What is your name? How old are you? What day is it?
Simple questions such as these are the basis for the mental state assessment (MMSE) commonly accepted and administered in a couple of minutes in primary care settings.1 But how valuable to you or your physician would a perfect score be? Or, on the other hand, would a failing score be?
In the first case, not very valuable, as most people would rattle off the correct answers, even if they had lost 30% or more of their peak cognitive ability. In the latter case, a failing score would not be very valuable either. Why? Because if one could not answer most of these questions correctly, one would be so diminished mentally that corrective measures would be of little, if any, use.
More than 2 million Americans have been diagnosed with Alz-heimer’s disease. If we do not do a better job now of preventing or slowing cognitive decline, this number will jump dramatically when the baby-boom generation reaches age 65.2,3 Fortunately, we have at our disposal tests that provide more-meaningful memory assessments that can be administered earlier when effective interventions can be prescribed.
Forewarned Is Forearmed
Just as cardiovascular disease is preceded by 20 years of cholesterol buildup and hypertension—conditions that now are being controlled or reversed—diseases such as Alzheimer’s and dementia are preceded by a long, steady decline in mental faculties, including memory function.
According to Eric Braverman, MD, an expert on brain function, “It is so sad when children bring 65-year-old parents to me who are so far gone mentally. If only I had seen these patients [while they were] in their early 50s, much heartbreak could have been avoided. Whole communities used to be wiped out by storms before the advent of radar, satellites, and sophisticated forecasting models. There’s no reason for future seniors to be deprived of vitality prematurely when we know what can be done 15 or 20 years prior to age 70. I have seen many patients experience a complete reversal of memory loss when it is diagnosed and treated in its early stages. I have also treated patients with advanced dementia who have, on rare occasions, experienced a return of speech and memory function.”
While age is the primary risk factor for dementia, recent studies have suggested that regular administration of memory tests can identify non-demented persons at greater or lesser risk for conversions to frank dementia.4 Tests such as the Wechsler Memory Scale (WMSIII) can be given in a primary care setting to quantify the decline toward Alzheimer’s. Although these tests take upwards of an hour to administer, their results provide a comprehensive assessment for baseline values and treatment protocols, and the tests are far more effective than the MMSE for early identification of cognitive impairment.5
The “Cholesterol Test” for Brain Function
Another test can now be used for an easier early assessment of memory function. Dr. Braverman and other doctors (see sidebar on p. 52, “Sources of P300 Testing”) use brainwave testing in a primary care setting as an early-warning signal of memory decline. Such tests are noninvasive and can be administered in 10 minutes using electrodes similar to those used in an EKG. As part of a quantitative electroencephalography (QEEG) test, the P300 wave shows a patient’s reaction time to an audio tone. Normal response is 300 milliseconds (ms) plus the patient’s age. So a 40-year-old patient should react to a sound 340 ms after he hears it.
An extensive study conducted by Dr. Braverman with more than 1,500 of his patients correlated age with P300 readings and has shown that readings in excess of 400 ms would correlate to a chronological age in excess of 100, which are typical of patients suffering dementia. The same study reviewed age-related P300 values with MMSE and WMSIII scores to correlate the P300 readings with actual memory impairment.5 Other studies have confirmed the correlation between P300 readings and age.6-8
How can this knowledge be used in a clinical setting? In cardiology, an established protocol exists for heart and vascular health assessment: electrocardiogram (EKG), echocardiogram, stress test, and blood analysis, with cholesterol levels as an early marker for future disease. A parallel can be drawn for the assessment of brain function: QEEG, attention, intelligence quotient (IQ), memory, and psychological testing, with the P300 reading as an early marker for future cognitive impairment. “I consider the P300 to be the cholesterol test for the brain,” says Braverman.
Other doctors recognize the value of P300 as an early diagnostic tool. “At a time when the US population is aging, the electrophysiological findings [of the study] bode well as a valuable prognostic tool for brain impairment,” says Ernest Noble, MD, PhD, professor of psychiatry at UCLA and former director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a division of the National Institutes of Health.
“The use of quantitative EEG measures is a promising technique to assess memory and other cognitive functions,” adds Orrin Devinsky, MD, professor of neurology, neurosurgery, and psychiatry at the New York University School of Medicine.
If a 50-year-old patient has a P300 reading of 370 ms, that would indicate his brain is functioning as though he were 70 years old, and he would likely exhibit cognitive declines consistent with that advanced age. In such cases, the WMSIII should be administered and additional tests of attention and IQ should be ordered to quantify such declines. Test results would be used as a baseline for future assessments after treatments are implemented. Just as a cholesterol test is instructive when evaluating future cardiovascular health, the P300 is an early-warning signal for cognitive impairment.9
The value of the P300 is perhaps best summarized by John Polich, PhD, associate professor of neuropharmacology at the Scripps Research Institute in La Jolla, CA: “It’s a better cornerstone than anything available today for Alzheimer’s early detection.”
Function Follows Form
The study of the brain over two millennia has resulted in an entire body of knowledge related to anatomy, physiology, and psychology. Much is now understood about the four lobe pairs, each of which has a primary neurotransmitter (biochemical) that initiates brain activity, a primary function associated with it, a dominant brainwave, and dominant psychological traits.
The frontal lobes, where dopamine provides energy, generates beta waves and controls thought. The temporal lobes, where gamma aminobutyric acid (GABA) provides calm, generates theta waves and controls hearing. The parietal lobes, where acetylcholine provides brain speed, generates alpha waves and controls memory. The occipital lobes, where serotonin provides restorative ability, generates delta waves and controls sight. As for psychological temperaments, strategic thinkers would be dominated by their frontal lobes, traditionalists would be dominated by their temporal lobes, idealists would be dominated by their parietal lobes, and artisans would be dominated by their occipital lobes.
The brain is very “plastic” by nature, with functions shared somewhat by all lobes. The cognitive functions of IQ, attention, and memory are subdivided into four types of each, related primarily to a specific lobe pair. So abstract, emotional, creative, and perceptual IQs are associated with the frontal, temporal, parietal, and occipital lobes, respectively, and consistency, commission, omission, and reaction time measures of attention can be similarly associated. When it comes to memory, primary function resides in the parietal lobes, where immediate, or short-term, memory supports three other types of memory—working, verbal, and visual—that can are associated with the frontal, temporal, and occipital lobes, respectively.
Why is this important? The initial stages of memory decline manifest problems associated with immediate memory. Assessing this earlier, starting at age 40, affords an opportunity to intervene as soon as a deficiency becomes apparent, when better outcomes can be achieved.
Holistic Memory Assessment
Medical conditions rarely exist or are treated effectively in a vacuum. Individual symptoms such as irritable bowel, palpitations, and clammy hands could be addressed with multiple prescriptions from multiple physicians in multiple locations—or one enlightened physician in one office could treat the underlying anxiety responsible for them all. The same holds true with memory.
Numerous illnesses, such as depression, obsessive-compulsive disorder, and diabetes, affect cognitive function.10-12 Addictions to alcohol, tobacco, and drugs also have been studied for their relation to the brain.13-15 Coronary bypass surgery and the menstrual cycle affect cognition.16,17 A temporary anxious moment could cause a “tip-of-the-tongue” short-term memory loss.
The list continues: toxic metal poisoning, menopause, posttraumatic stress, head injuries, chronic fatigue, anemia, kidney failure, pulmonary disease—all affect brain function and thus memory.18-21 A comprehensive health assessment would identify contributing factors to memory impairment and would provide the necessary information for a global treatment plan. Such an assessment can be administered in the primary care setting, and would include:
- Testing of the four types of attention, using a simple personal computer
- IQ evaluation using standardized written tests
- Psychiatric assessment, using a standardized true/false exam
- Ultrasound to assess carotid arteries
- Blood testing for toxic metal, amino acid, and vitamin levels
- Patient history
- Diet and lifestyle review.