What Are The Causes Of Abnormal Forgetting?

By Dr. David D. Rawlings, PhD –

In my last article, we talked about what was normal forgetting and what was not! We also talked about some of the possible sources for forgetfulness such as a sleep disturbance (e.g., sleep apnea), vitamin Bl2 deficiency, an underactive
thyroid (hypothyroidism), alcohol consumption, anxiety and depression, as well as metabolic changes (e.g., electrolyte imbalances in calcium and sodium levels).

For the reasons above, we also stated that it was important for you to see your primary care physician (PCP) to rule out treatable and/or, “reversible” causes of forgetfulness. However, if these potential sources of forgetfulness are ruled out, are determined to be insignificant, treated, or not applicable, and you are still experiencing forgetfulness that is not normal, it is possible that you, your loved one, or friend may have a form or type of neurological condition, and further evaluation by a specialist, such as a board certified clinical neuropsychologist, may be in order. What types of neurological conditions might there be that would cause undue, abnormal, or persistent forgetfulness? Well, the answer is not always simple. In the most extreme cases, forgetfulness may be diagnosed as a true memory disorder which Is part
of a constellation of symptoms found in dementia such as Alzheimer’s disease. The second leading cause of dementia, however, is cerebral vascular disease. Other forms of dementia can stem from Parkinson’s disease, Multiple Sclerosis, closed head injuries, multiple concussions, substance abuse, and other medical conditions, etc.

Dementia is best defined as the development of several cognitive deficits evidenced by:
1. a memory impairment, or the impaired ability to learn new information or to recall previously learned information,

2. one or more of the following cognitive/thinking disturbances:
a. a language disturbance;
b. an impaired ability to carry out motor activities despite intact motor function;
c. failure to recognize or identify objects despite intact sensory function;

     d. a disturbance in one’s ability to plan, organize, sequence, and abstract; and

3. the cognitive deficits listed above cause significant impairment in social or occupational functioning and also represent a significant decline from previous levels of functioning.

Not all individuals with abnormal forgetfulness, however, are diagnosed with dementia. Some individuals may develop a Delirium which is defined as: a) a disturbance of consciousness, b) a change in cognition (such as a memory deficit or disorientation), c) a disturbance which develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day, and d) evidence that the disturbance is caused by the result of a general medical condition (e.g., urinary tract infections, substance intoxication or withdrawal, or other metabolic influences, etc). These patients are typically seen by me in the hospital because of their rapid, and seemingly unexpected, change in thinking or behavior. Other individuals, however, may demonstrate a neurocognitive disorder referred to as Mild Cognitive Impairment or MCI. MCI is thought to consist of two broad types; one in which the patient has relatively good thinking skills but poor memory (amnestic type or a MCI). In the other form of MCI, the patient has relatively good memory but less than adequate thinking skills (non-amnestic type).

It is this combined group of MCI patients that I see most frequently in my outpatient office in order to distinguish between age-related problems and dementia. MCI is an intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia. It can involve problems with memory, language, thinking and judgment that are greater than normal age-related changes. If you have a MCI, you may be aware that your memory or mental functions have, “slipped”. Your family and close friends may also notice a change, but generally these changes aren’t severe enough to Interfere with your day-to-day life and usual activities. Unlike Alzheimer’s disease where cognitive abilities gradually decline, the memory deficits in MCI may remain stable for years. Mild cognitive impairment
may increase your risk of later progressing to dementia, caused by Alzheimer’s disease or other neurological conditions, but some people with MCI never get worse, and some eventually get better.

The type of MCI or dementia that a patient is diagnosed with will subsequently dictate the types of medications, diet, nutritional requirements, and lifestyle alterations that may be necessary to maintain, or improve brain and physical health. So, a specific diagnosis formed quickly is paramount. And by the way, the risk factors for MCI are similar to those of Alzheimer’s disease: increasing age, and having a specific form of a gene known as APOE-e4. Other medical conditions and lifestyle factors that have also been linked to an increased risk of cognitive change include: diabetes, smoking, depression, high blood pressure, elevated cholesterol, lack of physical exercise, and infrequent participation in mentally or socially stimulating activities(i.e. computer mind games, card playing, reading, and/or working). Personal care physicians {PCP) may question whether a patient actually has Alzheimer’s, or is it the early stages of dementia, or is it just mild cognitive impairment (MCI). This is understandable because PCP’s often see patients more frequently
than other specialties. However in our busy lives, signs of memory problems may not get the attention they need. Why?

First, PCPs may not be aware their patient requires more screening time until the patient arrives for the appointment and then their busy schedules cannot allow for longer appointments to give a full evaluation. Second, medical schools may not spend sufficient time training the students to diagnose the differences between the various memory loss conditions; and thirdly, there is no satisfying “mind” test that a doctor can quickly administer to a patient and that fits the short time frame that physicians’ schedules allow for when confronted with a patient who may have cognitive decline.

So, what type of specialist should one go see if their PCP has ruled out treatable or reversible causes of forgetfulness and there is still a question to determine whether they have benign senescence (normal age-related forgetting) or a possible
neurological condition?

Common practice is to refer the patient to two specialists; a clinical neuropsychologist, and a neurologist. A neurologist will examine you or your loved one physically, test motor, sensory and cranial nerves, do additional blood work, and likely send out for neuroradiological testing such as an MRI.

PET, SPECT, and/or CT scan of your brain. The scans are helpful at looking at the gross neuroanatomy of your brain to determine if there’s been brain volume loss or whet her t here’s the existence of a tumor or possible stroke-like event . Scans, however, do not reveal or demonstrate the brain’s functional capacity (i.e. what does the brain know? And what doesn’t it remember or know?). This is what the clinical neuropsychologist does.

Using a variety of paper/pencil and computer test s, the clinical neuropsychologist will assess the patient’s brain functions such as their memory, language, problem-solving ability, processing speed, motor abilities, judgment, attention and concentration, and reasoning skills. Those test scores are then compared to a database of similar patients with regard to age, sex, race, and educational level to determine whether the patient’s difficulties are, in fact, similar or different from other patients like themselves. In our office a further analysis compares the patient’s test scores to a database of over 10,000 other clinical patients to determine whether there is a correlation between that specific patient’s test profile and the profile of a specific, clinical, diagnostic group.

Since these tests are extremely sensitive to brain dysfunction, neuropsychological testing oftentimes reveals problems and difficulties that MRis and CT scans cannot pick up at a microscopic level. Why would paper tests administered by a neuropsychologist pick up things that a brain scan or MRI would not see? Because the paper tests are looking to see what parts of your brain handle your ability to handle math problems, or recall persons’ names or events, or speak clearly; or figure out a problem, etc. The medical tests reveal the anatomy found within your brain. The neuropsychological tests show what functions that anatomy performs for the person (or what functions are no longer
working).

Below you will find a dementia quiz from Bob DeMarco of the Alzheimer’s Reading Room that is reasonably accurate in detecting signs of memory loss. This, and others like it, can be found on our website at www.drrawlings.com. The Alzheimer’s Questionnaire (AQ) should not. however, be used as a definitive guide to diagnosing Alzheimer’s disease (AD) or amnestic mild cognitive impairment (aMCI).

Note: If you decide to use the test below, or any test like this at home, please be advised that this test is an assessment test. Not a diagnostic test. In order to diagnose MCI, Alzheimer’s, or any type of dementia a series of tests must be administered by a memory care specialist like a board certified neuropsychologist before a definitive diagnosis can be made.

How To Score:
Pick l answer to each of the 21 questions (yes or no). Then odd up oil the points to arrive ot a final score.

1. Does your loved one have memory loss?
Y=1 N=O

2. If so, is their memory worse than a few years ago?
Y=1 N=O

3. Do they repeat statements or stories in the same day?
Y=2 N=O

4. Have you had to take over tracking events or appointments, or does the patient forget appointments?
Y=1 N=O

5. Do they misplace items more than once a month?
Y=l N=O

6. Do they suspect others of hiding, or stealing items when they cannot find them?
Y= l N=O

7. Does your loved one frequently have trouble knowing the day, date, month, year, and time; or check the date more than once a day?
Y=2 N=O

8. Do they become disoriented in unfamiliar places?
Y= l N=O

9. Do they become more confused when not at home or when traveling?
Y= l N=O

10. Excluding physical limitations, do they have trouble handling money, such as tips or calculating change?
Y= l N=O

11. Do they trouble paying bills or doing finances?
Y=2 N=O

12. Does your loved one have trouble remembering to take medicines or keeping track of medications taken?
Y= l N=O

13. Do they difficulty driving; or are you concerned about their driving?
Y=1 N=O

14. Are they having trouble using appliances, such as the stove, phone, remote control, microwave?
Y=1 N=O

15. Excluding physical limitations, are they having difficulty completing home repair or housekeeping tasks?
Y=1 N=O

16. Excluding physical limitations, have they given up or cut down on hobbies such as golf, dancing, exercise or crafts?
Y=1 N =O

17. Are they getting lost in familiar surroundings, such as their own neighborhood?
Y=2 N=O

18. Is their sense of direction failing?
Y=1 N=O

19. Do they have trouble finding words other than names?
Y=1 N =O

20. Do they confuse names of family members or friends?
Y=2 N=O

21. Do they have trouble recognizing familiar people?
Y= 2 N =O

What the score means:
0 to 4: No cause forconcern
5 to 14: Memory /os.s may be on early warning of dementia
15+: demenrio may already have developed

If you feel you or a loved one/friend are having memory or thinking difficulties, request testing from a trained neuropsychologist for a thorough neuropsychological evaluation. The results will be shared with your primary care physician and/or neurologist. The test data provides a snapshot or baseline of abilit ies/difficulties from which
recommendations can be offered to your doctor. These treatment recommendat ions will also be shared with you following the evaluation. The test results can also be used for any additional testing that may be necessary years later to determine progress due to treatment or interventions by your physician(s). Lastly, undergoing the tests can help confirm your concerns that you are indeed ” losing your mind” and need treatment; or will convince you that you have the “usual aging of the brain” that comes with age.

Dr. Rawlings has over 35 years of clinical experience. He is the only Board Certified Clinical Neuropsychologist in Collier County (Naples), Florida and remains a staff member with the NCH HealthCare System.

Dr. David D. Rawlings, PhD
720 Goodlette Road N. | Suite 201 | Naples FL 34102
239-430-2303 | www.drrawlings.com