Kafkaesque Government Guidelines on Dementia

In 2011 the National Institute on Aging published a series of guidelines on dementia. They argued for biological determinism, where an organic disease causes dementia.  The new insight—they argue—is that we can see the early changes before there are any signs of the disease. There might even come a time when you have the disease but not suffer from dementia itself.  Which brings us another Kafkaesque moment from the government. The guidelines are an oversimplification and simply wrong.

Dementia is not one disease, and it might not even be a disease as much as a set of symptoms—perhaps a syndrome. What is interesting about these guidelines is how they were skewed in order to leave out the psychology of the disease.

The guidelines proposed an early, preclinical stage with no symptoms, followed by a middle stage of mild cognitive impairment and a final stage of Alzheimer’s disease dementia. The fear mongering might be implicit but not completely unpredictable. Associating mild cognitive impairment with dementia, where more than a quarter of older adults report some issues with memory, is an unconscionable bad science (correlation is not causation) and shows unscrupulously lack of moral or ethical standards.

In real science there are other such prodromes—early symptoms—for dementia, only one of which is memory lapses. An early symptom is depression. In the guidelines depression was completely left out. There is no mention of depression.

In 2010—before the guidelines were published—Meryl Butters and her colleagues from the University of Pittsburgh and the University of Toronto, Canada, reviewed 23 studies that followed around 50,000 adults in their 50s for five years. They found that depressed patients were more than twice as likely to develop vascular dementia and 65 percent more likely to develop Alzheimer’s disease than those who were not depressed. More recently, Deborah Barnes with the University of California, San Francisco similarly looked at 13,535 members of a health maintenance organization Kaiser Permanente—and  found that older adults who suffered depression earlier on in their middle age, were three times more likely to develop vascular dementia.

We find these early symptoms with other brain diseases as well. The fact that we find similar early symptoms of depression for Parkinson’s Disease is a significant indicator that depression is a serious early symptom. In a review of 14 studies encompassing 1500 patients, AM Gotham from the University of London estimated that just under half of people with Parkinson’s had earlier symptom of depression.

In the guidelines there is also no mention of the role that white matter has in dementia and how cognitive training is the only effective intervention reported so far. Daniel George (Penn State) and Peter Whitehouse (Case Western Reserve University, Ohio) both champions of the psychology of dementia, argue for a more social and intergenerational approach to addressing dementia. This is an exciting agenda. Instead the guidelines represent a dying proposition of biological determinism that exclude social and environmental factors as reflected in the emerging science of epigenetics and neuroplasticity.

© USA Copyrighted 2014 Mario D. Garrett

Garrett MD & Valle RJ (2014).A Methodological Critique of The National Institute of Aging and Alzheimer’s Association Guidelines for Alzheimer’s disease, Dementia and Mild Cognitive Impairment. Dementia: The International Journal of Social Research and Practice. DOI: 10.1177/1471301214525166

Down Syndrome and Aging

As the French film “Amour” has beautifully explored, becoming ill with cognitive impairment is difficult enough for white upper middle class. It is that much harder for people who have less support, resources, or are physical or intellectual challenged already.

One such group that rarely receives attention in gerontology is the group with Intellectual and Developmental Disabilities (I/DD). A new phenomenon has developed. Because I/DDs are surviving childhood in greater numbers, estimates suggest that their life expectancy has increased from 18 years in 1930 to 59 years in 1970 to 66 years in 1993.  Nowadays, life expectancy for those with mild I/DD is fast matching that for the general population. Although men are still lagging behind women in terms of life expectancy gains, the gains are positive across the spectrum.

Even those with severe I/DD are living longer—some living up to 80 years of age—doubling the number of older adults with I/DD in the United States from 641,860 in 2000 to 1.2 million by 2030.  In a commentary in 2010 Elizabeth Perkins and Julie Moran, report that within the aging baby boomers, those with I/DD are however further disadvantaged. For various reasons, adults with I/DD are more likely to develop chronic health conditions and they are more likely to develop them at younger ages. Some disabilities exacerbate specific diseases in older age. For example older adults with Down syndrome experience higher rates of cataracts, hearing loss, hypothyroidism, osteoporosis, epilepsy, sleep apnea and an elevated risk for Alzheimer’s disease. For more than twenty years, Vee Prasher has been reporting that those with Down syndrome are not only more likely to get dementia (15-40%) but they get it earlier (estimated at 51.3 years of age) and the disease affects their mental capacities faster. The cause is still not completely clear although there are both external factors—diet, exercise, mental stimulation, ecological/environmental—and internal factors—genetics and neural capacity, among other causes.

In a research study looking at I/DD’s health in fourteen European countries—Meindert Haveman from University of Dortmund, Germany and his colleagues reported that low levels of physical activity and high caloric and fatty diets are probably to blame for the development of obesity. Obesity then promotes ensuing problems with cardiovascular disease, diabetes, constipation, osteoporosis, incontinence, and arthritis.

The brunt of caregiving seems to remain with the family. Over 75% of people with I/DD live with families, and more than 25% of family care providers are over the age of 60 years and another 38% are between 41-59 years. Aging parents lovingly looking after their children.  Most studies address the incredible disconnect between available and appropriate services and needs of this aging cohort. And rightly so.

But the disconnect is not that this group is unique. The disconnect is that it exposes—because this population has such intense needs—the severe lack of policy for end-of-life and for aging in general. Policy seems baffled by the process of aging and the inevitability of death, which is most often preceded by ill-health. People with intellectual and developmental disabilities expose this disconnect because we did not expect them to age. The sad corollary of this is that we all do not expect to age, get ill and die ourselves.

© USA Copyrighted 2014 Mario D. Garrett

Aging brings challenges – and the resilience to deal with them Modesto Bee “There are neural changes,” said Mario Garrett, a San Diego State University gerontology professor and a blogger on aging for Psychology Today.

Following Your Spouse to Death

Caregiving is dangerous.

As early as the 1960s, the British psychiatrist Colin Murray Parkes reported that after nine years of bereavement among 4,486 widowers, 55 years of age and older, 213 died during the first six months of bereavement. This death rate was 40% above the expected rate for married men of the same age.  Often referred to as the “widowhood effect”—where the surviving spouse dies soon after—it is an example of how intimate relationships define what is important in life.  Death following spousal death among older adults is estimated at between 30% and 90% in the short term, and around 15% in the long term.

The months and sometimes years leading to death are stressful to both partners. In 1999 Richard Schulz and Scott Beach compared 392 caregivers aged 66 to 96 years who were experiencing stress looking after their spouse reported that they were twice as likely to die within the four years of the study then 427 similar older adults who were not providing care.  And there seems to be worse outcomes when their spouse dies.

In one of the largest studies, Nicholas Christakis and Paul Allison in 2006 looked at 518,240 Medicare married recipients. During the nine years of the study, 49 percent husbands and 30 percent wives died. The consequence on their surviving partner was dramatic. Overall male survivors were more likely to die than females. What is surprising from this study—for both male and female--was that the risk of death was the highest when the spouse died of dementia compared to other causes (20 and 16 percent higher mortality for males and female respectively).

One argument, that attempts to understand this proximity of death, is the shared environment. For example, people who die of heart disease are more likely to have a lifestyle that promotes such diseases and—the argument goes—this is likely shared with their spouse (e.g. smoking, high fat diet, no exercise.) In addition, older people are more likely to have diminished resilience.  This argument loses its strength in light of the work of Mairi Harper and her colleagues from the University of York, England.

These researchers looked at 738 bereaved Scottish parents who had stillbirth or death of their child in its first year of life. They found that the bereaved parents are more than twice as likely to die in the first 15 years after their child's death than non-bereaved parents. Unlike older adults, females tend to suffer worse consequences.  Bereaved mothers were more than four times as likely to die in the first 15 years. Although this rate decreases with time, the effect was still seen 35 years after the bereavement.

A consistent observation of increased longevity is that these unique older adults are accepting of changes that happen to them. They interpret negative events as part of their world.  It seems however that sometimes the death of a loved one destroys that part of the world that is important, especially when your children die before you.

© USA Copyrighted 2014 Mario D. Garrett

Complexity of our Brain

Our brain is the most complex machine that ever existed. With over 7.146 billion models it is also the most ubiquitous.   Despite this, we are unsure of its complexity. We still do not yet understand how it works. By defining the functionality of certain areas of the brain, and by understanding some of the mechanics at the neural chemcial level, we still remain ignorant of how the brain coordinates all of its activities and develops language, thought and a sense of self.

This three point three-pound wet mass—greyish on the outside, and whitish pink on the inside—controls every single thing you will ever do. Ever. Each one of us needs these complex structures because each one of us needs it to reflect the totality of the world we live in and how we function within it. Our brain constructs a representation of the world and how we function within it.  Other animals do this as well, but what is important in their world is different from what our brain determines is important for us.

In the past we took a different attitude to studying the brain. Most of the scientific writing on the brain was focused on establishing the superiority of human intelligence. But there is not one single factor that we can apply to distinguish our brains from those of other animals. We cannot just use size, because some mammals (eg whales) have bigger brains. Perhaps it is the size of the brain in proportion to the body. When we try that by measuring the Encephalization Quotient (EQ) ratio, small birds beat us. Perhaps it is size, EQ and something else. The correct question is to ask what aspects of the world are we, as humans, trying to represent in our brain? And how complex is the brain really?

In 2009, the Brazilian scientist Suzana Herculano-Houzel performed a review of what we know about the physical structure of the brain. The adult human male brain has 86 billion neurons--more than any other primate. Each neuron has between 1,000 to 10,000 synapses that result in 125 trillion synapses in the cerebral cortex alone. That is at least 1,000 times the number of stars in our galaxy. Stephen Smith from Stanford University reported that one synapse might contain some 1,000 molecular-scale switches. That is over 125,000 trillion switches in a single human brain.

With such a lean mean machine then it is a surprise to learn that the brain is obese. It is composed of 60 percent fat, with over 25 percent of that being cholesterol. Cholesterol is in every cell in our body and becomes concentrated in our brain. Most of the cholesterol in the brain is produced in the hypothalamus itself, establishing cholesterol as an integral part of our brain. Cholesterol is used by a specific type of glial cells in the brain to form myelination—sheathing which enhances neuron speed and integrity of signal. Glial cells outnumber neurons ten times over with 860 billion cells. It was only in 2010 that glial cells were found to assist neurons in forming synaptic connections between each other. Once thought to be simply support cells, cleaning up and helping with myelination, they are now known to also promote dendrite growth, and to be as important as neurons in forming the neural network that make up cognitive activity. Glial cells can also reproduce—if neurons reproduce they do it slower—and similarly release transmitters and control neural activity just like neurons. All of this activity is monitored by microglia cells that not only clean up damaged cells but they also prune dendrites, forming part of the learning process.

Comparing mapping the brain to mapping the human genome is like comparing the artistry of the Mona Lisa to Sponge Bath Bob. The total length of the human genome is over 3 billion base pairs, the brain has nearly 30 times more neurons. And whereas the genome base pairs has an on and off arrangement, each neuron might have a thousand switches. Mapping the brain will mean that if every switch in every synaptic end at every neuron is identified by a second of time then it will take 4,000,000,000 years to complete. The brain is that complex.

In the cortex alone, there are 100,000 miles of myelin-covered—insulted—nerve fibers. Leaving the brain to the outer reaches of our skin, we have a neural network that is incomparable. We have millions of nerve endings in the outermost layer of our body that sense minute variations of light, sounds, vibrations, touch, smell, pressure, temperature; all extremely sensitive in most cases more sensitive than any computer on earth. The marvel of the brain is not just the capacity but the sensitivity to stimuli.

There is a galaxy of neural networks active in our bodies designed to get information from the outside. All this information is travelling from the outer reaches of the body to the brain sometimes at speeds of 268 miles per hour. The brain is structured in such a way that information is processed both linear and parallel. And here is the beauty of the brain. It creates a kind of a dance, it orchestrates the flow of information in a way that we still do not fully understand.

We filter out most of the sensory information. Information travelling from our peripheral senses to the brain, making a vibrating, electrical symphony. Constantly on and constantly playing and the brain makes music from trillions of individual notes every second throughout our lives. And the musical composition has to do with the world outside and how it affects us. The brain teaches the body to survive. We represent the dynamics of the outside world inside our brain. There we can predict and therefore control the outcome. This is learning. Through learning and some innate ability we identify what is important and what is not so important. That “so” is crucial. Information as differing levels of importance, and also times when we are more prone to learn than at other times.

Our brain is an organic reflection of the environment that we face day-in-day-out. Our conscious attention is drawn to specific aspects of all sensory information monitored by the brain. We are monitoring many other peripheral events at a subconscious level. The more we learn the less we need the brain, unless we challenge it all the time. That constant state of unease, the novelty is what keeps the brain functioning as it is meant to function. Once it can predict then it no longer needs to learn new things.

All of this complexity allows the brain to continuously receive feedback from the outside to modify its construct of the world and then to determine what is important for us. Its aim is to be able to predict the environment we live in and to do that is has developed one of the most complex structures known to humans. By mapping the brain we will be holding a mirror to another mirror.

© USA Copyrighted 2014 Mario D. Garrett

Dementia and Gambling

In 2013 the gambling industry reported that more than half of its customers are 50 years and older. David Oslin at the University of Pennsylvania reports that 70 percent of the older adults 65 years and older had gambled in the previous year and that one in 11 had bet more than he or she could comfortably afford to lose. Using this percentage—despite older adults having the lowest rate of pathological gambling—in 2013, there were potentially more than four million older adults with a gambling problem.

Although there is very little independent research—that which is not sponsored by the gambling industry—on pathological gambling older adults, what we know is that they are likely to have poor mental and physical health and have less income. Although these are not the cases that make the news, these are the gamblers that fuel the profit margins of the gambling industry.

Most older adults are hesitant talking about their addiction—as Oslin found when half refused to participate. Most will not come out of the closet since it involves money-secrets at both ends. How you obtain money to gamble and what you do with the losses or the wins. For addicted gamblers both the winning and losing are highs, either way, casinos always profit. Casinos will not make a profit if they do not have compulsive gamblers.  The Wall Street Journal reports how Harrah's Entertainment Inc. in 2007 derived 5.6% of its Las Vegas gambling revenue from just one man, Mr. Terry Watanabe—despite their competitor Steve Wynn barring Mr. Watanabe because he was a compulsive gambler and alcoholic. 

Pathological gambling, or Gambling Disorder (GD)—as the DSM-V defines it now—is characterized by consistent, repetitive gambling and unsuccessful attempts at quitting. GD is seen an impulse control disorder and has been reported in patients with Parkinson's disease, frontotemporal dementia, and amyotrophic lateral sclerosis.   

However, there is no comprehensive study of how many patients with dementia gamble. Studies that show the benefits of gambling among nursing home patients do not report control studies or the amount of money being gambled and lost. There are also inconclusive results about the effect of dementia or Parkinson’s medication. One outcome is certain however. Gambling disorder responds to medication—either positive or negative. While 30-50 percent of adults with gambling disorders also have substance abuse—medication (such as opioid antagonists) used to treat drug and alcohol dependence also seems to work for gambling addiction. 

Gambling Disorder (GD) is argued to be different from recreational gambling.  However with an increasing aging population that exhibit more and more cognitive decline and impairment, the lines are becoming blurred. But this is not a no-cost venture. Older adults are unlikely to recover lost savings, while their families are usually the ones left without any resources. In the award winning and highly readable 2013 book “Addiction by Design”, anthropologist Natasha Dow Schüll from Massachusetts Institute of Technology defines exactly how slot machines, and the casinos that contain them, are designed specifically to create addiction and encourage their users to 'play to extinction'. 

© USA Copyrighted 2014 Mario D. Garrett

Casinos Preying on Older Adults

After it was revealed in February 2013 that San Diego’s former mayor, 67 year old Maureen O’Connor, lost more than a billion dollars at casinos, the gaming industry shed its disguise and became the gambling industry again. This was definitely not entertainment.

Maureen O’Connor reported that she was suffering from a brain tumor that might have impaired her judgment. A vulnerability that was not moderated by Las Vegas casinos sending private jets to fetch Ms O’Connor from San Diego. A trend that was also seen with Terry Watanabe who risked more than $825 million in 2007 at two casinos owned by Harrah's where it is alleged Harrah's senior management made a conscious decision to exploit his well-known addiction with alcohol and prescription drugs. No lawsuit has ever won. But what they do is expose the human tragedy fueled by the industry’s predatory use of complimentary services called “comps” against the increasing vulnerability of some older adults.

Bill Kearney—a staunch advocate for effective regulations of casinos—defines the world of comping in his excellent 2001 book “Comped”. Comping might start off with a free room, meals, free drinks and then, like Ms. O’Connor, ends up with to limos, helicopter and Lear Jet flights, interest-free loans, and lavish penthouse suites that the casinos provide as they cultivate their profits. These comps are in addition to exemptions that the gambling industry has gained, including no-limit ATM machines, sales tax exemptions, smoking exemptions, and many others. All these exemptions and comps transform the industry from one of entertainment—where you pay a predefined cost for a service—to predation.

Predation involves monitoring older adults’ gambling behavior and promoting both the frequency—through comping—or the amount—through interest-free loans, cashless gambling, free alcohol and medication pills. When you have older adults with obvious cognitive impairment then you need to question if such predatory behavior constitutes financial elder abuse under state laws.

In California, financial elder abuse has both criminal and civil definitions that apply to anyone 65 or older regardless of whether they have any diminished physical or mental capacity. Financial elder abuse occurs when any person or entity—takes, secrets, appropriates, obtains or retains real or personal property of an elder for a wrongful use or with intent to defraud—including assisting. “Wrongful use” is when a person “knew or should have known that this conduct is likely to be harmful to the elder.” Cal. Welfare & Institutions Code §15610.30.
This definition makes for a perfect storm. With increasing penetration of the gambling industry into nearly all States, increasing prevalence of older adults with cognitive and physical frailty, and an increasing awareness by families of the signs of financial elder abuse we might see our first test case of financial elder abuse laws against casinos. When Harrah’s comps $1.1 million to AARP we have to question what AARP is gambling with, and what are we likely to lose. Thom Reilly, executive director of the Harrah’s Foundation explained that “This relationship with the AARP Foundation allows us to extend our reach into that community and help them address caregiving issues.”

© USA Copyrighted 2014 Mario D. Garrett