Farewell to Falls

Posted By SHL Librarian

Presented by: Ellen Corman, MRA
Injury Prevention Coordinator, Trauma Services
Stanford Hospital & Clinics

Lecture Overview:

  • Fifty percent of adults 80 and older fall each year
  • Most falls take place at home
  • Older adults who fall are two to three times more likely to fall again
  • Take proactive steps in your home to avoid falls by installing handrails, removing clutter and keeping floors clear
  • Exercise to maintain strength, balance and coordination
  • Have your physician check your medications

Nearly 1 million older Californians experience a fall each year. For people 65 years and older, falls are the most common source of injury resulting in a visit to the emergency room.

The odds of falling each year after age 65 are about one in three; after age 80 the chance of a fall is about 50-50. People are more likely to fall as they get older because of common, age-related physical changes and medical conditions, along with the medications prescribed to treat such conditions, weakness related to a sedentary lifestyle, and home and environmental obstacles. About 20 to 30 percent of the people who do fall face reduced mobility, and many people-even those who are not injured-develop a fear of doing it again.

“Older adults who have fallen are two to three times more likely to fall again within the next year,” said Ellen Corman, MRA, injury prevention coordinator for trauma services at Stanford Hospital & Clinics, who gave an hour-long presentation at the Redwood City Public Library on April 30. “The older you get-and the more risk factors involved-set up an even greater chance of falling.”

Corman asserts that falls do not take place because “I wasn’t watching,” or “I just tripped.” The reasons behind a fall can range from being tired and not lifting your feet properly to poor vision, distractions, slower reaction time and medications that cause dizziness or lightheadedness. Other factors can include physical weakness, cognitive impairment, depression, dehydration or a balance disorder.

But many falls can be prevented by making even small adjustments in three specific areas: your home environment, your medications and your exercise routines.

Taking Positive Steps
“When it comes to home safety, there are specific changes you can make to control your environment. Be proactive. There is usually a combination of factors so it’s important to take a multifaceted approach to making changes,” said Corman. “Most falls are preventable.”

Because more than 60 percent of falls occur at home, she stressed the importance of making some simple modifications to make it safe:

  • Get rid of your throw rugs. Hang them on the wall or give them to someone who will appreciate it.
  • Remove clutter-including papers, pet toys and the grandkids’ playthings.
  • Move electrical cords out of the way.
  • Wear thin-soled, non-skid shoes, sneakers or slippers, especially in homes with hardwood floors.
  • Use nightlights, and bring a nightlight with you when you travel.
  • Install grab bars in the bathroom. An occupational therapist can aid in making an accurate assessment of where to place the bars to suit your height and movements.

“My dream is that all homes have grab bars in the bathrooms, no matter what the person’s age,” Corman said.

Fitness is Key
Older adults generally score between 20 and 49 percent lower on strength tests-an impairment that makes them three times more likely to fall. While today’s older adults realize that exercise is important and tend to remain active in their later years, for too many people retirement means a sedentary lifestyle.

Corman mentioned one study of men and women aged 88 to 92 years involved in a simple exercise program: All participants showed improvement in strength and balance after only eight weeks.

“It’s never too late to start some kind of exercise,” she advised. “Keep moving, and try to mix it up.”

Corman recommended tai chi or a walking routine in a safe, flat location such as a mall or school track. She also emphasized the importance of including weight training to maintain strength.

Check Medications
The number, type and combination of medications can affect a person’s balance, perception and reaction time. Medications should be checked for side effects listed like lightheadedness or dizziness as these drugs could contribute to the potential for a fall. Check regularly for expiration dates, and be aware of possible complications from polypharmacy-the use of multiple medications that may interact.

Corman suggested that all medications be placed in a plastic bag and brought to a physician or pharmacist for review.

Support System
Stanford established the Farewell to Falls program in 2005 to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides two home visits from an occupational therapist who evaluates the home for potential problems, performs a sensory-motor review and does a health risk interview. The therapist then offers individualized suggestions and a review of medications from a pharmacist. Participants also receive an exercise video to help improve strength and balance.

In addition to the home visits, participants receive periodic follow-up phone calls from volunteers to see how they’re doing. One year after the start of the program the occupational therapist returns to reassess the risk factors and to provide additional fall prevention tips.

“We’re hoping that seniors take advantage of this opportunity to participate in a program that can help them to maintain their independence,” said Corman, who added that more than 200 people take part in the program each year.

About the Speaker
Ellen Corman is the Injury Prevention Coordinator in the Trauma Service at Stanford Hospital & Clinics and has been involved in injury prevention activities for more than 20 years.

She is an occupational therapist and has a master’s degree in rehabilitation administration. Corman participated in the California state injury prevention strategic planning workgroup and is an active member of the California Stop Falls Network. She developed and manages the Stanford Hospital & Clinics Farewell to Falls program and co-chairs the San Mateo County Fall Prevention Task Force.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Stanford Hospital & Clinics Farewell to Falls
http://www.stanfordhospital.com/clinicsmedServices/medicalServices/emergency/fallPrevention

Centers for Disease Control
http://www.cdc.gov/ncipc/duip/preventadultfalls.htm

Fall Prevention Center of Excellence
http://www.stopfalls.org/

American Geriatrics Society
http://www.healthinaging.org/public_education/falls_index.php

Updates on Dementia: Translating Research into Practice

Posted By SHL Librarian

At a Glance:

  • Alzheimer’s disease is not just one disorder with one specific set of symptoms
  • Studies show other disorders, such as frontotemporal dementia and mild cognitive impairment, show similar symptoms but affect different parts of the brain than Alzheimer’s
  • Research is leading to new understanding of cognitive decline, which in turn may identify new targets for therapy and possible prevention

Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities. The most common form of dementia among older people is Alzheimer’s disease, which initially involves the parts of the brain that control thought, memory and language. As more and more of the brain is affected, areas that control basic life functions, like swallowing and breathing, become irreversibly damaged.

Although scientists are learning more every day, they still do not know what causes Alzheimer’s, and there is no cure. New understanding, improved treatments and viable preventive strategies are becoming ever more crucial: Increasing numbers of people are joining the more than 5 million Americans already living with Alzheimer’s disease, and its prevalence is expected to double by 2020.

More than 400 physicians, nurses, social service workers, caregivers and community members attended the 10th annual Updates on Dementia: Translating Research into Practice, a conference held at Stanford in early June that featured experts in clinical research and elder care who covered topics that included sexuality, bathing and hygiene, ethnic and cultural sensitivity, and gay and lesbian issues. The event was moderated by Victor Henderson, MD, MS, a professor of Health Research and Policy and a member of the Stanford Center on Longevity.

Transition Phase
“It’s a burgeoning crisis, and if we don’t do anything about it the population curves indicate that tens of millions of people will have it over the next 20 to 30 years,” said Ronald Petersen, MD, PhD, director of the Mayo Clinic Alzheimer’s Disease Research Center, who spoke on Mild Cognitive Impairment: The Current Status. “If we are to have an impact on Alzheimer’s disease, we will need to prevent the whole process. This will require predictive testing before symptoms develop and interventions to slow its progression.”

Petersen’s presentation focused on mild cognitive impairment (MCI), a transitional period between normal function and the onset of Alzheimer’s. This condition does not fit the criteria for dementia because although patients show diminished memory and judgment, most abilities are preserved and normal activities are maintained. The challenge, he said, is that there are no specific tests, and the indices, such as verbal recall, fall into the expected profiles of aging.

Mild cognitive impairment falls into two patterns, he said. Approximately 10 percent of the people with amnesiac MCI, in which memory is affected, develop Alzheimer’s disease, while only 1 to 2 percent of the patients with non-amnesiac MCI-those with no memory impairment but with cognitive complaints-do not go on to acquire the disease.

“We have been tracking patterns of impairment over the years,” Petersen said. “We can measure the degree of shrinkage in the hippocampus. The volume of the brain shows a greater degree of atrophy in amnesiac MCI. By documenting serial progression using magnetic resonance imaging, we may be able to use and track disease-modifying therapies.”

Petersen also discussed the potential of using biomarkers, including proteins such as amyloids and apo-E, to study the patterns of impairment.

“Is MCI just early Alzheimer’s? Not always, and it’s still too soon to be sure of the connections,” he said. “Our future progress will depend on getting a diagnosis earlier so we can figure out ways to intervene or at least delay onset or prolong the transitional stage. There are lots of variabilities in the studies and, in the meantime, we must reassess the criteria.”

Molecular Connections
Research is showing that Alzheimer’s is just one disease related to cognitive decline, according to Bruce Miller, MD, director of the Memory and Aging Center at UCSF, who spoke on Frontotemporal Dementia and Other Non-AD Dementia.

Frontotemporal dementia (FTD) refers to a group of diseases that are commonly misdiagnosed as Alzheimer’s-an important distinction because these diseases are treated differently. Patients with FTD have different behaviors early on that appear to last longer.

The symptoms of FTD include apathy, indifference, repetitive mannerisms and addictive behavior, such as gambling and overeating. These behaviors affect a different part of the brain, making it relatively easy to separate FTD from Alzheimer’s. At the same time, FTD is a social disorder, and input from caregivers is important because its victims have poor self perception. People who are misdiagnosed can end up in the legal system, under psychiatric care or as social pariahs.

“It’s not so much how we label the disease as much as knowing what molecule is responsible,” he said. “These are not pure disorders. They have mixed pathologies, which means that people are starting to think of new ways to intervene. Lots of problems are neurochemical, so I think this is a very promising period.”

Many cognitive disorders relate closely to other disorders: For example, Parkinson’s puts people at high risk for dementia but not necessarily Alzheimer’s, and most Alzheimer’s patients eventually develop symptoms similar to Parkinson’s. And 65 percent of patients with REM (rapid eye movement) sleep behavior disorder, in which the motor system is not turned off during deep sleep, develop some kind of Parkinsonian disorder. These connections all point to potential points of intervention, Miller said.

“The circuitry in the brain is breaking down, but it is the part that affects social behavior and regulation rather than memory,” said Miller. “It’s a social disorder. There is no amyloid accumulation in the brain as you would see in Alzheimer’s disease. This is important because it requires different interventions and the need to monitor and evaluate therapies.”

Other speakers during the day-long conference discussed Love, Sex and Alzheimer’s; Caring for Someone with Dementia when you are Lesbian, Gay, Bisexual or Transsexual; and Bathing Without a Battle. Handouts offered lists of local and national resources, and descriptions of Alzheimer-related clinical trials.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Stanford Geriatric Education Center
http://sgec.stanford.edu/

Stanford Center of Longevity
http://longevity2.stanford.edu/

Alzheimer’s Association
http://www.alz.org

Institute on Aging
http://www.ioaging.org/

VA Palo Alto Heath Care System
Geriatric Research, Education and Clinical Center
http://www1.va.gov/grecc/

Stress Fitness for Seniors

Posted By SHL Librarian

Presented by: Joan Vernikos, PhD
Director Emeritus, NASA Life Sciences
November 19, 2009

Lecture Overview:

  • Stress is neither inherently good nor bad-it’s simply the physiological and psychological response to external or internal tension.
  • Not everyone experiences stress the same way, but there are tactics that can help you deal with stressors more effectively.
  • Most stress is generated by the brain but if you can create it, you can also control it.
  • Older adults can often handle stress better because they have more experiences to draw from to deal with it.
  • Recognize the difference between effective and ineffective coping mechanisms in responding to stress

How early humans responded to stress was a matter of survival. Facing a predator, searching for food, and protecting a family were very real dangers that instigated an automatic, innate reaction that prepared them to attack or run away-the fight or flight response. Today, our bodies still instigate the same primitive response system even though our stressors have changed.

“Our genes are pretty much identical to our prehistoric ancestors, and the response to stress is identical even though the stressors are different,” said Joan Vernikos, PhD, former head of NASA Life Sciences, who spoke at a presentation sponsored by the Stanford Health Library. “However, you can learn stress fitness. By that I mean learning to engage the brain to enable it to be ready to encounter and deal with any stress that comes your way.”

For seniors, today’s stressors are less about sheer survival and more about personal trials, such as dealing with financial uncertainty, ailing health, the loss of a loved one, or family concerns. But the same biological cascade takes place, flooding our bodies with a surge of hormones, including adrenaline and cortisol, that increase your heart rate, elevate your blood pressure, and boost energy.

“But stress itself is neither good nor bad,” said Dr. Vernikos. “Stress is simply a stimulus. It’s our body telling us what we need to do. What’s important is not the stress but how we respond to it. It’s mostly a matter of perception.”

The fact is, everyone reacts to stress differently. Some people seek stress for stimulation or fun. A ride on a roller coaster can be great fun or a terrifying ordeal, depending on your personal perspective. And it’s impossible to eliminate stress completely – nor should we want to since it’s such an effective tool for both protecting and enhancing our health. The problem arises when we respond excessively to stress. That’s when the system can turn against you and do harm, said Dr. Vernikos.

“We need the response to stimuli to switch on energy,” she said. “But managing stress is fundamental. Most of the stress you feel is self-generated in the brain, which means that if you can create it, you can also control it.”

Dr. Vernikos said you can train your brain to respond differently to stress, much like how a computer can be programmed to filter out spam. If the brain creates the “what ifs” that keep you awake at night, you can design tactics to control them. “The brain is producing all sorts of worries, fears, and anxieties about things that have not happened yet,” she said. “Learn how to press the delete key.”

One way to do this is to draw upon your experiences as a sort of database to identify how you have successfully handled similar stressors in the past. Older adults can often handle stress better because they have a larger database to draw on. Culling your memories helps you build a strong, positive database to retrieve relevant information and respond rationally.

Another important factor is to recognize the difference between effective and ineffective coping mechanisms in responding to stress. Ineffective coping wastes energy does not address the problem and often involves tactics like eating, drinking, insomnia, or misdirected anger. Effective coping allows you to assess, take charge, and be prepared. It involves asking others for help and learning to say no as a way to step back and reprogram your thinking.

Dr. Vernikos also suggested that you be aware of your body language when stressed: By dropping your shoulders, taking deep and slow breaths, and opening your mouth to relax your jaw, you can provide instant relief. Other soothing tactics include laughter, pets, music, and developing a strong social network.

About the Speaker
Joan Vernikos, PhD, a space pioneer researcher and former head of NASA Life Science, is a member of the Space Studies Board of the National Academy of Sciences and an advisor to the European Space Agency. She is the author of “Stress Fitness for Seniors” and “The G-Connection: Harness Gravity and Reverse Aging.”

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Joan Vernikos
http://www.joanvernikos.com/

Stanford Aging Adult Services
http://www.stanfordhospital.com/forPatients/patientServices/geriatricHealth

Stanford Center on Stress and Health
http://stresshealthcenter.stanford.edu/

Alzheimer’s and Communication

Posted By SHL Librarian

Presented by: Judith L. London, PhD
Licensed Clinical Psychologist
Author, Connecting the Dots
February 24, 2010

Lecture Overview:

More than 5 million Americans are living with Alzheimer’s disease (AD), a long-term progressive disease that affects memory, intellectual ability, judgment, and behavior, depriving people of their independence and ability to communicate. Alzheimer’s accounts for 70 percent of all types of dementia, and more than half of these cases are in the middle to late stages, when individuals require extensive help with daily activities and lose the ability to respond to their environment.

There’s no known cause of AD, a slow but irreversible mental decline that lasts an average of seven years but that can linger for as long as 20. People in mid- to late-stage Alzheimer’s can no longer survive in society without an extensive support system.

“So many people mistakenly assume that there’s nothing left as the disease advances, and don’t bother trying to connect and communicate on a meaningful level,” said Judith London, PhD, a clinical psychologist specializing in dementia, who spoke at a presentation sponsored by the Stanford Health Library. “But when you focus on what’s still there rather than what’s gone and reach out, you discover the part that’s still there and very much alive.”

London, who worked extensively in public long-term health facilities, described how Alzheimer’s precipitates damage to the neurons in the brain, preventing cells from communicating with each other.

“You can help ‘connect the dots’ of scattered information and memories in a meaningful way. You become the connector, and help the person express him or herself,” she said.

Because Alzheimer’s patients often feel isolated, it’s up to the visitor or caregiver to initiate interactions. The easiest first step, London advised, is to make eye contact: Get into their field of vision and say who you are. “Start with a smile,” London advised, “and approach the person as you would want to be treated-with respect, kindness, and dignity.”

Make sure you can be seen and heard: Speak slowly and clearly, and use gestures, she said, and use anything you know about the person’s interest or background as a basis to communicate. Use the person’s name, not a nickname or term of endearment, to help validate their identity.

“They also often have poor vision and hearing, which adds to their sense of isolation,” said London. “Don’t assume they are no longer interested in engaging.”

She also suggested that instead of using distraction when people are repeating themselves to try to help them express what’s on their mind. “They are reacting to something that is emotionally important to them,” she said. “Be positive about their efforts to make a connection and communicate.”

London suggested that visitors carefully observe the immediate circumstances to find possible triggers for episodes of depression, paranoia, or anger. If you can identify a pattern by examining what happened right before, during, and after an incident, the time it occurred, and who else was involved, you may be able to alter the circumstances to head off an outburst. She advised caregivers to not take accusations personally.

In group therapy with dementia patients, London found that that people responded to personal questions and empathy even when they seldom initiated a dialog.

“Unconscious memory is still present in those with Alzheimer’s and is the last part of memory to go. People with late-stage Alzheimer’s can understand even when they cannot let you know in a direct way,” London said. “When you reach out to connect and communicate, the person will connect back with you.”

About the Speaker
Judith London, PhD, is a clinical psychologist licensed in New York and California who has worked with patients with Alzheimer’s and other forms of dementia for more than 20 years. A former adjunct professor at New York University, she now conducts seminars on Alzheimer’s, dementia, and maintaining brain health. She is the author of Connecting the Dots: Breakthroughs in Communication as Alzheimer’s Advances.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

Stanford Aging Adult Services
http://www.stanfordhospital.com/forPatients/patientServices/geriatricHealth

Stanford Alzheimer’s Translational Research Center

http://alzheimers.stanford.edu/

The Alzheimer’s Association

http://www.alz.org

National Institutes of Health
www.nia.nih.gov/Alzheimers

How is Your Memory? Evaluating Memory and Its Relationship to Alzheimer’s Disease

Posted By SHL Librarian

Presented by: Wes Ashford, MD, PhD
Clinical Professor, Psychiatry and Behavioral Sciences (affiliated)
Senior Research Scientist, Stanford/ VA Aging Clinical Research Center
May 19, 2010

Lecture Overview:

    MRI brain scan

  • While mild forgetfulness affects most people as they age, serious memory problems affect your ability to participate in everyday activities.
  • See your doctor if you have concerns about memory and forgetfulness.
  • Alzheimer’s is a type of dementia that progresses slowly over time and causes irreversible changes in the brain.
  • Brain imaging for dementia is pointing to specific patterns of amyloid plaque and neurofibrillary fiber build-up in the brain, and these patterns appear to be associated with genetic makeup.

Dementia is a medical condition that impairs memory and thinking processes, from remembering words to how to behave. While everyone forgets words or a person’s name at times, the condition is not dementia unless it is severe enough to interfere with a person’s ability to carry out daily activities and it declines over time.

The most common form of dementia among older people is Alzheimer’s disease, which initially involves the parts of the brain that control memory, and language. The disease was first diagnosed in 1907 in a patient with what are now considered classic symptoms of the disease. Her brain had both senile plaques (filled with a protein called beta-amyloid) and neurofibrillary tangles (made up of tau protein) that affected specific regions of the brain.

The cognitive decline associated with dementia and Alzheimer’s disease is an issue not only for affected individuals but also for society. New understanding, improved treatments, and viable preventive strategies are becoming more crucial since more than 5 million Americans are already living with Alzheimer’s disease, and its prevalence is expected to double by 2020.

“The problem is that it is difficult to recognize when people have a problem,” said Wes Ashford, MD. PhD, a clinical professor of psychiatry and behavioral sciences, at a presentation sponsored by the Stanford Health Library. “People with a memory problem often try to cover it up, and as much as 90 percent of patients are misdiagnosed early in the disease course. After a certain point they don’t recognize that they have a memory problem and by then they need to be in a nursing home.”

Making Connections
Ashford has spent his career researching the process of memory loss associated with aging. He and the other members of the group at the Stanford/VA Aging Clinical Research Center are involved in a variety of studies to measure the effectiveness of medications, mood, sleep, and other factors on disease progression. He has developed a simple memory test that can help track changes over time, using colorful images to detect early signs of memory loss.

Ashford explained that the brain is constantly creating new connections among its billions of neurons as it registers new information. As dementia progresses, the brain no longer maintains this neural network, affecting first short-term memory and then older, more established connections. Brain autopsies show that the hippocampus, the part of the brain involved in forming and maintaining memories, shrinks dramatically and becomes riddled with amyloid plaques and neurofibrillary tangles.

“Plaques and tangles occur in very specific areas of the brain that are responsible for learning and storing new information,” Ashford said, adding that plaques appear to be associated with Alzheimer’s disease, while tangles show a closer relationship with the dementia that accompanies Alzheimer’s in its later phases. “The disease progresses in a variable but measurable fashion, following a specific pattern. It may progress slowly but it tracks logically, and eventually old memories become destroyed.”

Genetic Differences
By using different imaging technologies, such as MRI, PET, and CT scans, scientists have been able to follow the progression of dementia and Alzheimer’s, and found that genetic factors play a significant role the age when patients develop brain patterns associated with amyloid plaques and with neurofibrillary tangles.

“We can actually see where the tangle develops and where the amyloid is depositing,” said Ashford. “We can track progression over time while it is still considered mild cognitive impairment, before it is officially dementia.”

For one common genotype (20 percent of the population), there is a 40 percent chance of developing Alzheimer’s by age 76; another genotype (one that affects only 2 percent of the population) has 10 times greater chance of having the disease by age 67; another group appears to develop Alzheimer’s only after age 95.

For Ashford, these studies may help to measure the early progression of disease and then identify a way to prevent its development in the people who would most benefit from intervention. Though a genetic approach to prevention is not on the immediate horizon, these studies do point to the possibility of targeted interventions based on genotype.

“If we can understand the genetics better, we will be able to understand how Alzheimer’s develops and the best method and timing to make changes,” he said. “To make progress we need diagnostic and treatment centers for humans and accessible genetic testing.”

In the meantime, other factors have been shown to decrease the risk of Alzheimer’s, such as maintaining a healthy lifestyle, interacting with others through social activities, keeping the brain exercised through games and learning, and keeping up with screening tests for high blood pressure and cholesterol.

About the Speaker
J. Wesson Ashford, MD, PhD, is a senior research scientist at the Stanford/Veterans Affairs Aging Clinical Research Center and a clinical professor of Psychiatry and Behavioral Sciences at Stanford. He is also the director of the War Related Illness and Injury Study Center at the VA Palo Alto Health Care System. Ashford received his MD and his PhD in neuroscience from UCLA, where he was a founding member of the Neurobehavior Clinic and the first chief resident and associate director on the Geriatric Psychiatry Inpatient Unit. He joined Stanford and the VA Palo Alto in 2003.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Ashford
https://stanfordwho.stanford.edu/SWApp/detailAction.do?key=DS513T335&search=ashford&soundex=&stanfordonly=&affilfilter=everyone&filters

Stanford / Veterans Affairs Aging Clinical Research Center
http://svalz.stanford.edu/

Dr. Ashford’s online memory test
http://www.medafile.com/

VA Palo Alto Heath Care System
http://www1.va.gov/grecc/

Alzheimer’s Association
http://www.alz.org/

Recognition and Management of Chronic Medical Problems in Aging Adults

Posted By SHL Librarian

Presented by: Yusra Hussain, MD
Medical Director, Stanford Aging Adult Services
Stanford University Medical Center

Lecture Overview:

  • Chronic conditions are not a normal part of aging
  • Early detection and acknowledgment of a condition is a critical first step
  • While a doctor is an important resource, it is up to the patient to manage a chronic disease
  • Many chronic disorders are reversible or controlled through behavior modification

The good news is that Americans are living longer. But with prolonged life expectancy come concerns about quality of life, including the demands of living with long-term, or chronic, conditions.

Chronic diseases are prolonged or recurrent illnesses that are rarely cured completely. While not all chronic diseases are life-threatening, they can make a substantial impact on a person’s physical and mental well-being, and can create financial concerns for both the individual and the health care system. Chronic conditions range from the inconvenient, such as psoriasis or allergies, to the serious, such as arthritis or diabetes, to the life-threatening, such as coronary artery disease. They can be caused by infection, environmental conditions, genetic predisposition or lifestyle habits like smoking or overeating.

“Although people tend to develop chronic conditions as they age, growing old does not have to mean becoming disabled,” said Yusra Hussain, MD, medical director of Stanford  Hospital’s Adult Aging Services and a clinical instructor of geriatrics, who gave a presentation on September 18, sponsored by Stanford Health Library, on living with chronic conditions. “The key is to learn how to identify the symptoms of chronic conditions early on and to find ways to take control.”

Almost 75 percent of people age 65 and over have at least one chronic illness. These conditions can lead to accidents, such as falls, as well as progressive disability that slowly erodes independence and confidence. Patients who recognize—and address—chronic problems early learn how to manage their symptoms and maintain their independence, said Hussain, and 80 to 90 percent of these people can improve their quality of life. Many conditions are reversible or at least controlled through behavior modification, such as changes in diet and exercise.

“In my practice I see the full spectrum of chronic diseases,” she added, “but many of my patients live full, healthy, active lives despite the disease. It depends on how well we can control and manage it.”

One of the biggest obstacles to early detection is that many patients show no symptoms or mistake a symptom as a normal aspect of another condition. For example, someone with asthma might assume an increased shortness of breath means his or her condition is getting worse, when instead it could be a sign of congestive heart failure.

“Changes in your lifestyle routine should always trigger you to assess your health,” said Hussain. “Often people adjust their lifestyle to accommodate symptoms without even realizing it. Or they ignore symptoms because they don’t want to acknowledge something may be wrong. Ignoring it will not make it go away.”

The most important step for early detection is to see your doctor regularly and discuss any changes in routine, mood or behavior, so he or she can determine the appropriate screening tests or diagnostic workups.

“Detection is the job of the physician,” said Husain. “But the responsibility is in the hands of the patient. You’ve got to work with your doctor as partners.”

About the Speaker
Yusra Hussain, MD, is a clinical instructor of geriatrics and the medical director of Stanford Hospital’s Aging Adult Services, a program designed to meet the unique demands of older adults by providing specialized care and access to resources. The program’s extensive network offers consultations and assessments, assistance with appointments, physician referrals, advocacy, coordination of services, access to community resources, and educational workshops.

For More Information:

Request a free information packet on this topic from Stanford Health Library

Stanford Aging Adult Services
http://www.stanfordhospital.com/forPatients/patientServices/geriatricHealth

Stanford Chronic Disease Self-Management Program
http://patienteducation.stanford.edu/programs/cdsmp.html

Agency for Healthcare Research and Quality
http://www.ahrq.gov/research/elderdis.htm

Changing Sleep Patterns As We Age

Posted By SHL Librarian

Presented by: Mehrdad Ayati, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
April 19, 2012

Watch the video

You go to bed, only to start tossing and turning, with no rest in sight. Or you fall asleep, only to wake up at 3 am. Having trouble falling asleep—or staying asleep—is a common problem, especially among older people.

But what is sleep exactly? And why does it become so elusive as we age? The reasons can range from physiological factors, such as chronic pain, hormones, or gastrointestinal problems, to environmental elements like light or noise, according to Mehrdad Ayati, MD, a clinical instructor of medicine, who spoke at a presentation sponsored by the Stanford Health Library.

We spend about eight hours a day, 56 hours a week, and 2,920 hours a year sleeping—almost a full third of our lives. But though sensory activity and voluntary muscles are on low, our brains are still quite active.

“Sleep is still a mystery,” said Dr. Ayati, “but we are understanding more about its function and what factors can affect our ability to sleep.”

Series of Cycles
Sleep involves a series of cycles triggered by a complex group of neurochemicals that respond to cues from the body and the environment. This sleep pattern follows an alternating cycle throughout the night. The first phase is called slow wave sleep, which is the deepest and most restorative stage. Slow brain waves occur at the beginning of the night, with a deep drop of consciousness. As we get older, however, there is a marked drop in these stages of our deepest sleep.

About 25 percent of sleep involves rapid eye movement (REM), the second cycle, which is associated with dreaming. REM sleep is sometimes called paradoxical sleep because the brain is still quite active. Blood pressure is low and muscles are inactive during REM sleep to prevent us from acting out our dreams. REM phases can last from five to 30 minutes, and most people can recall at least snatches of their dreams if they are wakened from this cycle. People with dementia tend to have more REM sleep and can develop REM sleep behavior disorders like sleepwalking.

Sleep is regulated by a complex network driven by several neurotransmitters, including acetylecholine, which appears to affect dreams; dopamine, which enhances wakefulness and alertness; and histamine, which can induce wakefulness (which is why many antihistamines cause drowsiness).

These neurotransmitters work in conjunction with our circadian clock, a biological time keeper that synchronizes our chemicals, hormones, body temperature, and sleep patterns. The circadian clock is also involved in the production of melatonin, a hormone produced by the pineal gland in the brain that is suppressed by light. Among other influences, melatonin regulates the core body temperature and circulation.

Together these processes control when we sleep and how deeply we sleep, said Dr. Ayati. For example, younger people spend more time sleeping and a greater percentage of sleep in a REM state compared with adults. He also described a typical wake-sleep cycle: Highest melatonin rates occur around 9 pm and production stops at 7:30 am; highest body temperature and blood pressure take place around 7 pm; deepest sleep takes place at 2 am, followed by lowest body temperature at 4:30 am.

Factors that can Affect Sleep
But as we get older, more internal and external factors can make sleep elusive or less satisfying. We spend more time in bed but more time awake, and the kind of sleep we get is the lighter stage. Dr. Ayati said close to 40 percent of older women develop sleep problems, usually related to hormone changes associated with menopause.

Sleep can also be affected by COPD and other respiratory problems; gastrointestinal ailments like irritable bowel syndrome; blood sugar fluctuations from diabetes; and chronic pain stemming from fibromyalgia and arthritis. There is a strong association between cardiovascular disease and sleep problems: people with sleep apnea, for example, are at a higher risk for heart attack.

But simply getting older may be the biggest cause of problematic sleep patterns. About 40 percent of older adults report having trouble falling asleep, and 30 percent report waking up in the middle of the night. About half use medication to help induce sleep, and more than half report experiencing daytime drowsiness. Almost two-thirds have some physical condition that can affect sleep.

Dr. Ayati said a key problem is that circadian rhythms change, causing sleep to become more fragmented, with disruptions from tossing and turning, and trips to the bathroom (a condition called nocturnia). For many people this change might be due to lifestyle changes, such as losing a loved one or limited social contact, which can cause anxiety. Because of physiological changes, medications, alcohol, and stimulants can also exert more influence over sleep patterns. Common prescriptions like antidepressants can actually make matters worse, he added.

“Older people are awake longer and more susceptible to changes in routine,” he said. “Over time the circadian cycle will change by itself.”

In hospitals and nursing homes, circadian cycles are affected by daytime napping, inactivity, noise, medication, and changes in routine.

Management and Treatment
A change in sleep hygiene is the best first step to managing and treating sleep problems.

“You can help yourself find your own circadian rhythm,” Dr. Ayati said. ”Go to bed the same time every day—even on weekends—and never go to bed unless you are sleepy. The bed is not the place to read, watch TV, or think.”

Though not a big proponent of naps, he did say that short naps of 15-20 minutes can be helpful for some people. He also suggested:

  • Stay in bed only when asleep and get up as soon as you awaken
  • Exercise daily but not just before bedtime
  • Relax mentally before getting ready for bed
  • A light snack is OK unless you have reflux
  • Cut out caffeine, alcohol, and nicotine
  • Control the noise, light, and temperature in your bedroom
  • If you can’t sleep after 30 minutes, get up but keep lights low

He also recommends using cognitive behavioral therapy, a psychotherapeutic approach designed to influence behaviors and perceptions by modifying mental processes. Other approaches may include bright light therapy to enhance melatonin production and relaxation techniques. Prescription or over-the-counter medications can help but only as a short-term remedy since they can cause even more sleeping problems, he said.

About the Speaker
Mehrdad Ayati, MD, is a clinical instructor of internal medicine with a special focus in geriatric medicine. He received his medical degree from the Iran University of Medical Sciences. He completed his internship and residency at the University of California, Davis, and his fellowship at Stanford.

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http://med.stanford.edu/school/psychiatry/coe/

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The Masquerading Headache:Chronic Daily Migraine, Positional Headache, POTS, or Spinal Fluid Leak? Why It Hurts When You Stand Up

Posted By SHL Librarian

Presented by: Ian Carroll, MD, MS
Assistant Professor of Anesthesiology
January 14, 2016

People who are suffering severe recurring headaches, neck pain, nausea, vomiting, dizziness, ringing in the ears, diffuse pain, fatigue, or brain fog may have a fixable condition that frequently goes unrecognized. The key to the diagnosis is recognizing that these symptoms get worse the longer the person is upright.

For some patients symptoms are rapidly progressive when someone becomes upright and rapidly relieved by lying down, but for others the postural symptoms are subtle. For these patients, headache, dizziness or other symptoms may only happen or be recognizably worse late in the day. In contrast, mornings for these patients after being recumbent all night are often better than the rest of the day. Doctors often recognize the first group, but fail to properly recognize the second pattern.

Ian Carroll, MD, thinks many can be helped if they find a doctor who recognizes the cause: a cerebrospinal fluid (CSF) leak.

Spinal fluid leaks occur when there is a tear or leak of the covering called the dura that surrounds the spinal cord and the brain. The dura functions like a watertight bag holding spinal fluid that bathes and protects the spinal cord and the brain. If the dura is pierced or torn, the fluid can leak. That can lower pressure around the brain, leading to “orthostatic” headaches that occur when someone stands up or sits up.

The telltale signs are headaches, neck pain, nausea, vomiting, dizziness, ringing in the ears (tinnitus), diffuse pain, fatigue, or brain fog that are worse when standing upright or late in the day (after patients have been upright for many hours). Patients can sometimes experience weird symptoms that make them worry they have a neurologic disease such as multiple sclerosis or visual disturbances, double vision, patchy numbness or tingling in the face or limbs, unusual smells (experienced as smelling odors that others don’t), and disturbances of taste like a persistent metallic taste in the mouth. Sometimes CSF leaks come with nausea, chronic fatigue and a racing pulse called tachycardia. The headaches have left some people without relief, trying to cope with an “invisible” disability that can ruin careers and rob them of a normal life, said Dr. Carroll, an assistant professor of anesthesiology, perioperative and pain medicine.

Disabling headaches from spinal fluid leaks have been in the news recently when the head coach of the Oakland-based Warriors professional basketball team, Steve Kerr, went on medical leave for several months while he recovered from this. Dr. Carroll said he hasn’t been involved in Kerr’s medical care, but he has seen plenty of other patients struggling with similar symptoms.

Spinal fluid leaks can often occur from whiplash injuries in a car accident or other physical trauma, but surprisingly many patients cannot identify a preceding trauma. Sometimes CSF leaks result from medical procedures like surgery or a spinal tap. Most doctors do not know that spinal taps can leak chronically or that leaks can present other than as a severe headache that is completely and rapidly relieved by lying down. Some cases occur spontaneously in people who have unusual connective tissue in their bodies and don’t know it, Dr. Carroll said.

People with CSF leaks are usually misdiagnosed. They’re told they have chronic migraines, chronic fatigue syndrome, fibromyalgia, or less known conditions like Chiari malformation, Tarlov cysts or POTS (postural orthostatic tachycardia syndrome).  A positive tilt table test and autonomic testing do not rule out a CSF leak as the underlying cause of the syndrome.

Dr. Carroll developed the hunch that some headaches were caused by spinal fluid leaks after his own family experience. After his young daughter had a spinal tap to evaluate some unrelated symptoms, she started getting headaches when she wasn’t lying down. “When she sat up, she screamed in pain,” he said. After the headaches persisted, she was treated for spinal fluid leaks and got better. That got his attention.

Then he read a New York Times column written by a Yale internist, Dr. Lisa Sanders, about a young woman who had endured 3 months of intractable headaches that started after she had whiplash. She later developed dizziness when upright, and  her pulse jumped from 74 when she was lying down to 130 when sitting up.

She was diagnosed with POTS, or postural tachycardia syndrome, a condition thought to be caused by blood vessels not constricting enough to keep blood flowing to the brain when a person stands up. Dr. Carroll suspects this patient and others were misdiagnosed and more likely had a CSF leak. He then began wondering if people at Stanford were being misdiagnosed as well. One of the reasons is that spinal fluid leaks may not show up on standard medical tests.

When spinal fluid pressure is extremely low inside the skull, it can show up on standard MRI tests. But many times the pressure drop may not be enough to cause MRI findings but are still enough to cause headaches, nausea and other symptoms, Dr. Carroll said. He has seen multiple headache patients whose MRI scans looked normal, but when they were given treatment to fix a spinal fluid leak, their headaches stopped.

Most physicians are trained to rely on MRI scans to determine if spinal fluid leaks are causing headaches, so they may miss this, Dr. Carroll said. “Most doctors think they know about this problem, but what they know is wrong,” he said.

Based on the patients he has seen, he said, “Most people are not extreme leakers. A lot of leaks may be more subtle.”

Another test, called a CT myelogram, is more likely to detect leaks and more commonly see the things that leak, such as aneurysms in the dura called meningeal diverticula or perineural cysts, Dr. Carroll said. But even that doesn’t show some leaks, in his experience.

Based on the patients he has seen, Dr. Carroll outlined three major causes of tears in the dura that cause spinal fluid leaks. A major cause, already widely known, can be any medical procedure that pierces the dura. That can be spinal surgery, a spinal tap or even the epidural anesthesia that some women get in childbirth. A headache that develops the day after any of these procedures is called a “post-dural puncture headache,” or PDPH, and is caused by a single leak. In most cases, a next-day headache after any of these procedures often goes away on its own as the dura heals and the leak stops. If it doesn’t stop, a treatment called a “blood patch” can be done that seals the leak in 90 percent of cases, Dr. Carroll said.

Two other causes of headaches from spinal fluid leaks are spontaneous, Dr. Carroll said. The first is a bone spur or any bony calcification that pierces the dura. People with degenerative changes in their spine can have bulging spinal discs that calcify and can then poke through the dura to cause a leak at a single site or multiple sites, he said. CT myelograms can detect bone spurs, but some patients with unexplained headaches may not get this test or their doctor doesn’t understand the connection between an “osteophyte” (bone spur) reported from the CT myelogram of the spine and the patient’s headache or neurologic symptoms.

A third cause is having unusual connective tissue that leaves the dura thinner and more susceptible to tearing or leaking, Dr. Carroll said. This kind of connective tissue is unusually stretchy. People who have it may be unusually flexible or appear “double-jointed” compared to most.

“If you have connective tissue that’s extra stretchy and flexible, the bag that holds your fluid in is thinner and more susceptible to having a tear or leak,” Dr. Carroll said. A small whiplash injury or fall could trigger the leak without being detected. “People are wondering why you’re having all these headaches and neck pains after a car accident. They don’t go looking down in your back,” he said.

Patients with Ehlers-Danlos, Marfan syndrome, neurofibromatosis, and adult polycystic kidney disease are all known to have weaker connective tissue and be more susceptible to having undiagnosed CSF leaks. Other tipoffs that may indicate unusual connective tissue are being very tall (above 6-foot-2), having scoliosis, having many bulging discs throughout the spine, or diffuse arthritis.

People who are so hyperflexible they can bend their bodies into difficult poses for gymnastics or ballet that others can’t do may have the type of connective tissue difference linked to spinal leaks. Having cataracts earlier in life than usual—by age 40 or 50, rather than 65—can also be a tipoff for connective tissue differences.

This kind of unusual connective tissue won’t show up on an MRI, so it may go undetected and lead doctors to miss spinal fluid leaks that can occur at multiple sites in the spinal dura, Dr. Carroll said. He explained that research suggests that 30 percent to 40 percent of patients with spontaneous CSF leaks have more than one leak when they are diagnosed. This seemingly unlikely occurrence can happen because the connective tissues in these patients are inherently weaker than normal.

When a patient has a spontaneous leak the conventional treatment for a spinal-leak headache­—a blood patch on the dura—has a roughly 30 percent chance of stopping the headache with the first patch, Dr. Carroll said. If further patches don’t work, other options to fix a leak include fibrin “glue” seals or surgery to close any defects in the dura.

He is working with other physicians at Stanford and elsewhere to examine more patients with unexplained headaches that fit the profile of spinal fluid leaks: daily headaches that worsen when standing up (or late in the day), as well as nausea and dizziness. In the past 6 months, he’s found 26 people who had unexplained or misdiagnosed headaches who were helped by blood patches or other treatment for spinal fluid leaks.

He wants to find more. He urges friends and family of people suffering from unexplained chronic headaches to contact him at Stanford if they show the tipoff symptoms. If people with headaches feel much better every day in the morning after sleeping all night lying down, that’s another tipoff, Dr. Carroll said. Patients can help establish the diagnosis themselves by simply spending 24 hours lying flat.  People who are leaking will feel that day is one the best days in a long time.

“Having lives derailed by intractable headaches is a tragedy, but it is a much greater tragedy when the person has an unrecognized CSF leak that could be fixed  easily if only recognized. We can help them be back at work, and live life again more fully,” he said.

About the speaker:
Ian Carroll received his MD from Columbia University and did his internship and residency at Stanford University School of Medicine. He also received an MS in clinical epidemiology from Stanford. He is board certified in pain medicine and anesthesia by the American Board of Anesthesiology, and in addiction medicine by the American Board of Addiction Medicine. He has received research grants from the NIH, the Foundation for Anesthesia Education and Research (FAER), and Stanford University. He also received a faculty award for teaching excellence in Stanford’s pain management division. He has previously lectured on neuropathic pain for the Stanford Health Library.

About the Stanford Pain Management Center
Clinicians and researchers at the Stanford Pain Management Center have made major advances in the understanding of chronic pain as a distinct disease that fundamentally alters the nervous system. The center’s work has earned it a designation as a Center of Excellence by the American Pain Society.

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Hearing, Hearing Loss, and Current Technology

Posted By SHL Librarian

Presented by: Gerald R. Popelka, PhD
Chief, Division of Audiology
Professor of Otolaryngology/ Head and Neck Surgery
February 20, 2014

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While hearing loss can have a variety of causes, including infection and some medications, its most prevalent cause is the simple act of aging. About 18 percent of the entire U.S. population are Baby Boomers—some 57 million people—who are now turning 60, and more of the population will continue to thrive and remain active until well into their 80s. Hearing usually holds steady until about age 50, starts to drop by age 60, and takes a more significant drop between age 70 and 80.

In fact about half of all men and women older than75 have age related hearing loss, said Gerald R. Popelka, PhD, a Stanford professor of otolaryngology and chief of Stanford Hospital & Clinics audiology program, at a presentation sponsored by Stanford Hospital Health Library.

Normal hearing receives frequencies from about 20 Hz (a very low buzz) to about 20,000 Hz (a very high squeal). Human speech falls mostly in the range of 250-6,000 Hz. For most people, hearing loss sneaks up gradually over the years. They start to drop the higher frequencies, picking up missing bits of conversation by context or visual signs. Phones are particularly notorious for dropping both the higher and lower ends of auditory frequencies.

Part of the Aging Process
Hearing loss does affect men and women differently, with a 20-year difference in rate of decline, he added. That means an 80-year-old woman might have the hearing of a 60-year-old man, which can add to communication problems between spouses and family members. Studies have shown that the age of hearing loss has remained consistent in the 60-year-old age group for the past 30 years, so lifestyle changes and Boomers’ love of loud music is not a major factor in terms of when onset occurs.

Age-related hearing loss cannot be corrected through surgery or medication, said Dr. Popelka, who helped invent the first digital hearing aid in the 1980s. Because hearing loss takes place in the hair cells, the cells deep in the inner ear that connect to nerves sending sound messages to the brain, the damage is permanent and, so far, irreversible.

But when hearing starts to decline, an almost-inevitable aspect of aging, many people hesitate to use a hearing aid. If their sight were failing, most people wouldn’t hesitate to get glasses, he added.

“The vast majority of hearing loss is simple age related and will worsen progressively,” he said. “There are no surgical or medical interventions for the 25 percent of people in the U.S. who have hearing loss caused by this type of damage. For most, the answer is a hearing aid.”

Customized Devices
A hearing aid is a miniature electronic device that amplifies sound. Most are made up of the same basic components—a microphone, a battery, a loudspeaker and a computer—that must be custom adjusted for each user. Listening to complex and changing sounds coming from different directions, blocking out unnecessary background noise, or interpreting environmental sounds involve a complex system of controls.

Hearing aids, which are devices regulated by the FDA, are not the same as hearing assistance devices or personal sound amplification systems. Amplifying a conversation without compensating for these other factors doesn’t make it easier to understand a conversation, he said. Hearing aids involve a computer chip that must be customized for each patient: These adjustments are very complex and require the skill of an audiologist.

Advances in technology have not only made hearing aids increasingly smaller but have added new features and address many of the problems of earlier models. The whistling sound many users complained about has been eliminated. Many people now prefer a “mini” version of a BTE (behind the ear), which is virtually invisible. Since BTE models have an open fit, the ear canal is not blocked and all sounds can come through naturally.

“They can be connected wirelessly to the TV, cell phone, GPS, car, or Internet. They can distinguish background noise and music from speech and automatically modify their settings accordingly,” said Dr. Popelka. “The controls are no longer manual. They automatically can adapt and adjust their settings. Sounds sound natural.”

BTE models also come in bright colors, which can act as a fashion statement and make them easier to find if they are dropped since they are so small. Many models are smaller than a dime.

Improved Technology
Another option is a disposable device that is fitted completely inside the ear canal. This style is totally invisible but can muffle sounds, and some users say that their ear feels full. This style must be inserted by a professional, and must be replaced every few months.

“Today’s hearing aids are physically comfortable, easy to put on, almost invisible, and have excellent performance,” said Dr. Popelka. “In fact over the past 10 years there’s been a reversal in usage, and now more people prefer the over the ear style. It’s a dramatic change.”

He also noted an increase of double usage—wearing hearing aids in both ears. Using two devices allows for three-dimensional acoustics, making it easy to identify the speaker or source of sound in an ambient or noisy environment.  A device worn around the neck can program the devices to communicate with each other and be adjusted accordingly. A remote microphone or smartphone app can be used to listen to the television or to amplify sounds in public places. For example, many theaters and performing arts venues feature a telecoil loop system so users can hear through their hearing aids perfectly from any seat. Those without a wireless hearing aid can link into the system with earphones supplied by the facility.

Dr. Popelka addressed concerns about the cost of hearing aids, which often are not reimbursed by insurance companies. The cost is related to demand, he said, and the expertise required to adjust each hearing aid to its user. FDA-approved manufacturers offer similar features, he added, but be leery of a facility that offers only one brand and select a place with professional audiology services, including diagnostics, evaluation, and follow-up care.

“The technology has improved immensely. There is less need for hearing aids to get smaller since the focus now is on adding in more features,” Dr. Popelka said.

While today’s hearing aids feature noise cancellation, automated controls, wireless configurations, internal memory, and water resistance, the future may hold strategies for preventing hearing loss in the first place. Research in Dr. Popelka’s department is looking to prevent hair cell damage as a side effect of some antibiotics and of chemotherapy. His associates also are exploring the use of stem cells and gene therapy to restore hearing.

“Age-related hearing loss affects quality of life,” he said. “Studies show a dramatic improvement in the quality of life when hearing is improved.”

About the Speaker
Gerald Popelka, PhD, is chief of the Division of Audiology and co-director of the Stanford Balance Center. His work focuses on refining digital hearing devices and developing strategies to assess the hearing-related effects of antibiotics and pharmaceuticals used to treat cancer. He is a faculty advisor at the Stanford Center on Longevity and is a board member of the Baker Institute for Hearing Impaired Children

Before coming to Stanford in 2004, Dr. Popelka was a faculty member for 24 years at Washington University in St. Louis and served as head of audiology at Central Institute for the Deaf, an affiliated research institution. He received a master’s degree in audiology from Kent State University, a PhD from the University of Wisconsin, Madison, and completed his research fellowship at UCLA.

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Stanford Initiative to Cure Healing Loss
http://med.stanford.edu/hearinglosscure

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Stanford Department of Otolaryngology – Head and Neck Surgery
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Cognitive and Affective Function in Late Life

Posted By SHL Librarian

Anxiety and Depression in Mid-To Late Life
Speaker: Ruth O’Hara, PhD
Associate Professor of Psychiatry and Behavioral Sciences
Stanford University Medical Center
April 17, 2014

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For most people, forgetting a word, misplacing the keys, or becoming easily distracted is a normal part of aging, the result of general wear and tear on the billions of neurons in the brain. Changes in cognitive function—the ability to think, reason, and remember—also affect behavior and mood, and may contribute to psychiatric disorders like depression and anxiety, particularly in older adults.

It’s estimated that major clinical depression affects 2 to 3 million Americans aged 65 years or older, and milder depression strikes as many as one in six of this age group. Studies have shown that anxiety is even more common, affecting as many as 10-20 percent of the older population. Often the two go hand-in-hand, reducing overall health and quality of life.

“Late-life depression is very significant and extremely underestimated,” said Ruth O’Hara, PhD, an associate professor of psychiatry and behavioral sciences, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “It often manifests as physical symptoms and so can be misdiagnosed and undertreated. It is not a normal aspect of typical aging.”

There are several aspects of cognition that are affected by aging, some more than others. The processes most impacted include:

  • Executive function—the ability to plan and organize
  • Psychomotor speed—coordinated thinking with simultaneous movement
  • Attention and inhibition—staying focused and avoiding distraction
  • Working memory—short-term recollection
  • Explicit verbal memory—retaining instructions
  • Visual memory—retrieving clues about location
  • Verbal fluency
  • Visuospatial ability—the ability to temporarily hold and manipulate information about places

Aging tends to cause structural changes in the brain, with a diminished hippocampus, reduced structural volume, and increased white matter lesions. And while it’s difficult to measure neuronal function, there are changes in neurotransmitters like serotonin, which is related to mood, and dopamine, which is involved in executive function.

“People with depression who develop dementia show greater problems with cognition,” Dr. O’Hara said. “And both memory performance and executive function are worse in older people who are depressed.”

Dr. O’Hara’s research looks at physiological function and neurophysiological changes related to cognitive decline and how they are related to anxiety and depression in older adults. Cognitive decline is not only a predictor of dementia, she said, it may also contribute to affective disorders such as late-life depression. There likely is a reciprocal relationship between affective and cognitive symptoms in late life. Anxiety, for example, is also related to lower cognition and can be as influential as depression: The more anxiety, the greater the cognitive decline.

Behavioral tests in a study of people age 60 to 89 years old showed that anxiety tends to affects inhibition and processing speeds, while depression impacts all aspects of cognition. Distractibility—the failure to inhibit—is the most significant cognitive change with age, she said, and the one that appears most related to emotion.

Other studies have shown that emotional regulation—techniques to keep emotions in check—may offer a means to stay in good mental health, and may lead to improvements in  both memory and overall cognition.

“Emotional processing is associated with different patterns of diminished brain neurocircuitry in late-life depression and anxiety,” Dr. O’Hara said. Other factors include stress, sleep disturbances, diseases, and changes in neurotransmitters—chemical messengers that carry and modulate signals between neurons.

Research suggests that activities that exercise the brain and regular practice of emotional regulation strategies can actually improve cognitive abilities but must be done on a regular basis to show results. Best results may come from courses targeted to each individual, with structure, feedback, and assignments, rather than a self-directed routine.

These studies are important, she added, because they provide a window to understanding psychiatric disorders. “Cognitive dysfunction is a risk factor for the development of depression and anxiety in older adults and can impact response to treatment. It also may provide a potential target for treating these disorders.”

About the Speaker
Ruth O’Hara, PhD, is an associate professor of psychiatry and behavioral sciences and director of the Veterans Affairs National Fellowship Program in Advanced Psychiatry and Psychology. Her work focuses on identifying the genetic risk factors and physiological markers of neurocognitive impairment in late-life disorders, including dementia and Alzheimer’s disease. Dr. O’Hara received her MA in experimental psychology from University College in Dublin, Ireland, and her PhD in experimental psychology from University of Southern California, Los Angeles. She worked at the UCLA Neuropsychiatric Institute before joining the Stanford faculty in 2000.

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