Brain Evaluation

Driving: When to Give Up the Wheel because it is Not Safe for Others

Driving skills deteriorate with increasing dementia severity.  High risk drivers are those with unidentified or identified mild cognitive decline.  It is important that a physician trained in the aged population be the person to direct their patient to stop driving to relieve that duty from family. Physicians may need the help of a neuropsychological evaluation to provide assessment to help diagnose their decision. It is important to pay attention to the following warning signs:

·       Decreased miles being driven

·       Collisions

·       Moving violations

·       Avoiding certain driving situations, driving at night or in the rain

Aggressive or impulsive personality traits

The presence of routine helps sleep quality in the Aged

Maintenance of daily routines in the elderly was found to be associated with a reduced rate of insomnia.  This study found in Sleep, (Vol 33, 4, 2010) highlights the need for routine in the elderly population and the importance of preserving routines even as changes are made in dwelling and living conditions.  Treatment would benefit from interventions that are structured and built into the individual’s already established routine.

TNF levels are a mechanism behind the Apnea-Stroke Link

TNF, the inflammatory protein tumor necrosis factor was identified as being significantly higher in OSA patients.  Authors think that the inflammation is the origin of vessel damage resulting in stroke.  (Neurology Today, July 1, 2010). TNF alpha levels were found to be increased in children diagnosed with OSA driven primarily by sleep fragmentation and body mass index, closely associated with the degree of sleepiness. Surgical treatment for OSA (tonsillectomy and adenoidectomy) was found to result in significant reductions in the TNF alpha levels as well as prolonged sleep.

TBI associated with Major Depression

Traumatic brain injury may lead to major depression. Finding of new study that half of those diagnosed with TBI had a major depression (Neurology Today, July 1, 2010).  The patients also reported a high level of anxiety.  Both of these issues affected their quality of life and contributed to more functional impairment one year post injury.  The study suggests that major depression is very common after traumatic brain injury and associated with significant disability. There can be a brain triggered depression following TBI that is too deep and too severe for psychotherapy and/or medication to make a tremendous difference which needs to be recognized as a treatment variable.  Treatment should involve the whole family as a result, in the recognition that the brain injured person does not have a great amount of control over their depressed thoughts and as such cannot make changes on their own without support.  Cognitive therapies are very critical in the need to establish open communication to address the internal thinking processes of the brain injured person that are often not reality based.  The tendency is to think that things are far, far worse than they actually are or need to be. Recognize that you may or may not be able to talk the person out of their thoughts or dark beliefs and be ready to be creative in offering alternative treatments such as brain training and other methods to address the “crooked thinking”.

Spouses of Dementia have a six fold increased risk of dementia onset with husbands at higher risk than their wives.

A large population of 2,442 participants were studied for up to 12 years showing that dementia was significantly associated with older age and having a spouse with dementia.

The Benefit of Reading and Hobbies to lower the risk of Dementia

Dementia is now recognized as a chronic disease affecting 35.6 million with the expectation of increasing to double that amount over the next twenty years.  There is scientific interest that older adults may alter their risk of dementia by keeping their brain active.  The MoVIES project was a study initially enrolling 1,681 participants from a blue collar rural area of southwestern Pennsylvania who were at least 65 years of age with at least a 6^th grade education beginning in 1987.  They were followed at two year intervals through 2002.  They were asked to self report their leisure activities and dementia assessment was completed.  942 people were used for follow-up, ruling out variables of reading ability and participation.  The result of this study (American Journal of Alzheimer’s Disease & Other Dementias, 25, 5) found that engaging in hobbies for one or more hours per day was protective against developing dementia in later life and associated with a lower risk to develop dementia.  Research points to the benefit and need to remain active in your life and to keep your brain active.

Executive Functioning Deficits in Parkinson’s Disease, Amnestic (Memory) Mild Cognitive Impairment

Studies are suggesting that mild cognitive impairment or MCI appears prior to the onset of dementia associated with PD or Parkinson’s.  A recent study (American Journal of Alzheimer’s Disease & Other Dementias, 25,5) assessed patients diagnosed with MCI and PD finding significant executive reasoning deficits using tests of distractibility, fluency, cognitive flexibility, sequencing and new and novel learning.   The suggestion is the presence of attention/executive reasoning deficits and the need to focus upon examination of memory and executive reasoning deficits in this population. 

Depression is a Problem, An Independent Risk Factor for Dementia and a number of Illnesses

Depression is not longer something to ignore.  Those individuals who have been depressed since childhood with what we call endogenous depression or depression throughout their life (often present in the family history) are likely at more risk for all kinds of problems with graceful aging.  Recent research (Neurology 7-6-2010) shows that depression is associated with an increased risk of dementia and Alzheimer’s disease seen in women in a study spanning 17 years.  949 participants from the Framington heart study were assessed for depression and during the 17 year follow-up period, 164 developed dementia and 136 of the cases were Alzheimer’s dementia.  Lifestyle factors associated with longstanding depression such as diet, physical activity and social engagement may be some reasons for the increased risk of dementia.  Research reports that depressed patients are 1.5 times more likely to develop dementia than those who are not depressed.  Each depressive episode resulted in a 14 percent increased risk for dementia. One depressive episode results in a significant 87 percent increased risk of dementia.  The suggestion is that depressive symptoms create a wear and tear on the brain making it more vulnerable to common pathologies of Alzheimer dementia. Doesn’t that make you want to address any symptoms of depression today?

Mild Cognitive Impairment is no Longer Benign, Pre-Cursor to Huntington’s disease

Mild cognitive impairment is a term that used to describe a person who was having some problems but not enough to worry about. Patients were reassured that they were all right.  Recent research is indicating that MCI is the gateway to dementia and if diagnosed should be treated with both medication as well as cognitive rehabilitation or brain training.  We have had excellent results at our facility using brain training with MCI showing improved memory functioning seen on neuropsychological testing.   Neurologists were surveyed (Neurology 8-3-2010) and 88 percent reported at least monthly encounters with patients experiencing mild cognitive symptoms. Mild cognitive impairment was found as a transitional stage between normal cognition and dementia.  One study saw it as a pre-cursor to Huntington Disease (Neurology 8-10-2010). MCI does not always mean memory problems.  MCI without memory problems has been seen almost twice as frequent as the MCI with memory problems.  Cognitive function problems of attention, verbal fluency, psychomotor speed executive functioning and visuospatial functioning are seen accompanying Huntington’s Disease.  As those with HD get closer to their estimated diagnosis based upon their genetic risk, the prevalence of MCI is greatly increased. 

Causal Factors for falls in the Elderly

Slowing of gait speed is common for the elderly population which develops into falls and then eventually a loss of independence due to further physical injury and/or a fear of living by themselves.  At 60 years of age, 85 percent of people have a normal gait however by the age of 85 years or older this declines to 18 percent.  Falls have been associated with gait abnormalities occurring in 30 percent of individuals 65 years and older.  Many diseases have been proposed as potential causes of falls in the elderly population.  A recent study (Neurology 5-18-2010) found that impaired cerebral blood flow regulation measured by cerebral vasoreactivity to CO₂ is associated with slow gait speed and may lead to the development of falls in elderly people.