Importance of neuropsychological assessment for the evaluation of childhood learning disorders

Stages of Alzheimers

by Mark L. Prohaska, Ph.D.

As a caregiver, it is important to understand the stages of the disease and what to look for so that you can adjust you level of care accordingly. Knowing what to expect also help you prepare well in advance to handling the more challenging aspects of care giving that arise as the disease progresses.

THE EARLY STAGE

In the early stage of Alzheimer’s disease, the primary symptoms include forgetfulness, absentmindedness, and fatigue. There may be some difficulty recalling common words, and learning new things may be more difficulty. In addition, judgment may seem impaired, and there may be notable declines in intellectual and social functioning. Important tasks for the caregiver in the early stage include:

• Help with decisions about finances, relationships, and substantial life changes.
• Start thinking about and observing the day-to-day tasks that you will eventually need to provide assistance with such as bathing, grooming, toileting, dressing, eating, exercising, and communicating. Be prepared to intervene when help becomes necessary.
• Begin planning for how caring for your loved-one is going to affect you, and begin developing your support system. Consider issues such as adult day care services, long-term care services, and other placement needs that may be necessary down the road.
• Ensure that a durable power of attorney is in place, and that items such as a living will, last will and testament, and estate planning are updated and complete.
• Identify the stressors you struggle with as a caregiver, i.e., those tasks or behaviors that are most frustrating or anxiety producing. Once identified, think through them and use your support system to help plan your responses to these situations and to get additional help when needed.

THE MIDDLE STAGE

In the middle stage of the disease, memory, logic, and motor abilities deteriorate further. Wandering and pacing may become more evident, and striking out verbally or physically may emerge as the capacity for patience deteriorates and their response to frustration becomes more aggressive. Speech and verbal understanding become slower, making communication more difficult. Performing mathematical operations becomes much more difficult. It is during this stage that psychiatric symptoms often emerge, including suspiciousness and paranoia. Social skills diminish further, and the hiding of objects becomes a frequent problem. Important tasks for the caregiver at this stage include:

• Provide increasing supervision and assistance with daily activities while allowing the patient to be as independent as safely possible.
• Give instructions slowly, clearly, and in writing (when appropriate).
• Control social situations closely.
• Obtain financial and legal advice – at this stage patients are no longer able to manage their own affairs.
• Consult with your physician– medications are often needed at this stage to help control psychiatric symptoms.
• Develop a structured daily routine and try not to deviate from it.

THE ADVANCED STAGE

In the advanced stage, the patient may become incontinent. Communication becomes even more difficult as the ability to speak and follow simple commands diminishes. Psychiatric symptoms now commonly involve hallucinations to which the patient may respond physically. Emotionally, the patient may become abusive, removed, or unresponsive. During this stage, the patient may appear ironically calmer and less distressed because they truly cannot remember how things used to be. There may be periods in which emotional symptoms seem to disappear. Issues for the caregiver in this stage include:

• Assistance will be needed in virtually every aspect of daily activities – utilize your support system to its fullest.
• Maintaining your own emotional well being during this stage is vitally important.
• Initiate the plans for end-stage care.

THE FINAL STAGE

In the final stage of the illness, patients lose almost all intellectual abilities, including memory, speech, and motor coordination. They typically recognize no one and remember nothing. Total care is required. Issues for the caregiver in this stage include:

• Provide comfort care. The patient needs to be bedded, bathed, and protected from harm. At this stage, placement in a nursing home or other long-term care facility is often needed.
• Keep in mind that the suffering for your loved one is now over – they are no longer able to understand what is going on.
• Prepare to resume your normal life-style, including reestablishing friendships and social outlets, and resuming hobbies and other pleasurable activities.
• Recognize that you have done all that you could have possibly done, and give yourself a pat on the back for a job well done.

Although Alzheimer’s disease is a tragic and terrifying illness, one must keep in mind that every journey through the course of this illness in unique. Not all symptoms occur in every patient with Alzheimer’s disease, and often times the imaginings of what may happen are far worse than what actually unfolds. Although it is important to be prepared, it is equally important to take life one day at a time, to be prepared to handle issues as they arise, and to daily look for opportunities to laugh and enjoy a pleasurable moment with your loved one in spite of all you both are going through.

Is Dementia Reversible?

by Mark L. Prohaska, Ph.D.

The answer is… it depends on the type. Most people equate the word dementia with Alzheimer’s disease which, of course, is a progressive, non-reversible dementing illness. There are other types of dementia that are also progressive and non-reversible. These include Lewy Body Disease, Frontal or Frontotemporal Disease, Subcortical Disease (e.g., Parkinson’s Disease, Huntington’s Disease, Progressive Supranuclear Palsy), and dementia due to stroke or cerebrovascular disease, all of which have a different presentation and course of progression than Alzheimer’s disease. However, you may be surprised to learn that there are some types of dementia that are entirely reversible. The term dementia is actually very nonspecific – it simply refers to the presence of cognitive or intellectual deterioration without regard to cause. So, while Alzheimer’s disease is indeed a type of dementia, having dementia does necessarily mean one has Alzheimer’s disease. This is a very important realization. I have had many patients experiencing forgetfulness or other thinking problems who were terrified of being evaluated because they were convinced that they had Alzheimer’s disease, but did not want to be told this by a doctor. On evaluation, many of these patients were found to not have Alzheimer’s disease at all; rather, they were suffering from other conditions for which treatments were available that cleared up their problem altogether. Some of the more common types of reversible dementia are described below.

Depression: Depression is often accompanied by a dementia syndrome characterized by memory and concentration problems that start slowly and grow progressively worse as the depression increases. It is not uncommon for older adults with depression to be misdiagnosed with Alzheimer’s disease. This type of dementia typically goes away with successful treatment of the underlying depression.

Delirium: Delirium is characterized by confusion and, very often, auditory and/or visual hallucinations. It typically has a very quick onset – often after a change in medications or following a surgical procedure. Symptoms typically fluctuate, with the individual alternating between seeming perfectly fine to being very confused. A delirium may persist for days or months, if the source is not treated. Typically, this type of dementia goes away with successful treatment of the underlying cause.

Medication Side Effects: Numerous medications have a direct effect on brain functioning, and this varies a great deal among individuals. Thus, where one person will be able to tolerate a particular drug with no difficulty, the same drug may cause a great deal of confusion and memory problems in another individual. These types of problems can usually be addressed through appropriate changes in medications and/or dosage with the related cognitive difficulties resolving fully.

Substance-induced persisting dementia: The most common form of this type of dementia is caused by excessive alcohol intake and associated nutritional deficiencies. The most common presentation is severe memory deficits and very poor problem solving. Although severe alcohol abuse canresult in an irreversible dementia, more often cognitive abilities improve over time after the use of alcohol has stopped.

Metabolic and Endocrine disorders: Uncontrolled or poorly controlled diabetes, hypo or hyperthyroidism, and B-12 deficiency are just some of the medical disorders that can result in significant alterations of cognitive functioning. Appropriate medical treatment of these conditions typically results in a full restoration of memory and thinking abilities.

Normal Pressure Hydrocephalus: This is a fairly rare type of dementia that is associated with normal pressure in the brain, but impaired absorption of the cerebrospinal fluid. This disorder presents with a classic triad of symptoms that includes cognitive changes, difficulty walking, and incontinence. Early detection of this disorder can lead to symptomatic improvement with a full return to functioning.

Hopefully, the message is clear - if there are concerns about your memory/thinking abilities, or those of a loved one, consult your doctor for a thorough physical examination and a medication review. Cognitive problems can be due to many things other than Alzheimer’s disease – many of which are treatable and reversible. If your doctor does not find the cause of your memory problem, seek a referral to a neurologist for a neurological evaluation. This will likely include taking some pictures of your brain (a CT scan or MRI) and a referral for a neuropsychological evaluation to get a detailed analysis of your memory functioning and other cognitive abilities. Understanding the cause of these problems is critical and, even if Alzheimer’s disease is the cause, early detection is critical in order to maximize the benefits of the interventions currently available.

Caring for the Caregiver

by Mark L. Prohaska, Ph.D.

I think Janice is a remarkable woman. Now in her mid-70’s, she has survived the poverty and hardships that came with growing up in a poor family in rural Alabama. She married young, in part to escape the drudgery and hard work of life on the farm. After somehow managing to successfully raise six children and caring for both of her parents through their old age illnesses, she had been looking forward to finally finding some time to travel and do some of the things that she’d had to put off for so long. Never in her wildest imagination did she think that one day she would spend these years caring for her husband as he succumbed to the ravages of Alzheimer’s disease. In spite of her own heart problems and declining health, she would not have it any other way. She has resisted suggestions from friends to put Howard in a nursing home, and is determined to keep him at home as long as possible.

At first, things were easily manageable – it brought back memories of caring for her children when they were young. Howard was still able to do many things for himself – he just needed some guidance and supervision to get him over the rough spots. But as things progressed, the tasks become more daunting, the obstacles higher, and the burden increasingly heavy. At the urging of her children, Janice took a week last month and traveled to the beach for a break. She returned home after only four days feeling guilty that she’d left Howard, and even more guilty that she’d actually begun to enjoy her time away. Nonetheless, she was growing tired, frustrated, and began doubting whether she was actually up to the task of caring for her husband.

If there is one consensus among caregivers, it is that caring for a loved one with dementia is hard work and, as with any difficult job, there is a high risk of exhaustion and burnout if the worker is not properly taken care of. Care giving is not a sprint in which you burn up all of your energy in a mad race to the finish line; rather, a very long marathon that must include rest breaks, time to heal blisters and wounds that develop along the way, and a tremendous amount of emotional support. Here are some suggestions to help you along the way:

Identify and develop your social support network. Your network may include family, friends, physicians, counselors, sitters, adult day care centers, support groups, and other community resources such as FOCUS on Senior Citizens. Develop your network, know what each piece in the network has to offer, and utilize it to the fullest.

Identify the stressors you struggle with as a caregiver, i.e., those tasks or behaviors that are most frustrating or anxiety producing. Once identified, think through them and use your support system to help plan your responses to these situations and to get additional help when needed.
Become a care-giving expert.

Educate yourself as much as possible about the disease your loved one is facing and its progression, as well as about different strategies to use in handling troublesome situations. Some excellent online resources include http://www.caregiver.org/ and http://www.alz.org/. Helpful books include Alzheimer's Disease --The Dignity Within: A Handbook for Caregivers; and A Caregiver's Guide to Alzheimer's Disease: 300 Tips for Making Life Easier, both available online at http://www.caringconcepts.org/.

Get adequate rest, even if it means sleeping in separate bedrooms or hiring a sitter at night.

Try to keep incidents in perspective. Much of what is happening is the disease, not the person. Writing down your feelings or thoughts in a journal will often help put them into better perspective, is a good way to release emotions, and will become a memorable record of your journey.

Set realistic goals regarding what and how much you can do for your loved one.

Be good to yourself. Give yourself frequent praise and rewards for your patience and endurance.

Continue to find ways to have fun.

Use your sense of humor – it relieves stress and is a positive emotional release for both of you.

If family or friends offer help, accept it.

Set aside certain days or parts of certain days for yourself, and find a companion or day program for your loved one for that period of time.

Forgive yourself for not being perfect and stop trying to be perfect. Don’t be hard on yourself when you experience impatience, frustration, sadness or anger.

Take care of yourself physically and emotionally. Eat well-balanced meals, get regular checkups and exercise.

Devotion to caring for a loved one is to be admired, but devotion from a caregiver not taking care of themselves is about as effective as personal trainer who is obese and out of shape – they just are not going to be up to the task. In order to be successful, a caregiver needs to be just as committed to taking care of themselves as they are their loved one, for if they are not around to do the job, who will be?

The Challenges of Caregiving by Mark L. Prohaska, Ph.D.

I recently interviewed a patient with moderately advanced Alzheimer’s disease who had been brought to my office by his wife, who was in the waiting room. “Who is it that brought you in to see me today?” I asked him. “Oh, that is an old friend” he responded. “Really, how long have you known her?” I asked. “Oh, for a very long time… we grew up together; she is a really good gal.” “What is her name?” I asked. “Janet” was his correct reply. “She seems very nice” I observed, “why didn’t you ever marry her?” I inquired. “I don’t know, just never really got around to it I guess.” Later, speaking with Janet, I learned that her husband frequently did not recognize her has his wife, something she found very frustrating and disappointing after over 50 years of marriage. To make matters even worse, he often asked Janet about “his wife” – wondering where she was and why she hadn’t been coming to see him. Confronting him with her true identity was to no avail, though thankfully there were periods during which he recognized her has his lifelong partner, providing all too brief periods of respite in which they could share the closeness that only the passage of so many years together can bring.

Caring for a loved one with dementia is a challenging task that seems to present ever-higher obstacles as the dementia progresses. Typically, the early challenges involve merely dealing with frustrating forgetfulness and difficulty keeping up with day-to-day activities. However, eventually functional declines begin to emerge such as difficulty handling more complex tasks, such as planning a dinner or managing the checkbook. Eventually, difficulties emerge in performing even simpler everyday activities such as shaving, picking out clothes to wear, dressing independently, bathing, and even toileting. These declines frequently leave the caregiver feeling as though they are again caring for a child; indeed, dementia can be seen as a slow progressive spiral back towards the dependency of infancy.

In addition to functional declines, and perhaps more frightening and difficult to deal with for the caregiver, are changes in the perception of reality that accompanies dementia. Talk to any caregiver, and you will hear countless stories of their loved one accusing them of all types of things, including stealing, infidelity, abandonment, plotting against them, and even of trying to poison them. The will tell stories of their loved one wanting to “go home” when they already at home, of seeing and hearing things that are not there, of accusing them of being an imposter, and of engaging in activities that make no sense and have no purpose. I remember one exasperated daughter who complained that her mother was constantly hiding her possessions around the house out of fear that someone would steal them, only to then angrily accuse her daughter of having stolen them when she was later unable to find them!

Changes in the perception of reality are typically accompanied by other behaviors with potentially serious consequences. These include agitation, verbal threats, and sometimes-physical outbursts and aggression in response to their perceived offenses. I have had patients that have made numerous complaints to law enforcement officials about perceived wrongdoings against them, and other that have actually filed lawsuits based on their delusional beliefs. Another common problem is wandering – frequently a result of the individual attempting to get to a place that, unfortunately, no longer exists, or due to sleep disturbance that has them sleeping during the day and then up wandering at night (referred to as diurnal rhythm disturbance).

In spite of all of the challenges involved, many family members tell me that they would not trade the experience of seeing their family member through the stages of dementia for anything, for intermixed in the periods of turmoil are periods of closeness, bonding, and reflection that would not have been experienced any other way. Clearly, both the level of independent functioning and quality of life are maximized and prolonged for the patient suffering from dementia that is able to be cared for in a loving and supportive home environment. Fortunately, it is rare for any one individual to exhibit all of the problems that can accompany a dementing illness, and a well-prepared caregiver with adequate resources can often find the knowledge and guidance needed to handle problems as they arise. In coming issues, we will address some of the more common challenges facing the caregiver, including handling behavioral problems, improving communication, preventing wandering, diffusing aggression, managing sleep problems, the issues involved in bringing in outside help, and, perhaps most importantly, caring for the caregiver.

Ten Steps to Keeping a Good Memory by Mark L. Prohaska, Ph.D.

Most of us have a fairly good idea of what it takes to keep our bodies in good shape. We watch our diet, try to control our weight, get regular check-ups, and exercise. As I approach my 47^th birthday, I can see where all of these efforts are paying off – I’m told that I don’t look a day over 45! But are there things that we should be doing to help maintain our memory and maximize our ability to remember? Well, as it turns out, there are things that can help us do exactly that. According to a Harvard Health Letter “Preserving and Boosting Your Memory,” here are 10 things that will help us all fine tune our memory abilities.

• Exercise your mind. Several studies have shown that keeping your mind challenged increases the capacity of your memory and may delay or prevent the onset of Alzheimer’s disease. So, pick up that musical instrument you’ve always wanted to play, get together with friends to play challenging board games or card games, learn that foreign language you’ve always to learn, read a good book, pick up a new hobby, or start a new career.


• Exercise your body and lower your blood pressure. Studies show that just 6 hours of leisurely walking per week, or 1½ hours of brisk walking per week, will increase cerebral blood flow, improve mental abilities such as memory, and protect against dementia, heart disease, and stroke. Engaging in strength training and stretching has additional benefits as well.


• Eat, drink, and be healthy. The guidelines are simple: eat diets high in whole grains, plant fats, fruits, vegetables, and nuts to lower weight and reduce the risk of cerebral artery disease. Drink sufficient water, reduce alcohol intake, and eliminate smoking.


• Develop reminders and cues. Normal aging results in difficulty freely recalling information. To help compensate, write things down, keep objects in designated locations, set up cues to remind you about certain tasks and activities, and use repetition to help remember important things like appointments and names.


• Take your time. As we age, our thinking speed declines, and it may take longer to retrieve information. Try to slow down and allow more time to devote your full attention to what you are trying to remember. If this doesn’t work, go on to think about something entirely different, and you will be surprised how often the information that you were trying to remember will come to you.


• Learn to relax. Too much anxiety and muscle tension markedly impairs learning and memory abilities. Calming your body and mind will allow your memory to work at its full potential.


• Maintain a positive attitude. Positive thinking creates positive emotional states, which markedly influences how our memory works. Interestingly, optimists live longer and maintain higher mental abilities, including memory, into old age.


• Get regular check-ups. Work with your doctor to identify any health factors that can affect your memory, including fatigue, stress, medication side effects, vitamin deficiencies, depression, poor vision and hearing, and numerous illnesses.


• Keep stress under control. Chronic high stress can result in the shrinkage of the part of the brain responsible for learning new information, and result in significant memory problems.


• Keep a rational perspective. Remember that EVERYONE forgets things sometimes, and that some forgetting is NORMAL. “Senior moments” are a part of the privilege of growing older.

Following these guidelines will help us to maximize our memory abilities well into our old age. However, if you have concerns about your memory abilities, consult your doctor for a thorough physical examination and a review of your medications. If the cause of your memory problem is not found, seek a referral to a neurologist for a thorough neurological evaluation. This will likely include taking some pictures of your brain (a CT scan or MRI) and a referral for a neuropsychological evaluation to get a detailed analysis of your memory functioning and other cognitive abilities. There are many causes of memory problems, and many options available for addressing them. If you or a loved one is experiencing memory problems that appear to be beyond “normal” forgetting, talk to your doctor today.

Normal Aging

by Mark L. Prohaska, Ph.D.

Dr. Prohaska is the director of the Neuropsychology Clinic located in Tuscaloosa, Alabama. For more information visit our website at http://www.npclinic.com.

The older I get, the more often I experience what my patients jokingly refer to as “senior moments.” I unexpectedly run into an acquaintance that I’ve known for years, and am unable to recall their name. My wife sends me to the store to pick up five items, and I come back with four. I’m in the middle of a conversation, and get stuck finding a word that I want to say. And don’t bother asking me where I laid down the checkbook last! I take some solace in having heard similar complaints from my patients over the years, and realize that this is just part of growing older. However, there is also the frightening realization that with age comes an increased risk for developing dementia. The question then is what type of age-related memory problems are considered “normal,” and what might indicate a more serious memory problem that needs medical attention?

During my years of training, I was surprised to learn that our “brain power” peaks out in our early thirties, after which at least some aspects of our thinking ability begin a long slow decline that continues throughout the life span. With regards to memory, highly practiced skills, familiar information, factual knowledge, language, and autobiographical information all endure well over the life span. Where our memory struggles, as we grow older is in our ability to formulate new memories, or our “short term” recall. So, we are more likely to forget recent experiences, new facts, or the sources of new information that we have acquire, and are also more likely to have difficulty remembering information when we need it. These difficulties in memory are part of the “normal” aging process. So, the experience of the following can generally be chalked up to having had another “senior moment” without much concern:

• Forgetting names


• Misplacing objects (keys, glasses, wallet)


• Forgetting where the car is parked at the mall


• Forgetting to buy things on the shopping list


• Not recognizing acquaintances in unfamiliar settings

Of course, there are other types of memory problems that may indicate a more serious problem. Even if this is the case, there is no need to panic. There are many reversible conditions that can be the culprit of memory problems. These include poor nutrition, dehydration, metabolic disturbances (such as poorly controlled diabetes), endocrine disorders (such as hypothyroidism), sleep disorders, depression, drug side effects, and other medical conditions. Even if it is determined that early Alzheimer’s disease appears to be the culprit, there are new medications that can help - particularly if the disorder is detected early. The more serious type of memory problems that should be further evaluated include:

• Getting lost while driving in familiar surroundings


• Completely forgetting appointments


• Repeating the same thing in conversation


• Having periods of disorientation (not knowing the time or where one is)


• Difficulty managing the checkbook or paying bills


• Personality change (either sudden or gradual)


• Frequently having difficulty thinking of the word to say or naming objects


• Experiencing a sudden change in musical or artistic ability


• Memory problems that are interfering with your conducting your normal routine.

If you are experiencing any of these more serious memory problems, consult your doctor for a thorough physical examination and a review of your medications. If the cause of your memory problem is not found, seek a referral to a neurologist for a thorough neurological evaluation. This will likely include taking some pictures of your brain (a CT scan or MRI) and a referral for a neuropsychological evaluation to get a detailed analysis of your memory functioning and other cognitive abilities. There are many causes of memory problems, and many options available for addressing them. If you or a loved one is experiencing memory problems that appear to be beyond “normal”, talk to your doctor today.