Sarasota Neurology

There are many studies that have shown excellent health benefits from taking omega 3 type fish oil. Omega 3 oils are found in fish oils, flax seed and several vegetable oils including canola, soybean and olive oils. There are different components to these oils that provide health benefits. The DHA and EPA oils in fish oil have been linked to reducing hardening of the arteries and lowering triglycerides. They also have the benefit of lowering blood pressure and heart rate to a mild degree. This all results in an overall reduction in risk for coronary artery disease, heart attack, sudden death, irregular heart beat and stroke. Fish oil can also have a blood thinning effect to reduce abnormal blood clotting, similar to that of aspirin. This latter effect is a two edge sword because too much fish oil can increase the risk for serious bleeding. Generally three grams (3000 mg) daily or less is considered safe. Daily intake of Omega 3 should come from dietary sources with no more than 2000 mg (2 grams) coming from supplements.

Omega-3 is derived from high fat containing fish such as albacore tuna, salmon, flounder, pompano, anchovies, sardines and mackerel. Fish in the equatorial regions around South America have a higher content of Omega 3 than do those caught in the more northern areas around Scandinavia and Iceland. Interestingly flax seed, flax oil and kiwi fruit contain higher amounts of Omega 3 oils than do that of fish. Flax seed can be added to cereal, baked goods or eaten alone. Fish oil capsules are available in 1000 mg and 1200 mg sizes. It is important to not confuse Omega-3 oils with Omega-6 oils. Omega-6 oils do not confer the health benefits that Omega-3 fish oils do. Omega-6 is found in high concentrations in various types of vegetable oils derived from the following: corn, safflower, sesame, soybean, sunflower and walnuts. It is important to reduce the consumption of Omega-6 oils as they compete with Omega-3 oils, thereby decreasing the benefit from Omega-3 fish oils. Eating fish twice a week is the standard recommendation, in addition to taking any supplements.

There have been many studies showing the beneficial effects of Omega-3 oils. The main benefit comes from reduction of hardening of the arteries (atherosclerosis), reduced coronary artery disease, decreased risk of heart attack and potentially fatal heart beat rhythms. Omega-3 oils have also been shown in some studies to have a brain cell protective effect in such conditions as Alzheimer’s and Parkinson’s disease. Fish oils can improve memory to a degree. Several studies have shown that 2000-3000 mg of Omega-3 oil intake daily, has a potent antiinflammatory action as that of high dose ibuprofen. Patients with arthritis or rheumatoid arthritis may benefit from Omega-3, without the risks associated with taking
antiinflammatory drugs for extended periods (such as bleeding stomach ulcers, kidney and liver damage.) It should be noted that the fish oil capsules have a more robust effect for reducing inflammation than that of flax seed oils.

Omega-3 oils can reduce total triglyceride levels and increase “good” cholesterol (HDL) levels. These oils also have an overall beneficial effect on the blood vessels, both in increasing blood flow and improving the health and stability of the vessel walls themselves. This effect is in part responsible for the risk reduction in having a stroke or heart attack as well as patients with problematic varicose veins and leg pains due to peripheral vascular disease. A word of caution: in patients with congestive heart failure, consultation with your cardiologist is first advised. As fish oil has a blood thinning effect, you should check with your doctor if you are taking prescription blood thinners. Additional benefits from Omega-3 fish oils have been shown in improving retinal (visual) function and possibly slowing down macular degeneration. Studies in psychiatric conditions have demonstrated Omega-3 beneficial effects in reducing depression, lessening memory loss and improving memory function.

Recent studies have suggested that qualifying Parkinson patients benefit from earlier treatment with deep brain stimulation, as reported in Clinical Neurology News. The study indicates that younger Parkinson disease patients are more likely to benefit from early brain stimulator treatment. There is information that may suggest that this therapy may have a protective effect in delaying the progression of Parkinson’s disease. Deep brain stimulation (DBS) was FDA approved in 2002 for treatment of Parkinson’s disease. Symptoms that are best controlled include tremor and dyskinesias although brain stimulation can also help reduce freezing and off time. Younger Parkinson patients develop motor complications such as dyskinesias, off time and freezing much earlier than older patients with Parkinson’s disease. As reported by Dr. David Charles, a Vanderbilt University Medical Center Parkinson neurologist, “No therapy…has bee shown to slow the progression of Parkinson’s.” The previous thinking was to wait until a patient had severe motor complications that could not be controlled with medications prior to considering DBS therapy. The new thinking, and research, is exploring benefits of DBS in earlier stages of Parkinson’s disease. In various reported cases, patients not only benefited from better control of their Parkinson motor symptoms but also had improved quality of life. Added advantages is that Parkinson patients treated earlier with DBS used less medications over an 18 month period, as shown in one small study. There are two studies currently looking at the benefits of early DBS therapy in Parkinson patients: EARLYSTIM is a French study and a smaller study at Vanderbilt University are in progress. It should be noted that Parkinson’s disease is a progressive neurodegenerative disorder. Even patients with DBS therapy do have progression of their symptoms. Memory loss can be a part of the Parkinson syndrome and is not helped by DBS therapy. DBS is not a substitute for optimal neurological and medication management of Parkinson symptoms. Dr. Kassicieh, at Sarasota Neurology, provides medical and neurological management for patients with Parkinson’s disease and brain stimulators. For more information click here.

Post-concussion syndrome (PCS) results from injuries to the head. This can range from mild concussions (being struck on the head) to severe head injuries. Not always does the degree of head trauma correlate with the degree and symptoms of PCS. It is estimated that approximately 60-80% of patients suffering a moderate to severe concussion, traumatic brain injury (TBI), will develop PCS. In milder head injuries, PCS will develop up in up to 40-50% of injured individuals. Loss of consciousness is not a requirement for development of PCS. It is not even a requirement that there be a direct head injury. Patients who have sudden jerking movements of the head, particularly in car accidents, with out direct head trauma can suffer from PCS. Risk factors for development of PCS can include lower education level, drug or alcohol abuse, prior head injuries, or preexisting depression or anxiety. The recognition and diagnosis of the symptoms of PCS are important in helping affected patients to return to normal a quickly as possible.

The symptoms of PCS may develop immediately or make take days to several weeks to become apparent. Headaches and dizziness are the most common complaints in patients with PCS. These however are not the only symptoms that can be associated with PCS. Varying degrees of memory loss, concentration difficulty, anxiety, depression, irritability, emotional and behavioral disturbances, insomnia and personality changes. The headaches can vary from mild, dull, generalized headache to severe migraine like headaches. These headaches usually occur daily and can be quite debilitating. Dizziness can be anywhere from lightheadedness to a spinning type of dizziness known as vertigo. Patient can have irritability, anxiety and depression, partly due to the head injury but also from the persistence of their symptoms. Insomnia frequently accompanies these other psychological symptoms. In more severe case, behavioral changes can occur. Patients can become impulsive and irrational in their behavior. Psychological changes are more apparent later in the course of PCS. Decreased ability to concentrate and slowness in mental function can occur, particularly in higher functioning individuals.

Treatment for PCS is primarily time. Many of the symptoms of PCS will clear within days to a few weeks. A typical time for clearing of symptoms is usually 3 months and as much as 6 months. In 10-15% of the cases it can take a year or more for improvement. The earlier the diagnosis is made, generally the better the outcome. Headaches and dizziness complaints most commonly bring the patient to a doctor’s office. Patients may have tension headaches, migraine headaches or a condition known as occipital neuralgia. The latter is an injury to the occipital nerve at the base of the skull. The most effective treatment for this condition is an occipital nerve block. Other headache conditions are treated with the usual preventative migraine medications protocols. As anxiety, irritability and depression are common symptoms of PCS, the antidepressant medications are the most effective treatment for both the headaches and psychological symptoms. Antidepressant medications have been used for decades in controlling migraine and other headache disorders. Over-the-counter analgesics can be used to relieve headache and neck pains. Narcotics should be avoided as they are addictive and do not help the overall patient outcome.  Mayo Clinic has an excellent, comprehensive summary of post-concussion syndrome.

In patients who have persistent complaints of memory loss, concentration difficulties, forgetfulness, anxiety and depression, neuropsychological testing followed by counseling can be helpful in patient management and improvement of symptoms. Testing is usually not done for at least 3-6 months following the head injury. This is because so many patients will spontaneously improve over this time period. Once testing is completed, the psychologist can help the patient through counseling to improve their overall well being. Other diagnostic tests may be performed and can include MRI brain studies, EEG or PET scan.

Prognosis for patients with PCS is excellent in the majority of the cases. Most patients are back to their normal baseline within a few weeks, with a few taking as long a 3 months. It is far less common for patients to continue having symptoms beyond this. It is estimated that only about 15% of patients with PCS will have symptoms a year or more. Early treatment by experienced neurologists or other physicians who have training in treatment of concussion, traumatic brain injuries and post-concussion syndrome are important in improving a patient’s quality of life in as short of period of time as possible.

Many patients over the age of 65 complain of memory loss and are concerned they have dementia. Others attribute their memory loss to aging. While there is a very mild degree of memory loss associated with aging, it is usually not significant. For example, forgetting where you put your keys or where you parked your car. These are not serious memory problems. A more problematic degree of memory loss, while not dementia, is called Mild Cognitive Impairment (MCI). MCI is characterized by an increase level of forgetfulness. There are two primary types of MCI: (1) Amnestic MCI (2) Non-amnestic MCI. In patients affected with amnestic MCI, they have significant memory and recall difficulty. There is a stronger association with this type of MCI with Alzheimer’s disease. Non-amnestic MCI usually does not progress to Alzheimer’s disease but may go on to other types of dementia. The good news is that about fifty percent of all patient’s with MCI never progress to Alzheimer’s or any other dementia. MCI can also spontaneously improve and clear.

The American Academy of Neurology published criteria for the diagnosis of MCI: (1) Individuals reporting their awareness of memory difficulty - preferably confirmed by a spouse or child; (2) Measurable memory loss greater than would be expected for age; (3) Normal general thinking and reasoning skills; (4) Ability to perform routine daily activities. Frequently patients with MCI have specific areas in which they are having memory trouble whereas patients affected with dementia have more global memory difficulties. Also quite frequently, patients with dementia are unaware of having any memory problem at all.

Risk factors for MCI and mild memory loss include such things as high blood pressure, lower educational levels, lack of physical and mental activities and vascular disease. Vascular dementia is seen in patients that have had multiple small strokes. Abnormally low blood pressure, particularly in patients with significant brain vascular disease (hardening of the arteries) can be a cause of reversible memory loss. Depression can cause a condition of memory loss known as pseudo-dementia syndrome of depression. Fortunately this is treatable and the “memory loss” is reversible in this condition.

In those patients affected with MCI, they can go on to develop dementia, usually Alzheimer’s disease. The true incidence is difficult to measure and ranges between 27-65% depending on which study one reads. Some studies have shown that the use of memory loss medications such as donzepil (Aricept®) can help improve memory function and potentially slow the progression of memory loss. It should be noted that in patients over the age of 70, approximately 12% will have some degree of memory difficulty. This is highly variable from patient to patient.

In summary, if you have a sense that you have memory difficulty, do not attribute it to normal aging. Consider seeing a neurologist trained in evaluating memory disorders and Alzheimer’s disease. You have everything to gain by improving your quality of life.

Namenda (memantine) is the newest medication used in the treatment of Alzheimer’s disease. New research has shown that Namenda may be effective in treating patients with both migraine and tension headaches. The study done by John Krusz, PhD, MD showed that some patients with chronic migraines that did not do well with other headache treatments, did well with Namenda therapy. Of the migraine sufferers, there was a 56% drop in the number of migraine attacks. In patients with tension headaches there was a 62% drop in the numbers of attacks. This study was well reviewed on the website, Help for Headaches and Migraines.

Migraine and other headaches are chronic medical conditions that require aggressive preventative treatment. Many therapies have been tried but no cure has been found. Botox treatment has been promoted by the press but no clinical studies have showed that it is superior in migraine treatment than placebo. Having said that, there are certainly patients that have had migraine and headache reduction after Botox therapy.

It is important to note that the use of Namenda, Botox and most other migraine treatments are off-label uses of these and other medications. The majority of medications routinely used in the prevention of migraines are off-label. This is the standard of care in most headache clinics. If you suffer from migraines that prevent you from routine activities or interfere with work, you need to seek out help from a qualified neurologist who specializes in migraine headache treatment.

Normal pressure hydrocephalus once again appears in the news. Zig Ziglar, a well known motivational speaker, recently was diagnosed with normal pressure hydrocephalus. About a year ago, Mr. Ziglar had suffered a fall down a flight of stairs, as referenced on a blog from Michael Pink. His family had noticed that Mr. Ziglar was having some memory loss associated with gait unsteadiness.  The characteristic clinical symptoms of normal pressure hydrocephalus are gait unsteadiness, memory loss and urinary incontinence. The exact cause of this condition is unknown but what happens is there is a build up of water (spinal fluid) on the brain. Diagnosis is difficult to make and one should see a neurologist familiar with the condition. The treatment for this is putting a special tube in the brain, known as a shunt. This is a fairly routine neurosurgical procedure.

For the diagnosis of normal pressure hydrocephalus, a patient should first have a CT scan or MRI brain scan. If the spaces in the brain that contain spinal fluid (ventricles) are enlarged, the patient should then have a spinal tap. About an ounce of spinal fluid taken drained off. Then the patient will have gait testing to see if their walking improves. If it does but then worsens a few hours later, the diagnosis is made. A brain shunt can then be permanently put in by a qualified neurosurgeon. Patient’s with true normal pressure hydrocephalus can show dramatic improvements in their ability to walk with gait training rehabilitation. The urinary incontinence will also improve. Unfortunately, if they have a degree of short term memory loss, this procedure will have little if any effect on restoring memory. It is this author’s hope that Zig Ziglar has improved and is doing well with his new brain shunt. To find out more about Zig Ziglar, check his blog site.

Normal pressure hydrocephalus (NPH) is a rare disorder that is characterized by progressive gait difficulty, urinary incontinence and memory loss. Although the press has covered this topic extensively in both the written and video media, true normal pressure hydrocephalus remains quite uncommon. The underlying problem is actually an excessive build up of spinal fluid in the brain. The areas of the brain that stores this fluid are known as the ventricles. In NPH, the spinal fluid flows out of the brain but, due to reasons that are not entirely clear, there is a build up of excessive fluid in the brain. This results in enlarged ventricles causing a condition called communicating hydrocephalus.

Normal pressure hydrocephalus develops very slowly, over months to years. It is usually seen in individuals over the age of 65. As the ventricles slowly increase in size, affected patients begin to show signs of slowed, wide based, unsteady gait. Urinary incontinence may also develop during this time. Later during the disease process memory loss begins. All of the symptoms are very slowly progressive. Patients can be diagnosed incorrectly with Parkinson’s disease, Alzheimer’s disease, depression or just dementia.

The gait difficulty comes from the fact the the nerve fibers that control walking and balance become stretched as the ventricles enlarge. With this comes progressively worsening gait imbalance and falling. Patients may complain of weakness and fatigue. Patients will actually will tell you that their feet feel stuck to the ground, giving rise to the term magnetic gait. Memory loss seen in normal pressure involves mainly recall and slowness of thinking. Recognition of objects, tasks and individuals is better preserved. Without careful testing however, one can easily make the mistake of making an erroneous diagnosis of Alzheimer’s disease versus normal pressure hydrocephalus associated dementia. Urinary incontinence is a later finding in the disease process. There is an increasing need to urinate more frequently and urgently. If the dementia progresses too far, patients will become indifferent to their incontinence.

Diagnosis is made by obtaining an MRI or CT brain scan. The ventricles appear enlarged in the absence of brain atrophy (shrinkage.) As a normal process of aging, there is a certain amount of atrophy. It other conditions such as Alzheimer’s disease, alcoholism or in patient’s who have received chemotherapy, brain atrophy can be more prominent. The key in diagnosing NPH is that the degree of ventricular enlargement is out of proportion to the expected degree of atrophy. The degree of ventricular enlargement can be measured as a ratio to the degree of atrophy. The second step in diagnosis, after a complete neurological exam, is to do a diagnostic spinal tap (lumbar puncture.) During this procedure, 1-2 ounces of spinal fluid is drained off. The patient is then tested to see if their gait improves.

Treatment for confirmed cases of normal pressure hydrocephalus is a brain surgery procedure know as a ventriculoperitoneal shunt placement. In this procedure, a tube is placed in the ventricles and the other end drains into the abdomen. The tube is run under the skin. Spinal fluid is then absorbed in the abdomen. There is no known effective medical treatment for NPH. Early diagnosis and treatment is important as the gait disorder and urinary symptoms can be alleviated. Once the memory loss has begun, this cannot be reversed.

In order to have the accurate diagnosis of normal pressure hydrocephalus, a patient should be seen by a neurologist or neurosurgeon familiar with the condition. It is not necessarily easily diagnosed, even by experienced physicians. Nonspecific gait disorder is common with advancing age. Dementia is also common, particularly over the age of 70. Stroke, Parkinson’s disease and low thyroid can mimic the symptoms of normal pressure hydrocephalus. The main point is that of all these conditions, true normal pressure hydrocephalus occurs very rarely and is generally considered a diagnosis of exclusion of every other problem plus meet the diagnostic criteria listed above.

The FDA has recently approved the dementia fighting drug Exelon in a patch form. The new formulation, Transdermal Exelon, offers patients a new and unique way to get medication which can help with improving cognitive function and slow down memory loss in patients suffering from Alzheimer’s disease. The new patch is also FDA approved for patients with Parkinson associated dementia. This is the second patch approved for use in treatment of Parkinson disease. The other is Neupro, a transdermal patch containing the dopamine agonist rotigotine.

Transdermal Exelon joins the group of other medications used to treat Alzheimer’s disease, such as Aricept, Razadyne and Namenda. The patch for of Exelon offers the advantage of not having to take a pill twice daily, continuous medication administration through the skin and less stomach upset. Another advantage is that the patch demonstrated beneficial effects equivalent to the maximum oral dosing of this medication. The problem with the oral medication was intolerance due to nausea and vomiting. While much less, there were some reports of stomach upset with Transdermal Exelon. Another side effect, common to most patch medications, was that of skin irritation. The patch needs to be changed daily and administration sites should be rotated, not using the same site more than once every two weeks. While Exelon, Aricept and Razadyne are in the same chemical family of memory disorder drugs - the acetylcholine esterase inhibitors - Namenda is in a class by itself. For this reason, it can be used in combination with any of the other three. Studies have shown that there is a beneficial effect in improving cognitive function with combining these two different types of medication. Studies are looking into the use of these medications for patients with mild cognitive impairment. These are individuals who have some memory loss but do not fit the criteria to be diagnosed with dementia. Depression, manifesting as dementia, also needs to be excluded.

Alzheimer’s disease is a chronic debilitating illness that slowly robs patients of their memory, cognitive abilities and ability to function independently. They become more and more dependent on others to provide care and transportation for them. Even dressing, eating and bathing become impossible for them to perform without assistance. With the availability of these new memory drugs, the progression of the debilitating symptoms of Alzheimer’s disease and Parkinson disease associated dementia can be slowed down. Some patients actually show functional improvement. Unfortunately, none of these medications halt the progression of the disease. Eventually their quality of life deteriorates and others will need to assist with care giving. The benefit of these medications is that they significantly slow the progression of the disease, possibly keeping loved ones at home, instead of a nursing home, for anywhere from 6-18 months. If you have a loved one with memory loss, early diagnosis and treatment is important. Studies are ongoing to show that with earlier treatment, patients do better over extended periods of time. Bring your family member with memory loss to a neurologist for a complete evaluation.

Memory loss is a frequent patient complaint that I see in my office. Patients with this complaint are generally over the age of 65 but occasionally I will see someone in their 40s or 50s with this problem. For all patients, it is important to get a detailed history of when they first noticed the problem and has it been getting worse. What kinds of things do they forget. Does it happen all the time. A brief memory test, the MMPI can be performed. This simple test can give the physician a general idea on the degree of memory loss. Further tests should be performed such as a CT or MRI brain scan to look for stroke, hydrocephalus or other abnormalities. Simple lab screening for diabetes, low thyroid and vitamin deficiencies are commonly ordered.

Once testing has been completed, treatment can be started. For many younger patients, memory loss is due to a combination of stress, depression and other situational problems. It is rarely due to dementia or some other progressive neurodegenerative problem. Antidepressant medications are frequently helpful in these situations. By alleviating anxiety and depression, a patient’s “memory loss” can be cleared. Patient’s with persistent memory problems may need to undergo a further course of memory testing by a psychologist. This 4-6 hour testing session gives a detailed analysis of what type of memory problems a patient may be experiencing. This can range anywhere from depression to Minimal Cognitive Impairment to Alzheimer’s disease.

Minimal cognitive impairment is characterized by simple memory loss. Affected patient’s have difficulty remembering certain things, without having their global memory function and other aspects of thinking impaired. There is commonly underlying depression, but this is not the specific cause of their memory loss. In patients with Alzheimer’s disease or other dementias, short and intermediate term memory is more commonly affected. These patients can also have trouble with finding words, commonly misplacing objects and loss of social graces.

There are several medications that are used in treating memory loss. Aricept, Exelon and Razadyne are all similar in the was that they work to help slow down the progression of memory loss and dementia. Namenda is another memory loss medication that works differently than the other 3 medications. It can be used alone or in combination with one of the other memory drugs. The combination therapy has been shown to have a very significant, beneficial effect in some patients in improving their cognitive processing and memory function. It is important that a patient be evaluated as soon as a problem is suspected. Studies have shown that the earlier one of these medications is started, the better the patient does over the long run. While these medications do not have FDA approval for minimal cognitive impairment, some studies have shown that the memory loss medications are helpful in these cases as well.