4/22/08

Memory loss: Training can prolong independence - MayoClinic.com

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Memory loss causes anxiety — which makes recall even harder. Here's a simple, inexpensive way to counter the problem by putting your "habit memory" to work. Memory loss is a fact of life for people with Alzheimer's disease. It's also quite common in people who've had traumatic brain injuries. Some of the memory training techniques used with brain-injured people are also proving helpful to people with mild cognitive impairment (MCI) — a disorder that often precedes Alzheimer's disease. Sherrie Hanna is the program coordinator of an ongoing study at Mayo Clinic in Rochester, Minn., to examine potential benefits of memory training for people who have MCI. In this interview, Hanna discusses the study's premise and its preliminary findings. What types of memory training techniques are you studying? 

We're using monthly pocket calendars, small enough to fit in a man's pocket or a woman's purse.

Each day on the calendar is divided into scheduled events, things to be done today but at no particular time, and then notes on anything — like the weather forecast or the fact that grapes are on sale at the supermarket. This type of memory training system has been successful with people who have had memory loss from brain injuries.

We're testing it with people who have mild cognitive impairment. While the physical causes of their memory problems are different, the practical outcome is the same. And the system seems to work for both. 

What's the difference between mild cognitive impairment and Alzheimer's? 

Mild cognitive impairment is a transition stage between the cognitive changes of normal aging and the more serious problems caused by Alzheimer's disease. It often includes the memory loss problems common to Alzheimer's, but doesn't meet the qualifications for full-blown dementia. While many people who have mild cognitive impairment go on to develop Alzheimer's, others don't. So a diagnosis of mild cognitive impairment doesn't necessarily mean you will certainly develop Alzheimer's. Because the cognitive problems are less severe in MCI, there is greater opportunity to use nonmemory skills to compensate for memory problems. 

How do people with memory problems remember to use the calendar? 

We work with them for six weeks, so that it becomes a habit. It's kind of like driving a stick shift or typing on a computer keyboard. You don't think about all the motions involved in the process. You don't say to yourself, "OK, now I'm going to depress the clutch with my left foot and move the shifter with my right hand." You just do it. One of our participants compared it to golfing. He doesn't think about how to position his head or his hips. He just does it. In addition to writing things in the calendar, we also ask our participants to look at their calendars at least twice a day. Three times is even better. At breakfast, they can look over what they're supposed to do that day. They need to check the day before, too, to see if there are any unfinished tasks that need to be carried forward. We also tell them to check things off right when they do it. So even if they don't remember doing something — if it's checked off, they must have done it. 

Does just writing things down help people remember? 

Writing it down helps it stick in your memory. Saying it out loud as you're writing it down also can help cement it in your memory. I tell people to use all their senses to help jog their memory. I had a big test to study for recently, and I said things out loud and had color-coded reminder notes. I even drew pictures. The good thing about this calendar is that it can encompass whatever works for you. This sounds helpful even for people who don't have memory loss problems. This can benefit all sorts of people. I personally never kept a calendar until this. I got a planner and followed right along with the study participants. 

Lots of people need something like this. 

For example, they'll get a phone call and then jot a phone number on the newspaper and then throw the paper away. 

One of our participants came in with a big stack of Post-it notes and scraps of paper, all bound together with a rubber band. We've just translated that into one system, so people can find what they need easily when they need it.

Is it working for the people in your study? 

Almost every person in the study has said that it has helped them. That has been very satisfying. Some people are still at it after more than a year. That's really something, to have people change the way they do things and have it stick. Every person who participates in this study is accompanied by a support person, usually a spouse or child. And these support people often say, "It's so nice not to have to answer the same question over and over." 

Are there other benefits? 

It helps make our participants feel a little bit more independent — that they don't have to rely on other people to remember things for them. This system also gives them a way of feeling they are doing something pro-active. Many people feel the control slipping out of their fingers. By giving them back some personal responsibility and control, it's really making a difference in that individual. It's hitting both needs at the same time. 

How long does this technique hold off the types of memory lapses that lead to loss of independence?

We don't know yet. In my mind, it's a "use it or lose it" scenario. You need to keep your brain engaged in attending to these things, or they're gone. 

This is basically a holding maneuver.

Some people may think they don't need it now, that they're functioning OK.

But it's like muscle memory. If they get it to become a habit, it will help them be prepared for that day when they really do need it.

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"A Stable Life, Despite Persistent Dizziness" - New York Times

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A Stable Life, Despite Persistent Dizziness

On the subway, children twirl themselves around the poles in the cars until they are so dizzy I'm ready to catch them. The young seem to delight in making the world spin out of control for a few moments, causing them to flop about like drunks. But when dizziness, vertigo or loss of balance is neither self-imposed nor short lived, it is anything but fun. It can throw one's whole life out of kilter, literally and figuratively.

This is what befell Cheryl Schiltz in 1997, when long treatment with the antibiotic gentamicin permanently damaged the vestibular apparatus in her inner ear. For three years, said Ms. Schiltz, of Madison, Wis., her world seemed to be made of Jell-O. Lacking a sense of balance, she wobbled with every step, and everything she looked at jiggled and tilted. Unable to work, Ms. Schiltz became increasingly isolated and struggled to perform the simplest household tasks.

Lisa Haven, executive director of the Vestibular Disorders Association, reports that "the risk of falling is two to three times greater in people with chronic imbalance or dizziness." Nearly 9 percent of Americans 65 and older have balance problems, the prevalence of which is likely to increase as the 78 million baby boomers age. Four Types of Dizziness The job of the vestibular system is to integrate sensory stimuli and movement for the brain and keep objects in visual focus as the body moves. When the head moves, signals are sent to the inner ear, an organ consisting of three semicircular canals surrounded by fluid. It in turn sends movement information to the vestibular nerve, which carries it to the brainstem and cerebellum, which control balance and posture and coordinate movement. Disruption of any part of the system can result in dizziness.

These are four types of dizziness, all of which are more common with increasing age:

¶Faintness, the feeling of being about to black out when upright. This can result from dehydration, abnormal heart rhythms, overmedication with blood pressure drugs and disorders of the autonomic nervous system.

¶Loss of balance, feeling unsteady and about to fall even though muscle strength is normal. This can be caused by disorders of the inner ear; the cerebellum because of stroke or chronic alcoholism; or the basal ganglia, because of Parkinson's disease, for example. It can also result from overmedication with drugs like sedatives and anticonvulsants, vision disturbances and neuropathy or spinal cord disease that causes a loss of position sense in the legs.

¶Vertigo, a false sense that the person or the surroundings are moving or spinning. This can result from motion sickness, Ménière's disease, middle-ear infections, migraines, multiple sclerosis, damage to the vestibular nerve and reduced blood flow to the brain after a stroke or transient ischemic attack. In the most common form, benign paroxysmal positional vertigo, sudden head movements cause a sensation of motion.

¶Vague lightheadedness, a feeling of giddiness or detachment from the world that can be caused by a panic attack, depression, anxiety disorders or hyperventilation. What to Tell the Doctor About 40 percent of people experience at least one of these forms of dizziness at some time during their lives. When dizziness persists, medical care is essential, and so is the ability to provide a detailed description of the symptoms and what provokes them. What does the dizziness feel like — faintness, loss of balance, lightheadedness, a sensation that you or your surroundings are spinning or moving? When did the symptoms begin? How long do they last? What provokes or relieves them? What other symptoms like headache, ringing in the ears, impaired vision, difficulty walking, weakness or hearing loss accompany the dizziness? Diagnostic tests may include trying to reproduce the symptoms. For example, by rapidly standing and sitting, standing after lying down or lying on a tilt table while changes in blood pressure are measured. The doctor may test heart function with an electrocardiogram or an echocardiogram, an exercise stress test or a Holter monitor to detect abnormal rhythms. Vision tests may be performed, along with tests to evaluate balance and gait and C.T. or M.R.I. scans of the head, including noninvasive tests that check for narrowed or blocked arteries to the brain. If no physical explanation for dizziness is found, the patient may be checked for psychological disorders like depression, panic attacks or dissociation from the world. Treatment will depend on the cause of the dizziness. For example, for benign paroxysmal positional vertigo, a simple head-turning maneuver that repositions crystals in the inner ear may bring lasting relief. If ministrokes are the cause, the treatment may involve anticlotting drugs or opening a blocked artery with a stent. If medication is the problem, adjusting the dose or changing the drug can relieve dizziness. If dizziness persists despite treatment, lifestyle adjustments can help like avoiding sudden movements, keeping often-used items within easy reach, standing up slowly and clenching hands and flexing feet before standing. Physical therapy can help, as can exercises that strengthen muscles and that combine eye, head and body movements.

Ms. Schiltz, whose vestibular system was damaged a decade ago, said she was told that nothing could be done about it. Nothing, that is, until she became the first patient to be treated with a device called a BrainPort invented by the late Dr. Paul Bach-y-Rita, a neurobiologist and rehabilitation medicine specialist, and his colleagues at the University of Wisconsin.

The device takes advantage of the acute sensitivity of the tongue and sends balance signals directly to the brain from the tongue, bypassing the ear's vestibular apparatus. At first, she used it a few minutes at a time, but soon found longer use kept her in balance for hours, then days, then weeks and months. Eventually, all that was needed was 20 minutes twice a day to train her brain, and she now uses it just occasionally. She is among more than 100 study participants who have used the BrainPort, including patients with multiple sclerosis, Parkinson's disease and stroke. The device is available commercially in Canada and is awaiting approval by the Food and Drug Administration in the United States.

Dr. Norman Doidge of the research faculty at the Columbia University Psychoanalytic Center and the University of Toronto describes Ms. Schiltz's dramatic recovery in his new book about the plasticity of the brain, "The Brain That Changes Itself." (Her case was also described in Science Times in November 2004.) With her sense of balance intact, Ms. Schiltz was able to return to school and on Dec. 20 received a degree in rehabilitation psychology.

"I feel like a restored, even enhanced, person," she said in an interview. "I'm living proof that the brain can be retrained. My goal now is to help people with acquired disabilities gain increased independence."

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4/21/08

The emergence of progressive multifocal leukoencephalopathy (PML) in rheumatic diseases.

Boren, EJ; Cheema, GS; Naguwa, SM; Ansari, AA; Gershwin, ME


University of California at Davis School of Medicine, Department of Internal Medicine, Division of Rheumatology, Allergy, and Clinical Immunology, 451 Health Sciences Drive, Suite 6510, Davis, CA 95616, USA.

Progressive multifocal leukoencephalopathy (PML) is a rare and devastating neurological disease with areas of demyelination in the central nervous system classically associated with profound immunosuppression. PML is caused by reactivation of latent JC virus, leading to the death of myelin-producing oligodendrocytes typically with a rapidly fatal outcome. Once seen primarily in severely immunosuppressed states including lymphoma, solid organ malignancies, and organ transplant recipients, PML became an AIDS-defining illness in the 1980s. PML has now emerged as a catastrophic illness in multiple sclerosis with biologic drug therapy (natalizumab) and reported in rheumatic diseases with and without biologic therapeutic agents. With current and future treatments that suppress and manipulate the immune system, there is risk for severe acute infections and reactivation of latent infections, such as JC virus reactivation leading to PML. It is critical, therefore, to proceed cautiously when immune system modification strategies are being evaluated for fear of unleashing undesirable or even fatal diseases. Fortunately this complication remains a rare event.

PMID: 18191544 [PubMed - in process]

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