Family Care

One way to understand progressive changes resulting from dementia is to compare them to the changes that occur as a result of human development.  Dementia unfolds as reverse development.  As a general rule, those skills we learn later in life (e.g., managing investments, complex technology, doing a checkbook, and writing poetry) decline earlier than those learn earlier in life (e.g., toileting, dressing, and language).  The major difference is that as we develop from infancy, we constantly learn new skills and information.  The opposite is true for most dementias.  Learning new skills becomes increasingly difficult or impossible.   Those who are demented must be managed based on skills that are already there and those skills progressively deteriorate.  Dementia is a backward moving target. The good news is that we can learn a lot about managing dementia by understanding and using principles of […]

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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 […]

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Type 2 diabetes mellitus is associated with Mild Cognitive Impairment (often presenting as short-term memory loss that is either subjective or confirmed by rigorous memory tests) as well as dementia (moderate to severe short-term memory loss that causes a lack of independence). Furthermore, insulin resistance, the hall mark of adult onset or type 2 diabetes, increases the risk of developing Alzheimer’s disease. Results from the Honolulu aging study provide an example of the association of the balance of glucose and insulin with risk of dementia. Study participants who had either very high or very low levels of serum insulin were more likely than those in between to become demented over the course of 5 years. Other studies, but not all, have shown this link between insulin resistance, impaired glucose metabolism, diabetes and dementia. You have probably read the headlines generated […]

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It’s interesting how we ignore the obvious. The latest article from the New York Times series, “The Vanishing Mind,” focuses on treatment for advanced Alzheimer’s disease. The title of the series has it wrong. The mind does not vanish. Rather it becomes limited and inflexible. As Alzheimer’s progresses, the client (yes, even those with severe cognitive decline are our clients and deserve to be treated as such) becomes unable to adapt to the environment. The environment must be adapted to the client – personalized care. We don’t expect more of children than they are capable and mold their environment to meet their competence but we don’t give those with Alzheimer’s the same courtesy. We expect them to adapt to our convenience and needs. I have often said that if I have to go to a facility, don’t make me play […]

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I was recently confronted with a situation that has caused me to again rethink the use and abuse of the power that we have as professionals- especially those with the title of “doctor.”  In my line of work, I am often confronted with difficult and emotional decisions that involve personal rights and freedoms.  I provide opinions regarding the capacity of persons to drive, manage finances, and live independently.  Most of the cases I am involved with involve various degrees of memory loss, sometimes to the point of impairment known as dementia.   Dementia presents as an irreversible loss of ability and coping skills.  Depending on the severity of the dementia, rights such as the freedom to come and go as one pleases must be removed for safety.  These are often gut wrenching for both the afflicted individual and those who love […]

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There is a new concern arising as “boomers” are now dealing with cognitive decline in their aging parents. They are now asking “What about me?” This is to say that boomers are concerned about dealing with one possible outcome of their own aging – dementia. As always I suggest getting a plan in place before you need it. We don’t wait until we are in our 70s to plan for financial needs in retirement – we purchase IRAs or 401Ks earlier in life. We don’t wait until we have cancer to act – we undergo cancer screenings from middle age. We don’t wait for medical problems to emerge – we have annual physicals. We are proactive about so many issues in life but remain reactive with our memory. There are several possible reasons for this. First, we treat decline in […]

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There is a flurry of articles appearing in both the medical and popular press as many experts are attempting to change the criteria for diagnosing Alzheimer’s disease. The new criteria are based on the “amyloid hypothesis.’ Amyloid is brain protein that sometimes goes awry and is associated with the formation of plaques on neurons. The theory is based on the belief that abnormal amyloids cause Alzheimer’s disease. If this is so, the theory suggests that treatment strategies should be based on arresting or reversing the creation of amyloid plaques. Most current clinical trials of medications for Alzheimer’s disease are based on this hypothesis. By the newly proposed criteria, finding plaque on a PET scan or in cerebrospinal fluids would be cause to diagnose Alzheimer’s disease in persons without memory loss or other symptoms. If adopted, many would be told either […]

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Behavioral problems like aggression, agitation, and hallucinations are common among those with memory loss and dementia. They are often treated with medications as a class called “antipsychotics” or “neuroleptics.” The newer medications in this class include Risperdal, Zyprexa, Geodon, Seroquel, and Abilify. Examples of older medications in this class of drugs include Thorazine, Haldol, and Melleril and are not widely used today. The newer medications are used in about 90% of prescriptions written. The belief was that these newer (and more expensive) medications are safer and more effective than older medications. However, these assumptions have been challenged by recent research. The overall risk of death from use of these medications is low – about 3%. However these drugs affect heart rhythm and may cause a higher rate of sudden cardiac deaths in vulnerable individuals. This is true for individuals treated […]

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The stress of caregiving takes an enormous toll even when it is a labor of love. It is a job that consumes you if you do not take active steps to get away from the constant demands. Being compassionate and caring does not mean total self-sacrifice. The most effective caregiving is accomplished by balancing the needs of the one you love and your own needs. I often talk with caregivers who are overwhelmed and worn out from their 24 hour/7 day a week job. Caregivers are so invested in the needs of the person with the memory loss that they lose sight of the fact that caregiving demands that you care for yourself as well. This self neglect is driven by either guilt (“I have to do it myself no matter what the cost”) or because by demands on time […]

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Placement in a memory care or skilled nursing unit is a very difficult decision, one of the most stressful decisions I have ever seen anyone make. Most people suffering from a dementing condition are cared for at home by family members. However, there may come a time when a caregiver can no longer manage alone at home. The most typical causes for placement are behavioral problems (e.g., wandering, aggression, delusions, hallucinations), incontinence, refusal of personal care, or caregiver illness or stress. All of these reasons involve a crisis and are often made when emotional resources are drained. I have worked with many who see me early in the disease process and we develop a plan that we follow by monitoring and decision making over the course of several years. Care evolves as decline progresses from being able to manage on […]

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