HEALTH TIPS

SECRETS OF A FADE-PROOF MEMORY

How t o minimiz e age- relat ed memory los s
TABLE OF CONTENTS
Can Alcohol Help Preserve Memory? ..............1 In the News: Physical Fitness Helps Maintain Cognitive Function ..............4 Medications That May Impair Mental Function ................................5 Drugs for Alzheimers: Fine-Tuning Your Expectations ........................7 To Drive or Not To Drive ......................10

certain amount of forgetfulness 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. An adage can serve to reassure those who are occasionally forgetful: You need not worry if you forget where you put your car keys; you only need to worry if you forget what theyre used for. Memory loss ranges from age-associated memory impairment, which is a normal degree of forgetfulness, to dementias such as Alzheimers disease that can profoundly affect a persons ability to function. Alzheimers disease, the most common form of dementia, affects 5.2 million Americans. According to the American Academy of Neurology, 10% of people older than age 65 and nearly 50% of people older than age 85 suffer from Alzheimers disease. The Alzheimers Association estimates that there will be as many as 7.7 million Americans with Alzheimers by the year 2030 if no prevention strategy or cure is found. Although Alzheimers disease is irreversible, memory impairment resulting from other causes, such as depression or thyroid problems, can be improved with treatment. Its therefore important to pinpoint the causes of your forgetfulness and be proactive about strategies for preserving and even improving memory. If Alzheimers disease or another type of dementia does develop, its important to have realistic expectations about how well the available medications work. Its also important to carefully monitor when a person with dementia should stop driving.

Can Alcohol Help Preserve Memory?

Moderate alcohol consumption has benefits, but the operative word is moderate The harmful effects of alcohol intoxication and alcohol abuse on memory are well knownweve all heard stories of people who drank too much and cant remember conversations or events that took place when they were intoxicated. But what may be less well known are the

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benefits that moderate amounts of alcohol can have on cognitive function. Growing evidence shows that people who drink moderately are at lower risk for cognitive decline and dementia.

Grow ing evidence show s that people w ho drink moderately are at low er risk for cognitive decline and dementia.

The Evidence Researchers looked at the relationship between alcohol and the risk of dementia in a study published in the Journal of the American Medical Association. When the researchers compared data from 373 people with dementia (age 65 and older) and 373 age-matched controls, they found that people who drank one to six alcoholic beverages per week were 54% less likely to have dementia than people who never drank. People who drank less often (less than once a week) or somewhat more often (seven to 13 drinks a week) also appeared to have a reduced risk of dementia, but this may have been a chance finding. Consuming 14 or more drinks a week was linked with an increase in dementia risk, although this finding also may have been the result of chance. (In the study, one drink was 12 oz of beer, 6 oz of wine, or a shot of liquor.) These results were similar for both Alzheimers disease and vascular dementia, and they are in line with the findings of other large-scale observational studies. The investigators also found that the effect of alcohol on dementia risk varied according to whether participants had at least one apolipoprotein E (APOE) 4 allele, a genetic predisposition toward Alzheimers disease. In people who did not have the APOE 4 allele, high levels of alcohol intake were not associated with an increased risk of dementia, even in those who had 14 or more drinks weekly. For those with at least one APOE 4 allele, however, the risk of dementia increased significantly with seven or more drinks a week. However, not all studies have found an association between drinking and this genetic predisposition to Alzheimers disease. Why These Effects of Alcohol? Research consistently shows that moderate alcohol intake lowers the risk of coronary heart disease and ischemic stroke in older individuals. Because factors that are good for the heart are often good for the brain as well, many experts believe that alcohol might help protect the brain in the same ways it helps protect the heart. For example, alcohol inhibits blood clot formation and raises blood levels of high-density lipoprotein (HDL, or good) cholesterol, factors that may limit atherosclerosis and help maintain blood flow to and within the brain. Furthermore, research in rats shows that low doses of alcohol can increase the release of the neurotransmitter acetylcholine in the

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The Negative Effects of Intoxication

Although moderate alcohol consumption appears to protect the brain from cognitive impairment and dementia, large amounts of alcohol consumed at one sitting or over prolonged periods can have negative effects on memory. Acute effects Intoxicating levels of alcohol can interfere with ones ability to create memories from new information, while interfering much less with established memories. For example, an intoxicated person will have difficulty with new facts (What was your name again?) or events (What was I just talking about?) while still being able to recall an established detail like a close friends phone number. Very high doses of alcohol can lead to blackoutsperiods of fragmented or blank memory for entire events that occurred while intoxicated. Long-term effects Persistent heavy drinking can interfere with certain aspects of memory. For example, a study of primarily young adults, published in the journal Alcoholism: Clinical and Experimental Research, found that heavy drinkers had more impairments than light drinkers or nondrinkers in everyday memory (repeating a story or joke to someone theyd already told it to) and prospective memory (remembering in the future, such as remembering to shut off the stove in 10 minutes). In addition, previous research has found that heavy drinkers have problems with decision making, learning word lists, problem solving, short- and long-term logical memory, and general working memory. These deficits usually become apparent in people who regularly consume 21 or more drinks weekly. Former alcoholics also process information more slowly and less efficiently than people who have never abused alcohol. In fact, it often takes four to five years of sobriety before cognitive functioning returns to near-normal levels. Korsakoffs syndrome Some severe alcoholics develop Korsakoffs syndrome, a condition that severely or totally disrupts the ability to acquire new information and form new memories. People with this syndrome often concoct stories to fill in the gaps in their memories, and they are often unaware of or unconcerned with their memory difficulties. The cause of Korsakoffs syndrome is a thiamine deficiency, resulting from chronic alcohol abuse. Months of thiamine treatment can help some people; often the damage is permanent. Alcoholic dementia People who abuse alcohol for many years can develop alcoholic dementia (also known as alcohol-induced persisting dementia). The symptoms are very similar to other types of dementia, and usually persist even if the person is not currently intoxicated or has quit drinking altogether.

hippocampus, which may improve memory function. On the other hand, high doses of alcohol can inhibit the release of acetylcholine and possibly interfere with memory. Another contributing factor may be the social experiences of moderate drinkers. Individuals who drink moderately also tend to have more social contacts than abstainers or heavy drinkers. This social

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Secret s of a Fade- Proof Memory

interaction may help lessen depression, anxiety, and stress, and help protect against dementia. Some studies show that wine, in particular, protects against dementia. It is possible that the antioxidant compounds in wine, especially red wine, play some role in this effect. However, many studies, including the Journal of the American Medical Association study described on page 2, have found that all types of alcoholic beveragesincluding beer and liquorhave a protective effect.

The Bottom Line Experts do not recommend that people who dont drink start drinking as a way to prevent dementia, but for current drinkers, having a drink or two a day for men or a drink daily for women is likely healthy for both the heart and the brain. However, women should be aware that alcohol may increase the risk of breast cancer. One study found that women who consumed two to five alcoholic drinks daily had a 41% higher risk of developing breast cancer than nondrinkers. Women who consumed about one alcoholic drink per day had only a slight increase in risk compared with nondrinkers.

In the News Physical Fitness Helps Maintain Cognitive Function

Physically fit adults are more likely to maintain their level of cognitive function as they get older, compared with adults who are less fit, a study in the Journal of the American Geriatrics Society shows. The study findings suggest, but do not prove, that regular physical activity helps prevent dementia. Investigators studied the aerobic capacity of 349 people, age 55 and older, who were free from major diseases and cognitive impairment. At the beginning of the study, the volunteers underwent a treadmill exercise test to determine their peak oxygen consumption, the length of time they could exercise, and how efficiently they used oxygen. Cognitive function was tested at the studys beginning and six years later. People with the highest levels of aerobic capacity at the studys onset were the ones most likely to maintain their initial cognitive scores when retested six years later. Those who performed poorly on the treadmill test were more likely to have experienced cognitive decline over the six years.

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Secret s of a Fade- Proof Memory

Medications That May Impair Mental Function

Many drugsparticularly when taken at high doses or for an extended timecan cause symptoms of dementia. Older adults are most likely to experience this problem and to have it confused with a permanent memory deficit. So if a loved one is being evaluated for dementia, be sure to bring all of his or her medication bottles to the doctors office. Drug Category
Allergy and cold medications

Dementia caused by medication can be treated by halting the drug (if possible), switching to another one, or lowering the dosage. The following are some of the more common medications that may cause memory loss. If you are taking one of these drugs and are concerned about memory side effects, talk to your doctor before making any changes. Brand Name
Veltane Chlor-Trimeton Benadryl Afrinol, Sudafed 12 Hour, Sudafed 24 Hour Keflex Cipro, Cipro XR, Proquin XR Flagyl, Flagyl ER, Floxin Transderm Scop

Generic Name
brompheniramine chlorpheniramine diphenhydramine pseudoephedrine cephalexin ciprofloxacin metronidazole ofloxacin scopolamine

Antibiotics

Anticholinergic

Anticonvulsants

carbamazepine phenytoin valproate amitriptyline desipramine doxepin imipramine nortriptyline chlorpromazine haloperidol chlorambucil cytarabine interleukin-2 (aldesleukin) amiodarone digoxin disopyramide quinidine atenolol methyldopa metoprolol nifedipine prazosin propranolol verapamil

Carbatrol, Epitol, Equetro, Tegretol,Tegretol XR Dilantin, Phenytek Depakene, Depakote, Depakote ER Norpramin Sinequan Tofranil, Tofranil PM Pamelor Haldol Leukeran Cytosar-U, Depocyt Proleukin Cordarone, Pacerone Lanoxicaps, Lanoxin Norpace, Norpace CR Tenormin Lopressor, Toprol-XL Adalat CC, Afeditab CR, Procardia, Procardia XL Minipress Inderal, Inderal LA, Innopran XL, Calan, Covera HS, Isoptin SR, Verelan, Verelan PM

Antidepressants

Antipsychotic drugs

Cancer drugs

Heart disease medications

High blood pressure drugs

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Secret s of a Fade- Proof Memory

Medications That May Impair Mental Function (continued)

Drug Category
Immunosuppressive drugs

Generic Name
cyclosporine interferon lithium hydroxyzine metoclopramide prochlorperazine promethazine aspirin baclofen codeine cyclobenzaprine hydrocodone hydrocortisone (cortisol) ibuprofen indomethacin meperidine methocarbamol naproxen oxycodone prednisone propoxyphene sulindac

Brand Name
Gengraf, Neoral, Sandimmune Infergen Eskalith, Lithobid Vistaril Reglan Compro Promethacon, Promethegan Bayer, Bufferin, Ecotrin, St. Joseph, etc. Kemstro, Lioresal combined with other medications, such as acetaminophen (Tylenol) plus codeine Amrix, Flexeril combined with other medications, such as ibuprofen plus hydrocodone (Vicoprofen) A-Hydrocort, Cortef, Solu-Cortef Advil, Motrin Indocin Demerol Robaxin Aleve, Anaprox, Naprelan, Naprosyn OxyContin, Roxicodone Darvon Clinoril Cogentin Parlodel Comtan Carbilev, Parcopa, Sinemet Xanax, Xanax XR Klonopin Valium Dalmane Ativan Tagamet, Tagamet HB Zantac, Zantac 25, Zantac 75, Zantac 150, Zantac 300

Mania medication Nausea medications

Pain medications

Parkinsons disease drugs

benztropine bromocriptine entacapone carbidopa/levodopa trihexyphenidyl alprazolam clonazepam diazepam flurazepam lorazepam cimetidine ranitidine

Sedatives

Ulcer/acid reflux medications

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Drugs for Alzheimers: Fine-Tuning Your Expectations

Aricept, Exelon, Razadyne, and Namenda are approved to treat Alzheimers disease, but how well do they work? Many patients and their caregivers have high expectations about what drugs approved for Alzheimers disease can do. In certain instances, these expectations are met. For example, some patients experience improved memory and thinking, and some see benefits for up to five years with cholinesterase inhibitors. However, for the vast majority of people with Alzheimers disease, the effects of medication on cognition and behavior are much more modest. Therefore, people with Alzheimers and their caregivers should have realistic expectations about these medications.

People w ith A lz heimers disease and their caregivers need to have realistic expectations about their medications.

Who Can Benefit? The U.S. Food and Drug Administration has approved five medications for the treatment of Alzheimers disease. Four of these are cholinesterase inhibitorstacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne)which are approved to treat mild to moderate Alzheimers disease (a score of 10 to 26 on the Mini-Mental State Examination). Doctors rarely prescribe Cognex because it can cause serious liver problems. Some studies show that cholinesterase inhibitors may benefit patients with severe Alzheimers disease, although the FDA has not approved them for this use. However, another medication, memantine (Namenda), is approved for the treatment of moderate to severe Alzheimersthat is, a score of less than 15 on the Mini-Mental State Examination. This drug is an NMDA receptor antagonist, not a cholinesterase inhibitor, and the two drug classes may have somewhat different effects. Cholinesterase inhibitors are being investigated in individuals with mild cognitive impairment. Researchers are also testing Namenda for mild to moderate Alzheimers disease. What Are the Benefits? Alzheimers medications may be helpful in the following two areas: cognition and daily function and behavior.
Cognition Cholinesterase inhibitors improve cognition (memory, thinking, and language) in about two thirds of people with Alzheimers disease and

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may slow cognitive decline in some. If a patient does improve, the amount of improvement over one year is roughly equal to the amount of decline typically observed in untreated people with Alzheimers disease over eight to 12 months. Yet a small number of patients continue to benefit from these drugs well beyond this time. Because Namenda is a newer drug, not as much information is available about its long-term cognitive effects. However, one 28-week study comparing Namenda with a placebo found that the drug was associated with significantly decreased cognitive decline. Also about 20% of patients taking Namenda had some improvement in cognition by the studys end. Another study found that patients taking Namenda plus Aricept averaged less cognitive decline over 24 weeks than those taking a placebo plus Aricept, and about 40% of people taking Namenda plus Aricept experienced cognitive improvements. Daily function and behavior Cholinesterase inhibitors and Namenda also can help with deficits in daily functioning and behavior that are prevalent in people with Alzheimers disease. Even small improvements in daily functioning and behavior are important because these problems are major reasons why caregivers end up placing patients in nursing homes. According to a review of 29 studies, published in the Journal of the American Medical Association, people with mild to moderate Alzheimers disease who took cholinesterase inhibitors experienced modest benefits in daily functioning (for example, dressing, bathing, and grooming) and modest improvements in behavioral problems (such as hallucinations, agitation, paranoia, and depression). The two previously mentioned Namenda studies also demonstrated that the drug slows declines in daily functioning significantly more than a placebo. Also, about 20% of patients treated with Namenda alone and about 30% treated with Namenda plus Aricept experienced improvement in daily functioning.

A ccording to a review of 29 studies, people w ith mild to moderate A lz heimers disease w ho took cholinesterase inhibitors experienced modest benefits in daily functioningfor example, dressing, bathing, and grooming.

Assessing Improvement Patients taking Alzheimers drugs may not display obvious improvements in cognition, daily functioning, and behavior during the first few weeks of treatment. In fact, benefit may not become fully apparent for several months. Also, cholinesterase inhibitors may possibly help in one problem areafor example, behaviorwhile not affecting another aspect of the condition, like cognition. Because all medications carry risks, patients should not remain on Alzheimers drugs if they do not experience benefit from them. Benefit can be determined in a number of ways: The persons doctor may

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Which Drug Should You Take?

Because most evidence indicates that all the Alzheimers disease drugs are similarly effective in treating cognitive and behavioral deficits, the drug that a doctor chooses to treat a patient typically depends on the drugs frequency of dosing and side effects. Heres a breakdown of the major differences: Drug donepezil (Aricept) Notes taken once a day not toxic to the liver agitation may occur with initial doses but should dissipate after a few weeks of treatment approved for mild to moderate Alzheimers disease taken twice daily associated with more gastrointestinal side effects than other cholinesterase inhibitors may be the best option for people with liver problems approved for mild to moderate Alzheimers disease taken twice daily dosage needs to be increased slowly over time to minimize side effects approved for mild to moderate Alzheimers disease usually taken twice daily increases in dosage should occur slowly (no more than 5-mg increases per week) not recommended for people with kidney problems approved for moderate to severe Alzheimer's disease

rivastigmine (Exelon)

galantamine (Razadyne)

memantine (Namenda)

notice improvements during an examination; the caregiver may report improvements in areas like memory, communication, mood, daily functioning, or behavior; or the patient may perform better on a standardized test of mental function. However, standardized tests may not reveal certain important gains. One study showed that 40% of untreated patients with Alzheimers were placed in nursing homes after three years compared with only 3% of those treated with cholinesterase inhibitors, even though both eventually had similar scores on tests of mental function. (Its not clear, however, whether the two groups were equivalent.) Because Namenda became available in 2004, practice patterns are still developing. However, in Europe, where cholinesterase inhibitors

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and Namenda have been available for longer, the two drugs are often prescribed together early in the disease. If the patient experiences no intolerable side effects from the medication, the physician will likely reassess the medications effectiveness roughly three months later and, from then on, about every six months. (If a patient cannot tolerate or doesnt benefit from one cholinesterase inhibitor, it is often worthwhile to try another one.) If no medication improves the condition but the person is still in relatively good health, you may want to consider entering the person in a clinical trial.

To Drive or Not To Drive

When is it time for a person with dementia to stop driving? After decades of the freedom and independence that driving can bring, many people with dementia are reluctant to stop driving. But the decline in cognition in people with diseases such as Alzheimers often makes them unsafe drivers. People with dementia are three to five times as likely as others their age to be involved in a car crash. Although experts agree that those with moderate or severe dementia should not drive, the data on individuals with very mild or mild dementia are not as clear. Evidence shows that those with very mild Alzheimers are no more likely to cause a car crash than a young person who has just obtained a drivers license. And new research is beginning to clarify when patients with dementia are fit to drive and when they should give up the keys.

The first driving skills to go are judgment, aw areness of how ones driving affects other drivers, and speed control.

How Safe Are Drivers With Dementia? One study, published in the Journal of the American Geriatrics Society, used a road test to evaluate and compare the driving skills of people without dementia with those of people with very mild Alzheimers disease and mild Alzheimers over two years. (Very mild Alzheimers is roughly equivalent to a Mini-Mental State Exam score of 25; patients with mild Alzheimers tend to have scores between 20 and 24.) The researchers reached the following conclusions: At the studys onset, more people with mild Alzheimers disease (41%) were unsafe drivers compared with those with very mild Alzheimers (14%) and people without dementia (3%). Of those fit to drive at the beginning of the study, the driving skills of those with mild Alzheimers disease declined to an unsafe level the fastest, followed by those with very mild Alzheimers. Individuals without dementia declined the slowest.

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Most of the people with mild Alzheimers who were initially fit to drive became unsafe drivers within two years.

Signs and Signals of Problem Driving Some people with dementia might seem like safe drivers in familiar traffic conditions, but they actually have underlying deficits that prevent them from reacting appropriately to unanticipated events. So what problems can family members look for? According to the article in the Journal of the American Geriatrics Society , the first driving skills to go are judgment, awareness of how ones driving affects other drivers, and speed control. Other behaviors that indicate that someones driving skills may be deteriorating include the following: braking often or unexpectedly not obeying traffic signs and signals becoming aggressive or angry while driving trouble staying in ones lane difficulty navigating through familiar locations. A report in Neuropsychology, which reviewed the results of 27 studies, found that deficits in visuospatial skills (see the box below) and, to a lesser extent, attention and concentration were the best predictors of which individuals with early dementia had problems with driving. Visuospatial deficits in people with early dementia are red flags indicating that their driving skills should be evaluated carefully, the researchers conclude.

What Are Visuospatial Skills?

Visuospatial skills are those abilities that allow a person to relate their visual perception to concrete spatial relationships. In driving, these skills allow people to judge distances, maneuver correctly, and navigate unfamiliar territory. When diagnosing a person with dementia, clinicians typically test visuospatial skills as a subset of overall cognitive testing using tests that include clock drawing (accurately drawing a clock depicting a specific time), block design (assembling real-life blocks to look like a two-dimensional drawing), picture completion (pointing out the missing details of a line drawing), and diagram drawing and copying (having a person draw a picture, such as a flower, from memory or copy a complex line drawing). Family members can ask the patients clinician for the results of their loved ones visuospatial testing.

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How can y ou get s omeone w it h dement ia t o s t op driving? A s k t he pers ons doct or t o t ell t he pat ient not t o drive or as k t he phy s ician t o w rit e a Do Not Drive pres cript ion.

What the Experts Recommend Guidelines from the American Academy of Neurology (AAN) say that people with mild or more severe dementia should not drive because of an increased crash risk. While noting that individuals with very mild Alzheimers disease have an elevated crash risk compared with their peers, the AAN clarifies that this elevated risk is no different from that in other acceptably impaired drivers: 16- to 21-year-olds and people with a blood alcohol content below 0.08%. The AAN therefore says that individuals with very mild Alzheimers may still be able to drive. The academy recommends that caregivers of people with very mild dementia consider having the persons driving examined by a professional, and a clinician should reassess fitness for driving every six months. Adding to this information, the authors of the Journal of the American Geriatrics Society study say that a small proportion of individuals with mild dementia retain the ability to drive safely and that fitness to drive should not always be determined by a diagnosis of mild dementia per se but through semiannual evaluations of driving performance. Some occupational and physical therapists are able to perform such evaluations, or you can request that someone at your states department of motor vehicles evaluate the person using a road test. When and How To Restrict Driving Although some individuals with very mild or mild dementia may retain the ability to drive safely, they should restrict their driving to nonchallenging situations, for example, driving only in familiar areas, during the daytime, in good weather, for short distances, and in light traffic. They should never drink any amount of alcohol before driving. In addition, family members need to ascertain that these drivers maintain skills necessary for driving: a quick reaction time; the ability to make decisions appropriately and rapidly; an alertness to what is going on in the environment; and good co-ordination, vision, and hearing. Eventually, the time to stop driving will come to every person with dementia. Yet a loved one with dementia may have a strong desire to keep driving and little awareness of his or her deficits. How can you get someone with dementia to stop driving if asking is not enough? Experts recommend that you ask the persons doctor to tell the person not to drive, or even ask the doctor to write a Do Not Drive prescription. Health care professionals in some states must report to the motor vehicle division that a person in their care

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has a medical condition that interferes with driving ability. The state may then revoke the persons drivers license. If the person still insists on driving, caregivers can take more drastic measures. These include hiding the car keys, parking the car where the person cant see it, or selling the car. A mechanic may be able to show you how to disable the car temporarily by removing the distributor cap or disconnecting the battery.

The Bottom Line Determining when a person in the early stages of dementia can no longer drive is not always easy. Enlist the help of doctors, lawyers, therapists, or the department of motor vehicles when difficult questions arise. But above all, patients, caregivers, and family members should let common sense be their guide. A good rule of thumb is the grandchild test: If you would not feel safe having the person with dementia drive his or her grandchild in the car, you should talk to the person about not driving.

The information contained in this Healt h Tips is not intended as a substitute for the advice of a physician. Readers who suspect they may have specific medical problems should consult a physician about any suggestions made.
Copyright 2006-2008 Medletter Associates, LLC All rights reserved.

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