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Published on: June 16, 2016
by Tony Dearing for NJ.com:
“Of all the things I’ve lost, I miss my mind the most.”— Mark Twain
The good news is, I haven’t lost mine yet. Although I was beginning to wonder.
Fortunately, Dr. David Libon, a geriatric neuropsychologist at Rowan Medicine, helped put my worries to rest.
I let Libon poke around in my head recently to do some cognitive testing. When he was done, I had a better understanding of how he evaluates people whose brains are being ravaged by dementia. And I had his assurance that I’m not one of them.
Libon has done a lot of research on dementia and cognitive impairment and published more than 120 research papers on the topic. So when I wanted to experience first-hand how someone is tested for Alzheimer’s, he was the guy I went to see.
At the end of an anxious, mentally draining one hour of testing, I asked, quite hesitantly, “So, how . . .” He cut me off in mid-sentence. “Oh, you’re fine,” he said with a wave of his hand.
Thanks, Dr. Libon. Those were the words I wanted to hear.
I lost my mother a little more than a year ago to a form of dementia called frontotemporal degeneration. Since then, I’ve been on a mission. I’m learning everything I can about dementia and how to protect myself against it. Whatever I learn along the way, I intend to share, so you can reduce your risk, too.
I’d met Libon at Rowan’s New Jersey Institute for Successful Aging while doing research for an earlier story on how to tell the warning signs of dementia. But I wanted to learn more. I wanted to see how he assesses someone who’s beginning to show serious signs of cognitive loss.
“There’s no better way to truly appreciate the assessment,” he told me, “than to actually go through it yourself.”
My test had been scheduled weeks in advance. The closer the date drew, the more nervous I became.
I feel my mind has been slipping lately. The other day, I was jotting down a date and it took me a good 10 seconds to remind myself whether this is 2015 or 2016. I notice, too, that when I’m composing emails, I often type in a wrong word, and I swear I didn’t used to do that. I have to proofread my emails more carefully now.
I know forgetfulness or minor word miscues are not harbingers of dementia. We all experience a mild, gradual decline in brain function as we age, although it varies from person to person and generally doesn’t impair our ability to lead a normal, active life.
Still, when you’re approaching your 60th birthday – as I am – and you feel you aren’t as sharp as you used to be, it concerns you. I didn’t want to wonder or worry. I wanted a clear answer. Am I OK up there? Libon was about to determine that, and I was anxious about the results.
“So you’re a little nervous?” he said. “That’s very common. It’s not unusual for there to be a little anxiety at the beginning, but as we get into it, patients become very engaged. They try hard. I can see they’re really trying to do their best.”
When I say that Libon poked around in my head, I’m speaking metaphorically. I didn’t know what to expect, but it turns out that the evaluation he administers is non-invasive. It involves verbal and pen-and-paper exercises, many of them deceptively simple.
“Some of them are extremely easy,” Libon told me. “But others are quite challenging. It ranges from situations where you’ll find there is very little difficulty, to situations where you may have to work a little bit.”
And with that, we began.
In the first exercise, he put a peg board in front of me, and asked me to fit 25 slotted pegs into it with my right hand and then with my left, while he timed me. It felt like an easy warm-up exercise, which I completed in a couple of minutes.
Next came a bevy of numbers and letters. These are exercises you can try yourself if you care to.
Libon had me count backward from 20. He then asked me to count forward, starting with 1 and adding 3 each time, as in 1 – 4 – 7 . . . Next, he wanted me to tell him the months of the year, forward and backward. Then he had me recite the letters of the alphabet that rhyme with the word “key,” such G or T. When I did that one, I missed the letter V, which I’m sure he noted. He followed that by asking me to think of the alphabet in upper case and give him all the letters that have at least one curved line, such as B or G, but not T or X. That one, I managed to do correctly.
We took a pause.
“What do you think so far?” he asked.
“I’m still feeling the nerves,” I told him. “But these seem like things most people should be able to do.”
“It’s really a collection of tasks which are designed to challenge an individual with something that should be quite automatized,” Libon said. “But when we’re asked to recite months backwards or the alphabet tests, these are not situations we necessarily deal with on a day-in and day-out basis. They’re not automatized. Tests like this can be quite sensitive to the early emergence of a problem. You, of course, did perfectly fine. No problems.”
Nice to hear that. But there was plenty of testing left, and the tasks got tougher.
Libon recited a series of numbers and had me repeat them. First two digits, then three digits, then four. He worked his way up to six digits, and I hung right with him.
Then he threw me a curve. He recited a new set of numbers, and I had to repeat them in reverse order, as you’ll see in the video here. Once he got up to four digits, I began to jumble the numbers. He said, “8 – 2 – 7 – 9,” but I responded, “9 – 7 – 8 – 2.”
I got two of the final four wrong. Was that normal? Or the first sign that something was amiss? My anxiety began to rise again.
“You can appreciate the difference when asked to repeat numbers forward versus asked to repeat numbers backward,” Libon said. “Asking patients to repeat numbers forward assesses something we call auditory span, which is how many bits of information can you keep in mind. When you ask patients to repeat numbers backwards, then you’re assessing a more sophisticated operation, which is sometimes referred to as mental manipulation, or working memory.”
I noticed that he didn’t say anything about how well I’d done.
The next exercise required digital dexterity and rapid response time, and I had trouble keeping up.
We took another pause.
“If you’ve had enough,” Libon said, “just tell me.”
But I was game to go on.
He took me through two more exercises. The first was a breeze. The second was what’s called a verbal fluency test, where you’re given a category, such as “fruits” or “professions” and you’re asked to name as many as you can in 60 seconds. I started out well enough, but then got stuck, and paused for what felt like an eternity (though it was only four seconds, according to Libon, who timed me). I regrouped, and managed to give him 19 responses, which he said was about average.
And then we were done. Whew.
“So when you finish,” I said, “is the first question people ask, ‘How’d I do?'”
“You’d be surprised,” Libon said. “A lot of people say, ‘OK, we’re done? Good. Can I use the bathroom now?’ Some patients ask, some don’t.”
Libon assured me I’d done fine on the abbreviated series of tests he’d given me, and explained what a full workup for dementia involves. Someone showing serious indications of dementia would get a complete medical examination, to rule out other possible medical problems, and a CAT scan or MRI.
Libon said the technology available today is “very powerful, totally mind-blowing,” but the simple tests he put me through remain fundamental tools of cognitive evaluation.
“What can an MRI tell you about cognition? Not one thing,” he said. “It tells you other things, but it doesn’t tell you how people think. This tells you how people think.”
Libon said some of the tests he uses today have their origins in the Golden Age of Neurology, a period from 1875 to 1914 when Dr. Alois Alzheimer and others did pioneering work.
“At the end of the day, the brain hasn’t changed that much from the 1870s to the beginning part of the 21st Century,” he said. “The brain is the brain. What I demonstrated just now to you is not that different than how Alzheimer worked up his famous patient Auguste, the person who was the reason it got called Alzheimer’s disease.”
The grim reality is that more than a century later, there still is no cure for Alzheimer’s. But we know a lot more now about how to prevent it.
I’m immensely relieved to know that I do not show the symptoms of Alzheimer’s, and I’m determined to stay that way. Every day, I gain a better understanding of what can be done to ward off dementia, or at least delay the onset of it.
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