Living at Home With Dementia

Most people with dementia who live at home have multiple unmet health and welfare needs, any number of which could jeopardize their ability to remain home for as long as they desire.

The researchers say routine assessments of patient and caregiver care needs coupled with simple fixes in the areas of safety -- grab bars in the bathroom, carpets safely tacked down to prevent falls, guns locked away -- and basic medical and supportive services could go a long way toward keeping those with dementia from ending up in a nursing or assisted-living facility. "Currently, we can't cure their dementia, but we know there are things that, if done systematically, can keep people with dementia at home longer," says study leader Betty S. Black, Ph.D., an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. "But our study shows that without some intervention, the risks for many can be quite serious."

Previous research has shown that greater unmet needs among people with dementia are predictive of nursing home placement and death. Caregiver stress also foretells of nursing home admission for people with dementia. The new study also finds most caregivers have multiple unmet needs, including lack of access to resources and referrals to support services and education about how to best care for their loved one.

Black says that paying for needs assessments and putting into place preventive safety measures isn't always feasible, and programs like Medicare don't typically cover them. "If they did," she says, "it may be far more cost-effective than long-term nursing home care."

An estimated 5.4 million people in the United States have Alzheimer's disease and other types of dementia, and 70 percent are cared for in the community by family members and friends. Most have mild to moderate dementia.

For the study, Black and her colleagues performed in-home assessments and surveys of 254 people with dementia living at home in Baltimore and also interviewed 246 of their informal, non-professional caregivers. They found that 99 percent of people with dementia and 97 percent of their caregivers had one or more unmet needs. Ninety percent were safety-related. More than half of the patients had inadequate meaningful daily activities at a senior center or at home, and one-third still needed a dementia evaluation or diagnosis.
Unmet needs fell into many categories including safety, health, meaningful activities, legal issues and estate planning, assistance with activities of daily living and medication management, Black says.

More than 60 percent of people with dementia in the study needed medical care for conditions related or unrelated to their dementia, a problem considering that those with dementia are more likely to have other serious illnesses for which they may eventually be hospitalized, Black says.
"This high rate of unmet medical care need raises the possibility that earlier care could prevent hospitalizations, improve quality of life and lower the costs of care at the same time," she says. Interestingly, unmet needs were significantly greater in those with higher cognitive function, most likely because many of them did not realize they had dementia and were not yet being closely cared for or monitored, Black says.

The researchers also found that African-Americans, those with lower income, those who were more independent in their basic daily living activities such as being able to feed and clothe themselves and those with more symptoms of depression had higher levels of unmet needs. Caregivers with less education and more symptoms of depression also had significantly more unmet needs. This suggests that identifying and treating depression in people with dementia and their caregivers may enable them to address their other unmet needs.

Why Women Are More Likely to Have Alzheimer's Disease?

Changes in the brain that happen after menopause may make women vulnerable to Alzheimer's disease, recent research suggests.

The hypothesis may explain why women are twice as likely to develop Alzheimer's disease after age 65 compared with men, the researchers say. (About 17 % of women in the U.S. over age 65 have Alzheimer's, compared with 9 % of men.)

Traditionally, researchers have believed that women's increased risk of Alzheimer's disease was due to the fact that women live longer, said Roberta Diaz Brinton, a professor of pharmacology, biomedical engineering and neurology at the University of Southern California's School of Pharmacy. However, women only live about four years longer than men, and Alzheimer's develops over decades, Brinton said.

Now, research from Brinton and colleagues suggests that, as women age, their brains experience a shift in the way they use energy. A woman's risk of Alzheimer's disease may, in part, be determined by how well it adapts to this energy shift, Brinton said.

"Just like the woman is going through a reproductive shift," Brinton said, "the brain is undergoing adaptations as well."

Brinton's studies on mice have shown that, during menopause, the cell's powerhouses, called mitochondria, become less efficient at producing energy. In addition, cells start to use fuel sources other than glucose, which is a sign that the energy system is not working well, Brinton said. The brain has the highest energy requirement of any organ in the body, using 20 % of the body's fuel, she said.

In a 2011 study, Brinton and colleagues removed the ovaries of mice and found that the subsequent loss of ovarian hormones such as estrogen harmed the mitochondria.

In both people and mice, declines in the brain's energy production have been shown to precede the development of Alzheimer's disease, Brinton said.

"Over time, the reduction in the ability to generate sufficient energy for the brain leads to, ultimately, an increased risk of developing Alzheimer's disease," Brinton said.

Brinton and colleagues are now conducting a clinical trial to see if a drug that promotes estrogen activity in the brain reduces cognitive difficulties in women going through menopause. The drug does not promote estrogen activity in other parts of the body, such as the breast, where the hormone has been shown to increase the risk of cancer.

The largest trial of estrogen therapy in postmenopausal women did not find that the therapy reduced the risk of Alzheimer's disease, Brinton said. But that may be because there's a window of time when the therapy is effective, Brinton said.

"If you treat a woman at age 65, her brain is no longer estrogen-responsive," Brinton said. The time to provide an estrogen therapy for cognitive benefits could be during menopause, when women are still experiencing symptoms, Brinton said.

Brinton said changes in brain metabolism likely increase the risk of Alzheimer's disease in men as well. However, men tend to experience hormonal changes, a stage known as andropause, later in life than women, Brinton said.

Divorce & Other Life Stressors Linked with Dementia

Common life stressors — such as divorce, widowhood or losing a job — may increase the risk of dementia later in life, a new study of women in Sweden suggests.

In the study, experiencing such psychosocial stressors in midlife was linked with a 21 % increased risk of developing  Alzheimer's disease, and a 15 %  increased risk of developing any type of dementia, over nearly four decades. The findings held even after the researchers took into account factors that may affect dementia risk, such as smoking habits, alcohol consumption and a family history of mental illness.

People who were exposed to psychosocial stressors were also at increased risk of experiencing prolonged periods of distress (or feelings of irritability, tension, nervousness, fear, anxiety or sleep disturbances). However, such distress could not fully explain the link between psychosocial stressors and dementia, meaning that the association may, in part, be due to biological factors that change in response to experiencing stressors, the researchers said.

"More studies are needed to confirm these results and investigate whether more interventions, such as stress management and behavioral therapy, should be initiated in individuals who have experienced psychosocial stressors," the researchers, from the University of Gothenburg.

Researchers analyzed information from 800 Swedish women who periodically underwent testing between 1968 and 2005. At the study's start, participants were asked whether they had experienced any of 18 psychosocial stressors, including whether their spouse or close relative had a mental illness or abused alcohol, or whether they or their husband had lost a job. Medical records and other information from psychiatric examinations were used to determine whether participants developed dementia over a 38-year period.

About a quarter of participants said they had experienced one psychosocial stressor, 23 % experienced two stressors, 30 % experienced three stressors and 16 %  experienced four stressors. The most common stressor was mental illness in a first-degree relative.

During the study period, about 20 % (153 people) developed dementia, 104 of whom developed Alzheimer's disease.

Psychological stress has been linked with increased production of inflammatory factors in the brain, and with an increased frequency of cardiovascular disease, and these, in turn, may be risk factors for dementia, the researchers said.

Exercise Beneficial for Dementia

Exercise may benefit older people with dementia by improving their cognitive functioning and ability to carry out everyday activities.

Due to people living longer, rates of dementia are expected to rise sharply in the coming decades. Dementia affects the brain in different ways and is associated with effects on memory and personality. It is thought that exercise might be useful in treating dementia or slowing its progression, through improvements in the ability to carry out everyday tasks and positive effects on mental processes such as memory and attention, collectively described as cognitive functioning. Exercise may therefore indirectly benefit family caregivers and the healthcare system by reducing some of the burden of dementia.

The study updates a Cochrane review carried out in 2008, when only four trials on the effects of exercise in older people with dementia were available. In the updated review, data from eight trials involving 329 people showed that exercise could improve cognitive functioning. Data from six studies involving 289 people showed that exercise could improve the ability of older people with dementia to carry out daily activities, such as walking short distances or getting up from a chair.

"In our previous review, we were unable to draw any conclusions about the effectiveness of exercise in older people with dementia, due to a shortage of appropriate trials," said researcher, Dorothy Forbes, an Associate Professor of Nursing who works at the University of Alberta in Edmonton, Alberta. "Following this new review, we are now able to conclude that there is promising evidence for exercise programs improving cognition and the ability to carry out daily activities. However, we do still need to be cautious about how we interpret these findings."

The researchers remain cautious because there were substantial differences among the results of individual trials. In addition, they did not find enough evidence to determine whether exercise improved challenging behaviours or depression in older people with dementia. They were unable to come to any conclusions regarding quality of life, or benefits for family caregivers and health systems, because there was not enough evidence.

However, the researchers suggest that if more evidence becomes available in future, it may help to address the question of whether exercise can help people with dementia remain at home for longer. "Clearly, further research is needed to be able to develop best practice guidelines to enable healthcare providers to advise people with dementia living at home or in institutions," said Forbes. "We also need to understand what level and intensity of exercise is beneficial for someone with dementia."