Live & Learn; Dealing with Alzheimer's and other Dementias

The lecture is June 6th, which is the challenges of depression and other mental illness with Dr. Sheldon Presscorn, and to go along with this lecture, a couple of notes on Tuesday, May 13th at 540, 740, and 940 AM. You can listen to KMUFM89 for a new segment that will address this topic, and then at 7pm on Tuesday, May 13th, KMUW will host a live call-in program, where you can call in with your questions, and have those answered about Alzheimer's and this topic. So, there will also be time this afternoon, or when Dr. Marsh gets finished, for questions and answers, so there will be time for that at the end. Dr. Marsh will be repeating your questions so that everybody can hear this, this is being videotaped as well as recorded for the radio.

So, both are a couple of notes for us today. Now for the introduction of Dr. Marsh, if everybody is ready, she has been a member of the KU School of Medicine, Wichita, since we're doing her residency training here in 1986. She received her Bachelor of Arts degree from Ottawa University in Ottawa, Kansas, the Master of Arts from the University of Kansas in Lawrence, and her MD from the University of Kansas School of Medicine, Kansas City. She's certified by the American Board of Psychiatry and Neurology in Psychiatry in Geriatric Psychiatry, and her wealth of experience has taken her from Hallstedt, Kansas to Wichita as consultant faculty supervisor and staff psychiatrist among many other roles. And as my pleasure to introduce to you, Dr. Connie Marsh. Thank you very much. And hopefully, if all the sound is working, and just let me know if we're doing okay. I'm very excited to talk about this subject. This is something that I deal with all the time. Particularly right now, we have made a lot of advances in the management of dementia, our understanding of dementia.

So it's an exciting time. As the introduction said, I've actually been in the field of medicine and then in the field of psychiatry for a long time. And I have seen changes in the management of people with Alzheimer's and dementia that I think are so positive and so encouraging. So that's why I like to talk about it, and I like people to know about it. Now, I was given the task of giving a lecture that with this title, dealing with Alzheimer's and other dimensions. Let me just tell you what we're going to do in the next hour or so. And there will be plenty of time for questions at the end of the lecture. We're going to be talking some about aging, but mainly about dementia, and a lot more specifically about Alzheimer's dementia. And we're also going to be talking as best I can hit some of these areas about dealing with dementia.

And that will be the whole spectrum of fairly mild symptoms to very severe symptoms. And that's our task for today. Now, I'm not one who lectures very well without a lot of interaction from the audience. So I'm going to prepare you for that. And the first thing I want to know is I like some people to volunteer some questions. What did you come here to learn today, or if there's one question that you would like to know about this topic, what would it be? And I would just take two or three questions from the audience. And since that time, she is an assisted living situation. She's made lots of improvements.

And so I have a doubt now in my mind, is it dementia? And you know, just kind of the expectations of the illness. What is the course? Okay. So that question is one that has been brought today essentially is diagnosis of a dementia, maybe a vascular dementia. What do we expect for time course? And is there a point at which we kind of rethink? Is the diagnosis correct or not? Good. And I think you've got a nice positive spin to this because you're saying you've seen improvement. Somebody else bring a question today? I'm wondering when do you know if it's Alzheimer's or some other disease that acts like Alzheimer's affects the memory. Another great question. That question is, when do we know whether it's Alzheimer's or another condition that maybe would seem like Alzheimer's? And I hope that we will cover that today so that you will have some understanding of that. One more question. Yes.

Who would be the most appropriate medical professional to make the diagnosis of psychiatrists and neurologists, family practice? Where do you go? Okay. Great question. It's been all the time answering the questions. And I hope I will. So that question was, who is the most appropriate healthcare professional to make the diagnosis? And we will try to answer that. Now here's the rule. If I get towards the end of this and have an answer those questions, please ask them again. But I think we will be doing that. So that's what we're going to do. We've got a lot of ground to cover. So let's just get started. And I'll do what I can to talk about how we're going to deal with dimensions. And I think we have to learn a little bit about dementia first. So we're going to talk about dimensions. We're going to learn a little bit about the illness, learn about the treatments, say something about managing the symptoms as a disease progresses. And we definitely want to emphasize the resources that are available in the community.

Now you are probably aware of this, but dementia is the principal cause of disability and decreased quality of life in this country for the aging population. This is it. This is what causes people to struggle during their last few years of life. And it's leading obstacle to successful aging. All right. Here's a question for you. In 50 years, one in 100 Americans will have Alzheimer's. Is that true or is that false? I'm going to have the truths raised our hand. We have a few people that say that's true. Well, hopefully we'll get an answer. It's much worse than that. One in 45 Americans has the potential of being diagnosed with Alzheimer's in 50 years. And this condition is will quadruple in that time period. Now here is the big reason.

It's because our population is aging. And you can see on this graph, the amount of population versus the time. And we have here 2000, we have here 2050 and the millions increase in population. And as we age, we are much more susceptible to Alzheimer's dementia and other forms of dementia. So that's the reason. So the answer is it's not one in 100, but it's one in 45 Americans that will be affected by Alzheimer's in 50 years. So just some more numbers for you 50 million or 5 million people in 2000 and 15 million people in 2050. This is again an explanation of what happens as the population ages. And if you look at these numbers, we have at age 60, 1% possibility of Alzheimer's dementia. And this doubles every 5 years so that by age 65, it's 2%, age 70, it's 40%.

And if we go up to age 85, greater than 30% of the people that are 85 will have Alzheimer's dementia. So it's very, very common as people age. You can imagine there's huge costs to this. Tremendous economic burden for this country and for the families. We have both, well we have, and I'll show this in the next slide, both direct and indirect costs of dementia. But the total economic burden currently is approaching $100 billion yearly. This is the third most expensive illness in the U.S. followed by heart disease and it follows heart disease and cancer is the most expensive illnesses. So we have both the direct cost, medication, nursing home care, in-home home health, and we have indirect cost, which is caregiver productivity.

And the caregiver sometimes has to give up job, can't work as often, and those hours and that expense is tremendous. And actually what we know is the expense for caring for a patient with Alzheimer's dementia is the same, whether the person is institutionalized or not, when we take into account the caregiver burden. And the cost shift, if the person goes into a nursing home, that's where the cost is. But if they stay in the home, the costs are to the family and the caregiver. So what do we mean by dementia? The broad term dementia. It means that there's a deterioration in cognition, and I'm going to explain cognition a little bit more, that this has to be a change from the prior level of functioning. And thirdly, that it interferes with functioning. So a person has declined, and it can then be that decline that we call dementia.

Now, what about cognition? Cognition involves memory, personality, language, and processing information, and I'll talk a little bit more about those things as we go along. So all of those things are involved with cognition. Now, a very common question is, is it normal aging? How do we know that the symptoms we're seeing are dementia, or is this part of getting older? Because, as we get older, things do change. We do lose our car keys. We do forget someone's name that maybe is pretty familiar, and it takes a few minutes to remember who that person is. So things happen with normal aging. Now, with a patient who's starting to have some dementia, it's a matter of this being much more prominent.

So it won't be that there will be a name lost once in a while. There will frequently be inability to remember names. We all search for the right word once in a while. Well, what do I call that thing? I don't remember. That happens again once in a while. But a person with Alzheimer's or a dementia will consistently have trouble with finding that word, or they will use a completely inappropriate word in place, such as, I can't find my street car. So sort of something pops out, which is completely inappropriate to the content. Losing objects, yes, we lose objects. But again, more consistent losing of objects, or sometimes placing objects in the completely wrong place, and that's why it's lost. For example, putting the wristwatch in the refrigerator, I can't find my watch, but it was put in a very inappropriate place.

Concentration, interestingly, we, as we age, think we don't concentrate as well, but we really do. When the tests are done, when we age, we still concentrate as well. But with the person developing dementia, they will have noticeable problems with the ability to focus, stay on track, do the task. And finally, memory. Again, yes, when we age, there is a tendency for us to take longer to form memories. We may need to read that list two or three times to remember that list. We may need to repeat the phone number two or three times. So there's a little delay in ability to remember, but we remember real well as we have the capabilities of maintaining memory real well as we age. So that's kind of the contrast with what happens as we get older and with normal aging and then with what happens with the dementia.

Now, to more specifically go through some of these areas, memory involves learning new information, performing once familiar tasks, such as knowing how to brush your teeth. It can involve an altered sense of time. Maybe I just had breakfast, but is the time for that evening TV show. So there's an altered sense of time. Sometimes this can involve getting lost. That all familiar Dylan's store, all of a sudden I don't know how to find a front door. I don't know how to find the checkout stand. This orientation, again, may be getting lost or not knowing the time of the day or even the time of the week. People that start to have memory problems get more repetitive, repeat the same stories, repeat the same questions.

Or might have trouble remembering appointments, remembering conversations. These things start occurring when people start developing dementia. Language can't find the right word, particularly names. Language also would involve having trouble following conversations. And you might notice that with people that you have familiarity with who have dementia, that they just don't stay on track for that conversation. And sometimes then speaking, not knowing the word to say, not knowing how to put the sentence together. Processing information is involved. We tend to take all of this for granted. It's like automatic to us. But when a person starts having dementia, it's no longer automatic. And there would be struggles with making calculations, finding the right change at the store, doing the checkbook properly, or problem solving. So in the past, the car broke down. We automatically think this is a problem with the battery. In the past, but now currently, the car breaks down and there is a great deal of frustration.

Even to know what to do in that situation. I call the motor club. I call my son. Not even knowing what to do within that particular situation. Personality can start to change. Oftentimes it's subtle. A person will become less spontaneous, perhaps more passive. But on the other hand, it can be the opposite of that. It can be more irritable, less inhibited, less attention to grooming or hygiene, or perhaps making no effort for these things. And then sometimes the personality can have more drastic kinds of changes. Paranoia, suspiciousness, maybe some anxiety, depression, overraction to minor stress. Having a senior citizen's dinner always took the tuna noodle casserole, but that dinner is coming up, and I don't know what to take, and I don't know what to fix.

Well, if I can really put it together this time. So it overreaction to even a common stress like fixing the casserole for the dinner that's been fairly routine for years. And sometimes then verbal or physical aggression can occur, and commonly there are problems with sleep. Now, when I just described to you, apply to all dimensions. And now I want to help us talk about dimensions and Alzheimer's dementia as one type of the dimensions. Alzheimer's dementia accounts for two-thirds of the dimensions, but the other one-third has the things that we'll go through here. The other one-third of dimensions are caused by strokes, head trauma, either in the past or currently, neurologic conditions such as Parkinson's, brain conditions, there are some other abnormalities that can cause dementia.

Vitamin deficiency, particularly B12 deficiency, low thyroid. At certain medications can look like dementia, but if they're stopped, then that problem with memory or concentration or confusion improves. And alcohol is another thing that over time can cause the brain to make changes so that dementia occurs. So to kind of give you a picture, then, we've got the whole bag of dimensions, and about two-thirds of these are Alzheimer's dementia. Now, let me just mention briefly, these then are risk factors for dimensions in general. If one has these kinds of problems such as high blood pressure, smoking, diabetes, these are all what we call dementia risk factors.

If there's been previous head trauma, it's a risk factor for dementia, or if there's been extensive alcohol use, it can be a risk factor for dementia. So, right off, if we want to manage these kinds of dimensions, then we manage these things. We live in healthy way. We stop smoking, and then if we've got a family member who does have a kind of dementia, we encourage that they stop smoking. There needs to be adequate blood pressure control. There needs to be adequate diabetes control. If that's an issue, there should be no alcohol at all. Even if alcohol didn't cause this, alcohol has enough of an effect on the brain so that it should be discontinued. And we need to minimize the possibility of falls or head trauma, which means if there's dangers in the home, rugs that can be tricked over, some physical conditions where there's pain and a tendency to fall, these are kinds of things that need to be minimized.

So, that's the other kinds of dimensions, and now I'd like for us to talk about Alzheimer's dementia. And Alzheimer's dementia was first described by Dr. Alzheimer. And he had a patient in probably 1905 that was in her early fifties, that was obviously confused and deteriorating. And he kept very good records, notes of this patient and her behaviors and her symptoms. And when the patient died, he did an autopsy, including looking at the brain and the pathology of the brain. So, in 1906, he described the strange ailments of the cerebral cortex, and he described the pathology of Alzheimer's dementia that we know today.

He described it so well that we haven't changed that description at all. He was extremely accurate in what he saw and what he observed. So, what do we mean by Alzheimer's dementia? Well, multiple cognitive deficits, and I've talked about cognition, there must have been a level of functioning where there's now a decline, a change. And here is the hallmark of Alzheimer's dementia. It's gradual and continuous. It does not start real suddenly. It has been coming on suddenly for years. That's the hallmark of Alzheimer's dementia. Now, it gets complicated because people with Alzheimer's dementia can also have some of those vascular things. I've led pressure, diabetes, they might be have fallen, so they actually may have a mix, so it's not always real clean. But if it is limited to Alzheimer's dementia, it literally is very slowly progressive.

And then we eliminate other reasons for the Alzheimer's dementia. So, just a review, we've got cognitive deficits, memory, we've gone over that, and then one or more of the following, problem with language, inability to do muscle functions, although the muscles work, let me give you an example. Sometimes a person would be told, for example, brush your teeth, and they have no problems with using the muscles or the arm, but they have the inability to have the brain give the proper signals and understanding to the arm to do a very familiar brush the teeth kind of movement. We have then the potential of problems in recognizing what objects are and finding what we call executive functioning, and that's problem solving, putting information together, being able to abstract, use our brains in a more sophisticated way.

And those then are the symptoms of Alzheimer's dementia. What do you think of this? True or false? The cause of Alzheimer's dementia is unknown. True or false? I'll have some hands go up for true. This is an educated audience. That's right. We know what it looks like pathologically, but we don't know what's causing it. We don't know the cause, but we're a lot closer to understanding it. We do know, as I said, that it starts very gradually and it's progressive, and it probably begins decades before symptoms occur. Decades before symptoms occur, and that's where we've got a target what we do with this condition.

Let's just kind of go through how we put some of this together. It's like there's something genetic, or something environmental, or both. It kind of starts this cascade of events in the brain, and the pathology described by Alzheimer was that we have beta amyloid plaques outside the cell, and what we call neurofibulary tangles inside the cell. And what happens with that is there is a gradual loss of nerve connections, and gradually then not only the connections are lost, but the nerve cells themselves are lost. This starts in the memory part of the brain, which is why that's usually the first thing we notice. But then it progresses to other areas, and I'll talk about that in a minute. We also know, interestingly, that there's inflammation at some point in this process. So those things we know.

What are risk factors? The big ones age, and I showed you that slide as people get older, their chances of having Alzheimer's go up. So age is the big one. If we live long enough, we've got a fairly good chance of having Alzheimer's to mention it. Family history, and I've got a slide that explains that a little bit more. There are some chromosomal mutations, and we also know a risk is what's called the April cycle for protein E for genotype, but I put that up there because some of you may have heard about that as a risk factor. Now, what is possible, but not proven, are the risk factors of a low education, being female, that's a little iffy. If you look at the numbers, of course I've got to say that. If you look at the numbers, it's women that live longer. So separating out the fact that we've got women living longer from whether there's actually increased risk for women, we're not so sure. Brain injury earlier in life is a possible risk factor, and depression, having depression for an extended period of time, may be a risk factor.

We're also finding interestingly that depression tends to be pretty closely tied to vascular dementia with those two are linked. And just to mention the genetics, for an individual who has Alzheimer's and they're under 60 years of age, half of those cases are from a gene. And it's an autosomal dominant gene, which means that their offspring have about a 50-50 chance. So for what we would call early onset, the genetic component and the risk to family members is pretty good. Now, over age 60, this decrease is quite a bit. There still is a genetic link, but it's much less with the over 60 years of age.

So what do we know about the course? From the time of diagnosis until the time of death can be from three up to 20 years, long and serious course. We tend to think that the average lifespan after the diagnosis is eight years, but that's just an average. Now, as I said, this starts changes in mood or memory, but then it expands to other parts of the brain so that there can start to be problems with behavior, agitation, pacing, restlessness. Then we can also have problems late in the illness with motor functioning, and eventually the person with Alzheimer's will not be able to walk or even sit up or even hold their head up. That's very in-stage.

Let's go quickly through some early symptoms. The person gets a little more repetitive. Tells that same story when they had just told it five minutes ago. Well, you know, if that's excessive, then we're concerned about it. Some people just tell stories over and over. But forgetting conversations or events, and then maybe even getting a little argumentative about that, losing items real consistently, language problems, finding words. But then here's another one. Sometimes language problems become evident when a person simply isn't able to explain things very well. You will ask a specific question, and their answers are vague or kind of confusing. Sometimes that's how the language problem is manifest. Difficulty with tasks. Always was making that Sunday dinner for the kids, but that's dropped off. Just can't put a meal on the table again. In spite of fact that banana bread was the thing that was always taken to the family dinner, just can't make that meal bread anymore.

Trouble-making decisions. Well, should I go to the store now or should I not go to the store now? Trouble with money. Making decisions about money. Difficulty following conversations. And a lot of times what will notice in family gatherings is that that individual who is always part of the news conversation and the politics wanted to talk about the world situation, that individual is now born to the side, sort of sitting passively not involved. Balancing checkbook, preparing meals, early symptoms. Has difficulty solving problems. Sometimes what happens is there's disregard for social conduct. Maybe we'll say something completely inappropriate. A lot of times it has to do either with sexual things, which can be pretty embarrassing for a family, or just off the wall comments that are just completely inappropriate.

There'll be a lot of sense of direction, getting trouble or having trouble. Oftentimes this is with driving, getting lost, or even organizing around the house. Finding way in what was very familiar surrounding us before, getting lost in one's own neighborhood. And then as I mentioned earlier, there can be some personality changes. Become more passive, more irritable, kind of unusual for that person, or perhaps overreact to the stress. Sometimes there's a misinterpretation of the stimuli that occur. You know, always looked out of the yard to watch the birds, and now starting to see maybe there's somebody in the bushes in the yard. And then start to focus more on who's that in the bushes, and a misinterpretation of maybe the bush moving, something like that.

Now, just to briefly go through how this progresses, early on, then we've mentioned a lot of symptoms. And there can be deficits that start showing up in demanding situations. If a person is employed, a common place to start to have promises in the workplace. Because that's where we often have to use our best skills and our abilities all the time for the boss. So maybe starting to have some deficits and problems that work. As this progresses more to a mild situation, this individual might require assistance with complicated tasks, such as the checkbook making decisions about finances, planning a family gathering, these might be examples of what the problem would be. As Alzheimer's advances to a more moderate stage, there'll be assistance required in such things as choosing clothing, knowing what to put on that day.

And finally, as this gets more severe, there'll be assistance necessary for even dressing properly. A lot of times, then, it gets to the point where there's inability to do hygiene, needs assistance with bathing, toileting. And during the moderately severe stage, there can even then be advancement to loss of control of bowel or bladder. And as this reaches a severe stage, the speech will be very limited, maybe only a few words, amulation becomes more and more decreased. And eventually, the person with Alzheimer's dementia will be confined to bed and will need help with everything involved for their needs. So, we're back to, how do we deal with dementia? First of all, as I said, I think it's important that we make inaccurate diagnosis.

I'll mention that just briefly in the next slide. And then, we're going to learn about the illness. And that's why you're here. And I'm also going to try to provide some additional resource in terms of information sources for you. I think it's important to learn about the treatments available, then you can make best decisions for the person without Alzheimer's. We need to know how to manage the symptoms as a disease progresses, and we need to know what the resources are that are available to us. So, what about the diagnosis? The diagnosis involves taking an excellent history, doing necessary physical examination, specific laboratory tests, brain imaging like a CT of the brain or an MRI of the brain, and specific memory testing. And this is kind of the package that helps us make the diagnosis of Alzheimer's dementia or another kind of dementia.

The question was asked, who is the best healthcare person to do this? I think there's a spectrum of people who can do this accurately. I think that there are family practitioners who are knowledgeable about Alzheimer's dementia, who are very capable of doing excellent exams, ordering appropriate tests, getting an order for the specific memory testing, putting it all together, and helping the patient and the family. So, family practitioners are a place to begin. I think then we also consider neurologists as a category of people who assess for dementia, and psychiatrists assess for dementia. And then the special field that I happen to represent is gyro psychiatry, in which people in gyro psychiatry really do this as specialized kind of work.

So, to answer the question, I think a spectrum of physicians can do this. It feels strongly that a workup does need to happen. And if there are problems with the workup, if things aren't going as predicted, that's kind of the time maybe to ask the family doctor is a more specific referral, a good idea. Learning about the illness. Well, how does that help us? What's that going to do for us? A few points that I think are important. One is, if we know about the illness, we can anticipate needs better over time. This is a long process. And just understanding how the illness will be progressive is important.

I think it's very important, early on, to involve the person and the family in appropriate legal decisions. Early on, a person with Alzheimer's dementia is usually very capable of making decisions about their care early on. And that's the time to get them involved with the financial decisions, as well as make appropriate legal decisions so that as they're less able, less able, that they've got in place things like a durable power attorney for health care decisions. I think it's very important to understand and to be prepared for and to start the process of accepting the role changes with this illness. We have a person who is highly competent and now a disease is affecting their brain so that they have less and less ability to think, remember, make decisions and take care of themselves.

And in most families, that's very difficult to see. For a husband to watch that in a wife, for a wife to watch that in a husband, for a daughter to watch that in a mother, it's very difficult because the role will change from an equal partner or a parent to a situation in which that caregiver is taking complete care of the other person. And understanding that that role is going to change and trying to get prepared for is really necessary. Another reason why knowing more about the progression of a disease helps us is it helps us be proactive. What can we do to get better prepared for what we know is going to be inevitable in this condition?

Oh, I've got a two-involved question. Okay, I have two questions there. I'm going to have to remember the answer myself. We'll go one at a time here. On the first one, 50% of the care is given by informal. That means not professionals. That would mean family members or friends. So the first question, 50% of the care is given by informal caregivers. Anybody agree with that? That's about half. The next question of the caregivers for Alzheimer's dementia or dementia is about half of these individuals are males. We have a loud false. We have a correct loud false. 80% of the care, so it's not 50%. It's 80% of the care for these individuals that's given by friends or family.

And these are what we call the hidden victims. Because the caregiver lives with a disease, has the role change, and deals with the day-to-day worsening of the condition, which will eventually lead to death. And there's a tremendous amount of strain involved. Traditionally, caregivers are female. And in this case, that's how it is. Only 27% of caregivers are male. But then, by far, the majority of them are female caregivers. Often this is the spouse. Now, women are traditionally caregivers. So we move into that role. And we're not very good at asking for help. We're better at becoming exhausted than we are asking for help.

So we're socialized to be caregivers, but we don't do a very good job of taking care of ourselves so that we can be adequate caregivers. Men, okay, maybe they do some of this right. In the sense that men caregivers tend to delegate responsibilities, tend to ask for people to come into help, tend to get the males or the housekeeping arranged. So males use outside resources, which is maybe a lesson that females need to learn. Caregivers get depressed. Over half of the caregivers eventually have a clinical depression. And it makes sense. They don't get adequate sleep. The sleep was often interrupted. They're dealing constantly, sometimes, at least towards the end with agitation, disruptive behaviors. There's the physical burden of caring.

They'll be exhausted. They're not eating well. They'll have a lot of physical symptoms. So caregivers do get depressed. And I think this is, again, I think as women caregivers, particularly, because it is giving the care, we've got to take better care of ourselves, which means doing what we can to avoid some of these things. So how can we help caregivers? Well, we can try to provide information, emotional support, no community resources, get legal and financial information, and try to come up with as many practical techniques as we can for managing this as it can be rather difficult situation. So how do we manage the strain that caregivers will ultimately have as they attempt to take care of this patient, the person? We have to recognize the limits of caregivers. You really can't do an adequate job of caregiving if you are exhausted, depressed, irritable, fatigued, overwhelmed.

So we have to recognize our own limits. We have to set boundaries for self-sacrifice. And as women, particularly, we do not do a good job of that. We will continue to be caregivers until we are burned out and exhausted. So maybe if we can recognize it and try to do something differently, it would help. Caregivers need to establish a predictable routine for the individual with Alzheimer's, and it also benefits themselves, and make use of outside support. Here's a good one. You know, patients or friends and family are always saying, how can I help? Have a list ready. So when that friend or family, so people are already writing. People, I mean some don't, but most are well-meaning when they ask, how can I help? Well, take some quiet time for yourself, and make a list. And the next time a family member or a friend says, how can I help?

You give them specific suggestions as to how they can help. We have to involve others in caregiving, whether that's other friends, whether that's children, whether that's outside people that we pay, whatever it is, we've got to involve other people in the caregiving. Particularly if it's family or friends, they will probably have a better understanding of the situation, if they've been involved in the caregiving of that person. It's kind of like, you know, back in my day, when mothers were dealing with a three-year-old, a two-year-old, a one-year-old, and you kind of leave the dad there for a day, and all of a sudden the dad realizes what it is to manage a three-year-old, a two-year-old, a one-year-old. And it's someone similar here. You know, the family member who's at a distance, it may be time to involve them, and they'll have a better understanding of what's involved with caregiving. I want to put a plug in for what's called safe return. Who's heard of safe return? Good, good.

Safe return is a program by the Alzheimer's Association in which it assists in the safe and timely return of individuals who wander and become lost. And I was very surprised by this number. Up to 59% of the patients who live in the community will wander, and we can't predict when that will be. And we do know if these individuals are not found within the first 24 hours, there is a very high mortality rate. Almost half of these individuals would die from dehydration or hypopharmia. So the Alzheimer's Disease Association has a program in which there's an identification, support, registration, and when this happens, that is put into place. I talked with the Alzheimer's Disease Association prior to this talk. They brought some brochures. They also said I could mention that currently they have some scholarships for people, because there's a little bit of a fee for this, but they currently have some scholarships available for people who have family that they would like to get involved in this. So how else can we manage dementia? Now, I'm going to spend just a brief amount of time talking about treatments, because you all ought to know what's available for treatment, what works, what doesn't work, where the science is at all this.

We're going to try to target the treatments that affect memory, behavior, and mood. Most of you are familiar with what we call the cognitive enhancers, the pills specifically for memory. We call them the colonesterase inhibitors. Originally, we said this is to help with memory, but as we've used them over time, we also are realizing that they probably do help a little bit with mood and maybe even with some of the behaviors. And you're familiar with what these are. Erisaptexalan, remanel, or the trade names. These are the pills that people with Alzheimer's are put on that help with quotes memory. These pills should be used if they can be used. They do not change the underlying disease process. Nothing is changing that, unfortunately. But they may help boost the chemical in the brain that needs boosted a little bit more, and therefore help a little longer retain some memory or not have some of the emotional instability.

They're all very similar. There's some mild variation in side effects, and it's something that you kind of work with your doctor to get the right dose with the right of tolerability. Now, we also need to consider treatment when other things come up such as depression, anxiety, suspiciousness, actively hallucinating, or when difficult behavior survives. What do we mean by depression? Well, we mean these things. Sad, not motivated, not very interested, problems with sleep, problems with appetite, maybe not much energy, sort of obsessing about something that seems kind of like excess guilt, not being able to concentrate. So, either being slowed down or being agitated, it can be either one, and hopeless or suicidal thoughts. All of these things can happen in a person with Alzheimer's dementia, and actually a person with Alzheimer's dementia is at increased risk for depression.

Again, something's happening in the brain, and that makes that individual more susceptible to depression. They can't express themselves necessarily, but things to keep an eye out for are not as interested in the needle, being a little bit more passive, maybe being tearful when that's a change. And these symptoms then, I think, do need treated, and oftentimes we will use medications that can be very safely given to treat the depression. I think I probably too quickly slipped past the slide in which I wanted to mention, in addition to depression, if anxiety is a huge problem, medicines can be helpful for that. Definitely, if there is suspiciousness in which the person is very uncomfortable, or it means that they're acting in an abnormal way, medicines should be used, or if there's hallucinations which make it very uncomfortable for the patient, medicines should be used.

For example, let me just give you an example, taking care of someone who would suddenly become very agitated, start yelling, and start pacing, and prior to that maybe was just sitting comfortably in a chair, so it was a very drastic change. And when we could get this woman to say what she was afraid of, she said, there's a fire in the hallway, there's a fire in the hallway. Well, she was seeing a fire in the hallway, and any of us seeing in the fire in the hallway would be running for the door, and that's exactly what she was doing. So an effort to kind of hear what that delusion or hallucinations like, and we need to try some medicine to help with that, because her agitation was because of what she was seeing, and it was extremely real to her so that she would have done anything to escape that fire in the hallway. Probably something that happens rather commonly is people get worried about a family member, and they're in a different place in time, so it might be an 80-year-old woman, but all of a sudden she's worried about Susie, her three-year-old daughter, and she's so worried that something has happened to Susie, her three-year-old daughter.

And I think when we try to remember our own panic in a similar situation, maybe we have a better understanding of when the brain is playing tricks on people like that, how real and how frightening it is for them. Let's go through some techniques that have to do with trying to deal with people who have Alzheimer's dementia. First of all, avoid reasoning. It's not going to work. It will usually lead to being a little bit agitated and irritable on both the caregivers part and the patients part, so kind of stop wanting to reason. Try to hear what they're saying, because it will often give you clues as to what to do. You have an example of the fire in the hallway.

If we listen carefully, we may hear my foot hurts. Briefly, the conversation has got a lot of other words in it. I'm worried about grandma. If we listen, then we can try to then use that information to deal with. Grandma's fine. I just saw her a few hours ago. She was having such a good time. You don't need to worry about grandma. Or three-year-old Susie. She went out to play. Somebody's watching her. She's fine. I'll go check on her for you. Listen, and that may help you know what to do. Maintain a trusting relationship that seems obvious, but sometimes I think we need to state the obvious. Be predictable. Be consistent. Don't give or promise something that isn't going to happen. Just try to be a person of your word, considering the circumstances involved. Offer choices.

Early on, people are using pretty aware of the illness. As it progresses, they're less aware of the illness. But all of us always want choices. Do you want to wear your red blouse or do you want to wear your black brush? Do you want this pair of shoes or that pair of shoes? Do you want to take your bath now or do you want to take your bath in 15 minutes? That puts some control back in the hands of the person who has lost control about so many things. So if possible, offer choices. How about this one? We'll go ahead and give you advanced notice. Why is that? Confusion. Confusion. We don't give advanced notice because there is this loss of sense of time. And when you say, we're going to the doctor Tuesday afternoon. First of all, that doesn't have any meaning most likely.

And secondly, they think it's now, what are we going? Let's get ready. I've got to take my bath and going to the doctor. So avoid the advanced notice because it usually just creates some confusion and agitation. Communicate thoughtfully. When I was rereading some of the things that I've liked over the years that give suggestions in this area, it said, treat this individual like a guest. That was great advice. Graciously with respect like a guest. Distract and divert. Very good technique. Mom is convinced she's got to go do shopping now. She has to leave the house now. She has to go to shopping now. So how do we distract that?

We'll go shopping in a few minutes. Let's go find this now. Let's see if this is on your favorite radio show is all now. How about if we look at this book before we go shopping? Follow a routine. A definite set way of doing things is very helpful for the patient. It's as much predictability as we can have in their lives is very important. Provide comfort. We assure it's again back to treating like a guest. And then I would say in a way it's okay if we realize what's happening with this person is that they are becoming like a child. And our efforts to treat them respectfully but comfortably with comfort, with reassurance, with nurturing. If we can kind of see it like that that sometimes that helps.

Stay calm. That's the big one. Stay really calm because our own emotions just see about and become then the emotions of that other person. If we're irritated, if we're angry, if we're upset, they're going to feel that. So back to caretakers taking care of themselves. Taking care of ourselves so that we can stay calm, relaxed is one of the best things we can do for that family member. And if the situation allows and you're not calm, you move out of it right then because not being calm is not going to help the situation will probably make it worse. Anything simple, although I said give choices, make the choices simple and not complex.

But more so you take the cause there.