Category Archives: Caregiving – Dementia

Warning for those with dementia about anticholinergics

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Like Alzheimer’s Disease (AD), those with many other types of dementia have an imbalance of acetylcholine in the brain.  Anticholinergic drugs can be problematic for those with AD and non-AD dementias.

I saw this Q&A recently in my Dad’s AARP Health Care Options newsletter called fyi.

Robin

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Ask Dr. Reed ([email protected])
AARP Health Care Options fyi (newsletter)
Fall 2006

Question:  My husband has Alzheimer’s disease.  His pharmacist told me that certain medicines could further worsen his memory problems.  Any advice?

Answer:  …You are wise to take steps to ensure that your husband’s mental status is not worsened by the effects of his medicines.  As we have mentioned in previous columns, many of us become more sensitive to medicines as we age.  As a result, a variety of medicines could produce unanticipated effects that could worsen mental status and overall function.

Alzheimer’s disease is characterized by low levels of a chemical that transmits signals between nerves called “acetylcholine.”  As a result, medicines called “anticholinergic” drugs that block the effects of this nerve chemical can be especially problematic for people with Alzheimer’s disease.  Unfortunately, these drugs are very common.  They include:

* Certain antihistamines such as diphenhydramine (Benadryl)
* Certain antidepressants such as amitriptyline (Elavil) and doxepin (Sinequan)
* Medicines for bladder problems such as oxybutynin (Ditropan)
* Muscle relaxants such as carisoprodol (Soma), cyclobenzaprine (Flexeril), and methocarbamol (Robaxin)

I always say to write down the name of every medicine that you or your loved one is taking, and review this list regularly with your doctor and your pharmacist.

Caregiver Health (New Fact Sheet from Family Caregiver Alliance)

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Family Caregiver Alliance has a good newsletter called “Update.”  The Fall ’06 issue has an interesting article on caregiver health, a topic we should all take seriously!  Here’s an excerpt:

“A large and growing body of evidence has revealed that providing care for a chronically ill person can have harmful physical, mental, and emotional consequences for the caregiver.  As families struggle to care for their loved ones, their own health is jeopardized.”

The article is about the availability of a Fact Sheet on this topic called “A Population At Risk.”  This link might work to get to the Fact Sheet:

www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1822

This link might work to get to the article:

caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1840

The article follows along with some highlights from the new Fact Sheet.

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FCA Introduces New Fact Sheet on Caregiver Health
Update, a newsletter of Family Caregiver Alliance
Fall 2006, Volume 23, No. 4

A large and growing body of evidence has revealed that providing care for a chronically ill person can have harmful physical, mental, and emotional consequences for the caregiver. As families struggle to care for their loved ones, their own health is jeopardized.

This important public health issue has broad implications. Medical advances, shorter hospital stays, limited discharge planning, and expansion of home care technology have placed increased costs as well as increased care responsibilities on families, who are being asked to shoulder greater care burdens for longer periods of time. To make matters worse, caregivers are more likely to lack health insurance coverage due to time out of the workforce. These burdens and health risks can hinder the caregivers’ ability to provide care, lead to higher health care costs and affect their own quality of life as well as that of the care receivers.

FCA has introduced a new Fact Sheet discussing this significant issue. It describes the impact of caregiving on the mental and physical health of the caregiver, summarizes research from a variety of sources, and offers recommendations from a health and public policy perspective.

Studies indicate that caregivers:

  • suffer from high levels of stress and frustration
  • show higher levels of depression
  • may exhibit harmful behaviors
  • are in worse physical health than noncaregivers
  • may have increased risk of heart disease
  • have lower levels of self-care
  • may pay the ultimate price for providing care­increased mortality.

This new publication joins the FCA library of more than 60 Fact Sheets on caregiving issues, with many translated into Chinese and Spanish. All are available at no charge on the FCA website at www.caregiver.org, or send $2 for each copy to Family Caregiver Alliance, 180 Montgomery Street, Ste. 1100, San Francisco, CA 94104.

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Excerpts from:

A Population at Risk
Fact Sheet of Family Caregiver Alliance
Fall 2006

Evidence shows that most caregivers are ill-prepared for their role and provide care with little or no support.

Caregivers show higher levels of depression.  Depressed caregivers are more likely to have coexisting anxiety disorders, substance abuse or dependence, and chronic disease.

Research shows that female caregivers (who comprise about two-thirds of all unpaid caregivers) fare worse than their male counterparts, reporting higher levels of depressive and anxiety symptoms and lower levels of subjective well-being, life satisfaction, and physical health than male caregivers.  According to one study, there is a dramatic increase in risk of mental health consequences among women who provide 36 or more hours per week of care to a spouse.

Caregivers suffer from high levels of stress and frustration.

Stressful caregiving situations may lead to harmful behaviors.  As a response to increased stress, caregivers are shown to have increased alcohol and other substance use. Several studies have shown that caregivers use prescription and psychotropic drugs more than noncaregivers.  Family caregivers are at greater risk for higher levels of hostility than noncaregivers.  Spousal caregivers who are at risk of clinical depression and are caring for a spouse with significant cognitive impairment and/or physical care needs are more likely to engage in harmful behavior toward their loved one.

High rates of depressive symptoms and mental health problems among caregivers, compounded with the physical strain of caring for someone who cannot perform activities of daily living (ADLs), such as bathing, grooming and other personal care activities, put many caregivers at serious risk for poor physical health outcomes. Indeed, the impact of providing care can lead to increased health care needs for the caregiver.

Caregivers are in worse health.  About one in ten (11%) caregivers report that caregiving has caused their physical health to get worse.
The physical stress of caregiving can affect the physical health of the caregiver, especially when providing care for someone who cannot transfer him/herself out of bed, walk or bathe without assistance. Ten percent of primary caregivers report that they are physically strained.  Caregivers have an increased risk of heart disease.  Caregivers exhibit exaggerated cardiovascular responses to stressful conditions which put them at greater risk than noncaregivers for the development of cardiovascular syndromes such as high blood pressure or heart disease.

Women who spend nine or more hours a week caring for an ill or disabled spouse increase their risk of heart disease two-fold.

Caregivers are less likely to engage in preventive health behaviors.  Caregivers’ self-care suffers because they lack the time and energy to prepare proper meals or to exercise. About six in ten caregivers in a national survey reported that their eating (63%) and exercising (58%) habits are worse than before.

Caregivers pay the ultimate price for providing care—increased mortality.  Elderly spousal caregivers (aged 66-96) who experience caregiving-related stress have a 63% higher mortality rate than noncaregivers of the same age.  in 2006, hospitalization of an elderly spouse was found to be associated with an increased risk of caregiver death.

“Understanding Difficult Behaviors”- recommended book

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This post might be of interest to those who have loved ones with dementia — all of the LBD, some of the PSP, and some of the CBD (especially late stage) folks…

There are a couple of great books with practical suggestions on how to cope with Alzheimer’s Disease and similar illnesses. One is “Understanding Difficult Behaviors” by Anne Robinson, Beth Spencer, and Laurie White, 1989, published by Eastern Michigan University.

You can purchase the book at local offices of the Alzheimer’s Association, which are in Mountain View, Lafayette, San Rafael, Sacramento, Santa Cruz, etc.

The difficult behaviors this book deals with are: angry, agitated behavior; hallucinations, paranoia; incontinence problems; problems with bathing; problems with dressing; problems with eating; problems with sleeping; problems with wandering; repetitive actions; screaming, verbal noises; and wanting to go home.

Copied below are some excerpts from the four-page section on “Screaming, Verbal Noises.”

Robin

 

Excerpts from

“Screaming, Verbal Noises”
in
Understanding Difficult Behaviors
by Anne Robinson, Beth Spencer, and Laurie White
1989
Published by Eastern Michigan University

POSSIBLE CAUSES

Physiological or Medical Causes
* hunger
* incontinence (wetness, etc)
* need to go to the bathroom
* fatigue
* need for help changing position in bed or wheelchair
* vision or hearing loss that causes misperception of the environment
* impaired ability to speak or be understood
* acute medical problems that result in feeling ill or pain and discomfort

Environmental Causes
* too much noise
* overstimulation or sensory overload
* use of physical restraints
* upset by behavior of other residents

Other Causes
* procedures which are uncomfortable or not understood, such as having an enema, having a dressing changed, being catherized, etc.
* bathing – person may be cold or feel exposed
* dressing – person may be cold or feel exposed
* purpose of mouth care not understood
* touch/turning/repositioning – uncomfortable or not understood
* fear/anxiety
* feeling threatened
* need for attention
* frustration
* boredom/lack of stimulation

COPING STRATEGIES

* Have a good medical evaluation to check for illness, infections, pain/discomfort, or impaction

* Provide adequate meals/snacks to minimize hunger

* Institute regular toileting schedule to minimize incontinence

* Change promptly after incontinent episodes

* Try rest periods to minimize fatigue

* Make sure there are frequent (at least every 1-2 hours) position changes if person is bedridden or restrained in chair

* Maximize sensory input. (Check to see whether hearing aids and eyeglasses are in place and working properly.)

* Lower stress; create a relaxing environment:
– minimize noise
– avoid overstimulation/sensory overload
– avoid use of restraints
– play soft, soothing music

* Use relaxation strategies to minimize fear, threat, anxiety. For example:
– try massage/therapeutic touch, stroking person’s head, arms, hands
– try placing your arms around the person and gently rocking back and forth
– talk in a soothing voice
– play soft, soothing music or soothing sounds such as tape of rainfall, waves breaking on shore, etc.

* Try these communication suggestions:
– approach person with soothing voice; call person by his/her name; identify yourself
– explain/prepare person for what is to be done using simple, clear, short sentences
– break task into short steps briefly explaining each one
– think of other ways for the person to communicate, such as using a bell. This can enhance the person’s sense of security by feeling that he/she is able to communicate needs to caregiver

* For staff in long term care settings:
– use consistent routines for activities such as bathing, meals, getting ready for bed; keep to the same schedule each day
– identify staff who work well with certain individuals. Consistency in staffing is important.
– plan time to socialize with the person for a few minutes in addition to assisting with activities of daily living
– encourage participation in meaningful activities to minimize boredom and frustration.

* Softly read to person.

* Medication should be used cautiously when other interventions have been unsuccessful and when the vocal behavior is very stressful to the caregiver(s) and/or residents living in the area. This medication should be monitored carefully by a physician/psychiatrist.

OTHER CONSIDERATIONS

Vocal behaviors are most commonly seen in the later stages of progressive dementia. Many people who shout or cry out are physically immobile – wheelchair or bed-bound. The underlying problem is the person’s inability to communicate his/her needs, wishes, thoughts, etc.

 

“Depression, Delirium & Dementia” – lecture notes

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Stanford University (stanford.edu) sponsored a 3-part series on geriatric health in May.  The first evening, May 11, 2006, included this lecture:

“Depression, Delirium & Dementia: What Should We Be Doing?”
Speaker:  Barbara Sommer, MD, Asst Prof of Psychiatry and Behavioral Sciences, Stanford Univ

Local support group member Karen D. gave me her notes on the lecture.  This post attempts to summarize some of the key points in that lecture.

Robin

Dr. Sommer stated that life expectancy increases are not due to doctors but to infrastructure changes, such as indoor plumbing.

She stated that 27% of people older than 60 living in a community have some degree of depression.  Depressed people have two times the number of doctors’ appointments than others.  75% of elderly suicides have seen their doctors in the last month.  The rate of elderly white males is increasing.  Elderly women’s suicide rates drop to zero after they stop caregiving for their elderly spouses!

Of those with dementia, 64% have AD, 25% have Vascular Dementia, and 12-15% have Frontotemporal Dementia (FTD).

She mentioned that there are several drugs on the market to treat AD:  three acetylcholinesterase inhibitors (including Aricept) and Namenda.  The standard treatment is to prescribe one of the acetylcholinesterase inhibitors and add Namenda.  Glutamate is essential to the brain.  Namenda restores the glutamate levels to normal.

Dr. Sommer said that memory can be optimized through mental gymnastics, dance and tai-chi, avoiding medication that affects the brain, diet, avoiding obesity, avoiding stress, and optimizing near vision.

Medication that affects the brain includes some anticholinergics, benzodiazepams or sleeping pills, antihistamines, etc.

Those with a higher BMI (body mass index) have a higher risk of dementia. She pointed out that when you lose near vision, you lose stimulation and the ability to participate in activities.  Bottom line – lose weight and see your optometrist!

Dr. Sommer repeatedly noted the negative effects of stress.

Dr. Sommer said that delirium is reversible.  She distributed an article on “Preventing delirium in older people,” published 7/15/05 in the British Medical Bulletin.  You can find an abstract of the article online at no charge:

bmb.oxfordjournals.org/cgi/content/abstract/73-74/1/25

The article states that:

“Up to 50% of delirium affecting older people develops after admission to (the) hospital.  These cases often result from hospital-related complications or inadequate care.” 

The paper focuses on how to prevent the delirium that is acquired in the hospital and is preventable.

 

“Cognitive Changes w/Aging” and “Maintaining Health” – lecture notes

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Stanford sponsored a 3-part series on geriatric health in May. The second evening, May 18, 2006, included two lectures:

“Cognitive Changes With Aging: How Much Is Too Much?”
Speaker: Michael Greicius, MD, MPH, Dept of Neurology, Memory Disorders, Stanford Univ

“The Big Picture of Maintaining Health — Medications, Tests and Safety At Home”
Speaker: Yusra Hussain, MD, Dept of Internal Med, Geriatrician, Stanford Hospital & Clinics

This email attempts to summarize some of the key points in those lectures and provide a web link to the handout.

Dr. Greicius said that one-tenth of people over 65 have Alzheimer’s Disease. One-third of people over 85 have AD. 70% of the dementia cases are AD. The most common non-AD dementias are Vascular Dementia, FTD, and LBD. According to the “nun study,” the more education you have, the less impaired you are than someone with less education for the same degree of AD.

There is a disorder known as Mild Cognitive Impairment (MCI). Half of those with MCI convert to AD every four years. Scientists are looking into who will convert and how this can be prevented. Neither Vitamin E nor Aricept helped treat MCI.

There are many reversible causes of memory loss including B12 deficiency, low thyroid, medication (anticholinergics including some medications for urinary incontinence, beta-blockers, enzodiazepines, opiates, anti-epileptics, some medications for neuropathy), depression, alcohol, and retirement.

In general, people in their 50s and 60s can handle less than half the alcohol they could handle in their 30s.

There are some cognitive IMPROVEMENTS with normal aging: emotionality, semantic knowledge (knowledge of the world), and vocabulary.

Dr. Greicius spoke about cognitive decline with normal aging. Related to that topic, he distributed an article from the journal Nature Review Neuroscience, Feb ’04, titled “Insights into the Ageing Mind: A View from Cognitive Neuroscience.” He said this was an excellent review of the topic. An abstract of the article can be found at: (The full article costs $30.)
http://www.nature.com/nrn/journal/v5/n2/abs/nrn1323_fs.html

What can be done to minimize cognitive decline? His guesses include living healthy, moderate alcohol consumption, and no cigarettes. He explored the possible role of NSAIDs and cognitive training in minimizing decline.

His recommendations include: all things in moderation; minimize cardiovascular risk factors; sell your TV; read, dance, exercise; spend more time with friends and family; participate in medical research. Two journals did a review of ginkgo biloba studies. They showed no benefit. He doesn’t recommend taking extra Vitamin E.

Dr. Greicius said that there is a GRAIN of truth only to the layperson’s notion that for the clock test (part of the 4-hours of neuropsychological testing) those with AD can draw the clock and those with LBD cannot. He said that generally speaking those with LBD have visuospatial impairment early on, which is why they can’t draw the clock. But not all those with LBD have visuospatial impairment at the time of diagnosis. Another point: those with late stages AD can’t draw the clock either.

Dr. Hussain said that most people get a serious chronic condition at the age of 55. These can include geriatric syndromes, which are urinary incontinence, MCI, and depression.

If you think your health is excellent, you will live longer. If you think your health is merely good, your lifespan is normal/average.

About half of all deaths are attributable to preventable factors.

A healthy lifestyle includes: maintaining social life; being active each day; eating well; avoiding tobacco and excessive alcohol intake; following up on periodic health examinations and screening tests.

The best diet is rich in fruits, vegetables, whole grains, and nuts. One should have moderate consumption of polyunsatured fatty acids, omega 3 fatty acids, protein and dairy. One should have low consumption of carbs and animal fats. She does not recommend taking a multi-vitamin with antioxidants as a supplement. She says that antioxidants should be part of the diet.

In order to maintain cognitive function, she said that the “nun study” shows that it’s important to have a purpose in life and to stay busy with family and friends.

Frailty cannot be reversed.

That’s it! I didn’t attend the third lecture nor was I very interested in it so I won’t be emailing out notes from that one.

Regards,
Robin