CHANGE YOUR BRAIN, CHANGE YOUR LIFE Master Questionnaire Plus PREVENTING ALZHEIMER’S RISK ASSESSMENT Questionnaire And HOW IS YOUR MEMORY? Screening Questionnaire Copyright 2008 Daniel Amen, M.D. 1 Table of Contents Change Your Brain, Change Your Life Master Questionnaire and Answer Key 3 Preventing Alzheimer’s Risk Assessment Questionnaire and Scoring Interpretation 9 How Is Your Memory? Screening Questionnaireand Interpretation 12 Preventing Alzheimer’s Disease: A Step By Step Plan 14 Amen Clinic Healing the Brain Quick Reference Summaries 18 Executive Brain -- Prefrontal Cortex  Gear Shifter -- Anterior Cingulate Gyrus  Anxiety and Motivation -- Basal Ganglia  Mood Center -- Deep Limbic System  Memory and Temper Control -- Temporal Lobes  Balance and Organization -- Cerebellum  About the Amen Clinics 2 CHANGE YOUR BRAIN, CHANGE YOUR LIFE Master Questionnaire Copyright 2008 Daniel Amen, M.D. The Change Your Brain, Change Your Life Master Questionnaire will be a great start to helping you evaluate the health and well being of your brain. Plus, it will lead you to specific parts of the program that may be most helpful for you. Think of this tool as the beginning of making your good brain great and having the best brain possible. For many years I have realized that not everyone is able to get a brain scan to check on the health of their brain. So, in order to bring the life-changing information that I have learned through our imaging work to the most people I have developed a series of questionnaires to help predict the areas of strengths and vulnerabilities of the brain. Feel free to give these questionnaires to your friends and family members. Brain healthy friends and families are happier friends and families. A word of caution is in order. Self-report questionnaires have advantages and limitations. They are quick and easy to score. On the other hand, people filling them out may portray themselves in a way they want to be perceived, resulting in self-report bias. For example, some people exaggerate their experience and mark all of the symptoms as frequent, in essence saying, “I’m glad to have a real problem so that I can get help, be sick or have an excuse for the troubles I have.” Others are in total denial. They do not want to see any personal flaws and they do not check any symptoms as significantly problematic, in essence saying, “I’m OK. There’s nothing wrong with me. Leave me alone.” Not all self-report bias is intentional. People may genuinely have difficulty recognizing problems and expressing how they feel. Sometimes family members or friends are better at evaluating a loved one’s level of functioning than a person evaluating himself or herself. They may have noticed things that their loved one hasn’t. Questionnaires of any sort should never be used as the only assessment tool. Use this one as a catalyst to help you think, ask better questions and get more evaluation if needed. Always discuss any recommendations with your personal physician. 3 CHANGE YOUR BRAIN, CHANGE YOUR LIFE Master Questionnaire Copyright 2008 Daniel Amen, M.D. Please rate yourself on each of the symptoms listed below using the following scale. If possible, to give yourself the most complete picture, have another person who knows you well (such as a spouse, lover or parent) rate you as well. List other person_____________________________ 0 1 2 3 4 NA Never Rarely Occasionally Frequently Very Frequently Not Applicable/known Other Self _____ _____1. Trouble sustaining attention _____ _____2. Lacks attention to detail _____ _____3. Easily distracted _____ _____4. Procrastination _____ _____5. Lacks clear goals _____ _____6. Restless _____ _____7. Difficulty expressing empathy for others _____ _____8. Blurts out answers before questions have been completed, interrupts frequently _____ _____9. Impulsive (saying or doing things without thinking first) _____ _____10. Needs caffeine or nicotine in order to focus _____ _____11. Gets stuck on negative thoughts _____ _____12. Worries _____ _____13. Tendency toward compulsive or addictive behaviors _____ _____14. Holds grudges _____ _____15. Upset when things do not go your way _____ _____16. Upset when things are out of place _____ _____17. Tendency to be oppositional or argumentative _____ _____18. Dislikes change _____ _____19. Needing to have things done a certain way or you become very upset _____ _____20. Trouble seeing options in situations _____ _____21. Feeling sad _____ _____22. Being negative _____ _____23. Feeling dissatisfied _____ _____24. Feeling bored _____ _____25. Low energy _____ _____26. Decreased interest in things that are usually fun or pleasurable _____ _____27. Feelings of hopelessness, helplessness, worthlessness, or guilt _____ _____28. Crying spells _____ _____29. Chronic low self-esteem _____ _____30. Social isolation _____ _____31. Feelings of nervousness and anxiety 4 _____ _____32. Feelings of panic _____ _____33. Symptoms of heightened muscle tension, such as headaches or sore muscles _____ _____34. Tendency to predict the worst _____ _____35. Avoid conflict _____ _____36. Excessive fear of being judged or scrutinized by others _____ _____37. Excessive motivation, trouble stopping working _____ _____38. Lacks confidence in their abilities _____ _____39. Always watching for something bad to happen _____ _____40. Quick startle _____ _____41. Short fuse _____ _____42. Periods of heightened irritability _____ _____43. Misinterprets comments as negative when they are not _____ _____44. Frequent periods of deja vu (the feeling you have been somewhere before even though you haven’t) _____ _____45. Sensitivity or mild paranoia _____ _____46. History of a head injury _____ _____47. Dark thoughts, may involve suicidal or homicidal thoughts _____ _____48. Periods of forgetfulness or memory problems _____ _____49. Trouble finding to right word to say _____ _____50. Unstable moods _____ _____51. Poor handwriting _____ _____52. Trouble maintaining an organized work area _____ _____53. Multiple piles around the house _____ _____54. More sensitive to noise than others _____ _____55. Particularly sensitive to touch or tags in clothing _____ _____56. Tend to be clumsy or accident-prone _____ _____57. Trouble learning new information or routines _____ _____58. Trouble keeping up in conversations _____ _____59. Light sensitive and easily bothered by glare, sunlight, headlights or streetlights _____ _____60. More sensitive to the environment than others _____ _____61. Snores loudly or others complain about your snoring _____ _____62. Other say you stop breathing when you sleep _____ _____63. Feel fatigued or tired during the day _____ _____64. Feel cold when others feel fine or they are warm _____ _____65. Problems with brittle, dry hair, or thinning hair _____ _____66. Problems with dry skin _____ _____67. Increase in weight even with low calorie diet _____ _____68. Chronic problems with tiredness _____ _____69. Require excessive amounts of sleep to function properly _____ _____70. Difficult or infrequent bowel movements _____ _____71. Morning headaches that wear off as the day progresses _____ _____72. Lack of motivation or mental sluggishness _____ _____73. Feel warm when others feel fine or they are cold _____ _____74. Night sweats or problems sweating during the day _____ _____75. Heart palpitations _____ _____76. Bulging eyes 5 _____ _____77. Inward trembling _____ _____78. Increased pulse rate even at rest _____ _____79. Insomnia _____ _____80. Difficulty gaining weight _____ _____81. Crave sweets during the day _____ _____82. Irritable if meals are missed _____ _____83. Depend on coffee to keep you going/started _____ _____84. Get lightheaded if meals are missed _____ _____85.Eating relieves fatigue _____ _____86. Feel shaky, jittery, tremors _____ _____87. Agitated, easily upset, nervous _____ _____88. Poor memory, forgetful _____ _____89. Blurred vision _____ _____90. Decreased sex drive _____ _____91. Decreased muscle mass and strength _____ _____92. Loss of body hair _____ _____93. Abdominal fat (pot belly) _____ _____94. Decreased bone mass that may lead to osteoporosis _____ _____95. Light sensitive and bothered by glare, sunlight, headlights or streetlights _____ _____96. Become tired and/or experience headaches, mood changes, feel restless, or have an inability to stay focused with bright or fluorescent lights _____ _____97. Have trouble reading words that are on white, glossy paper _____ _____98. When reading, words or letters shift, shake, blur, move, run together, disappear, or become difficult to perceive _____ _____99. Feel tense, tired, sleepy, or even get headaches with reading _____ _____100. Have problems judging distance and have difficulty with such things as escalators, stairs, ball sports, or driving _____ _____101. Night driving is hard _____ _____102. Increased appetite, binge eating _____ _____103. Winter depressions, mood problems tend to occur in the fall and winter months and recede in the spring and summer _____ _____104. Diet is poor and tends to be haphazard. _____ _____105. Do not exercise. _____ _____106. Put myself at risk for brain injuries, by doing such things as not wearing my seat belt, drinking and driving, engaging in high risk sports, etc. _____ _____107. Live under daily or chronic stress, in my home or work life. _____ _____108. Thoughts tend to be negative, worried or angry. _____ _____109. Problems getting at least 6-7 hours of sleep a night. _____ _____110. Smoke or am exposed to second hand smoke. _____ _____111. Drink or consume more than 2 cups of coffee, tea or dark sodas a day. _____ _____112. Use aspartame and/or MSG. _____ _____113. Around environmental toxins, such as paint fumes, hair or nail salon fumes or pesticides. _____ _____114. Spend more than one hour a day watching TV. _____ _____115. Spend more than one hour a day playing video games. _____ _____116. Outside of work time, spend more than one hour a day on the computer. _____ _____117. Have more than 3 normal size drinks of alcohol a week. 6 CHANGE YOUR BRAIN, CHANGE YOUR LIFE Master Questionnaire Answer Key Place the number of questions you, or a significant other, answered “3” or “4” in the space provided. _____ 1-10 Prefrontal cortex (PFC) problems, see Chapters 7, 8 in the book, plus PFC sheet. _____ 11-20 Anterior cingulate gyrus (ACG) problems, see Chapters 9, 10 in the book, plus AC sheet. _____ 21-30 Deep limbic system (DLS) problems, see Chapters 3, 4 in the book, plus DLS sheet. _____ 31-40 Basal ganglia (BG) problems, see Chapters 5, 6 in the book, plus BG sheet. _____ 41-50 Temporal lobe (TL) problems, see Chapters 11, 12 in the book, plus TL sheet. _____ 51-60 Cerebellum (CB) problems, see CB sheet. For the 6 above brain systems, find below the likelihood that a problem exists. If there is a potential problem see the corresponding section of the book or summary sheets. Highly probable 5 questions Probable 3 questions May be possible 2 questions _____ 61-63 Sleep apnea -- If you answered one or more of these questions with a score of “3” or “4”you may have sleep apnea. Sleep apnea occurs when people stop breathing multiple times at night. It causes significant oxygen deprivation for the brain and people often feel tired and depressed. This condition is best evaluated by sleep study in a specialized sleep laboratory. Treating sleep apnea often makes a positive difference in mood and energy. If you suspect a problem talk to your physician. _____ 64-72 Hypothyroid -- If you answered three or more questions with a score of “3” or “4”low thyroid issues should be evaluated by your physician. Low thyroid problems can cause symptoms of anxiety, depression, memory problems and mental fatigue. _____ 73-80 Hyperthyroid -- If you answered three or more questions with a score of “3” or “4”high thyroid issues should be evaluated by your physician. Excessive thyroid problems can cause symptoms of anxiety, agitation, irritability and depression. 7 _____ 81-89 Hypoglycemia -- If you answered three or more questions with a score of “3” or “4”low blood sugar states should be evaluated by your physician. Low blood sugar or hypoglycemia can cause symptoms of anxiety and lethargy. Eating four to five small meals a day, as well as eliminating most of the simple sugars in your diet (such as sugar, bread, pasta, potatoes, and rice) can be very helpful to balance your mood and anxiety levels. _____ 90-94 Low Testosterone Levels -- If you answered two or more questions with a score of “3” or “4”low testosterone issues should be evaluated by your physician. Low testosterone levels can cause symptoms of low energy, depression, moodiness, and low libido, as well as the other symptoms. Getting this condition properly diagnosed and treated can make a significant positive difference in your life for both men and women. _____ 95-101 Scotopic Sensitivity Syndrome -- If you answered three or more questions with a score of “3” or “4”you may have Scotopic Sensitivity Syndrome (SSS). SSS occurs when the brain is overly sensitive to certain colors of light. This can cause headaches, anxiety, depression, problems reading, and depth perception issues. Getting this condition properly diagnosed and treated can make a significant difference for your mental and physical health. To learn more about the diagnosis and treatment of SSS go to www.irlen.com. Most physicians do not know about this disorder, so please do not rely on them for accurate information. _____ 102 Carbohydrate Cravings -- If you answered this question with a score of “3” or “4”carbohydrate cravings may be a problem. Research has found that some people respond nicely to taking the supplement chromium picolintae, 400-600micrograms a day. _____ 103 Seasonal Mood Disorder – If you answered this question with a score of “3” or “4”you may have a seasonal mood disorder. Getting outside during daylight hours can be helpful, along with sitting in front of special “full spectrum light therapy” devices for 30 minutes in the morning. See http://www.mayoclinic.com/health/seasonal-affective-disorder/MH00023 for more information. _____ 104-117 Bad Brain Habit Questions. For these questions add up your total score, not just the ones you answered 3 or 4. If you score between 0-6 then odds are you have very good brain habits. Congratulations! If you score between 7-12 odds are you are doing good, but you can work to be better. If you score between 13-20 your brain habits are not good and you are prematurely aging your brain. A better brain awaits you. If you score more than 20 you have poor brain habits and it is time to be concerned. A brain makeover may just change your life! 8 PREVENTING ALZHEIMER’S RISK ASSESSMENT Questionnaire As I said in the presentation it is critical to know your specific risk for Alzheimer’s Disease. The following questionnaire is based on current scientific research to help you assess your specific risk. Once you know your risk you can do things to improve it. No matter what your age it is important to establish a baseline. It is useful to establish a baseline against which various preventive strategies can be measured, and establishing a baseline allows earlier detection of any disorders that cause memory loss or dementia, which allows them to be treated in their earliest stage to most effectively prevent or delay their progression. Preventing Alzheimer’s Risk Assessment Questionnaire The following questionnaire is meant as a general screening tool of cognitive function to indicate whether you should consider further testing. Early screening is essential to take full advantage of the preventive and disease therapies that are now available and can mean the difference between living your life without the symptoms of Alzheimer’s disease or living out life in a long-term care facility. The Preventing Alzheimer’s Risk Assessment Questionnaire is the first of two self-administered questionnaires that screens for the risk factors associated with Alzheimer’s disease. How Is Your Memory screens for its earliest symptoms. As mentioned, questionnaires of any sort should never be used alone as the only assessment tool. Like an isolated laboratory test result, they are not meant to provide a diagnosis. They are simply catalysts to initiate the process of further evaluation when needed. Both of these questionnaires are useful first steps to help determine whether you or a loved one should do further screening. You can find more information and an online Memory Screening Test should you wish to explore your risk further at www.preventad.com. Please answer the following questions with a yes or no. For every yes answer circle the number provided in parentheses, add your score at the end of the test for interpretation. To give yourself the most complete picture, have another person who knows you well also answer the questions (such as a spouse, partner, child, sibling, parent or close friend or colleague). Other Self _____ _____1.(3.5) One family member with Alzheimer’s or dementia _____ _____2.(7.5) More than one family member with Alzheimer’s or dementia _____ _____3.(2.7) Family history of Down Syndrome _____ _____4.(2.0) A single head injury with loss of consciousness _____ _____5.(2.0) Several head injuries without loss of consciousness _____ _____6.(4.4) Alcohol dependence or drug dependence in past or present _____ _____7.(2.0) Major depression diagnosed by a physician in past or present 9 _____ _____8.(10) Stroke _____ _____9.(2.5) Heart disease or heart attack _____ _____10.(2.1) High cholesterol _____ _____11.(2.3) High blood pressure _____ _____12.(3.4) Diabetes _____ _____13.(3.0) History of cancer or cancer treatment _____ _____14.(1.5) Seizures in past or present _____ _____15.(2.0) Limited exercise, less than twice a week _____ _____16.(2.0) Less than a high school education _____ _____17.(2.0) Jobs that do not require periodically learning new information _____ _____18.(2.0) Within the age range, 65 to 74 years old _____ _____19.(7.0) Within the age range, 75 to 84 years old _____ _____20.(38.0) Over 85 years old _____ _____21.(2.3) Smoking cigarettes for 10 years or longer _____ _____22.(2.5) has one apolipoprotein E4 gene, (if known) _____ _____23.(5.0) has two apolipoprotein E4 genes, (if known) _____ _____ Total Score -- Add up the scores in parentheses for all items checked for self and other. Interpretation: If the score is 0 - 3, then you have low risk factors for developing Alzheimer’s disease. If the score is 4-7, then you should do annual screening after age 50 years old. Visit www.preventad.com. If the score is greater than 7, then you should annually screen after age 40 years old. Visit www.preventad.com. See ways to decrease your Alzheimer’s risk on page 14. 10