“Cognitive Changes w/Aging” and “Maintaining Health” – lecture notes

Stanford sponsored a 3-part series on geriatric health in May. The second evening, May 18, 2006, included two lectures:

“Cognitive Changes With Aging: How Much Is Too Much?”
Speaker: Michael Greicius, MD, MPH, Dept of Neurology, Memory Disorders, Stanford Univ

“The Big Picture of Maintaining Health — Medications, Tests and Safety At Home”
Speaker: Yusra Hussain, MD, Dept of Internal Med, Geriatrician, Stanford Hospital & Clinics

This email attempts to summarize some of the key points in those lectures and provide a web link to the handout.

Dr. Greicius said that one-tenth of people over 65 have Alzheimer’s Disease. One-third of people over 85 have AD. 70% of the dementia cases are AD. The most common non-AD dementias are Vascular Dementia, FTD, and LBD. According to the “nun study,” the more education you have, the less impaired you are than someone with less education for the same degree of AD.

There is a disorder known as Mild Cognitive Impairment (MCI). Half of those with MCI convert to AD every four years. Scientists are looking into who will convert and how this can be prevented. Neither Vitamin E nor Aricept helped treat MCI.

There are many reversible causes of memory loss including B12 deficiency, low thyroid, medication (anticholinergics including some medications for urinary incontinence, beta-blockers, enzodiazepines, opiates, anti-epileptics, some medications for neuropathy), depression, alcohol, and retirement.

In general, people in their 50s and 60s can handle less than half the alcohol they could handle in their 30s.

There are some cognitive IMPROVEMENTS with normal aging: emotionality, semantic knowledge (knowledge of the world), and vocabulary.

Dr. Greicius spoke about cognitive decline with normal aging. Related to that topic, he distributed an article from the journal Nature Review Neuroscience, Feb ’04, titled “Insights into the Ageing Mind: A View from Cognitive Neuroscience.” He said this was an excellent review of the topic. An abstract of the article can be found at: (The full article costs $30.)
http://www.nature.com/nrn/journal/v5/n2/abs/nrn1323_fs.html

What can be done to minimize cognitive decline? His guesses include living healthy, moderate alcohol consumption, and no cigarettes. He explored the possible role of NSAIDs and cognitive training in minimizing decline.

His recommendations include: all things in moderation; minimize cardiovascular risk factors; sell your TV; read, dance, exercise; spend more time with friends and family; participate in medical research. Two journals did a review of ginkgo biloba studies. They showed no benefit. He doesn’t recommend taking extra Vitamin E.

Dr. Greicius said that there is a GRAIN of truth only to the layperson’s notion that for the clock test (part of the 4-hours of neuropsychological testing) those with AD can draw the clock and those with LBD cannot. He said that generally speaking those with LBD have visuospatial impairment early on, which is why they can’t draw the clock. But not all those with LBD have visuospatial impairment at the time of diagnosis. Another point: those with late stages AD can’t draw the clock either.

Dr. Hussain said that most people get a serious chronic condition at the age of 55. These can include geriatric syndromes, which are urinary incontinence, MCI, and depression.

If you think your health is excellent, you will live longer. If you think your health is merely good, your lifespan is normal/average.

About half of all deaths are attributable to preventable factors.

A healthy lifestyle includes: maintaining social life; being active each day; eating well; avoiding tobacco and excessive alcohol intake; following up on periodic health examinations and screening tests.

The best diet is rich in fruits, vegetables, whole grains, and nuts. One should have moderate consumption of polyunsatured fatty acids, omega 3 fatty acids, protein and dairy. One should have low consumption of carbs and animal fats. She does not recommend taking a multi-vitamin with antioxidants as a supplement. She says that antioxidants should be part of the diet.

In order to maintain cognitive function, she said that the “nun study” shows that it’s important to have a purpose in life and to stay busy with family and friends.

Frailty cannot be reversed.

That’s it! I didn’t attend the third lecture nor was I very interested in it so I won’t be emailing out notes from that one.

Regards,
Robin

“Health Challenges & Recommendations for the Older Adult”

Stanford University (stanford.edu) sponsored a 3-part series on geriatric health in May. The first evening, May 11, 2006, included this lecture:

“Health Challenges & Recommendations for the Older Adult”
Speaker: Peter Pompei, MD, Assoc Prof of Geriatric Medicine, Stanford Univ

Local support group member Karen D. gave me her notes on the lecture. This post attempts to summarize some of the key points in that lecture.

Robin
——————

Karen’s Notes from

“Health Challenges & Recommendations for the Older Adult”
Speaker: Peter Pompei, MD, Assoc Prof of Geriatric Medicine, Stanford University
May 11, 2006

Dr. Pompei distributed a document on “Aging parents: Five warning signs of health problems.” You can find a copy of this online at:

mayoclinic.com/health/aging-parents/HA00082

The five warning signs are:
* unintended weight loss
* difficulties maintaining their home (so that the home becomes unsafe)
* failure to keep up with daily routines and personal appearance
* poor mood (down or depressed)
* difficulty getting around (which means that they have difficulty caring for themselves)

Dr. Pompei introduced the concept of homeostenosis. When we were young, we could adapt to stressful environments. But when we’re older, we can’t bounce back.

Dr. Pompei also distributed an article in the April 2006 issue of Geriatrics magazine, titled “Health promotion in older adults: Promoting successful aging in primary care settings.” You can find a copy of this online at:

www.geri.com/geriatrics/data/articlestandard/geriatrics/152006/318873/article.pdf

The article states that:

“Although achieving and maintaining health is influenced by many factors,
one of those is within the grasp of almost everyone: Making wise health
choices… (These) choices…can be summarized by an easy to remember
phrase: eat right, eat less, and exercise more.”

(That particular issue of Geriatrics magazine has a number of interesting articles, including one on exercises for the frail and home bound:
www.geri.com/geriatrics/data/articlestandard/geriatrics/202006/327139/article.pdf.)

Dr. Pompei recommended two websites with health information:

American Geriatrics Association
www.healthandage.com

Merck Foundation
www.merckmedicus.com

The lead article on the American Geriatrics Association website is how
physical fitness can fight off dementia.

During the Q&A period, someone asked how a patient should be told he/she is losing it. Dr. Pompei’s answer was: be forthright but show that the patient may not understand.

Suggested gadgets (utensils and bed canes)

At the last support group meeting, some of us were talking about two gadgets in particular — weighted utensils and bed canes.  I said I’d follow up with a couple of folks about these gadgets.  Rather than just sending the follow-up email to those couple of people, I thought I’d include everyone.

UTENSILS

There was a disability conference in SJ last year.  There was a workshop devoted entirely to gadgets.  The presenter passed around some weighted utensils and explained that these were useful to those with Parkinson’s.  I’m sure many of you have seen the utensils with the large, black Oxo handles (ergonomic, soft, big grip).  (The assisted living center where my Dad lives ordered a set at my request.  They paid $20/each.)  The presenter made of point of saying that while those were good, the weighted ones were better.  Somehow the weight sends a signal to the brain that there’s something for the hand to grip.  The presenter works for activeforever.com (phone 800/377-8033).  I ordered the weighted soup spoon ($7.95, item #A17040 04) and weighted fork ($6.95, item #A17040 01) for my Dad.  The weighted utensils do improve my Dad’s grip and he’s better able to eat on his own.  If I had to do it again I’d probably get only the spoon.  Note that when someone else is holding the utensil and helping with the feeding, you will want to use a regular spoon.  The weighted soup spoon is purposely deeper than other soup spoons; we’ve found that the regular spoon works better if someone else is doing the feeding.  One other feature of these weighted utensils that we don’t really value but others might is that they are bendable.  This company distributes all sorts of accessibility and convenience products.  Another one I’ve purchased from them is a plastic scoop dish ($4.95, item #A17023); this is handy to have.

BED CANES

My dad has two — a regular one and a travel one.  The regular one is called a BedCane from Standers, Inc. (stander.com – company name ends in S but the web address doesn’t).  The handle is wide, very sturdy, and somewhat cushioned.  The handle attaches to a solid wood base, which is tied to the mattress.  The whole thing is very sturdy.  I think we paid $60 for this.  The travel bed cane is called TravelHandles from Bed Handles (bedhandles.com).  They cost $110 for a box of two handles.  Another support group member and I recently split the cost and each got a handle.  For us, one handle is sufficient.  It worked great in Acapulco with my Dad last week!  The only caution I would have is that the handle is a bit large; it would only fit in our large suitcase.  We also have the non-travel version called the Original Bedside Assistant; I would say the travel version feels just as sturdy although the travel handle is made from aluminum.

If any of you have a gadget you’d like to recommend, send me an email and I’ll distribute it to the wider group.

Robin

Points from an expert physical therapist – on PD and parkinsonism

I attended Marilyn Basham’s presentation this afternoon on “Caregiving Made Easy for Parkinson’s Individuals.”  She’s the physical therapist (PT) at The Parkinson’s Institute (TPI).  I picked up a few tidbits at the presentation that I thought I’d pass along.  As the presentation was focused on Parkinson’s Disease (PD), not everything applied to the situations we are dealing with but there were still many interesting points that apply.

Here are the points I found interesting….  (with some of my comments in parantheses)

People with PD and Parkinsonism MUST use a walker or wheelchair to make them as safe as possible.  It’s very important to have mobility and postural strategies worked out with a physical therapist and/or neurologist.

PD is evident when 60-80% of the cells in the basal ganglia have died.

The “automatic motor programs” we have are stored in the basal ganglia.  One of these “programs” is what tells us that to stand up from a low chair, we need to scoot to the edge, put our feet underneath us, lean forward, and push up.  PD folks must either receive cues as to the steps of these programs, or they must practice it so many times that doing it becomes somewhat automatic again.

To overcome freezing (called “gait initiation failure”), you can put masking tape on the floor to provide a visual cue.  Put the tape at thresholds or where ever the person often has the freezing problem.  (Of course this won’t work for those with PSP who have downward gaze palsy.)

A suggested verbal cue to give someone who wants to speak is:  “Swallow.”  (pause to let the person swallow)  “Take a deep breath in and then, at the top of your breath tell me what you want.”  (pause to let this happen)  Swallowing is important because fluid accumulates in the back of the throat and those with PD are not aware of it.  You can give them gum to initiate a swallow response.

Before someone with MSA (or PD with blood pressure fluctuations) stands up, give them a glass of water with salt in it or Gatoraid.  This will increase the blood pressure.  Obviously the person’s diet and blood pressure medication needs to be taken into account before following this suggestion.

We must give time for those with these diseases to process information!  Be patient!  Give long pauses.  Don’t overload them.  Don’t give them more than one complex task at a time.  Walking is a complex task.

(Some of you know that my father and I communicate by our holding up fingers to designate an answer.  Example, “do you want 1 for coffee, 2 for tea, or 3 for nothing,” and I hold up 1, 2, and 3 fingers.  He answers by holding up fingers.  Long after the fingers come up, he may try to verbalize the answer.)  I asked Marilyn why my father could hold up fingers faster than he could verbalize a response.  Marilyn said she didn’t know why but pointed out that parents of small children teach their children sign language long before the children can verbalize.

Dementia is rare in PD.  (It’s definitely common in the Atypical Parkinsonism diseases.)  PD folks may lose their keys but they still remember what keys are and how to use them.  (I thought that was a good story for remembering what dementia is.  My dad, for example, cannot remember how to use an ATM card.  I see the dementia very clearly.)

A patch for Sinemet is in the works.  (Some of your loved ones take Sinemet.)

The head of TPI thinks that PD is the most curable of all the neurodegenerative diseases.  (Let’s hope he’s right because hopefully those diseases related to PD can be cured quickly too.)

Regards,
Robin

“Hard Choices for Loving People” booklet

Most of us aren’t at the point yet when we are thinking about these things — feeding tubes, CPR, and end-of-life care — but it may be beneficial to review some of these decisions and information now with our loved ones.

There’s a book called “Hard Choices for Loving People:  CPR, Artificial Feeding, Comfort Care, and the Patient with a Life-Threatening Illness” that may assist in the discussion.  You can purchase the book online ($7). At the present time, it looks like you can read it online at no charge.  See:

www.hardchoices.com

The author, Hank Dunn, a healthcare chaplain, definitely has a point of view, which is that feeding tubes are not appropriate for those with dementia.

Note that “Hard Choices” is available in other languages as well, including Spanish and Chinese.

Robin

 

Free Recordings or Tapes – National Federation of the Blind

This post is about two free services available for those who can no longer read.

My father hasn’t been able to read a newspaper or a book since November.  He thinks it’s because he’s been sick; he says his eyes are tired.  I assume it’s the downward gaze palsy worsening.  He loves the Sunday New York Times.  Whenever I visit, I tried to read some of that paper for an hour.  I get very sleepy reading, however!  I’ve been trying to find someone (to pay) to come read to him.  I “auditioned” one college student who had to ask me how to pronounce every 5th word or so.  So that was a disaster.  I didn’t realize it was such a skill to read the NYT and to read aloud.

Yesterday I came across something that might work.  It’s called Newsline.  The National Federation of the Blind offers this service.  There’s a long list of national and local papers that are recorded, including USA Today, The New York Times, the Washington Post, Los Angeles Times, The Christian Science Monitor, and the Wall Street Journal.

You call a number (presumably local or tollfree), push some buttons, and recordings of the articles you want are played for you.  Obviously, this will work best if there’s a speakerphone.  Apparently you can set up “favorites” and the service will recognize the phone # you are calling from, some hopefully the button pushing at my Dad’s end will be minimal.  I figure that if he can’t do it however, I should be able to get an aide to help out.

You can find info online to sign up — nfb.org/newsline-how-sign.  There is a very easy one-page application.  There needs to be some certification of blindness or visual impairment.  We have a letter from Dad’s eye doctor (OD) saying that he has downward gaze palsy due to PSP.

I’ve also found that the Library of Congress has a National Library Service for the Blind.  The NLS offers many books on tape, even nonfiction books (history and biography).  It distributes these tapes via affiliated state libraries.  The affiliated libraries in northern CA are:

Library for the Blind and Print Disabled
San Francisco Public Library – Serves: San Francisco residents only
Civic Center
100 Larkin Street
San Francisco, CA 94102
Librarian: Martin Magid
Library Code: CA1C
Telephone: (415) 557-4253
FAX: (415) 557-4375
E-mail: [email protected]
Web site: http://sfpl.lib.ca.us/librarylocations/accessservices/lbpd.htm
Hours of Operation: 1:00-6:00 M, Th; 10:00-6:00 T, W; 12:00-6:00 F

Talking Book Library for the Blind
Fresno County Public Library – Serves Fresno, Kings, Madera, and Tulare counties
Ted Wills Community Center
770 North San Pablo Avenue
Fresno, CA 93728-3640
Librarian: Wendy Eisenberg
Library Code: CA1B
Telephone: (559) 488-3217
Toll-free (In-state): (800) 742-1011
TDD: (559) 488-1642
FAX: (559) 488-1971
E-mail: [email protected]
Web site: http://www.fresnolibrary.org/tblb
Hours of Operation: 9:30-5:30 M-F

Braille and Talking Book Library
California State Library – Serves all of Northern CA not served by SF or Fresno Libraries
P.O. Box 942837
Sacramento, CA 94237-0001
Librarian: Aimee Sgourakis
Library Code: CA1A
Telephone: (916) 654-0640
Toll-free (In-state): (800) 952-5666
FAX: (916) 654-1119
E-mail: [email protected] or [email protected]
Web site: http://www.library.ca.gov/html/pubser05.cfm
Hours of Operation: 9:30-4:00 M-F

(I got the preceding info from the web page http://www.loc.gov/nls/find.html and by calling the SF librarian.)

You don’t have to visit the library in person to get these materials.  A special tape player (slower than regular ones) and the tapes are mailed out.  There is usually an application that has to be filled out to get a patron #, and typically some sort of certification is required.  (Many different sorts of people and institutions can provide the certification.)

Both the Newsline service and the NLS service are free.  If you try out either of these services, let me know how it goes!

Robin

Large display clock

This is in the category of a small tip….

My dad (with PSP) had been getting up in the middle of the night, thinking it was morning.  Probably most of the time this happened he fell because he’s very tired and unsteady on his feet at the wee hours.  Over half of his falls used to occur at 3am or 4am.  I had been addressing the “cause” of the falls.  For example, he would often fall at 3am while putting on his robe in the bathroom.  I moved the robe to right next to his bed so he can put it on while sitting down.  But then I addressed the larger issue of why he gets up in the middle of the night.  I learned that he could not read the time on his alarm clock any more.  The display was too small.

I went to the Peninsula Center for the Blind and Vision Impaired (PCBVI) in Palo Alto, CA and found a large display clock for $26.75.  Their supplier is MaxiAids (www.maxiaids.com or 800-522-6294), who sells the clock for the same price.  It’s item #74852 – AM-FM Clock Radio with Extra Large LED Display.  The numbers are green.  Turns out that some low-vision people can see green better than they can white or red.  Anyway, this clock solved the problem of not knowing what time it was in the middle of the night.  Dad no longer gets up at 3am or 4am so those falls have been eliminated.  (Unfortunately there’s still lots of other falling!)

The PCBVI and MaxiAids also have clocks that talk (say the time).  We might have to go that route if Dad’s vision problems worsen.

Robin

 

Large display clock suggestion

This is in the category of a small tip….

My dad (with progressive supranuclear palsy) had been getting up in the middle of the night, thinking it was morning.  Probably most of the time this happened he fell because he’s very tired and unsteady on his feet at the wee hours.  Over half of his falls used to occur at 3am or 4am.  I had been addressing the “cause” of the falls.  For example, he would often fall at 3am while putting on his robe in the bathroom.  I moved the robe to right next to his bed so he can put it on while sitting down.  But then I addressed the larger issue of why he gets up in the middle of the night.  I learned that he could not read the time on his alarm clock any more.  The display was too small.
I went to the Peninsula Center for the Blind and Vision Impaired (650-858-0202) in Palo Alto, CA and found a large display clock for $26.75.  Their supplier is MaxiAids (maxiaids.com, phone 800-522-6294), which sells the clock for the same price.  It’s item #74852 – AM-FM Clock Radio with Extra Large LED Display.  The numbers are green.  Turns out that some low-vision people can see green better than they can white or red.  Anyway, this clock solved the problem of not knowing what time it was in the middle of the night.  Dad no longer gets up at 3am or 4am so those falls have been eliminated.  (Unfortunately there’s still lots of other falling!)

The PCBVI and MaxiAids also have clocks that talk (say the time).  We might have to go that route if Dad’s vision problems worsen.

Robin

Disclose early, find roses, and hope in Parkinson’s (2005 article)

I’ve been reading about the importance of hope, and ran across this article from The Washington Post, published last week. It’s certainly worth reading. The author, Daniel Stark, has written extensively about his battle with Parkinson’s Disease (PD). Though it’s about PD, I think the principles apply to any neurodegenerative disorder.

Here’s a link:

www.washingtonpost.com/wp-dyn/content/article/2005/06/20/AR2005062001057.html

Living Large With Parkinson’s
It’s A Messy Path Ahead, the Author Finds — But Better With a Map
By Daniel Stark
Special to The Washington Post
Tuesday, June 21, 2005; Page HE01

Robin

“Challenging the Odds: forget the prognosis”

Back in 2004 when my father was diagnosed with progressive supranuclear palsy, I joined some online support groups related to PSP.  I met an incredible woman named Aletta, who had been diagnosed in the mid-80s with multiple system atrophy (though she prefers the old term Shy Drager Syndrome).

Today, Aletta posted this wonderful article by Barry Bittman, MD on accepting the diagnosis (or getting a second opinion) but forgetting the prognosis.

Robin


Challenging the Odds: forget the prognosis
by Barry Bittman, MD
Emerge, March 1996

Have you ever met anyone who was given 3 months to live 10 or more years ago, who is still alive today?

Have you ever known a person, who despite an immediately fatal prognosis, managed to beat the odds and survive for a certain occasion such as a
child’s wedding?

Have you ever lost a grandparent who accurately predicted his/her death upon losing a soul mate?

Did you ever stop to consider if it is possible for a doctor to tell us how long we have to live?

If you’ve answered yes to any of these questions, read on.  It’s a fact that many people are alive and thriving today who were told many years ago
that they had only a short time to live.  It’s also common knowledge that some people live just long enough to witness the birth of a new grandchild or to attend a graduation or wedding.  And it doesn’t seem to surprise anyone when the death of one grandparent follows shortly after the other.

Yet, few of us understand how any doctor can make the statement, “You have 3 months to live.”  I’ll let you in on something …. they can’t!

Actually, all that a physician can tell you is how long the average person with your condition typically survives.  The problem here is with the
words, “average” and “typically.”  The doctor relies on statistical data based upon a bell-shaped curve that documents the range of survival for
people who are suffering from a given disease.  At the peak of the curve is the most common survival time experienced by the group under study.  It
comes as no surprise that everyone does not fit there, and often the range of possibilities is extensive.  Some succumb earlier than expected, while others far exceed their prognosis.

Sometimes, however, I wonder if physicians really understand how their conveyed prognosis has the potential to become reality, not because of
statistics, but rather as a result of its impact on the patient’s belief system.  In essence, the doctor’s words become a self-fulfilling
prophecy.  Some people go home and get their things in order, while others go home and get their lives in order.

You’re probably asking yourself what is the difference.  Frankly, the distinction is as wide as the Grand Canyon.  The first group of patients
returns home, announces the bad news, proceeds through the predictable stages of Kubler-Ross, (anger, denial, etc.) revamps their wills, tidies up
their safe deposit boxes, lies down and dies on cue.

The second group, however, goes home and gets their lives in order.  They maintain a fighting determination to complete unfinished business – to accomplish what they never have before.  Remaining time is spent on what they have always hoped to do.  A focus on surviving gives way to planting gardens, creating wildlife sanctuaries, teaching Sunday School, playing with grandchildren, volunteering time for others, and expressing their love.  This group attends classes, reads enlightening books, becomes more spiritual, and sets out on a quest to discover meaning in their lives.

And then something extraordinary occurs – they flourish.  Eating right, exercising, and taking care of one’s self comes naturally, and not as a way
to prolong survival.  Rather, self-care simply evolves as a logical means for enabling their mission in life.

It’s easy to pick such individuals out of a crowd.  These “survivors” make the world a beautiful place, help others, and fulfill their dreams.  They’re the ones who are living mindfully appreciating every moment, and treasuring each experience with gusto and gratitude to our
Creator.  They are our best teachers and guides.

So where does this leave us when faced with a less than desirable prognosis?  My recommendations are simple.  Accept your diagnosis, or, if in doubt, get another opinion.  But never accept your prognosis!

Know that all things are possible, and listen to your inner voice.  Realize that living beyond a serious illness may not be in the cards for all of us
no matter what we do. Yet always remember that it’s the way we live each day that makes the difference.  Love life, realize your dreams, and tip the balance in your favor – Mind Over Matter!
Copyright 1998,1999 Barry Bittman, MD. All rights reserved.