Cognitive Symptoms During Midlife
August 15th, 2010
Posted in During the menopausal transition, it is common for women to report problems with memory. In cross-sectional analyses of women ages 40 to 55 years in the Study of Women Across America (a multicenter study of the natural history of the menopausal transition1), forgetfulness was reported significantly more often among those in the menopausal transition or postmenopause compared to the premenopause.2 In the Seattle Midlife Women’s Health Study, more than two-thirds of middle-age women (mean age 47 years) reported difficulty recalling names; nearly one-half indicated problems with recalling telephone numbers just checked, whether they had already told someone something, things they had been told by others, where they put things, or what they were doing.3
Despite the frequency of memory complaints, effects of menopause per se on cognitive function has rarely been studied with objective measures. In a recent issue of the journal Neurology, Meyer examined scores on two brief psychometric tests in middle-age women. Eligible women were participants in the Chicago site of the Study of Women’s Health Across the Nation, selected from a geographically defined urban area. They were aged 42 to 52 years, had a uterus and at least one ovary, had menstruated within the past 3 months, were not pregnant or breastfeeding, and had not used hormone therapy in the prior 3 months. Women were assessed with the digit span backward test and the Symbol Digit Modalities Test. The former is an attentional and working memory task that required women to repeat in reverse order an increasingly long string of digits. The latter is a speeded task of complex visual scanning, attention, and working memory in which participants were presented with a key on whichprinted symbols are paired with a digit and with a list of these symbols. Each woman was asked to provide the corresponding number for as many of the listed symbols as she could during 90 seconds.
At baseline, most women were premenopausal or during the early menopausal transition. Over a mean follow-up of slightly over 2 years, women were assessed annually; approximately 600 women were assessed at least twice. During this time, 183 women progressed from premenopause to the early menopausal transition, 171 from early to late menopausal transition (defined as menses within the past year but not within the past 3 months), and 122 from the late transition to the postmenopause (no menses within the past year); 126 of these women changed reproductive stage more than once.
Results indicated no significant incremental change on these two cognitive tasks as women progressed from one menopausal stage to another. Within each reproductive stage, most scores increased slightly over time. Changes were significant for digit span backward during the premenopause (+0.17 items/year) and early menopausal transition (+0.19 items/year), and for the Symbol Digit Modalities Test during the premenopause (+0.52 items/year), early transition (+0.34 items/year), late transition (+1.5 items/year), and postmenopause (-1.1 items/year). Test changes were not accounted for by age, education, family income, ethnicity, or self-reported health. Although statistically significant, the mean magnitude of change on these tasks was not clinically meaningful, and incremental increases probably represented practice effects. The authors concluded that transition through the menopause is not accompanied by declines in cognitive skills assessed by their psychometric tasks.
Natural Hormones and Alternative Therapies
One of the many reactions to the published results of the canceled Women’s Health Initiative (WHI) trials has been a turn toward alternative therapies, natural hormones, and bioidentical hormones. Whatever you call them, the aim is the same: to sell products. The marketing implication is that these approaches escape alleged side effects associated with trade formulations,and in some way are better suited to a woman’s physiology. Measurement of multiple hormones in saliva often is part of the package, allegedly to tailor hormone administration based on the assay results.
The marketing of bioidentical hormones preys on emotions, including the response to the WHI. But clinical decision-making, in contrast, must be based on a foundation of knowledge: accumulated information and understanding acquired through experience, education, and appraisal of the literature. Applying this knowledge to a patient does require individualization, but it is dependent on the clinician’s familiarity with and understanding of that particular woman. The entire process is the art and science of medicine. It is the fundamental reason that clinicians enjoy being clinicians and why clinicians are so valued by patients.
There is only one medicine. Anything that claims to treat or prevent health problems must withstand the rigor of scientific studies of efficacy and safety. That information becomes part of our foundation of knowledge. Anything with the potential to affect health must be subjected to this requirement. Treatments that pass this test will become part of our medical practice; those that fail will fall by the wayside. The simplicity and correctness of this argument is so overwhelming that it must be required for any future therapies, whatever they are called.
Prevention of HIV
Universal Precautions
Universal precautions refer to personal protective measures that are followed in order to prevent contact with blood and body fluids of another person who may or may not have a communicable disease or infection.
The principles of universal precautions are:
- Use of protective barriers
- Prevention of accidents
- Proper use of disinfections and sterilization techniques
Blood and body fluids may contain HIV or other infectious agents such as for example hepatitis B and C.
Use of protective barriers
Appropriate barriers should be worn where exposure to blood and other potentially infectious fluids is anticipated. The protection selected will depend on the type of exposure:
- Gloves
- Gowns and aprons
- Mask
- Protective eyewear
Protection of accidents through safe handling and disposal of sharps
The greatest risk of blood borne pathogen transmission in health care settings is through percutaneous exposure. Efforts to prevent transmission must focus on preventing injury from contaminated sharp instruments by encouraging safe handling and disposal of sharps. Most sharp injuries associated with blood borne transmission involve deep injuries with hollow-borne needles. These injuries frequently occur when needles are recapped, cleaned, disposed of, or inappropriately discarded, e.g. used needles left on trolleys or beds.
Good practice for the safe handling and disposal of sharps:
- Always dispose of your own sharps
- Never pass used sharps directly from one person to another
- During exposure-prone procedures, the risk of injury should be minimized by ensuring that the operator has the best possible visibility, e.g., by positioning the patient, adjusting good light source and controlling bleeding.
- Never recap, bend or break disposable needles.
- Directly after use, place sharps, needles and syringes in a rigid container until ready for disposal. Never place those in other waste containers.
- Locate sharps disposal containers close to the point of use, e.g., in patient’s room, on the medicine trolley and in the treatment room
- Keep sharps and sharps disposal containers out of the reach of children
- Prevent overflow by sending sharps disposal containers for decontamination or incineration when three-quarters full.
Proper use of disinfection and sterilization techniques
As HIV and other blood borne infections can be transmitted via equipment contaminated with body fluids, these items should be cleaned and sterilized, or appropriately disinfected before each use. The method of decontamination of instruments and equipment depends on what they are used for and the associated level of risk of transmission.
Find Exercise Program
One of the most critical aspects of proper weight management is exercise. And the best way to find an exercise program that works for you is to find something that you enjoy doing, and make it part of your regular routine.
This may be as simple as walking to your local store instead of driving, going for a walk after dinner, or riding your bike to work instead of driving. Yard work and dancing are also good choices. Many people find it relaxing to do stretching routines in the morning or before bed at night.
You may find it easier to stick to an exercise routine if you begin gradually, and find a friend to exercise with you. Following are a few exercise suggestions:
- Find an aerobic activity that you can do for 15 to 20 minutes at a time.
- Do this exercise for 15 to 20 minutes each day for 4 days a week.
- Do this for about 2 weeks.
- After that, increase your workout to about 20 to 25 minutes each day, 4 or 5 days a week.
- Remain at this pace for another 2 weeks and then gradually increase the amount of aerobic exercise you are getting.
- You should ultimately be doing a 30 to 35 minute workout per day, 5 or 6 days per week.
- At this time you may want to add some exercises to build strength. If you can, use 5 to 8 lb dumbells in your workout.