Loneliness Bodes Poorly For A Healthy Old Age

They're time-consuming, demanding and require birthday cards, but they may help keep you alive. Friends and family, that is.

Loneliness in older people can predict declines in health and an increased risk of death, according to findings just published online by the Archives of Internal Medicine. People over 60 who felt lonely had a 45 percent higher risk of death than those who weren't lonely, the six-year-long study found. In absolute terms, the risk of death was about 23 percent for the lonely people and 14 percent for those who weren't.


The lonely people in the study were also more prone to have limited mobility and face greater difficulty performing basic tasks like grooming and housekeeping. On that score, about a quarter of lonely people were likely to develop trouble compared to about 13 percent who weren't lonely.

While the connection between well-being and friendships isn't new, the latest findings look specifically at people who self-identified as lonely, regardless of the how extensive their social network was.
"It's about connectivity," lead researcher Carla M. Perissinotto tells Shots. "Someone can have multiple social contacts but still somehow felt that they're not connecting." Many people who said they were lonely, for example, were married or lived with someone else.

Perissinotto, a geriatrician, cited one of her patients, a 93-year-old woman who had difficulty eating. The woman kept losing weight because she lived alone and viewed eating as a social activity. To treat her, Perissinotto looked for ways to help the woman be with peers during mealtimes.

The data, which were collected every two years from 2002 through 2008 as part of the nationally administered Health and Retirement Study, looked at 1,604 cases to assess risk factors. The study only included people living in the community — not those in care facilities or retirement homes.
By asking about patient's feelings, Perissinotto says she hopes physicians can broaden their understanding of potential health risks and think creatively about addressing them. She says the study can't conclusively prove cause and effect, but sheds light on a significant health issue.

"We could be missing a big part of the puzzle if we choose to focus on traditional medical risk factors," Perissinotto says. "By asking these questions, I may be finding one more way of intervening with these patients."

An accompanying editorial notes that some of the predictive factors found in this study and some others published at the same time should get more attention. "Loneliness is a negative feeling that would be worth addressing even if the condition had no health implications," the authors of the editorial note.

Copyright 2012 National Public Radio. To see more, visit http://www.npr.org/.

Early Burdens: Eldercare Falls on Young Shoulders

Suzette Armijo, 30, of Phoenix, right, oversees care of her 86-year-old grandmother, Elizabeth Armijo, left, a retired National Park Service ranger. (Courtesy Suzette Armijo)

By JANE E. ALLEN (@JaneEAllenABC) , ABC News Medical Unit

May 4, 2012

At 30, Suzette Armijo cares for her widowed 86-year-old grandmother, a retired National Park Service ranger in the final stages of Alzheimer's disease, while holding down a fulltime job, a part-time job and raising a 4-year-old son.

"This was nothing that I had planned for," says Armijo, who moved her grandmother Elizabeth Armijo into a nearby six-bed assisted living home because veterans' benefits "wouldn't pay for her to live with me." Still, she says, "I have to do everything for her, aside from her bathing. There's always something new going on with her medically."

Besides her fulltime marketing job with a Phoenix retirement community, Armijo supplements her income with outside consulting because "I do have to pay a portion of Grandma's bills."

 

Although she doesn't know anyone else her age doing what she's doing, she comes to her caregiving out of love for a woman who took care of so many others: "I don't feel torn because I know this is the way my Grandma was," Armijo said Thursday. "She took care of her parents. She took care of my grandfather. She took care of my little brother who had cancer when he was little. I grew up seeing that."

Suzette Armijo is among a generation of young adult caregivers, the majority of whom are women, navigating tough turf without a roadmap. Few of their contemporaries shoulder equivalent responsibilities. Members of the so-called sandwich generation, squeezed by parental caregiving and child-rearing, are a good 20 to 30 years older. As they try to tap into resources to help an ailing grandmother, Mom or Dad, these 20-somethings and 30-somethings are often on a lonely road. Armijo said she's drawn some of her strength from establishing a local young advocates group through the Alzheimer's Association. "You have to find something for yourself, otherwise you lose your mind."

Internet sites like AgingCare.com, which connects caregivers of elderly parents with others, may help this younger caregiving cadre find encouragement, empathy and tips on locating services.

"Other caregivers jump in and help," said Richard Nix, AgingCare.com's 49-year-old executive vice president. The National Stroke Association has launched a free, private Careliving Community with "more than 2,000 caregivers right now," said Taryn Fort, a spokeswoman for the Centennial, Colo.-based organization. Support groups for young caregivers have sprouted within some local chapters of the Alzheimer's Association, said Toni Williams, a spokeswoman for its public policy office in Washington, D.C.
Even the best-laid plans among 20-somethings can be thrown off course by a loved one's catastrophic illness and disability. After graduating from Purdue University in Indiana last May, Lauren Erickson spent six weeks in a competitive pre-medical enrichment program in Cincinnati. In September, she moved to Minneapolis to begin work as a hematology-oncology clinic assistant at Children's Hospitals and Clinics of Minnesota while studying for the Medical College Admission Test, which she hoped to take May 12.


Lauren Erickson, 23, left, moved back home to Prescott, Wis., from Minneapolis, to help care for her dad Jim Erickson, 71, right, following his stroke in March.

 

But on St. Patrick's Day, her father Jim Erickson, 71, suffered a massive stroke at home in Prescott, Wis., which left him unable to speak or move his right side. Because Erickson's mother, 61, was still recuperating from a Feb. 2 hip replacement, the couple's only child stepped in.

"I had to move home and help my Mom," Erickson, 23, said. As a result of new demands on her time, including a significant daily commute to Minneapolis, "I haven't opened an MCAT book or anything," Erickson said. She signed up to take the MCAT in July, but said her taking the test then will depend upon how her father is faring.

Even with a "very helpful" boyfriend and some free counseling through work, Erickson keeps wishing she could do more for her mother. "Through this whole process, I couldn't really break down or cry in front of her. I had to be the strong one." Still, she feels more rushed than ever about achieving her many life goals, including med school admission, "so that I can have my Dad present for all those events."
Having her father David Jenkins nearby was the only solution that Tara Leigh Adams, 28, found acceptable after he suffered a major stroke in November 2010. Adams, married and teaching second grade in Greenville, S.C., raced to her hometown of Charlottesville, Va., to help her 65-year-old father, a widower since Adams was a child.


Tara Leigh Adams, 28, right, a wife, expectant mother and second-grade teacher, moved her father David Jenkins, 65, seated, from Virginia.
 
"I think from the start I kind of, in my heart, knew that was just the way. I always knew he had to be near me," said Adams, who is expecting her first child in October. Aides help her father while she's at work, but once she walks back in the front door, she takes over everything, including getting him to the restroom.
Friends just don't understand, she said. "A lot of people my age look and say 'why do you do this? Why not a nursing home?'"

But for Adams, "there's no other option for me that would ever be as good."

Adams, who calls her husband the "rock that I lean on" said there is no substitute for "waking up and telling my Dad how much I love him in the morning."

When Lapses Are Not Just Signs of Aging

Who hasn’t struggled occasionally to come up with a desired word or the name of someone near and dear? I was still in my 40s when one day the first name of my stepmother of 30-odd years suddenly escaped me. I had to introduce her to a friend as “Mrs. Brody.”

But for millions of Americans with a neurological condition called mild cognitive impairment, lapses in word-finding and name recall are often common, along with other challenges like remembering appointments, difficulty paying bills or losing one’s train of thought in the middle of a conversation.

Though not as severe as full-blown Alzheimer’s disease or other forms of dementia, mild cognitive impairment is often a portent of these mind-robbing disorders. Dr. Barry Reisberg, professor of psychiatry at New York University School of Medicine, who in 1982 described the seven stages of Alzheimer’s disease, calls the milder disorder Stage 3, a condition of subtle deficits in cognitive function that nonetheless allow most people to live independently and participate in normal activities.

One of Dr. Reisberg’s patients is a typical example. In the two and a half years since her diagnosis of mild cognitive impairment at age 78, the woman learned to use the subway, piloted an airplane for the first time (with an instructor) and continued to enjoy vacations and family visits. But she also paid some of the same bills twice and spends hours shuffling papers.

Dr. Ronald C. Petersen, a neurologist at the Mayo Clinic College of Medicine in Rochester, Minn., described mild cognitive impairment as “an intermediate state of cognitive function,” somewhere between the changes seen normally as people age and the severe deficits associated with dementia.

While most people experience a gradual cognitive decline as they get older (only about one in 100 lives long without cognitive loss), others experience more extreme changes in cognitive function, the neurologist wrote in The New England Journal of Medicine in June. In population-based studies, mild cognitive impairment has been found in 10 percent to 20 percent of people older than 65, he noted.

Dr. Petersen described two “subtypes” of the condition, amnestic and nonamnestic, that have different trajectories. The more common amnestic type is associated with significant memory problems, and within 5 to 10 years usually — but not always — progresses to full-blown Alzheimer’s disease, he said in an interview.
“Subtle forgetfulness, such as misplacing objects and having difficulty recalling words, can plague persons as they age and probably represents normal aging,” he wrote. “The memory loss that occurs in persons with amnestic mild cognitive impairment is more prominent. Typically, they start to forget important information that they previously would have remembered easily, such as appointments, telephone conversations or recent events that would normally interest them,” like the outcome of a ballgame would a sports fan.
The forgetfulness is often obvious to those who are affected and to people close to them, but not to casual observers.

The less common nonamnestic type, which is associated with difficulty making decisions, finding the right words, multitasking, visual-spatial tasks and navigating, can be a forerunner of other kinds of dementia, Dr. Petersen said.

In general, Dr. Reisberg said, “mild cognitive impairment lasts about seven years before it begins to interfere with the activities of daily life.”

The Correct Diagnosis

Distinguishing mild cognitive impairment from the effects of normal aging can be challenging. Typically, new patients take a short test of mental status, provide a thorough medical history and are checked for conditions that may be reversible causes of impaired cognition. Problems like depression, medication side effects, vitamin B12 deficiency or an underactive thyroid can mimic the symptoms of mild cognitive impairment.
Other tests, like an M.R.I. or CT scan of the brain, can look for evidence of a stroke, brain tumor or leaky blood vessel that may be impairing brain function.
It is natural, Dr. Petersen said, for patients and their families to want to know whether and how quickly the disorder might progress. While patients decline by about 10 percent each year, on average, certain factors are associated with more rapid progression. Among these are the presence of a gene called APOE e4, more common among patients with Alzheimer’s disease; a reduced hippocampus, a region of the brain important to memory; and a low metabolic rate in the temporal and parietal regions of the brain.
Amyloid plaques in the brain, while a hallmark of Alzheimer’s disease and a predictor of progression, have also been found at autopsy in people with perfectly normal cognitive function.

Preserving Cognitive Function

Despite a number of clinical trials that tested various medications, no drug to treat mild cognitive impairment has been approved by the Food and Drug Administration. But experts like Dr. Reisberg and Dr. Petersen suggest several approaches that may slow the decline in cognitive function.
Although studies did not show that medications like donepezil (brand name Aricept) and memantine (Namenda), both used to treat Alzheimer’s disease, change the ultimate course of mild cognitive impairment, Dr. Reisberg said they can be useful temporary treatments that may stabilize patients for a few years.
Although the drugs are not approved for this condition, licensed physicians can prescribe approved medications “off label.” “Clinicians have to work with what we have,” Dr. Reisberg said.
There are people who think they are having memory problems, but tests do not show anything definitive. Some may be in Stage 1 of Alzheimer’s disease, Dr. Reisberg said, and perhaps could benefit from early treatment with the drugs.

It is also important to reduce cardiovascular risk factors like smoking, elevated cholesterol and high blood pressure; keep blood sugar at normal levels; minimize stress (which in animal studies can cause the hippocampus to shrink); and avoid anticholinergic drugs that can interfere with brain chemicals important to memory. These include Demerol to treat pain, Detrol to treat a leaky bladder, tricyclic antidepressants, Valium, and over-the-counter medications with Benadryl (diphenhydramine), like Tylenol PM, Dr. Petersen said.

Some cognitive rehabilitation exercises, like computer games that enhance focus, may be helpful, Dr. Petersen said, but there have been few good studies to demonstrate a benefit. Compensatory techniques, like taking notes, creating mnemonics and making structured schedules, can be useful aids, he added.
But most promising is regular physical exercise, which in animal studies was found to reduce the accumulation of amyloid in the brain. An Australian study in patients with memory problems showed that brisk walking for 150 minutes a week improved cognitive function.

By JANE E. BRODY

New York Times

2011 Alzheimer's Association Advocacy Forum

With newly elected leaders in Congress, it is more important than ever that our messages about the Alzheimer epidemic get heard. We need passionate Alzheimer advocates to come to Washington, D.C., to lend their VOICE to the cause.

Join us in our nation's capital May 15-17, 2011, for the Alzheimer's Association Advocacy Forum – become educated about the issues, learn new skills, network with fellow advocates and take our message directly to members of Congress to fight for our legislative agenda.

"I am going back this year! I met amazing, motivated people and had a life changing time. It is such an awe-inspirring time to be in an already beautiful place. To be able to make a difference, speak up... fight... I highly recommend this forum!"

—Advocate Suzette Armijo

2010 proved to be an outstanding year for Alzheimer advocacy. We saw:
•  The historic passage and signing of the National Alzheimer's Project Act (NAPA).
•  The inclusion of younger-onset Alzheimer's disease in the Social Security Administration's compassionate allowance program.

•  The first-ever inclusion of Alzheimer's disease and other dementias in the government's Healthy People 2020 report.

•  Detection of cognitive impairment included as a mandatory part of the new Medicare annual wellness visits
•  More than 112,000 petition signatures collected through the Alzheimer's Breakthrough Ride urging Congress to make Alzheimer's disease a national priority.

Each of these major victories, together with all important wins that have happened around the country on a state and local level, would not have been possible without the commitment and action of you, the Alzheimer advocate.

But even as we celebrate our successes, we still have much work ahead to ensure we build on this momentum to lead our country toward overcoming the Alzheimer crisis. The Alzheimer's Association Advocacy Forum is the premier experience to learn how we can continue to successfully advocate for these issues.

This year's Forum will be held May 15-17, 2011, in Washington, D.C. We have a program that is designed to help you hone your advocacy skills — not just for your visits on Capitol Hill, but also as you return home. You will learn about our legislative priorities, our critical messages and how to deliver these messages to key decision makers. You will learn about how to engage your local legislators and how to use a wide variety of resources in your communities to encourage more people to join with us as Alzheimer advocates.

I look forward to seeing you in May as we celebrate our recent victories and redouble our efforts to secure the Association's mission of a world without Alzheimer's.

Karen Kauffman
Advocacy Forum Chair

Alzheimer's management from diagnosis to late stage

With the aging of the population, the incidence and prevalence of Alzheimer's disease (AD), already the most common type of dementia, are projected to rise. A diagnosis of AD has implications for ongoing care across all settings and providers—whether you are the primary-care provider (PCP) and made the diagnosis, assuming the care of a new patient with AD, or a consultant asked to provide input for a chronic problem of someone with AD. A diagnosis of AD adds to the complexity and cost of care. This article focuses on post-diagnostic care and is based on the 2008 report from the California Workgroup on Guidelines for Alzheimer's Disease Management.1


Because it is a slowly progressive neurodegenerative condition that may continue for a decade or more after diagnosis, management of AD must change over time. The majority of patients with AD (and their caregivers) receive their medical care from PCPs.2 PCPs are key to ensuring the care provided is appropriate to the patient's needs and situation. 

Assessment


Appropriate treatment plans and goals that meet all of a patient's needs require ongoing comprehensive assessment of the patient, the family, and the living situation. This assessment should include daily functioning, cognitive status, comorbid medical conditions, behavioral symptoms, medications (prescription and OTC), living arrangement and safety, and need for palliative and/or end-of-life care. The use of standardized instruments to assess function, cognition (Table 1), and behavior (Table 2) can help the PCP monitor changes.

Longitudinal monitoring of disease progression and response to therapy, along with regular health maintenance examinations, are essential.3,4 The frequency of visits depends on a number of factors, including the patient's clinical status, likely rate of change, current treatment plan, need for any specific monitoring of treatment effects, and the reliability and skills of the patient's caregivers and support system. Assessment should occur at least every six months or any time there is a sudden change in behavior or increase in the rate of decline. 


It is essential that assessment also include identification of the primary caregiver and the adequacy of family and other support systems. Assessment of the caregiver should include knowledge, social support, health status (including psychiatric symptomatology), and ethnic and cultural issues.5 Family caregivers are central to the PCP's assessment and care of the person with AD.6 Therefore, establishing and maintaining a relationship with caregivers is crucial in the ongoing care of patients with AD.7 This relationship is most important as the disease progresses into the moderate and severe stages, at which time family members who oversee day-to-day care and implement and monitor treatment become the real managers.8 





Beginning at the time of diagnosis and continuing throughout the course of the disease, ongoing assessment of a patient's decision-making capacity is essential. Capacity assessment is decision-specific, with more complex decisions requiring higher cognitive function than simpler decisions.9 Since patients with AD experience decreasing cognition and will eventually lose all decision-making ability, identification of a surrogate decision maker early in the course of the disease is important. In the beginning stages of AD, patients typically retain their decision-making capacity and are able to appoint a surrogate decision-maker for the time in the future when they will no longer retain this capacity.10 In addition, identification of the patient's and family's culture, values, primary language, and literacy level is necessary to assure that an appropriate treatment plan is developed and can be carried out.


Treatment


In addition to monitoring function and cognitive decline, ongoing regular management of general health and other medical conditions is essential to the care of the patient with AD. Management goals and interventions need to be appropriate to the patient's (if capable) and family's preferences and modified as the disease progresses. When prescribing medications (whether for AD, associated behaviors, or other comorbid conditions), it is important to assess the ability of the patient and family member or caregiver to adhere to the regimen. Medications should be reviewed with attention to discontinuing nonessential medication, simplifying the dosing schedule, and using aids (e.g., pillboxes). 


Appropriate treatment of comorbid medical conditions is crucial and may require extra vigilance and adjustment depending on where the AD patient is in the course of the illness. The degree of cognitive impairment impacts the ability to manage other chronic and acute medical conditions, and the appropriate management of these other conditions can impact both cognition and function in AD. Whenever a new treatment or intervention is considered or a change in the current treatment is anticipated, the health-care provider must assess the patient's and the caregiver's ability to understand and participate in the decision-making process.11 


Schedule a meeting with every patient and his or her family about the use of FDA-approved medications for the treatment of cognitive decline. The currently available cholinesterase inhibitors (i.e., donepezil, galantamine, rivastigmine) all work by blocking acetylcholinesterase. These medications have similar efficacy and side effects. Patients and family members must be given realistic expectations about the medications, which are aimed at slowing—not reversing—cognitive decline. 




Reports from clinical trials and meta-analyses of individual agents and the class of acetylcholinesterase inhibitors demonstrate a small, statistically significant benefit in cognition, activities of daily living, and behavior over a period of six to 18 months.12-15 GI side effects, primarily nausea or diarrhea, occur in 10%-15% of patients and may require discontinuation of the treatment. Rivastigmine is available in a patch form, which makes it more tolerable. Patients with bradycardia or bradyarrhythmias have an increased risk for syncope or dizziness with cholinesterase inhibitors.12 Treatment with one of these agents should be started on diagnosis or after six months' duration of AD symptoms. Evaluation for adverse drug reaction should occur after two to four weeks of treatment. Reassess effectiveness every six months. 


Memantine, an N-methyl D-aspartate receptor antagonist widely used in Europe, is currently approved for use in the United States for moderate AD. Memantine has also been shown to have a small effect on cognition, function, and behavior.16 Use this medication either alone or in conjunction with an acetylcholinesterase agent. 


At this time there is insufficient evidence to support the recommendation of other pharmacologic treatments for patients with AD. Studies of antioxidant therapy with vitamin E,17,18 ginkgo biloba,19 estrogen,20,21 and nonsteroidal anti-inflammatory agents22 have failed to demonstrate any clear benefit in preventing or postponing cognitive decline or affecting function or behavior.


Behavioral symptoms and mood disorders are common in people with AD as well as their caregivers, affecting up to 90% of patients at some time during the illness.23 These include a broad spectrum of symptoms (e.g., apathy, wandering, agitation, verbal and physical aggression, and psychosis) that can vary from intermittent and mildly annoying to life-threatening. Behavioral symptoms in AD patients are among the most difficult aspects of care for patients, caregivers, and health-care providers. There is agreement that except in emergency situations, nonpharmacologic strategies are the preferred treatment approach for behavioral problems.24,25 This should include such approaches as environmental modification, task simplification, appropriate activities, and physical exercise. Consider psychotropic medication only when nonpharmacologic approaches have been exhausted and have failed to reduce agitation or improve behavioral symptoms. The use of psychotropic medications is controversial, and no agents are currently approved by the FDA for use in people with AD or other dementias. If used, medication should be targeted to a specific behavior, for narrowly specified and predetermined goals, with close monitoring for side effects and drug interactions.26,27 Start with a low dose, and increase slowly until the behavior improves or adverse effects emerge.3


Education and support


Education and support services for AD patients and their families are critical for effective long-term management of this progressive disease. Medical care must be integrated with education that connects patients and caregivers to support organizations. Patients and caregivers should be provided with linguistically and culturally appropriate educational materials and referrals to community resources, including support groups, legal counseling, financial resources, respite care and counseling, and consultation on care needs and options. 


Discuss the diagnosis, progression, treatment choices, and goals of AD care in a manner that is consistent with the patient's and family's values, preferences, culture, education, and ability. This discussion should occur at the time of initial diagnosis and recur periodically throughout the course of the disease. If feasible, encourage patients to complete an advance directive with identification of surrogates for making medical and legal decisions along with statements of their care preferences. 


Caregiver assessment, education, and community referral have been shown to lead to improved well-being and enhanced quality of life for the caregiver as well as the recipient.28,29 This counseling is often beyond the scope and time of a routine office visit and may require an additional appointment. At a minimum, providers should be familiar with agencies and services in their community that can provide assistance and routinely and repeatedly refer families and caregivers.


Legal considerations


Since cognitive decline over time will deprive the patient with AD of the ability to think clearly, major legal and financial decisions should be addressed early in the course of the disease, while the patient is still capable. Health-care providers occupy a unique position of trust and influence that provides an ideal opportunity to discuss the importance of basic legal and financial planning. 


A capacity evaluation may be required before a patient's chosen surrogate or substitute decision-maker can be authorized to act on his or her behalf. Utilize a structured approach to the assessment of capacity with attention to the relevant criteria for the kind of decisions being required of the patient. Depending on the state, a capacity declaration is usually required when one or more clinicians consider conservatorship of a patient with AD. 


AD patients are at increased risk for abuse and neglect.30 Because of their cognitive and functional decline, it is particularly challenging to obtain information about potential abuse from these patients. Providers need to actively monitor for evidence and report all suspicions of abuse to the proper authorities. Abuse can take many forms, including physical, sexual, and financial. Abuse may also involve neglect, isolation, abandonment, or abduction. Monitoring requires that the provider be alert to both the patient's and the caregiver's circumstances. In addition, be aware that the patient's behavior may be a reaction to a disturbing or dangerous situation in his or her environment.31 


The cognitive, visuospatial, and other impairments associated with AD increase the risks associated with driving. In some states, the diagnosis of dementia in a licensed driver requires automatic reporting. Patients with moderate or severe AD should not drive.32 In patients with mild or early disease, careful consideration of the ability to safely operate a motor vehicle is required.22





SPECIAL CONSIDERATIONS


Early-stage AD


Improved recognition of signs of cognitive decline has led to earlier diagnosis of AD. This is resulting in a growing population of early-stage individuals who are able to benefit from active involvement, education, and support interventions. Patients in the early stages of AD have unique concerns that need to be recognized and addressed. These individuals should be involved in planning their own care. Discussions about the implications of the diagnosis with respect to work and family may require more frequent medical visits and/or referral to community resources. Clinicians need to be able to provide patients in early-stage AD with recommendations that promote continued functioning, assist with independence, and maintain cognitive health (including physical exercise, stimulation, and social support). Support groups specifically for individuals with early-stage AD and their caregivers are being developed in many communities to address the special concerns and needs of this population.


End-of-life care


The course of AD is one of slow, gradual decline. As the dementia worsens and the ability to understand treatment options and participate in decision making declines, care should shift to a focus on relief of discomfort. The advisability of routine screening tests, hospitalization, and invasive procedures should be made based on a previously discussed care plan, patient wishes, and severity of the dementia. As the end of the patient's life nears, emphasize options that maximize comfort and avoid futile treatments that may not provide relief and could prolong the dying process. Generally, tube feeding is not recommended for patients with severe dementia.33 Consider referral to hospice sooner rather than later to provide the patient and family optimal support. 


A diagnosis of AD is often the beginning of a long period of decline in cognition and function that is frequently accompanied by behavioral changes. These changes can be challenging for everyone, including health-care providers. Evidence-based recommendations for ongoing assessment, treatment, education, support, and legal considerations enable clinicians to better meet the needs of patients and assist families and caregivers over the course of the disease.

Dr. Segal-Gidan is director of the Rancho/University of Southern California Alzheimer's Disease Research Center in Los Angeles. She has no relationships to disclose relating to the content of this article.


References


1. California Workgroup on Guidelines for Alzheimer's Disease Management. Guideline for Alzheimer's Disease Management. Available at www.caalz.org/PDF_files/Guideline-FullReport-CA.pdf.


2. Landefield CS, Callahan CM, Woolard N. General internal medicine and geriatrics: building a foundation to improve the training of general intern­ists in the care of older adults. Ann Intern Med. 2003;139:609-614.


3. APA Work Group on Alzheimer's Disease and Other Dementias, Rabins PV, Blacker D, et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007;164(12 Suppl):5-56.


4. Hogan DB, Bailey P, Carswell A, et al. Management of mild to moderate Alzheimer's disease and dementia. Alzheimers Dement. 2007;3:355-384. 


5. Dunkin JJ, Anderson-Hanley C. Dementia caregiver burden: a review of the literature and guidelines for assessment and intervention. Neurology. 1998;51:S53-S60.


6. National Institute for Health and Clinical Excellence (2006). Dementia: supporting people with dementia and their carers. Available at www.nice.org.uk/nicemedia/live/10998/30321/30321.pdf.


7. Bultman DC, Svarstad BI. Effects of physician communication style on client medication beliefs and adherence with antidepressant treatment. Patient Educ Couns. 2000;40:173-185.


8. Barrett JJ, Haley WE, Powers RE. Alzheimer's disease patients and their caregivers. Medical care issues for the primary care physician. South Med J. 1996;89:1-9. 


9. Karalwish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16:91-98. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2717553/.


10. KL Braun KL, JH Pietsch JH, PL Blanchette, eds. Cultural Issues in End-of-Life Decision Making, Thousand Oaks, Calif.: Sage Publications; 2000:31.


11. Larson EB. Management of Alzheimer's disease in a primary care setting. Am J Geriatr Psychiatry. 1998;6(2 Suppl 1):S34-40.


12. Birks J, Harvey RJ. Donepezil for dementia due to Alzheimer's disease. Cochrane Database Syst Rev. 2006;1:CD001190. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001190/frame.html.


13. Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006;1:CD005593. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005593/frame.html.


14. Winblad B, Cummings J, Andreasen N, et al. A six-month double-blind, randomized, placebo-controlled study of a transdermal patch in Alzheimer's disease - rivastigmine patch versus capsule. Int J Geriatr Psychiatry. 2007;22:456-467.


15. Loy C, Schneider L. Galantamine for Alzheimer's disease and mild cognitive impairment. Cochrane Database Syst Rev. 2006;1:CD001747. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001747/frame.html.


16. McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev. 2006;2:CD003154. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003154/frame.html.


17. Sano M, Ernesto C, Thomas RG, et al. A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer's disease. The Alzheimer's Disease Cooperative Study. N Engl J Med. 1997;336:1216-1222. 


18. Doody RS, Stevens JC, Beck C, et al. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:1154-1166. Available at www.neurology.org/cgi/content/full/56/9/1154.


19. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev. 2007;2:CD003120. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles
/CD003120/frame.html.


20. Hogervorst E, Yaffe K, Richards M, Huppert FA. Hormone replacement therapy to maintain cognitive function in women with dementia. Cochrane Database Syst Rev. 2009;1:CD003799. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003799/frame.html.


21. Shumaker SA, Legault C, Rapp SR, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled trial. JAMA. 2003;289:2651-2662. Available at jama.ama-assn.org/cgi/content/full/289/20/2651.


22. Tabet N, Feldmand H. Ibuprofen for Alzheimer's disease. Cochrane Database Syst Rev. 2003;2:CD004031. Available at mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004031/frame.html.


23. De Deyn PP, Katz IR, Brodaty H, at al. Management of agitation, aggression, and psychosis associated with dementia: a pooled analysis including three randomized, placebo-controlled double-blind trials in nursing home residents treated with risperidone. Clin Neurol Neurosurg. 2005;107:497-508.


24. Ayalon L, Gum AM, Feliciano L, Areán PA. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Arch Intern Med. 2006;166:2182-2188. Available at archinte.ama-assn.org/cgi/content/full/166/20/2182.


25. Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. Am J Geriatr Psychiatry. 2001;9:361-381.


26. Lyketsos CG, Colenda CC, Beck C, et al. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry. 2006;14:561-572.


27. Gambert SR. Alzheimer's disease for the primary care physician. Compr Ther. 1997;23:174-178.


28. Feil DG, MacLean C, Sultzer D. Quality indicators for the care of dementia in vulnerable elders. J Am Geriatr Soc. 2007;55 Suppl 2:S293-301.


29. Logsdon RG, McCurry SM, Teri L. Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Psychol Aging. 2007;22:28-36.


30. Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc. 2000;48:205-208.


31. Warshaw G, Gwyther L, Phillip L, Koff T. Alzheimer's Disease: An Overview of Primary Care. Tucson, Ariz.: University of Arizona Health Sciences Center Press; 1995.


32. Dubinsky RM, Stein AC, Lyons K. Practice parameter: risk of driving and Alzheimer's disease (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2000;54:2205-2211. Available at www.neurology.org/cgi/content/full/54/12/2205.


33. Volicer L. Medical issues in late-stage dementia. Alzheimers Care Q. 2005;6:29-34.


By Freddi Segal-Gidan, PA, PhD

Tips on Alzheimer's Wandering Why it Happens and What to do

Wandering is among the most unsettling and even terrifying behaviors people with Alzheimer's display. Often poorly clad, they leave safety at random hours and strike out into unknown territory, for no apparent reason. But this seemingly aimless activity usually does have a reason. It's often an attempt to communicate after language skills have been lost.

Alzheimer's caregivers ask if I am worried that my mother might wander away from me and get lost. Wandering is one of the more widely known behaviors of people suffering from Alzheimer’s disease.

I am not worried about my mother wandering at this time because she can't walk very far. I can say I would be very worried at this stage if she could walk.

I can't remember how many people emailed me and were lamenting that there loved one wanted to "go home." When you hear this you really need to start paying attention. The patient could make a break for it at any time.

"Going home" is an elusive term. It could mean back home to where they last lived, or home to the place were they were born. In many of the stories about wandering the patient takes off to a place they once lived that brings back fond memories.

It isn't easy to find a person suffering from Alzheimer's once they "take off." They don't wander logically. Sometimes it is like looking for a needle in a haystack.

One of the most fascinating stories of wandering I read was about a woman that wandered way from her home in Frederick, Maryland at night on foot.

To find the missing elderly woman the Frederick police had to use 50 to 60 police and civilians, and four civilian K-9 search and rescue groups.

The woman was missing for more then 8 hours in temperatures that dropped as low as 20 degrees. She was finally located "huddled up" on a property adjacent to her home. Go figure.

Another man wandered from a Denver, Colorado suburb to San Diego,California. He was lost for three days. How did he do it? He walked down to the corner and took public transportation to the Greyhound bus station. He then took a series of buses to San Diego.

Alzheimer's: Understand and control wandering

Find out why people with Alzheimer's wander and what you can do to keep them safe.

  

Alzheimer's disease can erase a person's memory of once-familiar surroundings and make adaptation to new surroundings extremely difficult. As a result, people with Alzheimer's sometimes wander away from their homes or care centers and turn up — frightened and disoriented — far from where they started, long after they disappeared.

Wandering is among the most unsettling and even terrifying behaviors people with Alzheimer's display. Often poorly clad, they leave safety at random hours and strike out into unknown territory, for no apparent reason. But this seemingly aimless activity usually does have a reason. It's often an attempt to communicate after language skills have been lost.

Wandering may communicate something as simple as "I'm feeling lost," or "I feel as though I've lost something." It can also signal such basic needs as hunger and thirst, the need to void, or the need for exercise or rest.

Other causes of wandering:

Too much stimulation, such as multiple conversations in the background or even the noise of pots and pans in the kitchen, can trigger wandering. Because brain processes slow down as a result of Alzheimer's disease, the person may become overwhelmed by all the sounds and start pacing or trying to get away.

Wandering also may be related to:

• Medication side effects  
• Memory loss and disorientation
• Attempts to express emotions, such as fear, isolation, loneliness or loss
• Curiosity
• Restlessness or boredom
• Stimuli that trigger memories or routines, such as the sight of coats and boots next to a door, a signal that it's time to go outdoors
• Being in a new situation or environment
• Tips to prevent wandering

Although it may be impossible to completely prevent wandering, changes in the environment can be helpful. For example, a woman who was a busy homemaker throughout her life may be less likely to become bored and wander if a basket of towels is available for her to fold.

People with Alzheimer's often forget where they are. They may have difficulty finding the bathroom, bedroom or kitchen. Some people need to explore their immediate environment periodically to reorient themselves.

Posting descriptive photographs on the doors to various rooms, including a photo of the individual on the door to his or her own room, can help with navigation inside the home. Offering a snack, a glass of water or use of the bathroom may help identify a need being expressed by wandering. Sometimes the wandering person is looking for family members or something familiar. In such cases, providing a family photo album and sharing reminiscences may help.

Watch for patterns

If wandering occurs at the same time every day, it may be linked to a lifelong routine. For instance, a woman who tries to leave the nursing home every day at 5 p.m. may believe she's going home from work.

This belief could be reinforced if she sees nursing home personnel leaving at that time. A planned activity at that hour, or arranging for staff to exit through a different door at the end of their shift, could provide a distraction and prevent the wandering behavior.

Make a safer environment

If wandering isn't associated with distress or a physical need, you may want to focus simply on providing a safe place for walking or exploration.

Living spaces will be safer after you remove throw rugs, electrical cords, and other potential trip-and-fall hazards. Rearranging furniture to clear space can help. Childproof doorknobs or latches mounted high on doors help prevent wandering outside. Sometimes a stop sign on an exit door is enough.

Rooms that are off-limits pose a different problem. Camouflaging a door with paint or wallpaper to match the surrounding wall may short-circuit a compulsion to wander into such rooms. Night lights and gates at stairwells can be used to protect night wanderers.

Help ensure a safe return

The Alzheimer's Association's Safe Return program is designed to help identify people who wander and return them to their caregiver. Caregivers who pay a registration fee receive:

• An identification bracelet
• Name labels for clothing
• Identification cards for wallet or purse
• Registration in a national database with emergency contact information
• A 24-hour toll-free number to report someone who is lost

You can register someone by filling out a form online at the Alzheimer's Association's Web page or by calling (888) 572-8566.

Source Mayo Clinic

By Bob DeMarco

Alzheimer's Reading Room

Fighting Alzheimer's with a touch of beauty

In her heyday, Rita Hayworth was known as the “Love Goddess”: so explosive was her appeal that her image was placed on the first nuclear bomb to be tested on Bikini Atoll after the second world war. As befits one of the world’s most glamorous women, she danced her way through 61 movies and five husbands. She was a pin-up for American servicemen and is listed as one of the American Film Institute’s greatest stars of all time.

But if Hayworth’s early life was sprinkled with stardust, her later life was tinged with tragedy. In her fifties, with a well established drink problem, she began to suffer mood swings and memory loss.
“The first signs were fear and extreme mood changes, paranoia — calling the police because she heard a burglar — and confusion. As a daughter I felt helpless,” says Princess Yasmin Aga Khan, Hayworth’s daughter by her third husband.

Nobody knew what the real problem was until Hayworth was diagnosed with Alzheimer’s in 1981, at just 63 years old. “It was extremely painful but I had to deal with it,” says Khan, who moved her mother into an adjoining apartment in New York and cared for her for the next six years until she died.

Hayworth’s behaviour could be nightmarishly difficult. She suffered from the anxiety, aggression and agitation common to Alzheimer’s, but as the disease progressed she found something that soothed her mood and gave her a focus — painting.

As her mind disintegrated, she worked away at an easel in her apartment, producing beautiful, detailed likenesses of flowers. “So many people give up with this disease,” says the princess, who is now president of Alzheimer’s Disease International, the umbrella organisation for Alzheimer’s associations around the world, “but it brought her peace of mind and helped her to relax.”

Could Hayworth’s experience help us to understand how to support and treat people with Alzheimer’s? John Zeisel, the founder of a pioneering programme caring for people with Alzheimer’s in the United States — endorsed by Khan — and a visiting lecturer at Salford University, believes that it could.

“What the scientific research tells us is that Alzheimer’s attacks the part of the brain that handles what we call logic — the executive function that copes with handling complex situations. Taking a photograph, for instance: you have to find the camera, slot in the memory chip, work out where the shutter button is and so on . . .

“But what’s not damaged is your appreciation of a beautiful picture. The part of the brain that deals with emotions is shaken up by Alzheimer’s but it’s not damaged in the same way. In fact, emotional response seems to be heightened, not lessened.”

In other words, people who appear to be lost to the world can still be reached through art, literature and music — and love. At Hearthstone, a group of seven homes looking after some 220 people with Alzheimer’s that Zeisel had helped to found in Massachusetts, residents are encouraged to paint and are taken on regular outings to galleries. They have reading circles and a film club.

“The development of new drugs to treat Alzheimer’s is helping people live a little bit longer,” says Zeisel. “What we’re asking ourselves is, how do we make that life worth living?”

Life expectancy remained low for centuries — in 1900 it was still only 47 — but advances in medical science and public health have added another 30 years to our lives. A British man can now expect to live until 77 and a woman until 81.

That increase in lifespan has brought with it a tidal wave of dementia, for which there is no cure. There are 700,000 people living with dementia in the UK, some 417,000 of them with Alzheimer’s. By 2015 that total is predicted to reach 1m and by 2050 it will be 1.7m.

“Everything has happened so fast we don’t know what’s hit us,” says Zeisel. “One of the reasons everybody’s so afraid of Alzheimer’s is that there are so many unknowns. When someone is diagnosed, we grieve for their lost future. But maybe everything isn’t lost: we have to get past the fear and grief to see what remains."

I’m Still Here, Zeisel’s book about the development of the Hearthstone programme, is to be published in paperback by Piatkus next month. On March 15 he is hosting an arts and dementia day at London’s October gallery, an event that is already booked out.

One of the first things the Hearthstone team looks for is an activity that elicits a response from a new resident. It might be an old hobby — gardening, perhaps — or something new. “Families come in and say, ‘My father doesn’t dance’, and I say, ‘Well, we’ll see — maybe he’s never been surrounded by women and nice music before’.”

They then build a routine around the activity. George, a former teacher, arrived at Hearthstone anxious and aggressive and, on the assumption that he would like books, was taken to the library. He now runs a residents’ book circle at 10 o’clock each morning.

“It’s a reason to get up and get dressed,” says Zeisel. “If he’s upset or confused, the staff will say, ‘You’ve got to get dressed, the book group needs you’. He has a meaningful role. He passes books around, he and the others read aloud. Often people with dementia give up on reading because the type is too small. It seems confusing but it’s easy to fix — our books have large type.”

This kind of meaningful role, plus a simple routine, is key to helping people with dementia cope with life. “It’s not just about activities,” says Zeisel. “If it’s ‘bingo at 10, muffins at 11’ one day and ‘reading at 10, gardening at 11’ tomorrow, that doesn’t work. It’s confusing. If we go to an art gallery, we go every Tuesday at 11. Someone might say they don’t want to go but after a month they’ll wake up and hear it’s Tuesday and think, ‘Okay, it’s gallery day’.”

One of the things we need to get away from is the constant testing of people with dementia, he says. Bombarding them with questions compounds confusion with a sense of failure. Rather than say, “Mum, do you know who I am?” it is better to walk in, take her by the hand and say, “I’m your daughter and I love you.” And smile. You’ll reach the bit of the brain hard-wired to respond. If you are looking at a painting, don’t test her on whether she can remember who it is by: instead, open a conversation about the shapes and colours.

People with Alzheimer’s need to stay useful. They might not be able to find the dinner plates, but if you get the plates out of the cupboard they can put them on the table. This is not a cure, nor even a replacement for drugs, although Zeisel insists that the more effective the “person-centred” care, the lower the need for the antipsychotic drugs used to treat Alzheimer’s.

In essence, it is about quality of life for the people with Alzheimer’s and their families. You don’t need a team of highly trained art therapists on hand to make a difference. If you are one of the thousands of people stuck at home caring for someone with Alzheimer’s — saving the government an estimated £6 billion a year in the process — here’s what to do.

“Start an Alzheimer’s community,” says Zeisel. “There will be a cafe near you that’s quiet at 10 o’clock on a Tuesday morning run by some nice person who will smile at your mother. Find other people in your situation and invite them along.

“Go to a museum, same date, same time. Create a routine so the person you’re looking after gets used to it and expects it.

“Start your own film club. Rent a bunch of films you think your mother might like. See what interests her. It might be she can’t watch a whole movie but loves 10 minutes of Singin’ in the Rain. Play it when she’s agitated and remember: everybody is reachable, it’s just finding the way to do it.”

By Margarette Driscoll, Times Online

Alzheimer’s Memory Problems Originate with Protein Clumps Floating in the Brain, Not Amyloid Plaques

Researchers at Mount Sinai School of Medicine have found that Alzheimer’s is not caused by amyloid plaques, as previously thought by many researchers......

Using a new mouse model of Alzheimer's disease, researchers at Mount Sinai School of Medicine have found that Alzheimer's pathology originates in Amyloid-Beta (Abeta) oligomers in the brain, rather than the amyloid plaques previously thought by many researchers to cause the disease.

The study, which was supported by the "Oligomer Research Consortium" of the Cure Alzheimer Fund and a MERIT Award from the Veterans Administration, appears in the journal Annals of Neurology.

"The buildup of amyloid plaques was described over 100 years ago and has received the bulk of the attention in Alzheimer's pathology," said lead author Sam Gandy, MD, PhD, Professor of Neurology and Psychiatry, and Associate Director of the Alzheimer's Disease Research Center, Mount Sinai School of Medicine. "But there has been a longstanding debate over whether plaques are toxic, protective, or inert."

Several research groups had previously proposed that rather than plaques, floating clumps of amyloid (called oligomers) are the key components that impede brain cell function in Alzheimer's patients. To study this, the Mount Sinai team developed a mouse that forms only these oligomers, and never any plaques, throughout their lives.

The researchers found that the mice that never develop plaques were just as impaired by the disease as mice with both plaques and oligomers. Moreover, when a gene that converted oligomers into plaques was added to the mice, the mice were no more impaired than they had been before.

"These findings may enable the development of neuroimaging agents and drugs that visualize or detoxify oligomers," said Dr. Gandy. "New neuroimaging agents that could monitor changes in Abeta oligomer presence would be a major advance. Innovative neuroimaging agents that will allow visualization of brain oligomer accumulation, in tandem with careful clinical observations, could lead to breakthroughs in managing, slowing, stopping or even preventing Alzheimer's.

"This is especially important in light of research reported in March showing that 70 weeks of infusion of the Abeta immunotherapeutic Bapineuzumab® cleared away 25 percent of the Abeta plaque, yet no clinical benefit was evident."

The Mount Sinai team included Michelle Ehrlich, MD, Professor of Pediatrics, Neurology, and Genetics and Genomic Sciences, and John Steele, a Mount Sinai graduate student, who performed the key analyses of the behavioral data. Dr. Charles Glabe, an oligomer expert and a member of the Cure Alzheimer Fund research consortium, is also a co-author of the paper. Dr Gandy is also a neurologist at the James J Peters Veterans Affairs Medical Center, an affiliate of Mount Sinai School of Medicine.

About The Mount Sinai Medical Center

The Mount Sinai Medical Center encompasses both The Mount Sinai Hospital and Mount Sinai School of Medicine. Established in 1968, Mount Sinai School of Medicine is one of few medical schools embedded in a hospital in the United States. It has more than 3,400 faculty in 32 departments and 15 institutes, and ranks among the top 20 medical schools both in National Institute of Health funding and by U.S. News & World Report. The school received the 2009 Spencer Foreman Award for Outstanding Community Service from the Association of American Medical Colleges.

The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiary- and quaternary-care teaching facility and one of the nation’s oldest, largest and most-respected voluntary hospitals. In 2009, U.S. News & World Report ranked The Mount Sinai Hospital among the nation’s top 20 hospitals based on reputation, patient safety, and other patient-care factors. Nearly 60,000 people were treated at Mount Sinai as inpatients last year, and approximately 530,000 outpatient visits took place.

For more information, visit http://www.mountsinai.org/.

By Bob DeMarco
Alzheimer's Reading Room

Should Mom Still Be Driving?

By Heather Frenette, RN, MSN, CMC

Whether or not an elderly person should be driving is a question I am frequently asked. It is a very touchy subject and most children do not want to force the issue with their parents. Getting a drivers license is a rite of passage that most teenagers look forward to. Having to give up that license can be very difficult. It affects a person’s independence. When a person has to surrender their driver’s license, they suddenly are dependent on others to get around. Going to the grocery store, going to the doctor and even going out with friends can become difficult without transportation.


There are several warning signs to look if you are concerned about a loved one’s safety behind the wheel. If you notice any of the following 17 warning signs, it is time to evaluate whether your loved one should continue driving.

1. signaling incorrectly

2. trouble making turns

3. changing lanes improperly

4. confusion at highway exits

5. difficulty parking

6. stopping inappropriately in traffic

7. confusing the brake and gas pedals

8. driving too fast or slow

9. hitting curbs

10. failing to notice stop signs or traffic lights

11. reacting slowly to traffic situations

12. failing to anticipate potential dangers

13. getting lost in familiar places

14. scrapes or dents on car, house, garage, etc.

15. traffic violations

16. near-misses

17. accidents

There are several options for driving evaluation. One option is to have an evaluation through a driving evaluation center. Although there are companies that offer these services, many of these programs are offered through larger rehabilitation centers as well. Another option is to have a physician write a letter to the Department of Motor Vehicles (DMV) expressing their concern about their patient’s driving ability. Once the DMV receives this letter, they will send out a letter to your loved one either revoking their license or requesting them to come in for a written test and/or an on the road driving test. Successful completion of the testing is necessary for the license to remain valid.

It can be hard for family members to address the topic of driving safety with their loved one. Involving the primary care physician in this process can be helpful because it takes the role away from the family. Another option is to consult with a Geriatric Care Manager. Care Managers are typically well versed in the resources to evaluate driving and can facilitate not only the testing, but also put a plan in place to address the need for transportation once the person stops driving. Again, involving an independent third party takes the pressure off the family and takes some of the emotion out of the situation.

Addressing driving concerns with your loved one can be stressful and very difficult. It is an emotional topic with significant consequences. Having a plan to both evaluate your loved one’s driving and to accommodate their transportation needs if they stop driving will help make this difficult task somewhat easier.

Alzheimer's I Want You to Know What I Know

Sometimes I write about how my mother went down hill fast, or did she? At 85 she was still walking long distances with me in New York. At 87 she couldn't walk a block. I found out later that she had stopped walking to the pool, she was bascially reduced to sitting around most of the day. Didn't know it. Nobody saw a problem.

I was living in New York and Reston, Va working away. The sound of my mother's feet and the way she complained constantly on the phone were already bothering me. These were new and different behaviors.

I thought something was wrong, but everyone seemed to think she was just "getting old". It seemed like a reasonable explanation, and I guess I was eager to accept this conclusion. I didn't have a clue about what was happening, so why not "old". It might have stayed that way if my stomach wasn't bothering me, and if I wasn't worried every time I thought about mom.

I know more now then I did back in those days. I now realize that my mother was deteriorating slowly over a long period of time. There were plenty of signs. Hindsight 20/20.

I continue to wonder about how things might have been. I wonder what if I had gotten my mother's memory tested the minute I felt concerned. I wonder if she had gotten on the combination of Aricept and Namenda early, what effect would they have had on my mother. Where would she be today?

I am never going to know the answers to those questions.

Now I spend time wondering how I can get the word out about mild cognitive impairment -- often the precursor to Alzheimer's dementia. The point at which a person starts to lose their memory faster than a person that is just getting "old".

The finding of the study below suggest that the memory and thinking abilities of person suffering from mild cognitive impairment declined two times as fast every year as the abilities of those without any cognitive problems. Thinking ability and memory in subjects with Alzheimer's disease declined four times as fast as in those without any cognitive problems.

"There persists the idea that some decline in memory is typical" with age. -- Robert Wilson

No doubt, memory does decline with age.

Here is my advice. If you have a parent or grandparent that starts to evidence new and different behaviors like meanness, worries about money, forgetfulness, gets lost while driving, or starts scrapping their feet on the ground -- get their memory checked.

If your stomach starts bothering you and you think there could be someone wrong with a parent or grandparent, don't assume they are getting old. Stomach bothering you? Pay attention. It is trying to tell you something -- get their memory checked.

If you have a parent or grandparent over 70 years of age -- get their memory checked every two years. People get physicals don't they? How about a brain physical? A memory test.

Alzheimer's dementia is ugly. You probably agree with that statement. But, if you haven't experienced Alzheimer's personally -- from the front row -- you can't imagine how ugly. No -- possible -- way.

There are treatments, not cures, available for Alzheimer's disease. They work very well for some people. We have people on this list that swear that the combination of Aricept and Namenda made a big difference in quality of life.

If you get worried about someone you love -- take action.

If its Alzheimer's, someone is going to have to assume the caregiver responsibility. The sooner you act the better the quality of life for the patient and the caregiver. The caregiver could be you.

Trust me, I know.

By Bob DeMarco, Alzheimer's Reading Room

Exercise associated with preventing, improving Mild Cognitive Impairment

Moderate physical activity performed in midlife or later appears to be associated with a reduced risk of mild cognitive impairment, whereas a six-month high-intensity aerobic exercise program may improve cognitive function in individuals who already have the condition, according to two reports in the January issue of Archives of Neurology, one of the JAMA/Archives journals. Mild cognitive impairment is an intermediate state between the normal thinking, learning and memory changes that occur with age and dementia, according to background information in one of the articles. Each year, 10 percent to 15 percent of individuals with mild cognitive impairment will develop dementia, as compared with 1 percent to 2 percent of the general population. Previous studies in animals and humans have suggested that exercise may improve cognitive function.

In one article, Laura D. Baker, Ph.D., of the University of Washington School of Medicine and Veterans Affairs Puget Sound Health Care System, Seattle, and colleagues report the results of a randomized, controlled clinical trial involving 33 adults with mild cognitive impairment (17 women, average age 70). A group of 23 were randomly assigned to an aerobic exercise group and exercised at high intensity levels under the supervision of a trainer for 45 to 60 minutes per day, four days per week. The control group of 10 individuals performed supervised stretching exercises according to the same schedule but kept their heart rate low. Fitness testing, body fat analysis, blood tests of metabolic markers and cognitive functions were assessed before, during and after the six-month trial.

A total of 29 participants completed the study. Overall, the patients in the high-intensity aerobic exercise group experienced improved cognitive function compared with those in the control group. These effects were more pronounced in women than in men, despite similar increases in fitness. The sex differences may be related to the metabolic effects of exercise, as changes to the body's use and production of insulin, glucose and the stress hormone cortisol differed in men and women.

"Aerobic exercise is a cost-effective practice that is associated with numerous physical benefits. The results of this study suggest that exercise also provides a cognitive benefit for some adults with mild cognitive impairment," the authors conclude. "Six months of a behavioral intervention involving regular intervals of increased heart rate was sufficient to improve cognitive performance for an at-risk group without the cost and adverse effects associated with most pharmaceutical therapies."

In another report, Yonas E. Geda, M.D., M.Sc., and colleagues at Mayo Clinic, Rochester, Minn., studied 1,324 individuals without dementia who were part of the Mayo Clinic Study of Aging. Participants completed a physical exercise questionnaire between 2006 and 2008. They were then assessed by an expert consensus panel, who classified each as having normal cognition or mild cognitive impairment.

A total of 198 participants (median or midpoint age, 83 years) were determined to have mild cognitive impairment and 1,126 (median age 80) had normal cognition. Those who reported performing moderate exercise—such as brisk walking, aerobics, yoga, strength training or swimming—during midlife or late life were less likely to have mild cognitive impairment. Midlife moderate exercise was associated with 39 percent reduction in the odds of developing the condition, and moderate exercise in late life was associated with a 32 percent reduction. The findings were consistent among men and women.

Light exercise (such as bowling, slow dancing or golfing with a cart) or vigorous exercise (including jogging, skiing and racquetball) were not independently associated with reduced risk for mild cognitive impairment.

Physical exercise may protect against mild cognitive impairment via the production of nerve-protecting compounds, greater blood flow to the brain, improved development and survival of neurons and the decreased risk of heart and blood vessel diseases, the authors note. "A second possibility is that physical exercise may be a marker for a healthy lifestyle," they write. "A subject who engages in regular physical exercise may also show the same type of discipline in dietary habits, accident prevention, adherence to preventive intervention, compliance with medical care and similar health-promoting behaviors."

Future study is needed to confirm whether exercise is associated with the decreased risk of mild cognitive impairment and provide additional information on cause and effect relationships, they conclude.

By e! Science News
Source: JAMA and Archives Journals

Exercise Associated With Preventing, Improving Mild Cognitive Impairment

Moderate physical activity performed in midlife or later appears to be associated with a reduced risk of mild cognitive impairment, whereas a six-month high-intensity aerobic exercise program may improve cognitive function in individuals who already have the condition, according to two reports in the January issue of Archives of Neurology, one of the JAMA/Archives journals.

Mild cognitive impairment is an intermediate state between the normal thinking, learning and memory changes that occur with age and dementia, according to background information in one of the articles. Each year, 10 percent to 15 percent of individuals with mild cognitive impairment will develop dementia, as compared with 1 percent to 2 percent of the general population. Previous studies in animals and humans have suggested that exercise may improve cognitive function.


In one article, Laura D. Baker, Ph.D., of the University of Washington School of Medicine and Veterans Affairs Puget Sound Health Care System, Seattle, and colleagues report the results of a randomized, controlled clinical trial involving 33 adults with mild cognitive impairment (17 women, average age 70). A group of 23 were randomly assigned to an aerobic exercise group and exercised at high intensity levels under the supervision of a trainer for 45 to 60 minutes per day, four days per week. The control group of 10 individuals performed supervised stretching exercises according to the same schedule but kept their heart rate low. Fitness testing, body fat analysis, blood tests of metabolic markers and cognitive functions were assessed before, during and after the six-month trial.

A total of 29 participants completed the study. Overall, the patients in the high-intensity aerobic exercise group experienced improved cognitive function compared with those in the control group. These effects were more pronounced in women than in men, despite similar increases in fitness. The sex differences may be related to the metabolic effects of exercise, as changes to the body's use and production of insulin, glucose and the stress hormone cortisol differed in men and women.

"Aerobic exercise is a cost-effective practice that is associated with numerous physical benefits. The results of this study suggest that exercise also provides a cognitive benefit for some adults with mild cognitive impairment," the authors conclude. "Six months of a behavioral intervention involving regular intervals of increased heart rate was sufficient to improve cognitive performance for an at-risk group without the cost and adverse effects associated with most pharmaceutical therapies."

In another report, Yonas E. Geda, M.D., M.Sc., and colleagues at Mayo Clinic, Rochester, Minn., studied 1,324 individuals without dementia who were part of the Mayo Clinic Study of Aging. Participants completed a physical exercise questionnaire between 2006 and 2008. They were then assessed by an expert consensus panel, who classified each as having normal cognition or mild cognitive impairment.

A total of 198 participants (median or midpoint age, 83 years) were determined to have mild cognitive impairment and 1,126 (median age 80) had normal cognition. Those who reported performing moderate exercise -- such as brisk walking, aerobics, yoga, strength training or swimming -- during midlife or late life were less likely to have mild cognitive impairment. Midlife moderate exercise was associated with 39 percent reduction in the odds of developing the condition, and moderate exercise in late life was associated with a 32 percent reduction. The findings were consistent among men and women.

Light exercise (such as bowling, slow dancing or golfing with a cart) or vigorous exercise (including jogging, skiing and racquetball) were not independently associated with reduced risk for mild cognitive impairment.

Physical exercise may protect against mild cognitive impairment via the production of nerve-protecting compounds, greater blood flow to the brain, improved development and survival of neurons and the decreased risk of heart and blood vessel diseases, the authors note. "A second possibility is that physical exercise may be a marker for a healthy lifestyle," they write. "A subject who engages in regular physical exercise may also show the same type of discipline in dietary habits, accident prevention, adherence to preventive intervention, compliance with medical care and similar health-promoting behaviors."

Future study is needed to confirm whether exercise is associated with the decreased risk of mild cognitive impairment and provide additional information on cause and effect relationships, they conclude.

By ScienceDaily, Adapted from materials provided by JAMA and Archives Journals.

Mild Cognitive Impairment Defined

Mild cognitive impairment (MCI) a condition in which a person has problems with memory, language, or another mental function severe enough to be noticeable to other people and to show up on tests, but not serious enough to interfere with daily life.

Because the problems do not interfere with daily activities, the person does not meet criteria for being diagnosed with dementia. The best-studied type of MCI involves a memory problem and is called “amnestic MCI.”

Symptoms
By Mayo Clinic staff

The forgetfulness of normal aging is minor. You misplace your car keys or lose your car in the parking garage. Perhaps you can't remember the name of a former co-worker when you meet unexpectedly at the grocery store. This is nothing to worry about.

But red flags should go up if you start forgetting things you typically remember, such as doctor's appointments or your weekly pinochle game. This happens to everyone now and then, but if a pattern develops, it could be a symptom of mild cognitive impairment.

Commonly used criteria for a diagnosis of mild cognitive impairment are:

■Deficient memory, preferably confirmed by another person

■Essentially normal judgment, perception and reasoning skills

■Largely normal activities of daily living

■Reduced performance on cognitive tests, compared with other people of similar age and educational background

People with mild cognitive impairment may also experience:
■Depression

■Irritability

■Anxiety

■Aggression

■Apathy