Q:

My father suffered a very small stroke some years ago. His mother had Alzheimer’s and his father had several CVAs. He has been through neurology and was told it was vascular. He is having more difficulties with new learning and orientation, and gets much more anxious. He is aware that there is something wrong we don’t know where to go for further help

A:

We know that a single stroke can cause memory deficits but the more usual cause of memory loss due to stroke is multiple strokes. A previous history of stroke can be a ‘red herring’ and indeed other causes of memory loss can co-exist. The history of the events and time line are very important. MRI scanning of the brain in this situation can be very helpful. I think in this situation detailed evaluation of the memory function would be important and that this should then be monitored to see if the memory function is stable or declining. It sounds to me that you are witnessing a gradual decline in memory function and this would not be my expectation in a patient who had a small stroke a number of years ago unless there was evidence on the MRI scan of brain of significant vascular abnormalities.

Q:

Good morning, I support a gentleman who has for information purposes Down Syndrome, is 65 years old, and now assessed as having some form of Dementia, (April 2010) his speech appears to be affected his STM is very poor however his LTM seems fair, his concentration levels have diminished, he is incontinent (doubly), balance is also affected, he has lost the ability to do anything without first being given instructions, he is reluctant to walk, and will not attempt to use the stairs, he has become anxious, verbally aggressive, he shouts out when you try and help him, he has not yet been prescribed any medication as we are waiting the results of tests, ie full bloods, ECG and Chest x-ray to rule out any other infections that may or could be present. My question is I understand that there may be a patch for Alzheimer’s/Dementia, is this correct, and are these medications licensed for people with a handicap? And what is the preferred medication for people who may or have dementia, is it Aricept?

A:

Thank you for your questions. There is unfortunately a link between Down’s syndrome and the development of Alzheimer’s disease. This is not fully understood but we know that people who have Down’s syndrome can develop the plaques and tangles in the brain that are found in Alzheimer’s disease. Your detailed knowledge of this person will be very helpful in highlighting the changes that have occurred in this person. One of the great difficulties especially in the early stages of Alzheimer’s is identifying the changes that have occurred. I note that tests are currently being conducted and that you are waiting for a formal diagnosis. My understanding of the treatments that are currently licensed for Alzheimer’s disease is just that. They are licensed for people who have been given a diagnosis of Alzheimer’s disease. If a person is deemed suitable for any treatment the potential benefits and risks have to be considered and this is a discussion to have with the local clinician. You are correct that there is a patch available for the treatment of Alzheimer’s disease. It is an Exelon patch and this contains the medicine Rivastigmine which is similar to Aricept (Donepezil). The most widely used licensed treatment for Alzheimer’s disease in the U.K. and probably globally is Aricept.

Q:

A very close friend, aged 69 and a widower is seriously diabetic and finds his memory failing. Can diabetes have an effect on the memory? He mis-spells words, makes mistakes in simple arithmetic, has to keep checking that he has locked the door, loses things frequently, leaves doors unlocked, has no idea of dates, days or even months. Would he be a candidate for treatment?

A:

Good diabetic control is very important for a wide range of health issues so this should be carefully evaluated. In addition it sounds as though memory testing is indicated and this should be discussed with the family doctor.

Q:

My father is 62 years old and has frontal lobe damage to the left side of his brain as a result of professional boxing. He is suffers memory loss, anxiety and violent moods swings. He is currently attending a psychiatrist but currently takes no medication. Is there any advice or recommendations you could offer?

A:

As far as I am aware there are no specific treatments for this particular condition. The symptoms you describe however can be closely evaluated. It is well recognised that head trauma can lead to these problems. You do not say how extensive the memory problems are or if they are having a significant impact on daily function. It is quite possible to have memory loss and yet function at a good level. The anxiety and mood swings are important symptoms that should be carefully evaluated. I think in this situation you would wish the memory function to be measured and monitored. There are also assessment scales that allow anxiety symptoms to be monitored. Depression must be considered in this situation. Anyone who has been a boxer has been used to being fit and active. There are now good antidepressant treatments available and the appropriateness of such a treatment would be worth discussing with your fathers’ doctor.

Q:

My 79 year old mother developed AMD very quickly last year and has now been registered blind, although she has very limited sight in one eye. She also has acute open angle glaucoma. At the same time that her eyesight deteriorated rapidly, her short term memory seemed to disappear overnight. She was recently assessed as 15/28 on the tests and Alzheimer’s was diagnosed, although the memory clinic said it was sometimes difficult to determine between loss of memory and loss of sight in assessing her. A recent brain CT scan from the hospital where she was taken after being hit by a car, and smashing the windscreen with her head, showed evidence of brain shrinkage. She has also suffered four other blows to her head when she has fallen due to her eyesight. She will soon start a course of Aricept. I have done some research on the internet and there seems to be strong evidence of a link between AMD and Alzheimer’s. Are there any other studies being undertaken at the present time with regard to this link? The doctor at the memory clinic was unaware of any link, and I wonder whether she will in fact get the correct treatment.

A:

This is an interesting issue that you raise. Age related Macular Degeneration is not in my experience a condition that I immediately associate with Alzheimer’s disease. In fact in my experience over the 20 years that I have been involved with assessing patients with Alzheimer’s disease it occurs infrequently in the Alzheimer population that I have seen. That is of course not to say that there is not an association and it is quite feasible, and certainly worthy of further investigation whether in some cases there is a link.  Please see a link below to a recent article highlighting the genetics of AMD http://www.dnaindia.com/health/report_additional-genes-linked-to-age-related-macular-degeneration-identified_1370978 Whilst it is commonly said that Alzheimer’s disease is not genetically inherited, our understanding of the condition continues to evolve. It is of increasing interest to test the genetic profile of an individual presenting with probable Alzheimer’s disease, the APOE4 gene being one in particular. We know in certain cases there is a strong family history of Alzheimer’s. You may already have had sight of the article below that links AMD and Alzheimer’s thought the APOE4 gene http://linkinghub.elsevier.com/retrieve/pii/S0002929707607411 I would encourage you therefore to continue to take an interest in this area. Your mother’s ophthalmologist may have some thoughts on this. Visual disturbance in Alzheimer’s disease is well documented and you may be familiar with the recently highlighted variant of Alzheimer’s disease PCA (Posterior Cortical Atrophy) suffered by author Terry Pratchett. Of course the presence of significant visual disturbance does make the diagnosis of Alzheimer’s disease more challenging, but I have seen patients, registered blind who are able to read the words and copy the various diagrams often presented in the course of memory testing used in the diagnostic process. The falls and blows to the head are of course very important in the history of this case. It would be very difficult to attribute the degree of cognitive impairment if any due to these episodes. I think offering a trial of treatment with donepezil seems very reasonable and I hope this is beneficial. I am not aware of current studies looking specifically at the link between AMD and Alzheimer’s.

Q:

My Mother is 85 was diagnosed with Ad 2003 from mini mental test scoring 23 twice. No other medical tests carried out. Prescribed exelon. Had B12 deficiency diagnosed 2008 now on monthly injections? Had recurrent urine infections & they wanted to put her in a home because of aggressiveness. 12 months later she is on permanent antibiotic and infections have stopped. She does remember who we are, she can do things herself but the system has nearly driven her to be an invalid. Only for me keeping on her case have I kept her out of a home. Following an ecoli infection last August I took her off Exelon and she improved no end. Got referred back to hospital and they agreed to keep her off it. After a fall & brain scan it appears the bits on the ends have died and the brain was described as extremely good for her age. I really don’t know where to turn for help but I have her at home and she is happy. She lacks lustre & gets very lethargic. Her history from 40 years back is one of sleepless nights, restless leg syndrome, temazepam & co-proximal for years which caused some convulsions. Her night sweats, leg cramps pins & needles all went with B12 injections. She sleeps like a log every night now she is off Exelon, doesn’t fiddle, wander or take things in & out of drawers. Can I do more for her like vitamins or Q10.

A:

he scenario you describe is possibly not that uncommon and highlights a number of issues. The Mini Mental State Examination is a test that is designed to give an indication of cognitive function. An MMSE score of 23 out of 30 is within the mild dementia range. You may wonder if this score was in fact due to the deficiency of Vitamin B12. Many elderly people have low Vitamin B12 levels and it is usually said that the level has to be very low for it to have an impact on memory function. However if the level is low then appropriate replacement therapy is usually given. The memory may not improve with the initiation of B12 therapy but other complications such as anaemia should be avoided. Recurrent urinary infection is common in elderly females and it is good that this problem now appears to have been dealt with. My understanding is that now your mother is on no memory enhancing medication. You wonder if vitamins may be beneficial. A good diet, exercise, fresh air, interacting with others are all important. The actual benefits of taking vitamin supplements (unless for a confirmed deficiency such as the B12 that your mother is taking) in this situation are not really known. It is important to remember that dementia is common in the over 80’s and monitoring the memory function even though no treatment is being prescribed may be worthwhile.