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Category: Memory Problems

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Adults Alzhimers Featured Memory Problems Patient Stories

Of menopause & memory

A is a generally healthy and active woman professional of about 48 summers. I know her socially, well, and was curious when she sought an urgent appointment to see me professionally. “I am losing my memory doc”, was A’s first statement as she walked into my office. Probing further I found A was complaining of much more that absent mindedness. Word finding difficulties, struggling with routine skills like driving, becoming disoriented on arriving in a hitherto familiar location, not precisely remembering why she was there anyway, the list seemed endless. “Am I getting Alzheimer’s doc” was her genuine concern, expressed more than once as our interview progressed. 

Different Strokes

I asked her about her general health- whether she had any of the four key lifestyle risk factors which predispose to memory loss: Hypertension, Obesity, Lipid (high cholesterol) or Diabetes. While she did not have high blood pressure, blood sugar or cholesterol, she had been overweight until 2 years ago when she went ahead and elected to have bariatric surgery abroad. Following this she has lost considerable weight and had been on a rather severe diet that was recommended for about 18 months after. “I am slowly resuming a normal diet, but the quantities I eat remain small”, said A. On questioning she reported normal thyroid function, no lupus or other such inflammatory condition, both of which can also predispose to memory problems in younger people. Her heart and kidneys had been declared “fit and well” by her physician, during her last master health evaluation. What about your monthly periods, I demurred? “Menopause finally set in doc, about 2 years ago”, said A. When did the memory problems start, I wondered? A thought for a few moments before responding; “about the same time as my periods started tapering off” she responded. A clarified to leading questions that she was not under any significant emotional stress, nor were there any stressful life events in recent times. Indeed, with both children off to college and her husband having come into considerable wealth recently, A felt life could not be better, especially as they now had the time, resources and freedom to travel, something they both enjoyed. I asked her about neurological events or symptoms during her lifetime: head injury, seizures, fainting episodes, strokes, to all of which she replied in the negative. 

On physical evaluation A was completely well and there were no signs of concern. On the bedside evaluation of memory and cognition, though, I found A struggled a little with tasks of attention (focus), recent memory (recall) & executive function (ability to perform tasks in sequence), resulting in her working memory being somewhat affected. She did manage to remember and perform most tasks: however, she was a little less efficient and speedy than I expected her to be, considering that she was a smart & efficient professional. The obligatory brain scan (as a measure of safety) was normal, but her blood tests revealed that she was deficient in vitamin B12 (an outcome of her dietary restrictions following bariatric surgery) with elevated homocysteine, a brain chemical that is associated with memory problems. I concluded therefore that A had two reversible causes of memory impairment: vitamin B12 deficiency & menopause. 

The Menopause Effect

The World Health Organization defines the perimenopause as the time immediately preceding the menopause, beginning with endocrine, biologic, and clinical changes, and ending a year after the final menstrual period. The Study of Women’s Health Across the Nation (SWAN) published in the American Journal of Epidemiology (2000) showed that of 12425 women aged 45-55 years across sociodemographic categories who participated, between 31 and 44 % of perimenopausal women, endorsed forgetfulness. Overall perimenopausal women were 1.4 times more likely than premenopausal women to be forgetful, this finding not being just due to emotional stress. Indeed, there is considerable research today to show that in the year after the final menstrual period, women do demonstrate deficits in attention, working memory, visual & verbal memory and motor speed. Interestingly, studies like the “Harvard Study of Moods & Cycles” show that in the perimenopausal period, women are twice as likely to be depressed, and while this is not related to negative life events, it is associated with vasomotor symptoms (hot flushes). This links up with the theory that the brain hormone cortisol (which exercises an influence on the reproductive hormones) may be associated with both memory and mood; that higher cortisol levels and/or greater cortisol reactivity may be the biological link between hot flashes, depressive or anxiety symptoms and perimenopausal decrements in memory. Indeed, research has shown that young women have lower reactivity to cortisol than older (perimenopausal) women. This of course brings up the inevitable question, which A asked me “doc, should I be on Hormone Replacement Therapy”? HRT has been both praised and vilified (like many medical procedures) in equal measure. The summary evidence suggests that HRT commenced during the perimenopausal period has the potential to help symptoms of mood, anxiety and perhaps importantly, memory. However, HRT started outside these time periods does not appear to have a similarly beneficial effect, indeed may even be detrimental. 

Prevention & Cure

I had identified in A, apart from menopausal transition, a reversible cause of memory impairment, vit B12 deficiency with elevated homocysteine; which has an impact on memory and makes one vulnerable to having strokes. Other reasons why middle aged individuals like A have problems with memory include depression, infections, inflammations and metabolic (including thyroid) problems (all reversible); cancer, strokes & brain tumours (potentially reversible, at least in part); and  brain degeneration (non- reversible but can be slowed, partly arrested). It is for this reason that people with memory complaints in middle life like A, need to be thoroughly evaluated for a range of causes. A did go through such an evaluation before we concluded that her problems were due to menopausal transition and B12 deficiency, both of which we proceeded to address. We recommended to her, all those things that can help a person stave off memory loss (and indeed lifestyle disease): a healthy and predictable life, an antioxidant rich diet, adequate rest and sleep; regular aerobic exercise (walking, jogging, gymming); yoga, pilates or tai chi as mind-body interventions; moderation in all that one does, including and especially social consumption of alcohol. Turmeric is today in advanced trials and extra virgin coconut oil in early phase trials as a memory protecting agent. The former is adequately present in Indian diets generally; the latter easy to add, admixed with rice etc. We recommended both to A. 

We learnt from her too, as we do from all patients; the links between mood, memory & menopause, preventive health and the importance of holistic evaluation and care. All memory loss is not dementia and women like A in menopausal transition would do well to consider and address that aspect of their health.

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Adults Buddhi Stories Epilepsy & Seizures Featured Memory Problems Patient Stories

Rare illness, caught on time

Rare illness, caught on time
Rare illness, caught on time

Seizures, memory loss, aggression: symptoms that left a television news editor unfit to work. Until a providential diagnosis helped him make a remarkable recovery.

When R, a television news editor in his 40s, came to us a couple of years ago, he was suffering from seizures, poor short-term memory, mood swings, irritability, suspiciousness and aggression. Although he had a great track record at work, his condition had left him unfit to return to his job at a well-known television company. We found that his symptoms were provoked by limbic encephalitis, an antibody syndrome where the body’s immune system attacks rather than defends it. Apart from repeated seizures, the condition, which affects parts of the brain that control memory and emotion (the temporal lobes), had left him with a set of neurobehavioral symptoms.

While treating him for this, a timely visit from Oxford by Angela Vincent, a world renowned expert on antibody syndromes, in 2014, helped us diagnose R with a second, hitherto undiagnosed — and rare — antibody-mediated syndrome called NMDAR 1. We gave him a second course of intravenous steroids (the first having been given during initial presentation) following this discovery, and saw a distinct improvement in his memory and behaviour.

Evaluating R in some detail, we found he had severe deficits in cognition, with very poor ability to remember any new information. Indeed, he took quite a while to even become familiar with our team that was meeting him each day.

Our integrative rehabilitation programme for him was, therefore, focused on memory retraining and behavioural management, but included shirodhara (an Ayurveda treatment with brain-behaviour focus), acupressure, reflexology and physiotherapy. He was also given a combination of drugs to control seizures, enhance memory and modulate behaviour.

Counselling the family, helping them understand his predicament — that his symptoms were not deliberate or put on but an outcome of brain injury — was also part of the treatment. Working with his employer, who was concerned about R’s inability to do even some simple crucial functions, and prescribing a time-frame for our continued efforts, was also essential, helping R retain his job. Indeed, his immediate boss, a popular media personality, visited the centre to discuss R’s condition.

R’s recovery over two years was stormy. Seizure clusters, poorly controlled (pre-existing) diabetes, and an extraordinary reaction to a drug prescribed for seizures resulted in three emergency hospital admissions.

Also, R had great difficulty in accepting changes at home, such as his wife taking on decision-making and financial management roles. Paranoia and disturbed sleep taxed him and his interpersonal relationships greatly. At work, a change in the software platform magnified R’s difficulties. No longer could he work on auto-pilot; skills learnt over two decades were suddenly obsolete.

Supported by a caregiving trinity — family, employer and medical team — working in tandem, R managed to overcome these multifaceted problems.

Two years on, the transformation in R is remarkable. He is seizure-free, composed, communicates clearly, manages well at work having learnt to use the new software platform effectively, and enjoys a close trusting relationship with his family. He still has some residual memory and cognitive dysfunction and attends our centre for weekly cognitive retraining sessions. He continues to take some medication to control seizures and improve his memory.

This father of two, the sole breadwinner of a young family, managed to retain his job and win back his life because of a providential and timely diagnosis.

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Buddhi Stories Dementia & Memory Loss Elders Featured Memory Problems Patient Stories

Jayaram – The Decline

Jayaram – The Decline
Jayaram – The Decline

Biography

It was six years into retirement, in 2009 when the early signs of mental illness surfaced in a subtle manner in Mr. Jayaram. Where had he kept the house keys? How could he forget to buy the cooking oil from the shop round the corner? He had never missed even one of ten items for routine household purchase that his wife verbally listed to him and so she spared herself the trouble of writing it down. Jayaram brushed aside his occasional memory lapses, and went on to read the day’s news, reclining comfortably in his planter cane-and-wood ‘easy chair’, while his wife brought him fresh south Indian filter coffee, even as the television audio sounded the Suprabhatham, the gentle daily chant to wake up the Lord of the Seven Hills.

The wife began to register concern as the memory lapses occurred more frequently. Jayaram appeared agitated at times as if he was experiencing an inner turmoil. Soon he showed signs of social withdrawal.

Exploring the Condition

When the family physician was approached for a routine check up of his hypertensive and diabetic status, for which he was on regular medication for several years, the wife shared her concerns with the doctor. A specialist consultation was advised, but at the very heel of the neurological consultation, Jayaram had lost his way home along his oft trodden path and had to be escorted to his house by tense family members and neighbours. A repeat of this behaviour resulted in GPS tagging and going out on his own became a taboo. A diagnosis of Alzheimer’s Disease was made and T2 Hyperintensities (with his history of long-term diabetes and hypertension) on MRI brain suggested an added vascular element to the dementia.

Following a successful career in a position of authority in Central Government, Jayaram had returned to his hometown near Chennai with his wife to settle to a peaceful retired life. His son and daughter having been married a couple of years earlier, had settled abroad with their respective families. They visited the parents once a year. Jayaram and his wife travelled to USA to be with the children and grandchildren for a few months, as was the practice with many Indian parents with children abroad. Life seemed to offer the best of both worlds. However, this state of well-being was not to last forever.

In early 2015, Jayaram’s condition took a marked downhill course. He developed global insomnia, decreasing appetite, weight loss, and refusal to extend his cooperation in simple activities of daily living, leaving the wife, the principal caregiver, in a desperate state and with increasing inability to cope with the situation. She was in a near ‘burn-out’ phase and that is what  brought her to the doors of TriMed-Neurokrish. He was bed bound, with double incontinence, expressive aphasia (inability to express language through speech or writing), and probable unexpressed pain and discomfort, resultant behavioural and psychological dysfunction. He became stubborn, refusing to follow any instruction. However, formal psychological testing revealed that he had retained several of his cognitive abilities. Repeated and staggered assessments had to be carried out, deriving maximum diagnostic leads during the lucid phases of orientation and patient co-operation.

Our Healing Approach

From the start, the patient management by our team had to be home-care based, since transporting him to the clinic would prove to be a great ordeal all round and would cause exacerbation of behavioural symptoms. A global assessment of the patient was the first step. Jayaram was clearly heading towards Stage 3 Dementia, in the absence of stimulation and positive hand-holding.

The patient was already on multiple drugs for Dementia, Behavioural and Psychological Symptoms of Dememtia (BPSD) and comorbid conditions, prescribed by his regular Neurologist and Diabetologist  over the years. He was on Escitalopam 10 mg – 0-0-1 (a mood elevator), along with Tab.Donamem 10 mg – 0-0-1  (a combination drug of Donapezil and Memantine and specific for dementia), Tab.Oleanz 2.5 mg – 0-0-1, Olanzipine (an antipsychotic), Tab.Ativan 1 mg – 1/2-0-1, Lorazepam (for a tranquillising effect) and follow up with a Diabetologist and General Physician, who had prescribed regular Tab.Glyciphage 1-0-1, Tab.Telista (Telmisartan) 40mg – 1-0-0,  Tab.Ecosprin 150 mg – 0-0-1 and Tab.Tonact TG (Atorvastatin)  0-0-1 towards control of diabetes and hypertension and blood thinning and cholesterol-lowering  actions,  respectively.

The team decision was to cash in on the patient’s cognitive reserve after reshuffling the regular medicine regimen and introducing add-on medication to tame the BPS.  In short, the focus was on pharmacotherapy to control the BPS, and cognitive therapy to encourage re-establishing basal activities of daily living to start with. He was treated with Dicorate ER 1 g a day and Tab. Escitalopam 10 mg was stepped up to 1-0-1, in addition to Donamem and his other regular medication. The physiotherapist encouraged gait training in a graded manner till the patient was able to walk around the house with support. With this the BPSD symptoms decreased. Remission or reduction of BPSD is known to produce remarkable improvement in the functional and even cognitive  abilities of the patient, which it did in the case of Jayaram. He became more responsive in interpersonal relations, responded to questions, showed some improvement in memory in terms of alphabets, numbers and was able to indulge in meaningful physical activities like throwing a ball.

Glycemic control was one of the foremost challenges at this point, with an erratic dietary pattern, at the patient’s bidding, often ending with poor intake followed by binging on carbohydrates and sweets of his preference. His regular diabetologist reviewed his diabetic status. Jayaam needed a short period of hospitalization as his blood sugar levels were high. On Tab.Galvus Met 50/500 – 1-0-1  and Tab.Diamicron 80 mg 1/2-0-0, the most recent prescription, good control of blood sugar levels and  hypertension was established. A lipids review showed a high level of triglycerides and cholesterol. With titration of the drug dosage during his period in hospital, his medication was lowered subsequently to Escitalopram  10 mg – 0-0-1 and Tab.Dicorate to 750 mg – 0-0-1, and the significant control of the BPS remained. However, the occasional lack of overnight sleep would bring on the screaming, which started as a whimper, built up to a crescendo, staying high-pitched for prolonged stretches into the morning hours.

Meanwhile Jayaram developed an intermittent headache, which he indicated by constantly holding his head with his hands, and tucked between his folded knees. As BPS can increase with pain or other discomfort, a detailed investigation for headache was done and diagnosed to be an exacerbation of the migraine which was recorded in his past history. He was treated with Tab.Sibelium 5 mg, 1 at bedtime which effectively controlled the headache.

Initial hand-holding of the spouse to reduce caregiver fatigue and hopelessness was an essential part of the treatment plan, as much to safeguard her health status as to encourage her active participation in the management of the patient. She had meanwhile learnt to cope with his illness, having reached the acceptance stage. However, episodic exacerbation of caregiver distress was inevitable in spite of formal caregivers employed.

“Initial hand-holding of the spouse to reduce caregiver fatigue and hopelessness was an essential part of the treatment plan…”

Dementia

Behavioral and Psychological Symptoms of Dementia (BPSD), represent a heterogeneous group of non-cognitive symptoms and behaviors which occur in subjects with dementia. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. BPSD constitute a major component of the dementia syndrome irrespective of its subtype and it has been estimated that it affects up to 90% of all dementia subjects over the course of their illness (Lyketsos, 2015). BPSD is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD.

BPSD also have a profound physical and psychological impact on both the formal and informal caregivers. A considerable part of caregiver distress relates directly to the manifestation of BPSD. Caregiver burden refers to the presence of problems, difficulties or adverse events which affect the life of significant other(s) of the patient (Platt, S., 1985). It is the extent to which caregivers perceive their emotional, physical health, social life, and financial status to be affected as a result of caregiving (Zarit et al., 1986). A qualitative quote from an Indian study reflects the Indian ethos and culture of caring for a near relative:  ‘‘Why are you using the word ‘Burden’? My father is not a burden to me. It is my duty to care for my parent and doing so makes me a little tired but gives me great satisfaction.”  (R.D. Pattanayak, 2010). Regarding BPSD, these symptoms are stressful for the co-resident caregivers, who lack support and guidance from the health care delivery system which service is poor in developing nations (Shaji K.S., 2009). Prince observes “Our findings underline the global impact of caring for a person with dementia and support the need for scaling up carer support, education and training.. Carer benefits, disability benefits for people with dementia and respite care should all be considered” (Prince, M., 2012).

References

  • Helen C. Kales , Laura N. Gitlin, Constantine G. Lyketsos Assessment and management of behavioral and psychological symptoms of dementia, State of the Art Review BMJ 2015;350:h369
  • Platt, S., 1985. Measuring the burden of psychiatric illness on the family: an evaluation of some rating scales. Psychol. Med. 15, 383–393. Zarit, S.H., Todd, P.A., Zarit, J.M., 1986. Subjective burden of husbands and wives as caregivers: a longitudinal study. Gerontologist 26, 260–270
  • R.D. Pattanayak , R. Jena , M. Tripathi , S.K. Khandelwal ,  Asian Journal of Psychiatry 3 (2010) 112–116 Shaji, K.S., George, R.K., Prince, M.J., Jacob, K.S., 2009. Behavioral symptoms and caregiver burden in dementia. Indian J. Psychiatry 51, 45–49.
  • Prince M., Brodaty H., Uwakwe R., Acosta D., Ferri C.P., Guerra M., Huang Y., Jacob K.S., Llibre Rodriguez J.J., Salas A., Sosa A.L., Williams J.D., Jotheeswaran A.T.,Liu Z. Strain and its correlates among carers of people with dementia in low-income and middle-income countries. A 10/66 Dementia Research Group population-based survey Int J Geriatr Psychiatry. 2012 Jul;27(7):670-82.

Looking Ahead

The merciless progression of the degenerative process cannot be halted or reversed at this stage of medical knowledge. However, reducing the BPSD significantly, encouraging some physical and mental activity in the patient and allowing some calm to prevail is in itself noteworthy.

The spouse’s understanding has changed from vacillating between anger, fear and panic, to one of acceptance and the need for pursuing individual activities to the extent possible within the circumstances. She is in better control of her emotions. She is aware that with progression of the degenerative process, the cognitive, language and motor decline will be steep and that the character of the BPS often can change from one of positive symptoms of aggression, night-wandering to a predomi-nant negative symptom cluster, characterized by apathy. She is thankful for being able to give some quality of life to her husband, and to have achieved some peace of mind and calm, having reposed faith in the treating team and managing reasonably with formal caregivers to share the work.She shudders at the thought of the day’s prior to TriMed-Neurokrish intervention when each day was a nightmare. Knowl-edge is power, and with it, if you have extended your resources-physical, mental, emotional, financial to the utmost, you know you have done your best.

Categories
Adults Buddhi Stories Epilepsy & Seizures Featured Memory Problems Patient Stories

Joseph – His Unedited Life

Joseph – His Unedited Life
Joseph – His Unedited Life

Biography

Equipped with a Masters in Political Science, a supportive wife and 2 young children and a video-editing job in a reputed TV channel, which he carried out with a natural flair, Joseph had his stars to thank for a comfortable and fulfilling life. He had always been hardworking, an amiable companion at work, a good husband and a loving father. It was not just the sudden onset of seizures that disrupted his life flow, but the inability to work, the prominent cluster of neurobehavioural symptoms, the agitation, the paranoia, which mounted within a few weeks of the seizure onset. Back at work after recovery from the subacute phase, he could not perform. To make matters worse, the software of the editing platform had been updated with a newer version, during the period of his absence!

When Joseph presented to us over three years back with a cluster of seizure episodes, delirium and subsequent neurobehavioral symptoms, one needed to step back and view the sequence of events that led to this acute/subacute symptom complex that altered the course of his life so dramatically. The hospital which had received Joseph as an emergency had done well to manage the acute phase of the illness. The patient was diabetic and on oral medication with moderate control of blood sugar levels. Other laboratory parameters were within the normal range. The MRI showed bilateral hippocampal atrophy and the EEG recorded bilateral epileptiform dysfunction. A course of IV methylprednisolone brought about some control of the acute phase of the illness.

Exploring the Condition

However, Joseph continued to have seizures, poor recent memory, mood swings, irritability and aggression. He was unable to return to work both due to cognitive deficits which acted as impairment to his job performance and also due to poor social tolerance, to interact with team members. This came to the notice of the TV channel in which he was Senior Video Editor and the managerial staff of the channel took it upon themselves to support and take an active role in the neurorehabilitation  process of the patient. It was then that they stumbled upon Neurokrish – The Neuropsychiatry Center where they met Dr. Ennapadam S Krishnamoorthy. After a detailed interdisciplinary evaluation of his clinical profile, a discussion was held with the family and employer’s Chief Medical Officer on Joseph’s protracted cognitive and neurobehavioural sequelae and its impact – personal, familial and occupational. Concerned that their key employee should continue to work with them, the employer readily offered to support his care in all possible ways. The family too was committed to helping him get back on his feet.

Most importantly, the doctor was the purveyor of good news – that recovery from the ravages of a significant brain inflammation was possible, with medication, prolonged therapy and  psychosocial support. “Patience and gentle persuasion are the key” he said, in a convincing voice, persuading and encouraging patient, family and employers, through the long dreary days and months of targeted therapy.

Understanding Joseph

The enormity of the challenge of comprehensive neurorehabilitation for Joseph descended on us, fully, only when the clinical psychologist along with some other TriMed-Neurokrish team members, tried to unravel from basic literature, the complex demands on the video editor of a TV channel. With this background knowledge the cognitive retraining and cognitive behaviour therapy interventions could be individualized more effectively. A brief account of the video editor’s role would not be out of place here.

Video Editing

Although video editing may be considered a creative act, it requires working through a well-established, predictable set of steps. The first step is the importing and ingesting phase, followed by rough edits to the footage, dragging clips into the timeline, synchronizing the audio track and then fine-tuning the clips. Once the structure is set at this level, some additional post-production steps are required, namely, adding transitions between clips and various kinds of video filters, which change the visual quality of one or more clips to impact on the tone and texture of a piece. Titles are added and finally the color grading is done. In short, TV video editing calls for thematic conceptualization and sequencing in a timeline as executive function, with clarity of online working memory, pattern recognition and creative abilities, visual and auditory sensitivity, coupled with addressing the emotional element of a broadcast, team work and alert, timely delivery of the end product. This end product must capture the main features of the program, have a flow and continuity and appeal to the viewer expectations to create an overall impact!

Our Healing Approach

We came to the diagnosis that his symptoms were provoked by an underlying antibody syndrome – Autoimmune Limbic Encephalitis (LE). Detailed assessment for a possible malignancy was carried out, to rule out Paraneoplastic Limbic Encephalitis A second course of IV methyl prednisolone (the first having been given during admission in the acute phase), intensive cognitive rehabilitation and stress management was the doctor’s well considered management schedule, along with the other integrative therapies .Other medication included Levetiracetam for seizures, Donepezil for memory, Clobazam (for seizures and anxiety), Piracetam and Gingko Biloba (cognitive enhancers). He was under regular antidiabetic medication with his Diabetologist who also saw him through an unexplained acute skin reaction together with a dermatologist.

Cognitive Retraining (CRT) sessions were focused on improvement of sustained attention and memory enhancement. Tasks followed were the cancelling of digits for attention and verbal games, reading and visual memory games. He was able to recall from a small paragraph initially, to quarter of a page at mid therapy and half a page of details by the end of ten sessions of CRT.

Cognitive Behaviour Therapy (CBT) was given for his neurobehavioural symptoms. Family counseling, worksite review, and introduction of Joseph’s family members as his treatment monitors were other focused methods to enhance patient motivation and to see him progressively attain his premorbid state at home, in the community and at his workplace 

Our Ayurveda Consultant prescribed Shirodhara, the calming effect of which has been elaborated in the ancient texts. We have observed remarkable improvement in some of our patients with neurobehavioural problems who have undergone this procedure and we saw it succeed once again in Joseph.

Within a three month period of therapy, with the overall feeling of well being and improvement in his cognitive ability, that glimpse of hope of recovery sparked off definite positive trend in his attitude, with less agitation and irritation, a more focused goal to help himself and to take maximum advantage of the therapies and counseling offered to him by the TriMed-Neurokrish team. From this point the improvement in his condition was by leaps and bounds and there was no looking back.

Our Integrative Medical Therapy

  • Shirodhara is a classical and well-established procedure, as described in the ancient Ayurvedic treatises, of slowly and steadily dripping medicated oil or other liquids onto the forehead. Shira – head, is the ‘Seat of the Mind’ and Dhara signifies flow – a constant flow of the medicated, warm liquid – oil, milk,  buttermilk or coconut water onto the forehead of the subject, lying supine on the Ayurvedic massage table in the yogic Shavasana posture of complete relaxation of body and mind.
  • The liquid is gently poured, in a constant stream, ‘the size of the little finger’ from a height of 8-10cms from a special vessel, (protecting the eyes), onto the centre of the  forehead for a minimum duration of 30 minutes and a maximum of 60 minutes. The liquid is allowed to flow down the scalp and is collected from the table, warmed and reused during the procedure. Shirodhara may be repeated 2-3 times with an interval of 7, 14 or 21 days, depending on the severity of the disease/disorder.
  • The constant flow of fluid stimulating the Sthapani Marma (this ‘vital spot’ being one of the 37 vital spots of the head, the whole body consisting of 107 such spots) indirectly stimulates the pituitary gland, at which brain level (Sthapani), the liquid flow occurs. The Ayurvedic texts mention the master gland and other endocrine glands and their function and clearly outline the calming neurobehavioural benefits of the procedure. The centre of the forehead, which was evolution-wise related to the third eye, is also connected atavistically to the pineal gland. This spot is known as Agnya Chakra, one of the vital energy centres in the yogic tradition. Focusing on Agnya Chakra with closed eyes during meditation leads to psychosomatic harmony.
  • As the oil drips on the Agnya Chakra, the authors propose, that the meditation-like effect is a consequence of stillness of mind leading to adaptive response to the basal stress. Shirodhara is popularized today by the modern health spas as a sure way to ‘rejuvenation and stress relief’! However, the ancient texts lay emphasis on its role in neurological and psychological disorders, headache and insomnia, and mention other indications and contraindications.

References

  1. Vaghbatta. Shirodhara Ashtanga Hridaya, Sutra Sasthana, Chapter 22
  2. GS Lavekar, TV Menon,  Bharthi, A Practical Handbook of  Panchakarma Procedures (2009)  Central Council for Research in Ayurveda and Siddha, Dept. of AYUSH, Ministry of Health and Family Welfare GoI, New Delhi
  3. Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1;  9 : 457–463
  4. Kalpana D. Dhuri, Prashant V. Bodhe,  Ashok  B. Vaidya . Shirodhara: A Psycho-physiological Profile in Healthy Volunteers J Ayurveda Integr Med. 2013 Jan-Mar; 4(1): 40–44.

Our Neuropsychiatry Focus

Autoimmune Limbic Encephalitis is a rare disorder, characterised by the subacute onset of seizures, short-term memory loss, and psychiatric and behavioural symptoms. This type of limbic encephalitis is associated with Voltage-Gated Potassium Channel (VGKC) or N-methyl-D-aspartate receptor (NMDAR) antibodies.

  • The emphasis in the management of autoimmune LE is on its timely recognition, in order to rule out malignancy and to initiate treatment early. This potentially life-threatening disease responds well to immunomodulatory therapy.
  • The diagnosis of Paraneoplastic Limbic Encephalitis (PLE) is difficult because clinical markers are often absent and the LE symptoms usually precede the diagnosis of cancer or may mimic other complications. The clinical diagnosis of PLE requires :
    • a compatible clinical picture;
    • an interval of <4 years between the development of neurological symptoms and tumour diagnosis;
    • exclusion of other neuro-oncological complications.

References

  1. M.J. Thieben, ; Lennon, V.A.  Boeve B.F.  Aksamit A.J.,Keegan M,  Vernino S. Potentially reversible autoimmune limbic encephalitis with neuronal potassium  antibody Neurology April 2004;62:1177–1182
  2. Guetekin SH, Rosenfeld MR, Voltz R, Eichen J, Posner JB, Dalmau J Paraneoplastic limbic encephalitis: neurological symptoms, immunological findings and tumour association in 50 patients. Brain. 2000 Jul;123 ( Pt 7):1481-94

Looking Ahead

At work a change in the software platform used, resulted in Joseph’s problems being magnified. No longer could he work on the auto-pilot, with skills learnt over two decades suddenly becoming obsolete. Supported by the three legged stool, his family, his employer and our therapeutic team, all working in tandem, he has managed to overcome these many hurdles. Apart from therapy and rehabilitation, he has benefitted too from a second course of intravenous steroids. Titrating his drug prescription, avoiding drugs that have unacceptable side effects and responding to his changing situation have all been necessary.

Two years on, the transformation of Joseph is remarkable. He is seizure free, composed, communicates clearly and well, manages well at work having learnt to use the new software platform, and enjoys a close trusting relationship with his family. He still has some residual memory and cognitive dysfunction and attends our centre for periodic cognitive retraining sessions. This father of two, the sole breadwinner of a young family, has managed to retain his job, thanks to the therapeutic alliance between his family, employer and our treating team. Indeed, his employer’s corporate social responsibility in walking the distance with Joseph deserves special commendation. This editor’s life continues unedited, thanks to the science of modern medicine, the wisdom in our ancient medical systems and the goodness that continues to exist in our society.

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Perspectives in Dementia Care and Health Policy

A health policy for dementia should be comprehensive, especially spelling out the role of family, community and government.A brainstorming session on future perspectives in dementia care and health policy, at the National Dementia Summit held recently in New Delhi, is most insightful. The key prompts for this interactive session are simple and follow a 5W1H management model — who, what, why, when, where and how, in Rudyard Kipling’s “six friendly men” mould. We begin by asking who should take part in developing public policy. The large number of stakeholders becomes apparent: apart from Government, civil society agencies, medical, nursing, paramedical and other professionals, university faculty and researchers and those engaged in the care of dementia; the person affected (if able), their caregivers and families, clearly should all have a say in health policy development. Other stakeholders include the insurance sector, private care providers and agencies rendering dementia related services — pharmaceutical, nutraceutical, medical instrumentation industries; hospitals, hospices and homes. There is unanimity on whom health policy should target; everyone affected by the condition regardless of their economic or social

Photo Credit: The Hindu : N. Sridharan

circumstances.Prevention of Risk FactorsWhen should dementia health policy become operational (at what point of time in the lifespan) we ask. The discussion among experts is animated. They point out that primary prevention i.e. the prevention of risk factors that increase the likelihood of dementia development: hypertension, obesity, high lipid factor levels and diabetes; smoking and alcohol consumption; should begin young, perhaps even in teenaged years. These being the risk factors for many chronic and lifestyle diseases, the benefits of such primary prevention will undoubtedly go far beyond dementia, to a host of other chronic and lifestyle diseases. Secondary prevention, the optimal management of risk factors once they have developed, usually begins in middle age, when risk factors surface and are first detected in individuals. Tertiary prevention, early diagnosis of dementia, even in the mild cognitive impairment stage, often mistaken to be part of normal ageing; the early treatment with drugs that can slow down the disease; and supportive interventions for the caregiver, is universally believed to be mandatory. The group is unanimous that the time for a well defined national health policy is now, when there are an estimated 100 million elders in India, 3.7 million of whom are believed to have dementia.Participants believe that a health policy for dementia should be comprehensive and cover standards for diagnosis, treatment, clinical management; spelling out clearly the role of the family, community and government. Aside from this, dementia requires considerable care, which goes far beyond cure: rehabilitation care, respite care and palliative care, all of which must be clearly outlined. Dementia is a condition with many ethical, legal and financial implications that need to be addressed; and is also the focus of much research. Participants feel strongly that such health policy development should be inclusive and bottom-up, assimilating inclusively the views of all stakeholders; not top-down, based on the views of a minority who have access to the corridors of power. International delegates point out that there is evidence today that the bottom up approach to policy making is far more likely to work that the top down one. In this context participants express their regret that much of health policy development in India remains top down, with stakeholders being seldom consulted.Discussing the focus of a health policy, there is general agreement that all essential domains of dementia care need to be addressed: thus the person, family especially the principal caregiver and community health resources all need importance. However, given dementia’s inherent nature, a disabling condition with complex medical and social needs, secondary care, even tertiary care, cannot be avoided at times of diagnosis; for management, both drugs and non-drug therapies; and complications. At the same time rehabilitation care, both in-patient and out-patient, needs emphasis. When asked to choose between these different domains of care, putting focus on one, participating experts and stakeholders are unanimous; the person, his family and the community resources they can leverage upon are a paramount focus of health policy development.We proceed to ask “who should do what?” for the person with dementia. Interestingly, the need for co-operation and partnership between government, civil society, private providers and affected families becomes immediately apparent. The government clearly has to lead on making dementia a national priority, guaranteeing support for the caregiver and developing new dementia policy and legislation, all of which need immediate and timely action. On the other hand civil society support groups and care providers clearly have their work cut out for them taking ownership for tasks like increasing awareness in the community, improving dementia identification and care skills, and developing community support systems. The development of comprehensive care-giving models will require the involvement of experts: universities and tertiary facilities, working in tandem with affected families. Research is seen as one area where all parties need to take part. The government must increase funding for dementia research; pharmaceutical agencies and industry must contribute their mite; as must universities and other academic agencies; civil society supporting and enhancing the process; families participating with enthusiasm and altruism.The development of dementia health policy, as it has unfolded here, is by no means unique to that condition. The majority of chronic diseases, a rising burden in India today, will require a similar approach: paradigms that address long term care (when cure is not an option); participation and co-operation among a range of agencies, often as different from one another as chalk is from cheese; and inclusive, bottom up health policy development. While a nodal national agency charged with this responsibility will probably be part of the answer, this discussion on dementia brings to the fore, an urgent felt need in this country, for health policy paradigms that will address the emerging epidemic of chronic and lifestyle diseases. Isn’t it time our policy makers and Kipling’s six friendly men, met?

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