Selected Podcast
Improving Memory
Daniel Llano, MD, PhD, discusses memory loss, disease processes that can cause dementia, and what treatments providers can use to help their patient improve memory.
Featuring:
Daniel Llano, MD, PhD
Daniel Llano, MD, PhD Medical Interests are cognitive and behavioral neurology, emphasis on Alzheimer’s disease.
Transcription:
Melanie Cole (Host): Expert insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episode’s posttest.
Certain brain changes may be inevitable when it comes to aging. Major memory problems are not one of them. That’s why it’s important for providers to know the difference between normal age related forgetfulness and the symptoms that may indicate a developing cognitive problem. My guest today is Dr. Daniel Llano. He’s a neurologist with the Carle Foundation Hospital. Dr. Llano, explain a little bit about memory loss as it relates to aging and is it a normal part of aging? Is it something that inevitable?
Dr. Daniel Llano (Guest): Yeah so it is normal to have a small degree of memory loss with aging. It actually begins younger than you might think. In our 40s and 50s we begin to have measurable changes in our ability to juggle multiple items in our head at one time for example and it tends to gradually get worse over time, but usually it doesn’t impair people’s day to day functions. If your patients are complaining to you that they’re unable to manage their daily affairs. For example they can’t manage their medications or they have a hard time with driving or having a hard time with their bills. That would be a suggestion that what your patient is suffering from is worse than normal aging associated cognitive impairments and may only have a diagnosis of a bonified memory disorder.
Melanie: Are there some disease processes and you mentioned medications as well, that can cause or accelerate memory issues or cognitive issues? What are some common conditions and factors that can lead to this type of loss?
Dr. Llano: Well the most common things that we see are mild cognitive impairment and Alzheimer’s disease and there’s a spectrum. With mild cognitive impairment, these are individuals who have memory loss which is worse than normal aging and that is found using objective measures typically done by a neuropsychologist, but patients with mild cognitive impairment don’t yet have functional impairment, meaning they’re still able to manage their day to day affairs but their memory difficulties are noticeable to them and their family typically. If the memory difficulties progress to the point that people have a functional impairment, at that point they’ve crossed a threshold into dementia. By definition dementia implies that there has been some cognitive loss that effects functional day to day activities and the most common kind of dementia is Alzheimer’s disease, and so mild cognitive impairment is often thought of as a prodromal state to Alzheimer’s disease. We know there’s a pretty significant risk, about 10% to 15% per year of individuals who have mild cognitive impairment who eventually develop Alzheimer’s disease. There is a family of other disorders that can cause memory difficulties so as a physician you don’t want to only focus on mild cognitive impairment and Alzheimer’s. Of course there are vascular cognitive changes that are quite common as people age that can cause memory impairment, other forms of dementia such as Lewy body dementia, frontotemporal dementia can sometimes manifest as a memory change so that often has some personality changes as well, and then certain disorders that are actually quite treatable like normal pressure hydrocephalus, which is not common, but you should be on the lookout for this because if you select your patients properly, patients could pretty well with a surgical intervention. So there really are a number of different disorders that can lead to an initial memory complaint.
Melanie: Speak about the clinical presentation, and for providers, what red flags should they be hearing from family members or the patient themselves as far as things that would warrant the history and to start the diagnostic process?
Dr. Llano: Sure so typically if it’s going to be an Alzheimer’s related process or an amnestic mild cognitive impairment, so a memory driven mild cognitive impairment, typically what patient’s families will complain of is the patient will repeat things. They’ll make a statement and 20 minutes later they’ll make the same statement or they’ll ask the same question multiple times and that’s simply because they don’t remember the first time they made that statement or the first response to a question. Often patients will have difficulty with visual special orientation so they might get lost easily with driving. That’s a pretty common problem and you have to be paying attention for that, and often this will be getting lost in familiar territory. Probably one of the most important things you should know is that the patients themselves almost always doesn’t have a real appreciation for the memory difficulty. So if you have a patient in your office and they’re by themselves and they say they’re doing great and there’s no memory issues at all, that’s typically not a very reliable source. So you definitely want to probe the family members, typically the spouse or the adult children because they’re usually the first ones who will notice any symptoms at all.
Melanie: So speak for us about diagnosis and why is it important to know what is underlying the memory loss the person is showing?
Dr. Llano: Sure, the key diagnostic test that we use to sort out whether it’s for example normal aging related cognitive impairment versus mild cognitive impairment that could lead to Alzheimer’s or to Lewy body disease or vascular dementia, the key test is what’s called formal neuropsychological testing. And what that consists of is meetings with a neuropsychologist and the neuropsychologist and their technician will spend about three or four hours assessing a patient’s memory, often testing multiple domains, multiple different ways to get a highly reliable result and then compare those results with typically age and education adjusted norms. So that’s people’s performance is compared to other people’s performances in the same age group and the same educational category and that will typically be a very good indicator as to what the underlying etiology is because each of these disorders has their own pattern in terms of strengths and weaknesses that the patient will display. There are other tests that we will order as well. Typically we’ll get a brain imaging study, like an MRI of the brain. That’s usually done primarily to rule out other structural illnesses. Often we do these studies and we’re surprised to find that there’s a lot more vascular diseases than we may have appreciated or there might be something like hydrocephalus which can be treatable, and the typically some lab work, often thyroid testing, vitamin B12 levels, occasionally other lab testing if there’s a clinical suspicion because occasionally we’ll uncover somebody who has a vitamin B12 deficiency and that’s the cause of their memory dysfunction and that’s a very easily treatable cause. So you definitely want to investigate to ensure that your patient isn’t suffering from something which is highly treatable and reversible.
Melanie: So as long as you’ve mentioned treatment, and I know it depends on the diagnosis, but if this is something that is Alzheimer’s related, dementia related, is there anything that can stop or reverse the disease process? What would you do for someone and also give some behavioral strategies for providers that they can share with their patients and their loved ones that they can try at home to optimize functioning?
Dr. Llano: Yeah those are great questions. In terms of medications to reverse the illness, right now we don’t have medication that can get into the brain and fix the underlying problems that occur in Alzheimer’s disease. There’s lots of drugs being developed but nothing yet that’s been approved. The types of medications that we have are designed to deal with the symptoms of the disease and there’s two categories of drugs. There’s the cholinesterase inhibitors. These are drugs that boost the acetylcholine levels in the brain and then there is memantine, which is the only drug in its class, and this drug has a more, we’ll just say mysterious mechanism. We’re not entirely sure how it works. Part of how it works it provide a blockade of what are known as NMDA receptors in the brain and both of these classes of medications offer modest benefits when it comes to memory decline and both of these classes of medications are very well tolerated and they can be combined, so typically eventually most patients will end up on both cholinesterase inhibitor plus memantine because we know that combination works better than either drug by itself. The other important component for the treatment of memory loss is exercise both physical and cognitive exercise. There’s a lot of data available now indicating that physical exercise can have very substantial benefits when it comes to memory loss. That’s in addition to the benefits that it has for someone’s general overall medical state, but physical exercise at this point is a standard part of what I recommend to my patient’s. And then cognitive exercise, there’s less data supporting it, but as far as we can tell certainly there’s no harm from it and there’s lots of things that patients can engage in that we think can potentially help their memory dysfunction. Now you asked about behavioral strategies, one thing to keep in mind, patients with memory related disorders like Alzheimer’s disease typically don’t appreciate the severity of their symptoms, number one, and number two later in the illness, they can have changes in behavior that can be pretty disturbing. They can have delusions for example. They can believe things that are not true. They can believe that people are out to hurt them or to steal from them or that their spouse is not being faithful to them, and as you can imagine these can be extremely distressing to the family when these delusions come up and is often extremely tempting to try to correct a patient out of a delusion and try to explain to them you know what’s really going on, and typically this ends up being a pretty futile process and often can make things worse. The patients can get pretty frustrated and upset at their loved ones during these situations. So I advise the patients to use what’s called a no fail strategy, which is to not necessarily confront the delusion but try to distract when it’s possible. Find some other topic of conversation and not necessarily try to engage to reverse the delusion because, as we know, these are almost impossible to reverse.
Melanie: Dr. Llano wrap it up for us. What great information. Tell other physicians what you’d like them to know about memory loss, what you want them to know as providers so that they can counsel their patients and their loved ones, possibly protect themselves from developing it, or at least to recognize the signs and symptoms that would get them the help that they need.
Dr. Llano: Yeah I think the most important thing is to try to get to as specific of a diagnosis as you can because each diagnosis is going to have a whole series of implications in terms of prognosis, how things are going to look down the line, and in terms of trying to activate treatment relatively early. Now even though we don’t have medications that can reverse the illness, when you do make an early diagnosis that can often make you much more aware of comorbidities that can come along with Alzheimer’s disease such as depression or malnutrition and being a little bit ahead of the game and having a diagnosis is going to allow you to intervene at an earlier stage of these other comorbidities and hopefully provide a better outcome for your patient. So I think having a high index of suspicion, paying attention to the loved ones when they complain to you about the patient’s memory loss, and having a low threshold to send the patient for neuropsychological testing because that really is the first step in understanding A) is this really a memory problem which is worse than normal aging? B) What’s the nature of the memory problem? What’s the most likely diagnosis? Does this patient need a neurologist, etc.? So that’s really where I think the emphasis should lie is having that high index of suspicion and feeling comfortable ordering neuropsychological testing.
Dr. Llano: Thank you so much Dr. Llano for being with us today. Really great information for providers to hear. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks for listening.
Melanie Cole (Host): Expert insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episode’s posttest.
Certain brain changes may be inevitable when it comes to aging. Major memory problems are not one of them. That’s why it’s important for providers to know the difference between normal age related forgetfulness and the symptoms that may indicate a developing cognitive problem. My guest today is Dr. Daniel Llano. He’s a neurologist with the Carle Foundation Hospital. Dr. Llano, explain a little bit about memory loss as it relates to aging and is it a normal part of aging? Is it something that inevitable?
Dr. Daniel Llano (Guest): Yeah so it is normal to have a small degree of memory loss with aging. It actually begins younger than you might think. In our 40s and 50s we begin to have measurable changes in our ability to juggle multiple items in our head at one time for example and it tends to gradually get worse over time, but usually it doesn’t impair people’s day to day functions. If your patients are complaining to you that they’re unable to manage their daily affairs. For example they can’t manage their medications or they have a hard time with driving or having a hard time with their bills. That would be a suggestion that what your patient is suffering from is worse than normal aging associated cognitive impairments and may only have a diagnosis of a bonified memory disorder.
Melanie: Are there some disease processes and you mentioned medications as well, that can cause or accelerate memory issues or cognitive issues? What are some common conditions and factors that can lead to this type of loss?
Dr. Llano: Well the most common things that we see are mild cognitive impairment and Alzheimer’s disease and there’s a spectrum. With mild cognitive impairment, these are individuals who have memory loss which is worse than normal aging and that is found using objective measures typically done by a neuropsychologist, but patients with mild cognitive impairment don’t yet have functional impairment, meaning they’re still able to manage their day to day affairs but their memory difficulties are noticeable to them and their family typically. If the memory difficulties progress to the point that people have a functional impairment, at that point they’ve crossed a threshold into dementia. By definition dementia implies that there has been some cognitive loss that effects functional day to day activities and the most common kind of dementia is Alzheimer’s disease, and so mild cognitive impairment is often thought of as a prodromal state to Alzheimer’s disease. We know there’s a pretty significant risk, about 10% to 15% per year of individuals who have mild cognitive impairment who eventually develop Alzheimer’s disease. There is a family of other disorders that can cause memory difficulties so as a physician you don’t want to only focus on mild cognitive impairment and Alzheimer’s. Of course there are vascular cognitive changes that are quite common as people age that can cause memory impairment, other forms of dementia such as Lewy body dementia, frontotemporal dementia can sometimes manifest as a memory change so that often has some personality changes as well, and then certain disorders that are actually quite treatable like normal pressure hydrocephalus, which is not common, but you should be on the lookout for this because if you select your patients properly, patients could pretty well with a surgical intervention. So there really are a number of different disorders that can lead to an initial memory complaint.
Melanie: Speak about the clinical presentation, and for providers, what red flags should they be hearing from family members or the patient themselves as far as things that would warrant the history and to start the diagnostic process?
Dr. Llano: Sure so typically if it’s going to be an Alzheimer’s related process or an amnestic mild cognitive impairment, so a memory driven mild cognitive impairment, typically what patient’s families will complain of is the patient will repeat things. They’ll make a statement and 20 minutes later they’ll make the same statement or they’ll ask the same question multiple times and that’s simply because they don’t remember the first time they made that statement or the first response to a question. Often patients will have difficulty with visual special orientation so they might get lost easily with driving. That’s a pretty common problem and you have to be paying attention for that, and often this will be getting lost in familiar territory. Probably one of the most important things you should know is that the patients themselves almost always doesn’t have a real appreciation for the memory difficulty. So if you have a patient in your office and they’re by themselves and they say they’re doing great and there’s no memory issues at all, that’s typically not a very reliable source. So you definitely want to probe the family members, typically the spouse or the adult children because they’re usually the first ones who will notice any symptoms at all.
Melanie: So speak for us about diagnosis and why is it important to know what is underlying the memory loss the person is showing?
Dr. Llano: Sure, the key diagnostic test that we use to sort out whether it’s for example normal aging related cognitive impairment versus mild cognitive impairment that could lead to Alzheimer’s or to Lewy body disease or vascular dementia, the key test is what’s called formal neuropsychological testing. And what that consists of is meetings with a neuropsychologist and the neuropsychologist and their technician will spend about three or four hours assessing a patient’s memory, often testing multiple domains, multiple different ways to get a highly reliable result and then compare those results with typically age and education adjusted norms. So that’s people’s performance is compared to other people’s performances in the same age group and the same educational category and that will typically be a very good indicator as to what the underlying etiology is because each of these disorders has their own pattern in terms of strengths and weaknesses that the patient will display. There are other tests that we will order as well. Typically we’ll get a brain imaging study, like an MRI of the brain. That’s usually done primarily to rule out other structural illnesses. Often we do these studies and we’re surprised to find that there’s a lot more vascular diseases than we may have appreciated or there might be something like hydrocephalus which can be treatable, and the typically some lab work, often thyroid testing, vitamin B12 levels, occasionally other lab testing if there’s a clinical suspicion because occasionally we’ll uncover somebody who has a vitamin B12 deficiency and that’s the cause of their memory dysfunction and that’s a very easily treatable cause. So you definitely want to investigate to ensure that your patient isn’t suffering from something which is highly treatable and reversible.
Melanie: So as long as you’ve mentioned treatment, and I know it depends on the diagnosis, but if this is something that is Alzheimer’s related, dementia related, is there anything that can stop or reverse the disease process? What would you do for someone and also give some behavioral strategies for providers that they can share with their patients and their loved ones that they can try at home to optimize functioning?
Dr. Llano: Yeah those are great questions. In terms of medications to reverse the illness, right now we don’t have medication that can get into the brain and fix the underlying problems that occur in Alzheimer’s disease. There’s lots of drugs being developed but nothing yet that’s been approved. The types of medications that we have are designed to deal with the symptoms of the disease and there’s two categories of drugs. There’s the cholinesterase inhibitors. These are drugs that boost the acetylcholine levels in the brain and then there is memantine, which is the only drug in its class, and this drug has a more, we’ll just say mysterious mechanism. We’re not entirely sure how it works. Part of how it works it provide a blockade of what are known as NMDA receptors in the brain and both of these classes of medications offer modest benefits when it comes to memory decline and both of these classes of medications are very well tolerated and they can be combined, so typically eventually most patients will end up on both cholinesterase inhibitor plus memantine because we know that combination works better than either drug by itself. The other important component for the treatment of memory loss is exercise both physical and cognitive exercise. There’s a lot of data available now indicating that physical exercise can have very substantial benefits when it comes to memory loss. That’s in addition to the benefits that it has for someone’s general overall medical state, but physical exercise at this point is a standard part of what I recommend to my patient’s. And then cognitive exercise, there’s less data supporting it, but as far as we can tell certainly there’s no harm from it and there’s lots of things that patients can engage in that we think can potentially help their memory dysfunction. Now you asked about behavioral strategies, one thing to keep in mind, patients with memory related disorders like Alzheimer’s disease typically don’t appreciate the severity of their symptoms, number one, and number two later in the illness, they can have changes in behavior that can be pretty disturbing. They can have delusions for example. They can believe things that are not true. They can believe that people are out to hurt them or to steal from them or that their spouse is not being faithful to them, and as you can imagine these can be extremely distressing to the family when these delusions come up and is often extremely tempting to try to correct a patient out of a delusion and try to explain to them you know what’s really going on, and typically this ends up being a pretty futile process and often can make things worse. The patients can get pretty frustrated and upset at their loved ones during these situations. So I advise the patients to use what’s called a no fail strategy, which is to not necessarily confront the delusion but try to distract when it’s possible. Find some other topic of conversation and not necessarily try to engage to reverse the delusion because, as we know, these are almost impossible to reverse.
Melanie: Dr. Llano wrap it up for us. What great information. Tell other physicians what you’d like them to know about memory loss, what you want them to know as providers so that they can counsel their patients and their loved ones, possibly protect themselves from developing it, or at least to recognize the signs and symptoms that would get them the help that they need.
Dr. Llano: Yeah I think the most important thing is to try to get to as specific of a diagnosis as you can because each diagnosis is going to have a whole series of implications in terms of prognosis, how things are going to look down the line, and in terms of trying to activate treatment relatively early. Now even though we don’t have medications that can reverse the illness, when you do make an early diagnosis that can often make you much more aware of comorbidities that can come along with Alzheimer’s disease such as depression or malnutrition and being a little bit ahead of the game and having a diagnosis is going to allow you to intervene at an earlier stage of these other comorbidities and hopefully provide a better outcome for your patient. So I think having a high index of suspicion, paying attention to the loved ones when they complain to you about the patient’s memory loss, and having a low threshold to send the patient for neuropsychological testing because that really is the first step in understanding A) is this really a memory problem which is worse than normal aging? B) What’s the nature of the memory problem? What’s the most likely diagnosis? Does this patient need a neurologist, etc.? So that’s really where I think the emphasis should lie is having that high index of suspicion and feeling comfortable ordering neuropsychological testing.
Dr. Llano: Thank you so much Dr. Llano for being with us today. Really great information for providers to hear. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks for listening.