Smell and Dementia

The sense of smell is accomplished through our olfactory system, which is an old system in our biological development. It is also one of the most evocative.

Smell acts as a portal to our emotions. It transports us directly to another time, another place and the only other medium that does this so quickly is the auditory sense--through music. But unlike music-- which can be written down and transferred in what Karl Popper calls World 3--smell is ephemeral.

Smell is somewhat undefined. Good, bad, sweet, acrid, then we loose track of translating the subtle smells into language. Smell has its own language and it cannot comfortably be translated into words.

Smell has power, it is evocative and nuanced so that a particular smell can immediately transport us to our first kiss, or the fear of high school, or your first child being born. Visceral and strong emotions which are hidden in the recesses of your mind. Never lost but subdued until dementia starts to erase them.

The olfactory system has a direct path to the brain. With humans, this system starts with the nose and ends a short distance away at the base of our brain. Olfactory receptors, with very thin fibers,  run  from the roof of the nasal cavity through perforations in the skull ending in the olfactory bulbs, which are a pair of swellings underneath the frontal lobes. It is the only sense that has such a direct physical connection to the brain. It is is also the first to be affected with the onset of dementia or Alzheimer’s. When the brain is affected by dementia, the area that deteriorates first is the area that is responsible for smell.

There is currently a patent, by researchers from Columbia University lead by Davangere Devanand, for a test using scents that include cheese, clove, fruit punch, leather, lemon, lilac, lime, menthol, orange, pineapple, smoke and strawberry. Using this test, the clinicians can predict that an individual who cannot recognize three of the ten scents are five times more likely to develop Alzheimer’s. It has also been found to predict Parkinson’s disease as well as certain types of schizophrenia and brain tumors.

Many people who lose their sense of smell also complain that they lose their sense of taste. Smell enhances the information we get from the mouth; salty, sweet, sour, and bitter tastes. Loss of taste might explain why weight loss is also an indication of dementia. It is not the weight loss on its own, but rather the loss of smell, which brings about the loss of appetite and consequently to diminished appetite.

There are some sixty seven medical conditions identified as possibly causing loss of smell--dementia being one of them. Some of these causes are temporary, such as colds, and nasal allergies such as hay fever.  It may also occur due to some medications and localized nasal polyps and tumors. Such factors reduces the odds of making the patent smell test a very reliable indicator in predicting dementia. But for individuals, it is important to notice changes in how well we can smell. So if you are having trouble with smell, check with your physician first to make sure that this is not a temporary condition.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Super Brains and Dementia

We have a lot of evidence showing that the older you get the more problems we start having with our brains. In healthy adults they tend to shrink, and then they become prone to diseases, not excluding our nemesis of Alzheimer’s disease. We always assumed that these changes are fixed.  But then how do we explain exceptional older adults.

Exceptional adults are examples of what is possible, and not what is statistically likely.

When Emily Rogalski from Northwestern University looked at two groups of Chicago-area older adults of 80 years and older with similar education--12 who had exceptional memory, and ten normal older adults--she was not ready for the findings.  Her study reported that the exceptional group not only had sharp memories--as sharp as people 20 to 30 years younger--but she also found that their brains appear younger.  When compared to 50 to 65 year olds, these exceptional older adults had a thicker outer layer of the brain important for memory, attention and other thinking abilities. While in another region deep in the brain, they had thicker anterior cingulate--which is responsible for attention. Not only was there no shrinkage, these exceptional older adults show youthful brains.

Henrikje van Andel-Schipper was the oldest woman in the world when she died at age 115 in 2005. After Gert Holstege, from Groningen University, undertook a post-mortem of her brain he found few signs of Alzheimer's or other diseases. It seems that these exceptional people have escaped the normal effects of aging.

Jessica Evert from Ohio State University and her colleagues support this view. When examining death from heart disease, nonskin cancer, and stroke, 87% of male and 83% of female centenarians that they studied delayed or escaped these diseases.

If we apply the concept of escapers to the brain, then we can say that exceptional older adults escape from damaging their brain.  As far-fetched as this might seem, researchers are now focusing on studying how we might be developing the brain in detrimental ways. Known as negative plasticity—by not exercising the brain, learning things the wrong way and responding to stress—could be  causing the brain to shrink and develop inefficiently. 

Although brain shrinkage is related to aging, we now know it is not fixed and invariable. If the brain shrinks because of trauma that we impose upon it, then we need to start taking better care of our brain. The brain likes to be challenged, to be happy, stress free, fed well and exercised--just like a precious teen.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Highway Brain and the Earthquake Dementia

Our brain changes as we grow older. Changes dictated by the slow shrinking of the brain, creating a widening of the pockets inside the brain. And there are also changes in parts of the brain used for certain tasks.

We are learning more about these changes because of a new technique of seeing into the brain called functional Magnetic Resonance Imaging. The functional part is that we can have people perform an activity while we watch their brain’s activity.

On the whole we witness variable results when we compare older and younger adults. Sometimes there is less activation among older adults, sometimes more activation, and invariable older and younger adults differ in which parts of the brain they use while undergoing the same activity (eg reading.)

The brain is a wonderfully clever but lazy organ. It works as hard as it has to and nothing more. Which is why sometimes it is hard to learn, because we have to persuade it that it has to. Like any precocious teenager, they will do enough to get by. The brain is like that teen.

David Snowdon studies 678 nuns—Catholic members of the School Sisters of Notre Dame—who are 75 to 106 years of age. The nuns undergo extensive testing and when they die, his team examines their brain. It was Snowdon who first reported a very strange anomaly. He found that a third of the nuns who for all intents and purposes acted normally throughout their life, when they performed the autopsy, they found that their brain had the disease of Alzheimer’s. This finding has since been found in other populations, notably in Sweden where otherwise healthy and competent older adults were found to have diseased brains.

The quick answer to this finding is that some people have “cognitive reserve”. Basically they have more brains and so they can afford to loose some to the disease.  But this does not explain why certain occupations—academic, research, engineering and art, occupations that develop your brain—do not protect you from dementia. It seems that the reserve is not just in size but that the reserve need to be in quality—how you develop and grow your brain.

Like a precocious teen, the brain knows of ways of escaping from its many duties. Doing things that we take for granted—like reading for example—the brain develops an interstate of neural pathways that makes it easy for it to accomplish that repetitive task.  What seems to work is when we trick our brain in developing new pathways.

In a 21-year study of older adults, 75 years and older, Robert Katzman and Joe Verghese, found that mental activities like reading books, writing for pleasure, doing crossword puzzles, playing cards as well as playing golf, swimming, bicycling, dancing, walking for exercise and doing housework did not offer any protection against dementia with some important exceptions:  frequent dancing, playing an instrument and playing board games.

Creating new pathways is what works. When disease interferes with the flow of traffic, then having alternate pathways helps divert traffic. This is what seems to be happening and why it is not just the size of the brain but the networks that we develop that protect us from dementia.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Elder Abuse and Dementia

Elder abuse is on the rise and the main predictor is the increasing number of older adults.  With the global population of older people (aged 60 and above) predicted to triple from 672 million in 2005 to almost 1.9 billion in 2050, it is expected that there will be a similar increase in incidence of abuse.

Cultural differences in attitudes towards older people and what people consider abuse make international comparisons problematic. With this caveat, international estimates of elder abuse in community settings from Canada, Finland, the Netherlands, the United Kingdom and the United States range from 4–6%. Globally we are anticipating that by 2050 there will be over 114 million older adults to have been abused.

As of 2010, there are an estimated 35.6 million people with dementia worldwide. This number will nearly double every 20 years, to an estimated 65.7 million in 2030, and 115.4 million in 2050.  Both elder abuse and dementia will form a part of our landscape.

There are many aspects of elder abuse. The landscape covers; prevention and legal prosecution; family dynamics and career con artists; health and economics; loneliness and vulnerability. Above all of these concerns—and an issue that cuts across all these issues—is the complication that dementia brings to elder abuse.

Dementia is a disease that slowly kills the brain. The term describes symptoms of memory and thinking that interferes with day-to-day activities. We still do not know the cause/s of dementia, and to this day, do not have any prevention or cure.

Dementia changes the dynamics of caregiving and care receiving. Although more than half of older adults with dementia live in the community, two out of three nursing home patients have dementia. Patients with dementia are more likely to end up in a nursing home or assisted living facility.

According to family members, one in four nursing home residents are likely to be abused. In some cases the patients themselves are the abusers—both resident-to-resident aggression as well aggression directed towards their caregivers.

For those that are still living in the community, caregiving becomes an added hardship. As the disease progresses, 15 to 75 percent of patients develop psychotic behaviors.  In addition, a third of patients will have delusion, in some cases resulting in aggressive behavior. Studies show that one in three caregivers reported that their patient become aggressive with them and as a result they were likely to physically retaliated.

The fact of having dementia increases the likelihood of abuse. But in some cases there is no abuse and the patient becomes uncertain of the facts. Did they misplace their wallet or did someone steal it? Distinguishing the facts is difficult especially when there is no one else involved in the caregiving. Even if there is obvious cause for concern—when there is physical abuse that is uncontestable—it is difficult to have the testimony of a person with dementia hold in a court of law.

We have very little information about the lives of people living with dementia who have also been abused—a testament of how weary district attorneys are to have their client evaluated especially since the defendant in the court case can subpoenas that information. Being judged as mentally incompetent diminishes their testimony in court.

But we cannot continue to deflect the issue that dementia affects everyone, and not just the patient. The only viable solution is more openness, education, and better information. In 2050 when we are projected to have over 114 million people who are abused and 115 million suffering from dementia, will we approach the problem as we are approaching it today?

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Aging and Pandemics

Populations change.  Not only do people change--people die and babies are born each day--but the structure of a population changes.  These sequential changes that every population goes through, predicts that we are entering a scary stage.

The theory goes something like this. A hundred and more years ago women gave birth to a lot of children only to see most of them die of infections and famine. Then we saw improved access to clean water, better sanitation and a better diet, which led to fewer diseases and a decline in deaths from infections and famine.  Women started having fewer children and most survived through adulthood. With fewer children being born and increasing survival, we reach a stage in our population where we are today in most developed countries--a very low incidence of infectious diseases and women continue having smaller families. In most developed countries today, women are having so few children that, without immigration, our populations will start to decline.

As a result we have entered the age of gerontology, were we have an aging population and a shrinking younger population.

With an aging population come a wave of chronic diseases--stroke, cancer, diabetes, heart disease, and neurological diseases such as Alzheimer's disease. Medicine,  in the face of such chronic diseases, starts focussing more on monitoring and maintaining health rather than battling infectious diseases. Because of this stability, from now on, populations fluctuate only as a result of wars and epidemics. We cannot predict wars, but we can predict pandemics.

We are at present going through one of the most lethal pandemics in our history. HIV/AIDS has now already claimed over 22 million people. More than 42 million are currently living with the disease and even if a vaccine for HIV were discovered today, over 40 million people would still die prematurely as a result of AIDS.

Despite this threat,  the two pandemics that clinicians seem more worried about--because of their unpredictability--are influenza and antibiotic resistant infections.

After five main pandemics of influenza, history has taught us that there will be emerging influenza pandemics every thirty to fifty years. Studies are showing how dangerous the last avian flu could have been if it became airborne. This type of airborne influenza--or its 144 variants--can devastate populations as the Spanish Flu did at the turn of the century with over 50 million people killed.

The second emerging concern is drug resistant infections. The spread of bacteria, virus or cancer cells that is resistance to drugs is man-made. Although Joshua and Esther Lederberg while at the University of Wisconsin-Madison showed that resistant bacteria has always been present, their increase is brought about by inappropriate and ineffective use of antibiotics. We are carelessly engineering super bacteria. The World Health Organization reports that, as an example, there are 50 million people with multi-drug-resistant tuberculosis, which exist in 49 countries, including the United States.

Although we have entered a tranquil and stable stage in our population--with an aging population where we are mainly dealing with long-term diseases--we do have the threat of pandemics that will dramatically affect this equilibrium. The question is not how, but when.


Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

How Physicians Die

Sherwin Nuland wrote a beautiful book about How We Die.  Similar to other physicians, Nuland got to observe a multitude of deaths. So he knows intuitively as well as scientifically about the dying process. From this vantage point, physicians have a unique perspective about their own morbidity and ultimate mortality which the rest of us non-clinical lay persons do not have.

Ken Murray, a retired family medicine physician and Clinical Assistant Professor at the University of Southern California, has written extensively on this and one of the conclusions that he makes is that physicians would want better quality of their remaining life rather than quantity.

Such assertions have been supported by convincing anecdotal evidence, but only recently did we obtain some proof to substantiate this.

In 2008, Marsha Wittink from the University of Rochester Medical Center, with her colleagues published a study that reported that physicians who initially wanted the most aggressive treatment for their disease, changed their mind three years later. However, although some changed their mind, there were some (41%) who still wanted the most aggressive treatment. It is therefore not clear-cut.

For some people, including physicians, they change their mind when they are dying. Some want a hasty natural ending, others hold on to life at all costs. How true is this if you know you are dying anyway?

The answer came in a study published in 2011 by Hans-Peter Brunner-La Rocca, and his colleagues from the University Hospital Basel in Switzerland. These Swiss researchers talked to 555 heart failure elderly patients about their end-of-life preferences. They repeated the interview again in twelve months and then again in another six months. What they found is that seven out of ten patients initially said they would rather live two years in their current state then live only one year in excellent health. After a year elapsed, this proportion grew to eight in ten and remained the same after eighteen months.

Some people have interpreted this finding as indicating that most people want to live at all costs which becomes more acute the closer you are to death.  However, surprisingly, when the researchers asked patients whether they wanted CPR in a crisis, about a third said no. While another third said they did want CPR—even among patients with "do not resuscitate" orders in their medical files.

In all this uncertainty, the correct interpretation is that most people opt to live despite the physical discomfort. But when the time comes, a third of patients want the natural process to take its course. What this tells us is that we are dealing with a lot of variables and that one policy does not fit all.

The statistics from the Oregon Death With Dignity Act (DWDA) tell us that for the 70 or so patients who go through with DWDA a year, they are exclusively White, are more likely to be better educated (four out of ten have a degree), tend to have cancer (eight out of ten) and have informed their family about their wishes. This is a very privileged and small minority but an important one.

The lesson to take is that each case is unique and there can be no one policy for everyone.We should respect all individual options when it comes to death.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Dying Priorities

The most divisive issue in America is not the economy, politics, war on drugs, racism, health care or our ongoing military wars across the world. The most recent Gallup's annual Values and Beliefs survey of 2010 reported that doctor-assisted suicide is the most controversial of the issues tested. Equally 46% reported that it is moral unacceptability and morally acceptable.

In contrast, Americans are fairly unified in their opposition to another life-ending choice--suicide--with 77% calling this morally wrong. Taking subordinate position in dividing the nation is gay and lesbian relations, abortion and having a baby outside marriage. 

All these issue drive to the heart of the American ideal of personal freedom.  And yet Americans remain fixated on an issue of doctor-assisted suicide—better known as Dying With Dignity Act (DWDA)—where nationally, in 2011, only 71 people died using this option. In contrast to the 2.5 million Americans that die each year, those that die with DWDA are a very very small minority. They are nearly exclusively White, primarily women, educated, and exclusively people with life threatening disease (mainly cancer.)  

While many people are blessed to be released from life from a final act of covert over-medication, such action is necessarily too late. And while most Americans think a good death consists of dying at home, surrounded by family, and free from pain and suffering—regardless of one’s age, gender, ethnicity, or religious background—one in five people die in an Intensive Care Unit. Death for most Americans is a medical failure rather than a dignified release.

Except for physicians, who tend to shy away from aggressive medical treatment when the prognosis is negative, most Americans tend to undergo a lot of unnecessary, expensive and invasive treatment.

But three of every four Americans do not fear death as much as they fear being in pain at the time of death.  Despite these clearly stated and seemingly universal preferences, too many of the 2.5 million Americans who die in health care settings each year suffer needlessly in pain at the end of life.

And this should be the national issue. Nearly eight out of every ten hospital deaths occurred without a palliative care /formal pain management. More than four out of every five older adults in long-term care facility experienced untreated or under-treated pain at the time of death. While 70 percent of all Medicare decedents, regardless of their age or where they died, received an inadequate amount of pain management.

Sara Imhof and Brian Kaskie predicted in 2008 that "we can only conclude that public policies will fall even further behind the advancement of evidence-based pain-policy guidelines, and the number of Americans who continue to suffer needlessly in pain at the time of death will only increase."

It does not have to be this way. Dying in pain is a national travesty. We need to honor the body’s capacity to let go. In studies that looked at voluntary refusal of food and fluids, nurses report that patients die more serenely then with DWDA. The body knows how to shut itself down. We need to incorporate a dignified exit in our health care system where Americans can at least be protected from a painful death.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com