The Early Diagnosis Problem with Alzheimer’s

29th October 2010 by Christian Elliott

Douglas Watt from Harvard Medical School provided a useful update on Alzheimer’s research at the National Academy of Neuropsychology conference earlier this month. His key points:

1. Late diagnosis of memory loss and cognitive impairment contribute to underestimation of the problem – the current estimate of 5.5 million with Alzheimer’s in the US alone is probably low.

2. Many physicians and associated health care providers still rely on the Mini-Mental State (MMSE) paper exam, which isn’t very useful for early stage memory impairments – MMSE is good for measuring moderate to severe dementia, but that doesn’t help with the goal of catching early signs of cognitive impairment. This is a prime reason why computer based cognitive screening can be very effective in a primary care setting.

3. A combination of short term memory screening and biomarker tests is the best scenario for catching Alzheimer’s in the pre-clinical, or prodromal phase. Biomarker tests for Alzheimer’s are all over the map right now (including very high false positive results with some tests), so this will take a while to sort out.

4. Moderate daily exercise, foods with high antioxidant content, and positive social engagement reduce the chances of developing Alzheimer’s. Sedentary daily routines, obesity, Type II diabetes, and social isolation greatly increase chances for Alzheimer’s and other forms of dementia.

There was also an interesting discussion on the role of general inflammation in the brain as a cause of Alzheimer’s. There is increasing speculation that beta amyloid may not be the cause of Alzheimer’s, but more of a symptom. This has implications for future drug discovery efforts, with more of a focus on compounds that reduce CNS inflammation.

Brain Injury Rehabilitation Protocols

21st October 2010 by Christian Elliott

Interesting update on TBI rehabilitation methods at the National Academy of Neuropsychology conference last week. The recovery period for even a “mild” traumatic brain injury can last for several months, and more severe injuries usually require a much longer period. TBI symptoms can many times include emotional regulation problems (commonly part of PTSD), along with cognitive issues with attention, memory retention, and learning.

Christopher Bell and Margo Villarosa from Walton Rehabilitation Health in Augusta, GA provided a detailed overview on their brain injury rehabilitation program, which is based on the Rusk Institute of Rehabilitation brain injury protocol, or Rusk Protocol. The protocol has the following components:

• 20-24 weekly outpatient sessions, with a minimum of 2 hours for each group session
• Emotional self-regulation training
• Practical problem solving training– “Clear Thinking”
• Achieve the best competence and stability of daily living arrangements for each patient
• Patient:Staff ratio of approx 2:1

This is a fairly intensive outpatient model that requires a significant 6 month commitment from both patients and staff. It is also a realistic model that recognizes that both cognitive and emotional rehabilitation is necessary with many forms of TBI.

The Walton Rehabilitation staff that presented the protocol also mentioned that the nearby Eisenhower Medical Center at Ft. Gordon may use the Rusk protocol for service members with blast related TBI.

Readers can contact me if they would like a copy of this rehabilitation protocol.

Defining Mild Cognitive Impairment

15th October 2010 by Christian Elliott

At the annual National Academy of Neuropsychology (NAN) conference in Vancouver this week, Mark Bondi from UCSD & VA San Diego provided a very informative update on defining and diagnosing mild cognitive impairment (MCI).

Why all the attention on MCI? Because MCI can be a portal to Alzheimer’s and other forms of dementia. The conversion rate from MCI to dementia is 10%-15% per year, which means someone diagnosed with MCI has a greater than 50% chance of declining into dementia within five years of the MCI diagnosis.

Catching MCI in the very early stages also allows for medical interventions that can be effective; the newer medications tend to be more useful in the “prodromal” or very early stage Alzheimer’s, rather than in later, more profound dementia.

The common definition of MCI is:

1. Memory complaint/impairment, corroborated by testing
2. Normal cognitive functioning in other areas
3. No impact on general daily activities (dressing, basic food preparation, reading, etc)
4. Mild or slight impact on more complex activities (personal finances, managing multiple medications, etc)

Baseline cognitive testing in your doctor’s office or other health care setting is a useful way to keep an eye on memory loss and other cognitive problems that could indicate MCI. Being able to retest on memory and cognitive performance every couple of years will allow seniors and physicians to compare the most recent results with the initial baseline test to flag any potential cognitive issues for follow-up.

There are also some paper-based tests for home use that can act as a “first pass” screen for memory impairment. Readers can download two of these tests here.

Home Use Tests for Memory Loss, Alzheimer’s, Dementia, MCI

5th October 2010 by Christian Elliott

Several readers have asked about cognitive tests for memory loss that can be used in the home. There are several paper-based tests that can provide a “first pass” screening for memory impairment. If the test scores indicate memory problems, then it’s a good idea to follow up with your physician for more detailed testing. Computer-based testing in a physician’s office or health clinic can pick up early signs of memory impairment that paper-based tests can miss.

**New: Download the MyBrainTest Consumer Fact Sheet on cognitive screening tests.

**New: Annual Wellness Cognitive Exam packet now available for health care providers. Includes standardized Annual Wellness Visit Exam Form and Personalized Prevention Plan Service template.

The following criteria were used to select free paper-based cognitive impairment tests:

1. Takes less than 15 minutes.
2. Can be administered by a family member or friend.
3. Meets the “gold standard” of peer reviewed published research that establishes the reliability and validity of the test.

Readers can download the tests here. Be sure to carefully read test information and instructions.

The US Military’s Definition of Mild TBI

1st October 2010 by Christian Elliott

The Department of Defense recently released a guide for primary health care providers on treating service members with traumatic brain injury (TBI). One thing I found interesting was DoD’s definition of “mild TBI”, which includes a loss of consciousness for up to 30 minutes and post traumatic amnesia for up to 24 hours.

In other words, if someone is knocked out cold for 30 minutes, and then is confused and disoriented and can’t remember much for the next 24 hours after they regain consciousness, then they have only received a mild brain injury according the Pentagon. This standard might seem a bit lax in the civilian world, but it’s also a realistic acknowledgement that US military service members operate in high risk environments for TBI.

The military and organized sports teams have taken the lead in attempting to address TBI risk through mandatory baseline cognitive assessments (to compare re-test results after a TBI event) and the newer use of portable EEG diagnostic systems. These are good first steps in a very complex problem, especially with blast related TBI, where the specific blast effects on white matter (axons) that connect different parts of the brain are still poorly understood.

The risk of re-injury is very high in these specialized groups due to their operating environments, along with a group culture that encourages members to return to the field as quickly as possible. Unfortunately, repetitive brain injuries can have devastating outcomes for some people. It’s possible we will find that personal genetics plays a role in how an individual’s brain responds to TBI – the idea that some people’s brains are simply more susceptible to long term problems from TBI. This would raise the (future) concept of screening and selection of “TBI resistant” CNS profiles for certain high risk jobs and environments.