Mar 092012
 
woman

This post originally appeared on the ChicagoNow blog, “Ask Dr. Chill: Practical Answers to the Toughest Caregiving Questions.” It is being reposted here with the author’s permission.

Almost eight years at the Alzheimer’s Association — five at the Utah Chapter and close to three at the National Office right here in Chicago — left equally enduring imprints on my mind and heart. The mental imprint is analytical, bridging science and people in the shape of a fervent belief that a cure is inevitable.

The imprint on my heart is much different. It’s in the form of my own grandmother, who died of complications from Alzheimer’s disease and vascular dementia at the age of 89. It’s a delicate imprint, and it still hurts sometimes, even though she died more than 20 years ago. I see her face in almost every person I meet who has the disease.

It is because of these imprints that I took great interest in the Alzheimer’s Association’s recent release of its 2012 Alzheimer’s Disease Facts and Figures Report. This compendium of facts is impressive and startling. For a very cool visual summary of the toll that Alzheimer’s disease takes on individuals, caregivers, families, and the health care system, check out this 2-minute video marking the report’s release:

It gave Dr. Chill the chills…and some tears. According to the report, there are more than 15 million caregivers in the United States caring for someone with Alzheimer’s or a related dementia. In 2011, they provided over 17 billion hours of care valued at more than $210 billion.

But here’s the thing that really disturbs me. Caregivers don’t only care for people with Alzheimer’s disease and other dementias. There are caregivers for people with cancer, diabetes, heart disease, lung disease and those who had a stroke among other health complications. Some of you reading this blog may be caring for someone with a developmental or physical disability. Others might be taking care of someone who is simply having trouble maintaining independence due to the normal course of aging.

The numbers in the Alzheimer’s Association’s report are stunning, but they paint just one swath of the caregiver landscape. I started to wonder how much of the landscape remained. Some digging turned up a 2009 report—the most recent I could find that provides general numbers — compiled by the National Alliance for Caregiving and AARP. Caregiving in the US states there are 65.7 million caregivers in the United States caring for someone who is aged, disabled, and/or ill. Now that’s really stunning.

Remember that mental imprint I described? The analytical, more objective one. When I hear these kinds of numbers, my mind turns toward concepts of magnitude, awareness, research, the badly mired health care system, graphs, charts, grant proposals, and yes, cool videos that send shivers down my spine. In other words, I see the big picture.

But if you recall that other, more subjective imprint inside me — the one on my heart — I see a different vision. Try to imagine these massive numbers melting together into an indecipherable glob of hurt. What I see is one caregiver, one that represents the hundreds I’ve known over the years. She is tired, distraught, scared and doesn’t know where to turn for help. She feels incredibly alone. Yet she is not alone. As we’ve learned, she is literally in the company of millions.

It’s a bittersweet reality.

About Guest Blog Author Carrie Steckl, Ph.D.

Carrie Steckl, Ph.D. is a freelance writer specializing in caregiving, psychology, and aging. Her blog, “Ask Dr. Chill,” provides practical answers to the toughest caregiving questions.

 

Mar 112011
 

I recently attended an event hosted by the American Heart Association and Go Red Chicago, where a panel of physicians and healthcare providers discussed the effect of diet, hormones and cardiovascular risk factors on the heart and brain. The physicians also touched on emerging data that suggest there may be racial/ethnic differences in the prevalence and effects of cardiovascular risk factors to the development of heart disease and brain functioning in these diverse populations. Thus, I was very interested in reading the following article from Korea that examined the effects of vascular risk factors in mid and late life to dementia risk.

The initial study population included over one million persons aged 30-95 years who participated in at least one biennial National Health Insurance Corporation (NHIC) medical evaluation between 1992 and 1995. The NHIC provides health insurance to government employees, teachers and their dependents and it was estimated that at the time of this study, approximately 11 percent of the Korean population was insured by this organization. Persons were excluded from the study if they reported having cardiovascular disease, cancer, liver disease prior to their initial visit, or if they had missing data on any study variables. Thus the final sample size for this study was 848,505 participants, aged 40 years or older, followed for up to 14 years.

As is typical with many studies focusing on cardiovascular disease, questions regarding history of cigarette use and alcohol consumption were obtained along with height, weight (for body mass index calculations) and blood pressure. Fasting blood samples were obtained for both serum glucose and serum cholesterol. The specific criteria for hypertension were a systolic blood pressure of at least 140 mmHg or a diastolic blood pressure of at least 90 mmHg. Cholesterol was characterized as “desirable” if the serum cholesterol was 200 mg/dl, “borderline high” if it was between 200-239 mm/dl, and “high” if it was greater or equal to 240 mg/dl. Diabetes was defined as a fasting serum glucose level of 126 mg/dl or higher.

As this was a large sample of persons evaluated in clinical hospitals, the main variable of interest was a dementia diagnosis. For these analyses, the dementia categories included Alzheimer’s dementia (AD), Vascular dementia (VaD), and “unspecified” dementia.

Of the 848,505 persons who were evaluated at the baseline examination, there were 358,060 women (age at baseline 53.6 yrs) and 490,445 men (age at baseline 51.9 yrs). The entire population had a low level of body mass index. Both cigarette smoking and alcohol consumption were more common in men compared to women. During the 14 years of follow up, 3,252 persons were hospitalized for issues related to dementia; the majority of those dementias were listed as Alzheimer’s. Increasing dementia incidence of Alzheimer’s was noted as age increased, peaking at the ages of 75-80 years, then decreasing at older ages.

In both women and men, diabetes was associated with all types of dementia, and appeared to be higher for VaD than Alzheimer’s in women. Hypertension (HTN) was also associated with all dementias; strongly associated with VaD in men, but did not appear to be associated with Alzheimer’s in women. In both groups total cholesterol was not associated with dementia.

Further analyses were conducted measuring the impact of vascular risk factors measured in midlife (<65 years old) compared to later (>65 years old). Diabetes appeared to be associated with Alzheimer’s in both the younger and older age groups for men, whereas smoking was associated with Alzheimer’s in midaged men (< 65 years) compared to older men (> 65 years). HTN had a strong association with VaD in both men and women before and after 65 years old. There were no notable interaction effects between HTN and diabetes on the risk of dementia for either gender.

This study in the Korean population supports data from Western population studies, suggesting that diabetes and HTN are important risk factors for the development of both Alzheimer’s and VaD. Further, this large study also suggests that vascular risk factors in midlife appear to have a higher risk for dementia development as compared to later risk factors. One limitation of the study, as noted by the authors, was the relatively high rate of “unspecified dementia cases” (36 percent for men, 39 percent for women) which could affect the strength of these associations. Nevertheless, this study provides support that there is an increased risk of dementia associated with these factors in this Asian population, and highlights the need for aggressive vascular risk reduction treatment as a dementia prevention method.

Thanks for reading.

Neelum T. Aggarwal, M.D.
Steering Committee Member, ADCS
This post originally appeared in Alzheimer’s Insights, an ADCS Blog.

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Jan 162011
 

Dear Readers,

I was recently on a conference call with women physicians discussing the latest in Women’s Health and was asked about vitamin D and its effect on cognition. Indeed vitamin D has received a lot of media attention lately; attention focused on its potential effect on cardiovascular and bone health, in addition to its anti-inflammatory and anti-oxidative effects. Thus, it was not a surprise to me when the discussion turned to “cognitive health” and whether or not (1) vitamin D levels were associated with cognitive function and (2) whether its supplementation would provide an “added cognitive benefit” to female patients.

At the time the question was posed, I immediately thought about an article I read in Neurology that examined whether weekly dietary intake of vitamin D was associated with cognitive function in older women. Participants in this study came from the EPIDOS, a French community dwelling cohort study that was designed to evaluate the risk factors for hip fracture among women aged 75 years and older. Over a course of two years (1992- 1994) over 7000 women – free of a previous history of hip fracture or hip replacement – were recruited from five French cities to participate in this study. At baseline evaluation all participants received a full medical examination, which consisted of structured questionnaires, information about everyday dietary habits, chronic diseases, disability, sun exposure and a clinical examination. Medications and vitamin supplements were reported by interviewer questions and also by direct inspection of medications brought to the visit. Women were excluded from the study if over the last 18 months they had taken vitamin D drug supplements. A total of 5,596 women met the inclusion criteria and analyses were based on this sample size.

Dietary habits were assessed at baseline examination using a 21 question food frequency questionnaire that included questions on intake of fish (two items), dairy intake (six items) and the consumption of eggs, fruits, vegetables, starchy foods, chocolate and drinking history. The dietary intake of vitamin D per week was calculated by multiplying the content of individual food items (across all areas) by the frequency of consumption and adding this together. The vitamin D content for all food items was based on a dietary content database – continually updated by the French food and safety agency. For the French adult population, the dietary intake of vitamin D was 400 IU /day (or 35 micrograms/week). The assessment of cognitive function used– the Pfeiffer Short Portable Mental State Questionnaire (SPMSQ). This is a 10 item measure that has been in use in large scale studies as a screening tool to assess moderate to severe cognitive deficits. A score of 8 or below indicates cognitive impairment.

Although the mean weekly dietary intake of vitamin D for the entire group was well above the suggestive value of > 35 micrograms/week (mean 62.3 micrograms/week), approximately 14% of the women had inadequate dietary intakes of vitamin D. Based on the cognitive testing results, a total of 11% of the women were deemed to have cognitive impairment. Further, women who had lower levels of weekly vitamin D intakes had lower mean SPMSQ scores. These women were also older and reported more disability on a disability scale. To further examine the association between weekly vitamin D intake and cognitive function, other factors such as body mass index, sun exposure, number of chronic diseases, history of hypertension, depression, disability or use of antidepressants or other medications, were controlled for in their analyses. The association between dietary vitamin D and cognitive function remained significant even after adjusting for all of these factors.

Although the mean weekly dietary intake of vitamin D for the entire group was well above the suggestive value of > 35 micrograms/week (mean 62.3 micrograms/week), approximately 14% of the women had inadequate dietary intakes of vitamin D. Based on the cognitive testing results, a total of 11% of the women were deemed to have cognitive impairment. Further, women who had lower levels of weekly vitamin D intakes had lower mean SPMSQ scores. These women were also older and reported more disability on a disability scale. To further examine the association between weekly vitamin D intake and cognitive function, other factors such as body mass index, sun exposure, number of chronic diseases, history of hypertension, depression, disability or use of antidepressants or other medications, were controlled for in their analyses. The association between dietary vitamin D and cognitive function remained significant even after adjusting for all of these factors.

This study nicely demonstrates that in women free of vitamin D drug supplementation, weekly dietary intake of vitamin D was significantly associated with the cognitive performance. Few studies have examined the association of dietary vitamin D to cognition in a large population sample. Such studies are needed to clarify whether the associations reported in this study exist in other populations (i.e. U.S. based and those that involve substantial numbers of minority participants) and will guide future research as to whether or not to persue large scale clinical trials that examine the benefits of vitamin D supplementation to treat or prevent cognitive impairment.

Here are 3 articles you can refer to, to learn about this particular study or the latest research on vitamin D and cognitive function:

Dec 152010
 

According to researchers at Columbia University, people with high levels of HDL cholesterol (the “good” form) are 60 percent less likely to develop AD. The researchers followed 1,130 seniors with no history of memory loss or dementia and measured their cholesterol levels every 18 months for four years. When the researchers compared the cholesterol levels of study participants with and without Alzheimer’s, they found that those with the highest HDL counts, greater than 55 mg/dL, had about a 60 percent reduced risk of developing the disease compared to those whose levels were less than 39 mg/dL.

Their findings support the theory that high levels of HDL cholesterol are correlated with lower incidence of AD. The study was published earlier this week in the Archives of Neurology and sheds more light on the interactions between cholesterol and AD.

Apolipoprotein E (apoE), as readers of this blog will recall, participates in the mobilization and distribution of cholesterol among various tissues of the body, including the brain. In humans, there are three common isoforms of apoE: apoE2, apoE3 and apoE4. ApoE4 differs from apoE3, the most common isoform of apoE. A single e4 allele is sufficient to increase the risk of developing atherosclerosis, and also Alzheimer’s disease. The e4 allele results in slightly elevated plasma LDL cholesterol levels and a small but significant decrease in plasma HDL levels. HDL is one of the major carriers of protein in and out of the brain, and also binds to beta-amyloid.

This finding further advances the idea that the interplay between cholesterol, cholesterol-carrying proteins such as apoE and HDL, and beta-amyloid may be critical in the development of Alzheimer’s disease. This study has important strengths. It is a prospective cohort study designed for the diagnosis of cognitive decline that has complete clinical and neuropsychological evaluation at each interval.

Guidelines recommend that men raise HDL levels that are less than 40 mg/dL and that women increase HDL numbers less 50 mg/dL. An HDL of 60 mg/dL or higher is optimal.

Michael S. Rafii, M.D., Ph.D.
Associate Medical Director, ADCS Medical Core
This post originally appeared in Alzheimer’s Insights, an ADCS Blog.

* Association of Higher Levels of High-Density Lipoprotein Cholesterol in Elderly Individuals and Lower Risk of Late-Onset Alzheimer Disease. Christiane Reitz et al., Arch Neurol. 2010;67(12):1491-1497.

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Nov 022010
 
Confused Lady

Dear Readers,

Whenever I give a presentation about the signs and symptoms of Alzheimer’s disease and discuss the known risk factors for the disease, I am asked this question . . . ( 90% of the time by the women audience members) . . . “Dr. A, is stress a risk factor for Alzheimer’s disease?”

Well, based on research findings from a variety of studies, the short answer is “Yes.” Let’s consider the latest finding from a study that revealed that stress in middle-aged women could lead to the development of dementia later on in life.

This research is based on a 35-year-study of 1,415 women from the Prospective Population Study of Women in Gothenburg, Sweden. The women were initially examined in 1968 (ages ranged from 38 years to 60 years), and then re-examined in the following cycles: 1974, 1980, 1992 and 2000. In addition to neuropsychiatric tests and questions on activities of daily living, the following question was asked by a physician to measure the level of stress in the first three cycles of data collection: “Have you experienced any period of stress (one month or longer) in relation to circumstances or everyday life, such as work, health or family situations?”

The measure of “stress” was defined as a sense of irritation, tension, nervousness, anxiety, fear or sleeping problems. Participants were asked to choose “0” if they never experienced stress, “1” if they have experienced stress more than five years ago, “2” if have experienced one period of stress during the last five years, “3” if they have experienced several periods of stress during the last five years, “4” if they have constant stress during the last year, or “5” if they have experienced constant stress during the last five years.

In addition, data was collected on a variety of factors (i.e. confounders) that may affect the association of stress to dementia, such as lifestyle factors (smoking and wine consumption), coronary heart disease, blood pressure and use of antihypertensive medication.

Participants were classified as having dementia at each cycle if they fulfilled the criteria put forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The diagnosis of Alzheimer’s disease was based on criteria put forth by National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association. The diagnosis of vascular dementia was based on the criteria proposed by the National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et 1″Enseignement en Neurosciences.

Of the women initially assessed in 1968, 161 developed dementia during the follow-up period of 35 years (105 diagnosed with Alzheimer’s disease, 40 diagnosed with vascular dementia, 16 with another type of dementia). The average age of dementia onset was 76 years. Stress that was rated as “frequent/constant” at the baseline and follow up cycles (1968, 1974 and 1980) was related to increased risk of developing dementia and these associations did not change when adjusted for potential confounding variables.

In addition, among women who participated in all three examinations, the risk of dementia increased with the number of examinations when stress was reported. Compared to a woman who never reported stress, if a woman reported stress at one examination cycle her risk for dementia was 1.10, if she reported stress at two examination cycles her risk was 1.73, and if she reported stress at three examination cycles the risk of dementia rose to 2.51.

These findings suggest that long standing psychological stress in middle-aged females is related to the development of dementia later in life. How the present findings could result in a better understanding of the risk factors for dementia and Alzheimer’s disease will need to be confirmed in studies that aim to study the potential neurobiological mechanisms for these associations.

Here are three articles you can refer to, to learn about this particular study or research in the area of Stress and dementia.

Johansson L, Guo X, Waern M et al. Midlife psychological stress and risk of dementia: a 35 year longitudinal population study. Brain,2010.

Hange D, Bengtsson C, Sundh V et al. The natural history of psychosomatic symptoms and their association with psychological symptoms: observations from the Population Study of Women in Gothenburg. Eur J Gen Pract 2007.

Wilson RS, Evans DA, Bienias JL et al. Proneness to psychological distress is associated with risk of Alzheimer’s disease. Neurology 2003.

Thanks for reading.

Neelum T. Aggarwal, M.D.
Steering Committee Member, ADCS
This post originally appeared in Alzheimer’s Insights, an ADCS Blog.

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