Advances against Alzheimer’s
BOSTON
Memories — we treasure them. Often people with dementia can retell stories from long ago, but forget what it is they had for lunch just hours earlier.
Recently, there have been glimmers of promising research, from a mechanism to switch off what is thought to be the gene that causes Alzheimer’s to studies of long-term memory studies that might enlighten us on ways to spur short-term memory.
But what about now? This is the question being asked since the Alzheimer’s Association March report, which stated: “An estimated 5.4 million Americans have Alzheimer’s disease. Another American develops Alzheimer’s disease every 69 seconds” (www.alz.org/facts). Additionally, the report noted, there were about 15 million family members and friends acting as unpaid caregivers giving 17 billion hours of support.
As nursing-home needs increase, families face difficult choices. Directors are challenged with how to balance patient needs and desires and involve family members in care plans.
David Knopman, M.D., who is co-investigator at the Mayo Alzheimer’s Disease Research Center and a professor of neurology at Mayo Clinic College of Medicine, says: “I am not an expert on design of nursing homes, but having worked around them for many years it seems as if the best facilities are the ones with the most engaged nursing leadership. It is nice to have a clean, bright, safe physical environment, but in my experience, the quality of the staff is far and away the key issue.
“Quality care comes from nursing leadership that sets high standards for the nursing assistants — who actually do the hands-on care,” he said, adding: “Thoughtful nursing leadership also helps to set an example by showing skill in defusing situations where residents are on the verge of becoming physically aggressive. Skillful nursing leadership also knows how to avoid the use of psychoactive (psychotropic) medications. In essence, quality care comes from the respect and patience that the nursing assistants show patients.”
As for families caring for dementia patients at home: Daniel Z. Press, M.D., a neurologist at the Division of Behavioral Neurology at Beth Israel Deaconess Medical Center, in Boston, says, “We try to work with patients and families together, not separately. We discuss challenges ranging from patients’ wishes to continue driving in the early stages to resistance to bathing. For bathroom issues, we find that positive reinforcement is not that different than toilet training children. There is a lot of evidence that negative actions do not work. But everything must be done on a person-by-person basis.”
With regard to food and alcohol restrictions, Dr. Press said: “The balance depends on the health issue and the intervention — alcohol is a bigger issue than sweets. Chocolate for someone who is otherwise healthy may be fine; but for someone with diabetes it is not appropriate.”
Then there is caregiver stress. “I always tell children or spouses to separate the person from the disease,” said Dr. Press. “When they get angry, they should get angry at the disease that is taking away someone they love. But to continue giving good care, they need a rest to recharge their batteries.”
With recent studies focusing more attention on memory loss, there is concern among Baby Boomers. However, some hopeful news may be presented at the Alzheimer’s Association International Conference on Alzheimer’s Disease (AAICAD) in Paris this July. One important topic is brain amyloid (protein deposits) and cognition.
Dr. Knopman is speaking at the imaging session at the AAICAD about how amyloid imaging will change our view of what Alzheimer’s disease means when it is used to detect brain amyloid in people who have normal memory and thinking.
He said: “In the past five years, it has become clear that the amyloid accumulation that represents Alzheimer disease begins as long as two decades before symptoms begin. While we thought of Alzheimer’s disease as a disorder of memory and thinking that showed certain changes in the brain, such as plaques and neurofibrillary tangles, we now think of Alzheimer’s disease as a condition that causes changes in brain chemistry and physiology for up to two decades before symptoms ever appear.”
As Alzheimer’s and other forms of dementia make the news, there seems to be a surge of interest in such brain games as crossword puzzles. “People who value their quick and retentive intellects can become very distressed over the possible implications of even a momentary memory lapse,” says, James M. Ellison, M.D., MPH, an associate professor at Harvard Medical School who specializes in geriatric psychiatry.
He pointed out: “The most authoritative evidence to date suggests that cognitive skills such as information processing speed, problem solving or memory can be sharpened through training and practice. Persistent gains have been demonstrated, but the gains achieved in one area have not been shown to generalize to other cognitive faculties. It seems plausible that cognitive challenges throughout life will support cognitive speed and flexibility, especially when they are experienced as enjoyable and pursued in moderation.”
Rita Watson (www.ritawatson.com), an associate fellow at Yale’s Ezra Stiles College, is a regular