I saw this article and thought it might be of interest to someone. There is an article in the Wall Street Journal that addresses this issue. My husband has had three heart attacks and they used stents so no anesthesia and no real surgery. He started having florrid symptoms of brain dysfunction after that. When we go to the doctor all of what I say is always started with "Since he had his heart attack.........." He has had symptoms off and on over the years, but they really increased and caused him dysfuntion mentally after his heart attacks. I had read where anesthesia does cause problems, but this is the first that I have seen where they say that even with stents mental accuity is reduced. They say that artery disease and mental acuity have a connection.
I personally believe that diminished blood flow & loss of oxygen that the blood carries to the brain is a big part of AD in many cases. Since no one really knows anyway, my layman's opinions is as valid as any other. So, yes, heart problems & possible resultant changes in pumping blood to the brain could have an influence. So do certain surgeries, especially heart and hip, and the anestesias and machines which slow down the body's functions, including blood circulation, so less blood gets to the brain. As in any part of the body, cutting off blood and oxygen will cause cells to die. No medical evidence or background, just a thought.
First, the anesthesia issue - We've discussed this before, as it is a big concern. Go to the home page of my website - www.thealzheimerspouse.com, and click on "previous blogs" on the left side. Scroll down and read #117 and 118 about anesthesia.
Second - the heart attack. There are multiple articles and studies that say what is good for the heart is good for the brain. If the blood is flowing freely through unclogged arteries, the heart pumps well, and there are no obstructions to cause heart attacks. If the blood is flowing freely to the brain, it keeps it in better condition.
This is a link to an article about heart disease and Alzheimer's. It is just one of many.
On the other hand, FYI, my DH never had heart disease. He had absolutely none--none--none of the conditions many experts think causes AD--none. My best guess has always been it was a recessive gene and his penchant for living with stress & anxiety may have animated it.
From what I have been reading, Vascular Dementia is a secondary dementia. That seems to mean that the primary illness is actually either strokes, or heart disease. I haven't seen anyone mention dying multiple times due to the heart stopping, but that is almost certainly why my husband has Vascular Dementia. He also had heart disease well before the day he got his pacemaker. He had had 6 bypasses about 13 years earlier. He also has high blood pressure, high cholesterol and type II diabetes. The day he got his pacemaker started with an accident at high speed. He hit his head that day in addition to his heart stopping several times.
One of the reasons it is very hard to figure out where and why our LOs have gotten this set of ugly diseases is that it is a SET of diseases. It turns out that Vascular Dementia itself isn't one disease but a group of them. And a substantial percentage of VD patients have Alzheimer's as well as VD. I'm pretty sure my husband is one of them.
One of the first things my husband's doctor checked for was blood flow to the brain. First an EKG, and when that appeared OK, then a 24-hour EKG (to see if there might be an intermittent problem) and also a carotid ultrasound. He was hoping it was something other than AD, something we might be able to "fix".
I don't know whether the type of damage Bettyhere hypothesizes would show up on an MRI -- it's not the same thing as a stroke, so I suspect you couldn't find it with imaging technology. But I DO think it's a pretty good hypothesis!
Our neurologist didn't do the ultrasound on the carotid artery. The Cardiologist had done three of them in the previous 18 months and the family doctor shared EVERYTHING he had with the new doctor. Most of the blood tests had already been done, but a couple did need doing so those were ordered.
There are a whole bunch of diseases that can be fixed that make people look like they have dementia. That is the reason for all the blood tests and imaging tests. They have a checklist and they make sure that none of them are left. The last one is where they try to figure out if it is one of the dementias that show up on a MRI or CAT scan. If there is nothing left, the diagnosis is Alzheimer's. One of the reasons that so many people who have been diagnosed with Vascular Dementia also have Alzheimer's, but aren't diagnosed with it is that there is no way to diagnose Alzheimer's until after death. If they have one of the other dementias they go with that one as the diagnosis.
Among the common diseases that give people foggy brain is thyroid disease. And it is very fixable with just a little pill every day to replace the thyroid. When I was being undermedicated one of my symptoms was foggy brain. When they upped the dosage, my hair stopped breaking off, I stopped gaining weight, I stopped having so much all over body pain AND I stopped having foggy brain.
OK, you guys got me intrigued, so I did a search on Google Scholar. Excerpts from a handful of the many articles that were produced:
Neurol Res. 2006 Sep;28(6):637-44. How do heart disease and stroke become risk factors for Alzheimer's disease? de la Torre JC.
...heart disease and stroke are important risk factors for Alzheimer's disease (AD). This review examines the evidence linking chronic brain hypoperfusion (CBH) produced by several types of heart disease and stroke on the development of AD. ...The evidence indicates a strong association between such risk factors as coronary artery bypass surgery (CABG), atrial fibrillation, aortic/mitral valve damage, hypertension, hypotension, congestive heart failure, cerebrovascular-carotid atherosclerosis, and transient ischemic attacks in producing CBH. In people whose cerebral perfusion is already diminished by their advanced age, further cerebral blood flow reductions from heart-brain vascular-related risk factors, seemingly increases the probability of AD. The evidence also suggests that a neuronal energy crisis brought on by a relentless CBH is responsible for protein synthesis defects that later result in the classic AD neurodegenerative lesions such as the formation of excess beta-amyloid plaques and neurofibrillary tangles. Knowledge of how heart disease and stroke can progress to AD should provide a better understanding of the physiopathology characteristic of AD and also target more precise therapy in preventing, controlling or reversing this dementia.
Neurol Res. 2006 Sep;28(6):630-6. Interventions for heart disease and their effects on Alzheimer's disease. Wolozin B, Bednar MM.
...Alzheimer's disease and vascular dementia both share significant risk attributable to cardiovascular risk factors. Hypertension and hypercholesterolemia at midlife are significant risk factors for both subsequent dementia. ...Stressful medical procedures, such as coronary artery bypass and graft operations also appear to contribute to the risk of Alzheimer's disease. ...The strong association of cardiovascular risk factors with Alzheimer's disease and vascular dementia suggest that these diseases share some biologic pathways in common. The contribution of cardiovascular disease to Alzheimer's disease and vascular dementia suggest that cardiovascular therapies might prove useful in treating or preventing dementia. Antihypertensive medications appear to be beneficial in preventing vascular dementia...
Microsc Res Tech. 2000 Aug 15;50(4):287-90. Link between heart disease, cholesterol, and Alzheimer's disease: a review. Sparks DL, Martin TA, Gross DR, Hunsaker JC 3rd.
Increased prevalence of Alzheimer's disease-like beta-amyloid deposits in the neuropil and within neurons occurs in the brains of non-demented individuals with heart disease. Heart disease is a prevalent finding in Alzheimer's disease, and may be a forerunner to the dementing disorder. In the cholesterol-fed rabbit model of human coronary heart disease there is production and accumulation of beta-amyloid in the brain. This accumulation of beta-amyloid can be reversed by removing cholesterol from the rabbits' diet. In culture cells, a cholesterol challenge has been shown to increase production of beta-amyloid, and dramatic reductions of cholesterol produced by HMG Co-A reductase inhibitors decrease production of beta-amyloid. Increased beta-amyloid production is also produced by dietary cholesterol in a number of transgenic mouse models of Alzheimer's disease. Administration of HMG Co-A reductase inhibitors may block beta-amyloid production caused by dietary cholesterol in rabbits. Clinical trials testing the benefit of HMG Co-A reductase inhibitors in the treatment of Alzheimer's disease are underway.
Aging (Milano). 2001 Jun;13(3):231-9. Heart disease and vascular risk factors in the cognitively impaired elderly: implications for Alzheimer's dementia. Polidori MC, Marvardi M, Cherubini A, Senin U, Mecocci P.
The term "cardiogenic dementia" was introduced a few decades ago to indicate an alteration of consciousness and cognition due to heart disease. Although this term is now disused, the relationship between cardiovascular disease and cognitive impairment is currently of great interest, not only for its potential therapeutic implications. but also for the recently recognized important role that vascular factors appear to play in Alzheimer's disease. The aims of this review are therefore 1) to show data supporting the role of cardiac disease--namely congestive heart failure, myocardial infarction and atrial fibrillation--and other vascular risk factors--i.e., hypertension and diabetes--in the development or worsening of cognitive impairment...
Oh, Sunshyne, I love you! I love this board, that we are not surprised that others know what Google Scholar is, or get turned off by polysyllabic words, and can consider these possibilities and start to fit our own pieces of the puzzle together!! My impression is that we, together, can teach the doctors and the social workers a LOT!
Sunshyne, I went to Google and typed in Google Scholar and there it was!!! ROFLOL
I REALLY appreciate your looking it up and sharing with all of us. My husband had a blood clot in the artery in his thigh in 1996. They tried blood thinners to try to dislodge it - while putting a stint in. During this process, they nicked the artery and he almost bled to death before they found it! His cholesterol was about 400 at the time, but we didn't know it until he was tested for the surgery. He has been on Lipitor ever since, and he now has great cholesterol readings. His pulmonary vasular disease is probably what started his AD if I read those articles correctly.
I found most of those same articles just with the regular Google searce engine. It is AMAZING what is out there these days for anyone to research and read.
I used to do medical research online for friends when they got sick and print things out for them. You used to have to be so careful with what you gave people because most of what came up wasn't real. These days it is mostly real stuff that comes up.
I'm still looking for a document that talks about being revived multiple times as being a factor in VD. If someone finds one, please let me know.
I just stopped by the local bookstore - not a SINGLE book on AZ or on medicare/medicaid planning.. but a book called "The Myth of Alzheimer's" or some such, in which the author apparently says that all the nonsense about "brain health" and half of the meds that are prescribed are a crock. That may be true, but we all know there's SOMETHING the matter with our spouses, even if it can't be diagnosed until after death. And we are all seeing the same behaviors, over and over!
(Sunshyne, I married an academic at the age of twenty, worked more than twenty years in academia myself, am still involved to some degree. Takes one to know one!)
Wow, are you gals SMART. I did a year of doctoral studies at the College of William & Mary, dropped out to move to Europe, but you all have me beat. Read the above with great interest. This is surely a learning process. I was hit with the enormity of it today. Here I was telling my husband YOU DON'T LISTEN! When in fact, after my posting, I learned that he doesn't comprehend. I feel a bit guilty about the times I chastised him for "not listening" but how was i to know?
Starling, there are four things I prefer about Google Scholar when I want reliable information on medical (or other scientific or engineering) topics.
First, it only scans the "scholarly" literature, so it does weed out a lot of the unreliable junk, especially and most notably all those annoying (to me) "news" articles about the latest incredible miracle cure. (The news media drive me nuts.)
Second, many of the journals are not scanned by the "regular" Google, so you will get a lot of different hits on Scholar.
Third, and most importantly from my perspective, Scholar groups the results, so that multiple "hits" for the same paper are presented as one, with a link to the different "versions" if you are interested. This is the very best way I've found to locate papers that can be downloaded in their entirety for free. And if they can't be downloaded for free, it's still a good way to find contact information for the corresponding author, if I'm interested enough to want to request a reprint.
Fourth, Scholar will also list the papers that cite a given paper, which can help you track down more recent info on your topic.
PHD counseling. We just had a big blow up. He was in my face, telling me I didn't care about the house. (Why should I, it's on the market, with no discussion w/ me.) He said we hadn't had sex in three months. Well, honestly, we haven't in a month. What's sexy about worrying about your survival & having to be on an antidepressant just to deal with the situation? He said, you think there's something wrong with my brain. I replied, yes I do. WRONG ANSWER. That sent him on a rampage which I have never seen. I know I should have just kept my mouth shut. But hey, he asked.
I told him if he didn't like the situation (I'm sleeping on the sofa), to divorce me. I told him to just take the action he thought necessary. This is getting a wee bit overwhelming. To put it mildly.
I will never again tell him, even though he asks, there is something wrong with his brain. Why did he ask me in the 1st place?
I am spiraling down. I am taking a nose dive. I don't know what to do with him or my situation. And, I could have sex with him and make it "all better" but I simply don't want to. I would feel like I am prostituting myself. (Even though he is my husband.)
He doesn't even have the means to pay his property tax on a house he wouldn't put me on the title to, but is now asking me to take out a home equity loan on my house to pay it. Yeah, that's a turn on.
Starling, could you be a little more specific about what you need? I've found references that mention when diagnosing VaD, one needs to differentiate between "true" vascular dementia and dementias that can follow anoxic/hypoxic brain injury from cardiopulmonary resuscitation (although they didn't mention HOW).
Are you trying to find out if there ARE differences between vascular dementia and cardiac-arrest induced dementia and what those might be, or are you trying to find out if someone CAN develop A dementia from CPR?
Sunshyne, I'm not sure what I am looking for. But I am taking a note of your language. I've discovered that sometimes if you use the "magic words" you find things you can't find without them. Thank you for writing them out for me.
Frankly, although I have found myself inside Google Books, I didn't know about Google Scholar. I'm going to try it out and see how it goes. I do find the multiple "hits" for the same site frustrating.
I mostly manage to avoid the "news" stories without much difficulty. <grin> I also probably have more patience with them because I have th heridity for Alzheimer's once I get older than I currently am. And I bet those puzzles and all the waking I'm trying to do will keep me in Stage 2 a lot longer then I would be if I was just vegging out. They are obviously useless in Stage 4 or above which is when you get someone diagnosed.
The funny thing is that I know that I've been on some sites that are identical to ones you have been on because when you quoted them, I found exactly the same words in the same order when I found them too. On the other hand it is likely that you have found things I have not found using Google Scholar, so I am going to try it.
OK, so in the meantime, I have an acquaintance who knows a lot of medical types. I did a little searching for him on another subject, and in doing so, mentioned your interest. He offered to broadcast email cardiologists on his list. Preliminary results for "whether repeated cardiopulmonary resuscitation can lead to vascular dementia"
Hi Ed:
As an ER physician, I can tell you that repeated CPR wreaks havoc on the human body, especially the brain - due to the hypoxia that occurs. Dementia can be caused by hypoxia as well as other insults. The difficulty has to do with attempting to relate the specific cause and effect in a given case. The devil, as always, will be in the details.
Best,
Rick Davis, MD
Ed, As a physician would say " absolutely, repeated cardiopulmonary resuscitation can lead to not just dementia, but many a time, organ failure - kidney failure, pancreatic gland failure leading to uncontrollable diabetes, CHF, Lung failure leading to COPD Why is cardiopulmonary resuscitation done? Because the heart has stopped and lungs are not converting the Carbon Dioxide in the blood to Oxygenated blood. As there is a temporary (and this depends upon how one defines temporary) stoppage of movement of blood in the cardio-vascular system, there is a lack or an inadequate amount of oxygenated blood to perfuse the micro-vascular circulatory bed in the brain, thus the brain gets no oxygenated blood and the brain cells die. If this repeteadly occurs, more and more brain cells die and the end result could be dementia or parkinsons disease, or any brain disorder, including psychiatric disorders. Many patients who undergo CABG can show signs of beiing 'looney' - because of the same issue and the issue of micro-debris/plaques causing a blockage of micro-vascular circulatory bed. Same thing happens at the level of any organ - heart, lungs, kidneys pancreas etc.
Regards,
Darrell
Yes, it can. Clinical study done in 1997 in Canada proved the theorem.
Yes, repeated cardiopulmonary resuscitation can result in multiple micro-infarcts in the brain, which is actually what causes vascular dementia. I hope this is helpful. Bennet Bennet I. Omalu, MD, MBA, MPH Forensic Pathologist/Neuropathologist/Epidemiologist San Joaquin County Sheriff-Coroner/Chief Medical Examiner
Dear Ed,
I cannot give you a specific reference in this regard, however, cardiopulmonary resuscitation is a procedure only carried out to revive individuals who are either in cardiac arrest or have ventricular fibrillation. In either case, there is likely to be a decrease in cerebral circulation. Decreased oxygenation of the brain, depending on its duration, may lead to loss of brain function. This may be transient or permanent depending on the length of oxygen deprivation. This is the case of drowning victims who are resuscitated after prolonged immersion.
Hope this information is of some assistance.
Don Margouleff, M.D. FACP
Ed, Vascular dementia is a degenerative cerebrovascular disease that leads to a progressive decline in memory and cognitive functioning. It occurs when the blood supply carrying oxygen and nutrients to the brain is interrupted by a blocked or diseased vascular system. Cardiopulmonary resuscitation is a poor substitute for the heart therefore, from the moment the heart stops and is functioning at full capacity, the blood supply to the brain is interrupted/not at its normal flow to the brain.
Art.
...the responses continue to pour in ... some of them really know what they're talking about, some aren't as knowledgeable as you, Starling. If there are better ones waiting for me tomorrow, I'll let you know. Right now, my 18-year-old cat is demanding dinner. And you know what THAT means ... I'm outta here!
Sunshyne-your cat dines late. My boys would demand white wine and candles if I fed them so late. As an RN I am starting to doubt the value of CPR in an unwitnessed arrest. Are we producing vegetables?
Wow. Thank you Sunshyne. The information that is coming in is very interesting. Even more interesting because except for the title of a paper that you can't actually read online, I haven't found anything through Google or Google Scholar that says this. The paper's title sounds like it is warning that multiple resuscitations are resulting in a VD epidemic. There is no summary or abstract, so I can't be sure what is in the paper.
My husband had an accident on Route 405 in Southern California about 4-1/2 years ago. Basically his heart slowed down enough that he passed out. He was using cruse control at 62 miles per hour. He totaled the car by ending up in a ditch. He broke 6 ribs and hit his head. (I know how fast he was going because he ALWAYS set his cruise control at 62 mph.)
He died at least 3 times the day of his accident, once in the ER and twice or three times in ICU. They put in a temporary pacemaker before noon and the permanent one around 6 that evening. With the temporary pacemaker you could see on the monitor that his heart was trying to stop multiple additional times, but the pacemaker started it up again.
Except for a few possible very early AD symptoms, all of his symptoms have happened in the last 4 years.
This is an incredibly interesting thread! Okay, we know that "vascular dementia" and "Alzheimer's" produce roughly the same symptoms - and progress? I don't know. But accurate diagnoses of the kinds of dementia people have do seem to be hard to come by.
CPR is relatively new, right? And so is the rise in dementia - of course that could be just that more people are aging and not dying of other things, and we know/think it's familial. But I wonder: does any neurologist ask the questions when interviewing people: Have you had heart disease? Have you had anaesthesia? Have you had CPR? and how often? Have studies been done at the DEMENTIA end, looking backward, as opposed to the CARDIO end, looking forward?
Anyone have a connection with a neurologist who could review that literature?
That's why I was asking you whether you wanted to differentiate between "true" VaD and the dementia caused by anoxia/hypoxia. I could find a slew of papers on the severe damage that can be done to the brain by anoxia/hypoxia, resulting in cognitive impairment, but very little that flat-out said, or even implied, it led to VaD.
I am beginning to conclude, however, that the distinction is associated with the pattern of brain damage. VaD is typically associated with one or more localized ischemic attacks; i.e., the damage is to a reasonably small region(s) of the brain. Cardiac arrest, on the other hand, would lead to a generalized ischemia (decreased blood flow) and generalized hypoxia (decrease in oxygen delivery); that is, the entire brain would be damaged.
Warning about the emails coming in: these are cardiologists. They are painfully familiar with the very poor prognosis statistics of CPR patients, but it is quite probable that they would not necessarily quibble over whether the cognitive impairment is caused by "true" VaD or some other sort of brain damage.
Google Scholar will pull up books (sections of which may be available on-line), and even PhD theses sometimes. There is some degree of cross-over between Scholar and "regular" Google, and sometimes I've found a few things on "regular" that weren't on Scholar (certain patent websites, for example.) If I need to really dig for something obscure, I'll use both, plus PubMed if it's medical/biochemical. Usually Scholar has everything that's on PubMed and a lot more, but not always.
You won't find the multiple hits for a given article so irritating once you get used to what the different sites will have. I prefer to hit those from "ncbi.nlm.nih.gov" first -- this is PubMed and it comes up very quickly, has the abstract if one is available, and may have a link to a free .pdf download (although it does NOT have all free links.) "cat.inist.fr" will have the abstract, but I don't like the format, because I like to cut-and-paste info on articles of interest. Sites like "ingentaconnect.com" and "elsevier" are publishers, and while you can get the abstract there, and sometimes contact information for the corresponding author, they are usually slow to come up and it's rare there will be a free download, even for very old papers; and again, I don't like the format for cut-and-paste.
What was the paper that you found (title, authors, year, etc)? I might be able to locate a copy. (Emphasis on "might".) It would make sense that, if a single CPR can cause severe, widespread damage, that having to do the procedure several times would be even worse.
briegull: two recent papers, mostly intelligible, discuss the differences among the most common causes of dementia, and the symptoms that are used for diagnosis.
Levinoff EJ. Vascular Dementia and Alzheimer's Disease: Diagnosis and Risk Factors. Geriatrics Aging. 2007;10(1):36-41.
Muangpaisan W. Clinical Differences Among Four Common Dementia Syndromes. Geriatrics Aging. 2007;10(7):425-429.
Neurologists do routinely ask about heart disease, but not about anaesthesia (strong anecdotal evidence, but there haven't been enough studies to pin down exactly what's going on), and probably not CPR per se, although they would question about the different types of heart/circulatory problems the patient may have encountered. And yes, I've seen quite a few studies done starting at the dementia end and looking backward, and have found many different types of brain damage that cause dementia. My impression, however, is that it is so well-known that cardiac arrest leads to brain damage that they tend to focus on minutiae (patterns of damage, biomarkers in the serum that might be used to predict the outcome, etc). Also, they have almost always looked at a single cardiac arrest even, not multiple arrests, as Starling was asking about.
bluedaze, my cat dines several times a day. Dinner can be fashionably late, as long as it's preceded by several post-lunch snacks. (And what makes you think she does NOT demand wine and candles as a course of habit? LOL)
Oh, Sunshyne, thanks! I'll be looking them up. At the moment, my husband is eating his lunch; our son and his wife and daughter are late arriving and he doesn't wait. It's a brunch, bagels and fruit salad. He said that ... that lady ... the one who gets the paper in the morning .. oh, I guess it's YOU... (talking to me) said we have a holder for bagels so we don't cut ourselves. (I had just shown him the one we have, with his bagel in it) He was very concerned that we not cut ourselves. NOT very concerned that he didn't know my name!
Well, briegull, at least he retained the info about the bagel holder for a little while. I live in dread fear of my husband getting even the smallest cut -- he's on plavix because of the TIA he had a while back, and even a scratch can bleed all over everywhere. I forgot to stop the plavix before one of his Mohs surgeries. The poor resident was beside herself, couldn't get it to stop bleeding long enough to see where to place a suture, even with cautery. This was just for the interim "fix" while they waited for the results of the frozen section biopsy. She got so rattled, poor thing, she asked the head surgeon to do the final stitching after surgery was completed.
From what I've been reading there are multiple typs of VaD (is that an "official" abbreviation?) Why would this one be less "true" than any of the other kinds?
I don't think my husband had much general brain damage. I'd expect more physical symptoms for that. At his last stress test he passed so well that the doctor said he doesn't see many 40 year olds doing that well. My husband is 70. The next one (in two years?) won't be any where as good if he can even managed to cooperate well enough to take it. He no longer works out 4 times a week. I think he has either forgotten that there is a gym, or forgotten how to use the machinery. He has taken a 2 hour walk, in the last few days as a matter of fact, and returned home.
The difference between AD and VaD symptoms seems to be that AD involves a slow steady decline. VaD is more stepwise. There will be a sudden change followed by a long period where things don't change much. Or at least that is what I am reading. I also think that an AD patient is more likely to have all the symptoms of a particular stage. My husband seems to be in multiple stages, with the verbal one being the worst. He has only not known who I was once. But he loses more and more words every day. Pretty soon I won't be able to figure out what he is trying to ask me.
In addition it is possible that AD patients live longer than VaD patients once they are diagnosed. Frankly it looks like no one gets diagnosed before early Stage 5. My husband seems to have gone through late Stage 4 to early stage 5 to the end of Stage 5 and early Stage 6 in about a year.
Only a year ago, about a month after he was diagnosed, we drove from Eastern Pennsylvania to Saratoga Springs, NY (a 5 to 7 hour trip) with him driving and no problems. This year, he no longer is allowed to drive and we won't be going to Saratoga Springs because I don't think he can handle the 2 days in the park an I also don't think he could handle the 2 hour bus ride to get us to my daughter's house in New York City. That is a HUGE difference in symptoms.
Starling, have you had a chance to look at the two references I posted for bluedaze? They give a nice, succinct explanation of the differences in the different dementia syndromes. Provided, of course, that a patient does not have a mixture of different dementias, which is quite common.
Answers from my friend continue to pour in, some ... ah ... "succinct", and others a bit more thoughtful and detailed. Note that one (who sent a .pdf file I can send through Joan if you want) says that even the repeated brief interruptions of blood flow associated with defibrillator implantation affects cognitive functioning. I have to split this into two or three answers ... too many characters for one!
A sampling of the answers:
The fact that a patient required "repeated cardiopulmonary resuscitations" indicates that the brain must have been deprived of oxygen for unkown amounts of time i.e. during the periods when the heart was stopped..There is no doubt that these periods of ischemia would cause brain damage, the amount varying from very minor to major, depending on how long the periods of cerebral ischemia were....It is not the resuscitation technique itself that causes the damage, it is the pathology, (usually cardiac), for which the resuscitaton was required..
Eric Milne (Professor Emeritus of Medicine and Radiology, University of California, Irvine.)
it can...repeated anoxic/hypxic insults
Ed --
This paper will give you information about the topic you mention. (.pdf attached, 2006 paper entitled: "Neuronal injury after repeated brief cardiac arrests during internal cardioverter defibrillator implantation is associated with deterioration of cognitive function." If you want a copy, let Joan know and I'll send her the .pdf by email.)
Not sure if the correct term would be "vascular dementia.
In repeated cardiac arrests and cardiopulmonary resuscitation depending upon what is meant by that term the patient is exposed to a risk of inadequate blood flow to the brain (and any anywhere else in the body for that matter) as chest compressions are less effective than a beating heart and as often as not some degree of hypoxia will also occur. This is associated with an increasing acidosis, which is a reflection of inadequate perfusion during the cardiac arrest and resuscitation effort(s). Bicarb given, is the correct thing to do - that corrects the falling pH but does not correct the cause of the falling pH. That becomes more and more of a risk with each successive cardiac arrest and the resulting CPR. The typical cause here is an unstable myocardium usually following an MI (more often that not a right coronary occlusion), which leaves an irritable RV focus within the myocardium and the patient tends to have successive runs of Ventricular Tachycardia (VT) which degenerates in to Ventricular Fibrillation (VF) or asystole and the next code is called. During the code the patient tends to turn blue from hypoxia and the BP is low even with chest compressions. Therefore you have the classic set up for inadequate perfusion but I would not usually call that "vascular" dementia.
There are various sensitive vascular beds within the brain and they often take a hit during an arrest. So long as the arrest is short and methods are effective in restarting the heart "vascular" dementiais unlikely but as the arrests get more frequent and of longer duration then cerebral hits are more likely to occur. Usually most patients by this time are on Class 4 antiarrythmic infusions i.e. Amiodarone etc.
Typical cerebral hits will result for example in PION or AION. Posterior or anterior ischemic optic neuropathy either or both will result in permanent blindness. The patient can sustain occipital cortical infarction resulting in permanent cortical blindness. You can get cerebral cortical infarction resulting in dementia. Frontal lobe infarction resulting in altered personality. You can infarct the otic nerve and get permenant hearing loss. You can sustain infarction in Brodman's Area 4 which result in stoke symptoms including hemiplegia, You can sustain a pontine, thalamic or diencephalon infarction, which will result in a persistent vegetative state meaning severe dementia. You can sustain infarction in the Pituitary gland, which results in a variant of Sheehan's Syndrome.more typical following delivery. But can occur with cardiac arrest - different cause same effect. You can infarct the temporal lobe resulting in post cardiac arrest seizure disorder. You can infarct the cerebellum resulting in unstable gait and past pointing know in the trade ia dysdiadokokinesia. These folks walk with an unstable wide gait and all hand arm movements are jerky. You can infarct the parietal lobe giving severe memory deficits. The list is extensive.
So the answer to your question is yes
Cardiac arrest can result in "vascular" dementia - The vascular part is only that the blood is carried or not carried in the case of cardiac arrest to the brain and dementia of many different names can result. CPR fights against that occurring but the actual acute cause is reduced cerebral perfusion and associated cerebral hypoxia and low cerebral blood pressures. It is unlikely to be a vascular cause, it is a perfusion deficit due to the diminished flow as a result of the cardiac arrest. Hope that helps.
Yes and no. I'm not sure I would call it "vascular dementia." But yes CPR, even once, can cause great mental confusion and changes of cognition. After any insult to normal circulation, such as CABG, temporary or permanent mental changes often occur. They occur so often after a patient being on bypass that they call it (slang) 'post-pump dementia.' But the precise terminology is probably not vascular dementia. Remember, Ed, I no longer practice, so this is coming from my memories of my days in the hospital.
Debby Jo Blank
Hi Ed,
The perfect guy to answer your question is Dr. Vijay. Send him an e-mail at vvijaymd@hotmail.com and tell him that I referred you. He is brilliant.
Best,
Jan D'Alvise
Absolutely! Repeated "CPR", lack of blood/O2 will lead to numerous anatomical deficits including neuro/kidney/all vascular deficencies. Why do you ask???? MJ
Sure it can.
Robert Boorstein, MD, PhD Director of Pathology, Bellevue Hospital
Ed: I think that it would depend on the time frame. If it were repeated resuscitation attempts in a short period of time then this would be more likely.
I don't personally have a reference.
Thomas S. Schultz, M.D.
Ed
I'm not sure whether there are systemtic retrospective investigations on that issue. It is conceivable, though. Single let alone repeated surgery using heart-lung-machines is known to potentially trigger dementia in a substantial percentage of patients (my guess: up to 25%). I'm sure that epidemiological evidence can be found in the literature. Whether that can be called "vascular dementia" is for discussion - anyway, its resembling VaD. There are hints that hypoxiaemia may trigger molcular degradation processes within neurons beyond the actual time point of reduced O2 impact that ultimately lead to apoptosis.
Best, Hans
Hell yes. And it is not the fault of the resuscictators. Brain ischemia kills brain.
It has all been very interesting. I've been following along pretty well although I've got some more "magic words" to look up. I've sent my information to Joan.
By the way, my husband did suffere hearing loss, and it probably happened the day of the accident.
For the doctor who asked about time frame, I'd say at least 3 times within less than 2 or 3 hours followed by an operation.
He also had a head injury that day during the accident. I'm not sure if it was just his scalp bleeding or something more important. They were going to do an exray, but I don't know if it every got done before he was released from the hospital. It certainly was NOT done after he was released.
He was not allowed to see a Cardiologist in California after the operation. The insurance company refused to pay for a post-op visit . The Cardiologist who ordered, but did not do, the operation saw him once without asking us to pay him after three attempts to get permission for him to be seen. I got a lot of that kind of thing from California doctors. At one point I was scheduled for major surgery BEFORE they had permission. I was told not to worry. They would fight with the insurance company if necessary after the fact. It turned out that the permission slip arrived less than 12 hours before I went into the hospital.
Two more responses ... this guy must know every cardiologist east AND west of the Mississippi!
The event causing the arrest may cause emboli that result in dementia (afib leading to emboli), the arrest itself may cause dementia (with sustained loss of oxygen-rich blood to the brain) and the CPR itself may dislodge emboli (ie plaques from the ascending aorta) which result in dementia. Lastly, if they received an intraortic balloon pump or ECMO, these have both been found to result in usually transient dementia (called pump-head when it occurs during bypass).
Dan
-- Daniel R. Burnett, MD
Ed,
Repeated CPR can lead to a variety of issues. Vascular Dementia is a common issue associated with such activity.
If you need any other assistance, I will be glad to help.
Dana Capocaccia President and CEO StatLinkMD
It is quite fascinating that the answers are all over the scoreboard. I don't suppose that's terribly helpful to you, Starling! other than giving you more "magic words".
And ... we have three more responses, which have some interesting "magic words".
Dear Ed,
I have no practical or personal experience in this. I do know that there are strong correlations with repeated brain ischemia and impaired cognitive function. For example cardio by pass in heart surgery has a fairly strong component of post-op ditziness and memory impairment. There are also more recent reports of post partem mental acuity impairments - in some cases apparently permanent or at least long lasting but not in all cases.Causes are not sorted out - in the specific instance you ask about it could also be due to the generation of small 'micro emboli' going to capillaries in the brain.
Ray Nunnally
Ed,
Cardiac bypass (on pump) does cause what is called "pump head". And is defined as some forgetfulness.
Some people recover, some do not. The longer patients are on pump during heart bypass the higher the likelihood of developing dementia. Vascular dementia is a new term to me.
This dementia is most likely due to small pieces of tubing being broken off during roller pump activity and or air bubbles in the lines.
Any time the brain is deprived of oxygen there is what is called "CVA" cerebral vascular accidents or "CIs" Cerebral Infarcts - exactly what happens to the heart when deprived of oxygen although these are called myocardial infarcts. Should a person require some type of cardiac resuscitation - if the brain is deprived of oxygen for more than 10 minutes - there is high likelihood for CVAs and CIs have taken place. Thus dementia.....
Hope this help.
Gary Young
Ed, There is plenty of professional documentation that supports the onset of dementia (with various symptoms), decreased ability for short term memory and even brain death as it relates to repeated CPR. The main correlation is a direct response to HOW long the brain went without adequate oxygen. I hope this helps.
June Gower
Try looking up "ditziness" in your next Google, Starling ... :-) Getting pretty darn technical here!
... but there are no answers that are "that's absurd. NO effect."
Bagels, grandchild, etc were a great hit. I didn't cut myself, nor did my rather inept son, I got a chance to give them the rundown on what's going on. Our other son is coming from California in a week to baby-sit his dad while my daughter and I go off to our Maine island for the week. The DIL here today was rather shocked, you mean he can't go away for more than an hour or two at a time? I said, what do you think *I* do day after day?!! I want him to understand what's going on.
Yes, marsh, I noticed that you did. My island is Monhegan. Ten miles out to sea however you slice it, directly east of Boothbay. We've been going out since 1981, and I'm currently the president of the land trust out there. One -year stint, by my stipulation; I wouldn't have taken it on if I'd realized how much my husband would deteriorate in this last year. Pretty much, google Monhegan and you find me.
Actually Sunshyne, it was more than just useful. EVERY doctor said, yes. Some of them didn't want to call it vascular dementia, but even they said yes.
There was probably some damage during the extremely long operation for the 6 bypasses years before the accident/pacemaker incident as well. In addition he was on a "balloon" beating his heart for him for 24 hours before the 9 hour bypass operation.
It all makes a lot of sense to me.
I also found a paper about brain ischemia (words I'd never seen before) which explained even more. It isn't necessary for me to fully understand everything I read. I've learned when to dig in and when to just let the stuff that is too hard pass right over my head and continue on anyway. There are Winpedia articles on both brain ischemia and ischemia cascades. There was obviously a lot going on the day he had his accident.
This is fascinating--what I can follow. It seems as if there are just too many variables to know how things will turn out. I do know that my cousin, an older man, had bypass surgery and never recovered cognitively, died many years later in a care facility w/some sort of dementia. On the other hand, my sister, in her early to mid 80's had bypass w/a pacemaker, and came thru it with no cognitive decline at all. She eventually developed other age-relatead problems and after she was 90 her body wanted to shut down, but I always felt the pacemaker just kept it going. She lived a few months longer than I think nature planned--a mixed blessing because during that time she did develop some dementia, but it had nothing to do w/surgery. I never considered that CPR may also be a mixed blessing, especially if done more than once.
This has been very educational. Why doesn't the Alzheimer's Association update the info? I don't think it is that rare, based on the responses from the MDs. Somebody here has to write a book. Why are all these very intelligent people on this site in the dark, except for this site? Yes, I called the Alzheimer's hotline, and honestly, I don't think she had a clue. And she was a social worker who specialized in Alzheimer's. I think you all are gathering very important information. I hope it doesn't just lie idle on this site. I don't know what I would have done without this site. I have learned more in several weeks than many years at a support group. I'm thinking back to when my husband had a seizure when he had chemotherapy. He hit his head & actually cracked the toilet bowl lid in half. They treated him for dehydration, but nobody did any tests re his seizure. It could have been a stroke. It was very frightening, seeing him shaking & his eyes rolled to the back of his head. Now I'm starting to wonder.
There is a problem with discounting all anecdotal evidence, which is what science does. I'm not saying that anecdotal evidence should be taken without a grain of salt, but it isn't a bad place to BEGIN a study.
I've described seeing this sort of thing where the patients figured it out before the doctors did once before in this forum. But I'll admit that the depth of experience here is much more than anything I've ever come across before.
I think it is the pain we are all feeling as caregivers. And the guilt that is endemic with all caregivers where the disease is terminal. We are all digging and trying to find answers.
I also think that knowing what we are learning here now is also going to make some of the hard decisions easier when this disease reaches its end.
.. and not only CPR, but also anesthesia. Do a search on dementia and anesthesia and you get all kinds of stories; the relationship has been known for many years, at least if the person has some dementia already. BUT do we hear from doctors that this is the case before they recommend something like "a total hip replacement" ??
The connection is there IF, like us today, you go looking for it. But why would a layperson THINK to look for it? "My goodness, I have to have anesthesia for this elective surgery. Might it kill off some brain cells and later contribute to dementia?? Am I sure I still want to DO it?"
Yes briegull, I think this information will affect my decisions here on out, regarding elective surgery. How would we have known? I have had several cosmetic procedures, but fortunately, I was alert & awake during them. The anesthesiologist was a master. I was talking the entire time. I now know, if it takes you any deeper - caution. From here on out, unless a procedure is absolutely life threatening, or I can't stand the pain, I will refuse it. Lots to say about acupuncture, which saved me from a life time of pain due to misdiagnosis. My cat is sitting in front of my computer screen, new habit, so forgive any typos.
Val-every computer needs a CAT scan once in a while. My husband had several surgeries and his dementia accelerated each time. I was able to speak to the anesthesiologist the last time and he listened to me about not intubating for general anesthesia. The proceedure was done under spinal which does not cross the brain barrier but the damage had already been done. My feeling is that if earlier diagnosis were possible brain insults 2° to lack of oxygen to the brain might be avoided.
Bluedaze, you are so funny! A CAT scan. LOL. Am I gathering here that there's a lot of information not shared with the general public? Those social workers at the Alz. Assoc. should read some of these threads, they'd get a real education.
From what I've read here on this thread, it is becoming obvious to me that my husband was already having some problems (low level stage 2 and 3 issues) as a result of his 9 hour, 6 bypass, 3 days on a "balloon" surgery in the early 90s. It is possible that he already didn't know his address or phone number while we were living in California and was doing a very good job hiding it. It is also possible that there was some hearing loss back then too. He certainly did a great job of hiding that. My daughter recognised language difficulties but we both thought it was just the English as a second language issue.
Then there was the accident, passing out on the highway, some head injury (but we have no idea how much), dying in the hospital several times (3 or 4), and them using the "paddles" on him each of those times. Possibly regular CPR as well. Followed by the temporary pacemaker and the permanent one. The permanent one required full anesthesia.
I now, finally, have a petty good picture of where all of this came from. It is possible that he also has Alzheimer's because it is all progressing. Or he is continuing to have either mini-strokes or mini-cardiac arrests. Or both.
Sunshyne, could you thank all of the doctors who responded for me. They provided information that I could not have gotten any other way. And although you saw multiple answers, I saw a repeated yes, yes, yes, with different viewpoints and additional details, a lot of which fit my husband's total situation. For example one of the doctors mentioned hearing loss, and my husband does have a hearing loss that got substantially worse after the accident/pacemaker, or maybe even originated then.
As for anesthesia and me, I've had something every year since I retired. I had a knee fixed (just cleaned out, not replaced) and was able to give up the walker and the cane pretty quickly. I had a colonoscopy with anesthesia because doing it without failed because I couldn't take the pain and my mother had colon cancer. Last year I had two cataract surgeries (not real anesthesia with those, but just pain killers and anxiety drugs). And if the other knee needs work, I'm going to get it done. It is good that we recognize that there are side effects, but putting off needed work isn't a good idea either.
Hadn't even thought of the colonoscopy I have scheduled for next week. Last time they put me totally under.
Starling, I know that is must be a comfort to you to have put the pieces of the puzzle together. (For the most part.) What great information to recieve. Not that it's good new, or that it makes things better, but just understanding things is a comfort. When I posted my blog, Does the AD brain have comprehension problems ?, I felt relief after the responses. Just need to understand what's going on.
Now, now, Starling, let's not go bashing scientists for "discounting all anecdotal evidence". We do not accept anecdotal evidence as being conclusive, and for good reason. However, if a reasonable amount of anecdotal evidence accumulates, we most certainly do take note of it and initiate studies. That's exactly what's been happening for reports that anesthesia may be a risk factor for developing AD. (Sometimes, we notice just the tiniest hint of some relationship, and go haring after that. In so doing, sometimes we make important discoveries; sometimes the only thing we discover is that there isn't a relationship. And because there often is no relationship, most scientists are loathe to waste their time paying attention to anecdotal evidence until a lot of it accumulates.)
The anesthesia issue is a perfect example of the problem with anecdotal evidence. Everyone is now running around hysterical that any and all forms of anesthesia will cause AD, and are concluding they can't possibly have surgery unless they would die otherwise. Not true. Now that scientists are beginning to study the possible relationship, preliminary conclusions are that local anesthetics are safe, and so are general anesthetics that are administered intravenously. The only correlation that is still holding up SO FAR is with general anesthetics administered by inhalation. And scientists have not yet concluded that ALL inhaled anesthetics are a problem, nor have they gotten into such subjects as whether other gases co-administered with the anesthetic might remove the risk, or that there might be genetic risk factors that predispose a person to develop AD if ALSO given inhaled anesthetics, and so on and so forth.
The research into the relationship, and possible underlying mechanisms, is still in the earliest stages. In the meantime, some doctors are aware of the research and some are not. This does not mean that some doctors are lazy and incompetent, this means that there is such a HUGE body of scientific research, no individual can keep up with all of it. Ergo, until something is firmly established, most doctors are not aware of it -- it isn't getting into the type of medical literature that a practicing physician typically reads -- or they are vaguely aware but do not act on it because not enough is yet known.
And Val ... the information obviously is shared with the general public ... that's how we are getting our hands on it. It's obviously out there for anyone who goes looking for it. Most people don't bother. We have become a nation of sound-bites ... if it's more than two sentences long, we won't listen.
Now, I would point out that the answers we've gotten so far about VaD and CPR have been all over the scoreboard. One reason is that some of the respondents are knowledgeable enough to differentiate between VaD and brain injury that results in cognitive impairment, while others think that any brain damage causes dementia. (One guy, who I did not bother to quote, wanted to know if vascular dementia was "a dementia of the brain".) Another is that two or three are clearly research-oriented and are investigating the mechanisms underlying cognitive impairment.
And one person DID say there was no relationship, but his answer was a very simple, one-sentence statement. I decided not to include it because he did not offer any support for his statement; and I think the scientific literature makes it extremely clear that an insult to the brain often induces cognitive impairment, so a flat denial of the relationship, to me, indicated a significant degree of ignorance.
I repeat: these guys are cardiologists (and/or are developing CPR equipment). They are not neurologists. We might get a VERY different set of answers if we were able to pose this question to neurologists.
On to a new topic: I saw a post over on "the other site" this morning that there is a greater than 25% chance of EOAD when there has been a head injury at any time in life. I remembered Starling mentioning that her husband had sustained a head injury at the time of the multiple CPRs. This post was by someone who is very knowledgeable, so I started looking into it.
Many studies have found that head injury is a risk factor for developing AD and other dementia syndromes later in life. (Free .pdf file available for Fleminger S et al. 2003. Head injury as a risk factor for Alzheimer's disease: the evidence 10 years on; a partial replication. J Neurol Neurosurg Psychiatry 74(7)):857-62)
Some have concluded that there is a relationship but that "other factors may be influencing this association." (E.g., Plassman BL et al. 2000. Documented head injury in early adulthood and risk of Alzheimer's disease and other dementias. Neurology 55(8):1158-66)
Recent studies have found that head injury is even more likely to be associated with AD in persons who have the apoE genotype. One reported, for example, a 10-fold increase in the risk of AD to be associated with both apoE and a history of traumatic head injury, compared with a two-fold increase in risk with apoE alone.
There is not nearly as much known about VaD as about AD. However, I did find a number of studies that concluded head injury could also result in VaD developing later in life. (One study also reported VaD was more likely to develop in people with occupational exposure to "vibrating instruments." I do remember hearing that playing the French horn could result in brain injury, long ago. I paid attention to that because both of my parents, my older sister, and my childhood sweetheart played the French horn.)