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dementia

From Science to Smartphones: Boosting Memory Function One Press at a Time

From Science to Smartphones: Boosting Memory Function One Press at a Time

Teaser: 

Eva Svoboda, PhD,1,2 Gillian Rowe, PhD,1,2 Kelly Murphy, PhD,1,2
1Neuropsychology and Cognitive Health Program, Baycrest Centre, Toronto, ON.
2Department of Psychology, University of Toronto, Toronto, ON.

Abstract
Memory problems can be devastating as they limit independent functioning and disrupt social, family, and occupational roles. One form of remembering, prospective memory - remembering to attend to a task or event in the future—is particularly vulnerable to disruption. Fortunately memory is not a singular ability and patients can learn to compensate for memory difficulties by using preserved memory systems. Combining smartphone technology with appropriate training techniques has been shown to be effective in supporting prospective memory function even in individuals with amnesia. We have evidence that such technology may be used in a similar fashion to promote memory in mild cognitive impairment with the aim of delaying or preventing dementia onset. Even in dementia, memory training or support in forming new habits and routines which tap into preserved memory systems can be effectively used to help patients learn new names, reduce repetitive questions and remain oriented to the present. The best prevention is early intervention. Older adults presenting with memory complaints, no matter how mild, should be directed to maintain, reestablish, or institute habits of organization and written reminders, both to support current memory functioning and to preserve functional independence into the future should their concerns turn out to be the early manifestations of a neurodegenerative condition.
Keywords: amnesia, technology, dementia, mild cognitive impairment, memory intervention.

Plants are Good for the Soul Including for those Living with Dementia

As I was leaving for a bike ride I passed my wife, out for her morning walk; "I think it was a successful resuscitation!" She asked who I was talking about and I answered, "The three foxgloves", beautiful purple flowered plants I had planted days earlier that were wilting in the terrible summer heat. I "diagnosed" severe dehydration and therefore I provided large doses of water so that overnight the leaves filled out and the tall stem holding the gorgeous flowers were almost upright. It seemed to be a miraculous feat of plant care for someone who having been brought up in Brooklyn knew close to nothing about flowers or plants. Betty Smith's famous 1943 novel, A Tree Grows in Brooklyn, had little impact on my botanical knowledge or skill.

My wife had a good laugh and I biked away recalling my fond association with the foxglove that was important to me because of my medical studies in Scotland in the 1960s. During medical school what is now digoxin, a medication used for various forms of heart disease was provided as a biological preparation known as digitalis leaf, which meant its purity could not be as exactly determined compared to the more contemporary purified digoxin product. I was on an outing with classmates to the west of Scotland which culminated in a difficult uphill hike on the foothills of Ben Nevis part of the western Scottish mountains. As I stopped to catch my breath, Andrew Johnson, one of my more playful classmates, kneeled over me with a flowering plant in his hand and said laughingly in his Yorkshire accent, "here Michael, take a nibble of this, it will strengthen your heart," while waving a foxglove in front of me. I had never seen the plant but from then on, its appearance and medical importance was imprinted in my brain.

Digitalis was introduced into medical practice by William Withering (1741-1799) a great English medical botanist. Born in Wellington, Shropshire, England, he attended Edinburgh Medical School from 1762 to 1766. In 1776, he published, The botanical arrangement of all the vegetables naturally growing in Great Britain, an early and influential compendium of British Flora. The foxglove plant, digitalis purpurea, had been known for centuries as a folk remedy for the treatment of dropsy, or congestive heart failure, and other conditions. Withering in 1785 published his classic work, An account of the foxglove, and some of its medical uses: with practical remarks on dropsy, and other diseases. His observations changed the course of medicine and although digitalis is presently used less in current medical practice, I had frequently used it previously and observed its often dramatically life-saving effects.

My personal foray into gardening has occurred late in life but I have witnessed professionally the important therapeutic impact that raising plants can have on elderly individuals including those with cognitive impairment and cancer. There is a growing body of knowledge, studies and observations about the beneficial effect that plant care and gardening can have on those living with dementia. On a March 7, 2008 the website Caring Today (http://www.caringtoday.com/reduce-stress/garden-therapy) provided some interesting insights as to the therapeutic benefits of gardening and the care of plants by individuals living with dementia. "Gardening requires certain steps or sequences," says David B. Carr, MD, a geriatrician at Washington University in St. Louis. "Lots of patients, especially those with Alzheimer's or dementia, need guidance or mentoring because they can't go through all the steps alone, but they can do some of them."

Carr describes one of his male patients whose wife was the brains of their gardening operation. "She told him how deep to dig the hole, what to put in it and how to water it. This way of attacking the activity worked for them," he notes, "and they got to spend quality time together. "It has been my experience that those patients (with Alzheimer's or dementia), doing activities (gardening being one example) do better in the long haul and have a slower rate of decline than those who don't do anything," says Carr. "Gardening is one of the non-prescription interventions that have the ability to slow the rate of cognitive decline."

As reported on a BBC News website in September 20, 2011 by Huw Williams a BBC Scotland reporter an article appeared entitled, Garden therapy could bear fruit for dementia care (http://www.bbc.co.uk/news/uk-scotland-tayside-central-14979146). In the article it is noted that "Dementia patients across the country may be spending 24 hours a day locked in hospital wards—an unacceptable regime even for convicted prisoners. But now growing numbers of experts say access to the outdoors, and physical activity such as gardening, could transform life for patients with conditions such as Alzheimer's disease or other forms of dementia.

Annie Pollock, landscape designer from the Dementia Services Development Centre at Stirling University, says it, "should not be surprising that core skills from one's lifetime of gardening remain, even as the disease takes away other aspects of one's personality."
And she says," there is plenty of evidence of the benefits outdoor activity such as gardening can have for people….(with dementia)."

Also in the article a note of caution from Fiona Thackeray, from Trellis, a charity promoting therapeutic gardening which is organising a course on designing gardens for people with dementia. She cautions that unlocking the garden gate does not necessarily mean you can keep the drugs cabinet closed. She says: "We wouldn't argue that gardening is going to cure you, or take away all need for any other interventions. "But it can be a really powerful addition, or complementary therapy, to any drug regime." "It's a great physical activity so it's a good way to keep fit, or get fitter. Most people find it calms them down, it's a great stress reliever." Ms. Thackeray adds: "More and more we're seeing the importance of vitamin D. Although we don't have much sunlight in Scotland, if you're outdoors in the garden you're going to be boosting your vitamin D levels." And, she says, "the sense of smell is a really strong trigger for memory, so what better place than a garden, with all the scented flowers and herbs, for people with dementia? It can help them think back to their past, and bring back positive memories."

On a You Tube video the beneficial aspects of gardening is the focus of the story: Therapeutic gardening helps residents with dementia: Residents with dementia at the Norwood Crossing assisted living center participate in therapeutic gardening that helps them build confidence and a sense of community. The center raised enough money to open a new garden outside, which residents will be able to tend to daily. (http://www.youtube.com/watch?v=T_hvKZv4ViE)

The short-story writer O'Henry captured poignantly the life-affirming impact of what was believed to be a lingering vine leaf on a pneumonia-stricken woman in The Last Leaf. The patient's ultimate recovery is at the expense of the old painter who as his last heroic artistic effort painted the leaf on the wall facing the window to give the illusion of the still-living leaf, only to contract fatal pneumonia as the price paid.

On the palliative care unit where I work at Baycrest, there is an active plant group that with a recreation therapist and dedicated volunteers helps patients nurture their plants. One elderly gentleman with advanced malignancy had always raised his own vegetables. His plant project was to raise some beans while he was on the unit and the joy that he experienced watching his carefully tended blooms yield their produce was a testimony to the life-affirming power of plants living and thriving through our human efforts.

Gardening and the tending of plants is part of the spectrum of life-affirming activities that we can use in the care of the elderly especially those with dementia or those with end-stage illnesses such as malignant and non-malignant disease. To tend to a plant, watch it grow and produce its leaves, flowers or vegetables affirms for many that there is a meaning to life, even as one may realize that one's end is on the horizon or when may not realize exactly what life has in store because of cognitive impairment but anything that gives life meaning is a worthwhile endeavor.

This article first appeared in part in the August 7th, 2012 issue of the Canadian Jewish News.

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Palliative and Therapeutic Harmonization (PATH): A New Model for Decision-Making in Frail Older Adults

Palliative and Therapeutic Harmonization (PATH): A New Model for Decision-Making in Frail Older Adults

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

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Teaser: 

Paige Moorhouse, MD MPH FRCPC, and Laurie Mallery MD FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax Nova Scotia

www.pathclinic.ca

Abstract
As the population ages, advances in medical technology paradoxically result in the accumulation of multiple chronic health conditions—known as frailty. Despite increasing numbers of frail older adults, healthcare systems have not been designed to meet the challenges associated with caring for this patient population. This article describes the characteristics of health systems that exacerbate the complex issues associated with caring for those who are frail and reviews one possible model, known as PATH—Palliative and Therapeutic Harmonization, as a way to respond to these system challenges.
Keywords: frailty, care planning, dementia, knowledge translation, health program.

Neural Plasticity and Cognitive Reserve

Neural Plasticity and Cognitive Reserve

Teaser: 

Zahra Bardai, BSc, MD, CCFP, MHSc, FCFP, Community Family Physician, Lecturer, University of Toronto, Assistant Clinical Professor (Adjunct), Department of Family Medicine, McMaster University, Hamilton, ON.

Abstract
Neural plasticity in the context of normal aging and dementia can be evaluated on a number of levels. Traditionally there has been much focus on cellular dysfunction, which is evidenced by the plaques and tangles that are the hallmarks of Alzheimer type dementia. Now, more than ever, there is an emerging spotlight on the preservation of functional levels despite failing cognition be it from normal aging, mild cognitive impairment (MCI) or diagnosed dementia. Neural plasticity can be viewed as the complex interaction between the neurons' electrical, biochemical and physical structure and the individual's behavioural, psychological and sociological activities.1 This article will briefly review the neurobiology of cognition and the sequence of events that lead to its demise. The remainder of this review concentrates on tangible, evidence based strategies to uphold clinical cognition through the aging process.
Keywords: neural plasticity, aging, dementia, cognition, neurons.

…there were neurons in her head, not far from her ears, that were being strangled to death, too quietly for her to hear them. Some would argue that things were going so insidiously wrong that the neurons themselves initiated events that would lead to their own destruction. Whether it was molecular murder or cellular suicide, they were unable to warn her of what was happening before they died.

-Still Alice
Lisa Genova

Later Stage Dementia: Promoting Comfort, Compassion and Care

Later Stage Dementia: Promoting Comfort, Compassion and Care

Teaser: 

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
 

Learning Objectives

When it comes to dementia much of the focus is related to diagnosis and treatment(s). A terminal phase is not always considered with conditions that cause dementia-but must be to properly plan care.

To address clinical and ethical challenges that face health care providers and families for this population and to provide health care providers with processes by which to address such ethical dilemmas.

Keywords: dementia, caregiving, end-of-life planning

When to Have the Critical Conversation? Issues in Planning for Persons with Dementia and their Caregivers

When to Have the Critical Conversation? Issues in Planning for Persons with Dementia and their Caregivers

Teaser: 

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.

Of the many challenges that face families when looking after their older loved ones, of the most difficult is deciding on end-of-life decisions. The accepting or rejecting artificial nutrition and hydration, apparently life-saving antibiotic intervention for an aspiration pneumonia or urinary tract infection or the implementation of theoretically life-saving cardio-pulmonary resuscitation are among the many decisions that substitute decision-makers, who are often close family members, have to make. More often than not, these types of decisions are required in urgent situations where a time-consuming deliberative process that might be expected for a well-thought out decision to be reached is not possible because of the pressures of the potentially fatal clinical situation. Proper preparation for such eventualities usually requires time and thought that includes exploration of personal values and wishes in what ideally should occur during conversations between older loved ones at risk of or in the throes of dementia when discussions might still take place. These revealing communications must occur with those that are responsible for making these very personal and potentially life-altering clinical decisions.

The Art of Listening Again and Again

It was a replay of a common interaction. I was telling my daughter some story from my past to make one point or another and she responded with, “I know, I know, you have told me that before.” At that moment I realized what a common occurrence this sort of interaction was and explained to my daughter, “Even if you have heard the story before remember that it is important to listen again because first of all I may not remember that I told you the story before and more importantly the telling of the story may have as much meaning and significance for me as it might have for you.”

As I thought about the issue I realized how often in my geriatric medicine practice one of the salient complaints by families is how often their loved one tells them the same thing over and over again, and they use that symptom as do we in practice as geriatric health care providers, as possible evidence of cognitive decline and the inability to recall what was said previously. I am beginning to believe that this symptom, although very common, and often indicative of a decline of cognitive function is also a manifestation of a very common human propensity to focus on the narrative of one’s life and to recall and recount that narrative as part of one’s process of self-identity and validation. The question is; what is the separation between the normal and very common attribute of story-telling and the narrative of one’s life, and the pathology of cognitive impairment that interferes almost completely with the awareness that a story or occurrence has been recently recounted to a loved one?1,2

What most of us understand at some level is that the telling of stories is a very important part of our existence. Some do it more than others, but in normal relationships and conversations we spend much of our efforts recounting events of our life and experience to others. And the propensity to be repetitive is quite universal as anyone in a long-standing relationship will admit. In fact, if one were to track the topics of conversation between spouses and family members over a period of time I predict that one would find the same topics in one form or another repeated. This includes the common topics related to work, especially when there are conflicts or important decisions to be made or about important family members that includes children or parents depending on one’s age. I would suspect that if there were a prohibition on the repetition of topics to be discussed between partners and other family members there would be very little to be discussed.

A very common point of evidence to this phenomenon is the discussion of newsworthy items and political views. Any member of a couple usually knows pretty well the political views of the other partner. When in a social setting the topic comes up they often patiently listen to their partner express their views to presumably a new audience (although this to the chagrin of some friends or family members is not always the case) without interrupting the narrative with statements such as “we have heard your views before—if you do not have a new one just stop talking”. That would be considered extremely rude and likely the basis of the disruption of a social or personal relationship.

The question and challenge for those facing the extremes of repetition in a loved one who is developing or already has evidence of dementia is what to do? Those in such situations usually learn very quickly to avoid conflict that interrupting the recounting of an event already recounted with a “you told me already or I know” usually results in some element of conflict with a denial that the conversation in fact has taken place. Also, in the context of normal aging, family members may find that the propensity to retell and recall one’s life narrative occurs more and more frequently. This is partially because it is one of the ways all of us validate our lives which is important as the past becomes increasingly important compared to the likely options for the future. It is because of this human need to tell our narratives that there is such an interest by many in writing autobiographies and memoirs and an interest in readers in learning about other people’s lives, some because they are “famous” and others because they are deemed to be interesting or unusual and at other times because the reader finds the particular narrative congruent with their own life experience. The recognition that another’s life story in some way intersected, overlapped or was in parallel to one’s own is a very powerful way of validating one’s own life and confirming its relevance and importance.

A special dimension to repeating stories and recalling the narrative is when those stories are associated with great suffering and pain. Those of us that deal with Holocaust survivors, or those who have lived through other atrocities as have occurred in many parts of the world in the last century may be plagued by the content of those stories and the retelling may be associated with great emotional reactions. This can be very disconcerting to a family member especially as each retelling of the story becomes in essence a re-living of that particular horrific episode in that person’s life.3

The best recommendation that I can make about this inevitable process of repetition of a loved one’s “stories” is to find ways to be patient with them and accept that even though you have heard the story before, actually acknowledging it and expressing an interest in it is helpful and even therapeutic to both of you.

  1. Bursack, CB. What to Do When a Parent Repeats the Same Things Over and Over? Aging Care.com, http://www.agingcare.com/Articles/elders-repeating-the-same-story-146023.htm
  2. Mild Cognitive Impairment (MCI); What do we do now?, Prepared by the Center for Gerontology, Blacksburg, VA October, 2006; http://www.gerontology.vt.edu/docs/Gerontology_MCI_final.pdf
  3. Gordon M. Dementia and the Holocaust: What to do with those memories? January 29, 2012, HealthPlexus.Net: /blog/dementia-and-holocaust-what-do-those-memories

 

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Late-Stage Dementia: Promoting Comfort, Compassion, and Care and previous two books being Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

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Helping Families Worried About Developing Dementia

Helping Families Worried About Developing Dementia

Teaser: 

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

One of the challenges faced by those of us who practice geriatric medicine or through another specialty is helping family members understand the hodgepodge of medical literature especially as it is reported by internet/Google searches rather than careful reviews of the peer reviewed literature. Even in the latter there is a wide range of opinions which even for physicians sometimes presents a challenge in how we make our recommendations. This is especially the case when dealing with dementia.
Keywords: dementia, burden, stress, fear, guilt, families.

Cognitive Decline and Dementia Risk in Type 2 Diabetes

Cognitive Decline and Dementia Risk in Type 2 Diabetes

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

Mainpro+® Overview
Teaser: 


Liesel-Ann Meusel1, PhD, Ekaterina Tchistiakova2,3, BSc, William Yuen4,5, BSc, Bradley J Macintosh2,3, PhD, Nicole D Anderson1,6, PhD, and Carol E Greenwood4,5, PhD
1Rotman Research Institute, Baycrest Centre, Toronto, ON. 2HSF Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, ON. 3Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Toronto, ON.
4Kunin-Lunenfeld Applied and Evaluative Research Unit, Baycrest Centre, Toronto, ON. 5Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON. 6Departments of Psychology and Psychiatry, University of Toronto, Toronto, ON.

Abstract
Type 2 diabetes mellitus is increasingly common, and previously unrecognized complications are emerging; namely, cognitive impairment and dementia. The mechanisms that link these factors together are still unknown, but likely result from the interplay of several variables, including vascular change, poor glycemic control, inflammation, and hypothalamic pituitary adrenal overactivity. At present, it is still too early to propose best practices related to the management of diabetes-induced cognitive change. All things considered, however, patients should be aware that proper management of metabolic and vascular complications may minimize the adverse effects of type 2 diabetes on cognitive function and quality of life.
Keywords: type 2 diabetes, cognition, dementia, vascular, metabolic
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The Launch of the Dementia Educational Resource: Interview With the Editor-in-Chief Dr. Michael Gordon

The Launch of the Dementia Educational Resource: Interview With the Editor-in-Chief Dr. Michael Gordon

Teaser: 


Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin
Geriatrician, ethicist, educator, speaker, author.

Following on the footsteps of the recent announcement of the launch of the Dementia Educational Resource, www.HealthPlexus.net recently interviewed Dr. Michael Gordon who was appointed as Editor-in-Chief for the newly re-focused educational channel. Dr. Barry Goldlist asked Dr. Gordon a few questions about the format and the plans for this project.