Power-Up: Stress Brain Drain

This week, I’m following up on Sonia Lupien, the Montreal researcher chronicled by Christa in her 9/8/08 post. Christa sent me a fascinating study published in Psychoneuroendocrinology (2005: 30; 225-242).

Using cortisol levels as a biomarker for stress, Dr. Lupien found that some adults run chronically higher levels of cortisol than others. Over several years, this group had more memory loss and 14% shrinkage of the hippocampus, (a major brain memory center), compared with those with low or moderate levels.

This appears to support Christa’s theory that stressful environments (read “institutional care”) may actually accelerate memory loss over time.

But there’s an even bigger story…

Dr. Lupien looked at children and adolescents and found different cortisol patterns in those with a lower socioeconomic status (SES). Children with low SES and higher cortisol levels also appeared to process thoughts more negatively, which could also lead to more depression. Stressful living environments clearly seem to influence how children view the world.

But what about their cognition? It is well recognized that people with fewer years of education have a higher incidence of Alzheimer’s disease. Decreased “brain reserve” is theorized, but I never quite accepted this, because many people with high IQs do not pursue advanced degrees.

However, most people of low SES have fewer options for advanced education. Maybe the real cause of increased dementia in the less-educated group is poverty, and the day-to-day stress this group encounters. With a widening gulf between haves and have-nots in the world, what will happen as this population ages down the road?

Two weeks ago, I gave the U.S. low marks in the fundamentals of health, education and welfare. I thought I was digressing into politics, but maybe I was talking about dementia all along!

--Al Power

Outrage of the Week

This from the BBC website on 9/19 :
British "ethicist" Baroness Mary Warnock was quoted in Scotland magazine as saying
that people with dementia should be able to voluntarily end their lives if they feel
they are "a burden to others or to the National Health Service".

Her comments, framed as empowering people to make advanced directives in the event
of worsening disease, instead expressed the view that people with dementia are
hopeless, wasting resources and burdening their loved ones.

What a far cry from the kind of life and growth many of us are giving to people with
all forms of dementia every day of the week! What a sad commentary that an ethicist
would feel that people with this disease should be judged more harshly than those
with any other medical illness!

--Al Power

The Zen of Dementia

This just in from one of my favorite new blogs...

posted by pjwh

Dementia changes people and changes relationships, sometimes for the better. In the latest edition of Newsweek (September 22, 2008), author Sara Davidson shares her story about her relationship with her mother who became less demanding and more accepting of life as her cognitive impairment progressed, much to the surprise of the family. This is not the first time we’ve heard the story of a relationship improving with progressive cognitive impairment.

My friend Robert Green is quoted representing the standard view that experts are only interested in negative behaviors. Yet carers such as Ann Davidson, Elinor Fuchs and Judith Levine who have written books (and are in our book) about their experiences know that relationships change in complex ways, some very much for the good.

In Sarah’s piece I am described as a practicing Buddhist who wants the world’s religions to attend more to the challenges of dementia. Just as they provide perspectives on life and death so too they should attend to the challenges of cognitive aging.

I consider myself an amateur (note the root of that word is “love”) Buddhist, not a regular practitioner. I have studied and practiced meditative approaches, for example in Japan and at Naropa University in Colorado – a wonderful place where the spirit of learning is very much alive). Buddhism is both a science of mind and a spiritual practice that recognizes that false expectations and personal desires are at the root of suffering.

As quoted in Newsweek and from my own conversations with him, Oliver Sacks, too, believes that interesting parallels can be drawn between “being present” and emptying the mind in Buddhism and the mental state of dementia. I am not suggesting that enlightenment and dementia are the same, but rather that thinking deeply about their relationships may enlighten our attitudes about the cognitive challenges we all face as human beings who age. Just as fully embracing our mortality makes us appreciate life deeply, can reflecting profoundly on dementia help us recognize our own intellectual limitations as sentient creatures. Can we become more heart-full and wise as a result? Moreover in the daily struggles with cognitive impairment, meditation may be of practical benefit in helping people with dementia address issues of attention and anxiety. Open your own mind and heart to broader and deeper ways of thinking and perhaps your fears and suffering will be alleviated.

Power-Up Friday: Changing Aging blogroll addition

There's a new blog out there that's worth following: http://alt-alzheimers.com. Thanks to Emi Kiyota for pointing me to it. The purpose of the blog is to challenge the dominant view of dementia in our society.

This blog has a varied and interesting cast of contributors, including: Jess Ballinger, a scientist and historian; Peter Whitehouse, a Case Western neurologist who has recently challenged the biomedical paradigm with his book "The Myth of Alzheimer's", co-written with Danny George a medical anthropologist; Mona Johnson, a former telecom analyst and care partner for her late father; Dr. Richard Taylor, a noted writer and lecturer who has chronicled his own experiences with an Alzheimer's diagnosis, and Don Moyer, who's a little bit of everything.

This group heads a site devoted to hearing opinions and theories that step outside the box we have created for this symptom complex. They don't all follow one philosophy and they welcome all perspectives.

This is a great idea. Only by letting people interact in a forum without "rules" can we hope to continue to re-define the very human experiences that comprise the landscape of "dementia".

Check it out!

-- Al Power

Stress and Memory Loss – an explosive cocktail

I attended the Montréal Ageing and Design conference over the past three days and I would like to share with you some things I have learned with great pleasure.

Montréal is a great city, my friends and I took our time to eat good food and drink wine, nothing seems rushed here. Laid back, friendly, bilingual Canadians. Oh yes, before I forget, from the conference, one of the most impressive lectures:

"Stress and ageing – an explosive cocktail." A lively and charming presentation by stress researcher Sonia Lupien, Ph.D., from Montréal*. As the "middle generation,“ we think we are stressed, but in fact children and our Elders are more stressed. Stress, not ageing, has a devastating effect on our brain.

What causes stress?

Four additive factors lead to stress, such as novelty, unpredictability, threat to one’s ego and the sense of low contol (acronym NUTS).

All four factors are continuously present in the life of Elders in an institution. Due to this environment they suffer from depression and memory loss, both reversible if we encourage social support through friends, family and staff, through supporting active grandparenting, laughing, physical exercise, singing, praying, listening to music, hugging, kissing and just being.

You can measure all this by taking saliva samples, testing for cortisol, a stress hormone. Suddenly the "touchy-feely soft facts“ of companionship, reciprocity and spontaneity as promoted by the Eden Alternative appear to have a "hard“ scientific backing.

-- Christa Monkhouse (out for some more wine again)

*Lupien S.J., Fiocco, A*., Wan, N., Maheu, F*., Lord, C*., Schramek, T*., Tu, M.T*. (2005). Stress Hormones and Human Memory Function across the Lifespan. Psychoneurondocrinology, 30:225-242

http://www.hlhl.qc.ca/crfs/lupien.html
http://www.hlhl.qc.ca/stress

Power-Up Brains

In this week's issue of Journal of the American Medical Association, a group of doctors from Australia attempted to look at the effects of exercise on cognition. They chose a smallish (170) group of youngish (avg. age 68.7) people who reported trouble remembering, but who had no definite evidence of dementia.

Half of the people were encouraged to perform at least 150 minutes of moderate home-based exercise each week. They also received a behavioral intervention to help keep them on track. The rest were given the usual "good health habits" advice, but with no specific information on physical activity.

After 18 months, the exercise group had a small but significant improvement in cognitive function, compared with the control group.

An accompanying editorial felt that the study was encouraging, and that the benefit of exercise was equal to or better than that seen with "cholinesterase inhibitor" drugs for dementia. (Doctors in other countries have a less favorable view of the value of these drugs than American doctors. I tend to agree with them.)

All well and good, but let's step back a bit. This appears to be a good study, though it doesn't break a lot of new ground as far as recommendations for healthy living are concerned. My beef is that this prominently featured article highlights a trend of medical journals in publicizing Alzheimer's research that follows one of only two directions - prevention or cure.

These are admirable goals to pursue, but meanwhile a third research goal is, in my opinion, all but ignored by the medical profession: improving the lives of the millions of people who already have the disease or will get the disease in the coming decades. There is a wealth of literature around this, but it seems to be primarily the domain of psychologists and social workers. The medical journals (a) don't touch it, and (b) perpetuate a medical view that assumes that between prevention and cure lies nothing more than a world of psychiatric drug treatment, institutionalization, generic interventions and custodianship.

Even many people who work for the charitable organizations have bought into a view of dementia as little more than tragedy. It's hard to find people who talk of Alzheimer's with words like life, engagement, growth, meaning and autonomy. "Quality of life" studies often measure only medical outcomes or quality of care.

Until we have a radical attitude adjustment and start to view people with dementia primarily as people rather than a disease, we will continue to be blind to myriad opportunities to enrich their lives to a far greater measure than any medication has ever accomplished.

-- Al Power

Power-Up Monday: More Dementia News

[Editor's Note: Al Power is filling-in for Christa "Monkhouse Mondays" while she's on vacation.]

I'll follow up Wednesday's "Pre-Dementia" post with three more items that have popped up in the past two days:

(1) On July 28th, our local newspaper described a new study from the University of Kansas, to be published this fall in the American Journal of Alzheimer's Diesase and Other Dementias. In this study, it was found that people with dementia take great offense to being talked down to with demeaning names or infantile language. Many people reacted with increased agitation and physical aggression. Even people with fairly advanced dementia can tell when they are being demeaned or patronized.

This lends support to those of us who feel that interpersonal interactions are an important factor in the genesis of behavioral symptomatology. I only have one complaint: The article states that this method of address is so common that "researchers have coined a word to describe it - 'elderspeak'".

Now wait just a minute here! That isn't elder-talk - it's baby-talk! Let's not besmirch a title of honor and respect by associating it with infantilizing language.

(2) The UK has a new drug that claims to "halt the decline of dementia", something no other drug has succeeded in doing. The media has descended like vultures on the report of this trial drug named Rember (get it?). The study claims that there was no significant decline in cognitive function after 19 months on the drug, compared with an 81% relative decrease in those not taking it.

The drug appears to work by attacking the "tau protein" that forms the damaged nerve tangles of Alzheimer's. This is an industry-sponsored study, and hasn't been put to intense scrutiny or replication yet. However, it was enough to impress Clive Ballard, a prominent researcher in the UK. Others cite the evidence that the drug decreases blood supply to some brain areas as an indication to proceed with caution into further trials.

So we'll keep our fingers crossed and see what happens here...

(3) Finally, back on the topic of social capital, the BBC also reports that single people have three times the risk of dementia that married people have. This was reported by the Karolinska institute, after a study of 1449 Finns. It is theorized that the "intense social and intellectual stimulation" of marriage has a protective effect. Those who were widowed at a young age and never remarried had six times the risk.

This certainly adds to recent evidence about the beneficial effects of social interaction on cognition and other health indicators, (though a few of my formerly married friends might take issue with the hypothesis!).

I would comment that the article does not tell if cognitive testing was done on these people, or just an interview and health history. The latter would not rule out the effects of an ongoing relationship in helping to "cover" for mild deficits. There is also evidence that untreated depression can be neurotoxic - this might also be an issue in cases of divorce and bereavement. Finally, there may be lifestyle differences associated with stable marriages (diet, exercise, etc) which contribute.


Keep an eye on this blog for the latest developments!

-- Al Power

Power-Up Friday: “Jim Crow” Dementia?

[Editors Note: Power-Up Friday is a weekly guest-blog by Dr. Al Power]

On July 7th, the Civil Rights Museum On Wheels, visited St. John’s Home. Van White, a Rochester, NY attorney, purchased a 1950s vintage bus from the movie set of “Hairspray”, and had it refurbished into an exact replica of the Montgomery city bus where Rosa Parks took a stand by staying seated.

Two days later, I was asked my opinion about whether people with dementia should live in specialized units or housing. In my upcoming book, I have a section that lists a number of reasons why I feel that the “dementia unit” is an idea whose time has come… and gone. But the biggest reason of all, I realized, is an issue of civil rights.

Most “memory care units”, as they are often called, are staffed by highly competent, caring people. But the basic concept stems from an institutional mindset that places people into an environment largely defined by their disease, not by who they are. It presumes that people with dementia are enough alike that they should share a common living space, and an approach to care and activities that reflects their illness more than their individuality. Segregating people due to a physical attribute – sound familiar?

Furthermore, there is a deep prejudice in elder care environments that is shared by other elders and families. “People with dementia should have good care – separate, but equal, and not in our neighborhood”. This reflects underlying fears and misconceptions about the disease, and sells short the potential for growth and engagement that still exists in people with dementia, as surely as it does in someone who is blind or has lost a limb.

In 1955, a widespread boycott of the Montgomery buses was begun. If everyone with dementia suddenly boycotted all segregated living environments, what changes would organizations make to regain their support?

Such a boycott is unlikely. Let’s make those changes anyway.

-- Dr. Al Power