Living with Alzheimer's, As a Patient and a Caregiver

Reprinted from: http://www.wnyc.org/story/alzheimers/
Jul 23, 2015

More than five million Americans suffer from Alzheimer's disease, and according to the Alzheimer's Association, and 15.5 million Americans are currently caring for them.

A new drug might provide some hope for those showing very early symptoms of the disease. This week at the annual Alzheimer’s Association International Conference in Washington, the pharmaceutical company Eli Lilly released new data on a drug that seems to prevent the buildup of amyloid plaques in the brain—the type of plaques many doctors believe are tied to Alzheimer's.

Scientists say it's much too early to tell if the drug will make it to the market, but for those who care for Alzheimer's patients, the potential treatment offers at least a glimmer of hope for a disease with very few prospective cures on the horizon.

Dr. David Kramer was diagnosed with Alzheimer's in 2012 at the age of 56. He retired from his job as an emergency room physician and currently lives with his wife and caregiver in Florida. He says he’s cautiously optimistic about the new data from Eli Lilly.

“I have some preliminary optimism with the results, but I had an opportunity to read the paper on the study that was discussed and presented,” says Kramer. “The data is very, very preliminary, and there’s not any clear evidence from what I can see that this will have any long-term effect. But it’s way too soon to tell.”

Like Kramer, Meryl Comer is also watching with some hope. She has been an Alzheimer's caregiver for 20 years—her husband, a former research physician at the National Institutes of Health, was diagnosed with early-onset Alzheimer's at the age of 57.

Comer, who is also a journalist and author of the New York Times bestseller, “Slow Dancing with a Stranger: Lost and Found in the Age of Alzheimer's,” cares for her husband along with her mother, who also has Alzheimer’s disease.

“It’s promising, but premature, and people tend to read the headlines only—we’ll receive calls saying, ‘Good news, your problems are over,” she says. “They don’t understand the complexities of the disease. It’s easier to get to Mars than it is to find a disease-modifying therapy for a very complex issue like Alzheimer’s.”

Comer applauds pharmaceutical companies that are working to find treatments and cures for the disease, despite the many false starts and failed attempts that have already been made.

“We went through a phase where, after these failed trials, we were afraid that we would be abandoned at a time when the numbers are growing exponentially—44 million globally are suffering from the disease,” she says. “The other new hopeful part is there are 13 new therapeutic compounds, and four or five are disease modifying therapies. I stay close to the science, as do all advocates, because we are desperate for a disease-modifying therapy. Just give us five more years of quality of life—think what that might mean to an individual.”

Despite the excitement around the findings presented by Eli Lilly, the hope of a treatment for an Alzheimer’s is just that—a hope.

“While these may have potential, even after the phase three trials are done, you still do not know if the effects will be long lasting—whether the slowdown in the progression of the disease, if it actually does occur, will be consistent overtime,” Kramer says. “There’s a lot to learn.”

Even with all the uncertainty, Kramer says that he does not feel powerless in the face of his diagnosis. 

“I feel that it’s important for me to enjoy the time that I have now,” he says. “My wife and I focus on doing everything that we can now and enjoying life. There is a definite benefit in having an early diagnosis, as I was fortunate to have. I can then say, ‘Alright, I know what I’ve got, but I’m doing well now.’ As long as I can continue to do well and live well with the disease, I plan on doing that.”

But not all are so lucky. Comer says that many doctors are reluctant to give an early diagnosis of Alzheimer’s because there is no cure. She says that her husband was misdiagnosed for four years, with doctors saying that her husband’s condition might have been Lyme’s disease or depression.

“It’s insulting to families who are lost and confounded by behaviors, because behaviors are the first things that appear around the disease,” she says. “We have to [call for] an early diagnosis—give us a chance to live in the moment with our loved ones, don’t decide for us.”

An early diagnosis, Comer argues, helps families and those suffering with the disease to live fully, especially since the disease can progress at different speeds.

“Often you’re moving from crisis to crisis,” she says. “You really try to look at the successes—that he had a good day. The caregiver actually forgets who they are because you are so focused on protecting the dignity of the loved one who has the disease and of giving them their last ‘hurrah.’ That takes tremendous energy.”

Comer adds that this is the “biggest women’s issue since breast cancer” since women often outlive men, and the majority of caregivers are women, who are also much more likely to give up their careers for a loved one in need.

“I interact a lot with many, many people with dementia, and I tell you that the primary concern that all of us have is about the health and welfare of our caregivers,” Kramer adds. “I’m much more concerned about the impact of this disease on my wife than I am on myself.”

Click here to hear the entire story from NPR

One-third of dementia cases could be prevented, report says

Reprinted from: http://www.cbsnews.com/news/one-third-of-dementia-cases-could-be-prevented-alzheimers-report/?WT.mc_id=enews2017_07_31&utm_source=enews-aff-28&utm_medium=email&utm_campaign=enews-2017-07-31

By ASHLEY WELCH CBS NEWS July 20, 2017, 5:00 AM

One-third of cases of dementia worldwide could potentially be prevented through better management of lifestyle factors such as smoking, hypertension, depression, and hearing loss over the course of a lifetime, according to a new report.

Across the globe, about 47 million people were living with Alzheimer's and other forms of dementia in 2015. That number is projected to triple by the year 2050 as the population ages. Health care costs associated with dementia are enormous, with an estimated $818 billion price tag in 2015.

The new study, published in The Lancet and conducted by the first Lancet Commission on Dementia Prevention and Care, brought together 24 international experts to review existing dementia research and provide recommendations for treating and preventing the devastating condition.

"Dementia is the greatest global challenge for health and social care in the 21st century," lead study author Professor Gill Livingston, of University College London, told CBS News. "The purpose of the commission was therefore to address it by consolidating the huge strides and emerging knowledge as to what we should do to prevent dementia and intervene and care for people with dementia."

There is currently no drug treatment to prevent or cure dementia. But the report highlights the impact of non-drug interventions and identifies nine modifiable risk factors through various stages of life — beginning in childhood — that affect the likelihood of developing dementia.

To reduce the risk, factors that make a difference include getting an education (staying in school until over the age of 15); reducing high blood pressure, obesity and diabetes; avoiding or treating hearing loss in mid-life; not smoking; getting physical exercise; and reducing depression and social isolation later in life. About 35 percent of dementia cases are attributable to these factors, the analysis found. Removing them could then theoretically prevent 1 in 3 cases.

In contrast, finding a way to target the major genetic risk factor, a gene called the apolipoprotein E (ApoE) ε4 allele, would prevent less than 1 in 10 cases – or about 7 percent.

"There's been a great deal of focus on developing medicines to prevent dementia, including Alzheimer's disease," commission member Lon Schneider, M.D., a professor of psychiatry and the behavioral sciences at the Keck School of Medicine of USC, said in a statement. "But we can't lose sight of the real major advances we've already made in treating dementia, including preventive approaches." Schneider presented the findings at the Alzheimer's Association International Conference (AAIC) 2017.

Of the nine risk factors, the researchers identified the three most common ones that could be targeted for dementia prevention.

The first is increasing education in early life, which the report estimated could reduce the total number of dementia cases by 8 percent if all people worldwide continued their education until over the age of 15.

The researchers note that not completing secondary education could raise dementia risk by reducing what's referred to as "cognitive reserve." It's believed that education and other mentally stimulating tasks help the brain strengthen its networks so it can continue to function at a higher level even if it starts to decline later in life.

For the first time, the researchers also identified hearing loss as a major modifiable risk factor for dementia. They estimated that reducing hearing loss in mid-life could also reduce the number of dementia cases by 9 percent if all people were treated.

Livingston notes that research surrounding hearing loss and dementia is still in early stages and the link likely has something to do with the social isolation that can come with losing the ability to hear.

"They may work in similar ways as they reduce the chance of interactions and conversations, which are like exercise for the brain and enrich it and predispose to depression," she said.

It's not clear from medical research yet whether using hearing aids can counteract this risk.

Additionally, the researchers found the number of dementia cases worldwide could be reduced by 5 percent if all people stopped smoking. It's particularly important to stop smoking later in life, they say, to reduce neurotoxins and improve heart health, which in turn improves brain health.

Other interventions likely to reduce dementia rates include increased physical activity and treating high blood pressure and diabetes.

The study authors say the report can offer guidance on ways to reduce the risk of dementia throughout life and improve the care for those living with the disease.

"This includes providing safe and effective social and health care interventions in order to integrate people with dementia within their communities," Schneider said. "Hopefully this will also ensure that people with dementia, their families and caregivers, encounter a society that accepts and supports them."

It's important to note that lifestyle interventions will not delay or prevent all dementia cases. But the researchers say they are hopeful that the report will help shift more focus to concrete steps that can be taken to help avoid the disease.

"We hope that this report will feed into individual nations' dementia policies and public health strategies, be used by individual clinicians to inform and improve their practice, and through media publicity inform the general public of what they can do to help avoid dementia, which is the most feared illness in old age."

© 2017 CBS Interactive Inc. All Rights Reserved.

Aging parents: 8 warning signs of health problems

Concerned about your aging parents' health? Use this guide to gauge how your aging parents are doing — and what to do if they need help.

By Mayo Clinic Staff

As your parents get older, how can you be sure they're taking care of themselves and staying healthy?

When you visit your parents, consider the following questions:

1. Are your parents able to take care of themselves?

Pay attention to your parents' appearance. Failure to keep up with daily routines — such as bathing and tooth brushing — could indicate dementia, depression or physical impairments.

Also pay attention to your parents' home. Are the lights working? Is the heat on? Is the yard overgrown? Any changes in the way your parents do things around the house could provide clues to their health. For example, scorched pots could mean your parents are forgetting about food cooking on the stove. Neglected housework could be a sign of depression, dementia or other concerns.

2. Are your parents experiencing memory loss?

Everyone forgets things from time to time. Modest memory problems are a fairly common part of aging, and sometimes medication side effects or underlying conditions contribute to memory loss.

There's a difference, though, between normal changes in memory and the type of memory loss associated with Alzheimer's disease and other types of dementia. Are your parents' memory changes limited to misplaced glasses or an occasionally forgotten appointment? Or are the changes more concerning, such as forgetting common words when speaking, getting lost in familiar neighborhoods or being unable to follow directions?

3. Are your parents safe in their home?

Take a look around your parents' home, keeping an eye out for any red flags. Do your parents have difficulty navigating a narrow stairway? Has either parent fallen recently? Are they able to read directions on medication containers? When asked, do your parents say they feel safe at home?

4. Are your parents safe on the road?

Driving can be challenging for older adults. If your parents become confused while driving or you're concerned about their ability to drive safely, it might be time to stop driving.

5. Have your parents lost weight?

• Losing weight without trying could be a sign that something's wrong. Weight loss could be related to many factors, including:
• Difficulty cooking. Your parents could be having difficulty finding the energy to cook, grasping the tools necessary to cook, or reading labels or directions on food products.
• Loss of taste or smell. Your parents might not be interested in eating if food doesn't taste or smell as good as it used to.

Underlying conditions. Sometimes weight loss indicates a serious underlying condition, such as malnutrition, dementia, depression or cancer.

6. Are your parents in good spirits?

Note your parents' moods and ask how they're feeling. A drastically different mood or outlook could be a sign of depression or other health concerns.

7. Are your parents still social?

Also talk to your parents about their activities. Are they connecting with friends? Have they maintained interest in hobbies and other daily activities? Are they involved in organizations or clubs? If a parent gives up on being with others, it could be a sign of a problem.

8. Are your parents able to get around?

Pay attention to how your parents are walking. Are they reluctant or unable to walk usual distances? Have they fallen recently? Is knee or hip arthritis making it difficult to get around the house? Would either parent benefit from a cane or walker?

Issues such as muscle weakness and joint pain can make it difficult to move around as well. If your parents are unsteady on their feet, they might be at risk of falling — a major cause of disability among older adults.

Taking action

There are many steps you can take to ensure your parents' health and well-being, even if you don't live nearby. For example:

• Share your concerns with your parents. Talk to your parents. Your concern might motivate your parents to see a doctor or make other changes. Consider including other people who care about your parents in the conversation, such as other loved ones, close friends or clergy.
• Encourage regular medical checkups. If you're worried about a parent's weight loss, depressed mood, memory loss or other signs and symptoms, encourage your parent to schedule a doctor's visit. You might offer to schedule the visit or to accompany your parent to the doctor — or to find someone else to attend the visit. Ask about follow-up visits as well.
• Address safety issues. Point out any potential safety issues to your parents — then make a plan to address the problems. For example, your parents might benefit from using assistive devices to help them reach items on high shelves. A higher toilet seat or handrails in the bathroom might help prevent falls. If your parents are no longer able to drive safely, suggest other transportation options — such as taking the bus, using a van service or hiring a driver.
• Consider home care services. If your parents are having trouble taking care of themselves, you could hire someone to clean the house and run errands. A home health care aide could help your parents with daily activities, such as bathing. You might also consider Meals on Wheels or other community services. If remaining at home is too challenging, you might suggest moving to an assisted living facility.
• Contact the doctor for guidance. If your parents dismiss your concerns, consider contacting the doctor directly. Your insights can help the doctor understand what to look for during upcoming visits. Keep in mind that the doctor might need to verify that he or she has permission to speak with you about your parents' care, which might include a signed form or waiver from your parents.
• Seek help from local agencies. Your local agency on aging — which you can find using the Eldercare Locator, a public service of the Administration on Aging — can connect you with services in your parents' area. For example, the county in which your parents live might have social workers who can evaluate your parents' needs and connect them with services, such as home care workers.

Sometimes parents won't admit they need help, and others don't realize they need help. That's where you come in. Make sure your parents understand the problem and your proposed solution. Remind your parents that you care about them and that you want to help promote their health and well-being, both today and in the years to come.

Reprinted from: http://www.mayoclinic.org/healthy-lifestyle/caregivers/in-depth/aging-parents/art-20044126

Exercise at any Age, with any Chronic Condition (Part 3)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

What this Geriatrician learned from the Gerofit program

The following describes an exercise program, Gerofit, and its proven benefits for its participants. The Gerofit program was started by Dr. Miriam Morey at the Durham VA and for the past 30 years has successfully provided an exercise venue for older adults with chronic conditions (Morey MC, 2007). The program requires a referral from the primary care provider, with a chart review and telephone interview. Then baseline and quarterly Senior Fitness Test assessments (Rikli RE 2013) tell you your percentile ranking by gender and five year age group.  This allows a prescribed individualized exercise program that includes exercises for aerobic/cardio, weight resistance, and balance.  Program participants demonstrated a 25% reduction in mortality over five years, and in a related study, those that showed a 0.1m/sec increase in usual gait speed had less hospital days and reduced one-year costs (Purser JL 2005).

This author was skeptical of this program and had concerns about its safety. What I learned from exercising with older Veterans, doing assessments, and adjusting exercise protocols was this:  besides being a lot of fun, the gym is a true respite from illness.  Everybody has chronic conditions, and instead of focusing on them, everyone is working to improve their fitness.  Second, I realized I was biased against exercise because I was fearful someone would get hurt.  Instead, what I have learned is to assess their fitness, then prescribe an appropriate starting place for cardio, weight-resistance training, and balance based on that assessment. Third, older adults need guidance/reminders to do exercises correctly and to adapt exercise to chronic musculoskeletal conditions, and most importantly, to progress the intensity of the exercises.  I also learned it is very hard to predict in whom exercise will really take hold and become life changing.  Prior history of some physical fitness training provides a clue, but is not a guarantee; while many with no background in exercise can just as readily take off.  Exercise is life changing in this cohort.

What do we do about exercise in the significant portion of older adults with varying forms of cognitive impairment?

How do we implement an exercise program that includes cardio, muscle strengthening, and some balance exercise in this population?  What I have learned from Gerofit is that some of the older adults in a program will develop cognitive decline, some will be unrecognized at time of enrollment but become more obvious when they do not learn exercise routines or technique; and in both cases, they will exercise effectively but need supervision and coaching. Those with moderate dementia can fit well into a group exercise program if there is enough staff support or their caregivers are trained and supervised as well.  Folding cognitive impairment participants into a fitness program really provides optimal socialization and engagement when the focus is on fitness and set exercise routines.  

Participants with dementia with past history of physical activity will have motor memory that exceeds cognitive memory.  Regardless, improvement in fitness assessment is the norm if participants engage in the exercise, and there is significant benefit to mood and reduced anxiety.

How can an Aging Life Care Manager™ help?

Aging Life Care Managers have an important role in promoting exercise for their older clients. Care managers can facilitate the interaction of older adults, families, and health care providers, making the initiation of an exercise program more possible.  Care managers can recommend exercise programs for their clients for fall prevention, but can also help to identify clients that have already fallen that could benefit from exercise as an intervention.

The recommendation by the CDC is that if someone has had two or more falls or a fall with injury in the past year, has decreased activities due to changes in their balance, or has demonstrated at-risk screening measures mentioned above, then the following should be done:

• Address chronic medical conditions that may be contributing to changes in balance, including inadequately controlled hypertension.
• Review possible risky medications that may impair balance for indication, efficacy, and safer alternatives.  A careful review of how medications are being administered for adequate adherence, and if a blood thinning medication is appropriate given the falls risk, adherence with meds and risk/benefit of the blood thinner.
• Have a thorough mobility and balance assessment, including drop in blood pressure with standing, vision (acuity and peripheral fields) cognition, and gait assessment.
• Be encouraged to participate in a balance exercise program.
• Address vision, appropriate shoes (no barefoot or socks), lighting and environmental risks.

An Aging Life Care Professional™ is in a unique position to encourage clients and their families to follow through with these recommendations, and begin or continue exercise programs that meet the guidelines.

We, as care managers and health care providers, need to address our own bias about exercise for older adults, in order to become effective advocates for this essential component of health and wellness.

Exercise at any Age, with any Chronic Condition (Part 2)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Why should Grandma and Grandpa perform muscle strengthening (weight resistance) training?

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

What are the components of exercise that help improve balance, reduce falls, and achieve mindful awareness? (Rose D, 2010)

The following are descriptions of the positive outcomes exercise can provide for older adults and how these outcomes can improve balance, reduce falls, and increase safety awareness.

1. Posture and control of Center of Gravity

Older adults who experience a decline in posture often develop inaccurate perceptions of true vertical. Curvature of the spine with decline in flexibility was significantly associated with falls (Kasukawa Y 2010). Mindful awareness of vertical targets (doors, windows, corners) is helpful in restoring postural alignment. Progressive improvement in balance from exercises can start with seated, progress to standing activities, and utilize compliant (foam) or irregular surfaces. In addition, posture control strategies using the ankle, knee, or hip should be included in the exercise training.

2. Strength and Endurance

Muscle strength declines as much as 20-40% between age 30 and 80. Weakness in the body core (alignment of low back, pelvis, hips) contributes to poor balance, and weakness of the muscles in the legs can cause significant challenge in going from a seated to standing position. Strength becomes of increasing importance in individuals with poor balance control. More strength is needed to correct posture to prevent a fall because inappropriate weight shift results in moving the center of gravity off the base of support.

3. Flexibility

Joint range of motion and muscle flexibility decline with age and are associated with impairment in function. Loss of flexibility to perform shoulder or spinal rotation is directly related to functional limitations and increased susceptibility to falls. Reduced flexibility in legs results in less efficient gait (limits endurance) and a decline in balance control (leaning) that also contributes to falls.

4. Gait speed and efficiency

Because of many of the changes described above, stride length and decreased height of each step results in a decline in gait speed. Slow gait results in less stability and shorter steps: shuffling increases the risk of tripping or catching a toe. Exercise programs that require negotiating obstacles and vary surface conditions allow participants to develop a walking pattern that is more efficient, flexible, and adaptive, with more speed to improve stability.

What else can we do to improve mobility and balance?

Falls prevention is difficult to achieve, while mobility and balance awareness should not be.  For the needed behavior changes for exercise and adaption to changes, mobility and balance awareness provides a platform for patients, family, and care managers.  One way to better address mobility and balance awareness is by doing balance assessments, including the 8 foot up and go as part of the Senior Fitness Test, or the more balance-focused Short Form of the Fullerton Advanced Balance Scale (Hernandez D 2008).  These objective measures provide the opportunity to discuss changes in balance which most of us are not cognizant or aware.  Most 80-year-olds will recognize their balance is not like when they were 30, but all 60 and most 70-year-olds are not aware of decline at all; and all older adults are not aware of the size of the risk or that they have the ability to improve their balance through a formal balance exercise program or the need to adjust their lifestyle to match.

Once aware of their change in mobility and balance, the next step is to try and have older adults work with their providers to figure out the cause of mobility and balance changes. A practical approach to identifying the underlying causes is by symptom categories:

• D:  Dizziness/Vestibular:  Benign positional vertigo, vestibular neuronitis, Meniere’s Disease, brainstem infarcts
• LH:  Light headed/Postural Hypotension: drop in blood pressure with standing
• BB:  Bad Balance
• Frame – kyphoscoliosis, leg length discrepancy
• Central – infarcts in basal ganglia, central microvascular infarcts, Parkinson’s, cerebellar
• Peripheral – Peripheral neuropathies, spinal stenosis
• Impaired vision – especially discrepancy between eyes
• Meds – sleep aids, neuropathic pain meds, psychotropics
• Barefoot or socks increases the risk of falls 10-13 times vs. wearing shoes w/heel; poor weight transfer to balls of feet (studies have shown that wearing socks or walking barefoot inside increases the risk of falling 10-14 fold.)
• W:  Weakness – MS, focal weakness (stroke, motor neuropathy)
• PA:  Poor awareness – all of us as we age, dementia (Lewy Body & Vascular in particular)

Visit www.DrBalance.com for more information.

Exercise at any Age, with any Chronic Condition (Part 1)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Introduction

Exercise and physical activity for older adults was an important theme discussed at the 2015 White House Conference on Aging.  Specific initiatives discussed included the NIH Go4Life campaign and the YMCA initiative to provide intergenerational physical activity.  The implementation of exercise and fall prevention programs on state and national levels sheds light on the importance of physical activity as being viewed as the core to healthy aging and preventing and lessening the impact of chronic disease.  Exercise is now known as an essential component of falls prevention, demonstrated by the fact that $5 million of President Obama’s budget is targeted for the National Falls Prevention Resource Center. Moreover, the CDC has also recognized its importance by providing free online webinars on falls prevention, which are currently being used by health care providers like Kaiser Permanente.  The reduced health care costs as a result of physical activity as well as the reduction of the most common form of accidental injury (falls) may also reduce the need for long-term services prematurely.

Everyone has heard that exercise is good for you, right?  Of us older adults, how many are heeding that advice?  How many of our primary care providers have spent the time to find out and help us do more exercise to the degree that they prescribe or monitor lipid lowering meds and follow cholesterol levels?  One reason why we as a society are falling short, as described below, is because there is a bias AGAINST exercise in older adults that no one is talking about.

Why Exercise?

Exercise is essential to improving balance and reducing risk of falls.  While the National Council on Aging (NCOA) has made a list of evidence-based programs, the evidence is not equal, and there may be other programs in the community which are actually more robust in improving balance.  A recent review on efficacy of exercise programs in preventing falls identified that 32 multicomponent exercises demonstrated reduction in falls by an average of 30%, while three single component (either walking or strength training) programs were not effective (Gillespie LD 2012).  The multicomponent programs target activities that address balance, strength, endurance, and walking.  Among successful programs, total weekly exercise time ranged from 80 minutes to more than seven hours. The duration of programs ranged from eight weeks to two years, while one review suggested a minimal dose of 50 hours of balance exercise is needed to be effective. Participation was improved by having a convenient location, incorporating social activities, and reimbursement for travel costs (Ganz DA personal communication).

In addition, engaging in physical activity is essential for maintaining mobility as we age. Dr. Debra Rose, Director of the Center for Successful Aging at Cal State Fullerton, defines mobility as “the ability to move oneself independently and safely from one place to another.”  The ability to walk 400 meters has been defined as an excellent proxy for community ambulation, which is central to aging in place and quality of life. This became the primary outcome measure of the LIFE (Lifestyle Interventions and Independence for Elders) Study (Pahor J, 2014).  This study randomized 818 (mean age 78.7 years) to physical activity (2x/week in a center and 3-4x/week at home) with 817 (mean age 79.1 years) to a health coaching group.  Of the physical activity group, 85.3% remained independent in community mobility versus only 80.2% of the health coaching group, for a 28% reduction in the risk of becoming dependent (p=.006).

How well are we doing?

Data from the National Health Interview Survey and the Centers for Disease Control (CDC) from interviews of the civilian and non-civilian population show that 42.4% of adults age 65-74 are reporting achieving aerobic activity goals as are 28.1% of adults age 75 and over (goal >50%).  Not bad.

However, only 14.4% of adults age 65-74 and only 7.9% of adults age 75 and over are achieving the goal of both the aerobic and muscle-strengthening activities.  Why aren’t older adults doing more muscle strengthening exercise? Probably because we are not aware of the benefits and have a bias that it will do harm. This is also due to the lack of resources, training, and coaching / supervision needed.

How much exercise should older adults participate in?

The US Office of Disease Prevention and Health Promotion established physical activity guidelines for “Healthy People 2020” to gain substantial public health benefits:

• Avoid inactivity, some physical activity will provide some health benefits (goal <33%)
• For substantial health benefits, older adults should do aerobic activity.
• At least 150 minutes (2 hours and 30 minutes) a week of moderate intensity (goal >50%)
• Or 75 minutes (1 hour and 15 minutes) of vigorous intensity (goal > 33%)
• Or an equivalent combination, performed in 10 minute increments
• Extensive health benefits occur when increased to 300 minutes (5 hours) of moderate intensity or 150 minutes of vigorous activity.
• Muscle strengthening exercises should be done 2 or more days per week of 8-10 exercises that train all major muscle groups (goal >25%)

Additional Recommendations for older adults from the American College of Sports Medicine:

• Maintain or increase flexibility (stretching) for at least 10 minutes a day, twice a week
• To reduce the risk of injury from falls, perform exercises that maintain or improve balance

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

A 1-Hour Walk, 3 Times a Week, Has Benefits for Dementia

By GRETCHEN REYNOLDS MAY 24, 2017

Exercise may bolster the brain function and thinking skills of people with dementia, according to a new report. The study’s findings suggest that walking a few times per week might alter the trajectory of the disease and improve the physical well-being of people who develop a common form of age-related memory loss that otherwise has few treatments.

The study looked at vascular cognitive impairment, the second most frequent form of dementia worldwide, after the better-known Alzheimer’s disease. The condition arises when someone’s blood vessels become damaged and blood no longer flows well to the brain. It is often associated with high blood pressure and heart disease.

One of the particular hallmarks of vascular dementia in its early stages, researchers have found, is that it tends to make the brain function less efficiently. In past brain-scan studies, people with a diagnosis of vascular cognitive impairment generally showed more neural activity in parts of their brains that are involved with memory, decision-making and attention than did people without the disease, indicating that their brains had to work harder during normal thinking than healthier brains did.

But while a great deal of research attention has been devoted to Alzheimer’s disease, less has been known about the progression of and potential curbs on vascular dementia. Some research has indicated that reducing blood pressure lessens the symptoms of the disease.

Exercise can likewise improve blood pressure and cardiovascular health. And some research suggests that frequent, brisk walks may improve memory and physical abilities in those in the early stages of Alzheimer’s disease. But, rather surprisingly, few past studies had examined whether exercise might also improve brain function in people with vascular dementia.

So for the new study, which was published in April in The British Journal of Sports Medicine, researchers at the University of British Columbia in Canada and other institutions decided to look into the effects of walking on this type of dementia.

They began by recruiting 38 older people in British Columbia who had been given diagnoses of a mild, early form of vascular cognitive impairment. None currently exercised. All agreed to visit the university’s lab frequently for six months.

On the participants’ first lab visit, the scientists measured their general health and also memory and thinking skills.

They then scanned each volunteer’s brain while he or she concentrated on a computerized test of attention and decision-making skills that involved rapidly clicking keys to indicate the direction that an arrow should point. This scan was designed to reveal neural activity and how hard different parts of the brain were working during the task.

Finally, the scientists randomly assigned their volunteers to start either walking or, as a control group, to visit the lab for weekly education sessions about nutrition and healthy living.

The walking program was simple, consisting of supervised one-hour sessions at the lab three times a week. The walkers were asked to move briskly enough during workouts to raise their heart rates to about 65 percent of their maximum capacity.

“We wanted to have some intensity” in the exercise, says Teresa Liu-Ambrose, the director of the Aging, Mobility and Cognitive Neuroscience Lab at the University of British Columbia and the lead author. Most of the walkers completed all of the sessions and “seemed to be enjoying the exercise” by the end of the six months, she says.

At that point, the volunteers in both groups repeated the physical and cognitive tests from six months earlier, as well as the brain scan. The results showed that the two groups had drifted apart, in terms of the functions of their bodies and brains. Most obviously, the walkers generally had lower blood pressures now than the volunteers in the control group.

But more striking, their brains also were working differently. The walkers’ brains showed less activation in portions of the brain required for attention and rapid decision-making than did the brains of those in the control group.

The differences were subtle, Dr. Liu-Ambrose says, but they correlated neatly with improvements on the cognitive tests. The less someone’s brain had to work to maintain attention and make quick decisions, the better that person typically performed on the tests of general thinking ability.

In essence, the walkers had more efficient brains and better thinking skills now than the control group did, she says.

Of course, this study was short term, lasting only six months, after which the volunteers were free to stop exercising — and most did. Dr. Liu-Ambrose and her colleagues hope in the future to study whether and how rapidly the brains and bodies of exercisers lose any gains if they become sedentary again. They also want to look into different “doses” of exercise and whether shorter or easier workouts would have an effect on brain function in people with vascular dementia.

Obviously, anyone with memory or other cognitive problems should consult with a doctor before starting to exercise and should probably not exercise alone, Dr. Liu-Ambrose says.

But even with so many questions remaining, the results of this study are encouraging, she says. They show that in the early states of vascular dementia, “something as simple and accessible as walking may make a meaningful difference” in how well the brain works.

Reprinted from: https://www.nytimes.com/2017/05/24/well/move/a-1-hour-walk-3-times-a-week-has-benefits-for-dementia.html?_r=1