Sunday, June 26, 2011

MEMORY- THE MOST IMPORTANT BRAIN FUNCTION

MEMORY- THE MOST IMPORTANT BRAIN FUNCTION

Introduction

Memory is, undoubtedly, the most important function of our brain. Our day-to-day functioning depends on good memory. A person with memory impairment is unable to perform even the most basic of the daily activities. This handicap is well seen in people suffering from dementia.


Better memory is also a prerequisite to being a more intelligent person, and all tests for testing I.Q (intelligence quotient) include some form of memory testing. Good memory becomes even more important in traditional teaching systems such as in India, where a student who can memorise more gets more marks, and also more accolades and so on!

Memory in other species

It is not only humans who have memory. Many lower animals too depend on various types of memory for their survival.
  • For example, migratory birds fly upto 10,000 km every year to survive harsh winters, across deserts, mountains and seas; with fear of starvation, exhaustion and death. Yet, they accurately reach the same destination without getting lost (remember, they dont have google maps, GPRS, etc). l
  • They can store upto 100,000 seeds underground and retrieve most of them later, when they need them (just imagine doing it without pen/paper or computer!) Birds store Acorn seeds (that grow into giant oak trees) in the ground, by covering with dirt. Acorn seeds are very nutritious and birds can’t eat them all for fear of becoming fat and not being able to fly
  • Remeber PAUL, THE OCTOPUS, who predicted so accurately during the recent world cup soccer!
  • Chimpanzees and gorillas have even better memory.
Some facts about human brain
Human brain is only 2% of body weight, but it receives 15% of cardiac output (blood pumped out by the heart), 20% of total body oxygen consumption and 25% of total body glucose utilization. Brain metabolism is very active, and brain continues to work even during sleep (during rapid eye movement- REM- phase of sleep, brain metabolism is 30% higher!)
At what age does learning in humans begin?
Human learning begins even before birth. All those who have read Mahabharatha know that! Abhimanyu (son of Subhadra and Arjun) learnt how to penetrate several layers of defence of Chakravyuha, while he was still in his mother's womb (while Arjuna was narrating that to Subhadra). The epic says that Subhadra fell asleep halfway, and so Arjun did not tell her the technique of coming out of Chakravyuha, and Abhimanyu could not learn that either (and later on during the war, he remembered how to enter the charavyuha, got trapped inside and got killed).

Recently, several research studies prove the above point. Ultrasound studies show that fetuses respond in a specific manner (by moving hands or legs) to a specific sound at 30 weeks of gestation. The response of fetuses were replicated at 34 weeks, indicating that they could remember the sound even after four weeks! Also, mothers know that newborn babies respond to their voice even on the first few days after birth. This is because these babies have heard their mothers' voices so many times before birth that they are very familiar with that.

One of my colleagues told me that when his wife was pregnant, world cup soccer was going on, and they would watch all the matches and discuss them in detail. This experience was handy for their yet-to-born son, who showed keen interest in soccer from very young age, and at 10, he was in the school team! So, all prospective parents, please discuss only good things because your yet to be born child is listening to every conversation!!

Brain growth is maximum during the first two years of life, and hence are very important for memory and learning. Any infection or insult to brain during this stage can adversely impact memory functions.
Between 6 months and 12 months of age, babies can recognize familiar places or people (this explains the fussiness on being brought to doctors cabin or smile on seeing grandma).

Long-term memory retention does not start until age 3, and hence most people dont have any memories of events that happened during the first three years of life.
Does memory decline with advancing age?
  •  lBrain volume is maximum at age 20 and starts to shrink after age 40!
  • lThough certain aspects of memory & cognition may change with age, most older people can function normally (indicating an insignificant memory loss)
  • lSo, memory loss causing disability in daily life of an older person is pathological,
  • lNew-learning ability and ability to form long-term memory is spared into old age. 
  • Different types of memories decline differently.
  • Episodic (what did I have for breakfast), source (where did I learn the new car) and falsh bulb (where was I on Sep 1 2001) memory decline fast
  • Semantic (words, phrases, facts) and procedural (driving a car) memory decline the least.
  • Amount of storage capacity is not an issue; however, retrieval of stored information may become slower with aging.
  • Memory lapses start in 20s, but they remain unnoticed till 50s.
  • In a recent study, psychologists asked about 2,000 participants to solve puzzles, identify patterns and remember words and details from stories, among other memory tests.
  • The top performers were 22-yr-old; researchers saw a notable decline in the ability to make rapid comparisons, remember unrelated information and detect relationships by age 27.
  • A weakening memory can usually be detected by around age 37, according to the study.
  • The good news was that people's vocabulary and general knowledge increase until at least age 60.
Memory problems in ageing- What is abnormal?


  • Forgetting things much more than you used to
  • Forgetting how to do things you've done many times before
  • Trouble learning new things
  • Repeating phrases or stories in the same conversation
  • Trouble making choices or handling money
  • Not being able to keep track of what happens each day
Whose memory is better- MEN or WOMEN?

Ever wondered why wives always manage to remember the wedding anniversary (and put you in a tight spot)! This is because verbal episodic memory (words, objects, everyday events) is better in women; however visuo-spatial memory is better in men (so women please watch, if you get stuck in dense forests of Amazon, its the men who will take you out of jungle to safety)! Women are also better at remembering faces!

"Husbands never remember marital spats, whereas wives never forget". This is because women have better emotional memory. This could also explain the higher rates of depression among women.

How to improve memory?

l1.Regular physical exercise- increases cerebral blood flow
l2. Regular brain exercises- solving puzzles, sudoku, learning a new language, or playing a new musical instrument, etc in old age can delay the onset of dementia
l3. Avoiding stress/tension; good social interaction
l
5. Good control of risk factors such as high BP, sugars or cholesterol.
6.Ensuring proper sleep and good nutrition

l
Are there any memory enhancing foods?
 
l1. Grape juice- antioxidant & anti-inflammatory properties (Br J Nutrition, 2010)
l2. Strawberries, blueberries, walnuts- (J Nutrition 2009)
l3. Choline rich foods- chicken liver, eggs (J Am Coll Nutrition 2004)
l4. Chewing gum- (Appetite 2004)
l5. Apples, apricots, broccoli, cabbage, cauliflower, cherries, eggplant, fish, onions, plums, beet root, spinach, green tea, soy, olive oil,
l6. Turmeric (a compound called cucurmin) may protect against Alzheimer’s disease- this explains the lower prevalence of AD in India)!
Are there any medicines/drugs to enahnce memory?
Generally no drugs can boost memory in normal people. Memory is genetically determined and it can't be boosted. However, in people with vitamin and nutrient deficiencies, appropriate supplementation can be useful. Multivitamins are safe (containing B12, thiamine, alpha lipoic acid and folic acid). Omega 3 unsaturated fatty acids are used. Chinese herb Ginkgo biloba is also in common use. Please consult your doctor before you consume any of the medications, as even vitamins can have adverse effects!

Dr Sudhir Kumar MD (Medicine), DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066

Tuesday, June 21, 2011

NORMAL SLEEP

What, When, Why and How Much of sleep?

Introduction

Sleep is one of the most important activities that we enjoy a lot. On an average, we spend about one-third of our lives sleeping (assuming one sleeps about 8 hours a day). So, if one's job/profession is important (which also occupies about 8 hours per day), sleep is equally important, if not more!

What is the normal sleep duration?

Normal sleep ranges from 5 to 9 hours per day. Those who sleep less than 5 hours or more than 9 hours per day, have a higher incidence of heart attack, brain stroke, cancer and death.

When is the best time to sleep?

Night is the time meant for normal sleep. This is because the sleep-inducing hormone, melatonin, is secreted only during nights. The secretion of melatonin is inhibited by light, hence, darkness in the bedroom is essential for sound sleep.

Based on the sleep-pattern, there are two types:

1. "Owl" type: Person sleeps late (11 PM-12 midnight) and wakes up late (7AM-8 AM)
2. "Lark" type: Person sleeps early (8 PM-9 PM) and wakes up early (4 AM-5 AM)

These patterns are genetically determined and hence, it is difficult to change them.

Are daytime naps good?

Most of us feel sleepy in the afternoon, especially after a good lunch. However, it is not a good habit to sleep in the afternoon. Between the ages 10 and 60, sleep is monophasic, which means, sleeping only once (at night) is enough. Infants and small children have polyphasic sleep, which means, they wake up and sleep several times in 24 hours. Preschool children and elderly have biphasic sleep, and they require an afternoon nap in addition to night sleep. For others, afternoon nap is not necessary. However, a very short snooze (20 min or so) can be very energizing, especially in those who have to work very hard in the post-lunch session. Sleeping more than 30 minutes in the afternoon may make one very groggy and difficult to concentrate in work.

Why do we need to sleep?

 Sleep serves may important functions, some of them are:

1. Makes us feel fresh, and restores the energy.
2. Consolidation of memory happens during sleep. Brain decides what is important and that gets stored in long-term memory. Whatever is un-importnat is deleted from brain storage. So, lack of night sleep can lead to poor memory functions.
3. Growth hormone secretion occurs at night, so, sleep is important for proper growth.
4. Dreams occur during sleep, which is important for normal human functioning. We shall discuss more about dreams separately.
5. Normal night sleep decreases the risk of cancer. This is because melatonin secreted during sleep is an antioxidant and has anti-cancer properties.

Sleep is therefore one of the most important funcitons of human brain, and those with a good sleep are truly blessed!

Dr Sudhir Kumar MD DM
Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066
drsudhirkumar@yahoo.com



Friday, June 17, 2011

POST-PARTUM CEREBRAL VENOUS THROMBOSIS (CVT)

POST-PARTUM CVT (CLOTTING OF BLOOD IN BRAIN VEINS)

Introduction

Pregnancy and delivery are normal physiological processes, which are experienced by more than 95% of women. Delivery and arrival of a newborn is a cause of joy and celebration all across the world. However, due to the normal physiological changes (and certain other factors), mothers in the post-natal period are prone to develop certain diseases. Cerebral venous thrombosis is one such major illness.

What happens in cerebral venous thrombosis?

Brain has two kinds of blood vessels- arteries that transport blood to the brain from the heart, and veins that drain the blood out of brain towards the lungs for purification. In CVT, blood in the brain veins clot (get thrombosed), which impedes the blood flow.

What are the clinical features of CVT?
  • Headache
  • Vomiting
  • Blurred vision, double vision, dimness of vision
  • Fits or convulsions
  • Weakness of hands or legs especially on one half of the body
Who are the women prone to develop cerebral venous thrombosis?

  • Women with severe blood loss during delivery- such as after caesarian section, etc.
  • Those who already had low hemoglobin (less than 10 gm%) before delivery
  • Women who are dehydrated- such as after prolonged labor, those who can't eat or drink properly after delivery, extreme weather conditions, etc. (In India, in certain cultures, women after delivery are kept isolated in a room, and they fast, which makes them dehydrated too)
  • Those with post-partum infections
  • Those with deficiency of anti-clotting factors (which increases the clotting tendencies)
How can CVT be diagnosed?

If any woman in post-natal period develops features suggestive of CVT (such as headache, drowsiness, seizures, weakness, visual problems, etc), they should immediately contact the neurologist.

CT scan or MRI scan with venography can be done within a few minutes and the diagnosis of CVT can be confidently made.

Further tests (blood tests) may be done to detect the reasons for blood clotting in the brain.

How is CVT treated?

1. Patients are started on hepain injections, which are anticoagulants, as early as possible. After a period of 5-7 days, they are changed over to oral anticoagulants (warfarin, etc), which may be required for 3-6 months.
2. Anti-epileptic drugs are used for those with fits.
3. Certain medicines (steroids, mannitol) are given to reduce the brain swelling.
4. Glucose and saline infusions are given to maintain hydration.
5. Anemia is corrected (blood transfusion may be required in more severe cases)
6. Any co-existing infections are treated.

What is the outcome of CVT after treatment?

Patients do very well and recover fast. Most women recover fully, without any neurological deficits. A minority may have seizures or mild weakness or other neuro deficits.

If you require any further information, please send me an email at drsudhirkumar@yahoo.com

DR. SUDHIR KUMAR MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone- 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Monday, June 13, 2011

VITAMIN B12 DEFICIENCY AND NEUROLOGICAL DISORDERS

Neurological Disorders due to Vitamin B12 Deficiency

Vitamin B12 is an important vitamin required for proper functioning of nervous system. Deficiency of vitamin B12 leads to anemia (low hemoglobin) causing generalised weakness, tiredness and fatigue. In addition, it is an important cause of various neurological disorders.

Common manifestations of vitamin B12 deficiency:

1. Tingling or numbness of feet and hands (due to involvement of peripheral nerves)
2. Imbalance while walking (due to spinal cord involvement)
3. Memory impairment
4. Dementia (due to brain involvement)
5. Psychiatric disturbances
6. Uncommonly, fits, tremors, parkinsonism, etc have also been reported.

Who are prone to get vitamin B12 deficiency?

1. Pure vegetarians- Vegetarian diet is a poor source of vitamin B12, hence, symptoms of vitamin B12 deficiency are more common in veg people.

2. Those with gastro-intestinal disorders such as malabsorption (where food is not properly absorbed after eating, manifested by diarrhea), after certain gastric surgeries, etc.

3. Those with other autoimmune diseases such as hypothyroidism (lack of thyroid hormone), vitiligo (white patches on skin), myasthenia gravis (manifested by muscular weakness and fatigue). This is because presence of auto-antibodies may inhibit the absorption of vitamin B12 in the gut.

How to prevent vitamin B12 deficiency?

1. Eating diet rich in vitamin B12 can prevent vitamin B12 deficiency. All animal sources are excellent sources of vitamin B12, such as meat, chicken, fish, shrimps, eggs, etc. Since, vitamin B12 can be stored in the body for long, 1-2 servings per week may suffice in normal people. No plant source is a good and reliable source of vitamin B12.

2. Regular check ups- If you notice any of the symptoms of vitamin B12 deficiency (as listed above), consult your family physician/neurologist so that it can be diagnosed and treated early.

How to diagnose vitamin B12 deficiency?

1. Vitamin B12 level can be estimated in blood. It is a simple investigation available in most labs.

2. Further tests may be required to see the effects of vitamin B12 deficiency on nervous system or to ascertain the cause of vitamin B 12 deficiency.

How is vitamin B12 deficiency treated?

Once vitamin B12 deficiency is establilshed (after clinical exam and blood tests), patients are started on vitamin B12 supplements. Initially, injections are given, so as to prevent the problem of less absorption. Then, maintenance treatment is given with oral tablets of vitamin B12.

What is the outcome of treatment?

Most patients who are diagnosed and treated early show a good recovery, which, however, may be prolonged over weeks to months.


Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Wednesday, June 8, 2011

SHARING NEGATIVE MEDICAL NEWS WITH CHILDREN

SHOULD WE DISCUSS "BAD NEWS" WITH CHILDREN-
a real life experience

We often come across younger patients especially children who are diagnosed to have illnesses/diseases with poor outcomes. These may include a child diagnosed to have cancer of blood (leukemia) or cancerous tumor of brain (glioma), etc. In our normal medical practice, we discuss in detail about the disease with the patients and immediate family members. Areas of discussion involve the nature and likely progression of disease, the likely causes of the disease, the different modes of treatment (including expensive medicines, operations, etc) and the expected outcomes of disease & treatment.

In case of children, parents often tell us not to share any medical details with the child, fearing the child would get depressed, won't be able to handle the "bad news" and many other excuses. Sometimes, we are asked to tell a lie to the child- for example, in stage IV glioma of brain, the expected survival could be 6 months to 12 months. In this case, parents may ask us to tell the child that "he does not have tumor" and that "there is no risk to his life because of the illness".

Are we justified in not sharing medical details (bad news) or distorting the facts to child patients?

I want to share an experience that I recently had.

An 8-year-old child Arjun was referred to me by the radiation oncologist for control of convulsions (fits). Arjun was diagnosed to have grade IV (late stage cancer) glioma of brain and was receiving chemotherapy after having undergone a brain operation. In my OPD, Arjun's parents met me first and urged me not to disclose anything to him about the illness including the diagnosis and likely outcome, and to tell him that "he will be well soon". They told me that Arjun does not know anything about his illness and outcome. I told them I would do what they expected of me.

When parents brought the child in, he looked very calm and composed. He was on a wheel-chair as he could not walk due to weakness of legs (due to brain tumor). He had a beautiful smile on his face. While interacting with him, I found him to be very intelligent and smart. I asked his parents if I could privately talk to Arjun and they agreed. As soon as his parents left the room, Arjun told me he knows everything about the illness. He had read the doctors' medical notes and then surfed the internet. He told me that he has grade IV glioma and that at best he would survive for less than six months. He told me not to disclose to his parents that he already knows all about his illness; otherwise they would feel "hurt".

Next I sent Arjun out and told his parents about my discussion with the child. They stood speechless and expressionless. They were shocked! Here, we had a family living in denial....that the other party does not know anything!.

Today, information is easy to get and at one click, one can find all about the disease. So, hiding information from a child may not be easy. On the other hand, I feel sharing all details over 2-3 meetings is more appropriate. In my medical practice, I like to tell all about the illness to my patients- old or young, men or women....unless, of course, they dont want to know (which is very rare).

(Arjun is the changed name to hide the identity)

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Tuesday, June 7, 2011

Importance of timely treatment in brain stroke (paralysis)

STROKE TREATMENT: Benefits the most within the FIRST 4.5 HOURS

Brain stroke, commonly causing paralysis of one half of the body (called as "lakwa" in Hindi) is among the top 3 causes of death and disability in the world (the other two being heart attack and cancer). Stroke brings about a sudden transformation in the sufferer's life. A completely independent person may become paralysed, making him/her dependent on others for even their basic needs such as bathing, toileting and feeding needs.

Moreover, stroke is a major cause of financial burden for the sufferer. The patient is unable to attend to his job due to disability leading to the loss of income. In addition, the treatment of stroke and caring for the stroke patient adds to the financial burden.

Therefore, it is important to recognize and treat stroke at the earliest. There is only a single approved treatment for brain stroke- thrombolysis (or clot-buster therapy) using a drug called as tissue plasminogen activator (tPA). The point to note is that this medicine should be started within 4 hours and 30 minutes of onset of brain stroke to achieve maximum efficacy and to avoid any complications.

Success of the treatment being linked to time after symptom onset, makes it mandatory to identify the stroke symptoms and transportation to a recognized stroke center at the earliest a priority. In Hyderabad, Apollo Hospital at Jubilee Hills is accredited by Joint Commission International (JCI, USA) for the management of acute stroke since April 2006.

In the best centers for stroke treatment, there is a stroke team comprising of an emergency physician, neurologist, radiologist, physiotherapist, intensivist, dietician, etc. There is a standard protocol for taking care of patients with stroke. The ER is notified beforehand about the expected stroke patient, which in turn alerts the stroke team. As soon as the patient reaches ER, a clinical examination is carried out to ascertain the stroke. CT scan is immediately done (within 20 minutes of arrival to ER). Blood tests are done to ascertain the patients' eligibility for thrombolytic therapy. These reports are obtained and treatment started within 45 minutes of patients' arrival to ER (i. e. door to needle time is less than 45 minutes). Stroke unit and treatment at Apollo Hospitals, Jubilee Hills, Hyderabad, adheres to all the above.

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Saturday, June 4, 2011

EPILEPSY- Is it treatable?

What is epilepsy?

Epilepsy is a neurological disease characterized by repeated abnormal electrical discharges from the brain, resulting in fits or convulsions. Either a part of the body can be involved called as partial or focal epilepsy; or the whole body is affected called as generalized epilepsy. During a generalized epileptic attack, the person can lose complete consciousness resulting in falls or injuries.

 How is epilepsy diagnosed?

Epilepsy is diagnosed on the basis of clinical description of the seizure episode. So, it is important for the eye witness to accurately describe it to the neurologist. Doctor may get brain scans and EEG to confirm the cause and type of seizure.

Is epilepsy treatable?

Epilepsy is very well treatable with medications (anti-epileptic drugs). Neurologist would be able to select the best medication depending on the type of epilepsy and also age & sex of the patient. The medicines are required to be taken for long-term without any discontinuation.

Can women with epilepsy get married?

Women with epilepsy can get married and have normal married lives. They can get pregnant and have babies just like other women. Neurologist would advise on the safe anti-epileptic drugs in pregnancy and some vitamins (folic acid) are also required. Please discuss regarding any concerns with your neurologist.

Can people with epilepsy do normal jobs?

Most jobs are safe for people with epilepsy. However, they should avoid driving, swimming and other hazardous activities, as occurrence of seizures during these activities can be dangerous.

Is epilepsy a result of bad evils/demons?

No, they are only misconceptions.

What are the first aid measures to be adopted when someone has an epileptic attack?

1. Make the person lie down on one side (either left or right)
2. Do not give water or anything else by mouth, as it can get aspirated into lungs (causing pneumonia) in an unconscous person.
3. Try to prevent any injury because of fall or tongue bites.
4. Intra-nasal midazolam may be safely given at that time.
5. There is no point giving any keys or any other metals in person's hands, or making him smell handkerchief or socks.
6. Take him to the nearest clinic/hospital at the earliest.

Dr Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Wednesday, June 1, 2011

Homocysteine in heart and brain disease

IMPORTANCE OF HOMOCYSTEINE

Myocardial infarction (heart attacks) and brain strokes (paralysis) are the two most common causes of death and disability in the world. They occur in all regions of the world, and the prevalence increases with advancing age.

There are a number of known risk factors for causing heart attacks and brain strokes, which include high BP, diabetes, high cholesterol, smoking, positive family history and so on.

Role of homocysteine in heart attacks and brain strokes
  • Homocysteine is a normal amino acid in our blood.
  • However, elevated levels of homocysteine in the blood is an additional risk factor for causing atherosclerosis (narrowing of blood vessels for heart and brain).
  • Elevated levels of homocysteine causes injury to the inside of blood vessel.
Though there are no definite reasons for elevated homocysteine levels, they tend to occur more in smokers and pure vegetarians.

It is easy to identify high homocysteine, by doing a simple blood test in fasting state.

Treatment of elevated homocysteine is also easy. One needs to use certain vitamins (folic acid, and other B group vitamins).
Please consult your neurologist for any further information.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com