Aging and Your Best Brain Booster: Good Friends

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Two Senior Women Playing Dominoes At Day Care Centre With Cups Of TeaAsk Edith Smith, a proud 103-year-old, about her friends, and she will give you an earful. There’s Johnetta, 101, who has Alzheimer’s disease and whom Edith has known for over 70 years. 

“I call her every day and just say ‘Hi, how are you doing?’ She never knows, but she says hi back, and I tease her,” Edith says.

There’s Katie, 93, whom Edith met during a long teaching career with the Chicago Public Schools. “Every day we have a good conversation. She’s still driving and lives in her own house, and she tells me what’s going on.”

Then there’s Rhea, 90, whom Edith visits regularly at a retirement facility. And Mary, 95, who does not leave her house anymore, “so I fix her a basket about once a month of jelly and little things I make and send it over by cab.” And fellow residents at Edith’s Chicago senior community, whom she recognizes with a card and a treat on their birthdays.

“I’m a very friendly person,” Edith says, when asked to describe herself.

That may be one reason why this lively centenarian has an extraordinary memory for someone her age, suggests a recent study by researchers at Northwestern University highlighting a notable link between brain health and positive relationships.

For nine years, these experts have been examining “SuperAgers” — men and women over age 80 whose memories are as good — or better — than people 20 to 30 years younger. Every couple of years, the group completes surveys about their lives and they receive a battery of neuropsychological tests, brain scans and a neurological examination, among other evaluations.

“When we started this project, we were not really sure we could find these individuals,” says Emily Rogalski, an associate professor at the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern’s Feinberg School of Medicine.

But find them they did: Thirty-one older men and women with exceptional memories, mostly from Illinois and surrounding states, are currently participating in the project. “Part of the goal is to characterize them — who are they, what are they like,” Rogalski says.

Previous research by the Northwestern group provided tantalizing clues, showing that SuperAgers have distinctive brain features: thicker cortexes, a resistance to age-related atrophy and a larger left anterior cingulate (a part of the brain important to attention and working memory).

But brain structure alone does not fully account for SuperAgers’ unusual mental acuity. “It’s likely there are a number of critical factors that are implicated,” Rogalski says.

For their new study, the researchers asked 31 SuperAgers and 19 cognitively “normal” older adults to fill out a 42-item questionnaire about their psychological well-being. The SuperAgers stood out in one area: the degree to which they reported having satisfying, warm, trusting relationships. (In other areas, such as having a purpose in life or retaining autonomy, they were much like their “normal” peers.)

“Social relationships are really important” to this group and might play a significant role in preserving their cognition, Rogalski says.

That finding is consistent with other research linking positive relationships to a reduced risk of cognitive decline, mild cognitive impairment and dementia. Still, researchers have not examined how SuperAgers sustain these relationships and whether their experiences might include lessons for others.

Edith, one of the SuperAgers, has plenty of thoughts about sustaining relationships. At her retirement community, she’s one of nine people who welcome new residents and help make them feel at home. “I have a smile for everybody,” she says. “I try to learn someone’s name as soon as they arrive, and if I see them it’s ‘Good morning, how do you do?’”

“Many old people tell you the same story over and over,” she says. “And sometimes, all they do is complain and not show any interest in what you have to say. That’s terrible. You have to listen to what people have to say.”

Brian Fenwick, administrator of the Bethany Retirement Community where Edith lives, calls Edith a “leader in the community” and explains that “she’s very involved. She keeps us in line. She notices what’s going on and isn’t afraid to speak out.”

Fifteen years ago, Edith became a caregiver for her husband, who passed away in 2013. “All the time he was ill, I was still doing things for me,” she recalls. “You cannot drop everything and expect to be able to pick it up. You can’t drop your friends and expect them to be there when you’re ready.”

What Edith does every day, she says, is “show people I care.”

William “Bill“ Gurolnick, 86, another SuperAger in the study, realized the value of becoming more demonstrative after he retired from a sales and marketing position in 1999. “Men aren’t usually inclined to talk about their feelings, and I was a keep-things-inside kind of person,” he explained. “But opening up to other people is one of the things I have learned to do.”

With a small group of other men who left the work world behind, Gurolnick helped found a men’s group, Men Enjoying Leisure, which now has nearly 150 members and has spawned four similar groups in the Chicago suburbs.  Every month, the group meets for two hours, including one hour they spend discussing personal issues — divorce, illness, children who can’t find jobs, and more.

“We learn people are not alone with the problems they’re dealing with,” Gurolnick said, adding that a dozen or so of the men have become good friends.

“Bill is the glue that holds the whole group together,” says Buddy Kalish, 80, a member of the group in Northbrook, Ill., a Chicago suburb. “He’s very, very caring — the first one to send out a thank-you note, the first one to send out a notice when there’s been a death in the family.”

Activities are another way of cultivating relationships for Gurolnick. On Mondays, he bikes 20 to 30 miles with more than a dozen older men — many of them from his men’s group — followed by lunch. On Tuesdays, he’s part of a walking group, followed by coffee. On Wednesdays, he goes to the Wenger Jewish Community Center in Northbrook for two hours of water volleyball. On Thursdays, it’s back to the JCC for pickleball, a racquet sport.

“You really get a sense of still being alive,” Gurolnick said, when asked what he takes away from these interactions. “You get a sense of not being alone.”

Without her best friend, Grayce, whom she’s known since high school, and friends who live in her condominium complex, Evelyn Finegan, 88, might have become isolated. Another SuperAger, Evelyn is hard of hearing and has macular degeneration in both eyes, but otherwise is astonishingly healthy.

“It’s very important to keep up with your friends — to pick up the phone and call,” says Evelyn, who talks to Grayce almost daily and chats with four other friends from high school on a regular basis.

Today, the staples of Evelyn’s life are her church; a monthly book club; volunteering at a resale shop in Oak Park, Ill.; socializing with a few people in her building; attending a club of Welsh women; and visiting her daughter, her son-in-law and grandchildren, who live in Oregon, whenever she’s able.

“It’s so nice to spend time with Evelyn,” says her upstairs neighbor, June Witzl, 91, who often drives Evelyn to doctors’ appointments. “She’s very kind and very generous. And she tells you what she believes so you really feel like you know her, instead of wondering what’s on her mind.”

Caregiver ‘Boot Camp” for Dementia Patients

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Boot camp alzheimer caregiversGary Carmona thought he could do it all. He has headed companies and chaired nonprofit boards. But since his wife was diagnosed with dementia, Gary, 77, has felt exceedingly overwhelmed. 



“I really see myself crashing at times,” he said. “In my mind, I’m saying, ‘You know, I can’t really handle all this.’”

There was the time his wife, Rochelle, wandered outside and fell down. And the time she boiled water and walked away, leaving the burner on.

“I’m always double-, triple-, quadruple-checking everything that she’s around,” he said.

Carmona was among about 25 people who went to a Los Angeles-area adult day care center on a recent Saturday for a daylong “caregiver boot camp.” In the free session, funded in part by the Archstone Foundation, people caring for patients with Alzheimer’s or another form of dementia learned how to manage stress, make their homes safe and handle difficult patient behaviors. They also learned how to keep their loved ones engaged, with card games, crossword puzzles or music.

Doctors and researchers increasingly recognize that caring for people with dementia compromises the physical and mental health of the caregivers. And that, in turn, jeopardizes the well-being of the people in their care. Some studies have shown that the burden on caregivers may increase the likelihood that the loved ones in their charge will be placed in a nursing home.

“People with Alzheimer’s who have stressed caregivers have been shown to have poor outcomes,” said Zaldy Tan, the medical director of the UCLA Alzheimer’s and Dementia Care Program who created the boot camp. “Their caregivers have essentially thrown in the towel.”

People with dementia are also more likely to visit the emergency room and be hospitalized if their caregivers are not prepared for the task, Tan said.

That’s one of the main reasons why UCLA Health and its geriatrics division started its caregiver boot camps in 2015.

UCLA holds four boot camps a year at community and senior centers in Southern California and hopes to expand over the next year to meet the growing need. About 5 million Americans, 1 in 10 people over 65, have Alzheimer’s disease — a number that could balloon to 16 million by 2050, according to the Alzheimer’s Association.

Similar caregiver training programs have taken place in New Jersey, Florida and Virginia.

Tan started the recent session by explaining the progression of dementia, noting that in its later stages people often do not remember their loved ones.

“Do they all reach that stage?” asked one woman, who takes care of her sister.

“They do, if they live long enough,” Tan said. “I know it’s heartbreaking.”

He also warned the group that their actions can inadvertently provoke anxiety or aggression in their loved ones.

“Many times, when you see someone shift from being calm to agitated, happy to angry, typically there’s a trigger,” Tan said. “A trigger is just like a trigger on a gun. Something is pushed and you get a reaction.” He told them that as caregivers they were in the best position to identify and avoid those triggers.

Leon Waxman, who also attended the boot camp, said he tries not to upset his wife, Phyllis. But sometimes she gets angry, as she did the day he dropped her off for day care while he attended the session for caregivers.

Taking care of Phyllis the past few years has been trying, he said. She can still dress herself, but she gets easily confused and can no longer make decisions.

“The hardest part for me is I don’t have my wife anymore,” said Waxman, who has been married to Phyllis for 58 years. “She’s not the same person she was 10 years ago.”

During the boot camp, recreational therapist Peggy Anderson demonstrated a game caregivers could play at home: music bingo. Each square had the name of a song, and she played music.

“What’s this song?” Anderson asked the group.

“Bye blackbird,” one yelled out.

“If you have that one, mark it off,” she said.

Anderson said that even people with dementia can sometimes recognize songs and read their titles. “There’s a lot of good things that come out of this activity — just listening to music, clapping your hands, reminiscing,” she said.

In another room, occupational therapist Julie Manton explained how to prevent people with dementia from falling. She advised the group to ensure their homes have good lighting and bed rails, as examples. She also urged them to remove throw rugs.

Manton warned the participants that their loved ones might wander off and suggested the use of monitoring devices. “The key thing is to know where your loved one is at all times,” she said.


Medical Technology Advances and Long-Term Care

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Couple on cruiseMedical advances have most definitely increased the number of years we live and have decreased the number of early sudden deaths. For example, identifying asymptomatic diseases through screening has helped to reduce their incidence and severity.

The overall results of medical advances are that:

 People are living longer and requiring additional years of care. 

 Hospital stays are shorter because more services are available at home.

 People are surviving more accidents, not always with full recovery, creating a

new group of LTC patients.

Some researchers argue that medical advances have increased life expectancy but have not delayed the onset of illness, predicting that declining death rates may actually increase LTC needs. That is, more people are living long enough to develop age-related conditions such as dementia, or they are living longer with existing disabilities and chronic conditions.

Advances in pharmacology and pharmaceuticals also impact the need for long-term care. These advances have not only reduced the symptoms of diseases but also have slowed their progression, thereby increasing longevity. However, increased longevity may necessitate periods of longer care.

The irony is that as medical advances help people live longer, the likelihood increases that long-term care will be necessary.

What is noninstitutional care? 

The U.S. Department of Health and Human Services reports that 31 percent of all caregivers are employed outside the home. This type of care is referred to as noninstitutional care.

Note that employed caregivers spend no less time on elder care than those who are not employed outside the home. Workers who provide elder care spend approximately four hours a day on caregiving in addition to their other responsibilities.

Consumer Attitudes and Understanding

Another social factor associated with the growing long-term care need is current consumer awareness and attitude. Generally, the public at large does not have a good understanding of the long-term care need, including why and how to plan for long-term care. Many simply deny that they will need long-term care; others believe, incorrectly, that Social Security, Medicare, or their existing health insurance will cover the costs.

They do not see long-term care as something one needs to plan for in advance, such as they would retirement. This attitudinal “disconnect” also explains one of the reasons why people may not consider the purchase of long-term care insurance.

According to a report issued by the U.S. Department of Health and Human Services, coverage purchased to cover acute medical care far surpasses the coverage purchased to cover long-term custodial care. Whereas almost all older individuals are protected from high acute medical care costs through Medicare and private Medigap insurance, a very small percentage have purchased long-term custodial care insurance.

This report cited the following, among others, as key factors limiting demand for long-term care insurance:

lack of information – Many underestimate the likelihood of requiring LTC services and the potential costs of those services.

 misperception of public and private programs – Many people believe that Medicare, retiree health plans, or Medicare supplement insurance covers LTC services. This is not the case.

 delayed preparation for/denial of long-term care needs – Many do not think about preparing for long-term care needs until the need arises. At that point, they may be too old or disabled to purchase insurance.

 long lag time between purchase and benefit payment – Long-term care insurance must be purchased before it is needed; often, this means a period of many years between purchase and when benefits are likely to be paid. Consumers prefer to spend their current dollars on coverage that provides a more near-term benefit, such as Medigap policies.

affordability – Many of today’s older consumers have low incomes and cannot afford long-term care premiums.

perception of need – Some consumers decide they do not need long-term care insurance because they have too few assets to protect or have family and friends available to provide care.

Consumer attitudes and perceptions notwithstanding, long-term care is a growing reality. It is also a very expensive reality.

The Cost of Long-Term Care

The medical, personal, and social services necessary because of an accident, a chronic illness, a disability, or simply the phenomenon of aging—services associated with long-term care—are among the most expensive of health care costs, especially considering the great numbers of people affected.

The actual cost of long-term care depends on where the care is received, what type of provider administers the care, and how long the care is required.

Some people require minimal assistance with only a few activities of daily living (ADLs) for a limited time.

Others require skilled nursing facility care for an extended period.

Unfortunately, no one can predict who will be stricken with the need for long-term care, what type of care will be needed, or how long the care will be necessary.

Planning for Long-Term Care

Given the likelihood of needing long-term care and the tremendous cost that this care entails, it is important that individuals plan for it—and the sooner the better. Certainly, there are barriers. For example, people tend not to think about becoming older and needing care, or they don’t anticipate that they will ever need care themselves; they resist the idea of becoming dependent.

They may believe [erroneously] that Medicare or their current health insurance will cover the cost of this type of sustained, ongoing care. They may find it difficult to raise this issue with their loved ones. Or they may underestimate the time and toll that future caregiving will demand of their family or friends.

Some are not aware of the tremendous costs of this care or how it is paid. Some may think of long-term care simply as nursing home care and assume that the “government” will cover the cost. Some are confronted with conflicting financial priorities. And some people may simply not know where or how to begin the planning.

But for every reason why people do not plan in advance for long-term care, there is a reason why they should:

Advanced planning for future care needs will allow for greater independence and choice as to where and how the care is delivered.

 Advanced planning can mean greater financial security, not only for those who may need care but also for their family and loved ones.

 Advanced planning can ease the financial and emotional toll on one’s family and release them from the burden of providing the care, if and when it is needed.

 Advanced planning will avoid the uncertainty, confusion, and mistakes that could arise in the event of a health care need.

 Advanced planning will promote a continued quality of life, as the person defines it, when care is needed.

College Freshman Learns About Growing Old

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April Pearce

April Pearce is in the middle of her freshman year at UCLA, settling into life away from home for the first time. But instead of thinking about dorm food or exams, the 19-year-old is focused on something a little more abstract: old age. 

That’s because of a unique course April is taking called Frontiers in Human Aging, designed to teach first-year college students what it means to get old — physically, emotionally and financially.

April said that before, she barely noticed elderly people when she passed them on the street. Since being in the aging class, seeing them fills her mind with questions: Do they live alone? Will they develop dementia? Do they interact with anyone apart from relatives?

“It’s weird, I know,” she said. “But before, I didn’t have any knowledge really about aging. I didn’t even interact with any older people except for my grandmother. Now I’m learning so much.”

In addition to teaching students about aging, the professors have another goal in mind: inspiring them to pursue careers working with the elderly.

With more than 10,000 baby boomers turning 65 every day, there is a growing need, said Rita Effros, a professor at UCLA’s David Geffen School of Medicine who teaches both undergraduates and medical students.

People over 65 represented about 14 percent of the U.S. population in 2013, and that figure is expected to increase to nearly 22 percent by 2040. During that same time period, the number of people over 85 is expected to triple.

And jobs working with the elderly won’t just be in medicine but also in social work, psychiatry, technology and law, Effros said.

We try to make it clear that aging is going to be big business,” she said. “Whatever their interests are, they should think about serving the elderly.” The strategy seems to be working on many of the students, including April. She started UCLA in the fall of 2015 wanting to be a veterinarian and now is thinking about becoming a geriatrician.

The class, which has about 120 students, is taught jointly by Effros, an immunologist, Paul Hsu, an epidemiologist, and Lené Levy-Storms, a social welfare professor. UCLA started offering the course in 2001, but the professors said it is becoming increasingly important.

Throughout the year, students hear lectures about anxiety, genetics and dementia. They discuss ageism and read about Social Security. They stage debates on assisted suicide and watch films about growing old.

The course lasts from September to June, and students can go on to take other classes about aging, including ones that focus on diversity or public policy.

Effros said she wants the students to understand people don’t suddenly become old. Rather, the aging process starts when they are conceived. “A lot of life habits and choices they make as college students can affect them decades later,” she said.

During one guest lecture, UCLA medical school professor David Reuben explained how geriatricians evaluate patients and told students about some of the most common problems older people face — dementia, falls, sensory impairment.

He also described how the students’ own lives will change as they age. Instead of traveling the world, older people eventually become unable to travel out of their own bedrooms.

One student raised his hand and said being a geriatrician sounded gratifying, but also seemed heartbreaking. “You watch so many people decline … how do you handle that?”

Reuben responded that he does get sad and he does cry. “Nobody lives forever and nobody should live forever,” he said. “Death is part of the human experience.”

Michael Margolis, 17, said being in the class has made him think for the first time about his own mortality. “It’s not something we typically think about as teenagers,” he said.

One requirement of the class is that students spend a total of 20 hours volunteering with seniors.

Just after the New Year [2016], the students gathered in a large room on campus to meet representatives from several agencies that serve the elderly. Andres Gonzalez, a director at St. Barnabas Senior Center in Hollywood, told the students they could teach technology classes to active seniors or help deliver meals to homebound ones.

“Even that short interaction becomes very meaningful to the seniors,” Gonzalez said. “You might be the only person they see that day. And they get even more excited seeing younger people.”

April Pearce was assigned to Wise & Healthy Aging, which runs an adult day service center for seniors with dementia. Catherine Jonas, who previously directed the center, said the students bring a lot of energy to the center, and they often lead bingo games and exercises. They also have lengthy conversations with the seniors.

“What the older adults need is that dialogue,” Jonas said. And for students interested in learning about dementia, interacting with people affected by it “is so much better than what they get from a book,” she added.

One morning in early February [2016], the center was decorated for Valentine’s Day, with red and white streamers and cut-out hearts hanging from the ceiling.

One of the student volunteers, Julia Gierasimow, led the group as they rolled their shoulders, stretched their legs and tried to touch their toes. Julia, who is also considering a career in geriatrics, said all the seniors she’s met so far have interesting life stories.

“I don’t know if they remember me from week to week … but they are very friendly,” she said. “As bad as their dementia may be, they still give you a hug.”

After the physical exercises, April sat in a chair in the middle of the room, picked up a microphone and commenced with the mind exercises she’s led each visit. Today’s activity: a quiz game about football.

“Which team won the first Super Bowl ever?” she asked, smiling.

Several of the seniors shrugged. One man, 76-year-old Tracy Williams, yelled out the right answer: “Green Bay Packers!”

Williams, retired from the Air Force, said he enjoys when the college students come to visit — even though he never would have done the same at their age. “When I was young, I didn’t want to even be near an old person,” he recalled.

April said that in just a few weeks of volunteering, she is becoming more patient and is learning how to talk to people with dementia. “If they say it’s Tuesday, you’re supposed to go with it,” April said. The class has given her a new perspective on her own life, too. She is trying to eat less fast food and exercise more. And she tries not to worry so much about things like not doing well on an exam. “I’m going to have health problems later if I let the stress get to me,” she said.

April is also seeing her grandmother in a new light, especially after doing an in-depth interview with her for a class assignment.

She said she learned that her grandmother had undergone hip replacement surgery, a kidney transplant, and treatment for cancer. She also discovered her grandmother had loved to dance when she was younger, and was popular with the boys.

“I had never really thought about my grandmother as a young woman,” April said. “This class is making me appreciate her more.” .


Advocate for Alzheimer’s Research

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Dr. Maria CarrilloAs the baby boomers age, the increasing number of patients with Alzheimer’s disease will take a serious toll on caregivers and families, and the costs associated with that care are expected to weigh heavily on the nation’s health care system.

A new study projects that the disease will be responsible for 25 percent of all Medicare spending by 2040.

Alzheimer’s is the most common form of dementia, and the number of cases is expected to balloon as people live longer:  Today 5.1 million people 65 and older have it. By 2025, the number will rise to 7.1 million, a nearly 40 percent increase, the Alzheimer’s Association estimates. The projections have sounded an alarm amid a tightening federal budget and concerns that there won’t be enough nursing facilities to take care of patients. Researchers and health policy experts met in Washington at a major conference in July 2015 to discuss the impact of and efforts to combat the disease.

Dr. Maria Carrillo (pictured), chief scientific officer at the Alzheimer’s Association, which paid for the research on Medicare projections that was released at the conference, talked in an interview about what the growth of Alzheimer’s will mean for the nation. The interview has been edited for length and clarity.

Why is there such an increase in Alzheimer’s disease?

We know that it is an older disease; it affects people mainly over 65. And it has been less than 100 years that we’ve lived to 65 plus. The average life expectancy now is 83 plus, and that’s why the baby boomer number is so critical. They’ll be living to 90, and that puts them at more risk for Alzheimer’s.

The other piece is that we’re more educated than we were 40 years ago, more people have high school diplomas and people are living older in professional settings.  They are working until 70 plus with the full expectation that they will continue to have a sharp brain.

Compare this to someone who stays at home. My mother-in-law, who has Alzheimer’s, stayed at home to raise her family. Her early symptoms weren’t as apparent because she wasn’t doing anything that required her to make mistakes that were glaring. In a professional setting, if you can’t multitask, it’s more apparent.

Much research is going on right now to prevent or slow down Alzheimer’s. Where does the research stand? What would you hope to see in screening for Alzheimer’s?

The federal government is making investments in research today — $350 million has been included in an appropriations bill for the Congress this fall, and if it’s approved, it will improve the National Institutes of Health (NIH) research dollars for Alzheimer’s by 50 percent. We’d also like to see things like saliva and blood screening tests that could be done in our primary care physician offices. It’s the first place where a loved one would go [if they started having symptoms]. If they could have something quick and easy, like a finger prick that says things aren’t right, we could pass the patient on to do more extensive testing.

You’ve mentioned, though, that there is no cure for Alzheimer’s. Why would someone want to be screened with that kind of outlook?

The reality is that what we have to do today is develop screening and detection simultaneously with treatments and cures. We have medications that are approved for Alzheimer’s and dementia, but the effects don’t last as long as we’d like. We’re trying to develop screening tools in conjunction with therapeutics that can slow its progression or provide more symptomatic relief than are available today.

How do you think the health system is going to adapt to a larger population with Alzheimer’s?

We’re going to need more skilled nursing and home health aides, because we won’t have enough institutions to support people. And not everyone wants to put a loved one in an institution. Even today, many home health workers aren’t specifically trained for dementia.

Unless we change the trajectory of what’s happening today or delay or stop the disease, Medicare and our society will have to think about creating more support systems as these patients age. We’re talking about assisted living and transition living, and more training of professional caregivers. There are 13 million caregivers right now, and we’re going to have to quadruple that. And two-thirds of these caregivers are women that have to slow down their careers or stop work altogether [to provide help to family members].

Respite care [which is non-medical care for a patient to allow the caregiver rest and time away from the responsibilities of looking after the person with dementia] is not covered by Medicare. It is paid for by Medicaid. But that’s only available when families [have spent down nearly all their assets] and don’t have resources to pay.

What does current research show that might help slow Alzheimer’s?

There won’t be a silver bullet, but a combination of therapeutics. What research is showing will be a mix of pharmacological, anti-inflammatory and psychological drugs, layered on with exercise.

We used to think it was just Diabetes Type 1 that led to Alzheimer’s but we’re seeing that it’s also Diabetes Type 2. The longer you live with diabetes, the greater risk you have. There’s a an 80 percent increase [in the likelihood of getting] dementia, so we need to figure out what it is about Type 1 and 2 that makes them more vulnerable to cognitive decline.

Other risk factors include a sedentary lifestyle, watching a lot of TV, which tells us what we do early in life does impact us late in life and increases our risk. So there must be public messaging. We owe it to the public to let them know.

What is the experience of caring for someone with Alzheimer’s like?

My father-in-law has vascular dementia, and my mother-in-law has Alzheimer’s – both need 24-hour care. My father-in-law has had a slow decline over five years – he’ll be stable for a year and then his health will drop, usually spurred by a physical event like a stroke. He is mainly disoriented, but remembers who we are and how to do daily tasks.

My mother-in-law has had a continuous and quick decline in a few years:  she doesn’t recognize family, she’s forgotten how to get into a car – standing, turning and sitting down, so she crawls.

You can’t leave a loved one like this with a caregiver all the time, so my husband, sibling and I take turns being there, and we pay for the care out-of-pocket, which not everyone can do. My mother-in-law has forgotten how to walk, and she needs to be carried everywhere. She doesn’t recognize us or her grandchildren, and she has to be cared for like an infant, it’s a low quality of life. At first our family tried to remind her of things, and it just caused anxiety in her and the family. You just kind of have to go with the flow, and stay even with emotions. I think it’s hard for me to see my children not having a grandmother that can care for them, and they’re instead caring for her. It makes me more committed to this cause.

I didn’t come into this work having this experience with my family. But now when I see this, it reinforces my passion to find an answer. It turns you into a champion for those that don’t have a voice.

Seniors Tell Medical Students Their Needs From Doctors

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Belle LikoverWhen doctors told Robert Madison his wife had dementia, they didn’t explain very much. His successful career as an architect hardly prepared him for what came next.

“A week before she passed away her behavior was different, and I was angry because I thought she was deliberately not doing things,” Madison, now 92, told a group of nearly 200 students at Case Western Reserve School of Medicine.

“You are knowledgeable in treating patients, but I’m the patient, too, and if someone had said she can’t control anything, I would have been better able to understand what was taking place.”

Belle Likover (pictured) recounted for the students how she insisted when her husband was dying of lymphoma that doctors in the hospital not make decisions without involving his oncologist. “When someone is in the hospital, they need an advocate with them at all times,” said Likover, who turns 96 this month [October 2015]. “But to expect that from families when they are in crisis is expecting too much. The medical profession has to address that.”

Madison and Likover were among six people all over the age of 90 invited to talk to the second-year medical students. The annual panel discussion, called “Life Over 90,” is aimed at nudging students toward choosing geriatric medicine, the primary care field that focuses on the elderly. It is among the lowest-paid specialties, and geriatricians must contend with complex cases that are time consuming and are often not reimbursed adequately by Medicare or private insurance. And their patients can have diseases that can only be managed but never cured.

Students often are attracted to more lucrative specialties such as orthopedics or cardiology, said Jeremy Hill, who was in the audience. One undeniable factor is money: the 35-year-old North Carolina native may owe as much as $300,000 when he graduates, enough – he is quick to point out – to buy “a nice-sized house.”

Yet Hill is one of the few Case students who say they are leaning toward choosing geriatrics.

The American Geriatrics Society estimates that the nation will require about 30,000 geriatricians by 2030 to serve the 30 percent of Americans over age 65 with the most complicated medical problems. Yet there are about 7,000 geriatricians currently practicing. To meet the needs, the society estimates medical schools would have to train at least 1,500 geriatricians annually between now and 2030, or five times as many as last year.

The low number of geriatricians is not surprising considering that their average salary was $184,000 in 2010, almost three times lower than what radiologists earned, the American Geriatrics Society has reported.

Elizabeth O’Toole, a geriatrician and med school professor who arranged the panel discussion, acknowledged in her introduction that most students were interested in other specialties. Yet she warned them not to overlook the needs and outlooks of older patients.

“No matter what you’ll be doing, you are going to be working with these people,” she said.  More than 400,000 people 80 years old and older received knee replacements last year, 35 percent of men over 80 and 19 percent of women have coronary heart disease and the most common medical procedure among people over 65 is cataract surgery. Successful outcomes depend on the patient’s cooperation and that, she said, requires “an understanding of who the patient is.”

Students who braced themselves for a solemn litany of medical problems from the panel were in for a surprise. It wasn’t just what the visitors said that made an impression, but how they said it.

The group offered the students advice, telling the doctors-to-be to look at their patients instead of typing notes into a computer, take more time with older patients and answer their questions.

“Having to see so many patients a day is tragic,” said Simon Ostrach, 92, a professor emeritus of engineering at Case, who recalled being rushed through an appointment with an orthopedic surgeon who did little for “excruciating pain” after his hip replacement.

When it was her turn, Likover (pictured) pushed back her chair, stood up and had no need for the microphone she was offered.

“Getting old is a question of being able to adapt to your changing life situation, having a little less energy, not being quite as healthy as were you were before,” said Likover, a retired social worker. Four years ago, she was hospitalized twice for congestive heart failure until she learned how to manage the disease through diet. She also has an occasional irregular heart beat and only recently began walking with a cane. She swims at least three times a week, serves on several committees addressing seniors’ issues, and is a Jon Stewart fan because “getting a laugh every day is very, very helpful.”

“I have lived a very good and hopefully useful life and death does not concern me. It is going to happen,” she told the students. “And I think that kind of outlook, not worrying about every little ache and pain makes a big difference and a very happy life.”

“That’s a perfect seque to my story,” said Ostrach. “I attribute my longevity to smoking, drinking and overeating,” he told the students. And doctors who tried to reform him “are all long dead and gone.” He was an athlete in college, wrestling and playing tennis, “but as I got past 60, I found that listening to opera, smoking good cigars and having a little cognac was much more pleasant.” All in moderation, he added.

Efforts to introduce relatively healthy older adults to medical students can “reduce the sense of futility and show [the students] that there are real people with real lives who can benefit from quality health care,” said Chris Langston, program director at the John A. Hartford Foundation, which focuses on aging and health who has been analyzing the trend for the past several years.

But Jeremy Hill and the roughly two dozen members of Case’s “geriatric interest group” are the exception. For them, the challenge of a complicated patient — “figuring out the puzzle” as one student put it — is what makes geriatric medicine worthwhile, even when a cure is out of reach.

“I have such respect and admiration for this population, and if I could somehow give them one extra good day they would not have had otherwise,” said Hill, who then paused for a moment, “I would be privileged to work with them.”

After the session, Hill went up to Ostrach, who had said he’s been lonely since his wife died. After chatting for a few minutes, he told Ostrach, “If you’d like to have lunch sometime, please call me,” and handed him a scrap of paper with his phone number.

Awake And Safe All Night Despite Dementia

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In their Manhattan apartment, Josephina is trying to coax her 84-year-old mother, Brunhilda, to get ready to go out. As she does most nights, Josephina makes up a story to get her mother, who has dementia, to cooperate.

In Spanish, Josephina asks her mother if she would rather go to Miami or the Dominican Republic. Her mother says she wants to go to the Dominican Republic, and then Josephina helps her mother gather her things and escorts her downstairs to a waiting van. The driver will take her mother to the Elderserve At Night program at the Hebrew Home At Riverdale in the Bronx. It’s a kind of day camp – but at night, for people like Brunhilda who suffer from Alzheimer’s disease.

Josephina says her mother was once a proud, hard-working immigrant who raised four children on her own, but she has changed. “Her memory has been totally lost. She’s very disoriented,” Josephina says. “She doesn’t communicate at all.”

For months, Brunhilda would sleep during the day and be up much of the night wandering around the apartment. Her daughter was too afraid to sleep – afraid her mother might fall and hurt herself or even try to leave the apartment.

“She wanted to sweep the floor. She wanted to watch TV. She wanted to clean the bathroom,” Josephina remembers. “She wanted to go out. This is at one, two o’clock in the morning.”

But now Josephina is finally getting some sleep – and her mother is being well cared for, along with about 40 other people, seven nights a week. Activities may include arts and crafts, cooking, yoga or Zumba, and even live performances. On the night we visited, Juan Ortega played American and Spanish favorites on his synthesizer.

Though it looks like entertainment, each activity has a therapeutic benefit for memory-compromised people, says Deborah Messina, who runs the overnight program. She described a common problem among dementia patients known as “sundowning.” It is thought to affect about 20 percent of Alzheimer’s patients.

“Their day is our night and vice versa, and they are confused about it,” Messina says. “It is usually at dusk where an agitation comes, a confusion comes.”

Many people with dementia are more alert at night than they are all day – just when their caregivers need to sleep. Rather than try to alter this mismatch, Elderserve At Night embraces it.

The program is the brainchild of David Pomeranz, the executive director of the Hebrew Home, who opened the program in 1996. He says the idea came to him after hearing heartbreaking stories from struggling families.

“People were sleeping in front of doorways because they were concerned that mom or dad would wander out of the house,” Pomeranz says.

Those families desperately needed a safe place for their loved ones at night – and a decent night’s sleep. And the Hebrew Home set out to meet that need.

It’s a similar philosophy – to meet clients’ needs wherever they may be – held by the therapists and social workers who now staff Elderserve. “Here, their behaviors are normalized,” Pomeranz explains.

“Everything is OK. Activities are structured for them to be successful. They eat, they relax – they can be themselves. To us, this is who they are. We’re not the family members who are dealing with that incredible loss of seeing someone who was and isn’t any more.”

The program is covered by some private insurers and by New York Medicaid, the federal-state program for poor and disabled people. To the extent that it can keep people out of nursing homes, it can save money.

Medicaid pays a typical nursing home in New York about $320 per day versus $200 for the overnight program. But so far, few, if any, other overnight programs exist solely for people with dementia. Pomeranz thinks the idea hasn’t caught on with other nursing homes because it is difficult to find staff who are willing to work the overnight shift. It was also important to get Medicaid and other insurers to reimburse for the program, and that funding has not been pursued in every state.

Elderserve At Night tries to serve its clients even as their conditions worsen. Next door to the room where Brunhilda and others are dancing and enjoying the live music, it feels like another universe. The music is soft, the lights are low and a subtle scent of lavender is in the air. People with more advanced disease spend the evening here. Some are sitting around a table, each with a caseworker, who helps them work with blocks and basic puzzles.

Several other people are slumped in wheelchairs, getting hand massages from the social workers. Though their faces look expressionless, they seem calm. For people with advanced dementia who might otherwise become agitated at night, this room is a sanctuary, says Messina.

“We’re engaging them on their level. And being able to do that might be through touch, it might be through sound, it might be through scent,” she says. “It works for them. It gives them a sense of serenity.”

When the sun comes up tomorrow, all the clients will be given breakfast and everyone here will return home. Brunhilda will take the van back to her apartment in upper Manhattan where she will be greeted by her daughter before she leaves for work. Josephina says she doesn’t know exactly what happens during her mother’s nightly sojourns, but she is grateful.

“She was very weak when she started there. We had to carry her up and down [the stairs]. But now she walks up and down. She walks to Broadway,” Josephina says. “She would not react to any of the conversation. Now she does. She’s a totally new person. I would say she’s 200 percent better.”

Josephina says the program helped to improve her mother’s life and her own life as well. But Brunhilda was battling congestive heart failure, and she succumbed to the disease a few months after we reported this story.

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