5 Steps to Reverse Dementia

Unraveling Alzheimers Disease

Unraveling Alzheimers Disease

I leave absolutely nothing out! Everything that I learned about Alzheimer’s I share with you. This is the most comprehensive report on Alzheimer’s you will ever read. No stone is left unturned in this comprehensive report.

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Master Activator Revolution

Master Activator Revolution is highly effective treatment approach which helps to improve a persons memory, problem-solving skills and language ability. People who have high perils suffering from dementia, they have to read this guidebook to prevent symptoms. It will work to all types of memory related problems which are people suffer from. This revolutionary program covers all treatments and strategies, considered to be one of its best features. Dementia barges in a persons work, social activities and family relationships. This treatment approach assesses a patients personal risk factors, evaluates their symptoms, decimates reversible causes of memory loss and helps people obtain appropriate care. Master Activator Revolution is not only treats the memory loss but it also treats behavior changes, sleep problems and other symptoms related to dementia and Alzheimers disease. Master Activator Revolution demonstrates various methods that work the best without causing patients to undergo any sort of a trouble.

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Alzheimers and Other Dementia

Dementia is a progressive, nonreversible deterioration in cognitive function with associated behavioral dysfunction. Alzheimer's disease accounts for the majority of dementia cases while vascular, Parkinson's disease, dementia with Lewy body, and fron- totemporal dementias are less prevalent. Drug therapy is targeted at slowing the progression of the cognitive symptoms and preserving the patient function. As patients progress toward end-stage dementia, in addition to memory loss and personality and behavioral changes, they require assistance in basic activities of daily living such as feeding, dressing, and toileting. At this point they may not respond to their surroundings, may not communicate, or have impaired movements and dysphagia. Depression, agitation, delusions, compulsions, confusion, hallucinations, incontinence, and disruption of sleep wake cycles are all common symptoms in end-stage dementias. Assessment of symptoms is challenging due to the cognitive impairment and...

Introduction About Alzheimers Disease

Take a good look at your own set of keys. Do you know what lock each key opens If you have forgotten what some of those keys do, you're pretty normal. But if you were a victim of Alzheimer's disease, you might see just a jangling mass of metal and wonder what those odd shapes were. Alzheimer's was discovered as a disease in 1907 by Dr. Alois Alzheimer. Until recently, little was known about it or about effective treatment. In the past decade, though, Alzheimer's has become the focus of much research. We are learning more about it every day. Alzheimer's disease (AD) and memory loss are not a normal part of aging, as once was suspected. It is a disease, one that progressively affects the brain and limits its ability to transmit and process information. Initially appearing as simple forgetfulness, it progresses to an inability to execute basic tasks and, eventually, an inability to interpret and comprehend sensory data. Ultimately, the body is no longer able to control its own functions,...

Studies of Cerebral Metabolism and Blood Flow in Dementia

Studies with FDG PET in Alzheimer's patients revealed a typical hypometabolism in neocortical structures, mainly the parietal, frontal, and posterior temporal association cortices, that is the same areas where neuronal as well as synaptic degenerations are most severe in postmortem studies. In addition to the regional abnormalities, these patients also exhibit a global reduction of cerebral glucose metabolism. Metabolic decrease in the parieto-temporal association cortex has been recognized as potentially diagnostic for Alzheimer's disease, and this recognition has facilitated the use of PET in clinical settings to evaluate patients with dementia. Also suggestive of dementia of Alzheimer's type (DAT) are bilateral metabolic reduction in the parieto-temporal association cortex glucose metabolism reduction in the frontal association cortex, mainly in advanced disease relative preservation of primary neocortical structures, such as the sensorimotor and primary visual cortex, and also of...

Treatment of memory loss a brainy pill

The neurotransmitter acetylcholine is known to be important in memory circuits. If a drug which blocks the effect of acetyl-choline is given to healthy young volunteers, short-term and episodic memory are impaired, although semantic, working and implicit memory are unaffected. In other words, it becomes difficult to learn new things or recall experiences, but knowledge and skills are unaffected. Working memory is still intact, so it is possible to repeat things or function from moment to moment. Because this pattern of impairment is similar to that seen in Alzheimer's disease, drugs that can increase the levels of acetylcholine in the brain have been used to treat its symptoms, with some success. There is now ample evidence that greater use of the brain protects against dementia, but while training for a specific task does protect against its loss, it does not have a more general protective effect on the brain and memory function.

Parkinsons Disease with Dementia

There are several forms of primary degenerative parkinsonism, including idiopathic (or sporadic) PD, sporadic PD with superimposed pathological features of AD, familial PD (or parkinsonian syndromes), and Parkinson's-ALS- dementia complex of Guam. Pathological substrates differ among these conditions, as do the frequency of cognitive disturbances. In patients with pathological evidence of AD, dementia is usually (but not invariably) present. In familial cases, genetic defects and pathological changes differ between kindreds, so it is difficult to generalize to sporadic PD. In each case of PD, however, when dementia is described, it is most consistent with a subcortical pattern to distinguish it from typical Alzheimer-type dementia. different anatomical or neurochemical systems, or separate pathogenetic processes.y Histological components of the Parkinson's dementia picture include both Parkinson's and Alzheimer-type pathology. Therefore, one must consider the roles of cortical Lewy...

Stages of Decline with Alzheimers Disease Level

Moderately severe cognitive decline (Early Dementia). Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4's or from 20 by 2's. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. Severe cognitive decline (Middle Dementia). May occasionally forget the name of the spouse upon whom they are entirely dependent for...

Mild Cognitive Impairment and Early Markers of Dementia

Some patients with MCI go on to develop the syndrome of dementia. Research with AD and other forms of dementia makes it clear that the cascade of events that eventually leads to dementia is well under way by the time clinical signs of a dementia are detected. This is most clearly the case with autosomal dominant conditions such as Huntington's disease. It is also apparent that in sporadic AD, the formation of abnormal beta amyloid and hyperphosphorylated tau precedes the development of clinical dementia, perhaps by several years (Cummings et al., 1998). Thus, it is likely that the most effective approach to treating AD and other forms of progressive dementia is early identification of persons known to be at risk. Marilyn Albert and colleagues have conducted multiple studies of potential pre-clinical markers of AD (Albert and Moss, 2002). They collected data from normal elderly control subjects, persons with questionable AD who did not convert to a later diagnosis of AD, and persons...

Definition Of Dementia

Current scientific definitions of dementia focus on a loss of ability to comprehend information or one's environment as well as a lack of ability to act in a fashion that is appropriate to one's circumstances. In addition to incorporating the concept of a loss of cognitive functions from a presumably normal premorbid state due to a biological cause, most current definitions indicate that the affected subject retains relatively normal consciousness. In this respect, the definition offered by the International Neuropsychological Society dictionary (Loring, 1999), is typical Generalized loss of cognitive functions resulting from cerebral disease in clear consciousness (i.e., in the absence of confusional state). Consistent with the contemporary emphasis on quality of life in medical research and practice, many current definitions also note that the deterioration in mental functions disrupts the ability of the affected individual to carry out everyday life functions. Thus, according to...

Alzheimers Disease History

In 1907, Alois Alzheimer, a Munich neuropathologist and clinician, published a report of a woman in her 50s who died in a Frankfurt asylum after a -year illness. Alzheimer wrote that the patient's illness was characterized by progressive cognitive decline (memory and language dysfunction, getting lost) as well as neuropsychiatric symptoms (psychosis, screaming, carrying and hiding objects). On postmortem examination of the patient's brain, Alzheimer noted atrophy as well as large blood vessel arteriosclerosis. Using microscopy and the Bielschowsky silver stain, Alzheimer also found neuronal loss, plaques, glial proliferation, and neurofibrillary tangles, a previously unknown phenomenon. Given the relatively young age of his patient, the unusual clinical features, and the unique neuropathological findings, Alzheimer hypothesized that he had discovered a disease distinctive from senile dementia (Alzheimer, 1907). TABLE 15.3. Fact Summary Alzheimer's Disease By the 1960s and 1970s, the...

Causes of poststroke dementia

The most frequent causes of dementia after stroke are VaD, AD and mixed AD-VaD 5 . AD and mixed AD-VaD account for 19 to 61 of patients with dementia after stroke (Table 13.3). Two Asian studies did not confirm this high proportion of AD patients, but in one 40 the study population was at least 10 years younger than in all other studies, and patients who were lost to follow-up at the 3-month evaluation were more cognitively impaired at the acute stage, and in the other 21 the diagnosis of VaD was based on the DSM IV criteria, which are the less specific 41 . In the following circumstances vascular lesions are the most prominent or only determinants of dementia after stroke (i) in stroke patients who are too young to have Alzheimer lesions, and became demented just after stroke (ii) when cognitive functions were normal before stroke, impaired immediately after, and did not worsen over time, or even slightly improved over time (iii) when a specific vascular condition known to cause...

Treatments of stroke in patients with dementia

There are no data in randomized clinical trials that may help in determining how acute stroke therapy and stroke prevention should be conducted in patients who are demented before or develop dementia after stroke 5 . PSD is not a specific entity that requires a specific treatment. Patients with dementia after stroke are patients with dementia and they are also stroke patients. In the absence of studies specifically designed for stroke patients with dementia, current guidelines for stroke prevention should be applied, but we should bear in mind that the specific issue of secondary prevention of stroke in patients with dementia (either pre-existing or new-onset dementia) is not addressed in any guidelines. Accordingly, a symptomatic approach to the dementia syndrome is necessary, depending on the presumed cause (AD, VaD or mixed AD-VaD). Both AD and VaD share a cholinergic deficit, and both conditions show improvement under cholinesterase inhibitors 5 .

Vascular Dementia History

Expanding upon the work of Binswanger and Alzheimer, Kraepelin in 1896 differentiated arteriosclerotic from senile dementia (Berchtold and Cotman, 1998). Despite this, in the first half of the 20th century hardening of the arteries was considered to be the most common form of dementia, and AD was considered to be a rare illness of younger people. It was thought that hardening of the arteries led to decreased cerebral perfusion and that this led to the formation of cortical plaques and tangles. By 1970 it had been shown that the correlation between vascular pathology and plaque and tangle formation is weak and that plaque and tangle disease is much more common than arteriosclerotic disease (Tomlinson et al., 1970). Hachinski coined the term multi-infarct dementia and posited that actual brain tissue destruction and not hypoperfusion is necessary for the manifestation of dementia (Hachinski et al., 1974). Today, the term vascular dementia (VaD) has supplanted multi-infarct dementia in...

Alcoholic Dementia and Cerebral Atrophy

Some authorities have contended that chronic excess ingestion of alcohol leads to cerebral atrophy and alcoholic dementia. However, the notion that alcohol has a direct toxic effect on cerebral tissue is greatly disputed. Most cases of dementia in alcoholics can be explained on the basis of Korsakoff's disease, other nutritional deficiencies, or medical causes. This syndrome has been described only in longstanding alcohol abusers, and the essential clinical features of this putative syndrome are the combination of cognitive and behavioral deficits including impaired memory and judgment, loss of social refinements, and paranoid ideation. Symptoms and signs develop gradually and continue to progress as long as alcohol abuse continues. Patients often show other stigmata of longstanding alcohol abuse. The major diagnostic distinction is with a slowly evolving form of Korsakoff's psychosis. Other considerations when encountering an impaired intellect in alcoholics include hepatic...

Dementia And Limiting Treatment

Severe and permanent dementia (in which all reversible causes have been excluded, in which no reasonable doubt as to diagnosis or prognosis remains, and in which there is an evident and progressive lack of meaningful thought processes) is a very troublesome problem. A sometimes long road separates its early stages from the ultimate, lingering non-being of the vegetative state. Along this road, various problems and options will inevitably present themselves and will need to be dealt with. Alzheimer's disease is one of the ways in which dementia most frequently presents itself, but it is not the only one. It can be an inborn state of affairs in which a severely retarded person can neither speak nor socially interconnect in any way it can occur due to accident or illness. Whatever its mechanism, dealing with permanent dementia is one of the more frequent and more troubling ethical problems in medicine. For caregivers no matter how loving it often represents a sometimes infuriating...

Risk Factors Associated with Dementia

In longitudinal studies, many risk factors for cognitive decline have been studied and or identified. In the Rancho Bernardo Study, where 800 women and 551 men were followed from 1972 1974 to 1988 1991, no gender differences were found in decline in cognitive function with age (Barrett-Conner and Kritz-Silverstein, 1999). In a study of 5781 mostly white women 65 or older followed for four years, depressive symptoms were associated with subsequent cognitive decline (Yaffe et al., 1999). Similarly, in a study of 1070 men and women aged 60 or older followed for five years, depressed mood at baseline was associated with an increased risk of incident dementia, after adjusting for age, gender, education, language, and baseline functioning (Devanand et al., 1996). Depressive symptomatology was a predictor of three-year cognitive decline in the Duke EPESE (Blazer et al., 1997). Other research has shown the association between depression and cognitive decline is related to level of...

Comorbidity of Depression and Dementia

Many studies have emerged estimating the comorbidity of depression and dementia (primarily Alzheimers disease) in the elderly. Virtually all report similar ranges of prevalence. Reifler et al. found that 20 of Alzheimer's disease patients admitted to an outpatient memory disorders clinic experienced major depression. Depression was more severe in the less cognitively impaired (Reifler et al., 1989). Patterson et al. found that 18 of Alzheimer's patients in an outpatient setting had mild-to-moderate symptoms of depression (Patterson et al., 1990). Lazarus et al. found mild depression in 40 of the patients with Alzheimers disease compared with 12 of the controls (Lazarus et al., 1987). Merriam et al. found depressive disorders in 87 of Alzheimer's disease patients (yet this included all varieties of depressive disorders) (Merriam et al., 1988). As with Reifler et al., they found that severe depressive symptoms were greater in the less cognitively impaired. dementia. This finding...

Outcomes Associated with Dementia

Witthaus et al. (1999) reported the burden of dementia in the general population has been shown to be similar to that of lung cancer or stroke. The authors used data from the Rotterdam study and compared lost life years in a demented population to lost life years in a healthy population. Fifty-five-year-old men were estimated to lose 1.2 life years due to morbidity and mortality due to dementia. Women lose an estimated 3.1 years to dementia. Lanska (1998) reported in the last year of life, most demented patients require assistance with activities of daily living (ADL), have severe impairments in cognitive functioning, and receive some hospi tal care. Poorer cognitive functioning has been linked to decline in physical functioning in longitudinal community studies. In the New Haven EPESE among persons who were free of limitations in physical functioning at baseline, individuals who scored more errors on a short cognitive screening measure were more likely to report incident ADL...

Delirium and Dementia

Dementia Common Types of Dementia Less Common Causes of Dementia Behavioral and Psychiatric Symptoms Accompanying Dementia Care Settings for the Dementia Patient Dementia and delirium are organic brain syndromes characterized by global cognitive dysfunction. Delirium is the recognized terminology for what has also been called acute confusional state, acute brain syndrome, acute cerebral insufficiency, and toxic-metabolic encephalopathy. Dementia has commonly been called senility or the insufficiently specific organic brain syndrome. It may be useful to conceptualize delirium as acute brain failure and dementia as chronic brain failure.

HIVAssociated Dementia

Human immunodeficiency virus (HlV)-associated dementia (HAD) develops late in HIV infection. It is a common cause of dementia worldwide. Motor deficits are observed in addition to cognitive decline. Patients are generally younger than most other dementia patients HAD has been diagnosed in pediatric HIV patients. The use of highly active antiretroviral therapy (HAART) has decreased the incidence of HAD, and newly diagnosed cases often respond to antiretroviral therapy (McArthur, 2004). Opportunistic CNS infections, particularly toxoplasmosis, can be a contributing factor and must be sought and treated.

Other Diseases and Conditions Alzheimers Disease

Studies show conflicting evidence linking smoking with Alzheimer's dementia and other causes of cognitive decline. However, a meta-analysis found that compared with never-smokers, current smokers had RRs of 1.79 for Alzheimer's disease (AD) and 1.78 for vascular dementia. Smokers in this study also had greater yearly declines in Mini-Mental State Examination (Anstev et al., 2007). Another systematic review and meta-analysis also found significant risk for AD among smokers (RR, 1.59) but less risk for developing vascular dementia (1.35) and cognitive decline (1.20) compared with never-smokers (Peters et al., 2008).

Alzheimers Disease and Alzheimers Dementia

Ihe two terms are related but not synonymous. AD is the disease process that ultimately results in Alzheimer's dementia. Alzheimer's dementia has a characteristic cognitive pattern. Early in a patient's course, AD may cause memory loss of insufficient severity to warrant the designation of dementia. Other patients with AD may follow an atypical course with progressive aphasia or progressive apraxia rather than a typical Alzheimer's dementia. Most of the time, however, AD causes Alzheimer's dementia. Synapse loss appears to be the most important correlate of dementia severity, 3 but the number of NPs and NFIs and the density of beta-amyloid load have each been associated Figure 12-1 Alzheimer's disease. Note the generalized cerebral cortical atroplfCourfesy J. E. Parisi, Mayo Clinic, Rochester, Minnesota.) with dementia severity. Mesial temporal structures, particularly the hippocampal formation, are involved early in AD, and this accounts for the amnestic syndrome in these patients....

Recent Clinical Studies 13191 Aromatherapy in Dementia

A meticulously conducted double-blind study involved 72 dementia patients with clinically significant agitation treated with melissa oil (Ballard et al., 2002). Agitation included anxiety and irritability, motor restlessness, and abnormal vocalization symptoms that often lead to disturbed behaviors such as pacing, wandering, aggression, shouting, and night-time disturbance, all characterized by appropriate inventories. The effect of the melissa oil was probably on cholinergic receptors as shown by previous in vitro studies (Perry et al., 1999 Wake et al., 2000). The authors also concluded that as most people with severe dementia have lost any meaningful sense of smell, a direct placebo effect due to a pleasant-smelling fragrance, although possible, is an unlikely explanation for the positive effects of melissa in this study but others may disagree with this conclusion as it has been shown that subliminal odors can have an effect. The fragrance may have had some impact upon the care...

Alzheimers disease destroys the self

Memory is one of the most fundamental properties of the nervous system, without which the individual self, culture, and history simply would not exist. Forgetfulness of recent events is common to normal aging, but it is also one of the first symptoms of Alzheimer's disease, which may inexorably progress to destroy the most essential characteristics of a person. Alzheimer's disease has achieved recent notoriety because its frequency has increased as a result of people living longer. The public awareness of this devastating disease was also greatly increased when former president Ronald Reagan dramatically announced in November 1994 that he was in the early stages of the devastating disease. The onset is insidious, but the course is relentless. The disease produces deep mental changes that lead to the complete deterioration of the mind. As Glenn Collins put it in the New York Times in 1994, the disease steals the soul 15 . The brain lesions in Alzheimer's dementia consist of senile...

Psychosis and Dementia in Parkinson s Disease

As the neurodegenerative process that underlies PD progresses, risk for developing psychotic ideation and a dementing illness increase significantly. At least 75 of PD patients who survive for more than 10 years will develop some form of PD dementia (PDD Aarsland & Kurz, 2010), but there is huge variation with some individuals not developing dementia at all, some developing a relatively mild form of dementia, and some not developing dementia until very late in the disease. The mean time from onset of PD to dementia is approximately 10 years. The strongest predictors for development of early dementia in PD are old age, postural and gait disturbances, and impairment in frontal ECFs (Janvin et al. 2006 Kulisevsky & Pagonabarraga, 2010 Marder, 2010). Because the ECFs are treated in this book as part of the agentic self system, in our terms, severe impairment in the agentic self system increases risk for later dementia in PD. Thus, if the agentic self system can be exercised so that...

Diagnosis Of Dementia

Once a patient is found to have the syndrome of dementia, it is necessary to identify the etiology. Numerous illnesses can cause dementia as broadly defined (see Table 15.1). Differentiation of these illnesses is important because some of them are reversible and some can be arrested. It is also important to identify the diseases that are neither reversible nor arrestable (e.g., neurodegenerative diseases) because some disease-specific symptomatic and neuroprotective treatments are now available and are discussed below. TABLE 15.1. Some Representative Causes of the Dementia Syndrome Reversible Dementia without Persisting Deficits Arrestable Dementia with Persisting Deficits Vascular dementia Alcoholic dementia Trauma (e.g., dementia pugilistica) Syphilis (i.e., general paresis) long-standing) Normal pressure hydrocephalus (e.g., long-standing) Postencephalitic dementia Anoxic dementia Progressive Dementia Alzheimer's disease Frontotemporal dementias Human immunodeficiency virus...

Prevalence of dementia in stroke survivors

Prevalence studies include both dementia pre-existing to stroke and new-onset dementia occurring after stroke 5 . The prevalence of PSD ranges from 5.9 to 32 , depending on the mean age of the study population, exclusion or not of patients with aphasia or severe physical disability, mortality rates, delay between stroke onset and cognitive assessment, and criteria used for the diagnosis of dementia 5, 12 . Dementia is 3.5-5.8-fold more frequent in patients who have had a stroke than in stroke-free controls, after adjustment for age 13, 14 . Details of studies evaluating the prevalence of PSD are provided in Table 13.1. Dementia is 3.5-5.8-fold more frequent in patients

Incidence of newonset dementia in stroke survivors

Incidence studies are limited by similar methodological issues 5 . The incidence of dementia after stroke depends on whether the study excluded patients with pre-existing cognitive decline or dementia or not. Many so-called PSDs are not actually new-onset dementia, but pre-existing dementia revealed after stroke, pre-existing dementia being present in 7-16 of stroke patients, and often undiagnosed before stroke 15-21 . In a community-based study conducted over a 25-year period, the cumulative incidence of dementia after stroke was 7 after 1 year, 10 after 3 years, 15 after 5 years, 23 after 10 years and 48 after 25 years 22 . In hospital-based studies, the incidence of dementia after stroke ranged from 9 23 to 16.8 24 after 1 year, 24 to 28.5 25 after 3 years, 21.5 26 to 33.3 27 after 4 years, and was 32 27, 28 after 5 years. In the Lille Stroke Dementia cohort after exclusion of patients who were demented at month 6, only 6 of survivors developed really new-onset dementia after 3...

Relative risk of dementia after stroke

In the Rochester study, the relative risk of dementia (i.e. the risk of dementia in stroke survivors divided by the risk of dementia in stroke-free controls) was 8.8 one year after stroke, then declined progressively to 2.5 after 10 years, and 2.0 after 25 years 22 . The risk of AD was also doubled after 25 years 22 . In the Framingham study, the results were similar 10 years after stroke, after adjustment for age, gender, education level and exposure to individual risk factors for stroke 29 . A study where stroke was not associated with an increased risk of dementia 30 was actually conducted in non-aphasic patients, with mild first-ever strokes, and only 1 year of follow-up, i.e. the best conditions to minimize the incidence of new-onset dementia. In hospital-based studies the risk of new-onset dementia within 4 years after ischemic stroke is 5-6-fold higher than in stroke-free controls 27, 31 . Finally, the results of hospital- and community-based studies can be summarized as...

Some Major Causes Of The Syndrome Of Dementia Introduction

As already noted, there are many brain diseases that can cause dementia. In this chapter we are primarily interested in the dementing diseases associated with aging and will focus on the four most common dementing diseases Alzheimer's disease, frontotem-poral dementia, vascular dementia, and dementia with Lewy bodies. TABLE 15.2. The Dementia Work-up TABLE 15.2. The Dementia Work-up

Alzheimers Disease

In 1906, Alois Alzheimer first described a neurological disorder of the brain associated with global deterioration of cognitive functioning and resulting in severe social impairment. Once thought rare, senile dementia of the Alzheimer's type is the most commonly acquired progressive brain syndrome. Alzheimer's disease begins with insidious intellectual and memory loss as the brain becomes shrunken from nerve cell loss and advances over 5-15 years to a chronic vegetative state. Progressive cognitive, psychological, and social dysfunction has a profound effect on family and friends. Alzheimer's disease may be the fourth leading cause of death in the United States. D. K. Kay and colleagues showed the average survival for demented men to be 2.6 years after the diagnosis of illness, whereas the survival period for nondemented men of the same age was 8.7 years. However, there is great variability in survival statistics from different studies. Although Alzheimer's disease is the leading...

Dementia

Dementia refers to the loss of multiple acquired cognitive and emotional abilities sufficient to interfere with daily activities. It is defined by a behavioral syndrome and not by etiology or lesion location. Its onset is often insidious and its course is often progressive. Dementia is an age-associated syndrome that has a prevalence of 1 percent at age 60 and doubles every 5 years, becoming 30 to 50 percent by age 85. y More than 50 diseases may produce dementia, but Alzheimer's disease is thought to account for Degenerative dementias Alzheimers disease, Pick's disease AIDS dementia complex Multi-infaret dementia Postenor cerebral artery occlusion about 70 percent of dementia cases.y The second main cause is multi-infarct or vascular dementia it may account for 10 to 20 percent of dementias. Other causes of dementia, including treatable causes, are rare. Although they account for relatively smaller percentages of dementias, some neurological diseases inevitably (e.g., Huntington's...

Vascular Dementia

Resting metabolic studies have also demonstrated cortical hypofunctioning in patients with multiple subcortical strokes (see Chapter 9) and diffuse axonal injury after trauma (see Chapter 11). For example, global glucose metabolism and regional metabolism in the right dorsolateral frontal lobe were lower in subjects with a vascular dementia compared to subjects who had subcortical infarcts and no demen-tia.71 Involvement of the cortico-striato-thal-amo-cortical loop by lacunes and small strokes may contribute to the pathology of vascular dementia. Color Figure 3-3 (in separate color insert) shows a PET scan from a patient who was told by his family physician that he may have had a minor stroke, but could return to work. The patient was bland, passive, and indifferent, even when confronted about his new cognitive impairments. Neuropsychologic measures of attention, word list generation, and verbal memory showed poor scores. He performed the Wisconsin Card Sort in a random,...

Stroke and dementia

For every three people currently living in Western countries, at least one will develop dementia, stroke or both 1, 2 . Stroke is the leading cause of physical disability in adults of one million inhabitants, 2400 people have a stroke every year, of whom more than 50 will die or become dependent 1 year later 3 . Dependency after stroke is often due to dementia 4 . Even in stroke survivors who are independent, slight cognitive or behavioral changes may have consequences for familial and professional activities 5 . Dementia is also frequent in Western countries, especially after the age of 75 years, where its prevalence is close to 18 6 . About 40 of demented people live in an institution, and among institutionalized residents two-thirds are demented 6 . Therefore, the economic burden of dementia is important. Stroke and dementia are both frequent and their relationship is more complex than being just a coexistence of two frequent disorders. Besides being a potential cause of dementia,...

Poststroke dementia

Stroke is an important risk factor for dementia and cognitive decline. According to the NINDAS-AIREN criteria, in order to make the diagnosis of post-stroke dementia (PSD) the patient has to be demented, with either historical, clinical or radiological evidence of cerebrovascular disease and the two disorders must be reasonably related 77 . On the other hand, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-4) 78 , vascular dementia is diagnosed by the development of multiple cognitive deficits manifested by memory impairment and at least one of the following cognitive disturbances aphasia, apraxia, agnosia and disturbance in executive functioning with the presence of focal neurological signs and symptoms or laboratory evidence indicative of cerebrovascular disease that is judged to be etiologically related to the disturbance. The deficits should not occur exclusively during the course of an episode of delirium. Despite the lack of accurate...

Pseudodementia

The term pseudodementia refers generically to treatable disorders that mimic dementia. The most common is depression. Depression and dementia can both lead to reduced motivation, impaired concentration, and mental slowing. Consequently, both diseases can lead to widespread cognitive and memory dysfunctions. Formal testing has shown that purely depressed patients perform better on declarative memory tests than genuinely demented patients, but this difference may be difficult to determine in particular patients. Because depression, with or without the co-occurrence of dementia, is treatable, it should be considered in any diagnostic evaluation. Some instruments, such as the Geriatric Depression Scale, may be useful in diagnosing depression in elderly individuals.

Activities of Daily Living

We will also look at activities of daily living in terms of both the person with AD and the caregiver. Alzheimer's disease gradually hinders peoples' abilities to perform activities of daily living. In some cases, the activity is conducted by your family member, in others the caregiver assists, taking on much of the burden. So home modifications will need to assist both the person with Alzheimer's and the caregiver, accordingly. In the early stages of Alzheimer's disease, your loved one will still be able to perform many activities of daily living and family responsibilities, despite occasional accidents or episodes of forgetfulness. As time goes on, more and more of these activities will require assistance. As a caregiver, you will need to simplify tasks, slowly begin to join in and assist, then carefully remove the tools and reminders of those responsibilities when they become too difficult or dangerous. Even as dementia robs people of their memory, the need for privacy and...

Access Denial

When taking steps to limit your family member's freedom, timing is all-important. Too many locks too soon, and you will cause unnecessary upset. Too little too late could result in an accident. Furthermore, with Alzheimer's disease change is Dementia happens gradually, with periods of clear thought sometimes intertwined in the confusion. Eventually the periods of lucidity become rare, and then nonexistent. In times of clarity, your loved one may feel he is fully capable of performing a certain task, whether it be driving to the drugstore or using the lawnmower. Denying him the dignity and independence of performing what seems perfectly safe to him may be met with anger. Try to balance independence with protection and constantly adjust from day to day. If your family member becomes a threat to the safety of you or your family, professional supervision in an Alzheimer's care facility may be in everyone's best interest. If that is not an alternative, then protecting and alerting yourself...

Incontinence

The problems that Betsy and Uncle Ken are experiencing have more to do with the confusion that Alzheimer's creates in its victims than with a medical condition. It would be irresponsible for us not to recognize that confusion alone may be the cause. There may be times when your loved one has an accident that almost appears intentional. When this happens, the best you can do is deal with the consequences. Clean up as best you can. No modification to your home can solve this type of problem. For this reason, caregivers dealing with incontinence often suggest Sometimes the trip to the bathroom is just too difficult to make the effort. Make the journey to the bathroom as easy and comfortable as possible, and most likely to result in success. If it is too difficult or likely to result in failure, it will be avoided. Remember those with Alzheimer's often seek the path of least resistance. Sometimes that path may be just remaining in place and not doing anything. Cognitive incontinence...

Safety

Keeping a person with Alzheimer's disease at home and safe throughout the entire course of the disease is a challenge that requires extraordinary preparations and foresight Consider the recommendations in this chapter as examples of a mindset that goes beyond the limits of normal safety-proofing, recognizing and responding to the special needs of a person with a dementing illness. Safety is a particularly important issue for anyone living with Alzheimer's disease. The word safety takes on a whole new meaning when applied to Alzheimer's disease, as it no longer refers just to accident prevention. Safety now also means creating environments that are easy to understand, less intimidating, more likely to result in success it means recognizing the unique demands that accompany Alzheimer's disease. Sensory impairments also present safety issues. Olfactory (sense of smell) impairments associated with AD may explain why some people don't realize that they are eating or drinking something...

Suggested Reading

The following books, brochures and pamphlets are written by the Alzheimer's Association and can be ordered by contacting The Alzheimer's Association, 919 North Michigan Avenue, Suite 1000, Chicago, IL 60611-1676 phone (800) 272-3900. The association has a wide variety of excellent publications. When you call, ask for their publications catalogue. Caregiver's Stress Signs to Watch Out For . . . Steps to Take. Chicago, 111. The Alzheimer's Association, 1995. (Order number PR200Z.) Family Guide for Alzheimer's Care in Residential Settings. Chicago, 111. The Alzheimer's Association, 1992. Respite Care Guide. Chicago, 111. The Alzheimer's Association, 1995. (Order number PF112Z) Terms & Tips An Alzheimer's Care Handbook. Chicago, 111. The Alzheimer's Association, 1995. The Alzheimer's Association Materials Public Catalogue. Chicago, 111. The Alzheimer's Association, 1997. Steps to Planning Activities Structuring the Day at Home. Chicago, 111. Alzheimer's...

Preparing Your Home

Caring for someone with Alzheimer's disease (AD) need not be an overwhelming burden. The more planning, thinking, and constructive action you take early in caregiving, the easier it will be for the entire family to cope. Preparing your home and family for living with Alzheimer's is not so difficult, when you know what to do. The difficulties you encounter are not unique. They have been faced by many other families coping with this disease. Because caregivers have been so willing to share their stories with us, we have practical advice to offer that will help get you started and keep you going as you confront new behaviors and seemingly impossible situations. The one consistent piece of advice we have heard from families is that you definitely need to arrange your home to care for a person with Alzheimer's. You may assume that you'll need to make changes to create a home that will serve you best in these difficult times. You should start with a plan. Alzheimer's disease is progressive...

Mobility

As Alzheimer's disease continues to affect your loved one's abilities and disrupt the signals traveling throughout the brain, mobility will become a problem. At first the obstacles may be cognitive, getting lost or failing to recognize the drug store. As time goes on the problems begin to manifest themselves in more significant and physical ways walking, using the stairs or a walker, until eventually even getting out of bed becomes too risky. Locate cues where they are most likely to be seen. Because people with Alzheimer's often see only what's directly in front of them, it is best to place cues right where your family member is likely to see them, not to the right or left, and especially in the places where he would most likely look if he were lost or confused. This strategy is called redundant cuingthe use of multiple cues and multiple senses, rather than relying on just one to get across a single message. Alzheimer's disease hinders the normal transfer of information from one part...

Wandering

Wandering is the repetitive, sometimes incessant, behavior of roaming, pacing, or attempting to leave home. It is a major concern for those caring for someone with Alzheimer's disease. Mv father has Alzheimer's disease and has moved in with us. He started walking off and he can't find his way home. In the early stages of Alzheimer's your loved one may struggle to remain independent. She may be capable of handling most situations, able to hide her condition, get away with minor episodes of forgetfulness, and navigate from one place to another without incident. At some point, your family member's memory and image of the once-familiar home may On the other hand, some people with dementia never wander at all. Freedom to Wander Alzheimer's disease erases memories, first those of only moments ago, then those of years ago. Remember our theory of last in, first out. Your loved one might be wandering Every room in your home is different Each has its own set of cues that help identify it....

Behavioral Problems

Rummaging, hiding, and hoarding are common activities among those with dementia. Rummaging is the constant searching for things. Once found or collected, these items may be either hidden or hoarded. Hoarding is the constant collecting of articles, much like the proverbial squirrel putting food away for when it might be needed. Rummaging and hoarding, if not controlled, can get out of hand. Often hoarding becomes an obsession, with extraordinary quantities of similar items collected and stored, as if the world were running out of Oreo cookies. We have heard stories of people who rummage in garbage day after day, collecting useless trash and storing it in their homes, until there is literally no room for them to live. Their houses become filled with boxes, garbage, and other unsanitary items. People with Alzheimer's disease often lose their ability to tell the difference Change is difficult for those with dementia, but it can be used to your advantage. Once discovered, trash cans, and...

New Conceptions of the Brain and of Creativity in the Latter Part of Life

Indeed we cannot escape the fact that physical functions and vital organs in the body get worn and lose the capacity of the young. For instance our pulse maximum decreases when we get older and it cannot be improved by training. Another example is that older adults have more difficulty focusing their attention and ignoring distracting stimuli. Much decline in mental ability is however often not caused by aging per se but by specific diseases, such as dementia or depression.

Three Giants Of The First Half Of The 20th Century

Of Mental Disorders, Fourth Edition, (DSM-IV) . He recognized that progress had to be based on systematic cross-sectional and longitudinal clinical observations, leading to diagnostic systematics. He recruited all possible varieties of objective measures including behavioral and cognitive as well as neurological and biochemical, to achieve the most comprehensive understanding possible in his day. Through his desire to reach a full appreciation of the organic underpinnings of pathological processes, Kraepelin gathered around him a remarkable group of talented neuroscientists who also became luminaries, such as Alois Alzheimer, Korbinian Brodmann, and Franz Nissl.

Care of the Elderly Patient

This chapter discusses common geriatric syndromes and outlines a process by which the family physician can effectively and efficiently care for the elderly patient. The main goal is to assist elderly persons to maintain function and quality of life with self-respect, preserving their lifestyle as much as possible. The chapter addresses functional assessment, falls, elder abuse, pressure ulcers, rational drug prescribing, and incontinence geriatric conditions such as dementia, delirium, and depression are discussed in other chapters.

Brain Diseases with BBB Dysfunction

Dysfunction of the BBB may be in the form of increased permeability or BBB breakdown to large and small molecules in brain diseases and or may take the form of alterations in endothelial transport mechanisms. Well documented in the literature is the increased BBB permeability to plasma proteins, which occurs in conditions associated with vasogenic edema such as ischemic and hemorrhagic stroke, infections, inflammation, seizures, trauma, tumors, epilepsy, and hypertensive encephalopathy (182, 183). Increased permeability to C14 sucrose implying increased ionic permeability has been reported in peripheral inflammatory pain (184). Increased BBB permeability to ions and plasma proteins has been reported in human and experimental diabetes (184, 185). Global vascular changes and altered expression of Pg-p have been implicated in the pathogenesis of degenerative diseases such as Alzheimer's disease (186, 187) and Parkinson's disease (188) as reviewed previously (136, 189).

Defining traumatic brain injury TBI

A short-lasting disturbance of neural function typically induced by a sudden acceleration or deceleration of the head usually without skull fracture The most dramatic aspect of concussion is an abrupt loss of consciousness with the patient dropping motionless to the ground and possibly appearing to be dead. This is usually quite brief, typically lasting just 1-3 min, and is followed by spontaneous recovery of awareness There appears to be an intimate link between amnesia and concussion so much so that if a patient claims no memory loss, it is unlikely that concussion has occurred. (Shaw, 2002, p. 283)

Is the Disorder Familial

Silverman and colleagues (1986) evaluated the reliability of the family history method for dementing illnesses such as Alzheimers disease. When rating the same individual, different informants had high levels of agreement on the presence of dementia and its age at onset. The rates of dementia found in this family history study were similar to what had been found in previous family studies using direct methods of assessment. The authors concluded that multiple informants would likely increase the validity of the family history method but, because they did not directly evaluate relatives, inferences about validity were limited.

Patient Specific Factors

Medical complications also contribute to functional outcome. In addition to the effects of primary brain tumor treatment, adjuvant medications may also cause cognitive and mood disturbance. Steroid therapy, which is ubiquitous in this population of patients, can independently contribute to memory loss and psychiatric symptoms. Such medications as antiemet-ics and pain medications may also contribute to the patient's overall functional status. Patients with brain tumor often have medical complications, such as seizures, that further compromise brain function and have a negative impact on the person's social function, ability to drive, and so on. Brain tumor patients may also have co-existing neurologic or psychiatric illness, such as learning disabilities, cerebrovascular disease, or bipolar illness. Reactive mood and adjustment disorders may also contribute to cognitive impairment a patient who is depressed and preoccupied with his or her situation may exhibit attentional problems.

The Supplement Shambles

Government Accountability Office (GAO) conducted an investigation. The GAO 2010 report indicated that dietary supplement products often were still promoted with deceptive and unfounded disease-related claims, encouraging consumers to use the products to prevent or treat diabetes, cancer, heart disease, Alzheimer's disease, and other serious conditions. The GAO investigation also found that most of the herbal supplement products tested were contaminated with heavy metals such as lead or pesticide residues, but usually at low levels.

A A Remedy for the Medical Inconsistencies of the BD Definition

Finally, a strong criticism of the cortical theory is constructed as a ''slippery slope'' argument. The opponents to this theory contend that, if the concept of death was to be linked to a psychological property (consciousness) instead of biological data, it would be easy to extend the concept from PVS to other abnormal psychological states, like dementia or severe mental retardation.

Associated Neurological Findings

The neurologist should be alert to signs of dementia (e.g., inattention, memory dysfunction, apathy, disorientation) in patients presenting with olfactory dysfunction, since decreased ability to smell is among the first signs of Alzheimer's disease and is also seen in some patients with Huntington's chorea, multi-infarct dementia, and Pick's disease. Evidence of fainting spells or blackouts, disorientation, seizure activity, and mood change should be sought because both increases and decreases in olfactory function are found in patients with temporal lobe epilepsy. Olfactory loss, along with short-term memory problems and associated confabulation, may help to define vitamin B-, deficiency and the Wernicke-Korsakoff syndrome. Cognitive alterations (e.g., mental slowing, confusion, depression, and hallucinations) may also signal the presence of pernicious anemia.

Tests for brain damage patients

The Autobiographical Incidents Schedule requires participants to recall specific events and is scored in terms of the richness and specificity of the detail provided for each memory. Further verification of memories is undertaken by communicating with the participant's relatives, checking medical records, and noting inconsistencies in the participant's responses. A standardized scoring system exists for the Autobiographical Incidents Schedule and it produces fairly reliable scores. The AMI has been found to accurately discriminate different types of special populations with memory problems, such as amnesia, dementia, and psychiatric patients (Koppelman, 1994).

Thalamic Systems Intralaminar Nuclei ILN

ILN lesions can generate (depending on their severity) relatively brief coma, vegetative states, akinetic mutism, delirium, and often various kinds of dementia as an end state (see case studies). Extensive bilateral lesions of the ILN systems (if other components of the extended reticular activating system are relatively undamaged) show Bilateral lesions of the ILN discussed in cases study 2 may be one clinical syndrome that more dramatically than any other underlines the extent of our fundamental ignorance regarding the complex integrative reticular-thalamocortical mechanisms foundational for consciousness. This syndrome, which shows a walk-through of all the major disorders of consciousness, suggests that the fundamental integrative mechanisms for consciousness are writ large throughout the brain's connectivities and functional neurodynamics in a fashion still not well mapped. This walk-through syndrome suggests that these fundamental integrative mechanisms cannot be neatly...

Neurotransmitters in disease

Concept of a dopaminergic abnormality in schizophrenia. Some symptoms of schizophrenia are reduced by naloxone, suggesting that opioid peptides (e.g. enkephalins) are involved, although naloxone also blocks GAB A receptors. The brain of patients who have died with Alzheimer's disease contains reduced concentrations of choline acetyl transferase, norepinephrine, GABA and somatostatin, although the most severe abnormality is a cholinergic deficit.

Termination of Parental Rights

Parental rights may be permanently terminated in extreme circumstances, when the parents are found to be unlikely to be able to change their parenting behaviors within the foreseeable future (e.g., parents with severe dementia or mental retardation). Generally, termination of parental rights occurs only if supportive interventions are deemed insufficient and the child remains at ongoing risk of harm. Upon termination of parental rights, the child may be permanently placed in an adoptive home, and the adoptive parents are given full decision-making authority.

Clinical Characteristics

A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. Coding note If delirium is superimposed on a preexisting vascular dementia, indicate the delirium by coding 290.41 vascular dementia, with delirium.

Amnesia Reversal Compounds

Primary degenerative dementia, also called Alzheimer's disease, is a clinical syndrome involving reduced intellectual functioning with impairment of memory, language and cognition. Research on new molecules, which are able to improve impaired cognitive functions, has led to the development of new compounds showing cognition-activating properties.

Other neurotransmitters in LTP

ACh has long been implicated in learning and memory, since the discovery that death of cholinergic neurones in the cholinergic basal fore-brain is one of the consequences of Alzheimer's disease (Bartus, 2000 Volume I, Chapter 31) and loss of cholinergic modulation may contribute to the cognitive impairments associated with this condition.

Assessment and Diagnostic Tools

Various published instruments are used to diagnose delirium and assess symptom severity in adults. They are usually structured to distinguish delirium from dementia, depression, or schizophrenia. Most consist of operationalized diagnostic criteria from DSM-IV-TR or the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10 World Health Organization 1992), usually in the form of a checklist, and incorporate information from patient observation and the medical record. Their breadth of symptom coverage varies, as does their applicability. No For many years, brief cognitive tests, such as the Mini-Mental State Examination (Folstein et al. 1975), were used to diagnose delirium. Although these tests documented cognitive abnormalities, they could not distinguish between delirium and dementia (Robertsson 1999) and they are not suitable for younger children. The Children's Orientation and Amnesia Test (COAT) is designed to assess cognition in...

What Are The Typical Side Effects Of Aeds

Within the first 6 months of treatment with a newly prescribed AED, systemic toxicity and neurotoxicity are as likely to contribute to AED failure as is lack of efficacy. Table 3.2 shows the common neurotoxic effects of AEDs these include diplopia, nystagmus, dysarthria, ataxia, incoordination, tremor, sedation, mood alteration, dizziness, headache, and cognitive impairment. Sufficient time should be allowed during office visits to determine whether a patient is experiencing any side effects. Patients often complain of memory loss. Neuropsychologic testing, as described in Chapter 6, may help determine whether memory loss or trouble concentrating is medication-related.

Diagnosis and Management

The diagnosis of CTBI requires a clear documentation of neurological deterioration over time and or the persistence of neurological symptoms time in the setting of multiple concussions or brain injuries. In severe cases of CTBI (i.e., dementia pugilistica) the athlete will exhibit obvious motor impairment (e.g., dysarthria, incoordination) in addition to cognitive and behavioral manifestations. In milder cases of CTBI only subtle changes in cognitive function may be evident. Accordingly, neuropsychologi-cal testing may be instrumental in detecting the cumulative effects of concussion, especially when a preparticipation baseline has been established. In CTBI neuroimag-ing typically reveals nonspecific findings. CT and MRI scanning may demonstrate brain atrophy with or without a cavum septum pellucidum. Single photon emission computed tomography (SPECT) may exhibit perfusion deficits in boxer that localize primarily to the frontal and temporal regions.

Cobalamin Vitamin B12 and Folic Acid Deficiency

The clinician must distinguish folate from B12 deficiency, because supplementing one will not correct the symptoms from deficiency of the other, i.e., folate replacement will not improve the neuropsychiatric abnormalities caused by vitamin B12 deficiency. The neurologic signs and symptoms, such as paresthesias, memory loss, dementia, and weakness, may precede hematologic abnormalities. Vitamin B12 and folate deficiency often coexist because some causes overlap (Table 15-11).

Frederic Barlett and the schema

Involved examinations of amnesic patients, people who were suffering severe memory loss as a result of specific brain damage. While debilitating, it turns out that the memory capacity lost was selective to aspects of conscious recollection described by James and Bartlett, and had properties shared with Tolman's characterizations of the cognitive map. Other capacities that the behaviorists might recognize as intact stimulus-response learning were spared, even in severe cases of amnesia in humans. Parallel studies on animals with experimental brain damage in the same brain areas implicated in human amnesia provided additional insights into the anatomical psychological bases and fundamental psychological mechanisms of cognitive memory. In addition, related physiological observations provide an understanding of the coding elements that underlie the cognitive mechanisms in conscious memory. These findings are the focus of this section.

Are sedativeshypnotics ever indicated in chronic low back pain

The role of sedative-hypnotics in chronic spine pain is controversial. Adequate restorative sleep is very important for patients with chronic spine pain. Many spine patients have sleep difficulties. The two hypnotics used most often are zolpidem (Ambien) and eszopicine (Lunesta). Limited data suggest zolpidem is somewhat more effective but also has more adverse effects, the most serious of which include sleep walking, talking, and eating, as well as some memory loss. The most serious adverse effects of eszopicine include a very bad taste in the mouth and feelings of anxiety. However, both drugs are generally preferred over the benzodiazepines, such as clonazepam or temazepam (Restoril). Long-acting drugs, such as diazepam or flurazepam (Dalmane), may accumulate with chronic use and produce cognitive impairment and depression, and there may be rebound insomnia when the drugs are discontinued.

Sleep Problems and Remedies from Ambien to Zolpidem

The problems with BZs, with regard to cognitive impairment, memory loss, and addictive potential (Chapter 19), are sufficiently large that a vigorous search was mounted for other effective agents that have no such problems. A new class of non-BZs that are stimulants for the BZ receptor, and hence GABA facilitators of SWS processes, has revolutionized the medication of sleep problems. The fast-acting, short-duration agent that has taken away a substantial market-share from triazolam (Halcion) is zolpidem (Ambien), which can be taken in the middle of the night to counteract early-morning wakenings. Of course there are also highly effective longer-acting agents, such

Watersoluble vitamins Vitamin B complex

Deficiencies can occur as a result of overconsumption of certain foods that contain specific antivitamins. For example, avidin in egg white binds biotin, thiaminases in raw fish can lead to thiamin deficiency in cats. Water-soluble vitamin deficiencies can also be demonstrated in pets fed unusual home-prepared diets. Dogs fed exclusively on cereals such as porridge have been reported to develop niacin deficiency (termed pellagra), which presents as dermatitis, diarrhoea, dementia and death.

Diagnosis Initial Symptoms

The symptoms and signs of patients with GC are nonspecific, reflecting the diffuse and infiltrative nature of this neoplasm. Interestingly, signs and symptoms are often minimal given the widespread areas of brain infiltrated with tumor. In the report by Jennings et al, the interval from onset of symptoms to diagnosis varied from days to 23 years, with 65 of the patients symptomatic for fewer than 24 months before diagnosis the authors noted that the delay in diagnosis of the more protracted cases made it difficult to distinguish presenting symptoms and signs from those consistent with progressive disease.13 The most common findings included corticospinal tract deficits (58 ), dementia (44 ), headache (39 ), seizures (38 ), cranial neuropathy (37 ), papilledema or increased intracra-nial pressure (34 ), spinocerebellar dysfunction (33 ), mental status changes (20 ), behavioral changes or psychosis (19 ), sensory deficits or paresthesias (18 ), and visual alterations (17 ), including...

Neurologic Examination

Vates et al reported that the most common deficit on formal neurologic testing was dementia (68 ) (see Table 28-2).20 Other deficits included corticospinal deficits (36 ), gait abnormalities (36 ), papilledema (27 ), dysphasia (23 ), visual alterations (23 ), cranial neuropathies (5 ), and paresthesias (5 ). Most of the patients with dementia had memory disturbances, but two were obtunded. Corticospinal tract abnormalities were varied and ranged from mild pronator drift or mild diffuse hyperreflexia to profound weakness. Speech findings were predominantly word-finding abnormalities, although two patients were obtunded with complete aphasia. The one patient with a cranial neuropathy (excluding cranial nerve I and II) had decreased oculocephalic activity and a right facial droop.

Neurotransmitter Correlates

One neuroendocrine challenge study of healthy volunteers found a positive correlation between DA agonist (bromocryptine)-induced prolactin release and a trait variable called positive emotionality (Depue et al., 1994). Positive emotionality correlates with NEO-PI-R extraversion and so could be conceptualized as the inverse of DAPP introversion (see Table 5.2). PET studies suggest that dopamine ligand binding may be negatively related to psychometric indices of interpersonal detachment in the putamen (Farde et al., 1997) and positively related to psychometric indices of novelty-seeking in the insula (Suhara et al., 2001), suggesting links between basal dopamine function and traits similar to NEO-PI-R extraversion. Further, a recent study combining both PET and a challenge with the dopamine releaser reuptake blocker amphetamine revealed a positive correlation between ventral striatal dopamine release and the personality trait of novelty seeking-exploratory excitability, which is...

Health and Health Care

The aging of the older population is significant for the health burden in a population because rates of disability and dependency increase rapidly at very old ages. Examples of differences in health problems and health costs for different segments of the older population in the United States are shown in Table 5.6. The contrast between the ''youngest-old'' (65 to 69) and the ''oldest-old'' (85+) tend to be striking. For example, compared to the youngest-old, the oldest-old are 16 times more likely to reside in nursing homes and 12 times more likely to have severe memory loss. Average per capita health care expenditures in 1999 increased from 6,711 for those aged 65 to 69 to 16,596 for those aged 85 or older. Thus one might anticipate that the challenge to provide adequate health care would grow in societies that are experiencing both population aging and aging of their older population. Indeed, assuming no future changes in age-specific rates of Alzheimer's disease and functional...

Other Transport Systems Responsible for Drug Transport at the Blood Brain Barrier

Of patients with Alzheimer's disease, and acyl-l-carnitines are one group of candidate drugs. However, it is unclear whether acyl-l-carnitine is transported across the BBB via a saturable system or by passive diffusion. Although it has not been established whether the Na+-dependent hexose transporter SGLT is expressed at the BBB, a recent report suggested a participation of SGLT in the BBB transport of cycasin (58). Cycasin, methylazoxy-methanol-d-glucoside, is proposed to be a significant etiologic factor for the prototypical neurodegenerative disorder Western Pacific amyotrophic lateral sclerosis and for Parkinsonism-dementia complex. Cycasin is taken up into primary-cultured bovine BCECs in a dose-dependent manner with maximal uptake at a concentration of 10 j.M. Since cycasin uptake was significantly inhibited by a-methyl-d-glucoside, a specific analogue for the Na+-dependent glucose transporter, SGLT, as well as by phlorizin (a SGLT inhibitor), replacement of extracellular NaCl...

Prevalence and incidence of secondary organic personality change following TBI

The second type of pattern of organic personality change to emerge following TBI is the symptom disorder of drive syndrome and is characterized by apathy or lack of motivation not attributable to intellectual impairment (i.e., not dementia), emotional distress (i.e., not depression) or a diminished level of consciousness (i.e., not delirium) (Marin, 1991).

Imaging of Other Neurotransmitter Systems

In the field of geriatric psychiatry, fluorodeoxyglucose (FDG) PET (or similar SPECT) approaches are increasingly being incorporated into routine clinical use for the diagnosis or differential diagnosis of dementia and related illnesses (also see Chapter 15). It is conceivable that new specific ligands for neurofibrillary tangles and plaques in patients suffering from dementia of Alzheimer's type will provide major breakthroughs in the diagnostic assessment of this disorder, providing the first in vivo proof of these pathognomonic brain alterations. Another promising future clinical application of functional neuroimaging may be in predicting clinical response to specific pharmacological or nonpharmacological therapeutic interventions. And last but not least, functional neuroimaging can be combined with genetic studies with the aim of finding genotype-phenotype associations typical for specific neuropsy-chiatric disorders (also see Chapter 14). If the fast...

Psychological Symptoms

Vivid dreams or nightmares may herald psychosis. Other potential causes of psychosis, dementia, or depression, such as infections, metabolic changes, electrolyte disturbances, or toxic exposures should be ruled out. Confusion may be alleviated by the presence of a night light or correction of vision and hearing deficits. PD therapy should be adjusted to decrease off periods when depression and anxiety may be more likely to occur. Low-efficacy PD medications should be gradually decreased and stopped in patients with psychosis. Patients should be encouraged to participate in tasks that improve cognition, such as puzzles or reading. Some patients and their families may benefit from professional counseling. Some antidepressants may be used for anxiety, panic, or depression. Low-dose quetiapine (12.5-200 mg) at bedtime can improve psychosis. Dementia symptoms may improve with an acetylcholinesterase inhibitor or memantine. Consider electroconvulsive therapy in depressed patients who fail...

Differential Diagnosis

While depression is generally thought of as a primary psychiatric disorder, it is also commonly seen with a variety of neurological and medical illnesses (Starkstein and Robinson, 1993 Glassman and Shapiro, 1998 Meyers and Scheibel, 1990). Recognition of these comorbid conditions is critical since different treatment strategies may be necessary for optimal clinical response in different populations. In evaluating a newly depressed patient, drug-induced mood changes, comorbid general medical illnesses, and substance abuse should always be considered, particularly in patients whose symptoms are atypical or of uncharacteristic onset. A related problem is the recognition of depression in patients with certain neurological disorders such as dementia or Parkinson's disease, where the diagnosis of depression may be obscured by neurological findings such as inattention, memory loss, apathy, motor slowing, or bradyphrenia (Marin, 1990 Starkstein et al., 1990a). Similarly, the presence of these...

Prediction of stroke in the general population

In a clinical setting, simple risk assessment tools that have been developed for instance for type 2 diabetes 53 might be useful since they do not require any laboratory testing. Similar tools have been now developed for dementia 54 , but unfortunately we do not have such a simple risk-assessment tool for stroke. Yet it is not difficult to design such given the large number of prospective studies using stroke as the outcome. In both men and women the FINDRISC predicted the stroke incidence well 55 . This avenue in risk assessment needs to be further pursued in order to identify people at risk of stroke as early as possible.

Applying Small Molecules in Biology

Was found that the binding of FK506 to FKBP inhibits immune function by shutting down a specific molecular signaling pathway. Another natural product, galanthamine (Figure 4.4, see Chapter 16), which is an inhibitor of acetylcholinesterase (AChE) isolated from certain species of daffodil and is used for the treatment of mild to moderate Alzheimer's disease, was used as a template for the so-called biomimetic DOS that is, a range of diverse chemical reactions was applied to a scaffold similar to that of galanthamine. A 2527 compound library of galanthamine-like structures was prepared and underwent phenotypic screening, identifying secramine (Figure 4.4), as an inhibitor of vesicular traffic out of the Golgi apparatus by an unknown mechanism. After an extensive effort it was discovered that secramine inhibits the activation of the Rho GTPase Cdc42, a protein involved in membrane traffic.

Population Measures of Onset

The preference for first or total incidence in etiologic studies depends on hypotheses and assumptions about the way causes and outcomes important to the disease ebb and flow. If the disease is recurrent and the causal factors vary in strength over time, then it might be important to study risk factors not only for first but for subsequent episodes (total incidence). For example, one might consider the effects of changing levels of stress on the occurrence of episodes of neurotic illness (Tyrer, 1985) or of schizophrenia (Brown and Birley, 1968). For a disease with a presumed fixed progression from some fixed starting point, such as dementia, the first occurrence might be the most important episode to focus on, and first incidence is the appropriate rate. In the field of psychiatric epidemiology, there are a range of disorders with both types of causal structures operating, which leads to discussion of the two distinct types of incidence.

Adsorptive Mediated Endocytosis

Several studies have been done on AME of neuropharmaceutical pep-tides, which have the characteristics of stability to enzymes and cationic charge as a consequence of suitable chemical modifications of the native peptides. Ebiratide a synthetic peptide analogous to adrenocorticotropic hormone that is used to treat Alzheimer's disease, is positively charged with an isoelectric point of 10, and its resistance to metabolism has been enhanced by chemical modifications of the constituent natural amino acids. The internalization of 125I ebiratide was saturable in primary cultures of bovine BCECs. Furthermore, the characteristics of its internalization were consistent with AME in various respects, including energy dependence and the inhibitory effects of polycationic peptides and endocytosis inhibitors (7, 61, 67). To prove the transcytosis of ebiratide across the BBB, a capillary depletion study and brain microdialysis study were performed (68). After infusion of 125I ebiratide or 14C...

The somatic marker hypothesis Cognition meets emotion

The apathetic abulic negative disorder of drive pattern of personality change has been noted in a number of neuropsychiatric conditions including TBI, stroke, Parkinson's disease, Huntington's disease, Alzheimer's disease, and disorders involving the frontal-subcortical circuitry including the thalamus, and the basal ganglia (Lichter & Cummings, 2001 Crowe & Hoogenraad, 2000), as well as compromise of the dorsolateral prefrontal cortex.

Monkeys with damage to the medial temporal lobe have a selective memory impairment

Another central characteristic of the amnesic syndrome is the phenomenon of graded retrograde memory loss. As described in Chapter 4, H.M. and other amnesic patients display a loss of memories backward in time from the moment of brain damage, with the most severe loss in the period just prior to the damage and total sparing of remotely acquired memories, including childhood recollections and general knowledge acquired early in life. However, a major problem in the interpretation of retrograde memory loss in human patients is that the amount and timing of prior learning experiences can only be approximated. Conversely, one of the major advantages of an animal model of amnesia is that one can examine the retrograde loss of memories with a prospective design. That is, one can provide measured amounts of learning at specific times prior Unfortunately, the DNMS task is unsuitable for this kind of study because single exposures to objects do not provide sufficiently strong memories to...

Receptor Mediated Endocytosis

Transferrin receptor is present at a relatively high concentration on the vascular endothelium of the brain capillaries. The OX-26 antibody, which is a mouse IgG2a monoclonal antibody to rat transferrin receptor, binds to an extracellular epitope on the transferrin receptor that is distinct from the transferrin ligand binding site, so binding of the OX-26 monoclonal antibody to the receptor does not interfere with transferrin binding. By means of the capillary depletion technique for estimating the extent of transport into brain parenchyma, it was established that the OX-26 monoclonal antibody is transported across the BBB and is effective as a drug delivery vehicle (59, 60). Saito et al. (77) used OX-26 monoclonal antibody to enhance the BBB permeation of P-amyloid peptide, A-P1-40, which binds to preexisting amyloid plaques in Alzheimer's disease. Since the dementia in Alzheimer's disease is correlated with amyloid deposition in the brain, if the peptide could be delivered to the...

Postmenopausal estrogen replacement therapy

Until menopause women generally suffer from a lower rate of vascular diseases, including ischemic stroke. This has been attributed to a protective effect of estrogen and thus research has focused on the beneficial effect of postmenopausal hormone therapy for the prevention of cardiovascular diseases and stroke. However, a meta-analysis of nine observational studies indicated an increased risk of stroke -especially of ischemic stroke - in women using hormone replacement therapy, with RR for overall and ischemic stroke respectively of 1.1 (95 CI 1.0-1.2) and 1.2 (95 CI 1.0-1.4) 82 . Another meta-analysis including 28 randomized controlled trials found a significant increase in total stroke RR of 1.3 (95 CI 1.1-1.5) and ischemic stroke RR of 1.3 (95 CI 1.1-1.6) for women using hormone replacement therapy 83 . A Cochrane systematic review came to the same conclusion and found hormone replacement therapy to be associated with an increased risk of stroke in primary prevention trials (RR 1.4...

Clinical Manifestations and Diagnosis Clinical Manifestations

Alzheimer-type senile dementia is associated with behavioral signs and symptoms that divide into corresponding stages. In the early stage, subjective memory deficit may be difficult to differentiate from benign senile forgetfulness. However, elderly persons with benign forgetfulness are unable to recall unimportant details, whereas patients with Alzheimer-type senile dementia forget important and unimportant information randomly (Krai 1962). Typically, patients with Alzheimer's disease forget where things are placed, become lost easily, and have difficulty remembering appointments. Both recent and remote memory are affected, which may be documented by neuropsychological testing. When patients recognize their cognitive and social losses, many develop feelings of hopelessness and despondency. As Alzheimer-type senile dementia progresses, the patient enters a confusional phase with more global impairment of cognitive functioning (Schenk, Reisberg, and Ferris 1982). Changes in higher...

Traumatic Brain Injury

Cognitive symptoms, especially in concentration and recall of recent events, than did the controls. Activity in the bilateral dorsolateral prefrontal and superior parietal cortices was similar for the 0-back (simple vigilance) compared to 1-back (low demand) condition. A much more extensive activation was found in these regions on the right in patients with TBI for the 1-back to 2-back comparison, although performance did not differ. Both groups had a similar magnitude of task-related increase in activation when the 0-back and 2-back were compared. Functional imaging, then, revealed a difference in the ability of the TBI subjects to modulate or allocate resources with an increase in working memory demand. The clinical symptoms of the patients suggested difficulties in the maintenance and manipulation of verbal information. A study of patients who were recovering from more severe TBI used the paced auditory serial addition test to assess working memory (see Chapter 7). Compared to...

Somatic Treatments For Major Depression Electroconvulsive Therapy ECT

Convulsive therapy for psychiatric illness was first demonstrated by Ladislas Meduna in 1934 via camphor injections. In 1938, Cerletti and Bini demonstrated that electrical induction of seizures was more immediate and better tolerated by the patients. Today clinicians have a choice of either right (nondominant) unilateral or bilateral placement of electrodes. In right unilateral placement the highest concentration of current is across the motor cortex, and seizures are elicited at lower energies than with bilateral placement in which the greatest current is induced in the brain's midline structures including the hypothalamus and pituitary gland (Fink, 2001). Since a right-handed patient will usually have memory function localized to the left side, it was proposed that right unilateral placement would result in less memory loss. However, for right unilateral placement to approach the greater efficacy of bilateral placement, energies of up to five times the seizure threshold must be...

Controversy over Source of Fetal Tissue

An even more troublesome source of fetal material might arise if a human fetus is conceived specifically for the purpose of aborting it for research or therapy. Although there is no documented evidence that this has happened, in at least two cases women have asked if they could become pregnant to produce tissues or organs for another person. In one case, the daughter of an Alzheimer's patient asked to be inseminated with the sperm of her father and, at the appropriate stage, to abort the fetus to provide her father with fetal neural tissue for transplantation. Although there is no evidence at present that this is technically possible, and the women's request was denied, this case demonstrates a possible demand for such applications. Similarly, another woman requested that her midterm fetus be aborted and the kidneys be transplanted to her husband who was dying of end-stage renal disease. There is also concern that increased pressures for fetal tissue could lead to a marketplace for...

Competencies in Civil

Autonomy and protection of those not fully capable of reasoned decision making. Similarly, the construct of mental capacity reflects a spectrum of cognitive abilities such as accurate perception of sensory impressions, memory, comprehension, use of language and various executive functions, contact with reality, and affect regulation. Short of severe dementia, retardation, or catatonic stupor, most people referred for competency evaluations have some abilities to understand and appreciate the world around them, to reach decisions, express preferences, and communicate with others. Determining threshold levels of abilities and the extent to which they must be demonstrated in adjudicating competency allow experts to reach differing opinions.

Competency to Make a Gift or Create a Bequest

The doctrine of lucid interval applies when the testator's mental state is in flux, through substance abuse, mental illness, or the early and middle stages of dementia. The burden is on the contestant to demonstrate that the will was not created at a time when symptoms were minimal. Demonstrating lack of capacity at other times, when symptoms are most severe, is not sufficient to create the presumption that the symptoms were so severe when the will was created. The expert will want to determine if there was a psychiatric, neurological, or medical diagnosis on the day of the creation and, more importantly, to establish if there were mental impairments or vulnerabilities at that time. It is relatively easy to establish from the medical records, for example, that the decedent had a stroke with expressive aphasia, but connecting the medical or psychiatric condition to the testator's abilities and limitations on the day of the creation of the instrument is more complex. The expert will...

Competency to Care for Oneself and Guardianship Proceedings

Guardianship was traditionally distinct from involuntary psychiatric commitment or involuntary medication proceedings, but the modern practice is to use guardianship proceedings for patients with dementia, which includes allowing the guardian to authorize the use of psychotropic medications. Some states allow a guardian to consent to administration of psychotropic medications in other situations. An individual with an appointed guardian may retain specific rights in some jurisdictions, these are granted under limited guardianships. A guardian ad litem is appointed by the court during a specific lawsuit to protect the interests of the minor or incapacitated person and report to the court.

Clinical Implications

Many human diseases involve pathologies of the vascular system cancer, heart disease, atherosclerosis, stroke, Alzheimer disease, AIDS, diabetes, and aging (Folkman 1995). Certain pathological features of these diseases could be corrected by manipulating the vascular system. In cancer, it would be beneficial to suppress the growth of the tumor blood vessels to limit the growth of cancer cells by starvation. In heart failure or stroke, it would be beneficial to directly grow new blood vessels or to create an organ environment permissive for rapid growth of new vessels. The growth of new functional vessels may facilitate the recovery of a failed heart or brain.

Research Evidence to Date

The placebo effect is basically a psychosocial effect, so that stimuli such as words and the very procedures of medical care may change the chemistry and circuitry of the brain. Studies show that the brain mechanisms activated by placebos are the same as those activated by drugs. If prefrontal brain function (the area higher-level thinking) is impaired, as occurs in Alzheimer's and other types of dementia, placebo responses are reduced or totally lacking, Knowledge of this kind is an example of insight that could not have been discovered by a randomized research study. It would not be ethical or possible to randomize people to get or not get something like Alzheimer's Disease. However, this type of accidental or natural real-life experiment sometimes happens. Here we learn that a healthy prefrontal cortex, which controls executive and cognitive brain function, is required for the placebo response to occur.

Occupational Therapists Responsibilities

Address visuospatial inattention, memory loss, apraxia, difficulties in problem solving, and the skills needed to return these patients to school or employment. Many occupational therapists manage dysphagia and interpret modified barium swallow studies. These professionals are especially adept at evaluating the need for a range of assistive devices and train patients and families in their use. In the patient's home and workplace, the therapist provides grab bars, rails, ramps, environmental controls, computer interfaces, architectural changes such as widening a doorway to allow wheelchair access, and emergency remote-control calling systems. For the working person with a disability, the therapist can design a work-hardening program to prevent back injuries or pain from overuse of a joint or muscle. Along with the physical and recreational therapists, occupational therapists seek out the environmental, personal, and activity-specific equipment and technologies that enhance the quality...

Attempts to address missing data in reports imputation

A common, but potentially dangerous, approach to dealing with missing outcome data is to impute outcomes and treat them as if they were real measurements (see also Chapter 16, Section 16). For example, individuals with missing outcome data might be assigned the mean outcome for their intervention group, or be assigned a treatment success or failure. Such procedures can lead both to serious bias and to confidence intervals that are too narrow. A variant of this, the validity of which is more difficult to assess, is the use of 'last observation carried forward' (LOCF). Here, the most recently observed outcome measure is assumed to hold for all subsequent outcome assessment times (Lachin 2000, Unnebrink 2001). LOCF procedures can also lead to serious bias. For example, in a trial of a drug for a degenerative condition, such as Alzheimer's disease, attrition may be related to side effects of the drug. Because outcomes tend to deteriorate with time, using LOCF will bias the effect estimate...

Oculomotor Dysfunctions

At the turn of the century, two researchers working in a psychiatric hospital in New England made the observation that patients with dementia praecox (now termed schizophrenia) had difficulty following an oscillating pendulum with their eyes. The investigation of eye movement dysfunction in schizophrenia, which was revived in the 1970s, focuses on smooth pursuit and saccadic eye movement systems.

Pharmacologic Therapy

Two dopamine agonists are used for the management of hyperprolactinemia, bromocriptine, and cabergoline (Table 46-5).39,45 Because these two dopamine agonists are ergot derivatives, they are contraindicated in combination with potent cytochrome P-450 subfamily IIIA polypeptide 4 (CYP3A4) inhibitors, including protease inhibitors (e.g., ritonavir and indinavir), azole antifungals (e.g., ketoconazole and itraconazole), and some macrolide antibiotics (e.g., erythromycin and clarithromycin). Furthermore, ergot derivatives can cause constriction of peripheral and cranial blood vessels. These medications are also contraindicated in patients with uncontrolled hypertension, severe ischemic heart disease, or peripheral vascular disorders. Caution should be exercised with concomitant use of other ergot derivates and in patients with impaired renal or hepatic function, dementia, concurrent antihypertensive therapy, or a history of psychosis, peptic ulcer disease, or cardiovascular disease.

Types of memory the long and the short of it

Memory of personal experiences is sometimes called episodic memory, because we remember the episode. For example, one day at school we learnt that London was the capital of the United Kingdom. Remembering what we did that day and that we learnt that London is the capital, is recall of an episodic memory, because it is a consciously recalled personal experience. Failure of episodic memory is one of the main features of Alzheimer's disease. If now asked what the capital of the UK is, we wouldn't necessarily recall the experience of learning it, but we would know that London is the capital, as a fact. This is a semantic memory.