Cognitive function, also called cognitive performance or cognition, refers to the ability of an individual to think, process, and store information in order to solve problems. Humans are the only organisms capable of cognition.

Cognitive disorders are characterized by delirium, dementia, and/or amnesia. Delirium is a term used to describe a confused mental state in which a patient has difficulty processing and interpreting information. Dementia is the loss of mental ability that is so severe that it interferes with daily functioning. Amnesia may cause difficulty remembering previously learned information. Patients with cognitive disorders may experience one or more of these symptoms.

Treatment for cognitive disorders depends on the underlying cause. Most disorders are incurable and some may have devastating effects. For instance, Alzheimer's disease eventually leads to complete cognitive impairment. Treatment may help delay progression of such disorders. Other disorders, such as age-associated memory impairment (AAMI) may only cause mild symptoms.

Cognitive learning disabilities occur when individuals have difficulty interpreting or processing what they see or hear. There is a gap between the patient's intelligence and his/her ability to perform. Patients may have difficulties with spoken and written language, self-control, coordination, and/or attention. As a result, patients may have a hard time with schoolwork or performing tasks at work.

Patients with cognitive learning disabilities are often able to live normal, healthy lives. There are many ways for patients to cope with their disabilities. Special education and adaptive skills training has been shown to improve patients' work and school performances. Patients who are diagnosed and treated promptly are often able to go to college and support themselves.

COMMON TYPES OF COGNITIVE DISORDERS AND DISABILITIES

Age-associated memory impairment (AAMI): Age-associated memory impairment (AAMI) refers to the normal decline in memory as patients age. AAMI causes mild forgetfulness in patients who are older than 50 years of age.

Alzheimer's disease: Alzheimer's disease (AD) is a progressive cognitive disorder that causes dementia. Dementia is the loss of mental ability that is so severe that it interferes with daily functioning.

Over many years, AD eventually leads to irreversible mental impairment. During the final stages of AD, patients are unable remember, reason, and learn new things.

AD typically develops in patients who are 65 years old or older. Although doctors know that AD causes healthy brain tissue to slowly degenerate over time, the exact origin of the disease remains unknown. Patients with AD develop abnormal clumps (called plaques) and irregular knots of brain cells (called tangles). Researchers believe that these clumps and tangles kill brain cells and may eventually lead to AD. It has been suggested that genetics may play a role in the development of plaques, which may lead to AD.

Inflammation of the brain has also been associated with AD. However, researchers have not discovered if there is a relationship between brain swelling and the development of AD.

There is currently no known cure for AD. Once diagnosed, patients typically survive eight to 10 years with the disease. Some have been known to live 25 years with the disease. In advanced Alzheimer's disease, people may lose all ability to care for themselves. This can make them more prone to additional health problems, such as pneumonia or malnutrition. They may have difficulty swallowing food and liquids, which may cause individuals with AD to inhale some of what they eat and drink into their airways and lungs, which may then lead to pneumonia.

Brain injury: Trauma to the head may damage brain cells and lead to cognitive dysfunction. Brain trauma can result from accidents (such as motor vehicle wrecks and falls), assaults (such as gunshot wounds or beatings), or from sports activities (such as boxing and football) without adequate protective gear. In some cases, injury may still result even if protective gear is worn.

Dementia caused as a result of trauma can be permanent or temporary, depending on the extent of the damage and the ability of the individual's brain to recover.

Infections of brain structures, such as meningitis (inflammation of the protective membranes in the brain) and encephalitis (inflammation of the brain), are primary causes of dementia. Other infections, such as human immunodeficiency virus (HIV) and syphilis (a bacterial sexually transmitted disease), can affect the brain in later stages. In all cases, inflammation in the brain damages cells. Damage to memory due to infection can be permanent or temporary, depending on the extent of the damage and the brain's ability to recover.

Niacin deficiency-induced dementia: Dementia can be caused by severe niacin insufficiency, a condition called pellagra. Niacin is a B-complex vitamin found in a many foods such as liver, poultry, fish, nuts, and dried beans.

Pellagra-induced dementia is uncommon in developed countries, such as the United States. It is most common in areas of the world where malnutrition is prevalent.

Multi-infarct disease: Multi-infarct disease is the second most common cause of irreversible dementia. The condition occurs when the blood flow to the brain is disrupted. If the brain does not receive enough blood, then it is starved of oxygen, and permanent brain damage may result.

In multi-infarct disease, multiple strokes lead to a progressive decline in cognition. Strokes cause neurological damage in the brain due to a lack of oxygen.

Multiple infarct dementia is more common in men who are older than 50 years of age. A person with this condition may also experience motor weakness, urinary incontinence, and ataxia (irregular muscle coordination). Patients may also develop high blood pressure, diabetes, or vascular disease.

Learning disabilities: Learning disabilities are disorders that occur when patients have difficulty interpreting or processing what they see or hear. There is a gap between the patient's intelligence and his/her performance in school, work, or other areas of life.

Patients may have difficulties with spoken and written language, self-control, coordination, and/or attention. As a result, patients may have a hard time with schoolwork or performing tasks at work.

Learning disabilities may be lifelong. In some cases, they may affect many areas of a person's life, including academics, work, social life, or daily routines. Some patients may have several different disabilities. Others may have only one problem that has little or no impact on their lives.

It is important to note that not all learning problems are learning disabilities or cognitive deficits. Some children are simply slower than others in developing new skills. In some cases, learning disabilities may be mistakenly suspected when a child is simply slower to mature.

Learning disabilities occur when certain areas of the brain do not function properly. Many factors, including genetics, may be involved in the development of learning disabilities.

Intellectual disability (mental retardation): Intellectual disability is a condition that causes significantly impaired cognitive functioning from birth or early infancy that ultimately limits the individual's ability to perform normal daily activities.

In the past, intellectual disability was commonly called mental retardation. However, the term, "mental retardation," has acquired a negative social stigma over the years. Therefore, doctors and other professionals have begun to replace the term with intellectual disability.

There is significant variation in the signs and symptoms of intellectual disabilities. Some patients may be able to live relatively normal lives with minimal assistance, while others may require 24-hour assistance with everyday tasks.

There are many potential causes of intellectual disabilities, including genetics, problems during pregnancy (e.g. infection or a mother who drinks or uses drugs during pregnancy), the baby not getting enough oxygen during delivery, and exposure to disease (e.g. whooping cough, measles, or meningitis). Doctors are only able to identify a cause of intellectual disability in about 30% of patients.

SIGNS AND SYMPTOMS

General: The signs and symptoms of cognitive disorders and cognitive learning disabilities vary, depending on the type and severity of the condition. Some patients may live normal, healthy lives and are barely affected by the disorder. Other may have severe disabilities that limit their abilities to function independently.

Age-associated memory impairment (AAMI): Age-associated memory impairment (AAMI) causes mild forgetfulness in patients who are 50 years old or older.

Alzheimer's disease: Symptoms of Alzheimer's disease (AD) typically develop in patients who are 65 years old and older. However, a less common form of AD, known as early-onset AD, may develop in patients who are 30-40 years old. The youngest patient to be diagnosed with AD was 29 years old.

At first, symptoms may be mistaken for normal forgetfulness. However, overtime, the patient loses all cognitive functioning.

Mild symptoms may include memory impairment, confusion, difficulty learning and remembering new information, difficulty with daily tasks, mood swings, restlessness, and depression. In most cases, the patient is still able to do most activities, such as driving a car. However, the patient may get lost going to familiar places.

Moderate symptoms may include forgetting old facts, continually repeating stories, and/or asking the same questions repeatedly. The individual may make up stories to fill memory gaps. Patients have difficulty performing everyday tasks, such as keeping a checkbook, shopping for groceries, or following written notes. Patients may need help performing daily activities. Other symptoms may include agitation, restlessness, repetitive movement, paranoia, delusions, and hallucinations. Deficiencies in intellect and reasoning, along with a lack of concern for appearance, hygiene, and sleep, become more noticeable.

In the advanced stage of AD, damage to the brain's nerve cells is widespread. At this point, full-time care is typically required. The patient is generally bedridden. For friends, family, and caregivers, this can be the most difficult stage. Individuals with severe Alzheimer's disease may have difficulty walking, and they often suffer complications from other illnesses such as pneumonia. Signs of severe Alzheimer's disease may include groaning, screaming, mumbling, or speaking incoherently. They refuse to eat and may inappropriately cry out. Individuals with severe or advanced symptoms fail to recognize the faces of family members or caregivers. Apraxia (inability to perform physical tasks such as dressing or eating) and aphasia (loss of ability in comprehension of spoken or written language) are seen. They have great difficulty with all essential activities of daily life.

Multi-infarct disease: Memory impairment is often the first symptom to be noticed. An individual with dementia may be unable to remember ordinary information, such as his/her birth date, phone number, and address. Patients may be unable to recognize friends and family members. There is a progressive decline in cognitive function, including decision making, judgment, orientation in time and space, problem solving, and verbal communication. Behavioral changes may be seen in eating, dressing, and using the bathroom. Dementia patients may be unable to dress without help and may become incontinent or lose the ability to control urine flow. Normal interests, such as hobbies and social groups, are abandoned. They are unable to perform routine activities, such as driving, grocery shopping, and housecleaning. Individuals with dementia also experience changes in personality, such as inappropriate responses and lack of emotional control.

Trauma may cause prolonged or permanent changes in cognition, memory, emotions, or behavior.

Niacin deficiency-induced dementia: Patients with Niacin deficiency-induced dementia may suffer from the same symptoms as patients with multi-infarct disease.

In addition, niacin deficiency may cause symptoms that affect other parts of the body. Other symptoms, unrelated to dementia, may include skin lesions, inflammation of the tongue, reddening of the tongue, pain in the mouth, increased salivation, ulcerations in the mouth, burning in the throat, swelling in the abdomen, abdominal pain, constipation, diarrhea, nausea, and vomiting.

Learning disabilities: Cognitive learning disabilities vary from mild to severe. There are several different types of learning disabilities, including dyslexia, dysgraphia, dyscalculia, dyspraxia, and auditory perceptual deficit.

Dyslexia occurs when patients have difficulty translating written images into meaningful language. Patients may be unable to recognize written letters or words. Some may be reading at grade levels far below average.

Dysgraphia occurs when patients have difficulty writing letters within a defined space. Patients may take longer to write and have extremely poor handwriting that is almost illegible.

Dyscalculia occurs when patients have difficulty doing arithmetic and understanding mathematical concepts.

Patients with dyspraxia have poor motor control of large movements. Patients may have poor balance, poor posture, lack of rhythm when dancing, poor hand-eye coordination, and clumsy movement.

Visual perceptual deficit occurs when patients have difficulty processing visual information. Although nothing may be wrong with their eyesight, patients may have difficulty identifying an object from a background of other objects or they may not see things in the proper order.

Auditory perceptual deficit occurs when patients have difficulty processing auditory information. Although nothing may be wrong with their hearing, the brain does not interpret sounds properly. As a result, patients may have difficulty understanding and remembering things that are said. They may have difficulty distinguishing between similar sounds or hearing one sound over background noise.

Intellectual disability (mental retardation): Patients with mild intellectual disabilities have intelligence quotients (IQs) of 52-69. From birth to age six, patients are able to develop social and communication skills, but motor coordination is slightly impaired. By late adolescence, patients are able to learn until about a six-grade level. They are generally able to learn appropriate social skills. Adults are usually able to work and support themselves. Some patients may need help during times of social or financial stress.

Patients with moderate intellectual disabilities have IQs of 36-51. Children younger than six years old are able talk or communicate with others, but social awareness is generally poor. The patient's motor coordination is typically fair. Adolescents are able to learn some occupational and social skills. They may be able to learn how to travel alone in familiar places. Adults may be able to support themselves with a job. They usually require guidance and assistance during mild social or financial stress.

Patients with severe intellectual disabilities have IQs of 20-35. Young children can say a few words, but their speech is limited. Motor coordination is generally poor. Adolescents can usually talk or communicate with others. They are able to learn simple habits. Adults typically require lifelong assistance and guidance with daily activities.

Patients with profound intellectual disabilities have IQs of 19 or lower. Children younger than six years old have very little motor coordination and may require nursing care. Adolescents typically have limited motor and communication skills. Adults usually require lifelong nursing care.

COMPLICATIONS

Depression: Depression is common in patients with Alzheimer's disease (AD), especially during the earlier stages when they may be aware of losing mental functions. Depression may be treated with medications called antidepressants.

Falls and their complications: Individuals who suffer from dementia may become disoriented, increasing their risk of falls. Falls can lead to bone fractures that require hospitalization, medications, and surgery. Falls may also lead to an increase in the severity of AD symptoms, such as confusion and agitation. In addition, falls are a common cause of serious head injuries, such as brain hemorrhage (bleeding in the brain). Long-term immobilization after surgery and hospitalization may increase the risk of a pulmonary embolism (blood clot in the lungs), which can be life-threatening.

Infections: In severe and advanced dementia, individuals may lose all ability to care for themselves. This can make them more prone to additional health problems including pneumonia, which is an infection of the lungs and respiratory system. The individual may have difficulty swallowing food and liquids, which may cause them to inhale some of what they eat and drink into their airways and lungs, which may lead to pneumonia.

Urinary incontinence: Patients with severe or advanced dementia may develop urinary incontinence or the loss of bladder control that causes urine leakage. These patients may require the placement of a urinary catheter, which increases the risk of urinary tract infections (UTIs). UTIs can lead to more serious, life-threatening infections, such as pyelonephritis (bacterial infection of the kidney).

DIAGNOSIS

Age-associated memory impairment (AAMI): There are currently no tests to diagnose age-associated memory impairment (AAMI). However, if symptoms of forgetfulness worsen over time, patients should be tested for Alzheimer's disease (AD) or other cognitive disorders.

Alzheimer's disease: The earliest reported Alzheimer's disease diagnosis purportedly occurred in a 29-year-old patient. However, most patients are diagnosed with the condition when they are older than 65 years of age. There is no one test to diagnose Alzheimer's disease (AD). Typically, doctors start the diagnostic process by ruling out other diseases and conditions, such as brain injury or stroke, which may also cause memory loss.

A Mental Status Evaluation (MSE) screens memory, problem-solving abilities, attention spans, counting skills, and language skills. Questions such as "what day is it today?" or "who is the president of the United States?" may be asked. Recall tests are another example. Doctors may list familiar objects and then ask a person to repeat them immediately and again five minutes later. The Clock Drawing Test, the Mini-Mental State Examination (MMSE), and the Functional Assessment Staging (FAST) are commonly used mental status evaluation tools for determining if AD is present. On the tests, the final score helps confirm a diagnosis of AD

Brain scans may also be used to take pictures of the brain. Images of the brain are then analyzed for changes in function and structure of the brain that are associated with AD. Researchers have performed studies to determine if these brain scans may help predict a person's risk of developing the condition.

Multi-infarct dementia: The American Psychiatric Association has established two generally accepted criteria for the diagnosis of dementia: (1) a decline in recent and past memory and (2) impairment of one or more of the following functions: language (aphasia or the misuse of words or inability to remember and use words correctly); motor activity (apraxia or unable to perform motor activities even though physical ability remains intact); recognition (agnosia or unable to recognize objects, even though sensory function is intact); and executive function (unable to plan, organize, and think abstractly). Symptoms often develop gradually and show a progressive deterioration in function.

Once dementia is diagnosed, brain scans may be performed to detect possible abnormalities in the brain.

Niacin deficiency-induced dementia: If a patient meets the diagnostic criteria for dementia, additional tests are performed to determine the cause. A blood test is performed to determine if a niacin deficiency is the cause. Patients with dementia that is caused by niacin deficiency will have low levels of niacin in the blood. Healthy individuals typically have 2.4-6.1 milligrams of niacin per deciliter of blood.

Learning disabilities: Prompt diagnosis and early treatment of learning disabilities has been shown to improve a patient's long-term prognosis. In order to diagnose a learning disability, a specialist will administer several tests, which may involve writing, speaking, and listening. These tests are designed to measure the patient's strengths and weaknesses. In addition, the specialist will interview the patient and family members about medical history and problems that are being encountered.

Intellectual disability (mental retardation): Even though intellectual disability (mental retardation) is an irreversible condition, early diagnosis and prompt treatment has been shown to help improve patients' long-term prognoses.

Doctors diagnose intellectual disability after a medical history, physical examination, and intellectual quotient (IQ) test. If a patient does not show signs of adaptive behavior and scores well below average on the IQ test, then a positive diagnosis is made. To measure the patient's adaptive behavior professionals will compare what the patient can do to other children of his or her age. Many skills, including daily living skills (e.g. getting dressed, feeding oneself, and using the bathroom), communication skills (understanding what is being said and being able to respond), and social skills are important to adaptive behavior.

Patients with mild intellectual disabilities have intelligence quotients (IQs) of 52-69. Patients with moderate intellectual disabilities have IQs of 36-51. Patients with severe intellectual disabilities have IQs of 20-35. Patients with profound intellectual disabilities have IQs of 19 or lower.

TREATMENT

Cholinesterase inhibitors: The U.S. Food and Drug Administration (FDA) has approved cholinesterase inhibitors for the treatment of Alzheimer's disease (AD). These drugs are also used to treat other types of permanent dementia, including multi-infarct dementia. Cholinesterase inhibitors increase the amount of a neurotransmitter, called acetylcholine, throughout the body. Acetylcholine is a chemical that carries messages between the nerves and muscles, and it appears to be involved in learning and memory. Patients with AD have low levels of acetylcholine. Commonly prescribed medications include donepezil (Aricept�), rivastigmine (Exelon�), and galantamine (Razadyne�). About half of the people who take cholinesterase inhibitors experience a modest improvement in cognitive symptoms, such as memory.

Side effects are common and may include diarrhea, dizziness, drowsiness, fatigue, nausea, and vomiting. These side effects may cause some patients to discontinue medications. Individuals with liver disease, peptic ulcer disease, chronic obstructive pulmonary disease (COPD), and slow heart rate should not take these drugs.

Memantine: Memantine (Namenda�) is a drug approved by the FDA for treatment of moderate to severe Alzheimer's disease. Memantine is also used to treat other types of permanent dementia, including multi-infarct dementia. Memantine, an NMDA (N-methyl-D-aspartate) receptor antagonist, is the first AD drug of its kind that has been approved in the United States. It appears to work by regulating the activity of glutamate, which is one of the brain's specialized messenger chemicals involved in information processing, storage, and retrieval. Glutamate plays an essential role in learning and memory. Excess glutamate, on the other hand, may lead to disruption and death of brain cells. Memantine may protect cells against excess glutamate by partially blocking NMDA receptors. Side effects include headache, constipation, confusion, and dizziness.

Nicotinamide supplements: Patients who develop dementia as a result of niacin deficiency receive nicotinamide supplements (e.g. Advicor�, Niacor�, or Niaspan�). Since the supplement is made from niacin, it helps the patient return to normal niacin levels in the body. Nicotinamide supplements effectively cures dementia in these patients.

Long-term care: An individual with dementia may need monitoring and assistance at home or in an institution. Options include in-home care, boarding homes, adult daycare, and convalescent or long-term care facilities (nursing homes).

Visiting nurses, volunteer services, homemakers, adult protective services, and other community resources may help a family care for a patient with dementia. In some communities, support groups may be available. Family counseling may also help relatives of the patient cope with homecare and the debilitating effects of cognitive disorders.

The patient should be surrounded with familiar objects and people. Leaving the lights on at night may help reduce or prevent episodes of disorientation. Patients should follow simple schedules that are easy to remember.

Behavior modification may be beneficial in patients who exhibit unacceptable or dangerous behavior. This type of therapy involves rewarding appropriate behaviors and ignoring inappropriate ones (when it is safe to do so). Reality orientation is a technique in which caretakers take every opportunity to orientate the patient, such as reminding the patient where they are and what time of day it is. Reality orientation with repeated reinforcement of environmental and other cues may also help reduce disorientation.

Patients who are diagnosed with a progressive form of dementia, such as AD, should seek legal advice before they are unable to make decisions about medical care and end-of-life issues.

IMPROVING WORK AND SCHOOL PERFORMANCE

General: Patients with cognitive learning disabilities are often able to live normal, healthy lives. There are many ways for patients to cope with their disabilities. Special education and adaptive skills training has been shown to improve patients' work and school performances. Patients who are diagnosed and treated promptly are often able to go to college and support themselves.

Education: Patients with learning disabilities or intellectual disabilities must have the option of receiving education that is tailored to their specific strengths and weaknesses. According to the Individuals with Disabilities Education Act, all children with disabilities must receive free and appropriate education. According to the law, members of the patient's school should consult with the patient's parents or caregivers to design and write an individualized education plan. Once all parties agree with the plan, the educational program should be started. The school faculty should document the child's progress in order to ensure that the child's needs are being met.

Educational programs vary among patients. In general, most experts believe that children with disabilities should be educated alongside their non-disabled peers. The idea is that non-disabled students will help the patient learn appropriate behavioral, social, and language skills. Therefore, some patients are educated in mainstream classrooms. Other patients attend public schools but take special education classes. If the disability is severe or profound, then patients may benefit from specialized schools that are designed to teach children with disabilities.

Adaptive skills training: Many patients with intellectual disabilities (mental retardation) need help improving their adaptive skills, which are needed to live, work, and function in the community. Teachers, parents, and caregivers can help patients work on their daily living skills, communication skills, and social skills.

TIPS FOR CAREGIVERS, FRIENDS, AND FAMILY MEMBERS

Caregivers, friends, and family members of patients who have cognitive disorders or learning disabilities should educate themselves about the condition. The more a caregiver or loved one knows about the condition, the better they can help the patient. Being educated on the disorder or disability may also help the caregiver learn how to communicate better with the patient.

Caregivers may find support from other families who are caring for patients with cognitive disorders. Many communities have local support groups for parents, family members, and caregivers of patients with cognitive disorders.

Parents of children with learning disabilities or intellectual disabilities should stay in close contact with their children's teachers. This helps ensure that the child is receiving appropriate education that is tailored to his/her specific needs. Parents are also encouraged to find out how they can support their children's learning needs at home.

INTEGRATIVE THERAPIES

Strong scientific evidence:

Ginkgo: Ginkgo biloba has been used medicinally for thousands of years. The scientific literature overall does suggest that ginkgo may benefit people with dementia (multi-infarct and Alzheimer's type), and may be as helpful as acetylcholinesterase inhibitor drugs such as donepezil (Aricept�). Well-designed research comparing ginkgo to prescription drug therapies is needed.

Avoid if allergic or hypersensitive to members of the Ginkgoaceae family. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin�)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Sage: Sage has long been suggested as a possible therapy for memory and cognitive improvement. Several trials provide evidence for the use of sage for this indication. Additional study is needed to confirm these findings and determine the best dose.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae (mint) family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.

Good scientific evidence:

Aromatherapy: Aromatherapy is the use of essential oils from plants for healing purposes. There is suggestive preliminary evidence that aromatherapy using essential oil of lemon balm (Melissa officinalis) may effectively reduce severe agitation in dementia when applied to the face and arms twice daily. Other research reports that steam inhalation of lavender aromatherapy may have similar effects. However, there is a conflicting study that reports no benefits of aromatherapy using lemon balm, Lavender officinalis, sweet orange (Citrus aurantium), or tea tree oil (Malaleuca alternifolia). Overall, the evidence does suggest potential benefits. It is not clear if this is because of anxiety-reducing qualities of these therapies. Additional study is necessary. There is also preliminary research suggesting that aromatherapy used with massage may help to calm people with dementias who are agitated. However, it is not clear if this approach is any better than massage used alone.

Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine (medicine practiced in India) and is widely used in India for enhancing memory, pain relief, and treating epilepsy. Although bacopa is traditionally used in Ayurvedic medicine to enhance cognition, high-quality clinical trials are lacking. Two methodologically weak studies found some evidence that bacopa improves cognition. However, more high-quality and independent research is needed before bacopa can be recommended for enhancing brain function in adults or children.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin�), and drugs metabolized by the liver. Use cautiously with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Ginkgo: Multiple clinical trials have evaluated ginkgo for a syndrome called cerebral insufficiency. This condition, more commonly diagnosed in Europe than the United States, may include poor concentration, confusion, absent-mindedness, decreased physical performance, fatigue, headache, dizziness, depression, and anxiety. It is believed that cerebral insufficiency is caused by decreased blood flow to the brain due to clogged blood vessels. Some studies report benefits of ginkgo in patients with these symptoms, but most have been poorly designed without reliable results. Better studies are needed before a conclusion can be made.

Avoid if allergic or hypersensitive to members of the Ginkgoaceae family. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin�)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Music therapy: Music is used to influence physical, emotional, cognitive and social well-being and improve quality of life for healthy people as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In people with Alzheimer's dementia and other mental disorders in older adults, music therapy has been found to reduce aggressive or agitated behavior, improve mood, and improve cooperation with daily tasks such as bathing. Music therapy may also be beneficial for dementia-associated neuropsychiatric symptoms, such as depression and aggressive behavior. Additionally, music therapy may help maintain mental performance in elderly adults undergoing surgical procedures, reduce postoperative confusion and delirium, and increase energy levels. Music therapy is generally known to be safe.

Sage: Alzheimer's disease is characterized by memory loss that interferes with social and occupational functioning. Early evidence suggests that sage oil may be useful in the treatment of Alzheimer's disease.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use the essential oil or tinctures cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.

Unclear or conflicting scientific evidence:

Acupressure, shiatsu: Acupressure may decrease verbal and physical agitated behavior in dementia patients. Further study is needed before a conclusion can be made.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Acupuncture has been reported to help improve memory and cognitive performance in the elderly. However, there is currently insufficient available evidence for the use of acupuncture in cognitive disorders and communication disorders. There is also insufficient evidence to recommend the use of acupuncture in the treatment of vascular dementia. More research is necessary.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Applied kinesiology: Applied Kinesiology (AK) is an assessment technique that uses muscle strength testing with the aim to identify nutritional deficiencies and health problems. It is based on the concept that weakness in certain muscles correspond to specific disease states or body imbalances. Applied Kinesiology, when used along with physical manipulation, massage, homeopathy, herbal remedies, and neuro-linguistic programming, showed some positive results in dyslexic children; however the effect of Applied Kinesiology alone for dyslexia cannot be isolated from the other therapies.

Applied kinesiology techniques in themselves are considered to be harmless. However, medical conditions should not be treated with AK alone, and should not delay appropriate medical treatment.

Arginine: There is not enough information available to make a strong recommendation about the use of the amino acid arginine in senile dementia.

Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin�) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. The aesthetic aspect of the creation of art is thought to lift one's mood, boost self-awareness, and improve self-esteem. Art therapy also allows the opportunity to exercise the eyes and hands, improve eye-hand coordination, and stimulate neurological pathways from the brain to the hands. Art therapy may be an effective means of improving quality of life in the elderly. Art therapy has been used in only a few studies with Alzheimer's disease (AD) patients, with some suggestion of benefit in alleviating negative emotions and minimizing problematic behaviors. However, further studies are needed for definitive conclusions. There is evidence that the non-directed use of visual art (pictures) as a means of encouraging communication among elderly nursing home residents may increase well-being. It may also reduce blood pressure and improve medical health status with regard to reported dizziness, fatigue, pain, and use of laxatives.

Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.

Astragalus: In traditional Chinese medicine (TCM), astragalus is commonly found in mixtures with other herbs. Based on human study, astragalus may help improve mental performance of children with low intelligence quotients (IQs). This study, however, used astragalus as part of a combination therapy, and it is difficult to ascribe the effects to any one constituent. Further, well-designed clinical trials are required before recommendations can be made.

Avoid if allergic to astragalus, peas, or any other related plants. Avoid with a history of Quillaja bark-induced asthma. Avoid if taking anticoagulants (e.g. warfarin or aspirin) or herbs or supplements with similar effects. Avoid with inflammation, fever, stroke, organ transplantation, or autoimmune diseases. Stop use two weeks before and immediately after surgery, dental, or diagnostic procedures that have bleeding risks. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously if taking blood-thinners, blood sugar drugs, diuretics, herbs or supplements with similar effects. Avoid if pregnant or breastfeeding.

Ayurveda: The herb Brahmi (Bacopa monnieri) is used in many Ayurvedic preparations for a variety of ailments. There is evidence from well-designed studies that it may improve memory and cognitive function in adults. Another study suggests that the herbal preparation Maharishi Amrit Kalash (MAK) -4 may enhance attention capacity or alertness, and thus reverse some of the detrimental cognitive effects of aging. Further research is needed to confirm these results.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long period of time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs may interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before use. Use guggul cautiously with peptic ulcer disease. Patients should avoid sour food, alcohol, and heavy exercise with use of this herb. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia chebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine and is widely used in India for enhancing memory, pain relief, and treating epilepsy. However, additional study is needed before a firm conclusion can be drawn.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin�), and drugs metabolized by the liver. Use cautiously with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents, or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Beta-carotene: Antioxidants such as beta-carotene may be helpful for increasing cognitive performance and memory. Long-term, but not short-term, beta-carotene supplementation appears to benefit cognition.