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Can Caring for Older, Sick Relatives Lead to PTSD?

Each year, millions of older adults in countries such as the United States, Canada, and Australia, develop health problems requiring hospitalization or specialized medical care.   In most cases, it is the family members, including spouses and children, who face the responsibility of making health care decisions and acting as a liaison between medical professionals and their loved ones.   And this is a burden that will continue to grow as more and more older adults require some form of medical treatment.

Though the stress this responsibility places on caregivers has been long recognized, a new study published in the Journal of Internal Medicine has found evidence of significant mental health problems in caregivers, including depression and posttraumatic stress.   A team of researchers led by Alexia Torke of the Indiana Center for Aging Research examined 364 adults over the age of 65 and their surrogate decision-makers in Intensive Care Units (ICUs) at three major hospitals.  Among the patients, the average age was 81.9 years and 62 percent were female with 67 percent of decision makers were adult children with an average age of 58.3 years (70.9 percent were female).

During the course of the study, family members made at least one difficult medical decision during the hospital stay and after their loved one was released.   This could range from use of a ventilator, placement in a nursing home, or providing informed consent for surgeries or other invasive medical procedures.  All decision-makers completed a battery of tests measuring depression, anxiety, and post-traumatic stress at the start of the study and six weeks after the patient left the hospital.  They also completed surveys measuring their satisfaction with the quality of health care received as well as how responsive they felt hospital and support staff to be.

As you might expect, anxiety and depression levels remained high for decision-makers over the entire duration of the relative's hospital stay.   Six weeks following release however, only 22.6 percent reported lingering anxiety with 11.3 percent reporting moderate to severe anxiety.   When looking at depression, 29 percent reported depressive symptoms with 14 percent reporting moderate to severe depression.   As well, around 14.6 percent reported symptoms of posttraumatic stress disorder (PTSD).  This is consistent with previous research in family members of ICU patients and has even led to a new clinical term, post-intensive care syndrome—family, though the results of this study suggest that the psychological impact for decision makers can be high even with dealing with non-ICU patients.

Decision makers who reported receiving good emotional support from hospital workers were much less likely to have lingering anxiety and depression.   The link between emotional support and anxiety in decision-makers were especially strong.   Interestingly enough, decision makers who reported receiving good informational support (having hospital workers provide clear explanations of diagnosis and care) were more likely to develop PTSD symptoms, even when accounting for emotional support.    

Though Torke and her co-authors recognize that this study cannot be used to prove causation, these results do highlight how critically important proper emotional support for decision-makers can be.  It also highlights how vulnerable decision makers can be and the need for counseling to help prevent or reduce mental health problems that can arise afterward.   With the rising number of older adults who will be needing medical care in future, the need for supportive counseling will certainly rise as well.  

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Can Sleep Apnea Increase The Risk of Alzheimer's Disease?

A new research study suggests that elderly people dealing with obstructive sleep apnea (OSA) may have an increased risk of developing Alzheimer's disease (AD).    The study, which was recently published in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine, examined OSA due to previous research suggesting that it might accelerate cognitive decline in people at risk for AD.  According to lead researcher Ricardo S. Osorio, MD, assistant professor of psychiatry at New York University School of Medicine, proving a causal link has been difficult up to now since OSA and AD often share risk factors and commonly coexist.

The study examined 208 participants aged 55 to 90 using a series of clinical tests including sleep testing to monitor breathing while they slept.   None of the participants had been previously diagnosed with OSA or had other medical conditions that might have affected study results.   Results showed that more than half of the participants had some form of OSA with 16.8 percent having moderate to severe breathing problems at night. 

Of these, 104 participants then took part in a two-year study that included undergoing lumbar punctures to obtain cerebrospinal fluid (CSF) as well as PET scans to measure amyloid beta plaque deposits in the brain. Amyloid beta is a peptide that has been implicated in the development of cognitive problems linked to dementia.  Research findings showed a significant correlation between OSA severity and decreased amyloid beta peptides in the CSF over time as well as increased amyloid deposits in the brain.

Surprisingly enough however, OSA doesn't appear to predict cognitive deterioration in healthy adults.  According to study coauthor Andrew Varga of the Icahn School of Medicine at Mount Sinai in New York, the measures use may not pick up on the very subtle cognitive changes often found in the very early stages of AD.   As for cognitive changes that can be detected, there is no reliable way of telling them apart from the cognitive problems linked to lack of sleep.

Though much more research is needed, these results suggest that standard OSA treatments such as CPAP, dental appliances, and positional therapy may help delay dementia in older adults.  "Results from this study, and the growing literature suggesting that OSA, cognitive decline and AD are related, may mean that age tips the known consequences of OSA from sleepiness, cardiovascular, and metabolic dysfunction to brain impairment," Dr. Osorio said in a recent interview. "If this is the case, then the potential benefit of developing better screening tools to diagnose OSA in the elderly who are often asymptomatic is enormous."

Considering that AD and other forms of dementia already affect millions of people worldwide, a number that will certainly increase as Baby Boomers grow older, finding better ways of helping patients cope with memory loss can play a critical role in future health care.

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"Dementia Village" Project Underway in Alberta

With more than 50 million  sufferers worldwide, a number that is expected to double in the next twenty years, dementia has already become a major health problem and is expected to grow far worse in time.  While Alzheimer's Disease remains the most well known of these neurological conditions,  there are numerous other dementias and the risk rises significantly with age.  As baby boomers grow older, new dementia cases will likely strain health care systems to the breaking point by 2050.  

As part of an innovative new strategy for helping people with dementia, "dementia villages" have been established in the Netherlands.  Designed as functioning communities where patients with severe dementia can live full-time, patients can interact with "villagers" (who are actually trained geriatric care staff) and allows them to function as close to their normal life as possible.   Inspired by the success of the Hogewey community in the Netherlands, similar villages have been established in the United Kingdom, Japan, and Australia.  

Here in Canada, two new pilot projects are now underway in the province of Alberta, one in the Calgary foothills and the other in the town of Okotoks.   Funded by the Alberta government, both projects involve training staff at recreation centres, grocery stores, and other businesses how to deal with people with dementia.   "Dementia is everybody's business," said program coordinator Emma Richardson in an interview with CBC News.  "Everybody will know somebody that has dementia, even in the wider community. So it's making sure that there's inclusion for everybody."

With more than 40,000 Albertans who have been diagnosed with dementia, many businesses have volunteered to participate in the project to provide better service for customers in need.   As part of the training they receive, staff members are taught to  recognize people with dementia and to use the following steps to put them at ease:

• Make eye contact, smile warmly.
• Use a gentle touch to get attention.
• Keep information short and to the point.
• Use gestures or pictures, if helpful.
• Say important things twice to help the person stay focused.
• Be patient, give the person extra time to answer.
• Give the person choices, like "Do you want a sandwich or soup," instead of asking open-ended questions like "What do you want for lunch?"

By providing clear guidance to customers who are confused due to dementia, Emma Richardson hopes that problems with miscommunication can be avoided.  "If they go to the bank, or if they go to the dentist, they go to any of these services, if the person that's helping them doesn't understand why they're behaving in a certain way, they can treat them with not so much respect and not give them the time that is needed. So having an education really creates that awareness."

Though the dementia villages projects have only just started, early signs suggest that people dealing with dementia, along with their families, are already experiencing the benefits.   As the number of new  cases continues to increase, they will need all the help they can get.

 

Can "Brain Training" Help Dementia Patients?

While previous research suggests that cognitive training can help older adults stay mentally active and delay potential memory decline, there is still considerable controversy relating to the many "brain training" apps that have been released in recent years.   Even though some experts have openly endorsed many of these programs, others argue that they are a waste of money.  But a new research study published in the International Journal of Neuropsychopharmacology has shown that a specializing brain training app can help improve memory for people in the very early stages of dementia.   George Savulich and Barbara Sahakian of the University of Cambridge helped developed the app which they tested on patients dealing with amnestic mild cognitive impairment (aMCI), an early form of memory impairment which can lead to more serious dementia.  The iPad app, titled "Game Show",  allows patients to assume the role of game show players who go through a series of rounds during which they can win gold coins.  Each round involves associating geometric patterns with different locations and players can continue until either finishing the game or making six errors in a row.  The app is designed to become progressively harder depending on the skill level of the player.   There is also an animated game show host to keep players motivated and to encourage them to keep trying to improve their last performance.

Research results show that patients who play the game for a total of eight one-hour sessions over a four-week period improve their overall memory functioning and are able to retain more complex visual information than patients in the control group who received conventional treatment.  They also improved their memory scores by as much as 40 percent.   Participants in the study report that they enjoy playing the game and are motivated to continue playing as a result.  

"Good brain health is as important as good physical health. There's increasing evidence that brain training can be beneficial for boosting cognition and brain health, but it needs to be based on sound research and developed with patients," says Professor Barbara Sahakian, co-inventor of the game: "It also need to be enjoyable enough to motivate users to keep to their programmes. Our game allowed us to individualise a patient's cognitive training programme and make it fun and enjoyable for them to use."

Given their success to date, the researchers hope to extend their study to include patients with mild Alzheimer's disease as well as learn more about how the app can help with normal aging.    

New Program Helps Patients Learn to Laugh at Death

"When both my kidneys failed, my wife donated her kidney.   After 35 years, she finally gives me a gift."  

In the YouTube video where the pleasant-faced older man makes this quip, we see the audience bursting into laughter.   Which is appropriate enough since he is on stage doing a very unique form of stand up comedy.  He is just one of the terminally ill patients participating in a new campaign organized by the Indian Association of Palliative Care (IAPC).   Intended as a national forum to help individuals receiving palliative care and provide more effective help for terminally ill patients and their families, IAPC is now working with Medulla Communications to run its #LastWords campaign.   In this campaign, patients are given a chance to "laugh at death" with standup comedy routines.   The patients in the videos were selected from the hundreds of terminally patients in the IAPC network and then trained by professional stand up comedians.  

The end product is a series  of two minute videos, all available on YouTube on the #LaughatDeath channel, featuring  patients giving performances that are memorable in every sense of the word.  The jokes range from the personal to the political including one by kidney patient Narendra Mhatre who quips, "Americans wish their new president would be like me. So he doesn't last long”.    Sixty-five-year-old Janice Powell says, “This is the first time I am doing this type of a show. Who knows, maybe it's the last time.”

Along with giving patients a chance to entertain family members and their doctors, providing stand up comedy also allows terminally patients to conquer their fear of death.   And it's proving to be wildly popular.  After the IAPC channel went online on YouTube on March 29 of this year, the first video drew more than 387,000 views in a single day and four others are now available.  The hashtag #LaughAtDeath has trended in India and may well do the same internationally as users continue to share the videos.

In an interview with Campaign India, Praful Akali, founder and managing director of Medulla Communications is overwhelmingly positive about these videos  "This is not just a campaign but an ongoing project and platform for terminally ill patients to share their stories and spread awareness on palliative care,"  he said.   While the bittersweet message being conveyed in the videos can be hard to take for many people, the tears, and the laughter, help demonstrate the critical importance of palliative care worldwide. 

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Can Hearing and Communication Problems Predict Dementia?

A new study published in the Journal of Neuroscience suggests that problems interpreting speech sounds may be a diagnostic marker for early dementia.  The study, which was conducted by researchers at Toronto's Baycrest Centre for Geriatric Care and the University of Memphis, used EEG measurement in older adults to show that abnormal functioning in regions of the brain that process speech predicted mild cognitive impairment (MCI) with over 80 percent accuracy.   Since MCI can be an early sign of developing dementia, testing for early communication problems may allow for doctors to diagnose potential dementia much earlier than is currently possible.  

While brain regions such as the brainstem and auditory cortex are not usually considered to be strongly affected by Alzheimer's disease and other dementias, the new study shows that the brainstems of vulnerable older adults show abnormally large activity within seven to ten milliseconds after speech sound first hit the ear.  This was tested by measuring brain activity while research subjects were watching a video as well as identifying vowel sounds.   Statistical analysis was then used to determine how changes to the brain can predict MCI.  

“When we hear a sound, the normal aging brain keeps the sound in check during processing, but those with MCI have lost this inhibition and it was as if the flood gates were open since their neural response to the same sounds were over-exaggerated,” says Dr. Gavin Bidelman, first author on the study, a former RRI post-doctoral fellow and assistant professor at the University of Memphis. “This functional biomarker could help identify people who should be monitored more closely for their risk of developing dementia.”

“This opens a new door in identifying biological markers for dementia since we might consider using the brain’s processing of speech sounds as a new way to detect the disease earlier,” says Dr. Claude Alain, the study’s senior author and senior scientist at Baycrest’s Rotman Research Institute (RRI) and professor at the University of Toronto’s psychology department.  “Losing the ability to communicate is devastating and this finding could lead to the development of targeted treatments or interventions to maintain this capability and slow progression of the disease.”

Even for adults who score below the normal cutoff score for dementia screening tests, potential communication problems can alert doctors that certain patients need to be monitored more frequently.  Researchers also hope to develop a portable test that can measure different senses quickly and inexpensively.  “MCI is known to cause changes in different senses, such as vision or touch,” says Dr. Alain. “If we could incorporate these changes into a wireless EEG test, we could combine all this information and develop a better biomarker. One day, doctors could administer a short, 10-minute assessment and instantly provide results.”

More research is still needed measuring communication problems in patients with dementia or who convert early from MCI to full-blown dementia. An early test for dementia risk can be especially valuable giving the rising number of Baby Boomers who are entering into their senior years.

 

Are Dementia Cases Declining?

Despite fears of a looming dementia epidemic as baby boomers enter their retirement years, new research suggests that new dementia cases may have actually declined in recent years.    A study recently published in the Journal of the American Medical Association reflected this recent trend by comparing dementia rates between 2000 and 2012 and finding a net drop in new cases.   The study was carried out by a research team led by researcher Kenneth Larga of the University of Michigan Medical School using data taken from a nationwide study of 21000 U.S. adults 65 or older.  According to their findings, overall prevalence of dementia dropped from 11.6 percent in 2000 to 8.8 percent in 2012.    

This declining dementia rate occurred despite a significant rise in cardiovascular problems such as hypertension, diabetes, and obesity, factors that have been traditionally associated with increased risk of Alzheimer's disease and related conditions.   On the other hand, level of education may be acting as a protective factor since average years of education appear to have increased during that same period from 11.8 years of education in 2000 to 12.7 years in 2012.   No other factors have emerged at this point to explain why this drop in dementia cases may be occurring.  

At this point, it is still unclear exactly why dementia appears to be on the decline and whether this trend will continue over time.   Though better preventive health care and increased awareness of health risks may  be having an impact in preventing or delaying new cases of dementia, other health risks, including diabetes and obesity, are still on the increase and may well offset whatever gains are being made in dementia care.   Certainly the fears that have been previously raised of health care systems worldwide being overwhelmed may still come to pass as these new health risks manifest themselves in new cardiovascular cases.

For now, all we can do is watch how things unfold in the years to come.   Will there still be a dementia pandemic or not?

A Window on the World

For many seniors, especially for those who are confined to nursing homes,staying mentally and physically active often depends on the emotional support they receive from friends and family.   Certainly research has demonstrated the that older adults with strong social networks often enjoy greater life expectancy, overall good health, and better cognitive functioning than seniors who are socially isolated.   If anything, this is a trend that seems to have grown even worse in an era of online digital communication that many older people feeling left behind.    

While a recent Swiss survey shows that Internet use in adults aged 65 years or older has risen 47 percent from 2009 to 2014, 44 percent of older adults still don't have Internet access, whether due to the expense involved or difficulty learning to use the different technologies involved.   The problem is even worse for seniors with visual or cognitive impairments that prevent them from going online without assistance from helpful family members or nursing staff.

But a new innovation developed by a team of researchers led by Francesco Carrino of the University of Applied Sciences and Arts Western Switzerland may provide the answer.    In  a recent research note published in the journal GeroPsych describes this system and recent case studies showing how well it works.   Known as the Tangible Interactive Window (or, simply The Window for short), older adults are able to establish permanent contact with distant relatives without many of the technical difficulties they would usually face.   With the Window,  all of the technology required to go online is kept hidden by making it resemble an actual window.   Users can even activate the system using special controls that resemble the kind of hand crank or glass pane found in a real window.  

 

To read more, check out my new Psychology Today blog post.

 

 

 

Understanding Elder Abuse

It was originally called "granny bashing" when the first stories about elder abuse came out in the 1970s. 

Since then, elder abuse has been identified as a serious social problem that is far more prevalent than most of us care to admit.  According to the 2009 National Elder Mistreatment Survey, at least ten percent of elderly people living in American communities (4.3 million people)  experience one or more forms of elder abuse each year.    This can involve financial abuse by a family member (5.2 percent), financial abuse by a stranger (6.5 percent), emotional abuse (4.5 percent). or potential neglect by a caregiver (5.1 percent).  More rarely, elder abuse can take the form of physical abuse (1.6 percent) and sexual abuse (0.6 percent) though these last two categories, along with emotional abuse, often go unreported by seniors.

Among the various reasons many elders have for not reporting what is happening to them are feelings of embarrassment, believing that they are somehow responsible for their abuse, fear of retaliation,  fear of being placed in a nursing home, not believing that help is available for them, or simply accepting that long-term abuse is "the way it's always been" and just putting up with it.   Even when people in the community, whether strangers or family members, become aware that the abuse is happening, they may often refuse to get involved believing there is nobody available to help.   

To read more, check out my new Psychology Today blog post.

 

Education and the Aging Brain

Anyone who stops learning is old, whether at twenty or eighty.  Anyone who keeps learning stays young.  Henry Ford 

How important is lifelong learning for older adults?

Along with severe neurocognitive conditions such as Alzheimer's disease and other forms of dementia, people over the age of sixty or seventy increasingly tend to experience what they describe as "senior moments."  These are memory lapses that are commonly regarded as a sign of old age and an inevitable part of the aging process.  While most of these lapses tend to be relatively minor and rarely lead to anything more serious, the fear of dementia is something that everyone faces sooner or later, whether in themselves or their aging parents. 

Researchers have long been exploring different medical options to help older adults cope with aging but staying active remains the best way to preserve health for as long as possible.  Along with physical exercise however, it is also important to encourage older adults to be mentally active as well. This ties into what researchers refer to as cognitive reserve (CR), or the ability of the mind to resist damage.   Whether the damage occurs due to normal aging, physical trauma, or emotional trauma, how well we are able to function often depends on how efficiently we are able to compensate for lost brain functioning.   

One of the first research studies to identify the importance of cognitive reserve was published in the Annals of Neurology in 1988.  By studying the brains of 137 elderly persons diagnosed with Alzheimer's disease, researchers found a large discrepancy between the amount of brain pathology present compared to the actual dementia symptoms the seniors displayed at the time of death.  The researchers concluded that dementia patients with a higher cognitive reserve were able to avoid many of the more severe aspects of their disease for as long as possible.  In other words, their brains were more resilient allowing them to cope with the loss of neurons that comes with advancing dementia.

To read more, check out my new Psychology Today blog post.