: It is worth trying a memory supplement or herbal pill before trying these drugs.

Truth: It's best to make a choice such as this after you discuss it with your doctor. Supplements or herbal treatments vary widely in their benefits and risks, and none are as well studied for Alzheimer's as are the four prescription drugs.

Myth 9: Not seeing any change after treatment means the drug is not working.

Truth: The course of untreated Alzheimer's is a progressive decline. So not seeing a change is usually a good sign because it suggests that the disease has stabilized, at least for the time being.

Myth 10: The side effects of the current Alzheimer's drugs are too strong to justify taking them.

Truth: Most beneficial drugs have side effects, and most people generally tolerate the cholinesterase inhibitors and Namenda quite well.

Adapted from The Alzheimer's Action Plan by P. Murali Doraiswamy, M.D., Lisa P. Gwyther, M.S.W., and Tina Adler. Copyright © 2008 by the authors and reprinted by permission of St. Martin's Press, LLC

When Is It Time To Stop Driving?

Mon, 08 Jun 2009 06:00:00 CDT

For most of us, driving is not only a symbol of our independence, but a practical tool of everyday living. So it's no surprise that taking away a patient's driving privileges is among the most difficult and potentially divisive decisions for the Alzheimer's caregiver. In this Health Alert, Dr. Peter V. Rabins, Medical Editor of The Johns Hopkins Memory Bulletin, answers questions about driving and the Alzheimer's patient.

Q. What signs should an Alzheimier's caregiver watch for when determining a loved one's driving competence?

A. While there are no set criteria for determining when a person with Alzheimer's disease should be prevented from driving, there are warning signs. Keep in mind that in some states, driving privileges are based on the stage of the Alzheimer's disease assigned by the physician.

The following are some common indicators that a person's Alzheimer's is making it difficult for them to respond safely while driving. Whenever you notice such problems, record the date and time when these behaviors occur, and discuss them with the person and his or her doctor:

Not signaling for turns or signaling incorrectly

Confusion at exits

Hitting curbs when trying to park

Parking inappropriately

Driving at inappropriate speeds

Delayed responses to typical and atypical situations

Getting lost along a familiar route

Getting unexplained dents on the car

Confusing the brake and gas pedals

Stopping at a green or flashing yellow light

Having near misses with pedestrians and other cars

Getting citations for poor driving

Having accident(s)

Q. When should a driving evaluation be sought?

A. If any of the above has occurred and the person will not voluntarily give up driving, then a formal evaluation by the motor vehicle bureau or private driving instructor should be sought. Most caregivers will restrict driving after a loved one has accumulated one or more of the warning signs listed above but many people with Alzheimer's disease will deny any problems and, when asked to limit their driving or stop driving altogether, will be highly resistant. Some people who have the early stages of Alzheimer's recognize that they are having changes and go in for testing on their own initiative. I always encourage and support this.

An evaluation by a driver rehabilitation specialist can be of great value in helping to make the difficult decision of taking away the car keys. A driver evaluation will assess the components of driving that may be compromised by this progressive condition. Areas assessed should include: attention, processing speed, visuospatial functioning, decision making, judgment, planning, memory, and behavior.

To find a certified driving rehabilitation specialist in your area who can perform such an evaluation, contact Driver Rehabilitation Specialists, ADED, 2425 N. Center Street #369, Hickory, NC 28601; Tel: 828-855-1623, or toll-free in the U.S. and Canada: 866-672-9466. Email: www.driver-ed.org

Caregiving from Afar

Mon, 06 Apr 2009 06:00:00 CDT

More than 30 million Americans currently provide care for elderly relatives, many of whom have Alzheimer's disease and may be unaware of any problems, resistant to care, and perhaps even irritable and unreasonable.

Long-distance caregivers constitute a large and growing group in this country. There are now an estimated five million caregivers living an hour or more away from the parent or other elderly relative they are caring for. These long-distance caregivers, about 60 percent of whom are women, have their own family, household, and work concerns.

In this Health Alert, Dr. Peter V. Rabins, world-renowned expert in geriatric psychiatry and medical editor of The Johns Hopkins Memory Bulletin, provides advice to a long-distance caregiver struggling to help an aunt with Alzheimer's disease.

Q. My aunt has been given a diagnosis of Alzheimer's disease and it is obvious that she will need care. I live 1,500 miles away. What should I do first?

A. The key here is common sense and ingenuity. First, you will need to learn everything you can about Alzheimer's disease. Do your research and understand all aspects of Alzheimer's disease so you can respond appropriately to day-to-day problems and plan for the future.

Second, assess how much assistance your aunt currently needs in carrying out Activities of Daily Living, or ADLs. These include such activities as bathing, dressing, and going to the toilet. In addition, you need to know how much help she will need to carry out Instrumental Activities of Daily Living (IADLs) -- activities such as meal preparation, shopping, housekeeping, and doing the laundry.

Finally, find out about all the Alzheimer's disease caregiving resources currently available in your aunt's community. They often include support groups, special classes, adult day care, and funding for adaptive equipment. You will be able to assess most of these needs during your initial visit with your aunt.

Be observant about health and safety issues. Does she seem to be ill, debilitated, depressed? Is she eating properly? Are friends and neighbors coming around to visit and help? Is the house clean? Is she handling her finances competently?

You should also call or schedule a visit with your aunt's primary-care physician for an update on her Alzheimer's disease and other medical issues you need to be aware of. Additional information can be gathered from your aunt's close friends, clergy, and relatives who have had close contact with her over the years.

Once you have assessed the situation, develop a plan of care based on what your aunt's primary needs are, who will provide assistance, and what community resources are available. Begin by calling the local chapter of the Alzheimer's Association. Most chapters have volunteer-run Alzheimer's disease programs, while others have paid, professional staff. All chapters should be able to tell you about good Alzheimer's disease programs in the area.

As the Alzheimer's disease worsens and your aunt becomes totally unable to care for herself at home, providing care will be even more challenging. Before that time comes, think about at what point you will no longer be able to provide the necessary level of home care. You should already be doing your research into nursing homes in your aunt's community, or in your own hometown.

Steps to Help You Avoid Medication Mistakes

Mon, 27 Apr 2009 06:00:00 CDT

When you consider how many different medications many of us take every day, it's not surprising that mistakes happen. According to a report from the Institute of Medicine, some 1.5 million preventable adverse drug events occur in the United States every year. As dire as this sounds, there is much you can do to avoid medication errors. Here are some tips from Johns Hopkins.

If memory problems hinder your ability to remember when to take medication, or if low vision makes it difficult for you to read labels, discriminate between similarly shaped pills, and read the information sheets that come with medications, you can still avoid adverse drug events by trying some of these helpful tips:

If You Have Memory Loss:

Try wrapping rubber bands around each pill bottle equaling the number of daily doses. Remove one band each time you take the medication, and then replace all of the bands for the following day.

Keep a medication chart in order to record whether you have taken your pills. This can be a simple dry-erase board on the refrigerator door; put a check next to each medication after you take it.

Use an alarm on your watch or cell phone to remind you when it's time to take your medication. Some fancier versions of dosettes come with built-in alarms. There are even automated medication dispensers that announce when it's time to take your medication, then dole out the appropriate pill.

If You Have Vision Loss:

Use a medication organizer or "dosette" to keep track of your pills, and put larger-type labels on each compartment so that you can read the days of the week and the times of day. Ask a family member or friend to fill the medication organizer for you each week.

Keep a magnifier handy with your pills.

Ask your pharmacist to use different-size bottles when dispensing similarly shaped pills. Or ask about talking pill bottles. They play a recorded message telling you the name of the medication and your prescription information.

3 Practical Strategies To Cope With Wandering

Mon, 20 Jul 2009 06:00:00 CDT

Wandering is a common behavior in people with Alzheimer's disease and other types of dementia. Many dementia patients will simply get up and walk away from their homes for the same reasons that healthy people do -- to release pent-up energy. In this excerpt from a recent article in the Johns Hopkins Health After 50 newsletter, experts provide practical advice to help caregivers cope with wandering.

Unfortunately, when people with dementia leave home alone, they can end up lost, confused, and unable to communicate vital personal information. Ideally, the dementia patient will always carry identification.

The Medic Alert + Safe Return program offered by the Alzheimer's Association is a reliable, inexpensive way to safeguard the dementia patient's identification . Initial enrollment costs $49.95 and there is an annual fee of $25. Members receive a medical alert ID bracelet or pendant engraved with their medical conditions and the Safe Return phone number. Members are listed in a national database that anyone can call at any time to report someone missing or found.

Another nonprofit organization called Project Lifesaver provides dementia patients who wander with wristbands that emit tracking signals and works with local law-enforcement agencies to find someone who is lost.

Microchip protection is another option for the dementia patient. If you have ever waved an ID card over a sensor to gain access to a restricted area, you've used Radio Frequency Identification (RFID) technology. In its latest incarnation, an RFID implant known as VeriChip is helping to manage a serious consequence of wandering: needing medical attention but being unable to communicate. The use of RFID technology for medical identification is in its infancy. Health insurance policies do not cover VeriChip; however, its cost is relatively low -- around $200.

Safeguards at Home

First, consider why the dementia patient might be walking off: Is he or she physically uncomfortable, agitated, or bored? Keeping people with dementia engaged can help control impulsive actions like wandering.

Ask the doctor if medications could be causing restlessness.

Keeping clocks in plain view can limit confusion about time.

You can bolt outside doors or install safety locks, but this practice can be dangerous in case of a fire or another emergency.

Attempting to stop the dementia patient in the midst of wandering can be difficult. Instead, follow them and gently lead them home when they are ready.

For more information:

Alzheimer's Association Safe Return
888-572-8566
www.alz.org/we_can_help_safe_return.asp

Project Lifesaver International
877-580-LIFE (5433)
www.projectlifesaver.org

VeriChip
800-970-CHIP (2447)
www.verimedinfo.com

Dementia, Depression, and Anxiety

Mon, 16 Mar 2009 06:00:00 CST

It's well known that people with dementia often suffer from anxiety and depression, but now researchers are realizing that symptoms of depression and anxiety actually wax and wane as cognitive dysfunction increases.

The cognitive changes of dementia -- impairment of memory, learning, attention, and concentration -- can also occur in people who are depressed, making the diagnosis of dementia more difficult. In fact, depression and cognitive decline often occur together.

Now a study in the journal Dementia and Geriatric Cognitive Disorders (Volume 24, page 213) shows that symptoms of depression and anxiety actually wax and wane as cognitive dysfunction increases.

The researchers compared four groups in various stages of cognitive decline from a community-based sample and a clinical sample of older people diagnosed with Alzheimer's. The prevalence of anxiety and depression symptoms among people in various stages of cognitive decline was established, then analyses were conducted to determine differences between the levels of cognitive functioning.

Anxiety symptoms were noted in 8.6% of people with good cognitive functioning, rising to 11.8% in those with moderate functioning and dropping to 10.7% in those with poor functioning. Similarly, depressive symptoms were found in 8.9% of those with good functioning, 22.1% of those with moderate functioning, and 21.1% of those with poor functioning. Of those diagnosed with Alzheimer's disease, only 6% had anxiety and 16.7% suffered from depression.

The increase in depression and anxiety symptoms earlier in the course of cognitive decline may be attributed to individuals noticing the decrease in functioning, while in later cognitive decline (and Alzheimer's) anxiety and depression may appear to decrease due to lack of awareness.

Coping with Alzheimer's Disease Symptoms

Mon, 22 Dec 2008 06:00:00 CST

In each issue of our Johns Hopkins Memory Bulletin, leading neurologists answer readers' questions about Alzheimer's disease, memory, and dementia. Here are two recent examples.

Alzheimer's Disease Question 1: My wife Elisa is 82 and has been taking Aricept for four months. She complains of having nightmares and says that the Aricept is the cause. I went to the Aricept website and I didn't read about nightmares as a side effect of the drug.

When I mentioned Elisa's complaint at my Alzheimer's disease support group meeting, no one there had any experience with nightmares caused by Aricept. What has been your experience with Aricept and nightmares? Cleveland, OH

Answer: Vivid dreams and nightmares can be side effects of all the cholinesterase inhibitors, the drug class in which Aricept, Razadyne, and Exelon reside. They can also be side effects of most antidepressant medications, especially those in the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) classes. Talk with the physician who prescribed the Aricept for your wife; I have found that lowering the dosage sometimes helps.

Alzheimer's Disease Question 2: What do you recommend that I do for my grandfather with Alzheimer's, who doesn't realize that he is actually home? Some background: Gramps worked for the railroad for 48 years and did a lot of traveling during his career. Now that he is 90 and was diagnosed with Alzheimer's disease a year ago, he suddenly says that someone should pick him up, along with his luggage, and help him get home. I live with him and tell him repeatedly that he is already home. He gets this blank look on his face and then repeats that he wants to go home. This has been going on for a month, and I don't know how I can convince him and ease his concerns that he is already safe at home. Westport, CT

Answer: You are describing what doctors refer to as an agnosia, an inability to recognize a familiar object, person, or place despite intact eye function. This symptom can be seen in other brain diseases that affect the parietal lobes of the brain, so it is not only a symptom of Alzheimer's disease but does become common in Alzheimer's disease as the illness progresses.

This is not merely "forgetting" where one lives; many individuals with this problem can accurately describe the home they live it. Rather, it is an inability of the brain to merge the memory of a place with the perception the person is seeing at that time. In my experience, there is no benefit and sometimes harm in repeatedly trying to convince the patient that "this is your house." I think it would be best to distract him by changing the subject, reminiscing about his home, or empathizing with his distress. On occasion, it is ethically permissible to lie to someone with Alzheimer's disease if that decreases his or her distress (for example, telling him, "We'll be going to the house tomorrow").

Living With Alzheimer's Disease – Your Questions Answered

Mon, 23 Feb 2009 06:00:00 CST

In each issue of our Johns Hopkins Memory Bulletin, leading neurologists answer readers' questions about Alzheimer's disease, memory, and dementia. Here are two recent examples.

Alzheimer's Disease Question 1: My 86-year-old father lives with us and has had Alzheimer's disease for three years. My wife and I are planning a trip by car (six hours) with my father to Jackson Hole, Wyoming. We are wondering if there is anything special we should be aware of during this two-week holiday when we will be far away from home with someone with Alzheimer's disease. Via e-mail.

Answer: If his Alzheimer's is relatively mild -- and especially if your father has enjoyed traveling in the past -- things should go well, if you remember a few things.

First, travel itself is tiring, especially these days, so make sure you don't expect too much. If your father appears fatigued, make use of a wheelchair.

Second, remember that people with Alzheimer's disease do best in familiar settings, so going to an unfamiliar place can "bring out" underlying cognitive impairments. You can minimize this by frequently reminding him where you are and what is going on ("Dad, isn't it great to be here in Jackson Hole for vacation?").

Third, you should not leave him alone, even if things are going well -- the unfamiliarity of the new environment can suddenly trigger disorientation, fear, and distress in someone with Alzheimer's.

If you hire a stranger to be with him while you go out and explore the area, the person should frequently (even every five or 10 minutes) remind him who they are, where they are, and what is happening.

Alzheimer's Disease Question 2: It seems like every mealtime is highly questionable for my 79-year-old father who has Alzheimer's disease. Many times he will start to eat and then abruptly stop, sometimes after just two minutes. On average, he eats half of his meals. Even after coaxing him to eat more, he always refuses. Dad used to have a hearty appetite, but now, with his refusal to eat, he is starting to lose weight and this has me concerned. Your counsel would be greatly appreciated. Montreal, Canada

Answer: The average person with Alzheimer's disease loses 1-2 pounds per year. If your father is generally keeping his weight steady, I wouldn't worry. If your father is losing more than 1-2 pounds per year, he should be assessed for depression, medications that suppress appetite, dental disease, and swallowing problems. If any of these is present, they should be directly addressed. Cancer is an uncommon but serious cause of poor appetite that needs to be considered.

In addition, make sure that he has plenty of time to eat. Some individuals are just slow eaters, or Alzheimer's disease seems to slow them down, but there is rarely any hurry to eat. Let him go at his own pace if he eventually eats enough but it takes one hour. Does he have favorite foods or things that are easier for him to eat? These might make a difference.

Sleep, Memory, and the Brain

Mon, 12 Jan 2009 06:00:00 CST

When you're sleep deprived, cognition is one of the first functions to decline. Shortchange yourself on sleep by staying up late, continue this night after night, and you ultimately shortchange your memory. And if the problem is not resolved, your memory -- and your brain -- will not be functioning in the best way possible.

In this excerpt from our Johns Hopkins Memory Bulletin, neurologists Marilyn Albert, Ph.D. and Guy McKann, M.D. answer questions about sleep and how it affects the brain and memory.

Q. How much sleep does an adult need each night?

A. As people get older, a decrease begins in both the total time sleeping and the amount of time spent in the stage of sleep associated with dreaming. A newborn sleeps 16 hours per day. In contrast, the baby's 30-year-old mother sleeps six hours per day (if she's lucky), and only one quarter of this time, or two hours, is occupied by the deepest stage of sleep.

Starting in middle age (between 45 and 60), not only does the amount of sleep per night start to decrease, but also the character of sleep changes. People at these ages spend less time in the stage of sleep associated with dreaming and more time in the lighter stages.

As people get older, they are more likely to shift the time when they sleep, some going to bed and to sleep earlier and waking up earlier. Others are the opposite, staying up late into the night and sleeping much of the day. When people are in their 80s, these changes are even more pronounced. Their total time asleep per day may be only six or seven hours, including time spent in daytime naps. Even though a person may take several naps a day, the total time sleeping in naps is rarely over an hour. The idea that older individuals should sleep soundly for eight to 10 hours is clearly wrong.

As a rule of thumb, one hour of sleep is required for two hours of being awake. As we get older, that ratio becomes closer to 45 minutes of sleep to each two hours awake. In other words, throughout the day you gradually accumulate a "sleep debt." By the end of a 16-hour day, a younger person owes the "sleep bank" eight hours. In contrast, an older person has a sleep debt of only about six hours. By the end of a week, you may have accumulated a sleep debt of eight to 10 hours.

Q. What are the effects of sleep deprivation?

A. If you don't allot enough time for sleep, you become sleep deprived. Besides being sleepy during the daytime, sleep-deprived people often have problems with their thinking. They are slower to learn new things, they may have problems with memory, and their ability to make judgments may be faulty, enough so that they may think they are really starting to "lose it" when the problem is really not enough sleep.

Elderly people do not recover from sleep deprivation as quickly as younger people. In experimental situations where people are kept awake for 24 hours, those in their 70s take at least a day longer to recover from their subsequent daytime sleepiness than younger people. Gender may also make a difference in the time it takes to recover from sleep deprivation; women seem to be able to recover faster than men.

How Memory Is Affected in Alzheimer's

Mon, 01 Dec 2008 06:00:00 CST

In this article from our Johns Hopkins Memory Bulletin, Dr. Peter V. Rabins and colleagues explain how the brain's memory systems are affected in Alzheimer's and other memory-stealing conditions.

The human brain contains an estimated 100 billion nerve cells (neurons). Chemical and electrical activity allows these neurons to perform their tasks and to communicate with one another. This elaborate communication system controls vital body functions and enables us to think, see, move, talk, remember, and experience emotions.

Normal aging leads to changes in the brain, especially in areas involved in learning and memory. Some neurons shrink; others are disabled by damaging molecules called free radicals. Daily "insults," such as high blood pressure or elevated low-density lipoprotein (LDL) cholesterol, also take their toll.

Over time, these changes can make it more difficult for an older person to learn new tasks or to retrieve information from memory, such as someone's name. With Alzheimer's disease, the damage is more severe and ultimately affects larger regions of the brain.

The different memory systems -- episodic, semantic, procedural, and working -- involve multiple areas of the brain.

Episodic Memory. The temporal lobe, which contains the hippocampus, and the prefrontal cortex are important to episodic memory, which enables us to learn new information and remember recent events. The hippocampus is one of the first brain structures damaged in Alzheimer's disease and accounts for one hallmark of early Alzheimer's: difficulty remembering recent events, without any trouble remembering events from long ago.

Semantic Memory. Semantic memory governs general knowledge and facts, including the ability to recognize, name, and categorize objects. This system also involves the temporal lobes and, researchers suspect, multiple areas within the cortex. People with Alzheimer's disease may be unable to name a common object or to list objects in a category, such as farm animals or types of birds.

Procedural Memory. The cerebellum is one of the structures involved in procedural memory. Procedural memory is what enables people to learn skills that will then become automatic (unconscious), such as typing or skiing. This memory system typically is not damaged in Alzheimer's disease or is one of the last cognitive domains to deteriorate.

Working Memory. Working memory involves primarily the prefrontal cortex. This memory system governs attention, concentration, and the short-term retention of needed information, such as a street address or phone number. Problems with working memory can impair a person's ability to pay attention or to accomplish multi-step tasks. Numerous cognitive disorders, such as Alzheimer's, Parkinson's, and Huntington's disease as well as dementia with Lewy bodies, can affect working memory.

How to Recognize Symptoms of Early-Stage Alzheimer's Disease

Mon, 10 Nov 2008 06:00:00 CST

What kinds of behaviors should you expect from a loved one who has just been diagnosed with early-stage Alzheimer's disease? Johns Hopkins discusses 10 common symptoms of early Alzheimer's.

Alzheimer's disease is progressive, meaning it worsens over time. It is also terminal, meaning all who develop it will eventually succumb to it. As Alzheimer's rides its course, it renders those who suffer from it increasingly dependent on the care of others. This is true for all people who develop Alzheimer's, but the particular symptoms and the degree to which they show themselves vary among individuals.

For convenience, the progression of Alzheimer's is often divided into three stages: early/mild, middle/moderate, and late/severe. The symptoms and signs of Alzheimer's have been identified by observing people with Alzheimer's disease as a group.

An individual may not show all of the symptoms in each stage of progression. For example, many -- but not all – Alzheimer's patients develop severe psychiatric problems, such as delusions and hallucinations. Among those who do, the symptoms appear in the middle to late stages of Alzheimer's.

It may help friends and family to familiarize themselves with the typical stages of Alzheimer's disease so that they know what to expect in the coming years. The early/mild stage of Alzheimer's is characterized by declining ability to form new memories, impaired ability to organize and manipulate complex ideas, and, sometimes, by personality changes.

Symptoms Mild Dementia/Early Stage Alzheimer's disease

Diminished short-term memory

Misplacing belongings in odd places; losing valuable belongings, like wallet or purse

Difficulty finding the right word: "Tip of the tongue" syndrome

Person seems "not himself" and shows uncharacteristic behaviors

Lapses in judgment

Difficulty with mental arithmetic and handling money

Disorientation in unfamiliar places or situations

May become apathetic or withdrawn, avoiding social situations

More difficulty with routine tasks at work or at home, or may take longer to complete tasks

Irritation or anger in response to increasing memory lapses

Specific Examples

Asks the same question repeatedly within the same conversation

Puts car keys away in refrigerator

Unable to recall word for "car" and then says in frustration, "The thing you drive to work in."

A normally shy person becomes uncharacteristically outgoing or talkative at a family gathering

Agrees to buy services or products he/she doesn't need from telephone sales person

Finds it difficult to balance checkbook or figure out correct amount of money to pay for an item

while shopping

Forgets to eat, skips meals, or eats the same food every meal

Red-Flag Changes in Mental Functioning

Mon, 08 Sep 2008 06:00:00 CDT

How can you tell if a friend or family member is beginning to exhibit signs of early dementia – or merely age-appropriate forgetfulness? In this health alert, Johns Hopkins provides six red-flag symptoms of early dementia.

Dementia refers to a significant intellectual decline that persists over time and affects several areas of cognition. Memory loss is a universal feature of dementia, but other functions are impaired as well, such as abstract thinking and language.

According to guidelines published by the Agency for Health Care Policy and Research, a person who has difficulty with one or more of the following activities should be evaluated for dementia:

Dementia Symptom 1 -- Learning and retaining new information. The person regularly misplaces objects, has trouble remembering appointments or recent conversations, and is repetitive in conversations.

Dementia Symptom 2 -- Handling complex tasks. The individual has trouble with previously familiar activities, such as balancing a checkbook, cooking a meal, or other tasks that involve a complex train of thought.

Dementia Symptom 3 -- Ability to reason. The person does not respond appropriately to everyday problems, such as a flat tire. Or a previously responsible, well-adjusted person may display poor financial or social judgment.

Dementia Symptom 4 -- Spatial ability and orientation. Driving and finding one's way in familiar surroundings become difficult or impossible, and the person may have problems recognizing known objects and landmarks.

Dementia Symptom 5 -- Language. The ability to speak or comprehend is impaired, and the person may have problems following or participating in conversations.

Dementia Symptom 6 -- Behavior. Personality changes emerge. For example, the person may appear more passive and less responsive than usual or more suspicious and irritable. Visual or auditory stimuli may be misinterpreted.

Dr. Rabins' Walking Prescription

Mon, 29 Sep 2008 06:00:00 CDT

In this excerpt from the Johns Hopkins Memory Bulletin, Dr. Peter V. Rabins provides readers with his personal formula for walking to preserve memory.

The benefits of exercise for health are not a new discovery: More than two millennia ago, Hippocrates said that when the body is unused and left idle, body parts become susceptible to disease and the body as a whole ages quickly.

Hippocrates's observations are still valid. Research has proven that regular physical activity helps decrease your chances of having a heart attack or stroke by improving circulation and metabolism. Regular exercise also lowers both your heart rate and your blood pressure and helps clear life-threatening plaque from arteries. This all not only translates into an improved heart profile but also may help ward off dementia.

Now, new research from Italy reported in the recent issue of the journal Neurology points out that daily walking and other forms of non-strenuous physical activity may significantly reduce your risk of vascular dementia, the second most common form of dementia after Alzheimer's disease.

In a four-year study of 749 men and women over age 65 with no dementia at the start of the study, researchers tracked weekly physical activity levels of walking and climbing stairs, and moderate activities including house work, gardening, and carpentry. At the study's end, 27 people developed vascular dementia, while 54 had developed Alzheimer's disease.

Dr. Rabins' Walking Prescription to Ward Off Dementia: I am going to ask you to walk daily over the next eight weeks. Of all the physical activities, I have chosen walking not only because it uses almost all of the 650 muscles and 206 bones in the body, but also because it is a great way to shed pounds and develop muscle.

Granted, most people walk no more than 6,000 steps daily. By the eighth week of your walking program, I want you to increase that distance to at least 10,000 steps a day.

All you will need to purchase is an inexpensive pedometer to do your step counting for you. I find that a step counter is an invaluable piece of equipment to own. Purchase one at your local sporting goods store or buy one on the Web at: www.digiwalker.com or www.accusplit.com. Compact, accurate models cost approximately $20 to $30.

My goal for everyone is to walk at least 10,000 steps a day, which, depending on stride length, is anywhere from four to five miles. I hope I do not scare you off with that distance, but stick with the program and I guarantee that by week eight you will have no trouble accomplishing this goal.

Keeping Your Mind Sharp With Stress Reduction

Mon, 28 Jul 2008 06:00:00 CDT

Now there's another good reason to reduce the stress in your life: researchers have found that elevated levels of stress hormone are linked to a decline in cognitive function.

Add stress reduction to the list of steps you can take to keep your mind sharp. Johns Hopkins researchers have linked high levels of the stress hormone cortisol with a decline in cognitive performance in older individuals.

The researchers examined the stress–cognitive function connection as part of the ongoing Baltimore Memory Study, in which they gave 20 standard cognitive tests to 967 participants (average age 61) while measuring cortisol levels in their saliva. Samples were collected before, during, and after the individuals underwent the cognitive tests and again at the end of the study. The tests provided data on mental abilities such as information processing speed, language skills, and verbal memory and learning.

The researchers found that as cortisol levels rose, cognitive performance declined in a manner comparable to the aging process. For example, the cortisol-related slide in language skills was similar to what would be expected from someone who had aged nearly six years. A possible explanation is that chronic stress leads to malfunctions in the brain pathway that both regulates cortisol production and influences the health of brain cells, resulting in a greater degree of wear and tear on the brain.

This study was reported in the Archives of General Psychiatry (Volume 64, page 810).

The Link Between In-Hospital Delirium and Dementia

Mon, 18 Aug 2008 06:00:00 CDT

Delirium commonly strikes after surgery, when patients are woozy from the lingering effects of anesthesia and pain medication. Johns Hopkins' specialist, Dr. Michele Bellantoni provides practical advice on minimizing in-hospital delirium.

The connection between delirium and dementia is still not fully understood, although doctors have known for quite some time that people who experience an episode of delirium and recover are more likely to go on to develop dementia.

Delirium may set off a cascade into Alzheimer’s in people who are already at risk. And there is some evidence that this risk may go both ways: People at higher risk for Alzheimer’s may be at greater risk for delirium. Another study published in the Journal of Gerontology found that patients who had the APOE susceptibility gene for Alzheimer’s, but were not diagnosed with Alzheimer’s were more likely to experience in-hospital delirium. That said, because people who develop delirium tend to be older and have coexisting health problems that increase their risk of developing both dementia and delirium, it’s difficult to tease out the direct role, if any, that delirium plays in dementia.

What you can do -- Family members can help minimize or prevent delirium by making sure that a loved one is not left alone for long periods, especially when he or she is coming out of anesthesia. “Often the patient who is waking up after surgery may not know where he or she is, which can be very frightening, so simply knowing that family is close by is a major consolation,” says Dr. Michele Bellantoni, Associate Professor of Medicine at Johns Hopkins.

You may want to arrange to stay overnight at the hospital -- this way someone who knows how the patient normally acts can quickly alert hospital staff to any changes in behavior. “Family members know the patient best, so they can keep doctors and nurses posted if a loved one’s behavior becomes uncharacteristic. It’s a huge help if someone says, ‘You know, this isn’t my mother’s normal behavior.’”

Making sure that the hospital room is well lit and that curtains are regularly drawn during the day can help patients maintain a sense of time and get back to a regular schedule of sleeping at night and staying awake during the day. Family members also can make sure that eyeglasses and hearing aids are worn. And familiar objects from home such as a favorite sweater, blanket, pillow, books, or family photos can also help patients maintain orientation and awareness while they are in the hospital.

Detecting Hospital Delirium

Mon, 16 Jun 2008 06:00:00 CDT

The connection between delirium and dementia is still not fully understood, although doctors have known for quite some time that people who experience an episode of delirium and recover are more likely to go on to develop dementia. In this Health Alert, Dr. Michele Bellantoni talks about the signs of hospital delirium.

Delirium is a common and sometimes serious medical condition that often strikes older people during hospital stays. Though delirium associated with dementia, delirium is temporary and the majority of people who get it improve in a matter of days. Michele Bellantoni, M.D., Associate Professor of Medicine and Medical Director, Johns Hopkins Bayview Care Center, explains, “It’s important to understand that unlike dementia, delirium is a temporary problem that can be treated by figuring out the cause and addressing it.”

The American Geriatrics Society estimates that one third of adults over 70 who are admitted to a hospital experience delirium, and the rates are higher for older adults in intensive care and nursing homes.

Delirium is not a psychological response to physical illnesses, as once thought. In fact, new scientific evidence suggests that abnormal biological processes in the brain are at work. A study published in the Journal of Gerontology compared the brain scans of 22 hospitalized patients taken before and after episodes of delirium. In roughly half the patients, decreased blood flow was specific to key regions of the brain known to control attention and orientation, perhaps explaining the inattention and disorientation associated with delirium.

This may also help explain why delirium can be dangerous: People who become delirious spend more recovery time in the hospital, are more likely to die, and are at higher risk for developing long-term cognitive impairment and dementia.

Detecting Delirium -- Delirium may be difficult to detect, particularly in people with memory problems or dementia. Be sure to make allowances for certain personality traits -- tell the doctor if a loved one is typically restless or introverted, for instance.

There is no universal rating system to help determine if a patient has delirium; however, the reliability of the following criteria tested positively in a study published in the Journal of Geriatric Psychology. Some central characteristics that researchers identified are listed below. Examples of the type of behavior that might indicate each characteristic are also included.

Delirium Symptom 1 -- Shifting attention:

Unable to concentrate during conversations

Switches topics frequently

Easily distracted

Completely inattentive

Delirium Symptom 2 -- Poor orientation:

Has problems articulating the date

Doesn’t know the days of the week

Doesn’t know where he or she is

Has trouble recognizing family members

Delirium Symptom 3 -- Incoherence:

Speech is difficult to understand

Stops in the middle of a sentence

Cannot express thoughts

Delirium Symptom 4 -- Restlessness and anxiety:

Jumpy, edgy, or fidgety

Suspicious of others

Anxious and afraid

Requires frequent reassurance

Delirium Symptom 5 -- Delusions and hallucinations:

Perception is distorted or completely wrong

Sees shapes or objects incorrectly

Smells scents that are not there

Delirium Symptom 6 -- Poor cognition:

Cannot spell simple words backwards

Cannot do simple math

Cannot recognize simple patterns of words or numbers

Questions About Alzheimer's Disease

Mon, 05 May 2008 06:00:00 CDT

Alzheimer's Question 1 – Where can I get the best medical evaluation for my wife?

Q. My wife’s doctor thinks she may have an early form of Alzheimer’s disease. It’s been a week since he gave us that devastating news, but I now feel able to gather my wits and do whatever I can to help get her the best care. We are retired, 78 years old, and able to travel to any center that is recommended. What medical specialists should we seek out for a more extensive evaluation and/or care? Eugene, OR

A. Your wife’s primary care physician might be the best person to oversee her care. If you would like to see a specialist in Alzheimer’s disease or would like to participate in research, you should contact the nearest Alzheimer's Disease Research Center or ask your internist if there is a specialist in your community who is particularly knowledgeable about Alzheimer’s disease. Even if you do pursue another opinion or participate in research, you should keep her primary physician informed. In the end, her internist’s care will be crucial to her well being.

Alzheimer's Question 2 -- Is it Alzheimer's or something else?

Q. Many people assume that if an older person becomes forgetful and can no longer deal with some of the basic activities of daily living, he or she must have Alzheimer’s disease. A sad case in point: My father’s internist diagnosed him with Alzheimer’s disease last year (my father was then 80) and prescribed medication that didn’t seem to help at all. It wasn’t until I took my father to a neurologist that we learned he actually had a benign brain tumor that was affecting his memory and behavior. With that as a backdrop, what are some other brain diseases that may be mistaken for Alzheimer’s? Santa Fe, NM

A. Dementia, the diminution of multiple cognitive abilities occurring in normal alertness, can be caused by numerous factors. These include space-occupying brain lesions (tumors, collections of blood called subdural hematomas, and abscesses); infection (meningitis, encephalitis, syphilis, to name a few); impaired cerebral spinal fluid flow causing normal pressure hydrocephalus; metabolic and endocrine abnormalities (too much or too little thyroid hormone or cortisol are examples); radiation to the brain; brain trauma; stroke; and medication side-effects. Severe depression can also cause dementia. This is why medical, neurologic, and psychiatric assessments are essential parts of the initial evaluation of dementia.

Dr. Rabins Talks About Long-Term Care

Mon, 14 Apr 2008 06:00:00 CDT

Many people admit that this is one of the hardest things they will ever do. That's how I once described the distress and despair that caregivers of dementia patients confront when they begin to ask themselves -- Has the time come to move my loved one into a residential care facility? In this excerpt from the Memory Bulletin, acclaimed Johns Hopkins professor Peter V. Rabins, M.D. discusses a caregiver's most difficult decision.

The uncertainties involved in making the decision to move a loved one to a long-term care facility are numerous, and the stakes could hardly be higher. However, for millions of caregivers, continuing to look after a loved one at home becomes, at some point, either dangerous or simply impossible. For many caregivers, the physical requirements of care, emotional stress of caregiving, lack of sleep, pent-up anger, resentment, and frustrations become overwhelming. To continue would threaten not only their health, but the health of the person with dementia as well.

Q. How does a caregiver know when the time has come to move a patient with dementia from the home setting to a long-term care facility?

Dr. Rabins. There really is not one answer to that question; any answer is different for each person with the illness and for each family. Everything depends on the symptoms the ill person has -- the degree of the impairment in his/her cognitive skills -- and on what other kinds of associated problems he/she is having in behavior and activity.

The decision also depends on the ability of the caregiver to adequately meet the person's needs. Perhaps the most important question is whether it would be dangerous to continue the current situation. If the ill person needs more physical care than can be provided at home, wanders away in spite of attempts to prevent it, has become aggressive towards others and has not responded to care, or has dangerous medical conditions that need more monitoring than can be provided, then moving to a place where these needs can be better met is the right thing to do.

It is important to consider, as well, the emotional well-being of the caregiver. How overwhelmed is the caregiver? Has the caregiver been able to use the resources that are available in the community? After weighing the pros and cons of each factor, you can better make a decision.

Q. Should the goal always be to keep the ill person at home as long as possible?

Dr. Rabins. Definitely not. Some people can stay at home and die at home, and for many families that's the ideal. However, even when that's desired, it is often not in the ill person’s best interest, especially from the point of view of their quality of life. Often we find that a person actually does better when moved to long-term care. And it’s better for the family members, because then they can visit and enjoy their time with the patient without having to worry about providing all the physical care.

Aging and Emotional Stability

Mon, 26 May 2008 06:00:00 CDT

Are you mellowing as you get older? A recent study shows that while memory function may decline as we age, our emotional stability actually increases.

The brain contains approximately 100 billion neurons. A common misconception is that tens of thousands of neurons in the brain die each day. In reality, few neurons die over a person’s lifetime, but they do shrink. This shrinkage may partially explain why mental functioning slows in middle and older age.

In addition to the shrinkage of neurons, starting in middle age the brain begins producing smaller quantities of many neurotransmitters -- chemical messengers that relay information between nerve cells. Brain blood flow is also reduced 15–20% between age 30 and age 70, although the shrinkage of neurons may account for the reduced flow because less tissue requires less blood.

Although memory function may decline with age, emotional stability increases, according to a study reported in the Journal of Neuroscience (Volume 26, page 6422). Forget the myth that older people are crankier than younger ones. In fact, the reverse is true: Age brings increased emotional equanimity.

Australian researchers evaluated 142 people between the ages of 12 and 79. All were in good physical health and had no current or past history of mental illness. The study participants were asked to complete a questionnaire that assesses emotional stability, with higher scores suggesting more positive emotions. In addition, the individuals’ brain activity was assessed by functional magnetic resonance imaging (fMRI) while they viewed images of various facial expressions. Scores on the questionnaire kept in step with age, rising along with seniority.

The brain fMRI images revealed that the older adults’ emotional reactions were primarily influenced by the medial prefrontal cortex, an area of the brain needed for conscious thought. In contrast, the emotional reactions of younger people were centered in the amygdala, a part of the brain implicated in automatic fear responses. This reorganization of the brain’s emotion system may happen as older people integrate their accumulated life experience and find meaning and patterns in that experience. The study provides a reminder that persistently negative moods in older people are not a normal part of aging.

New Frontiers -- Diagnosing Alzheimer's Disease With A Skin Test

Mon, 03 Mar 2008 06:00:00 CST

In recent studies, researchers have identified chemical changes that occur in Alzheimer’s disease, opening the door to a possible skin test to diagnose Alzheimer’s in the not too distant future.

Although only an autopsy can prove the presence of Alzheimer’s disease, the clinical diagnosis is usually accurate. The current approach to establishing the cause of memory loss involves ruling out some potential causes and finding evidence to confirm the presence of others.

Once other conditions, such as depression, Huntington’s disease, or hypothyroidism, have been ruled out, the diagnosis of Alzheimer’s is made by accumulating information on the individual’s history, mental status exams, and interviews with the patient, family members, and friends over a period of several weeks.

What’s on the horizon?

Researchers have identified chemical changes that occur in Alzheimer’s disease but not in other forms of dementia. Because the specific chemical signals can be detected in both brain and skin cells of Alzheimer’s patients, this opens the door to a possible skin test for Alzheimer’s.

In the study, which was reported in the Proceedings of the National Academy of Sciences (Volume 103, page 13203), researchers compared human skin cells from a tissue bank with autopsy samples from people who had Alzheimer’s disease.

As it turned out, the skin tissues from the Alzheimer’s patients were distinguished by changes in two related enzymes that are involved in inflammatory signaling pathways. Inflammation is believed to play an important role in the development of Alzheimer’s disease.

A skin test would have many advantages over a spinal tap or brain scan - -- two tests currently used to aid doctors in the diagnosis of Alzheimer’s disease. If such a test is eventually developed, it could be administered on an outpatient basis, in a clinic or physician’s office.

More important, it could be given early in the course of Alzheimer’s, when it is often difficult to determine whether a person has Alzheimer’s or another degenerative neurological condition. The earlier an accurate diagnosis of Alzheimer’s is obtained, the earlier treatment can begin. That’s important because current medications are effective only when given early in the disease process.

Behavioral Changes and Alzheimer's

Mon, 31 Dec 2007 06:00:00 CST

Serving as the primary caregiver to someone with Alzheimer's disease can take a heavy toll and lead to burnout. In this Q & A from a recent issue of the Johns Hopkins Memory Bulletin, Dr. Peter V. Rabins gives advice to a worried wife.

Question. My husband was diagnosed with early-onset Alzheimer’s disease when he was 59; he is now 65. He had been doing really well and I’ve been able to keep him home. However, in the last month, Kostas has been having problems. From being someone who had a great appetite, he now hardly eats anything. It’s also difficult giving him his Alzheimer’s medication.

Because I am now not sure whether he will do the simple things I ask him to do, I rarely take him to the store and other places we used to go to together. Over the past three years, I have been helping Kostas bathe, but now he refuses to bathe. My problems, then, have to do with Kostas’s lack of interest in food, as well as how to get him to take his heart and Alzheimer’s drugs and what might I be able to do to get him to bathe. Any suggestions would be welcome. Abilene, TX

Dr. Rabins answers. This is a difficult set of problems. If you are struggling with all these challenges alone, I urge you to look into getting help and support from family, friends, a social support agency, the Alzheimer’s Association, as well as a dementia specialist.

If some of these problems have developed quickly, consider whether a second issue such as depression, a new medical illness, or medication side effects is partly to blame. If swallowing difficulties are contributing to the problem your husband is having in taking medication, ask his doctor whether his medications are available in liquid form or as rapid-dissolving tablets. The bathing problems you describe become common as Alzheimer’s progresses; if no other cause is identified, consider getting bathing help from another person (family or paid aide), decreasing the frequency of the baths, or giving him sponge baths from time to time instead of a regular bath.

Editor’s note: Peter V. Rabins, M.D., M.P.H. is Medical Editor of the Johns Hopkins Memory Bulletin and Professor of Psychiatry at the Johns Hopkins School of Medicine. His best-selling guide for caregivers, The 36-Hour-Day, has provided support to countless thousands struggling to cope with the demands of caring for a loved one with Alzheimer’s and other dementias.

What to Do About Question Repetition and Cursing

Mon, 19 Nov 2007 06:00:00 CST

Dr. Peter V. Rabins and his team of psychiatrists and neurologists at Johns Hopkins answer questions about common behaviors of patients with dementia.

Dementia Behavior Question 1: My husband (82 years old) was diagnosed with Alzheimer’s eight months ago. He has now reached the stage where he asks the same question repeatedly, sometimes for several hours. I try to be patient and give him a real response to the same query, but it has gotten to the point where I can say just about anything and it really makes no difference what I say. Is there any "proper" way I should handle this behavior, or is there a medication that may reduce this type of behavior? He currently takes Aricept. Via email

Answer. Question repetition is a very common behavior with Alzheimer’s, and your struggles with it are similar to those of many other caregivers. Unfortunately, since this behavior results from the impaired memory that is an early hallmark of Alzheimer’s disease, the only medical therapy for it is the medication he is now taking.

Your attempt to answer him each time is both admirable and understandable, since we all would be insulted if our questions were not answered. However, after answering it once or twice, it is sometimes better for all involved to change the subject, to respond that you cannot answer right away but will in a minute (distraction), or to give a very brief response ("no” or "yes”) when a longer one would be more informative. It sometimes helps to get the person engaged in activities that keep him or her busy -- adult day programs are one way to do this -- since he is less likely to ask questions if he is otherwise engaged.

Dementia Behavior Question 2: My 86-year-old mother-in-law has lived with my husband and me ever since she was diagnosed with frontal-lobe dementia eight months ago. In the past, I have taken her with me to go grocery shopping, but lately she has been having outbursts that appear without provocation. She will start to curse a blue streak like an angry dockworker and I can’t get her to stop. I now leave her home, which upsets me, but I don’t have any choice. Is there any way she might lose this profanity aspect of her dementia, or is there a good medication you could recommend for her? Derby, CT

Answer. Emotional outbursts of the kind that you describe can occur in frontotemporal dementia (FTD) and any other disease that causes a brain injury. Sometimes their provocations are quite minor, but sometimes no obvious causes can be found. If this behavior happens only when you take her to the store, it may well be that being in the grocery store -- with its bright lights, bustle, and noise -- is the stimulus. If that is the case, try to find other places you can go together that don’t elicit the behavior. Keep in mind that this behavior does not in any way reflect what a person was like before the disease.

Do Alzheimer's Disease Medications Really Work?

Mon, 21 Jan 2008 06:00:00 CST

In this excerpt from an article in the Spring 2007 Memory Bulletin, Dr. Peter V. Rabins, Co-Director of the Division of Geriatric Psychiatry and Neuropsychiatry at The Johns Hopkins School of Medicine shares questions from his patients about Alzheimer’s disease medications.

When it comes to drugs for Alzheimer’s disease there are presently four drugs in the anti-cholinesterase class -- Aricept, Exelon, Razadyne, and Cognex (rarely used today because of it’s potential for significant liver toxicity). Namenda, a NMDA receptor antagoinist, was approved by the FDA in 2003 for middle-to-late-stage Alzheimer’s. While there is no cure for Alzheimer’s, these medications play a definite role in the treatment of Alzheimer’s symptoms.

Do the Alzheimer’s drugs really work? This question has caused a big firestorm within the Alzheimer’s field. About 15% to 30% of the time, it is clear that the drug is helping the Alzheimer’s patients. A caregiver will report to the doctor some noticeable change: For example, the patient remembered the caregiver’s name, they started to tie their shoes again, or they regained the ability to go to the bathroom by themselves. Unfortunately for many people, the benefit isn’t this clear, and they continue to decline. It’s hard to know what to do at that time.

Here are some frequently asked questions about Alzheimer’s disease medications.

Q. How do you determine which patient should be using an Alzheimer’s drug?

A. I will give the patient a cognitive screening test that consists of a series of questions and tasks designed to test an individual’s memory and other aspects of cognitive functioning. A common tool used in memory screenings is the Mini Mental State Exam (MMSE). This simple test is based on a 30-point scale and is divided into sections that address orientation, memory, attention, language, and perception -- all of which are aspects of cognitive functioning that become impaired when a person has Alzheimer’s disease or a related dementia.

Scoring on the exam is as follows:

A score in the mid to low 20s on the exam may indicate mild impairment

A score between 10 and 20 suggests there may be moderate impairment

A score of 9 or lower suggests severe impairment

Q. What patient should be taking the Alzheimer’s drugs?

A. The patient who should be taking cholinesterase inhibitors is one who has probable Alzheimer’s disease and is in the mild to moderate stage of Alzheimer’s. That means he or she has a MMSE score of approximately 10 to 26. This group happens to be the best studied of all Alzheimer’s disease patients and we have the most information on them.

Q. How long do the cholinesterase medications actually help the Alzheimer’s patient?

A. This is very hard to gauge. For six months to a year, a patient can maintain the modest benefits if the Alzheimer’s drug is working. Most people I respect as scientists and clinicians are not persuaded that cholinesterase drugs delay cognitive decline or that they slow the destruction of brain tissue caused by Alzheimer’s. I explain to my patients and their caregivers that a person who responds to the drug will experience an improvement in memory of about six to eight months. By this, I mean that if the Alzheimer’s medication were started in June, it is hoped that the patient’s cognition would revert to how it was the previous November. This would be an average improvement. Moreover, if a person does improve, they could maintain this improvement for six to eight months and sometimes longer.

Understanding How the Brain Stores Memories

Mon, 08 Oct 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | How the Brain Stores Memories

Johns Hopkins researchers discover a new mechanism for memory storage in the brain, according to a recent Johns Hopkins Medicine Press Release.

Our experiences -- the things we see, hear, or do -- can trigger long-term changes in the strength of the connections between nerve cells in our brain, and these persistent changes are how the brain encodes information as memory. As reported in Neuron , Johns Hopkins researchers have discovered a new biochemical mechanism for memory storage, one that may have a connection with addictive behavior.

Previously, the long-term changes in connection were thought to only involve a fast form of electrical signaling in the brain, electrical blips lasting about one-hundredth of a second. Now, neuroscience professor David Linden, Ph.D., and his colleagues have shown another, much slower form of electrical signaling lasting about a second can also be persistently changed by experience.

They simulated natural brain activity by applying short electrical jolts to slices of rat brain and measuring the current flowing across the cells. After repeated jolting, the strength of the slow nerve signals had dramatically decreased and remained at a low intensity for 30 minutes after electrical jolts ceased.

These slow signals are produced by a nerve cell receptor called mGluR1, which has been associated with behaviors such as addiction and epilepsy. "Both of these conditions also involve long-term changes in the function of nerve connections," says Linden. "So in addition to furthering our basic understanding of memory storage, our work suggests that drugs designed to alter mGluR1 are promising candidates for the treatment of addiction, epilepsy, and diseases of memory."

The research was funded by the Republic of Korea Ministry of Health and Welfare and the National Institutes of Health.

Authors on the paper are Paul Worley and Linden of Johns Hopkins and Sang Jeong Kim, Yunju Jin and Jun Kim of Seoul National University College of Medicine

On the Web:
http://neuroscience.jhu.edu/DavidLinden.php
www.neuron.org

Johns Hopkins Health Alerts | Memory | How the Brain Stores Memories

Calming Dementia-Related Agitation

Mon, 29 Oct 2007 06:00:00 CST

Johns Hopkins Health Alerts | Memory | Calming Dementia-Related Agitation

Peter Rabins, M.D., Director of the Division of Geriatric Psychiatry and Neuropsychiatry at Johns Hopkins offers advice to families caring for a loved one with dementia.

Agitation is common in people with dementia -- it occurs roughly 50% of the time, more often in the middle or later stages of the disease. In fact, managing agitation and other behavior problems account for roughly 30% of all the money spent on treatment for Alzheimer’s disease.

Because many people with dementia can’t adequately communicate the source of their frustration, it is difficult to help them. Peter Rabins, M.D. says, “We think that part of the reason people with dementia become agitated so easily has to do with the effects of disease or injury on brain areas associated with inhibition.

“In people with dementia, damage to the parts of the brain responsible for controlling reactions to frustrating situations or emotional stimuli results in a much ‘shorter fuse.’ Also, dementia renders people unable to think through problems -- to get up and turn down the radio if it is too loud, for example.”

One problem with agitation is the term itself: It tends to refer to a broad range of difficult to manage behaviors. “When talking to a doctor, be as specific as you can about the behavior problem. The more you can tell the doctor about the behavior -- when it first started or where it tends to happen, for instance -- the easier it is to figure out what may be triggering it.”

What to do? Some suggestions:

Dementia and music -- A study published in the Journal of Gerontological Nursing found that nursing home residents with Alzheimer’s disease who listened to their favorite music were substantially less agitated. Researchers cited music’s unique capacity to conjure up old memories and emotions as the reason for improvement in dementia-related agitation. Other research has found that soothing music helps calm people with dementia even if they are unfamiliar with the songs.

Dementia and art -- Art therapy may be helpful, whether dementiapatients create their own artwork or view artwork in museums -- though few formal studies have been completed. You can learn more about art therapy and other therapeutic activities at www.alzinfo.org/alzheimers-treatment-therapeutic.asp. Or contact your local museum about guided tours for people with dementia.

Dementia and Montessori --The Montessori philosophy applied to patients with dementia focuses on enhancing memory, learning and retaining skills, expressing emotions, and maintaining personality and self-esteem. Small studies have suggested that the Montessori approach reduces depression in people with Alzheimer’s disease. Patients typically participate in structured, hands-on activities in which individual tasks contribute to a larger goal. Activities evolve slowly from one-step tasks to more complex ones, and from concrete experiences to abstract ideas.

Dementia and relaxation techniques -- A summary of two small clinical trials involving a total of 110 participants found that massage and touch therapy temporarily reduced episodes of agitation, anxiety, and depression in people with dementia. To find a practitioner experienced in treating people with dementia, check with local physical therapists, long-term care facilities, or senior centers.

Johns Hopkins Health Alerts | Memory | Calming Dementia-Related Agitation

Distinguishing Normal "Senior Moments" From Dementia

Mon, 11 Feb 2008 06:00:00 CST

Johns Hopkins Health Alerts | Memory | Distinguishing "Senior Moments” From Dementia

Are you concerned about your memory? Johns Hopkins doctors compare symptoms of normal aging with those of more serious dementia.

Occasional memory lapses, such as forgetting why you walked into a room or having difficulty recalling a person’s name, become more common as we approach our 50s and 60s. It’s comforting to know that this minor forgetfulness is a normal sign of aging, not a sign of dementia.

But other types of memory loss, such as forgetting appointments or becoming momentarily disoriented in a familiar place, may indicate mild cognitive impairment. In the most serious form of memory impairment – dementia -- people often find themselves disoriented in time and place and unable to name common objects or recognize once-familiar people.

Here are examples of the types of memory problems common in normal age-related forgetfulness, mild cognitive impairment, and dementia.

Memory Condition -- Normal Age-Related Forgetfulness:

Sometimes misplaces keys, eyeglasses, or other items.

Momentarily forgets an acquaintance’s name.

Occasionally has to “search” for a word.

Occasionally forgets to run an errand.

May forget an event from the distant past.

When driving, may momentarily forget where to turn. Quickly orients self.

Jokes about memory loss.

Memory Condition -- Mild Cognitive Impairment:

Frequently misplaces items.

Frequently forgets people’s names and is slow to recall them.

Finding words becomes more difficult.

Begins to forget important events and appointments.

May forget more recent events or newly learned information.

May temporarily become lost more often.

May have trouble understanding and following a map.

Worries about memory loss. Family and friends notice the lapses.

Memory Condition -- Dementia:

Forgets what an item is used for or puts it in an inappropriate place.

May not remember knowing a person.

Begins to lose language skills. May withdraw from social interaction.

Loses sense of time. Doesn’t know what day it is.

Short-term memory is seriously impaired. Has difficulty learning and remembering new information.

Becomes easily disoriented or lost in familiar places, sometimes for hours.

May have little or no awareness of cognitive problems.

Johns Hopkins Health Alerts | Memory | Distinguishing "Senior Moments” From Dementia

Detecting Alzheimer's with Pittsburgh Compound B

Mon, 17 Sep 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Detecting Alzheimer's with Pittsburgh Compound B

A new imaging agent may revolutionize Alzheimer’s detection and treatment.

The brain guards its secrets well. Encased in the skull and protected by the blood-brain barrier (a membrane that filters out many substances), it resists some of the scanning techniques that have illuminated the heart and other organs. But recent advances in brain imaging are now offering scientists remarkable new views of the brain.

Until recently, an autopsy was the only way to confirm a diagnosis of Alzheimer’s disease. Only by directly examining the brain after death could researchers identify one of the telltale signatures of Alzheimer’s -- deposits of a sticky protein called beta-amyloid (also known as amyloid plaque). Amyloid plaques are not visible through conventional brain scanning techniques.

The inability to see beta-amyloid deposits in the living brain has been a serious limitation that forced doctors to rely on symptoms and cognitive tests to make a diagnosis of Alzheimer’s disease. Moreover, research and treatment were stymied by not knowing how early in life the Alzheimer‘s process begins, which brain structures are affected first, and how quickly Alzheimer‘s progresses through the brain. In addition, the inability to see the amyloid plaques meant that drug developers had no way to tell if their experimental agents were actually working to clear plaques from the brain in an Alzheimer’s patient.

That may be changing with the advent of a new imaging agent called Pittsburgh Compound B (PIB). Developed by researchers at the University of Pittsburgh, PIB slips past the blood-brain barrier and binds to amyloid plaques. Used with positron emission tomography (PET), PIB “lights up” the amyloid deposits, offering researchers their first look at amyloid plaques in the living brain. Another compound that binds to amyloid plaques, developed by scientists at UCLA, is at an earlier stage of development but is also promising.

Although the use of PET/PIB is in its earliest stages, the potential implications are immense. If further testing confirms its diagnostic ability, the technique may allow doctors to detect the beginnings of Alzheimer’s disease years, or even decades, before Alzheimer’s symptoms develop. That, in turn, would provide the opportunity to intervene early, when Alzheimer’s medications should be most effective. Moreover, having a visible "target” to use in evaluating experimental therapies would spur new drug research and development.

Johns Hopkins Health Alerts | Memory | Detecting Alzheimer's with Pittsburgh Compound B

The Six "R's"

Mon, 06 Aug 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Managing Difficult Behavior in People with Dementia

Here are six coping strategies for dementia-related behavior problems from renowned Johns Hopkins neurologist, Dr. Peter Rabins.

People with dementia often exhibit behaviors that are frustrating, embarrassing, and sometimes even dangerous to the caregiver and others. These may include angry outbursts, agitation, aggression, wandering, vocalizations, hoarding or hiding things, and inappropriate sexual behavior. For many caregivers, these difficult behaviors are the most challenging and exhausting aspect of caring for a person with dementia. Unfortunately, the available medications to treat Alzheimer’s disease have little effect on behavioral problems.

In their groundbreaking book on Alzheimer’s caregiving --The 36 - Hour Day -- Peter Rabins, M.D. (author of the Johns Hopkins Memory White Paper), and Nancy Mace discuss the six R’s of managing difficult behavior in people with dementia. They are:

Dementia Strategy 1 -- Restrict. First, calmly attempt to get the person to stop the behavior, especially if the behavior is potentially dangerous.

Dementia Strategy 2 -- Reassess. Consider what might have provoked the behavior. Could a physical problem (toothache, urinary tract infection, osteoarthritis) be behind the agitation or anger? Is a particular person or the noise level in the room triggering the negative reaction? Could the time of day and fatigue be contributing to the problem?

Dementia Strategy 3 -- Reconsider. Put yourself in the dementia patient’s shoes. Try to imagine what it must be like to not understand what is happening to you or to be unable to accomplish a simple task. Consider how frustrating or upsetting the current situation or environment might be for a person with dementia.

Dementia Strategy 4 -- Rechannel. Try to redirect the behavior to a safer, less disruptive activity. For example, if the person constantly disassembles household items, try finding simple unused devices, such as an old telephone or a fishing reel, that can be taken apart and put back together repeatedly. For someone who hoards or hides things, put away valuables and replace them with an array of inexpensive items. Distraction often works well to curtail disruptive repetitive behaviors and restlessness. For example, try asking the person you’re caring for to “help” with simple tasks, such as holding spoons or potholders while you cook.

Dementia Strategy 5 -- Reassure. The demented person’s brain injury and the resulting confusion and frustration can lead to anger, anxiety, and outright fear in certain situations. Calmly reassure the person that everything is okay and that you will continue to take care of him or her.

Dementia Strategy 6 -- Review. After an unsettling experience with your loved one, take time to review how you managed the problem and what you might have done differently. Think about what may have triggered the problem, how it might have been avoided, and what you might try the next time a similar situation arises. It also helps to create a patient-friendly environment. This might include soothing music in the background; pictures, words, or arrows to help orient the person in the house; or a secure place to sit outside or walk in the backyard.

Johns Hopkins Health Alerts | Memory | Managing Difficult Behavior in People with Dementia

Predicting Dementia Risk

Mon, 16 Jul 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Predicting Dementia Risk

Recent data from Scandinavian researchers suggest a way to predict dementia risk by looking at the synergistic effect of multiple risk factors.

An increasing amount of research is being directed at finding ways to prevent dementia. But even a treatment that simply delays the onset of dementia would represent an important step forward. Potential strategies for preventing or delaying dementia focus heavily on reducing cardiovascular risk factors but include other brain-protective lifestyle measures as well. The list includes lowering low-density lipoprotein (LDL) cholesterol, raising high-density lipoprotein (HDL) cholesterol, lowering blood pressure, quitting smoking, maintaining a healthy weight, preventing or controlling diabetes, consuming foods rich in antioxidants, getting regular exercise, staying mentally active, drinking alcohol only in moderation, restricting unhealthy fats and replacing them with healthy fats, and taking B vitamins.

While definitive strategies to prevent dementia are not yet available, for the first time researchers have developed a way to predict a person’s risk of developing dementia years before the disease takes hold.

In a study reported in the journal Lancet Neurology (Volume 5, page 735), Scandinavian researchers first studied 1,409 adults in midlife (their ages ranged from 39–64) and then re-examined them 20 years later for signs of dementia. Five factors -- increased age, less education, high blood pressure, high cholesterol, and obesity -- were found to increase a person’s risk of developing dementia.

In particular, the three cardiovascular risk factors emerged as strong predictors of dementia risk. Although having any one of the three doubled a person’s chance of developing dementia, having all three increased the risk by sixfold.

This approach -- looking at the synergistic effect of multiple risk factors -- has been used for other diseases, such as glaucoma and cardiovascular disease. But this is the first time it has been used for dementia. Thus, the results need to be validated in other studies. Moreover, there is no clear-cut guarantee that dementia can be entirely prevented, as genetics still plays a role and family history wasn’t included in the risk profile. Nevertheless, this study strongly supports the belief that aggressive treatment of high blood pressure, elevated cholesterol, and obesity are the best approaches we have at present for preventing dementia.

For more Alerts and Special Reports, please visit the Memory Topic page.

Johns Hopkins Health Alerts | Memory | Predicting Dementia Risk

The Stress of Caring for a Loved One With Alzheimer's

Mon, 25 Jun 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Stress of Caring for Loved One with Alzheimer's

With an illness such as Alzheimer’s, the most neglected person in the family is often the caregiver. Studies report that 46% of all caregivers are depressed, experience anger, frustration, and helplessness.

The long-term care provided by family members to people with Alzheimer’s disease is a central component of our health care system. At present, about 4.5 million Americans have Alzheimer’s disease, with the number expected to range between 11 and 16 million by 2050. Dementia is now present in 10% of people age 65 and older, and in almost half of people older than 85. As our population ages, many people will be called to serve as caregivers for loved ones affected by Alzheimer’s disease and other dementias.

If you are caring for a mother, father, spouse, or friend with Alzheimer’s disease, you know how challenging, even overwhelming, the task can feel. In a recent issue of the Johns Hopkins Memory Bulletin, medical editor Peter V. Rabins, M.D. shared some frequently asked questions he has received from people caring for loved ones with Alzheimer’s disease.

Q. Why is caregiving for someone with AD or some other dementia so difficult?

A. According to a recent study of caregivers, caregivers for those with Alzheimer’s disease or other dementias provide an average of 47 hours of care per week, compared with 33 hours by caregivers for physically impaired individuals. With Alzheimer’s disease caregiving, unfortunately, the person you are caring for will eventually not know who you are, which makes it extremely difficult to think of your loved one as you once did. On top of that, the loved one may not be able to perform the most basic tasks. He or she may also be argumentative, scream uncontrollably, say improper things, throw items, hit and bite, or wander away from home. All of these inappropriate behaviors will make a caregiver frustrated, annoyed, and extremely angry at times.

Q. When trying to help someone with a dementing illness such as Alzheimer’s -- and not succeeding -- should you try to control your anger?

A. Expressing your anger at the person with Alzheimer’s disease often makes their behavior worse. The illness may make it impossible for him to respond to your anger in a rational way. On the other hand, you may find that it improves a loved one’s behavior when you find other ways to manage both your frustrations and the problems themselves.

The first step in dealing with pent-up anger is to come to understand what you can reasonably expect from a person with Alzheimer’s disease and what is happening to the brain to cause the irritating behavior. If you are not sure whether the person can stop acting the way he does, find out from his doctor or another health professional. It may be possible to change the person’s irritating behavior by changing his environment or his daily routine. However, it can also be reassuring just knowing that unpleasant behavior is the result of the Alzheimer’s disease and that the person cannot control what he is doing any longer.

Johns Hopkins Health Alerts | Memory | Stress of Caring for Loved One with Alzheimer's

Untangling the Mystery of Alzheimer's Disease

Mon, 04 Jun 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Untangling the Mystery of Alzheimer's Disease

Scientists studying beta-secretese, gamma-secretase, and tau hope to gain a better understanding of how Alzheimer's progresses … and ultimately how to prevent it.

Amyloid plaques and neurofibrillary tangles are the structural hallmarks of Alzheimer's disease. Although plaques and tangles can be seen only at autopsy, they must be present to make a definitive diagnosis of Alzheimer’s. It remains unclear whether these abnormal brain deposits are the cause of Alzheimer’s or simply a byproduct of some other causative agent, but researchers now have a better understanding of how plaques and tangles are formed in Alzheimer's disease. This improved understanding has spawned new attempts to block the underlying process that may lead to their buildup and lead to Alzheimer’s disease. If plaques and tangles are, in fact, the cause of Alzheimer’s, the success of these new approaches may ultimately provide the foundation for effective prevention strategies and treatments.

Amyloid plaques are a mixture of abnormal proteins and nerve cell fragments that develop in the tissue between nerve cells in areas of the brain involved in memory. Their main component is beta-amyloid, a protein fragment that breaks off from a larger molecule called the amyloid precursor protein (APP). APP is part of the cell membrane that encases every nerve cell. When nerve cells die, this large molecule must be broken down and removed from the brain. Enzymes called secretases split the protein in two, forming the small beta-amyloid fragment.

How does this lead to Alzheimer’s disease? Researchers recently identified substances called beta-secretase and gamma-secretase as enzymes that slice the amyloid precursor protein. Beta-secretase and gamma-secretase cut the protein in a place that causes beta-amyloid to become insoluble (less easily dissolved), leaving it to be deposited in the brain. Investigators suspect that blocking beta-secretase or gamma-secretase activity might prevent production of this undesirable form of beta-amyloid, and experiments are currently under way to test this hypothesis. Still a mystery, however, are what happens to the beta-amyloid segment once it separates from the amyloid precursor protein, and how beta-amyloid might cause Alzheimer’s.

Neurofibrillary tangles are the other structural abnormality associated with Alzheimer’s disease. Composed mostly of a protein called tau, these twisted, hairlike threads are what remain after a neuron’s internal support structure (known as microtubules) collapses. In healthy neurons, microtubules function like train tracks to carry nutrients from one destination to another. Tau normally serves as the supporting "railroad ties.” In Alzheimer’s, however, the protein becomes hopelessly twisted and disrupts the function of the microtubules. This defect interferes with communication within nerve cells and eventually leads to their death.

Researchers are not sure why tau goes awry, but an enzyme called Pin1 may play an important role in keeping tau intact. In test-tube experiments, when Pin1 binds to an altered tau, the protein begins to function properly and microtubule assembly is restored. Furthermore, researchers have found substantially lower-than-normal levels of Pin1 in autopsied brains of people with Alzheimer’s. The significance of these findings remains uncertain, but the presence of an enzyme such as Pin1 may help maintain or restore the proper functioning of tau, thereby preventing the formation of tangles. This possibility raises the hope that therapies aimed at preserving the function of tau might one day prevent Alzheimer’s.

Johns Hopkins Health Alerts | Memory | Untangling the Mystery of Alzheimer's Disease

Understanding the Symptoms of VVAD: A Variant of Alzheimer's Disease

Mon, 02 Apr 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Understanding the Symptoms of VVAD

Patients with VVAD experience visual comprehension problems, which can’t be fixed with glasses or surgery.

Where are those darn car keys? Why can’t I remember her name? Fears of Alzheimer’s disease have us all second-guessing even the most routine of memory lapses. Indeed, impaired memory is one of the classic early signs of Alzheimer’s disease.

But in a few people, memory problems aren’t the first sign of trouble. Instead, the first sign of Alzheimer’s disease is a problem with vision, or more accurately, a problem with visual comprehension. A person in the early stages of Alzheimer's disease may end up in an ophthalmologist’s office complaining, "I can’t see,” or even, "I can see, but I can’t read or write.” Depth perception may be off, leading to falls and other accidents.

People with these symptoms may have what’s known as the visual variant of Alzheimer's disease, or VVAD. While VVAD is relatively uncommon today, it is expected to become more prevalent as the U.S. population ages and more people develop Alzheimer’s disease. Because the visual comprehension problems come first in VVAD, ahead of those related to memory, people who are affected may consult an ophthalmologist first, thinking that they just need new glasses or even cataract surgery.

Whenever a person claims that he or she "can’t see,” an ophthalmologist begins by assessing the person’s visual acuity and visual fields. While some people with VVAD do show some degree of visual field loss, others have normal eye exams. In a study of eight patients with VVAD, for instance, only half had any visual field loss. Moreover, the person’s visual acuity may be as good as 20/20. In other words, the problem is not that people with VVAD can’t see what’s in front of them, it’s that their brains aren’t accurately processing the information.

Once an ophthalmologist suspects VVAD, the individual will be referred to a neurologist for further evaluation and treatment. While the visual symptoms may be the initial -- or in rare cases, the only -- sign of Alzheimer’s disease, it does appear that most people with VVAD go on to develop the classic symptoms of Alzheimer’s disease, including impaired memory and personality changes.

It’s also important to note that many people with Alzheimer’s disease who first experience memory problems typically develop visual problems later on. For instance, these Alzheimer’s disease patients often develop problems with contrast sensitivity or visual attention. Contrast sensitivity involves the ability to detect different shades of gray. It’s an important consideration with nighttime driving, for instance, but it also helps us "read” complex surfaces.

Visual attention has several components: It refers to our ability to detect and identify objects in space, to pay attention to two things at once, and to tune into one type of information while ignoring other less important types of information. Problems with contrast sensitivity and visual attention play a role in the early stages of Alzheimer’s disease, such as problems with driving a car. Later on, they contribute to such well-known problems as being unable to recognize faces or navigate familiar places. As with VVAD, it’s important for family members to understand that the person’s visual problems are part of the Alzheimer’s disease and can’t be fixed with glasses or surgery.

Johns Hopkins Health Alerts | Memory | Understanding the Symptoms of VVAD

Research on Dementia Biomarker

Mon, 23 Apr 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Memory | Dementia Biomarker

High Uric Acid Levels: A Possible New Dementia Biomarker

Researchers at Yale and at Johns Hopkins, led by Barry Gordon, M.D., Ph.D., a professor of Therapeutic Cognitive Neuroscience at Johns Hopkins, have found that a simple blood test to measure uric acid, a measure of kidney function, might reveal a risk factor for cognitive problems and dementia in old age. Of 96 adults age 60 to 92 years, those with uric-acid levels at the high end of the normal range had the lowest scores on tests of mental processing speed, verbal memory, and working memory.

Reporting recently in the journal Neuropsychology, Dr. Gordon and his colleagues noted that high-normal uric acid levels, defined in this study as 5.8 to 7.6 mg/dL for men and 4.8 to 7.1 mg/dL for women, were more likely to be associated with cognitive problems even when the researchers controlled for age, gender, weight, race, education, diabetes, hypertension, smoking, and alcohol abuse. These findings suggest that older people with serum (blood) uric-acid levels in the high end of the normal range are more likely to process information slowly and experience failures of verbal and working memory, as measured by the Wechsler Adult Intelligence Scale and other well-established neuropsychological tests.

The link between high-normal uric acid levels and dementia is sufficiently intriguing enough for the scientists to propose clinical studies of whether medicines that reduce uric acid, such as allopurinol, can help older people with high-normal uric acid levels avoid developing the mild cognitive deficits that often precede dementia.

For reasons that are not entirely clear, uric acid levels increase with age, says Dr. Gordon. Higher levels of uric acid are linked with known risk factors for dementia, including high blood pressure, atherosclerosis, type 2 diabetes, and the “metabolic syndrome” of abdominal obesity and insulin resistance. There is also mounting evidence that end-stage renal (kidney) disease increases the risk of cognitive dysfunction and dementia in elderly adults. Given this web of connections, uric acid could potentially become a valuable biological marker for very early cognitive problems and dementia in old age.

The researchers say that it’s unclear why mild cognitive problems appear with high normal uric acid levels. Paradoxically, uric acid also has anti-oxidant properties that are thought to be protective in other situations. Dr. Gordon and his colleagues are also researching links between uric acid and vascular damage in the brain and attempting to dissect which aspects of uric acid and its production help or hurt the nervous system.

This research update by Peter V. Rabins, M.D., editor of the Memory Bulletin, and co-director of the Division of Geriatric and Neuropsychiatry at the Johns Hopkins School of Medicine, comes from the Winter 2007 Memory Bulletin.

Johns Hopkins Health Alerts | Memory | Dementia Biomarker

Dementia With Lewy Bodies

Thu, 07 Dec 2006 06:00:00 CST

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article Dementia With Lewy Bodies is no longer current, and has therefore been removed.

If you would like to read related articles about memory loss and related dementias, please go to the Memory Topic page. Thank you.

9 Coping Strategies for Alzheimer's Disease Behavioral Problems

Sat, 06 Jan 2007 06:00:00 CST

Johns Hopkins Health Alerts | Memory | Coping Strategies for Alzheimer's Disease Behavioral Problems

Some people with Alzheimer’s disease experience a worsening of agitation and confusion in the afternoon and early evening. Here are some practical strategies you can try.

Becoming agitated in the late afternoon or early evening is a common phenomenon among people with Alzheimer’s disease. In fact, a special word -- “sundowning” -- is used to describe this behavior. Sundowning can take the form of behaviors not seen during other times of day, or it may represent a worsening of ongoing daily behaviors.

Exactly what causes sundowning is unclear. Possible explanations include fatigue at the end of the day, being overwhelmed by too much sensory input, lack of stimulation (not enough activities or attention), and becoming confused in dim light. Sleep problems, such as sleep apnea and disturbances in the sleep/wake cycle (circadian rhythm), may also play a role. The behavior seems to be more common among Alzheimer’s disease patients who live in nursing homes. Of course, not everyone with Alzheimer’s disease experiences sundowning, and some individuals have more behavior problems early in the day rather than later.

How to cope with Alzheimer’s disease and sundowning

If you are caring for someone with Alzheimer’s disease who experiences sundowning, think about what might be triggering the episodes and take steps to minimize those triggers. For example:

Exhaustion -- A patient with Alzheimer’s disease may be tired in the evening from a day of trying to make sense of his environment. Plan the person’s day so that fewer demands, such as bathing, are placed on him in the evening.

Too much input -– For an Alzheimer’s disease patient, noise, glare, and distractions can contribute to agitation. If sundowning coincides with a busy time in your household, try to reduce the number of activities going on, or move the Alzheimer’s patient to a quieter area of the house.

Too little input -- Some people with Alzheimer’s disease are used to having constant attention and will become agitated when you turn to other responsibilities, such as returning phone calls. Try giving the person a simple task to do nearby, or enlist another family member to spend time with her.

Inadequate lighting -- An Alzheimer’s disease patient who cannot see clearly because of dim light may become confused and visualize objects that aren’t there, so make sure the house is well lit in the evening.

The role of sleep -- People with Alzheimer’s disease suffer disproportionately from sleep disturbances, including sleep apnea. Helping the person get a good night’s sleep can reduce daytime sleepiness and may reduce disruption of the circadian rhythm, a common problem in elderly people.

Medication -- Because Aricept and other cholinesterase inhibitors sometimes have a stimulant effect, try giving them in the mornings if the person is not sleeping well.

Light therapy -- Inadequate exposure to light can contribute to sundowning. Getting the person outdoors during the day or placing the person’s chair next to a sunny window can remedy this problem.

Activity -- Because inactivity can lead to sundowning, try to schedule an activity the person has always enjoyed -- such as going to the store or meeting friends -- on most afternoons.

Distraction -- Sometimes, distracting the person can help control sundowning. Try engaging the person in a conversation about a topic he or she finds important, such as family, hobbies, or politics.

Johns Hopkins Health Alerts | Memory | Coping Strategies for Alzheimer's Disease Behavioral Problems

New Research on Alzheimer's Disease

Mon, 19 Feb 2007 06:00:00 CST

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article New Research on Alzheimer's Disease is no longer current, and has therefore been removed.

If you would like to read related articles about memory loss and related dementias, please go to the Memory Topic page. Thank you.

Diagnosing Alzheimer's Disease

Tue, 07 Nov 2006 06:00:00 CST

Johns Hopkins Health Alerts | Memory | Diagnosing Alzheimer's Disease

While there is still no cure for Alzheimer’s disease, early diagnosis offers many benefits. Johns Hopkins doctors review the current diagnostic tools available for dementia and Alzheimer’s disease.

If you’re worried about Alzheimer’s disease, the first step is to talk to your primary care physician about any symptoms you’ve been experiencing. Because diagnosing Alzheimer’s disease is primarily a process of elimination, your medical history and any recent health changes you’ve noticed might point to an explanation other than dementia. Your physician should screen you for depression, which can impair memory and cause anxiety, irritability, and poor concentration.

Your physician should also inquire about any medications and dietary supplements you are taking: Are you taking the proper dosage? Are you on the right schedule? Has another physician recently prescribed a new drug or changed your dosage? Again, medications can have effects that mimic those of Alzheimer’s disease, and this possibility must be ruled out.

The Mini-Mental State Exam and other tests for Alzheimer’s disease

If your physician suspects Alzheimer’s disease, he or she may perform a test called the Mini-Mental State Exam (MMSE), a 17-item screening test that assesses general cognitive function and provides a single numerical score. A score of 24 or higher is considered normal. The MMSE is not a particularly sensitive test for Alzheimer’s disease. Scores can drift up or down according to educational level, cultural background, reading level, and language skills.

Further testing may be needed at a separate office visit with a dementia specialist, such as a neurologist, geriatric psychiatrist, geriatrician, or neuropsychologist. The doctor will administer some tests by asking you questions; other tests require you to make drawings, solve special puzzles, or answer questions in written form.

Depending on your symptoms, your doctor may order laboratory tests. Again, the purpose is to rule out causes other than Alzheimer’s disease, tightening the circle of diagnosis until it zeroes in on the probable cause. Blood tests can identify anemia, liver disorders, thyroid problems, nutritional deficiencies, and infections.

In recent years, there has been a wave of news reports on the latest and greatest brain scanning techniques for the detection of early Alzheimer’s disease. These high-tech tests go by a variety of acronyms: MRI; fMRI; SPECT; PET; and CAT. Of the imaging tests mentioned above, your doctor is most likely to consider a CAT scan or MRI to check for physical brain abnormalities associated with Alzheimer’s disease, or to rule out some other cause of the symptoms. These brain scans may detect small strokes, which can cause problems in the brain’s blood supply and lead to vascular dementia. So-called functional scans, such as positron emission tomography (PET), are increasingly being used in the diagnosis of Alzheimer’s disease. They reveal information about the level of activity (function) in various areas of the brain that might be affected by Alzheimer’s disease.

Why Pursue Diagnosis?

When people notice mental slips and fear dementia, they may be reluctant to push for testing. There is, after all, no cure for Alzheimer’s disease. But a positive diagnosis, while frightening, offers some positive opportunities. Medications can slow the progression of the Alzheimer’s disease, giving you more time to enjoy with friends and family. If Alzheimer’s disease is caught early enough, it allows people to participate in their own healthcare decisions. Early diagnosis provides time to prepare psychologically, spiritually, and financially for the inevitable consequences of the disease. And it also gives a potential caregiver—typically a family member—more time to obtain the education and training needed to provide a dignified and healthy life for their loved one.

Johns Hopkins Health Alerts | Memory | Diagnosing Alzheimer's Disease

Memory Lapses -- Normal Aging or Something More Serious?

Fri, 06 Oct 2006 12:27:13 CDT

Johns Hopkins Health Alerts | Memory | Age-Related Memory Loss

Johns Hopkins doctors explain how cultural attitudes and failure to pay attention may contribute to age-related memory loss.

The brain contains approximately 100 billion neurons (nerve cells). A common misconception is that tens of thousands of neurons die each day. In reality, few neurons die over a person’s lifetime, but they do shrink. This shrinkage may partially explain why mental functioning slows in middle and older age. Serious memory loss does occur when whole clusters of neurons are destroyed by major disorders such as a stroke or Alzheimer's disease.

In addition to the shrinkage of neurons, starting in middle age the brain begins producing smaller quantities of many neurotransmitters—chemical messengers that relay information between nerve cells. Brain blood flow is also reduced 15–20% between age 30 and age 70, although neuronal shrinkage may account for this because less tissue requires less blood.

Cultural attitudes and preconceptions about aging and memory loss can also influence the occurrence of memory lapses as people age. In one study, researchers compared the memory skills of two groups known to have few stereotypes concerning old age and memory loss (natives of China and deaf Americans) to those of a third group known to have numerous preconceptions about aging and memory loss (hearing Americans). Among these preconceptions is the notion that aging causes an inevitable decline in memory skills. The study results suggest a strong link between culture and memory: The first two groups were less forgetful than the third group, and older Chinese participants performed as well as the younger people in each of these groups. The implication is that if people expect their memory to get worse, they may be less diligent in trying to remember.

Other research indicates that the mental processes required to remember newly acquired information are the same as those needed to retrieve memories from long ago—something most older people do quite well. This implies that older individuals retain the capacity to recall recent events, but the new information is not being recognized as important or is being discarded when transferred to short-term memory. Some researchers interpret this to mean that occasional memory lapses may result from a failure to pay close attention to the information rather than an inability to remember. Thus, it appears that forging new memories depends in large part on staying interested, active, attentive, and alert.

Johns Hopkins Health Alerts | Memory | Age-Related Memory Loss

Questions & Answers on Alzheimer's Disease

Wed, 06 Sep 2006 11:41:52 CDT

Johns Hopkins Health Alerts | Memory | Questions & Answers on Alzheimer's Disease

Can Ginkgo Biloba help preserve my mother’s memory? Did I inherit the “Alzheimer’s” gene from my grandfather? Dr. Peter. V. Rabins, professor of psychiatry at Johns Hopkins, provides the answers.

Ginkgo Biloba and Alzheimer’s Disease

Q. My mother is 74 and was diagnosed with Alzheimer’s disease two years ago. She has been taking Aricept and aspirin, which worked for a while, but lately she forgets where she is and even has to be reminded of her own name. I’ve always doubted the effectiveness of herbal medicine, but a coworker whose father also battled Alzheimer’s disease swears that ginkgo biloba really works. Because of her recommendation, I’m planning to add ginkgo biloba to my mother’s daily pill regimen. Is there any proof of ginkgo biloba’s effectiveness? Will it at least “do no harm” if combined with the aspirin and Aricept my mother is already taking?

A. Ginkgo biloba is one of the oldest living tree species, dating back over 300 million years. Extracts of the fruit and leaves of the ginkgo tree have been used in China for thousands of years to treat a variety of ailments, including cardiovascular disease and asthma. More recently, scientists have been studying ginkgo biloba extracts as a treatment for cognition problems and hardening of the arteries. However, only one well-designed study has demonstrated any efficacy of ginkgo biloba for memory enhancement, and that benefit was very modest -- those taking ginkgo biloba scored one point better on a test of cognition after one year than those who took a placebo (sugar pill). Furthermore, many other studies have shown no benefit from ginkgo biloba. Some might worry that aspirin increases the risk of bleeding when taken along with ginkgo biloba; while there is little risk of harm unless your mother has a bleeding disorder, based on the data available at this time I do not recommend ginkgo biloba.

Genetic Link and Alzheimer’s Disease

Q. I am a 47-year-old woman. My maternal grandfather died of Alzheimer’s disease when he was only in his early 60s. My father died young of a heart attack, but my mother is 78 years old and healthy. Lately I have been having trouble recalling names on the spot, which can be embarrassing. For instance, during a recent business meeting I attempted to introduce a colleague I have known for ten years and completely forgot his name.

I’m not sure if what I am experiencing is the normal course of aging, some form of mild cognitive impairment, or the beginning stages of Alzheimer’s disease -- or if I’m magnifying or even imagining the entire problem. Can you could help me understand my symptoms, and offer some advice concerning the next steps I should take -- if any.

A. These symptoms could well be the result of what is referred to as “normal aging” (recall of names and words does become more difficult as we age), especially if you eventually remember the person’s name or the word. On the other hand, there is a very small likelihood that this is the beginning of something more serious. I suggest talking with your doctor about the problem, making sure that you are not suffering from depression or some medical illness that is interfering with concentration and memory. In my opinion, neuropsychological testing is currently the best way to distinguish abnormal cognitive performance, including memory impairment, from expected age-associated changes. No blood or imaging tests are as accurate, but this may change in the future.

Johns Hopkins Health Alerts | Memory | Questions & Answers on Alzheimer's Disease

Should Patients Be Told They Have Alzheimer's Disease?

Tue, 08 Aug 2006 10:18:40 CDT

Johns Hopkins Health Alerts | Memory | Alzheimer’s Disease Diagnosis

Peter V. Rabins, M.D., M.P.H, Codirector of the Division of Geriatric and Neuropsychiatry at Johns Hopkins, offers advice on this difficult decision.

Most Americans expect that their doctor will inform them of all medical findings and that they will be able to make their own decisions about their health care. Alzheimer's disease, however, presents two unique problems. First, many patients are unaware that they have a memory problem and, even when informed, are not able to understand or accept this fact. Second, since memory is impaired in all patients with Alzheimer’s disease, they often cannot remember the medical information once they have been told.

What, then, should doctors and caregivers tell patients with Alzheimer’s disease?

The American Medical Association recommends telling a person that he or she has Alzheimer’s disease, if at all possible, which means taking into account the degree of remaining cognitive function. A recent study, however, indicates that doctors are far more likely to give the diagnosis to a family member than to the person with Alzheimer’s disease. Researchers surveyed 57 family members of people with dementia and found that 93% had been given the diagnosis by the doctor, but only 49% of patients had been told. Of the patients who were told, 46% took the news well, and 51% reacted poorly. However, family members still overwhelmingly thought that a person diagnosed with Alzheimer’s disease should be told the truth (72%).

Peter V. Rabins, M.D., M.P.H, Codirector of the Division of Geriatric and Neuropsychiatry at Johns Hopkins, believes in full disclosure. “Since it is customary and desirable to be honest with patients regarding their health status,” he says, “I believe it appropriate to indicate to everyone, at the time of assessment, that a problem with memory is present.”

Having the Conversation About the Alzheimer’s Disease Diagnosis
If you are a family member who has been told of your loved one’s Alzheimer’s disease diagnosis, you need to decide whether and how to share this news with the patient. If you decide to tell the person about the Alzheimer’s disease diagnosis, take some time to plan your approach and to anticipate the person’s reactions:

Choose your setting carefully. A conference, consisting of you, other caregivers, the doctor, and the patient may be helpful for some people; others may respond better to a one-on-one conversation. If you fear the patient might direct anger at you, ask his or her doctor to deliver the Alzheimer’s disease diagnosis.

Confusion, anger, and denial are common reactions. If they occur, don’t try to argue with or convince the person -- further detailed discussion likely will not be helpful.

Don’t be surprised if the person already suspects that he or she has Alzheimer’s disease.

Provide as much information as the patient is able to understand, especially about symptoms, medications, and upcoming lifestyle changes.

Watch for signs of sadness, anger, frustration, or anxiety, and let the patient know that these are understandable feelings and you are open to discussing his or her needs and emotions.

Finally, reassure the person that you, the doctor, and other caregivers will continue to provide help and support.

Johns Hopkins Health Alerts | Memory | Alzheimer’s Disease Diagnosis

Men's Testosterone Levels Tied to Alzheimer's Disease Risk

Mon, 12 Mar 2007 06:00:00 CST

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article Men's Testosterone Levels Tied to Alzheimer's Disease Risk is no longer current, and has therefore been removed.

If you would like to read related articles about memory loss and related dementias, please go to the Memory Topic page. Thank you.

A Good Sign -- You Worry About Senior Moments

Wed, 07 Jun 2006 14:00:21 CDT

Johns Hopkins Health Alerts | Memory | Low Memory Loss, Dementia and Aging

The difference between normal forgetfulness that increases with age and serious dementia is that the former is frustrating but not disabling.

A certain amount of memory loss is to be expected with age. Most people have more difficulty recalling names and words as they get older, so this is by no means symptomatic of dementia.

If you are occasionally forgetful, an adage can serve to reassure you: “You need not worry if you forget where you put your car keys; you only need to worry if you forget what they’re used for.” The difference between normal memory loss that increases with age—known clinically as age-associated memory impairment—and serious dementia is that the former is frustrating but not disabling.

The memory lapses associated with age-associated memory impairment are more likely to occur when a person is tired, sick, distracted, or under stress. Under less stressful circumstances, the same person is usually able to remember the necessary information with ease.

Indeed, studies repeatedly show that older people who do poorly on timed tests actually do as well as or better than their college-age counterparts when they are permitted to work at their own pace.

People who worry about memory loss are unlikely to suffer from a serious memory condition, while people with serious memory impairment tend to be unaware of their lapses, do not worry about them, or attribute them to other causes.

However, if memory lapses interfere with normal daily functioning, or if close friends and relatives believe that someone’s lapses are serious, a more complex cause may be the reason—and a visit to a physician may be in order.

Johns Hopkins Health Alerts | Memory | Low Memory Loss, Dementia and Aging

A First Step to Clearing up Memory Loss -- Check Your Medications

Fri, 07 Jul 2006 13:56:54 CDT

UPDATE

As part of our ongoing effort to ensure that this website is up to date, we have determined that the information in the article A First Step to Clearing up Memory Loss -- Check Your Medications is no longer current, and has therefore been removed.

If you would like to read related articles about memory loss and related dementias, please go to the Memory Topic page. Thank you.

Four Strategies To Stretch Your Memory

Mon, 17 Apr 2006 13:29:57 CDT

Johns Hopkins Health Alerts | Memory | Strategies to Improve Memory Ability

Proven strategies can improve overall memory ability at any age.

Although age-associated memory impairment is common and is not a sign of a serious neurological disorder, it can be frustrating and socially embarrassing. There is no way to eliminate completely the minor memory lapses that occur with age-associated memory impairment—but a number of strategies can improve overall memory ability at any age.

Place commonly lost items in the same spot. If you are prone to losing certain items, such as keys or eyeglasses, choose a place to leave them, and always put them in that spot when not using them.

Write things down. If you have trouble remembering phone numbers or appointments, write them down and place the list in a conspicuous spot. Making a daily “to do” list can serve as a reminder of important tasks and obligations. In fact, the mere acts of writing notes and making lists reinforce memory.

Say words out loud. Saying “I’ve turned off the stove” after shutting off the stove will give you an extra verbal reminder when you later try to recall whether it is still on. Incorporating people’s names into the conversation just after you have met them will serve the same purpose. For example, saying “Very nice to meet you, Jennifer” will help consolidate the memory of this name.

Use memory aids. Use a pocket notepad, personal digital assistant, wristwatch alarm, voice recorder, or other aids to help remember what you have to do or to keep track of information.

Johns Hopkins Health Alerts | Memory | Strategies to Improve Memory Ability

Healthy Fats That Help The Heart Can Also Help The Mind

Mon, 17 Apr 2006 13:25:53 CDT

Johns Hopkins Health Alerts | Memory | Healthy Fats Reduce Risk of Alzheimer’s Disease

Consumption of omega-3 fatty acids, omega-6 fatty acids, and monounsaturated fats are linked to a reduced risk of Alzheimer’s disease.

Omega-3 fatty acids, a healthy type of fat, are known to reduce the risk of coronary heart disease and may also lower the risk of Alzheimer’s disease.

In a report from the Archives of Neurology, weekly consumption of fish (a good source of omega-3 fatty acids) among older people without dementia lowered the risk of developing Alzheimer’s disease four years later by 60% compared with people who rarely or never ate fish. The risk of Alzheimer’s disease was reduced by 70% for those who ate fish twice weekly.

Another Archives of Neurology report found that the consumption of other healthy fats—omega-6 fatty acids and monounsaturated fats—was linked to a reduced risk of Alzheimer’s disease.

You will find omega-3 fatty acids not only in fish, but also in canola, soybeans, walnuts, and flaxseed as well as the oils of these plants. Omega-3 fatty acids are also available as supplements. Omega-6 fatty acids are found in fish, nuts, seeds, and corn, soy and safflower oils; monounsaturated fats occur in olive and canola oils, almonds, and avocados.

Currently, the American Heart Association recommends two servings of fatty fish per week in addition to oils, nuts, and seeds high in omega-3 fatty acids to protect against heart disease. The results of recent studies support these recommendations for brain health, too.

Johns Hopkins Health Alerts | Memory | Healthy Fats Reduce Risk of Alzheimer’s Disease