Alzheimers

Total Cognitive Burden

Because it holds some personal resonance for me, my recent round-up of genetic news called to mind food allergies. Now food allergies can be tricky beasts to diagnose, and the reason is, they’re interactive. Maybe you can eat a food one day and everything’s fine; another day, you break out in hives. This is not simply a matter of the amount you have eaten, the situation is more complex than that.

tags problems: 

tags lifestyle: 

A new resource for Alzheimer's caregivers

I recently reported on a long-running study that found that husbands or wives who care for spouses with dementia are six times more likely to develop Alzheimer’s themselves than those whose spouses don't have it. The most likely cause for this is the great stress of caregiving. Both stress and depression increase the risk of Alzheimer’s, and both are common (well, stress is inescapable!) among caregivers.

tags problems: 

Mild Cognitive Impairment

Except in the cases of stroke or traumatic brain injury, loss of cognitive function is not something that happens all at once. Cognitive impairment that comes with age may be thought of as belonging on a continuum, with one end being no cognitive impairment and the other end being dementia, of which Alzheimer's is the most common type.

Most older adults are actually at the "no impairment" end of the continuum. A further 30-40% of adults over 65 will have what is called "age-related memory impairment", which is the type of cognitive loss we regard as a normal consequence of age -- a measurable (but slight) decline on memory tests; a feeling that you're not quite as sharp or as good at remembering, as you used to be.

Only about 1% of these people will develop Alzheimer's.

But around 10% of adults over 65 develop "mild cognitive impairment", and this is a precursor of Alzheimer's. This doesn't mean someone with MCI will inevitably get Alzheimer's in their lifetime, but their likelihood of doing so is substantially increased.

Whether you are one of those 10% depends in part on your age and your level of education. A study2 of nearly 4000 people from the general population of a Minnesota county, run by the Mayo Clinic, indicates 9% of those aged 70 to 79 and nearly 18% of those 80 to 89 have MCI. The prevalence decreased with years of education: it was 25% in those with up to eight years of education, 14% in those with nine to 12 years, 9% in those with 13 to 16 years, and 8.5% in those with greater than 16 years.

Whether or not this will develop into Alzheimer’s can be predicted with a reasonably high level of accuracy (75%) by the rate at which brain tissue is being lost, and in particular the rate at which it is being lost in the hippocampus (arguably the most important region for memory in the brain). Whether actions known to build brain tissue (physical exercise, mental stimulation) can counteract that in this population is not yet known — but it certainly can’t hurt!

Mild cognitive impairment doesn’t necessarily mean memory problems. There are two types of MCI: those with the amnesic subtype (MCI-A) have memory impairments only, while those with the multiple cognitive domain subtype (MCI-MCD) have other types of mild impairments, such as in judgment or language, and mild or no memory loss. Both sub-types progress to Alzheimer's disease at the same rate, but they do have different pathologies in the brain.

Mild cognitive impairment is not necessarily obvious to outside observers. A person with it can function perfectly well, and although they may feel their impairment is obvious to all around them, it's not likely to be obvious to anyone not living with them.

A person suffering from mild cognitive impairment may find that they have problems with:

  • finding the right words
  • making decisions
  • remembering recent events
  • placing things in space (for example, getting the proportions right when drawing a simple object such as a box).

Essentially, age-related cognitive impairment might be thought of as slight, non-important, cognitive impairment, while mild cognitive impairment is a condition where significant cognitive impairment exists which nevertheless doesn't affect daily functioning. Dementia is significant cognitive impairment that does interfere with daily life.

 

See more research at my companion website About Memory

References: 

  1. Becker, J.T. et al. 2006. Three-dimensional Patterns of Hippocampal Atrophy in Mild Cognitive Impairment. Archives of Neurology, 63, 97-101.
  2. Petersen, R. et al. 2006. Study presented April 4 at the American Academy of Neurology meeting in San Diego. Press release
  3. Quinn, J.F. & Kaye, J.A. 2004. Study presented at the 56th annual meeting of the American Academy of Neurology in San Francisco. Press release
  4. Small, G.W. 2002.What we need to know about age related memory loss. British Medical Journal, 324, 1502-1505.

tags problems: 

Preventing Dementia: Mental stimulation

Stimulating activities

A 5-year study1 involving 488 people age 75 to 85 found that, for the 101 people who developed dementia, the greater the number of stimulating activities (reading, writing, doing crossword puzzles, playing board or card games, having group discussions, and playing music) they engaged in, the longer rapid memory loss was delayed. Similarly, a study2 involving 1321 randomly selected people aged 70 to 89, of whom 197 had mild cognitive impairment, has found that reading books, playing games, participating in computer activities or doing craft activities such as pottery or quilting was associated with a 30 to 50% decrease in the risk of developing memory loss compared to people who did not do those activities.

Moreover, two activities during middle age (50-65) were also significantly associated with a reduced chance of later memory loss: participation in social activities and reading magazines. The value of social activities is consistent with another, small, study3 that found that social networks, like education, offers a 'protective reserve' capacity that spares individuals the clinical manifestations of Alzheimer's disease. As the size of the social network increased, the same amount of Alzheimer’s pathology in the brain had less effect on cognitive test scores. For those without much pathology (plaques and tangles), social network size had little effect on cognition.

This supports another study4 involving 469 people aged 75 and older, that found that those who participated at least twice weekly in reading, playing games (chess, checkers, backgammon or cards), playing musical instruments, and dancing were significantly less likely to develop dementia. Although the evidence on crossword puzzles was not quite statistically significant, those who did crossword puzzles four days a week had a much lower risk of dementia than those who did one puzzle a week.

Similarly, a study5 of 700 seniors found that more frequent participation in cognitively stimulating activities, such as reading books, newspapers or magazines, engaging in crosswords or card games, was significantly associated with a reduced risk of Alzheimer’s disease. On average, compared with someone with the lowest activity level, the risk of disease was 47% lower for those whose frequency of activity was highest.

In the first comprehensive review6 of the research into 'cognitive reserve', which looks at the role of education, occupational complexity and mentally stimulating activities in preventing cognitive decline, researchers concluded that complex mental activity across people’s lives almost halves the risk of dementia. All the studies also agreed that it was never too late to build cognitive reserve. The review covered 29,000 individuals across 22 studies.

A review7 of research on the impact of cognitive training on the healthy elderly (not those with mild cognitive impairment or Alzheimer's disease), has found no evidence that structured cognitive intervention programs affects the progression of dementia in the healthy elderly population.

Post-mortem analysis of participants in a large, long-running study8 has provided more support for the idea that mental stimulation protects against Alzheimer’s. The study found a cognitively active person in old age was 2.6 times less likely to develop dementia and Alzheimer’s disease than a cognitively inactive person in old age. This association remained after controlling for past cognitive activity, lifetime socioeconomic status, and current social and physical activity. Frequent cognitive activity during old age was also associated with reduced risk of mild cognitive impairment.

Research involving genetically engineered mice9 has found that mice whose brains had lost a large number of neurons regained long-term memories and the ability to learn after their surroundings were enriched with toys and other sensory stimuli, pointing to the importance of maintaining cognitive stimulation as long as possible. Similarly, another mouse study10 found that short but repeated learning sessions can slow the development of those hallmarks of Alzheimer's, beta amyloid plaques and tau tangles. And another11 found that an enriched environment, with more opportunities to exercise, explore and interact with others, dramatically reduces levels of beta-amyloid peptides.

Education & iq

A study12 involving some 6,500 older Chicago residents being interviewed 3-yearly for up to 14 years (average 6.5 years), has found that while at the beginning of the study, those with more education had better memory and thinking skills than those with less education, education was not related to how rapidly these skills declined during the course of the study. The result suggests that the benefit of more education in reducing dementia risk results simply from the difference in level of cognitive function.

Another study13 has come out supporting the view that people with more education and more mentally demanding occupations may have protection against the memory loss that precedes Alzheimer's disease, providing more evidence for the idea of cognitive reserve. The 14-month study followed 242 people with Alzheimer's disease, 72 people with mild cognitive impairment, and 144 people with no memory problems.

Another study14 has come out confirming that people with more years of education begin to lose their memory later than those with less education, but decline faster once it begins. Researchers note that since the participants were born between 1894 and 1908, their life experiences and education may not represent that of people entering the study age range today.

A study15 of 312 New Yorkers aged 65 and older, who were diagnosed with Alzheimer's disease and monitored for over 5 years, found that overall mental agility declined faster for each additional year of education, particularly in the speed of thought processes and memory, and was independent of age, mental ability at diagnosis, or other factors likely to affect brain function, such as depression and vascular disease. It’s suggested this may reflect the greater ability of brains with a higher cognitive reserve to tolerate damage, meaning the damage is greater by the time it becomes observable in behavior.

The Nun Study16 found that nuns who completed 16 or more years of formal education or whose head circumference was in the upper two-thirds were four times less likely to be demented than those with both smaller head circumferences and lower education.

Post-mortem study17 of the brains of 130 participants in the Religious Orders Study found that the relationship between cognitive performance and the number of amyloid plaques in the brain changed with level of formal education. The more years education you had, the less effect the same number of plaques had on actual cognitive performance. It’s worth noting that this considerable difference was observed in a population where even the least educated had some college attendance; presumably the difference would be even more marked in the general population.

A long-running Finnish study18 has found that compared with people with five or less years of education, those with six to eight years had a 40% lower risk of developing dementia and those with nine or more years had an 80% lower risk. Generally speaking, people with low education levels seemed to lead unhealthier lifestyles, but the association remained after lifestyle choices and characteristics such as income, occupation, physical activity and smoking had been taken into account.

An analysis of high school records and yearbooks from the mid-1940s19, and interviews with some 400 of these graduates, now in their 70s, and their family members, has found that those who were more active in high school and who had higher IQ scores, were less likely to have mild memory and thinking problems and dementia as older adults.

An analysis20 of 184 people with dementia found that the mean age of onset of dementia symptoms in the 91 monolingual patients was 71.4 years, while for the 93 bilingual patients it was 75.5 years — a very significant difference.

A study21 of 122 people with Alzheimer's and 235 people without the disease found that people with Alzheimer's are more likely to have had less mentally stimulating careers than their peers who do not have Alzheimer's.

 

A study22 of 173 people from the Scottish Mental Survey of 1932 who have developed dementia has found that, compared to matched controls, those with vascular dementia were 40% more likely to have low IQ scores when they were children than the people who did not develop dementia. This difference was not true for those with Alzheimer's disease. The findings suggest that low childhood IQ may act as a risk factor for vascular dementia through vascular risks rather than the "cognitive reserve" theory. 

References: 

  1. Hall, C.B. et al. 2009. Cognitive activities delay onset of memory decline in persons who develop dementia. Neurology, 73, 356-361.
  2. Geda, Y.E. et al. 2009. Cognitive Activities Are Associated with Decreased Risk of Mild Cognitive Impairment: The Mayo Clinic Population-Based Study of Aging. Presented April 28 at the American Academy of Neurology's 61st Annual Meeting in Seattle.
  3. Bennett, D.A., Schneider,J.A., Tang,Y., Arnold,S.E. & Wilson,R.S. 2006. The effect of social networks on the relation between Alzheimer's disease pathology and level of cognitive function in old people: a longitudinal cohort study. Lancet Neurology,5, 406-412.
  4. Verghese, J., Lipton, R.B., Katz, M.J., Hall, C.B., Derby, C.A., Kuslansky, G., Ambrose, A.F., Sliwinski, M. & Buschke, H. 2003. Leisure Activities and the Risk of Dementia in the Elderly. New England Journal of Medicine, 348 (25), 2508-2516.
  5. Wilson, R.S., de Leon, C.F.M., Barnes, L.L., Schneider, J.S., Bienias, J.L., Evans, D.A. & Bennett, D.A. 2002. Participation in Cognitively Stimulating Activities and Risk of Incident Alzheimer Disease.
    JAMA, 287,742-748.
  6. Valenzuela, M.J. & Sachdev, P. 2006. Brain reserve and dementia: a systematic review. Psychological Medicine, In press
  7. Papp, K.V., Walsh, S.J. & Snyder, P.J. 2009. Immediate and delayed effects of cognitive interventions in healthy elderly: A review of current literature and future directions. Alzheimer's & Dementia, 5 (1), 50-60.
  8. Wilson, R.S., Scherr, P.A., Schneider, J.A., Tang, Y. & Bennett, D.A. 2007. The relation of cognitive activity to risk of developing Alzheimer’s disease. Neurology, published online ahead of print June 27.
  9. Fischer, A., Sananbenesi, F., Wang, X., Dobbin, M. & Tsai, L-H. 2007. Recovery of learning and memory is associated with chromatin remodelling. Nature, 447, 178-182.
  10. Billings, L.M., Green, K.N., McGaugh, J.L. & LaFerla, F.M. 2007. Learning Decreases Aß*56 and Tau Pathology and Ameliorates Behavioral Decline in 3xTg-AD Mice. Journal of Neuroscience, 27, 751-761.
  11. Lazarov, O.et al. 2005. Environmental Enrichment Reduces Aβ Levels and Amyloid Deposition in Transgenic Mice. Cell, 120(5), 701-713.
  12. Wilson, R.S., Hebert, L.E., Scherr, P.A., Barnes, L.L., de Leon, C.F.M. & Evans, D.A. 2009. Educational attainment and cognitive decline in old age. Neurology, 72, 460-465.
  13. Garibotto, V. et al. 2008. Education and occupation as proxies for reserve in aMCI converters and AD: FDG-PET evidence. Neurology, 71, 1342-1349.
  14. Hall, C.B., Derby, C., LeValley, A., Katz, M.J., Verghese, J. & Lipton, R.B. 2007. Education delays accelerated decline on a memory test in persons who develop dementia. Neurology, 69, 1657-1664.
  15. Scarmeas, N., Albert, S.M., Manly, J.J. & Stern, Y. 2006. Education and rates of cognitive decline in incident Alzheimer’s disease. Journal of Neurology Neurosurgery and Psychiatry, 77, 308-316.
  16. Mortimer, J.A., Snowdon, D.A. & Markesbery, W.R. 2003. Head Circumference, Education and Risk of Dementia: Findings from the Nun Study.Journal of Clinical and Experimental Neuropsychology, 25 (5), 671-679.
  17. Bennett, D.A., Wilson, R.S., Schneider, J.A., Evans, D.A., de Leon, M.C.F., Arnold, S.E., Barnes, L.L. & Bienias, J.L. 2003. Education modifies the relation of AD pathology to level of cognitive function in older persons. Neurology, 60, 1909-1915.
  18. Ngandu, T. et al. 2007. Education and dementia: What lies behind the association? Neurology, 69, 1442-1450.
  19. Fritsch, T., Smyth, K.A., McClendon, M.J., Ogrocki, P.K., Santillan, C., Larsen, J.D. & Strauss, M.E. 2005. Associations Between Dementia/Mild Cognitive Impairment and Cognitive Performance and Activity Levels in Youth. Journal of the American Geriatrics Society, 53(7), 1191.
  20. Bialystok, E., Craik, F.I.M. & Freedman, M. 2007. Bilingualism as a protection against the onset of symptoms of dementia. Neuropsychologia, 45 (2), 459-464./li>
  21. Smyth, K.A. et al. 2004. Worker functions and traits associated with occupations and the development of AD. Neurology, 63 (3), 498-503.
  22. McGurn, B., Deary, I.J. & Starr, J.M. 2008. Childhood cognitive ability and risk of late-onset Alzheimer and vascular dementia. Neurology, first published on June 25, 2008 as doi: doi:10.1212/01.wnl.0000319692.20283.10 .

tags problems: 

tags strategies: 

Movement with Meaning

Barbara Larsen is the creator of a program called "Movement with Meaning", that aims to help Alzheimer's sufferers "hold onto" themselves for as long as possible. She's also written a book about the program: Movement With Meaning: A Multisensory Program for Individuals With Early-stage Alzheimer's Disease. And she's kindly written an article about the program just for us. Here it is.

Movement with Meaning: A Multisensory Program for Individuals in Early-Stage Alzheimer's Disease

Those of us in the field of dementia care are reexamining our philosophical beliefs and exploring practical, hands-on approaches in our relationships with individuals living with Alzheimer's disease. We are creating innovative programs and developing a new framework for preserving the emotional health, autonomy, and dignity of those who need us to walk hand in hand with them, witnessing the process of their experiences with empathy and respect.

Movement with Meaning is one such program. Designed for persons in the early stage of Alzheimer's disease, Movement with Meaning reinforces the remaining strengths and abilities of people with dementia by using a multisensory approach that stimulates all five senses. Practical and interactive by nature, the curriculum is ideal for physical therapists, recreational instructors, and activity directors in adult day centers and assisted living facilities, as well as health care professionals who are senior trainers, music or dance therapists.

As the mind begins to slowly unravel, the body becomes the refuge - the container - the ground - the point of reference. In a Movement with Meaning class, the multisensory activities are divided into five segments that create a choreography of movements in which short, repetitive exercises increase a sense of well being. The program introduces simple breathing techniques, poetry, music, movement exercises (bilateral integration exercises and yoga postures), and sensory activities. Once the person with Alzheimer's disease experiences a sense of his or her inner landscape, anxiety and confusion begin to subside. Movement with Meaning provides an opportunity for the participants to recognize the abilities and talents lying dormant behind the disease and find a new path to connect and communicate with each other and their families.

What an opportunity we have with the advent of early diagnosis. So why wait? Because the long-term memory is not affected in the early stage of Alzheimer's disease, these memories are preserved. I have found that repetition is an effective method for not only retrieving these memories, but as an essential tool in a Movement with Meaning class.

A study published in the American Journal of Alzheimer's Disease and other Dementias (Jan-Feb, 2004 issue) shed light on the effectiveness of repetitive work on maintaining functional levels in Alzheimer's disease patients. In the Adapted Work Program participants were given jobs that included packaging, shredding, folding laundry, stamping and sending our mailings. The program was closed due to budget cuts in funding. The participants were transferred to a traditional day care program which included activities such as bingo, ceramics, music, and current events. Before moving to the traditional day care setting the participants were assessed with the MMSE (Mini-Mental Status Exam), the Cognitive Performance Test, and the Geriatric Depression Scale. And then reassessed again in 4 months, after being at the traditional day care facility. The MMSE and the Cognitive Performance Test scores were lower than expected. All the spouses of the participants reported declines in Activities of Daily Living. The conclusion of the study stated that activities that involve repetitive, sequencing skills promote better self-care at home than traditional day care environments. As mentioned above Movement with Meaning is divided into five segments, with a thematic thread that reinforces the continuity of the program.

The first segment in a Movement with Meaning class is "Centering through Breathing." When an individual with Alzheimer's disease experiences disorientation, has difficulty remembering names, or finding the right word, this can be unsettling and cause anxiety. The antidote to help diminish anxiety is mindful breathing. Once the mind is calm and relaxed concentration will follow. In his book, "Your Memory: How it Works, and How to Improve it," K. Higbee documents that high anxiety interferes with attention and concentration. Therefore, it is imperative to establish an environment that promotes a peaceful inner state. When participants feel relax and calm the ability retrieve firmly rooted songs, prayer, and poems begin to surface.

The second segment in a Movement with Meaning class is "Learning by Heart." The participants memorize a short poem or song. Poems and songs that were learned early in life are stored in the long-term memory and remain accessible to the person with early-stage Alzheimer's disease. Repetition is the method for learning a new poem or song. The rhythm patterns and cadence in each poem or song creates an atmosphere that is safe and nonthreatening and brings something to the lives of the participants that is representative of what was there before the disease. Included in the second segment is the use of visualization techniques to expand on the imagines evoked by a poem or song. Visualization increases concentration because it creates focus on the more subtle "mental pictures" and "feelings" of a poem or song.

The third segment is a Movement with Meaning class (A Delicate Balance and Nice and Easy Yoga) including both bilateral integration exercises and yoga postures. Problems with balance and coordination begin to occur in early-stage Alzheimer's disease. Muscles love rhythmic movement. By satiating the body with repetitive bilateral exercises or yoga postures, participants are not only integrating both left and right hemisphere of the brain but are also increasing their spatial awareness, balance, and coordination. These exercises and postures are similar to Tai Chi in that they help the participant identify the body's midline - the median plan where the left and right sides of the brain and body cross or overlap.

In a study in the Winter 2003-2004 issue of Generations an article titled: "Balance Intervention to Prevent Falls," addresses the importance of exercises that include flexibility, balance, and sensory awareness. A multidimensional program is important for fall reduction. By aligning the body with the earth, a nonverbal statement is made: "I know where my body is in time and space." By incorporating a physical component in a Movement with Meaning class, the transition from the cadence of a poem or the melody of a song is experienced as part of a continuum, unfolding a choreography of movements with a theme and purpose.

The fourth segment is a Movement with Meaning class, "A Sense of Timing," which introduces music and rhythmic exercises to help the participants integrate and embody a poem or song. The rhythm patterns are synchronized with the cadence and melody of the poem or song. Rhythmic instruments such as chimes, drums, bells, and claves are nonverbal ways of communicating. The repetition of a beat or dance evolves an inner musical sense, and inner timing. Without thinking, the participants begin to tap their feet or sway their bodies from side to side. Studies in Germany reveal that when individuals with Alzheimer's disease participate in music therapy that include rhythm instruments sensory and motor integration are promoted.

The last segment is a Movement with Meaning class, "Reawakening the Senses," devoted to using the senses of smell, taste, and touch, with attention to color, shape, and texture. Exploring the senses allows individuals with Alzheimer's disease to gain access to their own unique internal landscape. We make sense of the world through our senses. The body is the primary receptor and container of experience. Appropriate sensory stimulation is a main avenue to awakening latent memories, as well as supporting existing functional abilities.

When the elements Movement with Meaning are put together in a daily program, attention is refocused back to the body of the person with Alzheimer's disease. For whatever was lost in the cognitive realm can be recalled through the senses. As one participant in a Movement with Meaning stated when asked what she thought about the program, "I have enough to hold on to."

I'll ask the same question again: So why wait? The time is now, in the early stage, to reinforce remaining strengths and abilities. The time is now, while the individual is aware of his or her personal biography, to investigate the sense of the individual's inner landscape is changing. The time is now to create an environment that strives to preserve the identity and dignity of each individual affected by Alzheimer's disease.

Barbara Larsen, M.A., Ed.
Creator & Author, Movement with Meaning
P. O. Box 2636
Nevada City, CA 95959
blarsen@nccn.net

tags problems: 

Subscribe to Alzheimers