Alzheimer's

A neural workout

Last week I wrote about some of the emotional benefits of regular moderate exercise. This week, several timely new articles have come out touting the cognitive advantages of even minimal daily activity. Numerous studies have shown evidence of the neurological benefits of exercise, which can foster cell growth and new cell generation (known as neurogenesis). One region that seems to be particularly impacted is the hippocampus, an area known to be involved in memory consolidation. Prior studies in mice have shown that exercise can trigger neurogenesis in the hippocampus, and in humans exercise has been linked to better performance on memory assessments and spatial learning, as well as a decreased risk for dementia. While some of these benefits are believed to be due to the new proliferation of cells in the hippocampus and other associated regions of the brain, several studies published recently suggest that exercise may serve more as a protective factor against neurological decay than boosting existing memory performance.

study presented last week at the Alzheimer's Association International Conference by doctors at the University of California, San Francisco used mathematical modeling to estimate risk factors for the development of Alzheimer's disease, and came up with seven critical variables: diabetes, hypertension, obesity, smoking, depression, cognitive inactivity, low education, and physical inactivity. Researchers predicted that these seven variables were to blame in nearly 50% of the current cases of Alzheimer's present today, and lack of exercise alone was attributed to over 20% of cases. In addition, researchers predicted that reducing these risk factors could potentially stave off over one million future cases. However, these numbers are theoretical and first author Dr. Deborah Barnes, as well as other lead researchers in the field, are careful to caution against using these numbers as hard goals and guidelines. Barnes notes that while these seven factors do increase the risk for Alzheimer's, a causal relationship has not yet definitively been established, and therefore simply changing one's behavior in regards to one or all of the variables may not be enough to prevent onset of the disease.

While the association between Alzheimer's and exercise is still tentative, there is certainly little doubt about the mental and physical benefits of daily activity. However, previous studies have largely focused on moderate to high levels of exercise in humans and animals, such as the widely recommended guidelines of 30 minutes of exertion 5 days a week. But what about those who cannot get out that much or that often? Fortunately there is new evidence that the cognitive benefits of daily activity can come from even minimal movement, akin to the normal amounts of daily exertion put forth via walking, household chores, and even fidgeting. In a longitudinal study investigating elderly adults aged 70 and up, those with the least amount of daily average energy expenditure had the greatest amounts of cognitive decline over a period of three years, whereas those who were most active had significantly less cognitive impairment both over the three year study period, as well as after a five-year follow-up. It seems that even small efforts such as walking around the block or even moving around the house, which often go unreported in other studies of physical activity, can help stave off the neural deterioration that commonly occurs as we progress into old age.

However, if you still can't be bothered to get up and start moving, you can always resort to surgical implants and get one of these to improve your memory.

When is euthanasia an ethical option?

Dr. Jack Kevorkian, the infamous suicide doctor from the 1990s, passed away last week at the age of 83. While his methods and criteria were at times questionable, seeking out publicity and media attention for his credo and often working out of his old beat-up Volkswagen van, he did crucially bring the topic of euthanasia to national attention. The debate about the ethics and humaneness of this procedure will continue to grow ever more important as the health of the baby boomer generation begins to deteriorate, and unfortunately must be discussed as a viable option in the course of treatment. Largely instigated by Dr. Kevorkian's efforts, the Oregon Death with Dignity Act was passed in 1997, long before health care reform and the so-called "death lists" dispute. Thus far, the Act has assisted 525 individuals with ending their own lives, and similar laws have been passed and upheld in Washington state and Montana. There are stringent criteria in the laws determining who is eligible, and in Oregon this includes whether the patient suffers from a mental illness or not. On the surface this seems like a necessary, sensible and humane criteria for the law. However, upon closer inspection it raises problems with feasibility, for who suffering from a terminal illness wanting to end there lives is not depressed? The Beck Depression Inventory (BDI) is a widely used and respected neuropsychological questionnaire used to assess depressive symptoms. While it is by no means as comprehensive as the DSM-IV diagnostics, it does provide a relatively sufficient snapshot of an individual's current mood and state of mind. Going by these questions though, it seems doubtful whether anyone in a position to take advantage of Oregon's Act would qualify. The BDI asks questions about recent weight loss, insomnia, sexual interest, thoughts of suicide, and general mood and interest in life. Surely someone who is terminally ill and considering ending their lives would not be as interested in sex, food and the day-to-day goings on around them. Assisted suicide is not merely another option for those who are contemplating it, it is a last resort.

Along these same lines, another contentious patient group to consider in this debate are those diagnosed with Alzheimer's disease or dementia. Anyone who has a family member suffering from these disorders knows how debilitating, humiliating and de-humanizing they are. It is difficult to imagine that individuals in the late stages of Alzheimer's take much satisfaction or joy from their lives, and represented both anecdotally and artistically there are numerous cases of patients ending their lives while they still maintain some semblance of control over them. However, these patients are also widely deemed ineligible to provide informed consent for medical procedures, and are thereby explicitly excluded from the above laws. This creates another problem in which those individuals who may be most likely to elect for this assistance are not eligible to obtain it.

I realize that this is an incredibly sensitive and controversial topic, however it does need to be discussed as both the future of our medical system and the health of our parents and grandparents deteriorates. No one wants to think that they will need to consider this decision for themselves or their family members, yet this issue must be addressed as the demand for health care increases and the supply dwindles.

Apart from the logistical question of treatment availability, the much larger issue at stake here is the humaneness and ethics of this approach. Every patient suffering from a debilitating terminal illness should have the right to determine their own course of treatment, including end of care plans. Do not resuscitate or DNR orders are commonplace in hospitals and hospice care, yet the active rather than passive implications of these orders are much more difficult to instigate and carry out. And when the patient no longer has full mental or emotional capacity this decision becomes all the more tenuous and ethically and emotionally demanding. Yet watching a loved one's mind and body deteriorate is torturous for all parties involved. Explicit end of life plans should be detailed by every individual as they age and discussed with family members in the case of an emergency.

Currently Belgium, Colombia, Luxembourg, The Netherlands and Switzerland all allow physician assisted suicide in some form, and there is a growing underground tourism industry to these countries for this specific reason. Perhaps as the demand for this type of treatment increases policies adequately addressing it will follow.

(Thanks to Steve Smith for the idea for this post.)

Pathologizing the norm

Going in to any introductory psychology course, students are warned that the basic education they are gaining does not make them experts in the field. They are cautioned against diagnosing friends and family members with their scant knowledge and are reminded that there are many nuances of both personality and personality disorders that they are far from privy to. A stirring op-ed piece in the New York Times recently highlighted the perils of the common citizen diagnosing themselves and their loved ones with Alzheimer’s disease or dementia. However, more and more it seems that clinicians and researchers in the field of psychology and psychiatry are at risk of making this same mistake by pathologizing natural neuropsychological slips and common cognitive errors. Neuropsychological assessments involve a series of challenging, and at times painstaking, tests of memory, decision-making and cognitive flexibility, among other executive functions. Standardized ranges are provided for these scores from the wider population, much as for an IQ test. These assessments are particularly useful in neurological patient populations (such as victims of a stroke or a brain tumor) and the elderly to assess cognitive decline, just as the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) and MMPI (Minnesota Multiphasic Personality Inventory) are helpful in a therapist or clinician’s office. However, these tests, as well as “significant” real-life examples are now being used as evidence of disorder in normal individuals.

Nowadays, misplacing your car keys can be seen as a precursor to dementia, and blanking on an old acquaintance’s name is indicative of Alzheimer’s. Likewise, niche expertise is an example of savantism and social awkwardness a sign of long undiagnosed Asperger’s syndrome, which is just a short step away from autism on the spectrum.

But this is what we have to remember and what is getting lost in this dichotomous system of diagnoses: all of these disorders or impairments lie on a spectrum. And the ultimate litmus test for a disorder is not how poor one’s verbal recall is, but instead how much distress this impairment causes. The world of psychiatric and neuropsychological diagnoses is far from clear-cut and these classifications must be based on more than just behavior. The perception and attitude of the patient must be taken into account, including whether this person even considers themselves to be a patient in the first place.

Similarly, over the past twenty years the diagnosis of ADD/ADHD (attention deficit / attention deficit hyperactivity disorder) has risen dramatically, as has the subsequent backlash against over-diagnosing and over-medicating society’s children. Before running to the doctor's office or the prescription pad, it is important to remember that kids are squirmy, and that no one, college students and professors alike, can maintain disciplined attention during a tedious lecture.

Everyone experiences memory loss as they age, just as we all feel sadness over the course of our natural cycle of emotions. Unhappiness is a universal human feeling that everyone must go through from time to time, and is not indicative of the pervasive demoralizing morose of true depression. Emotion, attention and memory are all fluctuating human traits and must be remembered as just that, natural and transient. Our culture is so eager for a quick fix, to get rid of any feelings of discomfort and receive instant release. But sometimes it is important to experience these sentiments, to sit and work through our problems and wrestle with our shortcomings. This is in no way meant to minimize the tribulations that accompany these very real disorders, but to serve as a reminder that all of us are flawed, mentally, physically and emotionally, and if we pathologize these feelings, these struggles, then we may  miss out on the robustness of life.