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MEMORY LOSS & ALZHEIMER'S DISEASE




1. What is memory loss?
 
In brief, memory loss may be defined as the loss of, or inaccessibility to, previously learned or acquired information over time. Individuals with memory loss may also experience difficulties learning new material. Memory loss is sometimes referred to by various terms including amnesia, forgetting, memory decay, memory decline, or memory impairment (see Loring, 1999). Pathology/lesions in a diversity of brain regions and systems have been associated with memory loss, and in particular, damage to the brain's temporal lobes and a part of the brain known as the hippocampus.
 
2. In relation to aging, is all memory loss abnormal?
 
As individuals reach middle age and beyond, they often notice declines in their abilities to remember information; however, such declines are not necessarily abnormal. Although a diversity of classification systems have been proposed to categorize memory and memory loss, clinically, memory loss/declines may be broadly grouped into two categories: normal, age-related (or age-appropriate) memory declines and abnormal (or age-inappropriate) memory declines (see also Ratcliff & Saxton, 1998). Specifically, while middle-aged and older adults may exhibit performances/scores on standardized memory tests that are lower than those of younger persons, if their scores fall above a certain cutoff for their particular age group (for example, less than one standard deviation below the test's age-related mean) and there is a relative absence of underlying medical/pathological conditions to account for their memory performances, then such declines may represent normal, age-related, or age-appropriate, memory declines. Alternatively, standardized memory test performances that fall below a specified cutoff (for example, scores that are more than one standard deviation below the mean) may reflect abnormal, or age-inappropriate, memory declines/impairment, which should be thoroughly evaluated by a licensed health care professional.
 
3. Do many people experience memory difficulties/concerns?
 
As individuals reach middle age and beyond, they often complain of memory difficulties and/or suffer concerns that they may be developing some form of dementia. It has been estimated that between 50 and 80 percent of older adults report subjective memory complaints (see Levy-Cushman & Abeles, 1998; U. S. Department of Health and Human Services [HHS], 1999). Furthermore, as the number of older adults continues to rapidly rise in the U.S. population, so too does the incidence of memory impairments related to Alzheimer's disease and other forms of dementia. In fact, the number of new cases of dementia is expected to nearly double over the next one to two decades (Rabins, Lyketsos, & Steele, 1999).
 
4. What causes memory problems?
 
Memory problems may be due to a wide diversity of underlying causes that may range from normal, age-related memory declines, to a diversity of past or present medical conditions, including, but not limited to, cerebrovascular (e.g., stroke, etc.), neurological (e.g., Parkinson's disease, brain tumor, epilepsy, etc.), endocrine (e.g., hypothyroidism, etc.), and/or infectious (e.g., meningitis, etc.) disorders, to previous head injuries and nutritional deficiencies (e.g., vitamin B12, etc.), to medication side effects and chronic drug (e.g., alcohol, etc.) use, to conditions such as depression and, in certain cases, to some form of dementia, such as Alzheimer's disease.
 
5. How are memory declines/loss evaluated?
 
From a neuropsychological perspective, memory declines/loss are typically evaluated via a series of standardized/objective verbal and nonverbal/visual memory tests that assess both immediate and delayed (e.g., after 20 to 30 minutes) recall and recognition of previously presented material (Lezak, 1995; Spreen & Strauss, 1998). Learning and rate of acquisition of information are also frequently evaluated, along with subjective memory reports from the patient and his/her significant other(s) (Lezak, 1995). Memory processes are often evaluated as components of comprehensive neuropsychological evaluations that typically include detailed reviews of patients' histories (e.g., medical, etc.) and presenting complaints (e.g., memory/cognitive problems, etc.), as well as assessments of a diversity of other cognitive processes/functions (e.g., attention/ concentration, language/verbal abilities, intellectual functioning, sensory-perceptual abilities, motor skills, complex cognitive processes/executive functioning, etc.). It should also be noted that persons who are experiencing memory declines/loss, and in particular age-inappropriate declines, often benefit from an evaluation by a licensed physician in an effort to determine the underlying cause(s) of such impairments so that individualized treatment plans can be formulated.
 
6. How are memory impairments treated?
 
The treatment of "age-inappropriate" memory impairments depends on the underlying cause(s) of the impairments. Just as there is a diversity of potential causes of memory impairments, so too is there an array of treatments for such difficulties. For example, treatments may range from antidepressant medications and counseling for persons who are found to be experiencing potentially reversible memory impairments secondary to depression, to medications such as cholinesterase inhibitors for the management and treatment of Alzheimer's disease. However, since proper treatment of memory impairments is dependent on determining the underlying cause(s) and extent of such difficulties, comprehensive evaluation of potential memory impairments by a licensed health care professional is crucial so that the most appropriate treatment interventions can be prescribed/instituted in a timely manner.
 
7. What is meant by the term "mild cognitive impairment?"
 
In recent years, studies have indicated that a decline in cognitive functioning may be an early indicator/precursor of Alzheimer's disease (Morris et al., 2001; Petersen et al., 1999). Specifically, this decline in cognitive functioning has been termed mild cognitive impairment (MCI), which is characterized by subtle cognitive deficits with generally intact cognition and activities of daily living (Petersen, 2003). The disorder may involve various cognitive domains resulting in a number of forms/subtypes of MCI (e.g., amnestic, single-, and multiple-domain MCI). The most common form has been termed amnestic MCI and has been defined by Petersen and his colleagues (1999, 2003) by the following criteria: 1. memory complaints; 2. objective memory impairment for age and education; 3. normal/ largely intact general cognitive functions; 4. essentially preserved activities of daily living; 5. not demented. Results from studies that have examined this syndrome have suggested that persons exhibiting MCI are at an increased risk of developing Alzheimer's disease at a rate of 10% to 15% per year (Petersen et al., 1999; Petersen and Morris, 2003).
 
8. What is dementia?
 
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision (2000), dementia is characterized by the development of multiple cognitive deficits that occur in the absence of a delirium (i.e., disturbance of consciousness). The deficits must include memory impairment and one or more of the following cognitive disturbances: aphasia (i.e., language impairments), apraxia (i.e., impaired ability to carry out motor activities, despite intact motor functioning), agnosia (i.e., impaired ability to recognize/ identify objects, despite intact sensory functioning), or executive functioning impairments (e.g., difficulties organizing, sequencing, planning, etc.). Changes in personality and behavior may also occur. The cognitive deficits must be of sufficient magnitude to cause significant impairment in social and/or occupational functioning and reflect a decline from a previously higher level of functioning. Dementia may result from a wide diversity of causes that range from Alzheimer's disease and cerebrovascular conditions, to infectious diseases (such as HIV) and the persisting effects of substances, such as alcohol.
 
9. How does dementia differ from Alzheimer's disease?
 
While dementia is a clinical syndrome that is characterized by multiple cognitive impairments, Alzheimer's disease (often referred to as Dementia of the Alzheimer's Type) is one subtype of dementia that results in similar signs and symptom presentation (American Psychiatric Association, 2000; see also question 8). Alzheimer's disease has been termed a primary degenerative dementia that results in gradual and continual cognitive decline, as well as changes in personality and behavior. Although pathological evidence of Alzheimer's disease remains difficult to obtain prior to autopsy, the disease is characterized by the presence of plaques (i.e., clumps of amyloid-beta protein found outside of cells/neurons) and neurofibrillary tangles (accumulation of tau protein in long filaments inside cells/neurons) in patients' brains (Ingram, 2003). The diagnosis of Dementia of the Alzheimer's Type is generally made after ruling out other potential causes (e.g., other types of dementia, etc.) of the presenting signs and symptoms. Both dementia and Alzheimer's disease are not parts of normal aging.
 
10. Are there any "warning signs" or common symptoms of Alzheimer's disease?
 
To assist individuals, their family members, and health care professionals to recognize signs of Alzheimer's disease, the Alzheimer's Association (2010) and Alzheimer's Foundation of America (2010) have compiled lists of common signs/symptoms that may be "warning signs" of Alzheimer's disease. These include: 1. memory loss; 2. difficulty performing familiar tasks (e.g., difficulty preparing a meal, etc.); 3. problems with language (e.g., word-finding difficulties, etc.); 4. disorientation/confusion about time and place (e.g., forgetting where one lives, etc.); 5. poor or decreased judgment (e.g., dressing inappropriately for the weather, etc.); 6. problems with abstract thinking (e.g., difficulty balancing a checkbook, etc.); 7. misplacing items; 8. changes in mood or behavior (e.g., rapid mood swings, etc.); 9. changes in personality (e.g., increased suspiciousness, fearfulness, etc.); 10. loss of initiative (e.g., passivity, not performing usual activities, etc.). Please note that individuals who may be experiencing Alzheimer's disease and other types of dementia will likely not exhibit all of the above symptoms at any given time and that a wide diversity of other signs and symptoms may also be present.
 
11. How common is dementia?
 
For persons under 65 years of age, the prevalence (i.e., the number of persons with a particular syndrome/disease within a given time period) of dementia is relatively low with an estimated prevalence rate of between 0.5% and 1.0% (Rabins et al., 1999). In persons over 65 years of age, the prevalence of dementia increases significantly with an estimated 5.0% to 8.0% of this population suffering from some form of dementia (American Psychiatric Association, 2007; Rabins et al., 1999). After age 65, the prevalence of dementia nearly doubles every five years. Specifically, between 15.0% and 20.0% of individuals over 75 years of age are estimated to be experiencing some type of dementia, while the prevalence rate of dementia in persons over 85 years of age ranges from 25.0% to 50.0% (American Psychiatric Association, 2007). It should be noted that Alzheimer's disease is the most common cause of dementia in persons over 65 years of age, followed by vascular disease causes (i.e., Vascular Dementia) (American Psychiatric Association, 2000; National Institute on Aging, 2003).
 
12. In addition to Alzheimer's disease, what are some other causes of dementia?
 
In addition to Alzheimer's disease, dementia may be caused by other degenerative brain diseases (e.g., Parkinson's disease, Pick's disease, etc.), cerebrovascular diseases (e.g., multiple cerebral infarcts/strokes, etc.), infectious diseases (e.g., HIV, syphilis, etc.), prion diseases (e.g., Creutzfeldt-Jakob disease, etc.), anoxia/lack of oxygen to the brain, psychiatric disorders (e.g., Major Depressive Episode, etc.), traumatic brain/head injuries, vitamin deficiencies (e.g., Vitamin B12 deficiency, etc.), endocrine disorders (e.g., hyperthyroidism, hypothyroidism, etc.), brain tumors, immune disorders (e.g., systemic lupus erythematosus, etc.), hepatic/liver conditions, metabolic disorders (e.g., Kuf's disease, etc.), toxin and drug exposures (e.g., heavy metals, alcohol, etc.), other neurological disorders such as normal pressure hydrocephalus and multiple sclerosis, and multiple etiologies (American Psychiatric Association, 2000; Rabins et al., 1999). It should be noted that depending on the underlying cause(s)/ pathology of the dementia and the availability and timely application of appropriate treatments, dementia may become progressively more severe, remain relatively unchanged (i.e., static), or be reversible (i.e., remitting) (American Psychiatric Association, 2000).
 
13. How are dementia and Alzheimer's disease evaluated?
 
Individuals who are experiencing signs and symptoms of dementia/Alzheimer's disease are often first evaluated by their primary care physician. Typically, the physician will complete detailed reviews of the person's history (e.g., medical, psychiatric, etc.), presenting signs and symptoms, and current medications with the patient and possibly his/her family members. A physical examination will likely be conducted, as well as a mental status assessment that evaluates overall cognitive and thinking processes. Laboratory (e.g., blood and urine analyses, etc.) and neuroradiological/neuroimaging (e.g., Head CT or MRI scan) tests/studies may also be ordered by the physician in an effort to precisely determine the underlying cause(s) of the presenting complaints. Depending on the findings of the primary care physician, an individual may be referred to a neurologist, psychiatrist, or neuropsychologist for further evaluation of his/her symptomatology. Once a determination has been made regarding the underlying (or most probable) cause(s) of the presenting complaints, a diagnosis is typically given to the patient and an individualized treatment plan is formulated.
 
14. Are there advantages to early detection/diagnosis of dementia and Alzheimer's disease?
 
There are a number of clinical advantages of early diagnosis of disorders such as dementia and Alzheimer's disease (see U. S. Department of Health and Human Services, 1999). In particular, early recognition/diagnosis of the disorders promotes timely pharmacotherapy (i.e., antidementia medications), as well as non-pharmacological interventions (e.g., psychosocial and behavioral therapies, etc.) that are likely to be most effective in improving functioning/quality of life and possibly slowing the progression of further cognitive decline when they are provided early in the course of the clinical syndromes. Early recognition may also result in improved diagnosis and more timely treatment of potentially reversible causes of cognitive impairment and dementia (e.g., hypothyroidism, depression, etc.). Furthermore, early detection of dementia and Alzheimer's disease can prove beneficial to patients and their families by providing them with more time to adjust to the disorders and plan for the future, as well as allowing patients the opportunity to actively participate in decisions that will likely impact them later.
 
15. How are dementia and Alzheimer's disease treated?
 
The treatment of dementia varies according to its underlying cause(s), as well as the presenting signs and symptoms of the clinical syndrome, although it often involves a multi-modal approach. In the case of a Dementia of the Alzheimer's Type, treatment may include a prescription for one or more of the U.S. Food and Drug Administration (FDA)-approved medications that have been shown to slow/delay the progression of further cognitive decline and improve overall functioning in patients with Alzheimer's disease. Additional psychoactive medications may be prescribed if signs/symptoms of other psychiatric disorders (e.g., depression, etc.) or behavioral disturbances (e.g., agitation, etc.) are present. A wide diversity of non-pharmacological treatment strategies may also be recommended to patients and their caregivers/family members in an effort to maximize patients' overall qualities of life, levels of functioning, and safety. Such techniques may address the cognitive (e.g., memory impairments, etc.), behavioral (e.g., agitation, pacing, etc.), and emotional/mood (e.g., depressed mood, anxiety, etc.) symptomatology that individuals with a Dementia of the Alzheimer's Type may experience. For example, patients and their caregivers/family members may receive training in the utilization of memory enhancement techniques (e.g., use of memory prompts and cues, etc.) to promote memory functioning, as well as in the use of interventions such as emotional support and modification of the patient's environment in an effort to decrease episodes of depression and agitation. In addition, caregivers/ family members may be taught strategies that can help them cope with the rigorous physical and psychological demands that often accompany caring for someone with dementia. Support groups may also be recommended to assist patients and their family members to deal with dementia and Alzheimer's disease.
 
16. Are there any strategies/measures that can be taken which may help to reduce the risk of developing dementia or Alzheimer's disease?
 
While the best-known risk factors for Alzheimer's disease, namely, increasing age and family history (i.e., genetics) of the disease, are generally beyond individuals' control, there is a preliminary, but increasing body of evidence suggesting that strategies typically employed for healthy living/aging may also help to lower the risk of Alzheimer's disease and dementia. Such measures include remaining physically, mentally, and socially active, controlling weight, blood pressure, and cholesterol, and maintaining a healthy diet (e.g., low fat, low cholesterol, and rich in fruits and vegetables that contain antioxidants and phytonutrients).
 
17. What internet-based resources/websites are available where additional information can be obtained on age-related health topics, such as memory loss, dementia, and Alzheimer's disease?
 
Although there are many websites that offer information on age-related health topics, such as memory loss, dementia, and Alzheimer's disease, individuals may find the following websites especially useful. Please note, however, that CogniCheck, Inc. assumes no responsibility for the accuracy or content of any of these websites.
MISCELLANEOUS NEUROPSYCHOLOGICAL QUESTIONS
18. What is a licensed clinical neuropsychologist?
 
According to the National Academy of Neuropsychology (2002), a clinical neuropsychologist is a professional with expertise in the science of brain-behavior relationships. Clinical neuropsychologists typically utilize their expertise in the assessment, diagnosis, treatment, and rehabilitation of individuals with neurological, medical, neurodevelopmental, psychiatric, and other cognitive/learning disorders, such as memory impairment.
 
19. What do the terms "standardized test" and "norms" mean?
 
A standardized test is generally defined as one that has clearly specified and uniform administration and scoring procedures. The standardization of psychological tests also typically involves the establishment of norms. By definition, norms represent the test performances/scores of a particular sample/group of individuals (often reported in terms of the mean and standard deviation of their scores) that are utilized as a reference for interpreting the performances of future test takers. For the CogniCheck Online Memory Screening tests, norms were obtained from eight age groups (i.e., 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-86) of cognitively intact adults, with generally unremarkable medical and psychiatric histories, who completed the standardized memory screening tests. The screening test performances of individuals who complete a CogniCheck Online Memory Screening will be compared to those obtained by the similar-aged reference sample of cognitively intact individuals who participated in the standardization/normative study.
 
20. How do "recall" and "recognition" memory tasks differ?
 
While both recall (sometimes referred to as "free recall") and recognition tasks assess/screen aspects of memory, recall tasks require individuals to spontaneously retrieve from memory information that has previously been presented to them without the assistance of any external cues or prompts or presentation of any of the previously administered information/items. Alternatively, recognition tasks involve the presentation of items that have previously been administered, along with new items that have not been presented previously. Individuals are typically asked to indicate which of the items that are presented to them do they remember/recognize from a previously presented set. For cognitively intact persons, retrieval of information via recognition tasks is usually easier than retrieval by means of free recall.


References


American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Fourth Edition, Text Revision). Arlington, VA: Author.

American Psychiatric Association. (2007). Practice guideline for the treatment of patients with Alzheimer's disease and other dementias. American Journal of Psychiatry, 164(12):48A, 1-85.

Alzheimer's Association (2010). Ten warning signs of Alzheimer's. www.alz.org.

Alzheimer's Foundation of America (2010). About Alzheimer's, Warning Signs. www.alzfdn.org.

Ingram, V. (2003). Alzheimer's disease. American Scientist, 91(4), 312-321.

Levy-Cushman, J. & Abeles, N. (1998). Memory complaints in the able elderly. Clinical Gerontologist, 19, 3-24.

Lezak, M. O. (1995) Neuropsychological Assessment (Third Edition). New York: Oxford University Press.

Loring, D. W. (1999). INS dictionary of neuropsychology. New York: Oxford University Press.

Morris, J. C., Storandt, M., Miller, P., McKeel, D. W., Price, J. L., Rubin, E. H., & Berg, L. (2001).
Cognitive impairment represents early-stage Alzheimer disease. Archives of Neurology, 58(3), 397-405.

National Academy of Neuropsychology. (2002). Definition of a Neuropsychologist. www.nanonline.org.

National Institute on Aging (2003). 2001-2002 Alzheimer's disease progress report. Bethesda, MD: U. S. Department of Health and Human Services, National Institutes of Health, National Institute on Aging.

Petersen, R.C. (2003). Conceptual Overview. In R. C. Petersen (Ed.). Mild Cognitive Impairment: Aging to Alzheimer's Disease. New York: Oxford University Press.

Petersen, R.C. & Morris, J.C. (2003). Clinical Features. In R. C. Petersen (Ed.). Mild Cognitive Impairment: Aging to Alzheimer's Disease. New York: Oxford University Press.

Petersen, R. C., Smith, G. F., Waring, S. C., Ivnik, R. J., Tangalos, E. G., & Kokmen, E. (1999). Mild cognitive impairment: Clinical characterization and outcome. Archives of Neurology, 56, 303-30

Rabins, P. V., Lyketsos, C. G., & Steele, C. D. (1999). Practical dementia care. New York: Oxford University Press.

Ratcliff, G. & Saxton, J. (1998). Age-appropriate memory impairment. In P. J. Snyder & P. D. Nussbaum (Eds.), Clinical neuropsychology: A pocket handbook for assessment, 192-210. Washington, DC: American Psychological Association.

Spreen, O. & Strauss, E. (1998). A compendium of neuropsychological tests: Administration, norms, and commentary (Second Edition). New York: Oxford University Press.

U. S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville, MD:     U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.