Life and Memory Center

In the past few weeks I have covered several issues regarding depression. It is clear that being demented does not necessarily cause one to be depressed. Furthermore, being diagnosed with dementia or being placed in a care facility does not necessarily lead to depression. Depression is common but not inevitable outcome for all of us as we age. Medications work in less than half of those who are depressed and are clearly not a panacea. Finally, treating depression requires getting moving despite a lack of motivation.

What about depression in those who care for someone who is demented? Caregiving does not itself cause depression. Many caregivers have never had to deal with these feelings before and are too busy giving care to attend to their own needs and feelings. Statistics provide a wide range of estimates (20 to 60%) suggesting that depression is a common but not inevitable consequence of caregiving. Of course, there is also the issue of how depression is defined and diagnosed that is well beyond the scope of this article.

Let’s agree that we will define “depression” in caregivers as a constellation of feelings rather than a clinical diagnosis. Caring for someone with a dementia is associated with a number of possible feelings including: sadness, anxiety, worry, irritation, impatience, fear, anger, irritation, loneliness, grief, and guilt. Caregiving isolates the caregiver from others and calls for sacrifice of needs and desires. Additionally, being a caregiver is not the outcome we ever expect as a spouse, sibling, or child of someone who we love and care about.

Caregiving for someone with a progressive dementia is a very complex stressor. For Alzheimer’s disease, caregiving averages nearly a decade and may extend out two decades. The onset of Alzheimer’s and many other neurological diseases are subtle and, in the earliest stages, are difficult to tell from the changes of aging (mostly a slowing and loss of efficiency). Progression provides a moving target requiring periodic adjustments both in skills needed to mange deficits (ranges from managing the checkbook to helping with personal care) and feelings that one has in reaction to the changes. Caregivers must manage changes that do not unfold in a linear manner and differ from one person to the next.

In short, caregiving requires difficult and progressive role changes. Parents and children become parents for their spouses or for their parents. The efforts of caregivers are not appreciated – and may even be resented – by those receiving the care. Caregivers may have to confront issues for which they have no training: child-like behavior from an adult, profound forgetfulness, aggression, sexuality, and disinhibition. It’s a wonder that so many cope so well and figure out what to do.

As discussed the past two weeks, depression is frequent in both community dwelling elders and those with dementia. No matter what the source of depression, the most effective treatment for depression is to get activated even though you don’t want to. This is true for the young as well as the elderly and for caregivers as well as care receivers. We have often discussed the benefits of exercise for cognitive skills but there is also considerable evidence suggesting that exercise improves mood.

For example, active people are less depressed on average than inactive people. Furthermore, people who exercise regularly and stop tend to show a decline in mood when compared to those who start or maintain exercise. A recent study randomly assigned depressed adults to an exercise group, a medication group, or a placebo group. Both exercise and medications improved mood compared to the placebo. A year later, those who continued to exercise were less depressed than those who stopped.

Another example of the benefits of exercise is found in diabetics. Diabetics report higher levels of depression than nondiabetics. Furhermore, those who are depressed and at risk of diabetes are more likely to develop diabetes. A twelve week exercise program improved mood in diabetes.

So why is it so hard to exercise when the benefits for cognition and mood are so clear? First, exercise is the antithesis of depression. Depression robs you of motivation and makes everything you do seem futile. Second, exercise takes time to improve mood. You must exercise consistently for 4-6 weeks to see benefits in mood. But it also takes antidepressants 4-6 weeks to improve mood when they work. There is no quick fix. Finally, some push too hard when they start to exercise. This causes discomfort and many don’t continue. Start slow, exercise despite contrary feelings, and be persistent.

How much exercise do you need to improve mood and cognition? Should your exercise plan consist of aerobic or resistance training? The best answer is that it is not clear. My belief is that some combination of both types of exercise is the best plan. Aim at a total time of about 2 and a half hours (that would be 5 days at 30 minutes a day) a week for aerobic training. Add resistance training twice a week. There is evidence that exercising outdoors improves mood more than exercising indoors. Consistency is far more importance than intensity.

It’s close to time for us to make behavioral changes for 2012. I suggest you take out your new calendar and mark your exercise schedule for the first 6 months. For many of us it is better to exercise in the morning as the day begins with a sense of accomplishment. Let the rest of life fill in around exercise. You will improve your mood.

As discussed last week, depression is frequent in both community dwelling elders (by most standards those over 55) and those with dementia. Depression is more likely in dementias due to either vascular disease (strokes) or Lewy body disease than in Alzheimer’s disease (maybe there’s a benefit to short term memory loss). In short, depression is a common but not inevitable outcome for all of us as we age. What are the best treatments for depression? How well do different treatments work for those who are demented as well as for those who are not?

Medications in the class called selective serotonin reuptake inhibitors (SSRIs) such as Lexapro, Prozac, Zoloft, Celexa, and Paxil are the most common medical treatment for depression. However, they are not a panacea – especially in the elderly and those who are demented. A large portion of the elderly obtain only a partial response to medications and fewer than 30% display full remission. Antidepressant medications have an even poorer track record in those with dementias. There is little evidence that they are more effective than placebos in the treatment of depression in Alzheimer’s disease.

Furthermore, there is a negative interaction between use of SSRIs to treat depression and age. Treatment with SSRIs may lead to worsening cognition in those over 75. The reason behind this finding is unclear at present. Is this a result of inaccurate diagnoses? Is it a result of increasing risk of dementia with age? Is it a result of confusing the symptoms of dementia (e.g., apathy, poor initiative, changes in sleep patterns) with those of depression? Is it a negative side effect of the SSRRIs associated with aging?

There is treatment that is effective for depressed elders. Don’t reach for the medications too quickly in the treatment of depression. Adding psychotherapy to use of medications dramatically improves outcome. Use of an SSRI produced 29% treatment response in one study. Adding psychotherapy improved treatment response to 58%. Psychotherapy (broadly defined) is also effective in treating depression in those with Alzheimer’s disease. Effective treatments include: reminiscence, music, cognitive stimulation, conversation, and physical activity.

A first approach to treat depression in the elderly or demented is to start with nonmedical interventions and then add medications if needed. Start with cognitive therapy that addresses the lack of worth. Be sure to also include a treatment plan for increasing exercise and socialization immediately. Whether the issue is apathy or depression, the treatment needs to follow a plan that promotes and structures physical and social re-engagement. The most effective treatment for depression is to get activated even though you don’t want to.

Depression comes in many forms. Mild depression may range from the colloquial use of “I’m having a bad day” to depressive symptoms that are not severe or pervasive enough to meet current diagnostic standards for Major Depressive Disorder (which is more severe and has to persist for at least two weeks). Dysthymia is an enduring but comparatively mild form of depression. Sadly, recent surveys indicate that as many as 40% of community dwelling elders (by most standards those over 55) have some form of depression. This puts those afflicted at greater risk of mortality and suicide as well as poorer quality of life than those who are not depressed.

Does having a diagnosis of dementia increase the prevalence of depression in the elderly? The answer depends on the cause of dementia. The prevalence of depression in dementia due to Alzheimer’s disease is estimated to be between 20-40%. This is true for all stages of Alzheimer’s disease and is slightly lower than for community dwelling elders who are not demented. Depression is more likely to occur with dementias due to either vascular disease (strokes) or Lewy body disease than with Alzheimer’s disease.

What are the mechanisms associated with depression when it occurs in Alzheimer’s disease? One possibility is that genetics determines who will become depressed and who won’t. But genetics explains only about 8% of the variance in studies of Alzheimer’s disease. Furthermore, there is no association between the putative pathology of Alzheimer’s disease (i.e., plaques and tangles at autopsy or amyloids in cerebrospinal fluid) with depression. Interestingly, there is also no association between cerebrovascular disease in those with Alzheimer’s disease and depression.

Does being diagnosed with dementia lead to an increase in depression? Apparently not. A recent prospective study indicated that there was little change in mood during the first 2-3 years after being diagnosed with dementia. Therefore, there is no catastrophic reaction to a diagnosis of dementia. On average, those who were depressed to start stayed depressed and those were not depressed do not become depressed.

Does placement in skilled nursing home of those with moderate to severe dementia make them depressed? Not as much as one would intuitively expect. The prevalence of depression after placement is about 21% (the incidence is about 15%). But if placement induces depression, the depression persists in about 45% of cases. Therefore, depression is not an inevitable outcome of placement (stressful adjustments do not always lead to depression).

Does being depressed make dementia more likely in the elderly? There are several studies indicating that being depressed and over 55 doubles the risk for dementia in the elderly. The largest study involved 280,000 veterans over 55 and concluded that there was two times the risk of dementia in veterans who were depressed when compared to those who weren’t. So depression increased the risk of dementia but dementia does not appear to increase the risk of depression.

In conclusion, contrary to intuitions, being demented does not necessarily cause one to be depressed. Furthermore, being diagnosed with dementia or being placed in a care facility does not necessarily lead to depression. Depression is common but not inevitable outcome for all of us as we age. Next week, what are the treatments for depression? How well do different treatments work for those who are demented as well as for those who are not?

Alzheimer’s disease unfolds over the course of decades. In the early stages (as discussed in part one), the afflicted person displays increasing loss of short-term memory and becomes increasingly disengaged from activities. Higher level, complex skills such as doing a checkbook and using a computer become more of a challenge. Older, overlearned skills work well whereas learning new skills or habits become increasingly difficult. Rehabilitation is self-generated if started early.

If memory loss becomes severe enough to meet the criteria for dementia, rehabilitation must be accomplished by others (e.g., family, home care, or facilities) as independence is lost. The goal of treatment and rehabilitation is not to restore memory but rather to increasingly mold the environment to take advantage of learned habits and skills and keep the person with memory loss engaged and active. Competence no longer matters. What matters is productivity. Short-term memory fails to the point where the forgetful person increasingly lives in the moment.

Early Dementia. Most persons in the early dementia phase live at home with spouses or close to family who look in often. There needs to be a caregiver who compensates for severe forgetfulness. Complex tasks like preparing meals, shopping, problem-solving, and driving are usually unsafe. Structured day programs or unique personalized care such as provided by CompanionPlus is very helpful for both the person in this stage as well as their caregiver. Initiation is limited to the point where the caregiver must nudge or prompt or arrange for activities to occur. For example, the person can still golf (if that skill was learned before), but someone else must organize and monitor the outings. Regularity and routine are essential to safety and well being. Personal care remains fairly good and communication works albeit with lots of repetition and forgetfulness. The goal of rehabilitation is to keep the person engaged in what they still do well and in simple activities that do not involve short-term memory.

Middle Dementia. Most persons in the middle dementia phase can no longer attend to personal care. They usually need cues and prompting to change clothes, to toilet, to engage in things they like but forget to do. Communication is difficult because of even more severe forgetfulness and expressive language deficits (there are many what-do-you-call-its and empty speech). Care at home is a challenge for any one person as 24 hour supervision is necessary.

Rehabilitation consists of structuring the environment rather than trying to make the person fit into the environment. A memory care facility with well structure programs and experienced staff can make a remarkable difference in quality of life. Participation in structured activities, one-on-one or in small groups works best. Music, reminiscing, old TV shows, old movies, recordings of great sporting or historical events provide stimulation and engagement.

Late Dementia. Fortunately most of the hundreds of clients I have worked with do not live into this stage of very severe dementia where total care is needed for basic functions like eating. Communication and mobility are lost. The object here is to make the person as comfortable as possible. In this stage of care hospice services are often very helpful even if the person resides in a facility.

Alzheimer’s disease unfolds over the course of decades. It is slow and progressive. Alzheimer’s is a chronic disease that may or may not produce symptoms and the symptoms vary from one person to the next. The good news is that, as with any chronic disease, we can manage and treat all seven stages of Alzheimer’s disease if we focus on memory and engagement in the world. This article focuses on memory rehabilitation before you become demented. The next part will focus on rehabilitation if memory loss becomes severe enough and you meet the criteria for dementia.

Normal. The normal stage of memory loss is where we all hope to stay. You are independent. You have senior moments. You are engaged with life and have good initiative. You manage your own short term memory with strategic memory supports.

Forgetfulness. Forgetfulness is the stage where short-term memory is a little worse than it should be (e.g., forgetfulness a little worse than for age, more trouble with very complicated tasks than is your norm). You have senior moments and a bit more. You are engaged with life and have good initiative. Memory rehabilitation consists of more external memory supports and evaluation that allows you to be proactive. It’s the planning and work you do here that sets the course if things get worse.

Early confusional state. Early confusion is the stage where short-term memory is clearly worse than normal aging. You remain independent and you still do quite well on the memory screenings such as the Mini Mental State Exam. You take inordinately long to do tasks that you used to do quickly. You have more trouble spending time doing what you like because of the time it takes to sort and do the paperwork. You may be becoming less engaged. Others are concerned but you do not need external care. Rehabilitation consists of stepping up short term memory supports and making plans (e.g., how long to do the checkbook, how long to continue to work, how to keep doing the activities that you enjoy) in case your memory loss increases in the future. You need to make sure you plan ways to stay engaged socially and intellectually.

Late confusional state. Late confusion is the stage where medical workups diagnose early Alzheimer’s disease. Memory loss is more severe and complex tasks such as doing a checkbook, using technology, remembering to pay the bills, or preparing meals may be compromised. Independence is marginal but you do very well on all but complex tasks. Rehabilitation needs to focus on both you and your potential caregiver. You need to live by your calendar and have a daily calendar that you make out and carry with you each day. You need to include both what you have to do and what you love to do on calendar and you need to involve family if you have not already some so. Life can be good if you confront little that is new or challenging.

Alzheimer’s disease is often misunderstood. These misunderstandings create a false sense of fear and futility. We are bombarded by new studies that are often contradictory. We are inundated with “alternative” treatments that are supported by anecdotal testimony and clever marketing. We live in a time of reductionist medicine that promises cures and preventative lifestyles but can’t deliver on all of its promises.

We can treat chronic diseases: diabetes, certain cancers, heart disease, and chronic pain. Alzheimer’s is a chronic disease that is also easier to manage and treat if caught early. The key is to identify small changes early and, as with any chronic disease, focus on life style and proactive planning.

1. Alzheimer’s unfolds over the course of decades. There is a great deal of time to plan treatment strategies that work. Plan to have a good life even if you don’t remember it.
2. The onset of Alzheimer’s is very subtle and overlaps with changes that are a natural consequence of aging. The key is to know how to tell senior moments from early memory loss.
3. We still don’t know the pathology underlying Alzheimer’s. Are plaques and tangles the cause or the result of Alzheimer’s? We do know that removing plaques in those already diagnosed does not help and may worsen the symptoms.
4. Many who have Alzheimer’s never become demented. Many who are demented do not have Alzheimer’s.
5. The greatest risk factor for Alzheimer’s is age. Age trumps everything else: genetics, head injury, stroke, Lewy body disease, etc.
6. Alzheimer’s is not an inevitable consequence of aging.
7. Available treatments produce reliable but small benefits in many who can tolerate them.
8. There are effective treatments. Don’t believe those who tell you there’s nothing you can do.
9. Life style interventions are effective for Alzheimer’s as they are for any other chronic disease. Prevention is unrealistic. We can’t prevent stroke, cancer, or heart attacks. But we can proactively manage chronic conditions by interventions like medications, eating habits, and exercise.
10. Alzheimer’s is a progressive deterioration of short term memory and initiative. Short-term memory can be treated and rehabilitated and loss of initiative can be treated by re-engagement.

There are no short cuts in treating Alzheimer’s. Treatment involves careful evaluation and monitoring of short-term memory by a memory specialist (just as you do for blood sugars, thyroid function, blood pressure, and polyps in your colon). Liberal use of external memory supports is essential. It’s OK to use a calendar and speed dial. It’s OK to write down what you want to remember.

Your brain and body will work better if you are in good physical condition. There are no proven supplements despite extensive marketing. Develop healthy eating habits 80% of the time. Finally, keep engaged and be social. Build on your strengths, interests, and passions. Make a written plan that includes all of these elements and commit it to your calendar for 2012.

My last two articles focused on medical treatments for Alzheimer’s disease. Cholinesterase inhibitors donepezil (Aricept), Rivastigmine (Exelon), galantamine (Razadyne), produce statistically significant but small effects. Namenda (memantine) appears to only work in moderate to severe dementia. Attempts to find effective drugs that modify the disease process have so far failed. As long as there are no powerful treatments for Alzheimer’s disease, we need to consider strategies for delaying the onset. Physical exercise and diet are the best strategies for delaying onset.

The so called Mediterranean diet may be an effective way to slow down the progression of Alzheimer’s disease based on epidemiological evidence. Although there are many variants, the main components of a Mediterranean diet are high consumption of fruits, vegetables, nuts, legumes, cereals, and fish. Olive oil is the central source of monounsaturated fat (canola oil is the main source of monounsaturated fat in the US diet). Additionally, meats, eggs, and dairy products are limited and alcohol is consumed in “moderate” amounts. Generally, studies indicate that consuming a Mediterranean diet is correlated with slowing the progression of dementias.

There are two research strategies used to determine if what we eat influences the risk of developing dementia. The first strategy explores the effects of individual components of the Mediterranean diet: e.g., fish oil, vitamins, antioxidants, antiinflammatory medications, alcohol consumption (there are no data indicating that consuming alcohol reduces the risk in those who don’t drink). Despite the intense search for the magic food or supplement in prospective studies, there are no good data associating single foods or supplements with better outcome for Alzheimer’s disease.

The second research strategy is to assess the effects of whole-diet on the occurrence of Alzheimer’s disease. The idea is that the whole is greater than the sum of the parts. Furthermore, we don’t eat isolated nutrients but rather we eat whole foods as meals. Several longitudinal studies have demonstrated that eating a Mediterranean type diet reduces the risk of developing Alzheimer’s disease.

The key to eating for brain health may be to eat (80% of the time) a diet consisting of foods that are associated with a Mediterranean style of eating. There are no long term guarantees but supplements (despite good marketing) and single foods do not appear to make the grade. It’s the pattern of eating that is important. Increase your consumption of plant foods (e.g., fruits and vegetables) and fish. It may be better to use olive rather than canola oil. Limit your intake of whole milk products, eggs, and red meat. Drink alcohol in moderation, if you drink.