Dr. Barbara C. Fisher United Psychological Services Clinic Director 47818 Van Dyke Rd.

1. Dr. Barbara C. Fisher United Psychological Services Clinic Director 47818 Van Dyke Rd. Shelby Twp., MI 48317 586.323-3620 Brainevaluation.com

2. Who Ages Gracefully and Who Does Not? MALA 9th Annual Assisted Living Conference September 26, 2007

3. Seminar Objectives • Age of neuroscience and tools to age gracefully • What we can in our 40’s and 50’s to promote graceful aging • Different types of dementia • Early symptoms, markers of Dementia onset: psychiatric versus cognitive • Signs suggesting neuropsychological evaluation • Treatment options: Benefit of Brain training and day to day suggestions/interventions

4. The Age of Neuroscience • Connection of mind, body, spirit • Finding out how the brain works • How sleep affects the brain • How medication affects the brain • How we can prevent brain disease • The value of neuropsychological assessment

5. The Value of Neuropsychological Assessment • The use of paper and pencil tests to measure brain processes • Frontal: • Temporal or memory • Parietal, sensory or visuospatial • Scientific measurement of the working of the brain to see things before they appear on the radiological testings (such as the MRI, PET, CT Scan, or EEG) • The Neuropsychologist is the arm of the neurologist

6. Frontal Processes: The Supervisory System • Decision making • Inhibition system • Regulation of emotions The Communication Manager • Selective Attention The Director Of Operations • Output

7. The True Facts of Graceful Aging • Reading rate does not change during aging process • Memory does not decline until the late 80’s or 90’s in the normal aging process Everyone has the ability to age gracefully

8. Tools to Age Gracefully • Life Tasks: Physical and Mental • Physical: Diet, Nutrition, Toxic Substances, Sleep • Mental: • Develop a “you” • Control of anger and fear • Belief in a power greater than yourself • Extrinsic or Intrinsic Locus of Control • Happiness and coherence

9. Develop a “You” • Celebrate every day • Turn down the stress and anger • Dial down the tasks you set for the day • Turn up time for reflection on your life • Dial in on your priorities • Schedule your time based on your needs hierarchy • Obstacles are challenges not limitations

10. Control of Anger and FearEveryday Goals: • Keep peaceful thoughts, avoid anger of others • Remain focused and committed to your schedule • Know that over-thinking complicates life • Feel your feelings, Face your fears • The understanding that one unresolved fear unleashes more fears

11. Anger demands a lot of energy When we are stuck in being angry we become…. • Bitter • An irritable malcontent • A blight to the gathering of friends • A stone in someone’s shoe • Someone to be avoided

12. Four Steps to Discharge Anger 1. Disengage (anger diary, activities, exercise) 2. Identify your feelings (anger=sadness) 3. Make conscious decisions 4. Examine alternatives (options, big picture) 4. Re-frame the situation to re-engage Different Perspective (seek to understand)

13. Who do you turn to when you feel challenged? • Belief in a power greater than yourself • Knowledge that everything works out • Daily affirmation that you are loved and taken care of • TUA: Total Unconditional Acceptance of you and those around you • Knowledge that you are always cared for

14. Internal or External Locus of Control • When bad things happen: Who is in control? Life or You? • Any event has intrinsic or extrinsic control • Problems are opportunities for learning and change • Dependent personalities see life as happening to them: Lack of control increases anxiety • Intrinsic control is power, the ability to fix anything

15. What do we need to do? • Be peaceful • Honor your feelings • Accomplish your goals • Fix the problem, take action • Laugh at your mistakes • Congratulate yourself • Think highly of yourself

16. Cognitive dissonance • Anger escalates, calm dissipates • Being loving and anger are two opposing thoughts • Bring in loving thoughts and you cannot be angry • When you feel loving so does everyone around you

17. What We Can in our 40’s and 50’s to Promote Graceful Aging Keep yourself and your brain active People who Age Less Gracefully Impact of stress Identify problems early Watch your sleep Diagnose ADD

18. My Mother’s Aging Tips • Remain organized, Never give up • Exercise regularly • Join different groups, don’t not sit at home alone • Ride a bike, Go to movies and plays • Don’t believe anyone who says you are “too old” • Political and social groups are good • Read lots of different books, Keep up on all the electronics, know the news, world and local • Most important: Learn the computer and use it every day to communicate

19. People who Age Less Gracefully • People who are lonely: (Alzheimer’s Dementia increased by 50% with each point increase on loneliness scale)(AAN:7:4: 3-6-07) • Divorced men and women • Men and women without children • Negative thinking Individuals • Men who have lost a spouse • People who are continually stressed • People who lose their belief and will

20. Impact of Stress • Well known factor in cardiovascular disease • Contributes to insomnia • Increases anxiety and depression • Decreases attention and focus • Decreases energy

21. Identify Problems Early • Sundowner’s Syndrome: Cognitive or memory deficits may not appear until the sun goes down • AZ: Increased agitation, wandering, aggression, maladaptive behavior at the time of sunset • Do not assume that someone is fine if you only see them during the daytime hours • Little signs can become big issues (heavy breathing or snoring, loss of energy) • Cancellation of social engagements

22. Impact of Poor Sleep • Recognition of the interaction of age, sleep, and health • Less than 6 hours of sleep results in: Alterations in cytokines, increase in obesity, metabolic, immune and vascular markers • Decreased number of neurons in SCN seen more often with AZ

23. Rule Out Sleep Disorders • Sleep Apnea: NIH study-12 million people have OSA, heart function, sleep deprivation • Advanced Phase Sleep Syndrome • Aging process: Increased arousals, reduced sleep efficiency • Insomnia: Correlation between short sleep time and weight gain, increased illness • REM Sleep Behavior Disorder: Marker for neurological disease

24. Adult ADD/ADHD • ADD different from ADHD • Complication of cardiovascular • TBI, alcoholism, sleep apnea, • Psychiatric disturbance, • Additional long term neurological disorder • ADD: Undiagnosed in childhood, very bright, hands on, use of logic & strategy to compensate for deficits, new arena in college, anxiety & depression • ADHD: Identified in childhood due to additional brain issue or high degree of anxiety

25. Adult ADD and being Male • In the home: • Being a dad and a husband • Lack of time • Overwhelmed by tasks that need completion • At the work setting: • The paperwork • Mis-communication on detailed information • Deadlines • Time management

26. Being ADD and female means…. • Increased distractibility due to multiple roles • Developed obsessive compulsive traits and perfectionism as tools to combat feeling overwhelmed and out of control • Working too hard to perform within average limits • Being passed over in the work setting • Lack of knowledge of social tools • Low self-esteem and anxiety (major issues reported on 15 year study)

27. Primary Types of Dementia • Mild Cognitive Decline • Alzheimer’s • Cardiovascular • Lewy Body • Frontotemporal Dementias • Brain Injury, Epilepsy, Frontal lobe disorder

28. Mild Cognitive Decline/Dementia • Pre-cursor of another form of dementia, more often Alzheimer’s Dementia • Detected early: MRI, PET studies, SORL1 gene, CSF • Increased risk with: Age, Obesity, Dietary fat, Diabetes, TBI • Elevated homocysteine, depleted B12, APOE-4 • Sleep fragmentation, decreased REM • Individuals married longer who lose their spouse • 8% increased risk for each additional child, risk lowers if live in suburbs • Emotional Trauma: Early life sustained stress, mother infant interaction changes regulation of HPA axis

29. Alzheimer’s Dementia • Doubles every 5 years over the age of 65 years • Age 60 the incidence rate is 1%, rises to over 40% by age 85 • Stress, PTSD (cortisol) Diabetes (I, II) Insulin (IR) • Reduced volume of hippocampus= Memory↓ • Genetic, family history, ↑ Risk with APOE-4 allele marker • 70% of those diagnosed for 2 years show mood change, apathy, depression and social withdrawal • Lack of awareness, recognition, cognitive problem • Psychosis, agitation in the later stages of AZ.

30. AZ Dementia is associated with: • Downs’ Syndrome • Traumatic Brain Injury, early/late, APOE-4 worse • Diabetes Type I and II • Female (ratio of 1 male to 8 female) (AAN 2-6-07) • Lower education and occupation • PTSD, Depression • Fragile persona/avoidant reclusive personality • Toxicity, brain infection, medication interactions

31. Typically Seen Thinking Problems with Alzheimer’s • Memory loss is immediate and severe • Misplaced objects- cannot find things • No recall of conversations • An inability to learn anything new • Memory of the past remains intact • Visuospatial functioning immediate • Lost in familiar places

32. Thinking Problems Typically Seen • Route finding problem: cannot re-trace steps, even at home, everything looks different • Memory: Forgetting faces, names of people known for years, including immediate family • Procedural Learning: Cannot learn new tasks; the coffee pot, anything with a procedure • Word Retrieval: Continual loss of the word needed to complete sentences (category worse than letter fluency)

33. Cardiovascular Dementia • 3rd leading cause of death, affects 700,000 yearly, two-thirds survive • 20% have depression • Various diverse processes: Silent events, hypertension, TIA’s • One to one Male-Female ratio • Incidence rate in women: 0 to 1% for age 65 to 69, increases to 9% for age of 85 and older • Incidence rate for men: 1 to 2% for age 65 to 69; increases to 9 to 16% for the age of 90 years & and older

34. Common Risk Factors: Genetic versus Modifiable Genetic: • Age • Diabetes • Family History • UARS, OSA: Higher risk of heart attack and stroke

35. Common Risk Factors: Modifiable • Smoking • Poor diet and nutrition: Overweight, Lack of exercise • Homocysteine level • High blood pressure, Stress and anxiety • Sleep apnea: • Loss of time for rest of heart, impedes left ventricular function, relationship between AHI and total serum cholesterol and HDL, severe AHI in 72% Acute coronary syndrome • Poor sleep: 66% more hypertension (SDT:2:1:2007) • Alcohol abuse • 3 or more drinks per day for 3 to 4 days per week found to be significantly associated with risk for future TIA events, transient ischemic stroke

36. Symptoms of Cardiovascular Dementia • Memory problems: Confusion and efficiency • Frontal deficits: selective attention, focus on the irrelevant, excess stimuli • Poor cognitive flexibility, rigid, black-white • Getting stuck, perseveration, repeats thoughts • Sequential, difficulty with step by step instruction • Problems planning, organizing, decisions • Emotional reactivity; impulsive, judgmental

37. Symptoms of Cardiovascular Dementia • Social withdrawal, depression, extreme behavior • Inappropriate sexual behavior, comments • Impulsive, loss of inhibition, feel and do • Problems communicating thoughts • Loss of sense of self, connection to past, values, morals and beliefs • Difficulty anticipating consequences of actions

38. Primary signs of Lewy Body Dementia: • Up to 20% of dementia • Frontal lobe processes: Decision making, attention, problem solving, rigid thinking • Parietal processes: Visual spatial, visual perceptual, visual constructional problems • Pre-cursor to Parkinson’s Disease • Mental illness/frank psychosis immediate

39. Lewy Body Dementia: Emotional Symptoms • Suspicious, accusatory of others, paranoid • Socially uncomfortable, dislike of crowds • Agitated, restless, unreal, crazy thoughts • Unpredictable emotions not fitting the situation • Easily upset, deep depression, nothing matters • Fantasy, living in the movies, inside themselves • Visual and auditory hallucinations that are real to them

40. Lewy Body Dementia: Cognitive Symptoms • Problems drawing and copying of designs • Visual perception affects balance and driving • Difficulty adding or calculating numbers • Word retrieval, selective attention • Poor problem solving, anticipating consequences • Illogical thinking, Misinterpretation of conversation

41. FTD (Frontotemporal Dementias) • Deteriorating condition involving Tau positive and negative, protein marker Ubiquitin/TDP43 • Re-defined: 4 markers of social interpersonal, personal conduct, emotional blunting, loss of insight • Primarily frontal (behavioral indices) or temporal (language, semantic dementia) • Left hemisphere (language) or right hemisphere (visual memory, prosopagnosia, visuospatial)

42. FTD versus AZ • Initially normal structural findings • Primarily frontal • PET studies and SSP (stereotactic surface projection) • AD: hypometabolism greater in posterior association cortex • FTD: hypometabolism greater in frontal association cortex

43. Early Symptoms, Markers of Dementia Onset • Psychiatric-significant emotional changes or small changes seen consistently over time, less social • Cognitive-memory, making decisions, word retrieval in conversations • Energy level down-easily tired, affects participation in life activities

44. Markers of Cognitive Decline • ↑ Brain inflammatory (cytokines,c-reactive protein) Homocystine levels, Increased influx of calcium, intracellular Ca • Increased oxidative stress-free radical production • Increased CSF cortisol & HPA activation, ↓regulation, Increased insulin resistance • Decreased volume of hippocampus • Impaired alteration of smell • REM Sleep Behavior Disorder

45. Signs Suggesting Need for Neuropsychological Evaluation • Memory problems: Daily tasks, appointments, cooking, routine activities, conversations, loss of items (keys, glasses, credit cards, check book) • Getting lost and disoriented in familiar places • Unable to make decisions, stuck and obsessed • Emotional: Accusations, paranoid, moody • Conversations not making sense • Old personality emerges, deepened depression • Actions occur without rhyme and reason

46. Memory loss can be the primary symptoms in the following: • Sleep apnea • Alzheimer’s dementia • Cardiovascular dementia • Frontotemporal Dementias • Certain medications • Vitamin B deficiency • Poor diet, low blood sugar • Thyroid problems

47. Memory Questions • Difficulty remembering things that someone recently told you? • Do you forget places where you have been? • Do you forget the things that you need to do? • Do you forget where you have placed something just that day before or even an hour ago? • Do you keep getting lost, even if it is the same route to the same place that you have been going to for years and years?

48. Memory Questions • Do you find yourself forgetting what you wanted to say? • Do you just think about things, becoming upset, unable to take action to change things? • Do you forget names of people you have known for years? • Is it hard to learn new things? • Do you make the same mistakes? Over and over? • Do you continually ask for directions to be repeated?

49. Treatment Options: Benefit of Cognitive Training • Cognitive decline occurs prior to adults having difficulty functioning in life in older adults • Large NIH study: 2,802 adults aged 65 years or older, living independently • Those seniors who had cognitive training had less of a cognitive decline (JAMA 296:2805-2814)

50. IM: Pre/ Post Testing Comparisons For typical ADD Adult there is an overall improved sense of well being and the concept that adversarial life events can be handled Pre and post testing comparisons indicated: • Improved overall functioning on the Quality of Life Scale • Improved overall functioning on the Beck Depression Inventory • Improved overall functioning on the Beck Anxiety Inventory