Nourishing and nurturing your brain: from the things we eat to the things we do

Nourishing and nurturing your brain: from the things we eat to the things we do

 

 

Nitin K. Sethi, MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address for Correspondence:

 

Nitin K. Sethi, MD

Department of Neurology

NYP-Weill Cornell Medical Center

525 East, 68^th Street

New York, NY 10021 (U.S.A.)

Email: sethinitinmd@hotmail.com

            The human brain is indeed complex made of millions of small cells called neurons working in close harmony with each other. Its capacity far exceeds that of any supercomputer designed as of yet by man. This fist full of about 1500 grams of tissue is the seat of our emotions, our memory, our senses and serves as the motherboard for all other body systems. This delicate supercomputer of ours is enclosed in a resilient bony skull able to withstand significant trauma. Our brain like our body needs to be nurtured and nourished.

 

Nourishing the brain: brain foods and more

 

            What we eat does to an extent determine the health of our brain. Recently the concept of brain foods has come into vogue. This refers to foods that have been postulated to boost brain power, improve memory and functioning of the brain. So what are these foods that have been postulated to help keep the brain young?

 

Omega 3- fatty acids: belong to the family of unsaturated fatty acids. The important ones among them include alpha linolenic acid, eicosapentaenoic acid and docosahexaenoic acid. Fatty acids form an important constituent of cell membranes. They thus perform important roles in various cell functions including cell to cell transmission and help maintain stability of cell membranes. A growing body of work has shown the beneficial effects of omega 3-fatty acids in prevention of atherosclerosis. The data showing a beneficial effect of fish oils is more robust for the cardiovascular system while no consisting relationship between fish consumption and stroke reduction has been documented. So while the data may not be robust, it probably makes sense to increase the omega 3-fatty acid content in your diet. I would advise replacing some of the saturated fats with polyunsaturated fatty acids rich in omega -3s like canola oil, walnut and olive oil.

 

Numerous other foods have been touted to promote brain heath. Some of these include avocado, various legumes (rich source of protein for vegetarians), oatmeal, peas, soybeans (again a good source of protein for vegetarians), wheat germ, fish like tuna, yogurt, brown rice, brussels sprouts and eggs among others. The brain just like any other organ of the human body needs a balanced nutritious diet consisting of the right mix of carbohydrates, proteins, fats, vitamins and minerals.

 

Role of Ginkgo biloba in enhancing memory: the extract of the Ginkgo leaves has been used for medicinal purposes for years. It contains flavonoid glycosides and terpenoids and is thought to enhance memory and concentration. Studies though have yielded conflicting results. While some studies on patients with Alzheimer’s dementia showed a benefit, others did not and benefits were attributed to a placebo effect. Ginkgo biloba affects the coagulation of blood and can interfere with other anticoagulants like warfarin and aspirin. It might be reasonable for people who have dementia or an early stage of dementia called mild cognitive impairment (MCI) to take Ginkgo biloba. Its use in healthy young adults as a memory enhancer is probably ill advised.

 

Role of vitamins and minerals in promoting brain health: Vitamins and minerals are also referred to as micronutrients. The body needs them albeit in small amounts for its well being. Vitamins and minerals are involved in diverse cellular functions. Deficiency of certain vitamins has been implicated in causing neurological diseases. Vitamin B1 also called thiamine is a water soluble vitamin. Deficiency of vitamin B1 causes a disease caller Beriberi. It presents clinically as a peripheral neuropathy (the peripheral nerves get involved). Deficiency is commonly seen in alcoholics and those with marginal diets like the elderly. Thiamine deficiency in heavy alcoholics may cause other neuro-psychiatric problems. Wernicke’s encephalopathy and Korsakoff psychosis occur in alcoholics and present clinically with confusion, gait, balance and memory problems. Foods that are rich in vitamin B1 include whole-grain cereals, bread, red meat, legumes, green leafy vegetables and brown rice. I would recommend vitamin B1 supplementation in the elderly and those who drink heavily. Ideally all people who drink a moderate amount on a regular basis should take one multi-vitamin a day.

Vitamin B12 deficiency can occur in people who have pernicious anemia or inflammatory bowel diseases like Crohn’s. Deficiency of B12 also called cyanocobalamine may present with neuropsychiatric manifestations (referred to as megaloblastic madness). It may also cause loss of vision (amblyopia) and weakness of the legs due to involvement of the spinal cord (the spinal cord involvement is referred to as sub-acute combined degeneration of the spinal cord). Meat and meat products like liver, beef, mutton, fish and egg are rich sources of B12. Hence vitamin B12 deficiency occurs mostly in pure vegetarians. In these groups, yes, vitamin B12 indeed does nourish the brain and in fact is vital for it to function normally.

Vitamin E is much in vogue today and has been aggressively touted as an anti-oxidant important for everything from aging gracefully to preventing cancer. Again there is yet no scientific evidence that it indeed does help in all this. Vitamin E deficiency causes ataxia and balance problems (ataxia of vitamin E deficiency). Deficiency occurs in people who for some reason cannot absorb the vitamin from the gut. Wheat germ, vegetable oils, whole grains and nuts are good sources of this vitamin. No one knows what the ideal dose of this vitamin should be. Even giving supratherapeutic doses (mega doses of 1000 IU and above) of vitamin E to patients who had neurodegenerative conditions like Alzheimer’s dementia did not result in any observable benefit.

This is a good time to talk about the role of various anti-oxidants in promoting and maintaining brain health. A variety of anti-oxidants are nowadays been marketed as a visit to any of the health stores shall reveal. These have been touted for their anti-cancerous properties as well as their cardiovascular and cerebrovascular benefits. Among them coenzyme Q10 and alpha lipoic acid are popular. There has been no proven benefit of coenzyme Q 10 when controlled trials have been done in patients with Parkinson’s disease or even in ALS. My personal view is that if someone has a strong family history of Alzheimer’s dementia, Parkinson’s disease or ALS, it may be reasonable to advice supplementation as these preparations are relatively safe with no major side-effects. Studies have shown that when you give them to patient’s who already have an advanced neurodegenerative condition like Parkinson’s disease they seem to be ineffective, no one though knows that if you take these supplements from a young age (before the onset of the disease), would they lessen the chances of developing Parkinson’s disease or dementia in the later life. Meaning do they actually promote brain health? I usually do recommend alpha lipoic acid supplementation in my diabetic patients with neuropathy. In health men and women, I would recommend taking them in moderation as there is no proven benefit.

 

 

Role of exercise in promoting brain health: “ The brain too needs to jog everyday” exercise is a natural aphrodisiac for the brain. It promotes the release of endorphins and other feel good neurotransmitters. The benefits of regular exercise in promoting brain heath have been documented repeatedly. Even people who have neurodegenerative conditions like Alzheimer’s dementia and Parkinson’s disease seem to do well if they exercise as compared to those that don’t. These patients are less prone to fall and have improved assessments on care-giver rating scales. My personal belief is that exercise promotes brain healing and improves synaptic transmission. Recently cognitive exercises have come into vogue. Brushing with your left hand (if you right handed), playing mind-games like crossword puzzles and scrabble have been documented in some studies to slow down the progression of dementia and improve memory and concentration. People who are high functioning and use their brain regularly like lawyers and teachers have a lower incidence of developing later life cognitive problems as compared to a construction worker whose job is more manual and does not involve the use of these higher mental functions. “ Use it or lose it!!!”

 

 

 “ Do not just exercise your body, exercise your brain too”

 

 

The mind-brain connection: How to keep your mind healthy

 

One should not only have a healthy brain but a healthy mind too. Inner peace, calmness, introspection, tranquility are essential qualities that nurture the mind and help to maintain its internal equilibrium. Meditation, been spiritual and doing yoga are ways by which that elusive inner peace can be obtained ensuring a healthy mind as well as brain. One should never forget the healing powers of the mind. Some cancer patients and patients who have had a devastating stroke have been able to overcome their illness and disability due to the healing power of their minds. One should harness this power in a positive direction because the mind can be your best friend as well as your worst enemy. Protect your mind against depression as attacks of major depression make one prone to later life dementia. Have healthy relationships that nurture and nourish your mind.

 

Someone once rightly said and I quote “ Your mind is your best friend, do not hurt him for whomsoever or whatsoever”.

HIV related neurological conditions

HIV or human immunodeficiency virus causes AIDS or acquired immunodeficiency syndrome. The HIV virus affects every level of the neural axis, by that I mean that the virus affects the brain, the spinal cord, the nerves as well as the muscles. I shall discuss the neurological manifestations associated with HIV infection in this section starting with the brain.

HIV manifestations in the brain: the brain may be affected soon after the patient gets infected with the HIV virus. Research has shown that soon after entering the human body, HIV virus can be found in the brain. Its first manifestation may be in the form of an aseptic meningitis. The patient has characteristic signs and symptoms of a viral meningitis with headache, neck stiffness, photophobia, body aches and myalgias but when the spinal fluid is analysed no organisms are seen, though the cell count in the spinal fluid may be elevated. This attack of aseptic meningitis subsides on its own (no antibiotics are required).  All that is needed is bed rest and some hydration. The HIV virus then enters a dormant state in the brain, remaining silent, causing no overt manifestations.

In the later stages of HIV infection (when the virus has multiplied extensively in the body and the patient’s viral load is high and CD4 counts are low) the virus again manifests in the brain clinically. Viral load refers to the amount of virus in the body usually expressed as the number of viral copies in the blood. CD4 count refers to the number of CD4 cells present in the blood. The CD4 cells are a group of immune cells, the HIV virus selectively destroys CD4 cells and thus makes a patient immunodeficient and prone to opportunistic infections.  Opportunistic infections refers to infections which normally do not occur in a person with an intact immune system, in people who have immunodeficiency these infections are a major cause of morbidity and mortality. A number of these infections have been associated with late stage infection with HIV. These include:

1) CNS toxoplasmosis

2) Cryptococcal meningitis

3) Progressive multifocal leukoencephalopathy (PML)

4) Cytomegalovirus infections (CMV infections)

5) Tubercular infections of the brain–tubercular meningitis and tuberculoma

6) Various fungal meningitis

HIV affects other levels of the neural axis. It involves the spinal cord causing a vacuolar myelopathy causing stiffness and weakness of the legs and bladder/ bowel problems.

It affects the peripheral nerves and can cause painful neuropathies. The neuropathy associated with HIV infection is usually distal, painful and symmetrical. The drugs used to treat HIV infections are quite strong and some of them too have been implicated in causing neuropathies. HIV can also cause a Gullian Barre Syndrome like presentation. This is an acute peripheral inflammatory demyelinating polyneuropathy (AIDP) which at times can prove fatal due to involvement of the respiratory muscles.

HIV can also involve the muscles causing diffuse proximal muscle weakness (HIV myopathy). Some of the antiretroviral drugs have again been implicated in causing a toxic myopathy.

HIV infection can also involve the brain diffusely (by that I mean no focal or mass lesions are found). This diffuse involvement of the brain causes AIDS dementia complex or what is also referred to as HIV encephalopathy. The virus involves the subcortical parts of the brain and causes psychomotor slowing, cognitive deficits and memory problems.

 

Let us now discuss the above one by one.

 

1) CNS toxoplasmosis: CNS toxoplasmosis is one of the most common opportunistic infections seen with HIV/AIDS. It is caused by Toxoplasma gondii and usually presents with intracranial space occupying lesions. By that I mean, it causes lesions in the brain that occupy space much like any other mass such as tumor (cancer). The lesions due to Toxoplasma may either be single or multiple in number and clinically may present with a seizure (as they irritate the brain) or if they lie near the motor strip they may present with weakness or numbness on one side of the body. If they are multiple in the brain they may cause encephalopathy (patient is obtunded and poorly responsive). How is the diagnosis secured? The diagnosis of CNS toxoplasmosis is usually quite easy as the lesions are readily seen on either a CT scan of the brain or an MRI. Your doctor may order the test with contrast to see the surrounding edema and to differentiate them from other similar appearing lesions.

As I stated earlier the diagnosis is relatively easy if there are multiple lesions. The problem arises when there is only one lesion. Then CNS toxoplasmosis has to be differentiated from other disease processes which too may present with a solitary intracranial lesion, especially primary CNS lymphoma. It is important that the correct diagnosis be made as the treatments for the two differ widely. So in cases like these, we neurologists may order other tests such as a Thallium SPECT (single photon emission computed tomography) which is a special type of scan able to differentiate between infection (toxoplasmosis) and tumor (CNS lymphoma) or a biopsy of the lesion may be attempted. Biopsy of course is an invasive procedure and hence we try hard to avoid it.

At times we emprically treat the patient for CNS toxoplasmosis (as treatment is relatively simple and free from side-effects). The CT scan is repeated after 2 weeks of therapy, if the size of the lesion has regressed then it implies that we are dealing with CNS toxoplasmosis. If the lesion has not regressed in size after treatment for 2 weeks or has increased in size, then the possibility of it representing a solitary CNS lymphoma increases.

 

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Back pain

Back pain (radiculopathy/ myelopathy)

Back pain is one of the most common conditions for which patients seek a neurologist’s opinion. There can be protean causes of back pain and before we discuss them here, a brief discussion about the anatomy of the spine shall serve us well.

 

Anatomy of the spine:

The human spinal column is made up of bones called the vertebra stacked one on top of the other (like a column), As the vertebral column is made up of multiple bones articulating with each other, it allows for mobility. We can bend forward (flexion of the spine), arch our back ( extension of the spine) and can also flex our spines laterally in both directions (lateral flexion of the spine). The soft cartilagenous tissue found between two vertebral bodies is called an intervertebral disc. The spinal cord is enclosed in this skeleton of vertebral bones and thus is protected from injury. From the sides of the vertebral bodies the nerve roots come out. These are the roots which later on join to form the big nerves which innervate the muscles of the arms and legs.

 

What is meant by disc herniation?

Other terms used to describe this common condition include “slipped disc” . A herniated or slipped disc refers to the condition where-in the intervertebral disc gets dislodged (herniates out of its right place or slips out of its right place). When the disc herniates out it puts pressure on the nerve roots exiting the spinal cord at that level. Inflammation of the nerve roots results. This can lead to an intense painful condition where-in the patient complains of pain radiating down in the distribution of that nerve root. We in neurology refer to this condition as Radiculopathy.

Depending upon which nerve root is compressed and at which level patients have pain. For example a disc in your neck slips out, you have pain radiating usually into your arms or even into your finger tips, while if a disc in the lower back slips out, patients usually have pain radiating down their leg ( a condition  commonly referred to as sciatica).

Causes of back pain:

As I stated earlier there can be protean causes of back pain. Here I shall list some of the common causes.

1) Slipped or herniated disk.

2) Mechanical trauma to the back resulting in soft tissue injury (injury to the para-vertebral muscles or the soft tissues eg fat).

3) Fracture/ dislocation of the vertebral bodies: sometimes the vertebral bodies may get dislocated or malaligned. One vertebral body may get displaced in relation to the vertebrae below. This condition is referred to as Spondylolisthesis. The vertebral body itself or any of its parts (arch, pedicle) may get fractured resulting in pain. Fractures of the vertebral column can either be traumatic (occuring in the setting of significant trauma) or they can be secondary fractures. Secondary fractures occur when the vertebral body is weakened by an infectious or malignant (cancerous) process.

4) Spondylosis: is one of the most common causes of back and neck pain especially in the middle aged and elderly population. In its most simplistic defination, spondylosis refers to degeneration of the vertebral column. This degeneration of the bones of the spine becomes more apparent as we age, spur formation may occur (osteophytes). These osteophyted may compress the exiting nerve root leading to pain (radicular symptoms). Further on the spinal canal may get narrowed. When this occurs the spinal cord does not have enough space, a condition referred to as spinal canal stenosis. Spinal canal stenosis classically presents with pain which radiates into the buttocks. Patient complains of pain when he walks, with relief of pain on sitting or when he bends forward (flexion). This condition is referred to as neurogenic claudication.

It is important that spinal canal stenosis be diagnosed correctly as it responds to surgical intervention with good relief of pain and discomfort.

 

“For one who has conquered the mind, the Supersoul is already reached, for he has attained tranquillity. To such a man happiness and distress, heat and cold, honor and dishonor are all the same“

Lord Krishna in the Bhagavad Gita

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Neuropathy presenting features

So what are the signs and symptoms of someone with a neuropathic condition:

Sensory neuropathies present with the following signs and symptoms:

1) Numbness in the arms or legs ( a clue to neuropathy is that the signs and symptoms are usually symmetrical and start distally. For example the patient may complain of numbness in both legs or hands initially in the toes and the fingertips. As the disease progresses this numbness also moves more proximally reaching to the ankles, shin and the arms).

The patient may not complain of numbess rather may use words like ” my legs feel dead” or “my hands burn” to describe his symtoms.

2) Pins and needles sensation in the arms and legs: people with neuropathy have what doctors call paresthesias or abnormal sensations.  They may complain of feeling pins and needles , electric shocks or at times as if their skin is been touched with a feather.

They have allodynia (a non-noxious stimuli feels noxious meaning that if I touch you with a feather you may feel as if I am boring a sharp pin into your skin) and hyperalgesia (meaning that they have an increased sensitivity to pain).

3) Patients with neuropathy may present with skin changes. This is most commonly noted on the skin overlying the shin and feet. The skin is shiny and atrophic, the overlying hair are sparse or completely lost. At times people may develop non-healing ulcers of the feet which may get infected and even gangrenous. This condition is commonly seen in diabetic patients with severe neuropathy (diabetic foot).

4) If a patient has a large fiber neuropathy, he may complain of difficulty with balance especially at night or when his eyes are closed. They feel as if they are walking on cotton wool.

5) Patients may present with ulcers or burns in their hands: this is because as they are not able to detect the sensations of heat etc they may touch something hot like a gas stove and get burnt.

 

 

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Neuropathy

In this section we shall discuss neuropathies. This is a vast topic and I shall try to make it simple. First lets start with the basics. What is neuropathy? Neuropathy refers to disease and dysfunction of the nerves.  There are different types of nerves in the human body: some nerves supply the muscles of the head, face and neck example the facial nerve supplies the muscles of the face ( it is this nerve which helps you to smile or frown).  Another  example is the auditory nerve which helps you to hear. These nerves which supply the muscles of the head and face are referred to as Cranial Nerves.

Apart from the cranial nerves there are other nerves which supply the muscles of the arms and legs and carry sensations of pain, temperature, pressure, joint sense, vibration and light touch. As these nerves supply the muscles in the periphery of the body they are referred to as peripheral nerves. Peripheral nerves are of three types:

1) Motor nerves : nerves which carry out motor functions example closing and unclosing your fist , walking etc

2) Sensory nerves: nerves which carry sensation of pain, temperature, touch, joint sense, vibration and position sense from the periphery back to the brain.

3) Mixed nerves: nerves which carry out both the above functions.

Neuropathies can thus be of different types based on which type of nerve is involved by the disease process. So you can have a motor neuropathy, a sensory neuropathy and a mixed motor-sensory neuropathy.

Another way to classify neuropathies is on the basis of the size of the nerve fibers involved. Pain, temperature and crude touch is carried by small sized nerve fibers and hence neuropathy of the small sized sensory nerves is referred to as small fiber neuropathy. Vibration, position sense and joint sense are carried by larger diameter nerve fibers and hence neuropathy of larger diameter nerve fibers is referred to as large fiber neuropathy.

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Dementias

In this section we shall discuss a little about dementia. Just what do we mean when we say a person has dementia?

Dementia is a disorder in which a person has cognitive impairments in multiple domains. Meaning a patient with dementia has problems with memory ( forgets things), language ( speech gets sparse and content/ vocabulary decreases), calculation (person loses the ability to calculate: subtract, multiply etc), and abstract thinking. Depending upon what part of the brain gets affected, a patient with dementia may have personality changes and problems with executive functions like planning and other goal directed actions. They may also experience what we neurologists refer to as apraxias. Apraxia is an inability to do a learned act (example you can tie your shoe laces, it is an act you learnt as a small child. Now assume you get demented, you lose the ability to tie your shoes laces even though you are not weak and have full strength in your arms and legs). Patients with dementia may exhibit various kinds of apraxias, as the disease evolves they become dependent on care-givers for nearly all activities of daily living: cannot drive, cannot tie their shoe laces, cannot feed themselves or take a shower on their own.

There are many different types of dementia. These differ from each other in the cognitive domains affected and in the way they present clinically.

Classification of dementias:

 

1) Alzheimer’s dementia

2) Fronto-temporal dementia also referred to as Pick’s disease

3) Multi-infarct dementia also called vascular dementia

4) Dementia associated with Parkinson’s disease also called Parkinson’s disease dementia

5) Diffuse Lewy Body dementia

6) Primary Progressive Aphasia

7) AIDS dementia complex or HIV encephalopathy

8) Dementias associated with infections like syphilis

9) Reversible dementias like that due to hypothyroidism, deficiency of vitamin B12, thiamine (vitamin B1), hydrocephalus (normal pressure hydrocephalus)

10) Conditions which can mimic dementia example depression (pseudodementia)

 

Let us now discuss a few of these disorders. I shall start with the most common cause of dementia in the elderly namely Alzheimer’s dementia.

 

Alzheimer’s dementia: AD is the most common primary dementia seen in the elderly age-group. The onset of AD may be very subtle and frequently the care-givers or the patient cannot tell when did the disease first start. By the time the patients come to medical attention, the dementia is usually quite prominent. A point to note here, patients with dementia usually do not seek help by themselves. They do not feel anything is wrong with them, are not bothered by the lack of memory or their forgetfulness. It is their relatives and friends who first notice something is amiss. They notice that the patient keeps forgetting simple things, may get lost in their own neighbourhood ( for example the patient may not know what street he lives on and get lost while driving), other things like going to the grocery store and forgetting why one went there in the first place and having problems with names etc may be noticed.

Suprisingly in the earlier stages of the disease patients maintain their social graces pretty well. They may interact pretty gracefully in a social setting like a party or at work and if you are inter-acting with them casually you may never realise that they are having memory problems.

Diagnosing Alzheimer’s dementia: the diagnosis of Alzheimer’s disease is mostly clinical and a neurologist would be able to make the diagnosis clinically with a reasonable level of accuracy. Your doctor may order some tests like an MRI study of the brain and some blood tests to measure the thyroid hormone levels in your body, vitamin B12 level and also to rule out diseases which can mimic Alzheimer’s disease in its presentation such as syphilis. Nowdays more advanced imaging tests are been used to diagnose Alzheimer’s disease at an earlier stage of minimal cognitive impairment (MCI), these include PET (positron emission tomography) scan, SPECT (single photon emission computed tomography) scan and fMRI (functional MRI) scans. These facilities should be available in the big neurological centers.

 

Managament of Alzheimer’s Dementia: Alzheimer’s dementia is as of now incurable. However there are medications which can slow the progression of this neurodegenerative disease and improve the cognitive abilities of the patients. These drugs belong to a class of drug called cholinesterase inhibitors.  They inhibit the cholinesterase enzyme from breaking down acetylcholine, so increasing both the level and duration of action of the neurotransmitter  acetylcholine. Commonly prescribed drugs include: donepezil (Aricept), rivastigmine (Excelon), tacrine (tetrahydro aminoacridine) and galantamine. A few years ago, a new drug called memantine (Nemanda) was introduced into the market. This has a different mechanism of action as compared to the cholinesterase inhibitors. It is a NMDA receptor antagonist. Treatment with cholinesterase inhibitors does not alter the natural history of Alzheimer’s dementia. Patients though do get a few more months and possibly a few more years of relatively preserved cognitive abilities. Caregiver burden is reduced and patients may remain independent in some activities of daily living. Certain other medications and nutritional supplements have been advocated for Alzheimer’s disease patients with no proven efficacy. These include supplements like Ginkgo biloba and supratherapeutic doses of Vitamin E.

In the more advanced stages of the disease, patient’s become mute, akinetic (do not move spontaneously), they are incontinent, cannot feed themselves and become totally dependent on caregivers. Caregiver burn out is quite common and patients may be placed in nursing homes. In this advanced stage urinary tract infections (UTI), respiratory tract infections (pneumonias) and bed sores (decubitus ulcers) are common causes of morbidity and mortality. These advanced Alzheimer’s disease patients need good nursing care.

 

Let us talk a little about other neurodegenerative dementias. Fronto-temporal dementia also called Pick’s disease resembles Alzheimer’s disease except that these patients have early and more prominent frontal lobe involvement. Thus early on in the disease course, these patients have executive dysfunction (problems with planning things, thinking about future plans and how to go about making them happen). They also have prominent personality changes (may become angry, argumentative and suspicious) and also disinhibited (say whatever comes to mind, act inappropiately in social gatherings eg may start masturbating or touch themselves inappropiately).  The cholinesterase inhibitors used to treat Alzhemier’s dementia may also be tried in patient’s with fronto-temporal dementia (Pick’s disease). The name fronto-temporal dementia comes from the fact that these patients have prominent atrophy (decrease in mass or bulk or size) of the frontal and temporal poles/lobes.

Dementia of Lewy Bodies: is another type of dementia in which patient’s typically exhibit fluctuating symptoms. Visual hallucinations is a prominent component of this type of dementia. Patient’s respond poorly if medications like Haldol (haloperidol) are used to control their behavior. Atypical antipsychotics like Seroquel (quetiapine) are better drugs to control behavioral problems in these patients like agitation and aggression.

Dementia of Parkinson’s disease: Patient’s who have Parkinson disease may also develop dementia (memory problems) later on in their disease course. I shall discuss this further under Parkinson’s disease.

Depression or pseudodementia: Patients who have major depression may also look as if they are demented. These patients have anhedonia (no interest in any pleasurable activity like watching TV, getting a cup of coffee, watching a movie with friends). They just sit still, may not eat if not asked too and look akinetic. These depressed patient’s superfically may resemble dementia patients and hence depression is also referred to as pseudodementia. Once you treat their depression, they improve and all their “memory problems” go away.

Demented patients may have superimposed depression and vice versa hence a thorough search should be made to rule out depression in a patient with dementia as it is readily treatable.

I shall discuss depression under a separate heading. There are caretaker support groups for people who have loved ones suffering from dementia. They offer advice and help in preventing caretaker burnout.

 

 

“A self realised man is one who controls his mind“

Lord Krishna in the Bhagavad Gita

Depression

Depression is a relatively common neurological condition. It may occur on its own (as an episode of major depressive disorder or MDD) or it may occur during the course of another chronic neurological illness such as stroke. It is important that depression be recognized and treated since studies have shown that it increases the morbidity and mortality associated with these conditions.

Sometimes it is difficult to weed out which symptoms are due to depression and which due to the organic brain (neurological) condition. Patients who have fronto-temporal dementia (Pick’s disease), Parkinson’s disease, frontal lobe strokes may look depressed. They are akinetic (do not move spontaneously), have mask like emotionless faces and do not talk readily (abulia). On the first glance it may seem they have depression and not an organic neurological condition.

The point I am making is that depression may mask an underlying neurological condition like dementia or a frontal lobe tumor. The reverse is also true, people who have neurodegenerative conditions may have superimposed depression. Upon treating the depression they feel much better and may improve in caregivers rating scales.

The diagnosis of depression is essentially a clinical one. There are certain clinical features which if present for a sufficient length of time usually 2 weeks suffice to make a clinical diagnosis of major depressive disorder (MDD). These features include what is called anhedonia (loss of pleasure in day to day activities), depressed mood ( in children it may present as irritability), weight loss or weight gain, insomnia or hypersomnia (sleeping more than usual), changes in behavior and personality, feeling tired and fatigued, feeling of hopelessness and worthlessness and thoughts of death or sucide.

In a clear cut case no other investigations are warranted but like I stated earlier, at times some organic neurological conditions can present as depression. So to rule out secondary causes of depression, your doctor may order a MRI brain and tests like thyroid function tests (to check if your thyroid hormones are within the normal range–this is usually a simple blood test).

Treatment of depression: Treatment of depresion when it presents along or during the course of a neurodegenerative condition like dementia and Parkinson’s disease is essentially the same as treatment of idiopathic depression (depression which occurs without any organic cause). It involves using drugs. The most commonly prescribed drugs are those which belong to two classes:

1) Tricyclic antidepressants–drugs which belong to this class include medications like Elavil (amitriptyline) and  nortriptyline.

2) Selective Serotonin Reuptake Inhibitors (SSRIs)–drugs include Prozac (fluoxetine) and Paxil (paroxetine) among numerous others.

If a neurological condition is responsible for the depressive symptomatology. example a frontal lobe tumor then removal of that tumor or treatment of the underlying neurological condition is needed. Other treatments that may be attempted include CBT (cognitive behavioral therapy).

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Parkinson’s disease

Parkinson’s disease is a relatively common neurodegenerative disease. It was first described by James Parkinson in his now classical essay titled ” The Shaking Palsy”. James Parkinson was an astute observer and his longitudinal description of the disease which now bears his name was on the basis of just a single patient.

Like other neurodegenerative diseases, Parkinson’s disease starts in the later age groups (60′s and onwards). Sometimes it may start in the younger age groups especially if there is a family history of the disease. This is referred to as Familial Parkinson’s Disease.

Typical Parkinson’s disease has a clinical triad consisting of:

a) rigidity (patient’s are rigid–when you passively move their limbs you experience increased resistance. Rigidity is a condition in which the tone of the body is increased. Tone refers to the resistance offered to passive movement of a limb across the joint)

b) bradykinesia or akinesia: as the name suggests, this means that the patient’s are bradykinetic. They have paucity of spontaneous movements, when they walk they do not have the characteristic arm swing which describes the human walk.

c) resting tremor: Parkinson’s disease (PD) patient’s have a characteristic tremor in their hands and feet. The tremor is a resting tremor meaning that it is most prominent when they are relaxed and their arms are at complete rest (when you walk, your arms are at rest by the side of your body and the tremor can be clearly seen).

 

Other features of Parkinson’s disease (PD):

d) PD patient’s have a typical disturbance of gait and posture. They seem off balance and are prone to falls. They walk bend forward in short quick steps (as if chasing something). This characteristic gait of PD patient’s has been referred to as festinating gait. If you accidently push a PD patient to the side or backward or forward, they are unable to compensate and may fall down. Falls and the disturbance in gait and posture is an important cause of morbidity in PD patient’s. When PD patient’s turn they do not turn in one smooth motion rather thay turn with small steps.

e) PD patient’s have a mask like face. They do not have the characteristic facial expressions which so define when humans talk. They may not blink while speaking ( sort of staring look), do not smile or frown.

f) PD patient’s may notice a change in their writing. Typically the hand writing becomes smaller and smaller and more illegible. This is referred to as micrographia.

g) The voice of PD patient’s is monotonous and lacks the variations in the pitch and tone which defines human speech.

 

A point to note here is that unlike Alzheimer’s disease, PD patient’s usually have no impairment in memory at least in the early to middle stages of the disease. Later on in the disease course, they may develop cognitive impairments, this condition is referred to as Parkinson’s disease dementia (PDD) or dementia associated with Parkinson’s disease.

Brain Care Foundation

Please visit the Brain Care Foundation of India website at www.braincarefoundation.com

We would appreciate your suggestions and comments as we strive in our endeavor to make neurological services accessible to the poorest of the poor and to care for the brain just not in disease but also in health.

Visit our website:

www.braincarefoundation.com

 

Contact me at:

neurologistnyc@yahoo.com

” It is declared that the senses are superior but more than the senses the mind is superior but more than the mind the intelligence is superior and more than the intelligence that which is superior is the individual consciousness“

 

Lord Krishna in the Bhagavad Gita