The responsibilities ahead are new and different, which makes the experience much more difficult. Not knowing what we are getting into creates fear within us and causes us to worry about the future. We start worrying, not only for ourselves but for our loved ones, too. Doubting whether or not we are “good caregivers” is something that can destroy our self-esteem.

There is an incredible amount of questions that bombard our minds daily. It is haunting not knowing how much longer we will be caring for our loved one. We get filled with uncertainties like wondering where, when, and how are the best ways to help. These uncertainties are accompanied by feelings of guilt for losing our temper and/or wishing it all would come to an end. Caring for someone with dementia is exhausting and complicated. Often, we feel overwhelmed by a feeling of exasperation when our loved one insists on not showering or insists on continuing to drive, or by blaming us for their struggles.

It may feel difficult or cruel when we repeatedly correct our loved one’s behavior or try to convince them of something. At the same time we realize how our relationships with others start slipping away. Suddenly we get reminded as if we’ve just received an app reminder notification, that we have stopped devoting time to the things we love and enjoy. The feelings of frustration and depression associated with caring for our loved ones with dementia are undeniable. Undoubtedly, it does not make sense at the beginning. However, to help improve our loved ones with dementia, we must better ourselves first.

Even when it feels inconceivable, we, caregivers, do the best we can under extremely challenging situations. Doing our best requires constant curiosity and the commitment to embrace the habit of keeping our minds open. How often do we beat ourselves up? Criticism comes in three different kinds of ways. Destructive criticism, constructive criticism, and the one caregivers tend to identify with the most, Self Criticism.

In considering a better, more nurturing way to talk to ourselves, changing the voice to one of a cheerleader, or parent who thinks we are the best thing in the face of the earth, can improve how we view ourselves. The best way to stop ourselves from being our own worst critic is by not doubting whether we are “good enough.”

Napoleon once said “The person who never makes a mistake will never make anything.” Certainly, as caregivers to a loved one suffering from dementia, we will make many mistakes. Making mistakes is the way we enhance the quality of who we are and how we care. By beating ourselves up, we not only make our life more difficult but the life of our loved ones, too. Therefore, we must have a positive outlook to maintain our loved one as calm and happy as possible.

To improve ourselves and our loved ones, we must discern some key and elemental things about the disease. By committing to understanding why our loved ones seem to purposefully want to disagree and contend with us, we can improve our negative self-talk. Understanding why they act the way they do will comfort us. Feeling drained by the situation is not healthy for anyone, instead, try to develop feelings and thoughts of willingness to make positive changes.

Understanding the process of why they treat others better than us has the power to reframe our thoughts.

Our loved ones are not in denial, nor are they being stubborn – they have a “lack of awareness or lack of insight.” This state is called anosognosia. “Anosognosia refers to a person’s lack of awareness of their own motor, visual, or cognitive deficits.” Since they are not capable of being aware of their brain problem, they see us as the enemy who is getting in their way from doing what they want, instead of seeing us as the person who is helping them. When we decide to understand what is happening with the disease process, then we will understand that we must retire the term ‘’good caregiver” and replace it for “doing the best job we can.”

Communication is the key to relationship

First off, do not highlight their weaknesses. Our loved ones with dementia are not capable of stepping back to look at any factors from a clear perspective. Also, laying off arguing, correcting, or reasoning with our loved ones with dementia can allow us to start a new way of communicating and relating with them. Keeping in mind that happiness is linked to how others treat us can help us keep the peace. Learning to communicate in a new way with your loved ones and ourselves will give us a new sense of compassion and will allow the situation to improve.

The Key to a better relationship

Before correcting our loved ones, let’s remember to take a step back and ask ourselves if we can avoid making our loved ones feel bad. Is it necessary to correct them? More than likely, it is better to save that energy and put it towards something more important. Let’s ask ourselves, is it kinder to just agree with them to not cause them any more anxiety, worry, or pain? Agreeing or lying to your loved one for their mental benefit is a form of compassion. Understanding what they want relieves pain and heartache from our loved one.

Our caregiving journey will have many hardships along the way. It is up to us to decide which struggles are best to leave alone. At the end of the day, there is no need to correct or challenge them, as long as their safety is not at risk. No one likes to be reminded of what we can’t do, right? Aiming towards behaviors that can alleviate our loved one’s anxiety, sadness, and anger will teach us a lot about them, and in turn, make it easier for us to understand their needs and desires. When we communicate intending to relieve their anxiety, instead of correcting them, we realize we are good caregivers. Certainly, we are doing the best we can under extreme circumstances. Reframing and rewiring our self-talk, the unempowering questions, and the desire to correct is the beginning of appreciating the great job we do.

Eileen Silverberg is the author of a book on empowering caregivers called A Warrior of Light. Eileen is also the caregiver to her mother, who has Alzheimer’s, and a life coach who specializes in emotional management and meditation. Find out more about Eileen at  https://eileensilverberg.com/.

People who suffer from Alzheimer’s disease experience a progressive escalation of symptoms that increase like the temperature of a pot of water over an open flame. The most common manifestations include memory loss, challenges solving problems, difficulty completing tasks, misplacing things, general confusion, and mood swings. When these signs reach a boiling point, it’s often too late to address them with any hope of long-lasting success.

However, there is hope for cases that are diagnosed and managed with early, customized treatment programs. Research has identified that combining the foundational tools of a keto diet, exercise, brain stimulation, sleep, and supplements is a useful way to start shifting the direction and progression of the disease.

Here are a few general pillars for your consideration. Of course, you should consult a qualified healthcare provider to determine which, if any, are right for you.

Ketogenesis

Once skeptical, scientists are now acknowledging the major role played by dietary alterations in neurological diseases. Ketones are the product of fat metabolism, and diets that are higher in healthy fats and lower in sugars and refined carbohydrates have been linked to support brain function.

A 2010 study examined 60 people with dementia who had medium-chain triglycerides introduced to their diets. The results revealed that 90 percent experienced improvement in one or more areas, including cognition, memory, social interaction, speech, sleep, and appetite. This underlines the importance of making smart eating a basic ingredient in our cognitive health.

High-Intensity Interval Training

For years, we have known about the physical and emotional benefits of a regular exercise routine. Now there is proof that physical exercise can also reduce the risk of developing Alzheimer’s disease by as much as 50 percent.

When individuals exercise with high-intensity interval training, they are increasing both neural growth factor and brain-derived neurotrophic factor (BDNF). These two hormones are critical for the rebuilding of neural pathways. By comparison, reduced levels of BDNF have been linked to Alzheimer’s disease and dementia symptoms like

depression, struggles with memory, and brain degeneration. By embracing activities that get our heartbeats going we can keep our bodies and our minds in shape.

Brain Stimulation Exercises

There are many cognitive exercises available that deliver a variety of benefits. However, it is a challenge to curate a one-size-fits-all set of exercises that triggers all of the functions required to increase cognitive pathway in the brain.

A new study by Duke University School of Medicine received global attention by running a healthy group of younger and older adults through a series of memory tasks. It turned out that the individuals who received repetitive transcranial magnetic stimulation (rTMS) therapy performed better than those who received a placebo.

According to the study’s co-author Simon W. Davis, “Contrary to much of what we hear, aging brains have a remarkable capability to remember past events and to use that information in a flexible manner.” He concluded, “The brain stimulation applied in our study shows that older adults benefited just as much as the young.”

Sleep

Sleeping is an essential ingredient for brain repair. In fact, it’s within the state of deep sleep—when the brain is unburdened by the tasks of daily living—where the brain prefers to rebuild and heal. According to the National Sleep Foundation, adults over the age of 65 should be sleeping seven to eight hours per night. Going one step further, researchers have found that poor sleep patterns can activate pathological processes that speed up Alzheimer’s disease.

Because patients suffering from cognitive decline may experience insomnia, it is imperative that they receive proper support from their healthcare provider. For many, a combination of melatonin and 5-HTP supplements can be life-changing, yet for others, it might not get the job done. Always consult a trained professional before taking any supplements.

Supplementation

There is a growing amount of evidence showing that consistent and long-term supplementation can be immensely therapeutic for maintaining cognitive conditions. A study by the American Academy of Neurology evaluated 1,658 healthy people over the age of 65. They discovered that subjects who exhibited lower levels of vitamin D increased their risk of developing dementia by 53 percent. After an average of six years, 102 of those participants had been diagnosed with Alzheimer’s disease. These findings underline the importance of building custom supplementation plans based on individual needs.

No two cases of Alzheimer’s disease are exactly alike, with every individual possessing a unique combination of mechanisms that are driving their experience. Because the idea of a single cookie-cutter solution to combat this growing affliction is obsolete, we need to address multiple mechanisms at the same time. By engaging in a ketogenesis diet, committing to high-intensity interval training, participating in brain stimulation exercises, maintaining healthy sleep habits, and following a personalized supplements plan, we’ll know we have done our best to change the momentum of the disease.

Dr. Candice Hall, DC is an author, speaker, practitioner, and authority on integrative and functional medicine. She is founder of Next Advanced Medicine, a functional medicine practice in Orange County, CA.  Shelaunched Natrueal Products, an organic food company, with the mission to provide natural, true, and real food options for her patients and all consumers.   Dr. Hall educates hundreds of people suffering from chronic disease each month through free information seminars on how to find the root cause of disease. 

Dr. Hall has 18 years of postdoctoral training in functional medicine and clinical nutrition, including training in the area of cognitive decline and Alzheimer’s disease. Dr. Hall’s passion for functional medicine comes from personal success battling and overcoming three (3) autoimmune conditions. Functional medicine was the reason she went into remission, and the reason she is inspired to bring hope and solutions to others.

To learn more about reversing and preventing Alzheimer’s disease and cognitive decline, please visit https://nextadvancedmedicine.com/cognitive-decline/

In 2014, the number of cases of Alzheimer’s disease and related dementias (ADRC) in 2014 was 5 million people, which is 1.6 percent of the U.S. population in 2014 (total population is 319 million people). By 2060, the number is projected to grow to 13.9 million people, which is nearly 3.3 percent of the U.S. in 2060 (projected total population is 417 million people).

The figures come from a study by the federal Centers for Disease Control and Prevention (CDC)

The study, published online in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, is the first to forecast Alzheimer’s disease by race and ethnicity. The CDC researchers predict that Hispanic Americans will have the largest projected increase due to population growth over the period between 2014-2060, although because of the relative size of the population, non-Hispanic whites will still have the largest total number of Alzheimer’s cases.

“This study shows that as the U.S. population increases, the number of people affected by Alzheimer’s disease and related dementias will rise, especially among minority populations,” said CDC Director Robert R. Redfield, M.D. “Early diagnosis is key to helping people and their families cope with loss of memory, navigate the health care system, and plan for their care in the future.”

Alzheimer’s disease is the fifth most common cause of death for Americans ages 65 years and older. It is an irreversible, progressive brain disorder that slowly destroys memory and, eventually, a person’s ability to perform even the simplest tasks.

For their study, CDC researchers estimated the number of people with Alzheimer’s by age, sex, race and ethnicity in 2014 and 2060 based on population projections from the U.S. Census Bureau and percentages of Medicare Fee-for-Service beneficiaries ages 65 years and older with Alzheimer’s disease and related dementias from the Centers for Medicare & Medicaid Services.

Alzheimer’s disease is the fifth most common cause of death for Americans ages 65 and older.

Among people ages 65 and older, African Americans have the highest prevalence of Alzheimer’s disease and related dementias (13.8 percent), followed by Hispanics (12.2 percent), and non-Hispanic whites (10.3 percent), American Indian and Alaska Natives (9.1 percent), and Asian and Pacific Islanders (8.4 percent).

By 2060, the researchers estimate there will be 3.2 million Hispanics and 2.2 million African Americans with Alzheimer’s disease and related dementias. The increases are a result of fewer people dying from other chronic diseases and surviving into older adulthood when the risk for Alzheimer’s and related dementias goes up.

The report also addresses the need to provide support to caregivers of persons living with Alzheimer’s and related dementias because an early diagnosis can help caregivers plan for the life-changing experience of caring for a friend or family member and maintain their own health and well-being. (See our story, “Long-Distance Caregiving: Dealing with Frustration and Guilt.”)

“It is important for people who think their daily lives are impacted by memory loss to discuss these concerns with a health care provider. An early assessment and diagnosis is key to planning for their health care needs, including long-term services and supports, as the disease progresses,” said Kevin Matthews, Ph.D., health geographer and lead author of the study with the CDC’s Division of Population Health within the National Center for Chronic Disease Prevention and Health Promotion.

For more information on CDC’s activities related to Alzheimer’s disease, click here.  To learn about the government’s project with the private sector, called the  Healthy Brain Initiative, click here. For more information on the National Plans to Address Alzheimer’s Disease, click here.

The risk is across the board, regardless of gender, race, ethnicity or education — or whether you have regular social contact with friends and family.

The study was published in the Journal of Gerontology: Psychological Sciences.

“We are not the first people to show that loneliness is associated with increased risk of dementia,” said Angelina Sutin, the principal investigator on the study. “But this is by far the largest sample yet, with a long follow-up. And the population was more diverse.”

A TOTAL OF 1,104 PARTICIPANTS DEVELOPED DEMNETIA

The Sutin team’s paper made use of the federally funded Health and Retirement Study, a longitudinal look at Americans 50 and older and their spouses. Participants reported on their loneliness and were also administered a cognitive battery every two years, up to 10 years after their reports of loneliness. During this time, 1,104 people developed dementia.

Participants who reported greater feelings of loneliness were more likely to develop dementia over the next 10 years. Individuals who feel lonely are likely to have several risk factors for dementia, including diabetes, hypertension and depression, and are less likely to be physically active and more likely to smoke. Even after adjusting for those shared risks, loneliness still predicted dementia.

DIFFERENT INTERPRETTIONS OF LONELINESS

“Lonely” can have many interpretations, said Sutin, an associate professor in the college’s Department of Behavioral Sciences and Social Medicine.

Her team’s study referred to “the subjective experience of social isolation,” which is separate from actual social isolation.

“It’s a feeling that you do not fit in or do not belong with the people around you,” Sutin said. “You can have somebody who lives alone, who doesn’t have very much contact with people, but has enough — and that fills their internal need for socializing. So even though objectively you might think that person is socially isolated, they don’t feel lonely. The flip side is that you can be around a lot of people and be socially engaged and interactive and still feel like you don’t belong. From the outside it looks like you have great social engagement, but the subjective feeling is that you’re not part of the group.”

Sutin urges against blaming the victim for feelings of loneliness.

“People might say, ‘You’re lonely. Go make a friend,’” she said. “But it’s not that easy.”

There are significant long-term consequences to having these kinds of feelings. It’s not the individual’s fault or choice to be lonely.

“I think this study adds to the literature highlighting the importance of psychological factors and how individuals subjectively interpret their own situation,” Sutin said. “That’s equally important and separate from what we objectively measure. It also lends credibility to the idea of asking people how they feel about things — in this case, how they feel about their social interactions.”

There are a number of ways that loneliness may put one at risk for dementia. One way may be physiological, such as through higher inflammation — the body’s natural response to infection that can be harmful when it lasts a long time. A second way may be through behavior. People may cope with loneliness through behaviors that can damage the brain, such as heavy drinking or being sedentary. A third way is through lack of meaningful social interaction. Keeping the mind engaged in a meaningful way can promote cognitive health that provides the motivation and structure to help maintain cognitive functioning.

In the end, Sutin said, loneliness is a signal that your social needs are not being met. And there are ways to counter that.

“Loneliness is a modifiable risk factor,” she said. “Most people might describe periods where they felt lonely and then periods where they didn’t feel lonely. So just because you feel lonely now, you don’t always have to feel this way.”

Sutin’s co-authors are Martina Luchetti, a research faculty member in Behavioral Sciences, and Antonio Terracciano, a professor in the medical school’s Department of Geriatrics. The other co-author, Yannick Stephan, is from the University of Montpellier in France.

The word-recall quiz accurately predicted whether people had elevated brain levels of beta-amyloid, a protein that has been linked with the increased risk of mild cognitive impairment and the development of Alzheimer’s.

The investigators say they hope the procedure, which puts pressure on memory, could help identify signs that might have been missed by standard memory tests.

The test, known as the Loewenstein-Acevedo Scales for Semantic Interference and Learning (LASSI-L), was developed by a group of researchers led by Dr. David Loewenstein of the Center for Cognitive Neurosciences and Aging and the University of Miami Miller School of Medicine.

The team’s preliminary findings were published in the journal Neurology.

Investigators used answers on a simple word quiz to evaluate the degree of cognitive impairment.

Here’s how it works: Study participants listen to a list of categorized objects (fruits, musical instruments, or clothing) and then after a brief delay, repeat as many of the words as they can recall. Shortly afterwards, they repeat the process with a different list of words from the same category. The research team found that “semantic intrusions”—recalling either a word from the previous list, or a word that fits the category but was not on either list—can indicate potential problems with memory, cognition, or control of verbal inhibition.

As part of the study, the scientists also conducted PET and MRI scans on 88 participants. The scans showed that those who had more semantic intrusions on the word test also had higher levels of beta-amyloid.

Overall, the study showed that semantic intrusions on the LASSI-L helped researchers separate participants who were cognitively normal from those with harder to detect cognitive impairment. Previous memory test methods likely would have labelled the latter group as cognitively unimpaired since only their correct memory test results were counted.

Since it offers a potentially faster and less expensive way to screen people for high amyloid burden than current tests, the researchers hope to make LASSI-L a low-tech tool to assist in medical evaluations and clinical trial recruitment. Still to be done: additional research with larger numbers of participants.

The study, which draws on data collected from following hundreds of elderly Pittsburghers for more than 15 years, was published October 16^th in the Journal of Alzheimer’s Disease. The main finding is that arterial stiffness is a good proxy for predicting who will go on to develop dementia. Even minor signs of brain disease were not as telling. Since arterial stiffness can be reduced by antihypertensive drugs, and likely also lifestyle interventions, these findings suggest that at-risk patients may have the power to prevent or delay the onset of dementia.

A release from the university quotes senior author Rachel Mackey, Ph.D., M.P.H., assistant professor of epidemiology, University of Pittsburgh Graduate School of Public Health, as saying, “As the large arteries get stiffer, their ability to cushion the pumping of blood from the heart is diminished, and that transmits increased pulsing force to the brain, which contributes to silent brain damage that increases dementia risk. Although arterial stiffness is associated with markers of silent, or subclinical, brain damage and cognitive decline, until now, it was not clear that arterial stiffness was associated with the risk of dementia.”

The authors analyzed the association between arterial stiffness and dementia among 356 older adults, with an average age of 78, who were part of the Cardiovascular Health Study Cognition Study (CHS-CS), a long-term study to identify dementia risk factors. This study is unusual because it had 15 years of almost complete follow-up of cognitive status and outcomes for older participants.

All participants included in the present study were dementia-free when the study started in 1998. During this same period, Mackey and her team tested their aortic stiffness with pulse wave velocity (PWV), a noninvasive measure of the speed at which the blood pressure pulse travels through the arteries. Study participants also had MRI scans of their brains to measure signs of subclinical brain disease.

The researchers found that subjects with high PWV readings were 60 percent more likely to develop dementia during the following 15 years compared to those with lower PWV values.

Although arterial stiffness is correlated with subclinical brain disease and risk factors for cardiovascular disease, these confounding variables did not explain the results.

“It’s very surprising that adjusting for subclinical brain disease markers didn’t reduce the association between arterial stiffness and dementia at all,” said Chendi Cui, M.S., first author on the paper and doctoral student at Pitt Public Health. “We expect that arterial stiffness increases the risk of dementia partly by increasing subclinical brain damage. However, in these older adults, arterial stiffness and subclinical brain damage markers appeared to be independently related to dementia risk.”

That’s promising because there isn’t much evidence that it’s possible to reverse subclinical brain disease, whereas arterial stiffening can be reduced by antihypertensive medication and perhaps also healthy lifestyle changes such as exercise. For example, this study showed that exercise at an average age of 73 was associated with lower PWV five years later. So, if elderly patients get flagged with a high PWV reading or marker of subclinical brain damage, they may still have the chance to stave off dementia.

“What’s exciting to think about is that the strong association of arterial stiffness to dementia in old age suggests that even at age 70 or 80, we might still be able to delay or prevent the onset of dementia,” Mackey said.

###

Additional authors on this study include Akira Sekikawa, M.D., Ph.D., M.P.H., Lewis Kuller, M.D., Dr.P.H., Oscar Lopez, M.D., Anne Newman, M.D., M.P.H., and Allison Kuipers, Ph.D., all of Pitt. Drs. Lopez and Kuller directed the CHS-CS study. Pitt’s Ultrasound Research Laboratory enabled the PWV measurements.

A release from the association states that while the memory and thinking symptoms associated with the disease are the most well known, it is the behavioral and psychological symptoms of dementia (BPSD) — agitation, anxiety, apathy, depression, wandering, hallucinations, insomnia, incontinence, disinhibition — that often cause the greatest caregiving challenges and are the leading causes for placement in assisted living or nursing homes. Left untreated, these symptoms can accelerate decline and reduce quality of life.

At this time, the U.S. Food and Drug Administration (FDA) has not approved any drug treatments for these symptoms in people with Alzheimer’s dementia. All drug treatments currently used are approved for other indications and prescribed for people with Alzheimer’s “off-label.”

The release quotes Maria Carrillo, PhD, Alzheimer’s Association Chief Science Officer, as saying, “These underrecognized and undertreated symptoms in people with Alzheimer’s and other dementias are often very difficult to live with and challenging to treat. One of the ‘untold stories’ of Alzheimer’s is the regular occurrence and overwhelming impact of these symptoms on the lives of people with Alzheimer’s, their family members and caregivers.”

“It is very important that as we continue to make advances in treating and preventing the memory and thinking symptoms of Alzheimer’s and other dementias, we also focus on therapeutic strategies for the behavioral and other non-cognitive symptoms,” Carrillo added.

The Alzheimer’s Association recommends non-pharmacologic approaches such as psycho-social interventions as first-line alternatives to pharmacologic therapy for the treatment of dementia-related behaviors. These therapies include validation therapy, reminiscence and other personalized psychosocial interventions.

For example:

• Validate that the person seems to be upset over something.
• Separate the person from what seems to be upsetting.
• Engage in regular physical activity to potentially reduce irritability and aggressive behavior.
• Assess for the presence of pain, constipation or another physical problem.

Psychotropic medications (antipsychotics, antidepressants, anticonvulsants and others) may need to be considered when the dementia-related behavior has not responded to non-pharmacologic approaches, especially if it is causing physical or emotional harm to the person with dementia or caregiver(s), however they must be used with extreme care, and must be regularly evaluated to determine the appropriate time of cessation. The FDA found that using antipsychotics to treat dementia-related behaviors in elderly persons with dementia was associated with increased mortality.

Synthetic Cannabinoid Treatment Shows Improvement in Agitation in People with Alzheimer’s

Results of a randomized, double-blind clinical trial suggest that nabilone — a synthetic cannabinoid — may be effective in treating agitation in people with Alzheimer’s disease. “Agitation, including verbal or physical outbursts, general emotional distress, restlessness, pacing, is one of the most common behavioral changes associated with Alzheimer’s as it progresses, and can be a significant cause of caregiver stress,” said Krista L. Lanctôt, PhD, Senior Scientist at Sunnybrook Health Sciences Centre and Professor of Psychiatry and Pharmacology/Toxicology at the University of Toronto.

Lanctôt and colleagues investigated the potential benefits of nabilone for adults with moderate to severe Alzheimer’s dementia with clinically significant agitation. Over the 14-week trial duration, 39 participants (77 percent male, average age 87) received nabilone in capsule form (mean therapeutic dose=1.6 +/- .5 mg) for six weeks, followed by six weeks of placebo, with one week between each treatment period. In addition to measuring agitation, the researchers assessed overall behavioral symptoms, memory, physical changes and safety. They found that:

• Agitation improved significantly in those taking nabilone, compared to placebo, as measured by the Cohen-Mansfield Agitation Inventory (p=0.003).
• Nabilone also significantly improved overall behavioral symptoms, compared to placebo, as measured by the Neuropsychiatric Inventory (p=0.004).

The researchers also observed small benefits in cognition and nutrition during the study. More people in the study experienced sedation on nabilone (45 percent) compared to placebo (16 percent).

“Currently prescribed treatments for agitation in Alzheimer’s do not work in everybody, and when they do work the effect is small and they increase risk of harmful side effects, including increased risk of death. As a result, there is an urgent need for safer medication options,” said Lanctôt. “These findings suggest that nabilone may be an effective treatment for agitation; however, the risk of sedation must be carefully monitored. A larger clinical trial would allow us to confirm our findings regarding how effective and safe nabilone is in the treatment of agitation for Alzheimer’s.”

Note: Marijuana is not approved by the FDA for the treatment or management of Alzheimer’s disease or other dementias. As medical marijuana use becomes more common, it is important to point out that much about its use in people with Alzheimer’s or other dementias is unknown.

Marijuana is, essentially, an untested drug in Alzheimer’s. There is currently no robust, consistent clinical trial data supporting the use of marijuana for treatment of Alzheimer’s disease dementia — nor for related issues. The Alzheimer’s Association believes that more research in this area is needed.

Lighting May Improve Sleep, Mood and Behavior in People with Alzheimer’s

Many people living with Alzheimer’s disease and other dementias experience changes in their sleep patterns, insomnia, and daytime sleepiness. Mariana G. Figueiro, PhD, Director of the Lighting Research Center at Rensselaer Polytechnic Institute in Troy, NY, and colleagues tested whether a tailored lighting system could help to improve sleep, mood and behavior in people with Alzheimer’s disease in nursing homes.

“Given that light/dark patterns are a person’s primary cues to the current time, the constant dim light typically experienced by people living in residential care facilities may be an underlying cause of the sleep pattern disturbances so commonly found in this population,” said Figueiro.

To test this hypothesis, over a four-week period, lighting interventions were placed in areas where nursing home residents spent the majority of their waking hours and were left on from wake-up time until 6 p.m. Forty-three (43) residents (31 female, 12 male) participated in the short-term study, and 37 residents (25 female, 12 male) have completed the long-term study so far, all recruited from 10 nursing homes in the New York Capital District, Bennington, VT, and South Bend, IN.

Study participants experienced alternating periods of lighting that provided either high- or low-circadian stimulus for four weeks (short-term study) and six months (long-term study, successive four-week periods spaced by a four-week washout). The circadian stimulus (CS) metric, developed by the Lighting Research Center, characterizes a light source’s effectiveness for stimulating the circadian system as measured by its capacity for acutely suppressing the body’s production of the hormone melatonin (a well-established marker of the circadian system) after a one-hour exposure.

Both arms of the study used either a custom-designed LED light table or individual room lighting to deliver the intervention, depending on where the participants spent the majority of their time. Personal light meters were used to measure the light exposures received at the participants’ eyes. Sleep disturbance, mood and agitation were also assessed using standardized questionnaires.

With the lighting intervention, researchers found that study participants who experienced the high-circadian stimulus showed significant decrease in sleep disturbance, depression and agitation. Positive effects observed in the short-term study continued to improve over the long-term study.

Beyond Anti-Psychotics: Exploring Efficacy and Harms of Z-Drugs for Sleep Disturbance

Many people with dementia have problems sleeping. This affects their quality of life and that of the people who care for them. Non-benzodiazepine hypnotic “Z-drugs,” such as zolpidem, zopiclone and zaleplon, are often prescribed to help treat insomnia in older adults, but it is thought that they may cause problems such as falls, fractures, and increase confusion. People living with dementia are especially vulnerable and it is not clear whether Z-drugs are particularly harmful for them.

Chris Fox, MD, Professor of Psychiatry at Norwich Medical School University of East Anglia in Norwich, U.K., and colleagues analyzed existing data from the UK Clinical Practice Research Datalink, and from three clinical studies of people with dementia. They compared data for up to two years for 2,952 people with dementia who were newly prescribed Z-drugs with data for 1,651 who were not, in order to evaluate the benefits and harms of these medicines.

They found that the use of Z-drugs is associated with a 40 percent increased risk of any type of fracture, with risk increasing for those on higher doses. Z-drug use was also associated with a greater risk specifically of hip fracture. The study did not identify a higher risk of other effects, such as falls, infections or stroke.

“Fractures in people with dementia can have a devastating impact, including loss of mobility, increased dependency and worsening dementia,” said Fox. “We desperately need better alternatives to the drugs currently being prescribed for sleep problems and other non-cognitive symptoms of dementia. Wherever possible, suitable non-pharmacological alternatives should be considered, and where Z-drugs are prescribed, patients should receive care that reduces or prevents the occurrence of falls.”

A release from the university quotes Maiken Nedergaard, M.D., D.M.Sc., co-director of the Center for Translational Neuromedicine at the University of Rochester Medical Center (URMC) and lead author of the study, as saying, “Prolonged intake of excessive amounts of ethanol is known to have adverse effects on the central nervous system. However, in this study we have shown for the first time that low doses of alcohol are potentially beneficial to brain health, namely it improves the brain’s ability to remove waste.”

The finding adds to a growing body of research that point to the health benefits of low doses of alcohol. While excessive consumption of alcohol is a well-documented health hazard, many studies have linked lower levels of drinking with a reduced risk of cardiovascular diseases as well as a number of cancers.

Nedergaard’s research focuses on the glymphatic system, the brain’s unique cleaning process that was first described by Nedergaard and her colleagues in 2012. They showed how cerebral spinal fluid (CSF) is pumped into brain tissue and flushes away waste, including the proteins beta amyloid and tau that are associated with Alzheimer’s disease and other forms of dementia. Subsequent research has shown that the glymphatic system is more active while we sleep, can be damaged by stroke and trauma, and improves with exercise.

The 2018 study, which was conducted in mice, looked at the impact of both acute and chronic alcohol exposure. When they studied the brains of animals exposed to high levels of alcohol over a long period of time, the researchers observed high levels of a molecular marker for inflammation, particularly in cells called astrocytes which are key regulators of the glymphatic system. They also noted impairment of the animal’s cognitive abilities and motor skills.

Animals that were exposed to low levels of alcohol consumption, analogous to approximately 2 ½ drinks per day, actually showed less inflammation in the brain and their glymphatic system was more efficient in moving CSF through the brain and removing waste, compared to control mice who were not exposed to alcohol. The low dose animals’ performance in the cognitive and motor tests was identical to the controls.

“The data on the effects of alcohol on the glymphatic system seemingly matches the J-shaped model relating to the dose effects of alcohol on general health and mortality, whereby low doses of alcohol are beneficial, while excessive consumption is detrimental to overall health” said Nedergaard. “Studies have shown that low-to-moderate alcohol intake is associated with a lesser risk of dementia, while heavy drinking for many years confers an increased risk of cognitive decline. This study may help explain why this occurs. Specifically, low doses of alcohol appear to improve overall brain health.”

###

Additional co-authors include Iben Lundgaard, Wei Wang, Allison Eberhardt, Hanna Vinitsky, Benjamin Reeves, Sisi Peng, Nanhong Lou, and Rashid Hussein with URMC. Nedergaard maintains research labs at both URMC and the University of Copenhagen in Denmark. The study was funding with support from the Department of Navy’s Office of Naval Research, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

The study was published online December 7, 2017 in the journal Scientific Reports by researchers at the Lewis Katz School of Medicine at Temple University (LKSOM).

“Canola oil is appealing because it is less expensive than other vegetable oils, and it is advertised as being healthy,” explained Domenico Praticò, MD, Professor in the Departments of Pharmacology and Microbiology and Director of the Alzheimer’s Center at LKSOM, as well as senior investigator on the study. “Very few studies, however, have examined that claim, especially in terms of the brain.”

Curious about how canola oil affects brain function, Praticò and Elisabetta Lauretti, a graduate student in Pratico’s laboratory at LKSOM and co-author on the new study, focused their work on memory impairment and the formation of amyloid plaques and neurofibrillary tangles in an Alzheimer’s disease mouse model. Amyloid plaques and phosphorylated tau, which is responsible for the formation of tau neurofibrillary tangles, contribute to neuronal dysfunction and degeneration and memory loss in Alzheimer’s disease. The animal model was designed to recapitulate Alzheimer’s in humans, progressing from an asymptomatic phase in early life to full-blown disease in aged animals.

Praticò and Lauretti had previously used the same mouse model in an investigation of olive oil, the results of which were published earlier in 2017. In that study, they found that Alzheimer mice fed a diet enriched with extra-virgin olive oil had reduced levels of amyloid plaques and phosphorylated tau and experienced memory improvement. For their latest work, they wanted to determine whether canola oil is similarly beneficial for the brain.

The researchers started by dividing the mice into two groups at six months of age, before the animals developed signs of Alzheimer’s disease. One group was fed a normal diet, while the other was fed a diet supplemented with the equivalent of about two tablespoons of canola oil daily.

The researchers then assessed the animals at 12 months. One of the first differences observed was in body weight – animals on the canola oil-enriched diet weighed significantly more than mice on the regular diet. Maze tests to assess working memory, short-term memory, and learning ability uncovered additional differences. Most significantly, mice that had consumed canola oil over a period of six months suffered impairments in working memory.

Examination of brain tissue from the two groups of mice revealed that canola oil-treated animals had greatly reduced levels of amyloid beta 1-40. Amyloid beta 1-40 is the more soluble form of the amyloid beta proteins. It generally is considered to serve a beneficial role in the brain and acts as a buffer for the more harmful insoluble form, amyloid beta 1-42.

As a result of decreased amyloid beta 1-40, animals on the canola oil diet further showed increased formation of amyloid plaques in the brain, with neurons engulfed in amyloid beta 1-42. The damage was accompanied by a significant decrease in the number of contacts between neurons, indicative of extensive synapse injury. Synapses, the areas where neurons come into contact with one another, play a central role in memory formation and retrieval.

“Amyloid beta 1-40 neutralizes the actions of amyloid 1-42, which means that a decrease in 1-40, like the one observed in our study, leaves 1-42 unchecked,” Praticò explained. “In our model, this change in ratio resulted in considerable neuronal damage, decreased neural contacts, and memory impairment.”

The findings suggest that long-term consumption of canola oil is not beneficial to brain health. “Even though canola oil is a vegetable oil, we need to be careful before we say that it is healthy,” Praticò said. “Based on the evidence from this study, canola oil should not be thought of as being equivalent to oils with proven health benefits.”

The next step is to carry out a study of shorter duration to determine the minimum extent of exposure necessary to produce observable changes in the ratio of amyloid beta 1-42 to 1-40 in the brain and alter synapse connections. A longer study may be warranted in order to determine whether canola oil also eventually impacts tau phosphorylation, since no effects on tau were observed over the six-month exposure period.

“We also want to know whether the negative effects of canola oil are specific for Alzheimer’s disease,” Praticò added. “There is a chance that the consumption of canola oil could also affect the onset and course of other neurodegenerative diseases or other forms of dementia.”

In its earliest stages, dementia is not easy to detect and studies have suggested that as many as half of those with dementia are undiagnosed. When a diagnosis of dementia is missed or delayed, people in the early stages of dementia continue to engage in behaviors that may be disastrous; primarily risking financial abuse and fraud, but also driving, managing medications, and sometimes caring for another person. Family members, especially if they don’t live with their elder relative, may be unaware that cognitive decline is causing functional impairment. This oversight can have devastating consequences.

Dementia is not a disease. It is an umbrella term for a group of illnesses that have different causes but similar symptoms. Those symptoms might include varying degrees of memory loss, language difficulty, poor judgment, inability to concentrate, personality changes, and impaired visual perception. But the initial signs can be difficult to spot. They may be transient or they may be mistaken for the “senior moment” instance of memory loss that is a natural consequence of aging. A person may seem like “themselves” – perfectly lucid and functioning well – on one day but agitated, confused and angry or withdrawn the next.

Initial signs and symptoms can be subtle and can vary considerably from one individual to the next. In the past, uncertainty might have led to years of gradual decline and its attendant risks before a diagnosis was made. Fortunately, most people are more aware now of the signs of dementia and the lead time before diagnosis has been reduced. Primary care physicians are also more actively involved and routinely ask elders and their families about memory and ability to function. And yet, the subtle changes in judgment, and risk assessment are often missed in evaluation.

The traditional teaching is that the Mini Mental Status Exam, (MMSE) a 30-point test that does not judge risk assessment or abstract thinking, can diagnose dementia. Less than 24 indicated dementia, over 24 there is no dementia. That has been proven wrong. An older individual may have a perfect score and have dementia to the point that all their finances can be swindled from them. The Montreal Cognitive Assessment tool (MoCA) is better, requiring abstract thinking to draw a line between a field of letters and numbers, A1B2C3, but still does not address the early changes of judgment and risk assessment. Much better is the geriatric neuropsychological assessment, which takes four to five hours, and costs significantly more. However, if an elder is at risk for having their life savings stolen from them or their rights incorrectly taken from them, it is a crucial investment.

Tips on Recognizing Signs and Symptoms

As a general rule, memory lapses associated with normal aging do not interfere with the performance of daily activities or the ability to live independently. And warning signs of dementia typically include loss of memory, but NOT always, and the ability to use judgment and risk assessment. Here are s some examples of troubling signs:

• Difficulty performing familiar tasks: Forgetting where you put your keys is normal. Trouble paying bills is not.
• Difficulty retaining newly learned information: Forgetting the name of a movie star is normal. Forgetting what the doctor told you to do for your asthma medication is not.
• Showing repeated poor judgment: Everyone makes an occasional bad decision. Not understanding the risks of lottery schemes, unwanted home repair salesmen doorway advice, or obviously poor financial advice (an annuity for an 86 year old client) and not paying bills is not.
• Personality changes: Having a “down day” is normal. Dramatic mood swings, apathy, or a significant change in personality are not. Having a “new friend” who controls their schedule, who they see, and usually later, their finances, is a red flag to get help immediately.
• Confusion in familiar circumstances: Occasionally forgetting where you were going is normal. Getting lost in your own neighborhood or forgetting where you are or how you got there is not.
• Difficulty having or sustaining a conversation: Occasionally having trouble finding the right word is normal. Having trouble putting thoughts together to communicate effectively is not.

Older individuals suffering early signs of cognitive decline may or may not be aware that they are having trouble with financial decisions and risk assessment. Friends and families must also be alert and ensure that a diagnosis is confirmed or ruled out as soon as possible in order to take advantage of treatment and support options that can improve quality of life. An initial screening by a primary care physician is a start. Ask for the MoCA, but if there are worrisome changes and you are told “Everything is all right”, get a geriatrician, or a geriatric neuropsychologist for a more complete evaluation.

Elizabeth Landsverk, MD, is founder of ElderConsult Geriatric Medicine, a house-calls practice in the San Francisco Bay Area that addresses the challenging medical and behavioral issues often facing older individuals and their families. Dr. Landsverk is board-certified in internal medicine, geriatric medicine and palliative care and is an adjunct clinical professor at Stanford University Medical School and lead educator for the California Coalition for Culture Change. http://www.elderconsult.com