Traveling with Dementia

Most people have become accustomed to the rhythm of airport security checks— lap top out, jacket off, shoes off, belt and any metals onto the tray, and then waiting patiently for instructions. These routines become second nature, except when some cognitive impairment like dementia starts eroding this familiarity. Traveling alone is a necessity for most people but we need to rethink how viable this is with early stage dementia.

People with dementia might not feel comfortable taking their jacket off or their shoes. Such (familiar) behaviors in unfamiliar surroundings are likely to agitate the older adult. And a security checkpoint is not the most accommodating venue to address anxiety and agitation. These scenarios will become more frequent with an increasing prevalence of dementia and other cognitive disorders. And it is not just at the security gate.

On Friday, May 3rd 2013, an 83-year-old Victoria Kong walked past the assistance agent waiting to meet her at the gate as she deplaned from her flight from Barbados to Washington D.C. She was found the following Monday in wooded area about 200 yards from the airport perimeter. She died of hyperthermia. Victoria King suffered from dementia and wondered out of the airport oblivious to the pickup arrangements made for her by her relatives. Most airlines do not have an escort policy/program in place for adults, traveling alone with cognitive impairment. Airlines only have escort policies/programs in place for minor children traveling alone.

In addition, most airlines do not include dementia as needing medical clearance, and although there are some provisions offered by airports and some airlines—in most cases dictated by law—these provisions are insufficient given the type of problems likely to be experienced by persons suffering from dementia. The increasing prevalence of dementia in the population and the lack of training of security personnel and flight attendants make this a recipe for more common friction.

Although in the early stages of dementia older adults might behave normal, this sense of normalcy might evaporate in an unfamiliar environment, or confusing situations as air travel has increasingly become. New faces, new environments, a change in daily routine, not to mention a time zone change, can prove to be a challenge for the dementia traveller.

You might get escort passes to help the person on board and then someone at the other end to escort the person out of the airport, but the flight itself might prove disorientating. Flight attendants should not be dealing with—at best—agitated passengers.

If we are to address this growing friction, education needs to come from both ends. Caregivers and family members need to understand the limitations of their loved one and that unfamiliar and stressful situations compound cognitive unease. Air travel is a stressful event at the best of times. On the other side, security personnel and air flight attendants need to learn to identify and defuse agitation because  of dementia.  Although it might be difficult to distinguish anxiety and agitation because of dementia from other types of erratic behavior  (alcohol, drugs or stress), the only way to reduce these misunderstandings is by not putting the older adult with dementia in that position in the first place. 

 © USA Copyrighted 2014 Mario D. Garrett

Death by Numbers

What if we eliminated the top diseases of older adults? Goodbye Cancer, Diabetes, Cardiovascular Disease, Stroke, Influenza and Pneumonia, and chronic obstructive lung disease. Will we then live forever, as some have suggested?

The surprising answer is that curing all of these diseases will result in very little change in additional life. Of course, we can only do this statistically.

Kenneth Manton and his colleagues from Duke University eliminated one disease at a time in their statistical modeling. What they found is that if we eliminate all of these killer diseases overall we expect to see those over 87 years of age to live an addition 5.7 years for males (estimated for 1987) and 6.5 years for females. This is about the same improvement in life expectancy at 65 in the last 100 years in the USA (5.7 years.) If you are 65 years old today, you have a 50/50 chance of living an additional 5.7 years than if you were living in the 1900s. In the last hundred years, the great improvement in life expectancy is not amongst older adults, but among newborns and infants and have very little to do with clinical care at later ages.

However, this is not the end of the story.

Most older adults suffer from not just one, but multiple health conditions. So if we assume that we can cure one disease, say cancer, we will still be faced—sooner rather than later—with another disabling disease that might kill us slower. And this is what happens.

Douglas G. Manuel with the Institute for Clinical Evaluative Sciences, Toronto, Canada, and his colleagues calculated what happens when they eliminated specific killer diseases from their data. They reported that by eliminating cancer they predicted that one fifth of the years of life gained would be spent in poor health—and increased cost. On the other hand, eliminating musculoskeletal conditions, would result in a year of good health for women and under half a year for men. And that is what we are finding across the world.

As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries. Joshua Salomon from the Harvard School of Public Health and his colleagues found that although most countries have made substantial progress in reducing mortality over the past two decades, non-fatal disease and injury have not improved to the same degree.

Our progress in health outcomes is also slowing down in the US, especially diseases that we can control and especially for women. Nearly 20 years ago, the United States was closer to the middle of other industrialized countries, but countries like Ireland and South Korea improved sharply, leaving the United States behind.

In addition, across all industrialized countries, because we are living longer and living with diseases, the occurrence of chronic diseases has increased. Finding a cure should be matched with finding care. Our reliance on medical breakthroughs at the cost of statistical outcomes ignores the immediate need that we face. We need to think about finding care as much as finding a cure. 

 © USA Copyrighted 2014 Mario D. Garrett

Dating in Older Age

When most people think of their parents and grandparents, they do not see them as sexual beings. It is the same way that we do not like thinking of our children and grandchildren as sexual beings either. Our mutual relationships are based on nurturing non-sexual behaviors. But with the worldwide discrepancy between male and female life expectancy, it is likely that one of us will become widowed or—in industrialized countries—divorced. We will become single again.

Single older adults are a unique phenomenon because there are so many. In the United States there are whole communities and cities built exclusively around older adults. And it is not surprising to learn that older adults are the fastest growing demographic of online daters.

Sheyna Sears-Roberts Alterovitz and her colleagues from the University of California, Berkley analyzed Internet personal ads. They found that across all ages, men sought physical attractiveness and offered status-related information more than women. On the other side, women were more selective than men and sought status more than men. With older age, men desired women increasingly younger than themselves, whereas women desired older men until ages 75 and over, when they sought men younger than themselves. Which is not surprising since at age 75 years and older, most male peers are dead.

Women are pickier than men in online dating. Their preferences for age and ethnicity are stricter than men’s, and they initiate contact and reply to fewer adverts. Most academic papers talk about evolutionary theory that predicts that men have a stronger preference for attractive mates and that women value good earning potential and education more than men do, as well as women's preference for taller men. But with older adults, there is no evolution to worry about. Post-menopausal women are not after a strong partner to secure the future of their offspring.

Women are likely to have experienced caregiving of their deceased partner. They are likely to have endured caregiving of their children, their parents, their spouse’s parents, family members, neighbors and friends. Their priorities are different from men’s. They want someone who is independent, solvent, healthy and mobile. They do not want to spend their time caretaking--again. This is not evolutionary theory, but pragmatism.

Men on the other hand ensure that they do not end up caregiving by wanting someone younger, someone who can liven up their sex life, drive, cook, and look after them. In online dating men and women construct different profiles. Women focus on their looks and sociability while men focus on their financial and occupational successes. With a changing environment, it is more important for older adults to meet someone that fits their needs. There is some urgency and older adults are willing to lie. Studies with younger online daters (under the age of 50) have reported that men are more likely to lie about their wealth while women are more likely to lie about their age. Men tended to overestimate their height and women tended to underestimate their weight. There is a collusion of lies. Giving women and men what they are both looking for.

 © USA Copyrighted 2014 Mario D. Garrett

Our Subconscious Internal Reality

We live in automatic mode most of the time.

Our brain is the most complex structure. Throughout our lifespan--culminating in our mature years--our brain develops a working model of our reality. We live in our mind much more than in reality. The mind becomes so good at this that we live in an unconscious mode. Even if we think that we are making conscious decisions, they are not conscious in the way we understand it.

As we grow older we become more sophisticated at internalizing the world and learning to predict and anticipate changes. We get so good at this that we do this automatically all the time. It is not that we are not aware of what we are doing, it is that we become aware and respond after our unconscious mind has already determined it. John Bargh from Yale University has written extensively on the unconscious. He pushes for the concept of the unconscious determining decision-making. People often do not give much conscious thought to how they vote, what they buy, what they eat or the way they negotiate their daily life. Consciousness is an afterthought.

The world has always been very complex and we cannot deal with this complexity without shortcuts that our internal model of reality can create. We live in an subconscious world. Our brain is complex enough to allow an internal representation of the world, and we live vicariously through this model. Chun Siong Soon and other scientists from Germany and Belgium have studied this phenomenon and measured in minute details when consciousness is brought into play within our internal world. They reported that there is a network of high-level control areas in the brain that initiate an upcoming decision long before it enters awareness. Our awareness seems to be an illusion of control, an after thought.

Writing more than three decades ago, Felicia Pratto discussed how we are constantly engaged in evaluating our immediate environments without being aware of the process, the outcome of the process, nor even of the stimuli we are faced with. Furthermore, she perceptively argues that it may be that we cannot control automatic evaluations, but they can influence our conscious experiences, including judgments, emotions, and attitudes.

Older adults are experts of this unconscious reality. Our brain has been designing these simulations of our immediate environment for many decades and it has become so good at it that we interact in our life in automatic most of the time. Most psychologists put this reliance on our internal world as a result of some diminished or compromised cognitive or recall ability.  A reliance on “gist” memory is just older adults reliance on their very complex internal representation rather than the unique details of the immediate environment. This works well until we have a trauma. Then we wake up. We switch the automatic pilot off (or it is switched off) and we have to figure how to engage in our immediate environment consciously. That is when we face problems.

© USA Copyrighted 2014 Mario D. Garrett

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