In September 2008, the International Journal of Geriatric Psychiatry published an interesting article: Smell test predicts performance on delayed recall memory test in elderly with depression. Who would’ve thought that a smell test might be a tool to forecast cognitive impairment. But it turns out that the elderly, particularly those diagnosed with depression, have an increased risk for cognitive dysfunction and dementia.

According to sensonics.com, Sensonics, Inc. tests can be used to detect smell loss but cannot be used alone to diagnose disease. Smell and taste monitor the intake into the body of all nutrients and airborne chemicals required for life.

Here is an abstract of the study that was done.

Purpose

To assess the validity of the CC-SIT (Cross-Cultural Smell Identification Test) as a screening test for cognitive impairment in elderly with depression.

Methods

Forty-one patients, aged 60 and over, were assessed with the CC-SIT and CVLT (California Verbal Learning Test) after three months of treatment of a Major Depressive Episode (DSM-IV) at the Day Hospital for Depression, Baycrest. Patients already diagnosed with dementia, or other psychiatric and neurological disorders, were excluded. Receiver Operating Characteristics (ROC) analysis was applied to assess the CC-SIT’s accuracy in identifying individuals with impairment (2 SD below the mean for age and education or less) on CVLT delayed recall trials.

Results

Forty-one patients (33 women and eight men) were assessed. Mean age was 76.8 (SD: 6.5), mean HRSD scores before treatment was 22.0 (SD: 5.1). Nine patients had impairment on CVLT delayed recall measures. The area under the ROC curve was 0.776 (95% CI = 0.617-0.936).

Conclusions

Our results support the use of the CC-SIT as a screening tool for cognitive impairment among elderly with depression as an indicator for the need of a comprehensive neuropsychological evaluation. Replication with larger samples is necessary. Copyright © 2008 John Wiley & Sons, Ltd.

The American Journal of Alzheimer’s Disease and Other Dementias recently reported in an open-label pilot study that apple juice improved behavioral, but not cognitive symptoms in moderate-to-late Alzheimer’s disease patients. Although this was a very small study of only 21 institutionalized patients who drank two 4-ounce glasses of apple juice twice a day for a month, the study suggests that apple juice may be a useful nutritional supplement since, as Alzheimer’s disease (AD)  progresses, the mood of AD patients may decline as well. It may help ease the burden for caregivers.

The study said, “Caregivers reported an approximate 27% (P < .01) improvement in behavioral and psychotic symptoms associated with dementia as quantified by the Neuropsychiatric Inventory, with the largest changes in anxiety, agitation, and delusion.”

Exactly how apple juice might help remains unclear. It’s possible that the antioxidant nutrients in the apple juice reduces the oxidative damage to the brain tissue.

Since this was a very small study funded by the apple industry with no placebo, the conclusions need to be viewed with caution. However, given that apple juice is a healthy and inexpensive beverage, it would seem a positive thing for caregivers to try.

Continuing my highlights of Alzheimer’s Care with Dignity by Frank Fuerst, in today’s post I list 6 caregiver products that Fuerst considers specifically helpful for people with dementia. You may be able to get them free or at a reduced cost. Ask your contacts such as members of your support group or see if it’s a Medicare-qualified item.

Consult his guide for a complete list, but the following are those that solved major physical and psychological challenges for him. Having gotten them sooner he feels would’ve prevented a good deal of stress.

1. Bathroom transfer bench
2. Geriatric chair
3. Plastic runner
4. Hand-held shower
5. Stair lift
6. Wheelchair

A bathroom transfer bench is one where two legs remain inside of the tub with suction cups and two legs are outside of the tub.  It comes with a backrest. Since the person remains seated while bathing, a hand-held shower works well. (Hand-held showers work well for cleaning the tub as well).

A geriatric chair is like a wheelchair except that it is larger and more comfortable. Get one with a tray that can swing down and out of the way.

Plastic runners will help to keep your carpet in good condition in case of accidents. They have spikes on the bottom to hold it in place. Not all plastic runners are alike even though they may look alike. Since you need to walk on the runner, a softer plastic might be more  comfortable than a stiffer one. Use them in areas where there are likely to be accidents such as from the bed to the bathroom and in eating areas.

Stair lifts are expensive, but might still be a less costly alternative to other home alterations. Fuerst suggests that you check the Internet. One source is http://silvercross.com for more information. They also sell used equipment and will buy back equipment, but don’t expect to recover much of your purchase price.

Finally, wheelchairs are available everywhere, but if you’ve never ridden in one, they are not exactly comfortable. Be sure to add a cushion, preferably a high quality gel cushion as mentioned in this post.

Caregiving at a Glance

The Alzheimer’s Family Day Center has a wonderful booklet for Alzheimer’s disease caregivers called Caregiving at a Glance. It’s designed with tabs that you can simply slip your finger under and get to the information you need. Sample topics covered include:

• Sleeping
• Bathing
• Car and Home Safety
• Activities … What to do Between Meals
• Hostility and Aggression

On the topic of “Wandering,” for example, they suggest you register your loved one with the Safe Return program sponsored by the Alzheimer’s Association. You can call them toll-free at 1.888.572.8566 or on the Web at www.alz.org/safereturn.

“Troublesome Behaviors” is another section of this booklet. This covers a wide gamut, but they talk about things like screaming, repetitive phrases, or picking at clothes, tearing paper into tiny shreds, and other behaviors that develop in the middle to the late stages of the disease.

This wonderful resource is available at the Alzheimer’s Family Day Center by calling 703.204.4664 or e-mailing them at AFDC@alzheimersfdc@org.  The booklet is free – one copy per person. It was published with the permission of the Alzheimer’s Association. The project was supported, in part, by a grant from the Administration on Aging, Department of Health and Human Services, Washington, DC, 20201.

Blanchette Rockefeller Neurosciences Institute

Today there are no reliable tests to determine conclusively if a person has Alzheimer’s disease (AD). However, there are several breakthrough tests on the horizon that have us hopeful that soon we may have an accurate test to diagnose Alzheimer’s disease. That’s a good thing. On an emotional level, though, sometimes I wonder if I really want to know. I prefer to not know and simply do all that I can to prevent it. (Click here for examples). There are several institutions and companies working on breakthrough tests and in this post I will cover what’s happening at the Blanchette Rockefeller Neurosciences Institute (BRNI) at West Virginia University and Inverness Medical Innovations.

At the Blanchette Rockefeller Neurosciences Institute (BRNI), the only non-profit independent institution in the world dedicated to the study of human memory and memory disorders, they located a biomarker that can be tested witout the invasive procedures previously required.  A biomarker is an objective, biological measure that is used to assess health or make a diagnosis of disease. The BRNI biomarker had a 98 percent level of accuracy in detecting AD. With the prick of a finger, it detects defective enzymes involved with memory function that are found in both brain and skin cells.

What is really exciting is that researchers discovered that low doses of the chemotherapy drug, bryostatin, reactivates the defective enzymes. It can actually rewire broken connections in the brain and restore memory! This means that it could be used to reverse the brain diseases. Clinical trials in people will start this year.

Center for Molecular and Behavioral Neuroscience

The Center for Neuroscience at Rutgers University – Newark publishes a wonderful newsletter, Memory Loss and the Brain. In the Winter 2010 issue, one of the articles is on Parkinson’s disease. Although Parkinson’s is known as a movement disorder which affects how they walk  — slowly with a stiff gait — as well as possibly producing tremors, it also affects memory, learning, and behavior. Alzheimer’s disease and Parkinson’s disease have similarities such as:

• Both develop slowly over many years
• Both tend to develop later in life
• Both are currently incurable
• Both affect the brain

As a neurological disorder, Parkinson’s disease affects the part of the brain that controls muscle movement. The neurons that make dopamine, a chemical that helps your body coordinate movements, die. As a neurotransmitter, dopamine is essential for the central nervous system to function. Medications are prescribed that increase the amount and effectiveness of dopamine in the brain. However, medications can cause serious cognitive side effects and even possibly addictions such as gambling and overeating.

Unlike Parkinson’s, the cause of Alzheimer’s disease is not as specific. It may be a composite of causes. Medications are available as mentioned in a previous post, but they only work temporarily to slow down the disease and they don’t address the underlying causes. It is difficult to develop effective treatments when the exact cause is not known.

In both cases, lifestyle choice might make a difference. There is growing evidence that aerobic exercise improves memory and various other brain functions … even modest exercise. Click here to see an amazing video of a Parkinson’s patient riding the bicycle. Besides exercise, a healthy diet — one low in “lousy” cholesterol (LDL) and high in fruits, vegetables, and fatty fish — can help possibly prevent dementia. Mental activities that you enjoy and challenge you is possibly another preventive.

We all hope that cures for Alzheimer’s disease and Parkinson’s disease will be found. In the meantime, we can only do what the evidence tells us might possibly help.

I recently had a chance to have lunch with a couple who had just had a month of caregiver duties for her mom to give her sister (primary caregiver) some time off. Steve put his engineering background to work and devised an ingenious contraption which I asked him to share. He wrote this delightful piece which shows caregiver creativity in caring for his mother-in-law with Alzheimer’s disease.

PERCHANCE TO SLEEP ALL NIGHT
The more we talk to fellow Alzheimer’s family caregivers, the more we hear about sleep challenges.  Successfully managing those challenges has, of course, two-fold benefits — if your patient sleeps well, they do better during the day, and so do you.

We live those challenges when we take care of my mother-in-law, normally for only a month at a time.  Admittedly, that’s not a major load.  BUT you have to understand how important sleep is to my wife.  Nighttime interruptions are the snails on the cabbage of slumbering bliss.

For Mom’s recent visits, her first week or two of nights were disorienting, compounded by an inability to tell the time (either digital or hands on a clock).  And since nearly all activities such as reading and TV watching are not favored, the only activity she believed she could engage in was eating.  So, after an unsupervised 2:00 a.m. gustatory session with half a pound of corned beef (which gives cream-colored carpet lovely splotchy foot-applied tattoos), it was time to take preemptive action instead of spending an hour every morning spot cleaning.

My solution was to catch her in the act and rely on her fortunate good nature to be convinced it was not time to rise and shine and dine.  It was a bit like trying to defeat squirrels at a bird feeder … if at first I didn’t succeed, I wasn’t worth my salt as an engineer.  The solution evolved to clamping a $35 outside motion detector to the top of the vacuum cleaner, positioning it outside Mom’s bedroom door, and plugging the bell alarm within my earshot (but out of my wife’s dream-addled earshot).  When the motion alarm goes off, downstairs I shoot and one glance at me sends her back to bed without much argument.  Eventually, she learned that when the lights are not on, an undeniably under-dressed man will not appear and she would do better to go back to sleep.

For the last two weeks of her visits, we are all lucky enough to sleep soundly.  But then, didn’t somebody once say, “Luck is the residue of good planning”?

Continuing to use the stages as defined by the Alzheimer’s Association, Stage 6 is severe cognitive decline or also defined as moderately severe/mid-stage Alzheimer’s disease. As memory difficulties continue to worsen, significant personality changes may emerge and affected individuals need extensive help with customary daily activities. At this stage, individuals may:

• Lose most awareness of recent experiences and events as well as of their surroundings

• Recollect their personal history imperfectly, although they generally recall their own name

• Occasionally forget the name of their spouse or primary caregiver but generally can distinguish familiar from unfamiliar faces

• Need help getting dressed properly; without supervision, may make such errors as putting pajamas over daytime clothes or shoes on wrong feet

• Experience disruption of their normal sleep/waking cycle

• Need help with handling details of toileting (flushing toilet, wiping and disposing of tissue properly)

• Have increasing episodes of urinary or fecal incontinence

• Experience significant personality changes and behavioral symptoms, including suspiciousness and delusions (for example, believing that their caregiver is an impostor); hallucinations (seeing or hearing things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue shredding

• Tend to wander and become lost

One of the common problems is that the Alzheimer’s patient sleeps during the day and is awake at night. What a challenge for the caregiver. Can you imagine having your sleep interrupted every night? I do remember dad getting up at night and wandering around the house and needing help getting back to bed. I was always afraid that he would not know who I was and hit me. (He was a boxer in his youth). I could feel myself tensing up.

The big fear is your loved one wandering and becoming lost. In dad’s case, doors were always locked and someone was always watching him. However, many times when we’d take him out and upon returning, he would say he wanted to go home. No amount of convincing him that we were indeed at his home, was believable to him, but a short drive around the block and back home was generally enough to convince him. Of course, he could never tell us what “home” meant. His childhood home? His previous home? If only it was possible to read his mind to determine what he was trying to communicate.

According to the Alzheimer’s Association, there are seven stages of Alzheimer’s disease. In stage 5, there is moderately severe cognitive decline. This is the moderate or mid-stage Alzheimer’s disease. The Alzheimer’s Association says:

Major gaps in memory and deficits in cognitive function emerge. Some assistance with day-to-day activities becomes essential. At this stage, individuals may:

• Be unable during a medical interview to recall such important details as their current address, their telephone number or the name of the college or high school from which they graduated

• Become confused about where they are or about the date, day of the week or season

• Have trouble with less challenging mental arithmetic; for example, counting backward from 40 by 4s or from 20 by 2s

• Need help choosing proper clothing for the season or the occasion

• Usually retain substantial knowledge about themselves and know their own name and the names of their spouse or children

• Usually require no assistance with eating or using the toilet

Life becomes quite a challenge for the primary caretaker at this point. I was not the primary caregiver; my mom was, but my sister and her family lived in the same house so she was always available to assist. Mom never had a break, but each summer I would go to assist when my sister and her family went on vacation.

I do remember dad being frustrated with his situation at this point and he voiced his frustration. It is such a helpless situation. He definitely recognized me at this point and I remember the big smile he had to see me, although he wondered how I had gotten there.