Providentia

How Does Stress Affect Cognition in Older vs. Younger Adults?

Does acute stress differentially alter cognitive functioning in older versus younger adults? While older adults may be better at handling stress psychologically, their physiological systems are less elastic, potentially impairing the cognitive functioning of older adults after a stressor. In a study published in the journal Psychology and Aging, researchers examined cognition following an acute stressor among older (n = 65; ages 60–79) and younger (n = 61; ages 25–40) adults. Participants were randomized to complete the Trier Social Stress Test (TSST) in one of three conditions: (a) negative feedback, (b) positive feedback, or (c) no feedback. Participants reported mood states and appraisals of the speech task and we measured cortisol via saliva throughout the study. After the TSST, participants completed standard cognitive tasks to evaluate cognitive flexibility, problem solving, and short-term memory. Results showed that after the TSST, older adults took longer to solve problems compared with younger adults, though they were able to solve the same number of problems. Older adults showed less cognitive flexibility compared with younger adults in all conditions, a finding that was partially exaggerated in the positive feedback condition. There were no age-group differences in short-term memory; however, for older adults greater perceived resources and positive affect were associated with better memory performance. In sum, older and younger adults were both affected by acute stress, and older adults were not more (or less) vulnerable to the effects of stress on cognition, though they did show stronger associations between self-reported affective states and memory performance. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

For the abstract

Can a Ketogenic Diet Help Prevent Dementia?

Dementia (major neurocognitive disorder) is an increasingly common syndrome with a significant burden on patients, caregivers, the health-care system, and the society. The prevalence of dementia will certainly continue to grow as the US population ages. Current treatments for dementia, though, are limited. A new review article published in  the Journal of Geriatric Psychiatry and Neurology discusses the possible benefit of a ketogenic diet for the for the delay or prevention of dementia . The ketogenic diet was originally employed to treat refractory epilepsy and has shown promise in many neurologic diseases. It has also gained recent popularity for its weight loss effects. Several preclinical studies have confirmed a benefit of ketosis on cognition and systemic inflammation. Given the renewed emphasis on neuroinflammation as a pathogenic contributor to cognitive decline, and the decreased systemic inflammation observed with the ketogenic diet, it is plausible that this diet may delay, ameliorate, or prevent progression of cognitive decline. Several small human studies have shown benefit on cognition in dementia with a ketogenic diet intervention. Future, large controlled studies are needed to confirm this benefit; however, the ketogenic diet has shown promise in regard to delay or mitigation of symptoms of cognitive decline. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

For the abstract

Using the Montessori Method For Dementia Care

Can an educational approach developed in the early 20th century for training disabled children be used to help dementia patients stay active?  

Maria Montessori's revolutionary teaching method differs from classical education models by encouraging independent learning and self-discovery in a safe space with a wide range of ways of stimulating children to learn.   Now used in an estimated 7,000 pre-schools, primary schools, and high schools worldwide, the Montessori method has been highly popular in teaching children from birth to the age of eighteen.

But could it also work for people with dementia?   Certainly, the number of elderly patients suffering from Alzheimer's Disease and other dementias continues to rise, providing specialized care has already strained existing geriatric programs worldwide to the limits.   As a result, family members are often left to deal with the financial and emotional burden with few alternatives.   With the number of dementia patients  expected to triple by 2050, developing more innovative ways of helping patients stay mentally active longer has become a critical health issue.  

Inspired by Maria Montessori's teaching methods, noted psychologist Cameron Camp developed the first  Montessori program for dementia patients in the late 1990s.   A past-president of the Adult Development and Aging Division of the American Psychological Association and a fellow of the American Gerontological Society, Dr. Camp currently serves as the Director of Research for the Center for Applied Research in Dementia.   Through research funded by the National Institute of Health and the National Institute of Mental Health, as well as the National Alzheimer's Association,  he has demonstrated the effectiveness of Montessori methods in helping dementia patients retain their dignity and independence.  

In the author's preface of his book, Hiding the Stranger in the Mirror, Dr. Camp wrote about the common humanity in dementia patients and their caregivers.  "We are not helpless in the face of Alzheimer’s disease and associated illnesses. We can best care for ourselves and our loved ones with dementia by embracing the humanity that exists, and has always existed, within each other." he says.    Through lecturing and training workshops, Dr. Camp has helped launch Montessori programs for dementia sufferers in Asia, Australia, Europe, and much of North America. 

Building on the principles he established, Gail Elliot has become one of the leading authorities on Montessori programs to help the elderly.   A former Assistant Director at McMaster University's Gilbrea Centre for Studies in Aging, she is now the Founder and CEO of DementiAbility Enterprises Inc. which provides training and certification  in Montessori methods for dementia.   In one interview with the Globe and Mail, Elliot stressed the importance of finding clues to help dementia patients slow their decline.  "Find the story and see the person: Who is that person today and how can we bring that person out?” she said. “Memories aren’t all gone. Let’s find out what still exists and capitalize on it and enhance the quality of life."  

While it is important not to regard dementia patients as infants despite using methods traditionally associated with preschoolers, there are still parallels.   “It’s so basic,” Elliot says. “When you’re doing something with your child, you’re thinking what are the needs of this child? What does he like to do, what is he able to do? You don’t challenge him to do too much because he’ll be frustrated and gives up. But you make it a little harder than what he can do so he can improve.”

In most programs using the Montessori methods, dementia patients are encouraged to engage in familiar tasks along with various brain-boosting games and discussion groups.  The point of the program is to provide a safe environment to provide mental and physical stimulation and help patients stay active.  Familiar tasks can be anything that the people attending the program once enjoyed and for which they retain the cognitive and manual skills to carry out.   Whether it be baking bread or working on a computer, doing these tasks helps keeps people in the program focused.   The program workspace also contains a large calendar to remind participant of the right date, self-serve refreshments tables (with everything, including the sugar bowls, being well-marked),  carefully labelled bathrooms, and cupboards for extra supplies.   Also important is the need to camouflage exits to prevent participants from wandering off - always a concern with dementia patients, despite careful monitoring. 

When not working on their tasks, program participants can also work on puzzles, games, and sorting tasks.  As a contrast to regular daycare activities, Montesssori programs for dementia patients allow for work on prepared tasks such as folding towels, matching socks, or sorting familiar objects.    For the very low-functioning dementia patients, there is a connected room filled with baby dolls and clothes which participants can play with as they choose.   By keeping their minds occupied with meaningful activities, dementia patients can spend their day without engaging in many of the disruptive activities that can cause stress in caregivers, including grabbing at other people, asking the same question repeatedly or pleading for attention. 

According to the recent Globe and Mail story on a Toronto-based Montessori program for dementia patients, family members of dementia patients in the program report extremely positive results.   One woman described her mother, who had been attending the program for four months, as being much more engaged and active despite having been in a decline prior to entering the program.    Since the program allows patients to focus on their strengths rather than their weaknesses, they can stay active and preserve their remaining skills as long as possible.  

Though more research is definitely needed concerning the long term benefits of  Montessori programs for  dementia patients,  the testimony of family members  already shows it to be a valuable addition to the arsenal of treatment services already available for dementia care.   As the demand for dementia care programming continues to rise, we will likely be seeing many more Montessori programs in the near future.

How Does COVID-19 Affect Dementia Patients?

The number of positive and death cases from coronavirus disease 2019 (COVID-19) is still increasing until now. One of the most prone individuals, even in normal situations is patients with dementia. Currently, no study provides clear evidence regarding the link between dementia and COVID-19. A new study published in the Archives of Gerontology and Geriatrics analyzes the relationship between dementia and poor outcomes of COVID-19 infection. The authors  systematically searched the PubMed and Europe PMC database using specific keywords related  to COVID-19 and dementia. The quality of the study was assessed using the Newcastle Ottawa Scale (NOS) tool for observational studies. Statistical analysis was done using Review Manager 5.4 software. A total of 24 studies with 46,391 dementia patients were included in the subsequent meta-analysis. which showed that dementia was associated with composite poor outcome [RR 2.67 (95% CI 2.06—3.47), p< 0.00001, I² = 99%, random-effect modeling] and its subgroup which comprised of risk of COVID-19 infection [RR 2.76 (95% CI 1.43—5.33), p = 0.003, I² = 99%, random-effect modeling], severe COVID-19 [RR 2.63 (95% CI 1.41—4.90), p = 0.002, I² = 89%, random-effect modeling], and mortality from COVID-19 infection [RR 2.62 (95% CI 2.04—3.36), p< 0.00001, I² = 96%, random-effect modeling]. The authors concluded that extra care and close monitoring should then be provided to patients with dementia to minimize the risk of infections, preventing the development of severe and mortality outcomes. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

For the abstract

Why Are Dementia Patients Filling Psychiatric Beds?

"Sometimes it's very difficult for a person with dementia to get their thoughts across, then they get agitated and upset," said Dr. George Heckman, associate professor at the University of Waterloo and Schlegel Research Chair in Geriatric Medicine in a recent interview. "They have behaviours that are very difficult, sometimes, to manage, and when that happens you need a lot of specialized work to be done. Unfortunately we just do not have the resources."  

In what Ontario mental health experts are describing as a worsening trend, dementia patients are being increasingly assigned to hospital beds reserved for psychiatric patients.    According to the latest data from the Canadian Institute of Health Information,  a third of all psychiatric beds in Ontario hospitals are  being filled by dementia patients, largely due to a shortage in regular hospital beds and long-term health care facilities.    Unfortunately, psychiatric treatment staff often lack the necessary training to diagnose dementia properly, let alone providing the necessary treatment.   This means that dementia patients may end up receiving treatment that does more harm than good, including the overuse of psychiatric medications that may worsen their symptoms. 

Since anti-psychotic drugs and major tranquilizers are frequently used as "chemical restraints" for agitated patients, being forced to take these medications can lead to adverse side effects as well as potentially dangerous drug interactions with other medications they are taking.  Also,  many dementia patients have additional medical problems such as coronary disease and hypertension which psychiatrists and mental health nurses may not be properly trained to treat.  "I've never seen a person come back from a psychiatric admission with dementia who didn't have at least one other major psychotropic drug added or increased," said Dr. Allen Power of the University of Waterloo Research Institute for Aging . 

 Over the past ten years, psychiatric admissions for dementia patients has more than doubled  in Ontario hospital as dementia becomes more prevalent in seniors.   The current COVID-19 pandemic is expected to make the problem far worse due to the reduced number of beds available as well as the increased care needed by residents in long-term care facilities.   Also, due to current pandemic control guidelines,  care facilities are no longer allowed to house patients in close proximity to one another.  That means that residents can no longer be placed in open wards but only in dedicated rooms that can only accommodate one or two residents at a time.  Even before the pandemic began, the average time patients needed to wait for a spot in a long-term care home can be as long as a year or more.   While the average wait time across the province is around ninety days according to Health Quality Ontario ,  this will certainly soar since the number of dementia patients is expected to double by 2038.

Tying up psychiatric beds with dementia patients also means fewer beds being available for people experiencing mental health crises or who are actively suicidal.   And having been in a psychiatric hospital may actually reduce the likelihood of getting a long-term care bed for many patients.   Though there are hospitals such as Ontario Shores in Whitby, Ont., and Baycrest Centre in Toronto, that have created units to  house such patients, these units lack the capacity to meet the current demand, not to mention the increased demand will will be seeing in future.  

For now, the lack of beds across Ontario, especially in smaller communities means that the problem will become far worse as hospitals and the provincial government continues to wrestle with this dilemma.

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Neuropsychological differentiation of early-onset and late-onset Alzheimer's disease in autopsy confirmed cases.

Early-onset Alzheimer's disease (EOAD) is thought to be associated with greater clinical heterogeneity than late-onset Alzheimer's disease (LOAD), with up to one third of patients displaying an atypical, nonamnestic cognitive profile. While this heterogeneity has been recognized in the existing literature, past studies have been plagued by small sample sizes and potentially inaccurate clinical diagnoses.  A recent dissertation study sought to characterize cognitive differences between patients with EOAD and those with LOAD in a large autopsy-confirmed sample. Participants included 1,567 individuals with autopsy-confirmed Alzheimer's disease (AD) pathology who completed a battery of neuropsychological tests during their initial presentation to a memory clinic. Participants were divided into two groups for primary analyses: the EOAD group included patients aged 65 and younger; the LOAD group included patients over the age of 65. Secondary analyses investigated the role of apolipoprotein E (APOE) genotype on retentive memory abilities in patients with EOAD. For this analysis, participants with EOAD were divided into two groups based on APOE genotype: one group was composed of those with one or two ε4 alleles; the other group included those with no ε4 alleles. Results indicate significant differences in overall neuropsychological profile between EOAD and LOAD, F(10, 1554) = 34.938, p < .0005, Wilks's Λ = .816, partial η2 = .184. Follow-up logistic regression identified two measures of attention (Digit Span Forward, Digit Span Backward), two measures of processing speed (Trail Making Test Part A, WAIS Coding), and two measures of language (Vegetables, Boston Naming Test) as significant predictors of group membership. Secondary analyses examining differences in retentive memory performance between ε4 carriers and noncarriers within the EOAD group were notable for significantly better memory performance in ε4 noncarriers, t(229) = 2.291, p = .023, Cohen's d = 0.30. These findings are consistent with past literature that describes a unique neurocognitive profile in EOAD. Further, these findings suggest that some of the heterogeneity in EOAD may be related to APOE genotype. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

For the abstract

 

Are Dementia Rates Actually Declining?

With an estimated 47 million people l worldwide living with dementia and a rapid aging of the population in most places, researchers and health agencies have long been warning of a "gray plague" with new dementia cases tripling over the next three decades.   Along with a tripling of the socioeconomic costs of caring for these additional dementia patients, health care systems worldwide are expected to be increasingly overwhelmed as dementia care competes with the other health care needs in an aging population.   

But a new study published in the journal Neurology suggests that this projected burden of dementia care may not be as dire as previously studies have reported.   The study presents the results of a comprehensive research project, the Alzheimer Cohorts Consortium  (ACC).  combining nine cohort studies conduct across the United States and Europe examining thousands of individuals over the age of 65 between 1988 and 2015.   The countries included in the combined study were the United States, France, the Netherlands, Sweden, the United Kingdom, and Iceland.  With over 49,202 participants (59 pecent female), the ACC combined demographic and medical data including type of dementia diagnosis.  Overall, 4,253 of the study participants had developed some form of dementia by 2015 with the incidence of dementia steadily increasing with age.  

Contrary to expectation though, the researchers found a 13 percent decrease in all-cause dementia per decade since 1998.  A similar decrease turned up for cases of Alzheimer's disease alone with men showing a much higher decrease than women (24 percent vs 8 percent).   Based on these results, and assuming that this trend continues in Europe and North America over the next few decades, then 15 million fewer people may develop dementia by 2040 in high-income countries alone.  If the this same trend could be achieved worldwide, there could be 60 million fewer new cases of dementia by 2040.   

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

Fact or artefact? Childhood adversity and adulthood trauma in the U.S. population-based Health and Retirement Study.

Despite the well-known deleterious health effects of childhood adversity (CA) and adulthood trauma (AT) and ageing of the global population, little is known about self-reported CA and AT in older populations. Existing findings are mixed due to methodological and sampling artefacts, in particular, recall and selection biases, and due to age-period-cohort effects.  In a new study published in the European Journal of Psychotraumatology, researchers provide data on the prevalence of retrospective self-reported CA and AT in a large population-based sample of older adults and discuss the data in the context of major methodological and sampling artefacts, and age-period-cohort effects.  Data are derived from the U.S. population-based Health and Retirement Study (N = 19,547, mean age = 67.24 ± 11.33, 59% female). Seven birth-cohorts were included (< 1924, 1924–1930, 1931–1941, 1942–1947, 1948–1953, 1954–1959, >1959). Results: showed that 35% of participants reported CA and 62 *% AT, with strong variability among birth-cohorts. Opposing trends were observed regarding prevalence of CA and AT. As age of cohorts increased, prevalence of CAs decreased while that of ATs increased. Investigating the distributions of incidence of specific ATs across age and period per cohort revealed incidence of exposure was associated with (1) age (e.g. having lost a child), (2) time-period (e.g. major disaster), and (3) cohort (e.g. military combat).  In conclusion, retrospective self-reported CA and AT in older samples should be interpreted with caution and with regard to major methodological challenges, including recall and selection biases. Untangling fact from artefact and examining age, period, and cohort effects will help elucidate profiles of lifetime exposures in older populations.

For the abstract (Open access)

Prisons Warn of "Silver Tsunami" of Prisoners with Dementia in Coming Years

Much like the rest of society, there are more elderly prisoners behind bars than ever before.  And it's a trend that will only worsen in the future.

According to the U.S. Census Bureau, the number of people over the age of 55 will likely double over the next ten years.  That will mean more than 400,000 older prisoners accounting for almost one in every three incarcerated people, many of whom will have serious health problems that can only become worse given prison conditions.   Due to the "tough on crime" policies of the past three decades, including "three-strikes" laws and mandatory sentencing, the United States currently houses 22 percent of the world's prisoners (despite accounting for only 4.4 percent of the world's total population).   The costs of operating federal and state prisons, jails, and parole/probation offices currently costs about $72 billion dollars a year and, as the costs of caring for elderly prisoners also continue to rise, likely far more in future.  

Along with all the other age-related medical problems that cost the Federal Bureau of Prisons an estimated $881 million dollars, the rising number of elderly prisoners suffering from dementia has become the focus of a legal and ethical battle that seems unlikely to end.    In 2019, the first Federal unit dedicated to caring for prisoners with dementia opened with trained staff, including nurses, to provide specialized care as needed.  Still, with the number of prisoners with dementia expected to rise as high as 211,000 by the end of the decade, prisons will need to do far more to provide the round-the-clock care many of them will need.

One of the legal concerns in keeping prisoners with dementia behind bars is the Eight Amendment of the U.S. Constitution banning cruel and unusual punishment.  Which means that prisons may not be able to justify holding prisoners who are no longer able to understand why they have been incarcerated and who are unable to cope with daily life inside.   A February 2019 case has already determined hat it is unconstitutional to execute someone who cannot rationally understand their death sentence because it serves has no retributive purpose.   That particular case centered around a prisoner who developed severe dementia after a series of strokes but more legal challenges are expected concerning the legality of indefinitely detaining prisoners with dementia.   

Prisoners with dementia are also at increased risk of being victimized by other prisoners, many of whom will them as easy targets who are vulnerable to bullying and intimidation.    Along with the frequent threat of violence, affected prisoners will also be unable to understand why they are in prison at all and why they are unable to get visits from family members and friends.  All of which may lead to their acting out in ways that will subject them to solitary confinement and other punishments that will make their dementia symptoms much worse.  

When I was working in the prison system as a psychologist, I dealt with numerous elderly inmates who showed many of the classic signs of dementia though they were never formally diagnosed due to their incarceration.  For the most part, they were frail, confused old men who needed to be kept in solitary confinement for their own protection given how vulnerable they were to being attacked or bullied by other inmates taking advantage of their mental confusion.   That this problem remains unresolved twenty years later, and will likely become far worse in prisons across the United States and Canada in the years to come, represents a critical challenge that needs to be addressed.    The alternative seems far too gruesome to contemplate.

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Does Bilingualism Slow Cognitive Aging?

Research has suggested that using two or more languages on a daily basis helps older adults maintain a heightened functional state and improves neurocomputational efficiency. In a new review published in the Journal of Neurolinguistics, researchers discuss studies that have examined the effect of life-long bilingualism on age-related cognitive and neural decline, with a focus on discrepancies between different sources of evidence. The review outlines and characterizes factors which might explain inconsistencies between studies claiming that bilingualism has neurocognitive benefits and those that failed to find such evidence. The authors argue that individual variation in language proficiency and exposure, especially language switching frequency and daily frequency of use of the two languages, likely account for a significant chunk of the inconsistencies found in the literature and constrain the effectiveness of bilingualism as a cognitive and brain reserve factor. Finally, the reviews discusses studies of cognitive intervention and speculate on the potential of developing language training protocols to increase cognitive and neural resilience in older adults.

For the abstract