Alzheimer’s, the caregiving experience, and helping the caregiver

Myth #1:Alzheimer’s is normal aging.

Dementia — "a loss of intellectual abilities of sufficient severity to interfere with functioning….The loss involves memory, judgment, abstract thought, and a variety of other higher cortical functions". (DSM IV, 1994).

Alzheimer's disease — Most prevalent form of dementia. Alois Alzheimer, a German neurologist, discovered in 1907 neurofibrillary tangles and neuritic plagues in the autopsied brain of a 51 year old patient who demonstrated demented behavior.

Because of the patient's age Alzheimer's disease was thought of as presenile dementia. Until 35 years ago it was considered rare.

Alzheimers was referred to as Primary Dementia in the DSM.

Different from delirium — literally means "off the track" (de=“off”; lira=“the ridge between furrows”).Not due to arteriosclerosis -- "hardening of the arteries" — not cause of most dementias.Not multi-infarct dementia (MID) caused by circulatory problems and clots lodging in the brain.Not Lewy-body or Parkinsonian dementia

Not Creutzfeld-Jakob disease – “Kuru”, a strange affliction of the Fore of New Guinea.

Not “dementia pugilistica”

All of these afflictions and forms of dementia are, like SDAT, not normal aging!!!!

Alzheimer prevalence increases with age

Assessment of Dementia

1. Differential diagnosis

2. Functional assessment and care needs

3. Evaluation of the caregiver

Differential diagnosis of SDAT

lnclusionarv evidence

Exclusionary evidence

Why do we need both inclusionary and exclusionary evidence in disorders like SDAT?

What is types of evaluations or tests are included in the differential diagnosis process?

Conditions considered in the Differential Diagnosis of SDAT:

1. Diffuse diseases of the CNS, e.g., other dementias (Lewy-body, Parkinson's, etc.), Huntington's chorea, epilepsies.

2. Metabolic disorders, e.g., liver and kidney failure, hypo- and

hyperglycemia.

3. Vascular disorders, e.g., MID, hypoxia, anoxia.

3. Brain tumors.

5. Trauma and hematomas.

6. Infections, e.g., meningitis, encephalitis, CJD, neurosyphilis.

7. Dificiency disorders, e.g., Korsakoff's, B12 dificiency, folate dificiency.

8. Intoxications, e.g., alcohol, lead, mercury.

9. Other mental illness, e.g., MS.

Exclusionary evidence – “Rule outs” (see previous slide)

Inclusionary evidence:

1. History of cognitive deterioration

2. Presently unable to function

3. Memory impairment

4. At least one of the following:

a.Impaired abstract thinkingb.Impaired judgementc.Personality change

Myth #2:Alzheimer’s is hard to diagnose accurately.

Dementia is diagnosable with 90% accuracy. That is substantially better than many medical diagnoses for which there are no sensitive and specific, e.g., most viruses, depression, etc.

Autopsy provides sensitive and, for the most part, specific markers for SDAT. What are they?

Neurons

Plaques and Tangles

Formation of Plaques

Neuritic plaques

Formation of Tangles

Neurofibrillary tangles

Myth #3:

Dementia is not treatable.

Basic notions of treatment:

"Excess disabilities” and the “Rule of Halves”

Effects of SDAT extend beyond the patient. Treatment targets functioning and extends beyond the patient.

Questions we will address today

1. In what ways do we change with SDAT?

2. Are these abnormal SDAT changes associated with functional changes?

3. Can we prevent or diminish these functional changes in the face of predictable abnormal SDATchanges?

Basic theme:1. Diminished capacity associated with

progression of SDAT

2. Loss of functioning at any point not be a necessary consequence of diminished capacity associated with SDAT.

3. Selection, optimization, and compensation (SOC) can transform activity and maintain functioning.

4. There are limits to maintenance of function in SDAT.

Caregiving for SDAT from the “Stress and Coping” Perspective

Stress and Copingas “hardwired” experience

Holmes & Rahe (1967)Social Readjustment Rating Scale (SRRS)

Lazarus and Folkman (1981)Hassles and Uplifts (HSUP)

Coping style vs.Coping success

What kinds of coping styles might be effective in coping with caring for and SDAT patient????

Q: How did Glenn Kirkland cope?

The importance of feeling “in control”

Langer and Rodin (1976)

Depression literature

Learned helplessness – Seligman’s rats, Harlow’s monkeys

Cognitive therapy for depression – Beck’s “negative triad”

Relocation effects

Lots of death following relocation.

Hypothesis

Elders moving to a nursing home given enhanced personal responsibility would demonstrate more physical and mental alertness, activity, well-being, and sociability than elders given less responsibilty.

Design and Procedure

Quasi-experimentor

Non-equivalent control group design

“Responsibility induced”vs

“Comparison”

Participants

•Drawn from two floors of a nursing home

•Subjects on the floors were of similar functional status and SES

•Whole floors in one condition or another

•91 ambulatory adults 65-90 yrs

47 in Responsibility-induced 44 in Comparison

Conclusions

Importance of free action and enhanced sense of control

What is the nature of this sense of control?

Mindfulness vs. mindlessness?

Do we have to be aware of the control we have?

Conclusions (cont’d)

18 month follow-up

Twice the mortality rate in the Comparison condition vs. Responsibility-induced condition (>30% vs. 14%)