Is Cognitive Decline a “Normal” Part of Aging?

Posted on February 1, 2012 by krandall

New research published in the British journal Age and Ageing suggests that cognitive decline among older adults is not normal. In fact, two out of every three older adults experience only a trivial amount of decline in cognitive performance over a decade. The finding challenges widely held beliefs about cognitive decline and aging.

These findings have important implications for the care of seniors. Doctors and hospital staff often assume that cognitive decline is a part of normal aging, which leads to clinicians writing off poor performance from an elderly patient as something that is to be expected. With an understanding that cognitive decline is not normal, however, poor performance is more likely to be investigated. Preventable or reversible conditions, such as delirium, medication side effects, or vitamin deficiency can then be properly addressed.

The researchers were from Duke University, Rush University, and the Institute for Aging Research of Hebrew SeniorLife, an affiliate of Harvard Medical School. They analyzed data from the Religious Orders Study, a long-term study of cognitive aging and neuropathology conducted at Rush University in Chicago. More than 1000 study participants aged 56 to 102 were followed for up to 12 years, and their cognitive abilities were measured annually.

The researchers identified three groups of people: those experiencing slow, moderate and rapid cognitive decline. “This was a study of cognitive performance, not IQ,” explains Dr. Richard N. Jones, a senior scientist at the Institute for Aging Research. “But one could think of our results in terms of an outcome that was scored like an IQ test, where 100 was average and the normal range is between 70 and 130.”

Take a 75-year-old person, with a score of 100 in 2005. In 2015, they would be expected to have a score of 94 if they were in the slow decline group. “That is not much of a change, and it is the group where most people fit,” says Dr. Jones.

About one in four participants were in the moderate decline group. A 75-year-old with a score of 100 in 2005 would be expected to have a score of 75 in 2015 if they were a member of this group. If they were experiencing fast cognitive decline, a 75-year-old with a cognitive performance score of 100 in 2005 would be expected to have a score of 57 in 2015.

“People with moderate or fast cognitive decline, and their families, probably need medical or social support,” says Dr. Jones. The authors found that people in the moderate and fast decline groups had more Alzheimer’s disease neuropathology than did people in the slow decline class.

The group now hopes to find a way to identify people who have a high probability of belonging to the moderate or fast decline groups, and to try to predict what factors influence when a person might switch from a slow decline group to a moderate or fast decline group.

The researchers are grateful for the voluntary participation in the Religious Orders Study on the part of more than 1,000 nuns, priests and brothers from across the country. “Without the generosity of their gifts of time, effort and organ donation, we simply could not advance science in this or any other area of cognitive aging,” says Dr. Jones.

Source: Founded in 1903, Hebrew SeniorLife, an affiliate of Harvard Medical School, is a nonprofit, nonsectarian organization devoted to innovative research, health care, education and housing that improves the lives of seniors. For more information, please visit www.hebrewseniorlife.org.

Help Protect Senior Loved Ones from Dangerous Falls

Posted on January 18, 2012 by krandall

If your loved one has taken a fall—or if the possibility of falling is something that worries you and your parent—you are not alone. Studies show that the risk of falling increases dramatically as a person ages. They also show that most seniors put falling and fall-related injuries at the top of their list of things to worry about.

There is reason to be worried. Each year, falls involving older adults account for thousands of hip fractures and other serious injuries. In fact, falling and injuries resulting from a fall are a leading cause of death for older persons. According to a recent study from Kaiser Permanente Center for Health Research, women who break a hip are five times more likely to die within a year—even if they were in good health at the time of their injury. Said lead author Dr. Eric LeBlanc, “This finding suggests that it is the hip fracture itself that ultimately leads to death in these women. Even though they start out in excellent health, the hip fracture is so devastating that many of them don’t recover.”

Not all falls can be prevented, but many can! So, it is important to understand the risk of falling and what can be done to prevent falls. Here is some information seniors should consider:

Why Older Adults Are At Greater Risk of Falling

As a person ages, physical changes make falling more likely, and also increase the chance that the person who falls will be injured. But physical changes to eyesight, balance, muscle tone, and bone structure are only one part of a bigger picture.

Here are four major reasons seniors are at an increased risk of falling:

Environmental causes—Throw rugs, electrical cords, wet and slippery floors, rough floor surfaces, slick walkways and steps, and poor lighting are all examples of things or conditions that can trip us up.
Physical and mental changes—Most seniors, sooner or later, will experience problems with their eyesight, sense of balance, mobility, bone structure, and reflexes. Confusion, forgetfulness, stroke, Parkinson’s disease, and Alzheimer’s disease are also important risk factors.
Medications—Most seniors take a variety of medications, both over-the-counter and prescription. Many medications can cause dizziness, drowsiness, or other side effects that make it harder to keep one’s balance.
Things we don’t expect—Often, a contributing cause in a fall is the circumstance we do not expect and have not prepared for. We lean against a door, thinking it is closed. We walk down a poorly lighted walkway, not prepared for the small pile of weeds and clippings someone has left there.
Practical Ways Seniors Can Reduce the Risk of Falling

Although it is unrealistic to think we can prevent all falls from happening, there are many proven ways of reducing the risk of falling. Here are some important protection ideas to share with older loved ones:

Ask your doctor about setting up an exercise program to build up your strength and coordination. Or, if you are in a fitness program or are in physical or occupational therapy, make fall prevention one of the issues you discuss. Make lowering your risk of falling one of the explicit goals of your program or therapy.
If you have experienced episodes of dizziness, or if you think you may have a problem with balance, vision, or your medications, talk with your doctor. Be persistent in seeking answers to your questions. Ask to have balance and dizziness problems tested, diagnosed, and treated. Don’t accept the view that falls are just part of getting older. You are entitled to the support of your doctor and other health care providers in making sure you take all reasonable steps to reduce your risk of being injured in a fall.
Eat right. Getting the nutrition you need is just as important as getting appropriate exercise and rest.
Be aware of your surroundings. Don’t be tripped up by something you didn’t anticipate. Plan your motions a little more ahead than you used to. Give yourself time to react to your physical surroundings and the other people around you. Pay special attention any time you are in new or unfamiliar surroundings. For example, heads up when you are traveling away from home.
Do a careful safety inspection of your living spaces. Look for anything that could trip you up, like rough floor surfaces, throw rugs, poor lighting, extension cords, clutter, etc. While you are at it, try to identify improvements that could make your situation even safer—that could give you a critical margin of safety. Examples: extra grab bars in the bath or shower, a second hand railing on the stairs, etc.
Make fall prevention a topic for discussion. If you are concerned about preventing falls‚ put the topic out on the table for discussion. Preventing falls is a topic that deserves time and attention, especially in a doctor’s appointment or during a care conference. Explain your fears and concerns. If you have experienced falls or problems with balance, vision or medications, bring that history up. Make sure your doctor and other healthcare providers are dealing with a full understanding of your situation. If they recommend testing or other steps, such as a change of diet or special exercises, take their advice.
Copyright © IlluminAge AgeWise, 2011

Holiday Hints for Alzheimer’s Caregivers

Posted on December 13, 2011 by krandall

The holidays are a time for visiting and reconnecting with family, friends and neighbors. For people with Alzheimer’s disease or other dementia, the holidays can be a meaningful, enriching time. Maintaining (or adapting) old family rituals and traditions helps all family members feel a sense of belonging and family identity. For the person with Alzheimer’s, this link with a familiar past may be reassuring.

But when a loved one is living with the challenges of dementia, the season can be one of stress and sadness. Memories of holidays past are a reminder of the changes that come with the progression of the disease. And the challenges of providing care for a loved one with dementia leaves caregivers little extra time to deal with holiday tasks.

The Alzheimer’s Disease Education and Referral Center, part of the National Institute on Aging, offers tips to help ensure a more enjoyable holiday season for everyone:

Set your own limits early, and be clear about them with others. You do not have to live up to the expectations of friends or relatives. Your situation is different now.
Encourage family and friends to visit even if it is painful for them. Keep the number of persons visiting at one time to a minimum, or try a few people visiting quietly with the person in a separate room.
Try some simple holiday preparation with the person several days ahead. Just observing your preparations will familiarize him/her with the upcoming festivities. Participating with you allows your loved one to experience the pleasure of helping and giving, as well as the fun of anticipation and reminiscing.
Prepare potential quiet distractions (a family photo album or a simple repetitive chore like cracking nuts) to use if the person with Alzheimer’s becomes upset or overstimulated.
Try to avoid situations that further confuse or frustrate many people with Alzheimer’s:

crowds of people who expect the person to remember them

noise, loud conversations, or loud music

strange or different surroundings

changes in light intensity—too bright or too dark

over-indulgence in rich or special food or drink (especially alcohol)

a change in regular routine and sleep patterns

Try scheduling activities, especially some outdoor exercise, early in the day to avoid the fatigue from added activity at the end of a long day. Familiar holiday music, storytelling, singing or faith community services (even on TV) may be especially enjoyable.
If you receive invitations to holiday celebrations which the person cannot attend, go yourself. Enjoy the chance to be with friends and family who love you and enjoy your company, with or without your relative.

Preparing Your Guests

Explain as clearly as possible what has happened to the person with Alzheimer’s. Give examples of the unusual behaviors that may take place: incontinence, eating food with fingers, wandering, hallucinations.
Explain that it may not be appropriate behavior but the person with Alzheimer’s has a memory loss and does not remember what is expected and acceptable.
Remind the visitor through phone calls or letters to be understanding and not to shun the person with Alzheimer’s.
If this is the first visit since the person became severely impaired, tell the visitor the visit may be painful. The memory-impaired person may not remember the guest’s name or relationship.
Explain that memory loss is the result of the disease and it is not intentional.
Stress with the guests that what is important is the meaningfulness of the moment spent together and not what the person remembers.

Preparing the Memory-Impaired Person

Begin showing a picture of the guest to your loved one a week before the arrival.
Spend more time each day explaining who the visitor is while showing the picture.
Arrange a phone call for the person with Alzheimer’s and the visitor. The conversation may help both. The call gives the visitor an idea what to expect and gives your loved one an opportunity to familiarize him/herself with the visitor.
Keep your memory-impaired loved one’s routine as close to normal as possible.
During the hustle and bustle of the holiday season, guard against fatigue and find time for adequate rest.

Is Cognitive Decline a “Normal” Part of Aging?

Posted on December 5, 2011 by krandall

New research published in the British journal Age and Ageing suggests that cognitive decline among older adults is not normal. In fact, two out of every three older adults experience only a trivial amount of decline in cognitive performance over a decade. The finding challenges widely held beliefs about cognitive decline and aging.

Hospice, Advance Directives

Posted on December 2, 2011 by krandall

New Reassurance About End-Of-Life Discussions

During the debate over health reform, the topic of end-of-life discussion received increased attention, much of it negative. A new study from the University of Colorado School of Medicine helps put to rest some of the misconceptions. Sharing our thoughts with family and our healthcare provider concerning the kind of care we would—and would not—want to receive in the event of a life-limiting illness is far from the “death panel” scenario claimed by some detractors.

Discussing and documenting patients’ preferences for care at the end of life does not cause them any harm, contrary to recent claims. In September 2011, a study published in the Journal of Hospital Medicine found that patients who talk with their physicians about end-of-life care and have an advance directive in their medical record have similar survival rates as patients who do not have these discussions and documents.

The study included 356 patients admitted at three different hospitals who had a low or medium risk of dying within one year. Patients were followed from 2003 to 2009. During the study, there were no differences in survival for patients who had an end-of-life discussion versus those who had not. There also were no survival differences for those who had a living will in their medical record and those who did not.

“Our findings are reassuring. They support health care providers, who can initiate these discussions, and policy makers, who seek to reimburse these time consuming discussions,” said lead researcher Stacy M. Fischer, MD of the University of Colorado School of Medicine. “Most importantly, our findings are reassuring for patients and families who desire these discussions with their health care providers.”

Fischer adds, “The term ‘death panels’ has sparked considerable controversy recently. It has undermined the efforts of clinicians who provide end-of-life care by scaring patients into thinking that their lives may be cut short for their families’ or society’s best interest. We hope our study provides data to help inform the national debate about advance directives for health care providers, policy makers, patients and families.”

Source: AgeWise, adapted from Journal of Hospital Medicine/Wiley-Blackwell

“Big Cleanout” is No Cure for Hoarding

Posted on November 27, 2011 by krandall

If basic cable is any indication, we have a fascination with hoarding. “We all love a good train wreck” says Mark Odom, clinical consultant to the Orange County, CA Task Force on Hoarding. He says many people – including psychiatrists – think hoarders are obsessive/compulsive. It’s even listed that way in the “bible” of psychiatric disorders, the DSM IV.

But that’s not necessarily true, according to several studies presented at this year’s annual conference of the American Society on Aging. Hoarders are more likely to be depressed, anxious or have social phobias than to have OCD.

And the problem worsens with age. University of California, San Francisco researcher Monika Eckfield studied 22 older adults and found that changes in their social environment created boredom and isolation. So, for some, shopping became a socially-appropriate way to interact with the world. And then, they don’t get rid of anything once they bring purchases home.

All 16 women and 6 men described “blockages,” with no motivation to discard many things, though no one kept everything. One woman said her house was “constipated,” Eckfield reports.

And the hoarding was not because they had lived in the same place for decades. Even people who moved in the last 5 to 10 years didn’t purge when they moved. They hired helpers, who packed, moved and then stacked boxes. Eckfield said their homes “looked like storage lockers.” In fact, because they seemed to lack the capability or help to unpack, and then they couldn’t find things like kitchen supplies, they went out and bought more.

In the March 2011 issue of the International Journal of Geriatric Psychiatry, R. Scott Mackin, also from UCSF, and a team of researchers found that about 15 percent of older adults with depression had “severe compulsive hoarding behaviors,” while just 2 percent to 5 percent of non-depressed older adults are hoarders. He notes that both depression and hoarding are “frontally mediated” – that is, both seem to affect the frontal lobes of the brain, which are associated with planning, motivating and organizing.

The hoarders had much more trouble categorizing objects – such as sorting cards based on color or shapes – and solving problems. These “cognitive deficits” need to be taken into account before intervening to clean out the hoarder’s home, the team concluded.

Christiana Bratiotis, of the Boston University School of Social Work, says cognitive behavioral therapy can help. Prior to a recent study the school did with the Elder Services of Merrimack Valley, MA, the agency used only large scale clean-outs to clear the clutter. She said 100 percent of the time, the elders began hoarding again immediately. And they were angry, distressed and distrustful of anyone (family members, social workers) who tried to intervene again.

For their study, social workers visited 26 people, ages 60-90, weekly for up to a year. They found that the older adults described themselves as “packrats” or “collectors,” not hoarders. The social workers worked with them slowly, to reduce the mistrust and to build organizing skills.

They put the hoarders in control of all the decision-making, except eliminating imminent risk (such as papers on the stove) and found that by the end of the year, most could tolerate incremental changes and none had been evicted.

That jives with the Orange County task force’s experience. Mark Odom notes that an effective strategy for them is to emphasize “harm reduction.” He said by invoking regulation-enforcers, such as landlords or fire departments, hoarders had “exterior motivation” to clear at least some of the clutter.

“It’s about house ‘safe and functional,’” he said, “not ‘house beautiful.’”

This article was reprinted from Kaiser Health News (www.kaiserhealthnews.org) with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Avoiding the Hospital “Revolving Door”

Posted on November 8, 2011 by Admin

The New England Journal of Medicine recently reported that 20% of Medicare patients return to the hospital within a month of discharge, and many of these re-hospitalizations are unnecessary. The Centers for Medicare & Medicaid Services confirms that these re-hospitalizations cost $17 billion per year. As our population ages and healthcare costs soar, there is increased focus on the problem of costly readmissions. There will also soon be a financial incentive: as of 2012, Medicare will reduce payment to hospitals for additional costs that result when certain preventable conditions cause patients to be readmitted.

In a 2011 report from the Dartmouth Institute for Health Policy and Clinical Practice, Dr. Dr. David C. Goodman cites “widespread and systematic failures in coordinating care for patients after they leave the hospital.” He says, “Irrespective of the cause, unnecessary hospital readmissions lead to more tests and treatments, more time away from home and family, and higher health costs.”

Successful recovery is a team effort. The American Medical Association stresses that the hospital, outpatient and inpatient providers should all work together to coordinate care across sites. The association also calls attention to the need for improved aftercare education and communication to help patients understand and comply with post-discharge instructions.

Patients and family caregivers also have a role to play. Patients should discuss aftercare with their healthcare provider or hospital discharge planner before they leave—even better, before their treatment. They should take notes and bring a list of questions. How long is recovery expected to take? What is the best setting for recovery? What are the financial considerations? What kind of care will be needed? What support resources are available? Whether a hospital stay is planned or unexpected, following instructions provides the best chance of a successful recovery, with the fewest complications.

But the recovery regimen can be complex—a real challenge for senior patients who may be in pain, sleeping poorly, and perhaps taking medications that leave them groggy, all of which can lead to confusion. Northwestern University researcher Lee Lindquist says, “A helper on the day of discharge could make sure a senior understands discharge instructions…and follows instructions safely.” Lindquist adds, “When the senior is no longer sick enough to be in the hospital, it doesn’t mean they’re 100% ready to be on their own. It’s a critical time and they need extra support and understanding from healthcare professionals and family.” This is why it is recommended—and in many cases required—that the patient be accompanied upon discharge, and have assistance at home.

The term “sicker and quicker” is no joke—long hospital stays are a thing of the past for most patients. Patients are discharged as soon as the physician determines they are no longer in need of hospital-level care. But this doesn’t mean they are fully recovered, and they often need continued assistance with recovery. A post-acute care facility, rehabilitation facility or nursing home may be the next transition.

When patients return home, they may still require help with healthcare tasks and the activities of daily living. More and more families are called into action to support the recovery of senior family members. These impromptu caregivers may find the role challenging! Family caregivers, many of whom are seniors themselves and dealing with their own health issues, may lack the physical strength and training to perform unaccustomed care tasks.

It’s important to learn about support services such as home health care and medical equipment. These services may be covered by Medicare or the patient’s private insurance. In-home companion care, while not covered by Medicare, is also a great support for patients and family. Consult with the hospital discharge planner, a geriatric care manager or social worker to learn what services are available and appropriate.

Ten Tips for a Successful Recovery at Home

Enlist a relative or friend to help you through the process.
Find out ahead of time who to contact with questions.
Learn all you can ahead of time; discharge can happen quickly.
Arrange for home care if necessary.
Follow aftercare instructions carefully.
Go to all follow-up appointments.
Take medications correctly and be alert for side effects.
Know what symptoms to be alert for, and report them promptly.
Make necessary home modifications to create a safe recovery environment.
Arrange for assistance and transportation.

Special concerns of family caregivers. Your loved one may or may not be able to understand discharge instructions. Be there for meetings with the discharge planner if possible. Take notes. Provide information. Speak up if you don’t think you can provide the level of care your loved one will need. Ask for help. And take care of yourself. If you are burned out, you will not be able to support your loved one during recovery.

Information for Patients and Families

You can download the free booklet “Taking Care of Myself: A Guide for When I Leave the Hospital ” from the Agency for Healthcare Research and Quality.

The Dartmouth Atlas of Health Care offers the tip sheet “Care About Your Care: Tips for Patients When They Leave the Hospital ”