Dementia – Myths and Realities

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Presented by: Simon Tan, PsyD
Adjunct Clinical Instructor of Neurology, Clinical Neuropsychologist
Stanford University Medical Center
September 27, 2007

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Lecture Overview:
Given that approximately 6%-8% of those over 65 years of age, and 33% of those over 85 years old have some symptoms of dementia, Dr. Tan’s lecture provided valuable information about this distressing condition. Dr. Tan began with a basic definition of dementia. It is the development of multiple cognitive deficits that include memory impairment and at least one other cognitive area such as speech (aphasia), recognition (agnosia), movement (apraxia), or a disturbance in executive functioning, defined as, for instance, multitasking, planning and organizing. Dr. Tan’s profession involves administering neuropsychological tests to patients, and he feels that it is important to convey information about dementia because it is difficult to understand and there are many misconceptions. At present, there are no medications to permanently stop the progression of dementia. However, the good news is there are ample services available for these individuals (see websites listed below).

The functioning and cognitive abilities that are evaluated when screening for dementia include:

  • Short term memory
  • Spatial skills
  • Sense of direction
  • Language ability
  • Comprehension
  • Executive function (planning, problem-solving, multi-tasking)

The most common MYTHS about dementia include:

  • Dementia only happens to others
  • Dementia only affects the patient, not the patient’s family
  • People with dementia behave this way because of negative prior life experiences
  • People with dementia can control this behavior and do it deliberately due to laziness, stubbornness, and lack of motivation

Some important FACTS about dementia include:

  • A person with dementia is not insane, necessarily psychotic, or learning disabled.
  • There are many different types of dementia. Although Alzheimer’s disease is the most common, it is not the only kind.
  • Patients with Parkinson’s disease and other neurological conditions may have dementia.
  • Frontal Temporal Dementia involves an impairment in the ability to plan and
  • What may seem like aggressive behavior may be an indication of fear, anger, dissatisfaction, particularly in the early stages of dementia.
  • Persons with dementia are not necessarily incompetent, particularly in the early and intermediate stages. Persons with mild dementia may be able to comprehend and make choices about their own health.

Often, some problems are overlooked in assessing a person’s well being and may be confused with dementia. There may be competing causes as to why a person develops certain symptoms, which may or may not be dementia. Here are some things to watch:

  • A fall is not always just a fall. It could be an indication of macular degeneration or poor balance.
  • People with dementia may have other disabilities including, for example, trouble walking, poor balance, and sleep problems.
  • Forgetfulness may indicate a medication interaction.
  • Sometimes persons with dementia may speak very well despite the onset of other symptoms that reveal dementia.
  • Some persons with early onset dementia try to compensate for it and hide it.
  • Persons with depression and dementia often exhibit the same symptoms including loss of interest, withdrawing, and apathy. The two conditions may occur simultaneously and be misdiagnosed.

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Understanding Adult and Pediatric Eating Disorders

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Presented by: Debra L. Safer, MD
Co-Director, Stanford Eating and Weight Disorder Program
November 1, 2012

Eating disorders are abnormal behavior patterns that compromise physical health and mental well-being. These behaviors include anorexia nervosa (self-starvation), bulimia nervosa (binge eating and purging), binge eating disorder, and other non-specified conditions.

Anorexia affects 10 times more females than males while rates of binge eating are 1.5 times more common in females than males. The National Institute of Mental Health estimates that 5 to 10 percent of the U.S. population has an eating disorder of one type or another.

Though eating disorders affect relatively few people, the impact on those suffering from them is severe. Anorexia has the highest mortality rate of any psychological disorder.

“Eating disorders are not about vanity, or choice, or needing attention,” said Debra L. Safer, MD, co-director of Stanford’s Eating and Weight Disorders Program, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “Nor are they a phase. They are serious mental illnesses with dire consequences, so they need to be taken seriously.”

Growing Numbers
Eating disorders affect primarily females and are most common among teens and young adults. About 86 percent of eating disorders patients say they developed the condition before age 20, and there appears to be a higher risk of anorexia nervosa among Caucasians, people from higher socio-economic levels, and from subcultures that put a strong emphasis on appearance, such as models and athletes.

“The numbers appear to be growing in all populations,” Safer said, “but it’s difficult to assess anorexia because there are often inadequate numbers of patients who will participate in studies. Only about .5 to 1 percent of the population has anorexia and the dropout rate from studies by adult anorexics is often about 50 percent.”

Anorexia nervosa causes people to obsess about their weight and the food they eat. They will attempt to maintain a weight that’s far below normal, and to prevent weight gain or to continue losing weight, they may starve themselves or exercise excessively.

People with bulimia may secretly purge, trying to get rid of calories by forced vomiting or excessive exercise. While most people overindulge now and then, there are strict criteria for defining a binge, Safer said, that include consuming an excessive amount of food in less than two hours. Bulimics are preoccupied with weight and body shape and may also misuse laxatives, diuretics, or enemas.

Binge eating involves rapid and uncontrolled consumption of excess food, usually in solitude, followed by feelings of guilt or self-disgust. Unlike bulimia or anorexia, binge eaters do not purge their food, exercise excessively, or eat only small amounts of only certain foods. Because of this, binge eaters are often overweight or obese.

Anorexia usually manifests around age 1214, bulimia around age 1416, and binge eating at age 1822, but many patients report having some symptoms much younger, she added. Almost 40 percent of American 9-year-olds report that they been on diets and/or already started on risky behaviors.

Multiple Complications
“Anorexia is associated with lots of medical complications. They tend to be multisystem, affecting all the organs,” Dr. Safer said. “There are many long-term effects because it interrupts the adolescent growth spurt. In severe cases, the body goes through a ‘hibernation response,’ which is a physical shut-down with low blood pressure, lowered body temperature, and abnormal heart rhythms that can be fatal.”

Other consequences include bone loss, which increases the risk of early-onset osteoporosis; hormone imbalances that cause the absence of periods in girls and decreased testosterone in boys; and gastrointestinal problems, such as constipation and bloating, which make it even harder for patients to want to eat. Purging depletes the body of nutrients, leading to low potassium levels that can cause heart arrhythmias.

There are also neurological consequences. With reduced blood to the brain, eating disorder patients really do think and respond more slowly than their peers and tend to suffer short-term memory loss.

“The cognitive changes associated with malnutrition affect their sense of self and distort their self-assessment,” Dr. Safer said. “The disease causes an actual change in brain chemistry that can perpetuate the cycle. Happily, the effects of malnutrition in the brain can be reversed.”

In bulimia, stomach acids can erode both the esophageal lining and tooth enamel. Binge eaters tend to suffer from high blood pressure, high cholesterol, heart disease, and gall bladder problems.

It’s a misconception that eating disorders in adolescents are the fault of controlling parents or the result of a culture that emphasizes lean bodies and unrealistic beauty standards, Dr. Safer said. In fact, the cause may stem from multiple factors, including genetics, environment, and personal psychology.

Researchers are exploring the tie between eating disorders and larger issues of cognition and thinking patterns. They hypothesize that, for some, reduced self-esteem can lead to distorted concerns about appearance and a destructive cycle of behavior (a cognitive behavior model). For others, an emotional trigger may set off a way of seeing control of food as an escape from emotional pain that makes them dependent on their behavior (an emotion regulation model).

“No one chooses to have an eating disorder,” she added. “Many are in denial about the seriousness of their illness or have distorted perceptions about how they really look.”

Early Intervention
Treatment for eating disorders includes family-based, individual, and group therapy, with a majority of patients being treated as outpatients. Fifty percent of eating disorders patients make a full recovery; about 20 percent maintain a chronic condition; and 30 percent keep some symptoms or experience recurrence.

While there are no FDA-approved medications to treat anorexia nervosa, family-based therapy—in which the parents participate as active caregivers—works for many adolescents. Another approach is called cognitive behavioral therapy: It focuses on changing flawed thoughts and beliefs to improve the patient’s emotional state. And interpersonal behavioral therapy seeks to improve underlying interpersonal relationships.

“The goal is first to make our patients medically stable and restore their weight,” said Dr. Safer. “Then we start to address other aspects and look at contributing issues. Early intervention can treat or cure the disease. Over time the habit becomes part of the person’s identity so it’s harder for them to change.”

About the Speaker
Debra Safer, MD, is an assistant professor of psychiatry and behavioral sciences and co-director of Stanford’s Eating and Weight Disorder Program. The program involves staff from the Lucile Packard Children’s Hospital’s Center for Adolescent Health and the Stanford University School of Medicine divisions of Adolescent Medicine and Child Psychiatry. A specialist in adult and pediatric eating disorders, Dr. Safer studies the nature and treatment of these disorders, the development and treatment of obesity, and the relationship between binge eating and the metabolic syndrome. She received her MD from UCSF Medical Center, and completed her internship, residency, and fellowship at Stanford. Dr. Safer is board certified in psychiatry by the American Board of Psychiatry and Neurology.

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Cognitive and Affective Function in Late Life

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Anxiety and Depression in Mid-To Late Life
Speaker: Ruth O’Hara, PhD
Associate Professor of Psychiatry and Behavioral Sciences
Stanford University Medical Center
April 17, 2014

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For most people, forgetting a word, misplacing the keys, or becoming easily distracted is a normal part of aging, the result of general wear and tear on the billions of neurons in the brain. Changes in cognitive function—the ability to think, reason, and remember—also affect behavior and mood, and may contribute to psychiatric disorders like depression and anxiety, particularly in older adults.

It’s estimated that major clinical depression affects 2 to 3 million Americans aged 65 years or older, and milder depression strikes as many as one in six of this age group. Studies have shown that anxiety is even more common, affecting as many as 10-20 percent of the older population. Often the two go hand-in-hand, reducing overall health and quality of life.

“Late-life depression is very significant and extremely underestimated,” said Ruth O’Hara, PhD, an associate professor of psychiatry and behavioral sciences, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “It often manifests as physical symptoms and so can be misdiagnosed and undertreated. It is not a normal aspect of typical aging.”

There are several aspects of cognition that are affected by aging, some more than others. The processes most impacted include:

  • Executive function—the ability to plan and organize
  • Psychomotor speed—coordinated thinking with simultaneous movement
  • Attention and inhibition—staying focused and avoiding distraction
  • Working memory—short-term recollection
  • Explicit verbal memory—retaining instructions
  • Visual memory—retrieving clues about location
  • Verbal fluency
  • Visuospatial ability—the ability to temporarily hold and manipulate information about places

Aging tends to cause structural changes in the brain, with a diminished hippocampus, reduced structural volume, and increased white matter lesions. And while it’s difficult to measure neuronal function, there are changes in neurotransmitters like serotonin, which is related to mood, and dopamine, which is involved in executive function.

“People with depression who develop dementia show greater problems with cognition,” Dr. O’Hara said. “And both memory performance and executive function are worse in older people who are depressed.”

Dr. O’Hara’s research looks at physiological function and neurophysiological changes related to cognitive decline and how they are related to anxiety and depression in older adults. Cognitive decline is not only a predictor of dementia, she said, it may also contribute to affective disorders such as late-life depression. There likely is a reciprocal relationship between affective and cognitive symptoms in late life. Anxiety, for example, is also related to lower cognition and can be as influential as depression: The more anxiety, the greater the cognitive decline.

Behavioral tests in a study of people age 60 to 89 years old showed that anxiety tends to affects inhibition and processing speeds, while depression impacts all aspects of cognition. Distractibility—the failure to inhibit—is the most significant cognitive change with age, she said, and the one that appears most related to emotion.

Other studies have shown that emotional regulation—techniques to keep emotions in check—may offer a means to stay in good mental health, and may lead to improvements in  both memory and overall cognition.

“Emotional processing is associated with different patterns of diminished brain neurocircuitry in late-life depression and anxiety,” Dr. O’Hara said. Other factors include stress, sleep disturbances, diseases, and changes in neurotransmitters—chemical messengers that carry and modulate signals between neurons.

Research suggests that activities that exercise the brain and regular practice of emotional regulation strategies can actually improve cognitive abilities but must be done on a regular basis to show results. Best results may come from courses targeted to each individual, with structure, feedback, and assignments, rather than a self-directed routine.

These studies are important, she added, because they provide a window to understanding psychiatric disorders. “Cognitive dysfunction is a risk factor for the development of depression and anxiety in older adults and can impact response to treatment. It also may provide a potential target for treating these disorders.”

About the Speaker
Ruth O’Hara, PhD, is an associate professor of psychiatry and behavioral sciences and director of the Veterans Affairs National Fellowship Program in Advanced Psychiatry and Psychology. Her work focuses on identifying the genetic risk factors and physiological markers of neurocognitive impairment in late-life disorders, including dementia and Alzheimer’s disease. Dr. O’Hara received her MA in experimental psychology from University College in Dublin, Ireland, and her PhD in experimental psychology from University of Southern California, Los Angeles. She worked at the UCLA Neuropsychiatric Institute before joining the Stanford faculty in 2000.

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Mental Health Improvement Through Early Detection and Intervention

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Presented by: Steven Adelsheim, MD
Clinical Professor of Psychiatry and Behavioral Sciences
Stanford University Medical Center
June 5, 2014

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Psychosis is a serious mental disorder that causes thinking and emotions to become so impaired that the person loses contact with reality and the ability to function in ordinary life. Psychotic disorders such as schizophrenia and conditions like clinical depression, anxiety, and bipolar disease remain some of medicine’s deepest mysteries—and some of its most misunderstood.

Mental disorders are extremely pervasive and have a serious impact on physical, social, and economic well-being—not only for people living with the disorder but also for their families, friends, schools, workplaces, and communities. Depression, for example, is predicted to be a leading cause of disability by the year 2020.

Focus on Teens
These conditions affect adolescents and young adults at a disproportionate rate. About half start showing symptoms by age 14, and more than 75 percent start by age 24. Almost 80 percent do not receive care, whether because of a lack of awareness, family concerns, or the perceived stigma of being different.

“Mental health is a worldwide public health issue,” said Steven Adelsheim, MD, a clinical professor of psychiatry and behavioral sciences, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “We do not do enough to address the concerns of young people.”

Schools need to be key contributors to mental health education, said Dr. Adelsheim, who works closely with community high schools in developing mental health education programs geared to teens. Taking an approach that parallels how the public is taught about obesity can help to increase awareness, offset the stigma, and point to warning signs and early interventions.

Warning Signs
Psychosis rarely appears out of nowhere. Most often family, friends, teachers, or the individual recognizes that something is not quite right about their thinking, feelings, or behavior before an illness appears in its full-blown form. This early stage, before symptoms really start to show, is called the prodromal stage. “It’s like feeling the symptoms of a cold before you are completely sick. You know something is starting to develop,” he said.

Multiple studies have shown that the shorter the duration of untreated psychosis, the better the outcome. That is, patients respond best to treatment when the symptoms are recognized and treated early, showing improved social skills five to 10 years later. One long-term study, called PACE 400, showed that early intervention reduced incidence and severity of episodes, improved function, and extended the length of time between episodes.

“Recognizing early symptoms really matters and has a huge, positive effect on outcomes,” Dr. Adelsheim said. “The more time goes by, the higher the rate of developing problems.”

Without intervention, 33 percent of young people with symptoms go on to develop full-blown psychosis; with intervention, only 10 percent experience psychosis. However, currently the average time between the time symptoms start and getting treatment is one to two years, often because the changes are gradual or because people think some unusual behaviors are a normal part of teenage behavior.

New Models
Dr. Adelsheim is a strong advocate of reorienting community and school mental health programs to establish new models of care for early intervention. He points to an Australian program called headspace that sponsors numerous free clinics focused equally on physical, mental, and sexual health. The messaging is young and hip, and designed to remove any embarrassment about getting support for one’s psychological well-being.

Similar national programs are being developed in Ireland, Canada, and the United Kingdom. A prototype program in Oregon focused on early intervention for prodromal symptoms and early psychosis has demonstrated reduced hospitalizations due to psychotic episodes and improved performance in school. The target for all these efforts, he said, is to bring in young people for early support.

Dr. Adelsheim has helped develop innovative programs locally to improve teenagers’ understanding of mental health and to strengthen peer networks. The programs encourage kids to identify signs of mental illness, seek and offer help, and expand their social connections. Other efforts are designed to link families to share experiences, improve communication, and educate kids and families about early warning signs.

“It’s about creating a climate change, so that it’s not only OK to get help for a friend, but it’s cool to do so,” he says. “The goal of early detection and intervention is to build emotional health and address the mitigating effects of mental illness.”

About the Speaker
Steven Adelsheim, MD, is a clinical professor of psychiatry and behavioral sciences and director of the department’s community partnership programs. A specialist in developing community mental health partnerships, Dr. Adelsheim focuses on developing early detection programs for children and young adults at risk for psychosis. He received his MD from the University of Cincinnati College of Medicine in Ohio and did his residency and fellowship at the University of New Mexico School of Medicine. He is Board Certified in child and adolescent psychiatry and in psychiatry by the American Board of Psychiatry and Neurology.

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A Practical, Holistic Approach to Stress & Wellness in a High Pressure World

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Presented by: Nadia E. Haddad, MD, MS
Clinical Instructor, Psychiatry and Behavioral Sciences
April 14, 2016

Stress is an undeniable aspect of modern life. Though everyone experiences and responds to stress in an individual way, stress is defined as physical and psychological pressure that causes a disturbance in your body’s natural equilibrium. It’s actually an important short-term adaptive response for meeting natural threats: The stress response prepares the body to fight or flight, a protective mechanism that could save your life.

But the daily trials and tribulations of managing a career, making ends meet, or taking care of a family can cause our bodies to activate the same physical reaction, turning on that fight-or-flight response indefinitely. The effects can damage your health if you don’t find a way to address the root cause or learn to manage your stress.

“Stress in itself is not a bad thing—but how you manage it is key.” said Nadia Haddad, MD, MS, L.Ac, a clinical instructor of psychiatry and behavioral sciences, who spoke at a presentation sponsored by the Stanford Health Library. “There is a message encoded in our stress, and to manage it we need to understand the message and respond.”

Dr. Haddad specializes in integrating modern science with Chinese medicine’s holistic approach to health and well-being. She looks at the relationship between the mind and body in a field known as integrative medicine, which combines conventional and complementary approaches to address the biological, psychological, social, and spiritual aspects of health and illness.

Ongoing Stress
Dr. Haddad emphasized that, in the short term, some stress can help you meet daily challenges, keep you motivated, and enhance learning. But she sees a glorification of stress in modern society, with people boasting about how many hours they put in at work or how little sleep they need. “The current mentality is, if you’re not stressed, you’re not working hard enough,” she said. “There’s also a regular bleed of work into daily life as email, text and cellular phones give us easy access even when out of the office.”

The result is chronic tiredness, an overactive mind, and poor sleep, which in turn leads to decreased work performance. People often overcompensate with caffeine or energy drinks to address their tiredness, medications to fall asleep, or stimulants for focus.

“Many of us have a control mentality, as in, ‘my body and mind should do what I want them to when I want them to, and willpower and self-medication are my tools.’ But ignoring stress is not the same as controlling it,” she said.

Maintaining Balance
The body has a set point to function efficiently, a natural balance of pH, oxygen, carbon dioxide, temperature and other physical mechanisms that work in conjunction with complex factors like sleep, activity, diet, and social interactions. Together, all biological systems work in conjunction to regulate this homeostasis and maintain physiologic rhythm. Stress applies pressure to this programmed equilibrium and can hamper virtually every aspect of health, from contributing to heart disease to causing weight gain. Stress has also been associated with the development of certain types of cancer.

Dr. Haddad recommends developing an awareness of your body’s messages to learn how to regulate its balance. An important internal rhythm is based on your circadian clock, a biological timekeeper that synchronizes chemicals, hormones, body temperature, and sleep patterns. This biological clock induces “larks” to go to bed early and wake earlier in the morning, and “owls” to stay awake later into the night, often with difficulty waking up.

Studies show an increased mortality risk for those reporting less than seven hours of sleep per night. Most of society is based on a lark schedule, which creates a long-term mismatch for owls’ sleep cycles. This mismatch can affect alertness and performance, and chronic sleep deprivation can cause obesity, depression, high blood pressure, stroke, and heart attack.

Management Tactics
She suggests that you try to establish a regular wake-up time that fits your circadian clock and maintain a regular sleep schedule all week. If sleep is problematic, avoid the vicious cycle of taking stimulants like caffeine, which can affect sleep no matter how early in the day you drink it: Studies have shown that caffeine in the morning can affect sleep the following night. You might consider switching to a less-potent stimulant like tea, and avoid alcohol, which disrupts sleep patterns. Some people respond to melatonin, which helps to shift the natural sleep cycle (she recommends 3-5 milligrams taken an hour before bedtime). Exposure to early morning light can also help adjust the body’s circadian rhythm.

Another important body rhythm is controlled by eating, which maintains metabolism and energy. Dr. Haddad recommends eating a wide variety of nutrients, avoiding processed foods, and increasing your intake of foods rich in omega-3, such as flax seeds, and fatty fish (sardines, mackerel, salmon). Incorporate physical activity and exercise that you enjoy into your daily routine, and take classes to expose yourself to new ways to move your body.

She also suggests you build in some downtime to relax and enjoy being in the present, such as breathing exercises, stretching exercises, yoga, or meditation. Attune yourself to external rhythms through music and dance, which can alter your brain waves, lower blood pressure, and improve immune function. Stress also can come from interpersonal friction, so seek meaningful connections with people you enjoy.

Fine-Tune Your Rhythm
People who have trouble identifying their emotions may benefit from short-term psychotherapy, though it’s important to find a professional you can relate to. Acupuncture is designed to support both balance and rhythm, and can improve sleep patterns, reduce inflammation, and diminish perceptions of pain. Massage with moderate pressure has also shown to reduce the effects of stress.

To make positive, permanent changes, choose two small, measureable steps for one week, such as reducing coffee or meditating for 10 minutes a day. Become aware of your circadian rhythm and modify your sleep accordingly.

“We have important internal cues that help us navigate the world.” Haddad said. “The key to reducing stress is to get to know yourself to help support your body’s internal rhythms. Handling stress better means handling our bodies better as well.”

About the Speaker
Nadia E. Haddad, MD, MS, is a clinical instructor of psychiatry and behavioral sciences, who specializes in merging traditional science with Chinese medicine. She received her MS in Oriental Medicine from Dongguk Royal University in Los Angeles, her MD from the University of Colorado School of Medicine, and she completed her residency at Stanford, where she joined the faculty in 2015. She is board certified in psychiatry by the American Board of Psychiatry & Neurology.

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