Fear of Alzheimer?s undermines health of elderly patients

By Marjorie Centofanti

When geropsychologist Gregory Hinrichsen, PhD, holds his workshops on how to cope with memory loss, he?s struck by two things: First, the overflow audiences of men and women in their 60s who crowd into the room at Long Island Jewish Medical Center. And second, the anxiety in their faces. 'They?re absolutely engaged,' he says. 'They focus on every word. They ask pointed questions.'

But it isn?t just memory loss, per se, that accounts for the worried looks, he believes. Memory loss, he says, is really a buzz word for older people?s underlying fear that they?re getting Alzheimer?s disease. And that worry, according to a select APA task force of geropsych-ologists?to which Hinrichsen belongs?is widespread and rising among those 60 and older.

About 3 million adults in this country?roughly 11 percent of those over 65?suffer from Alzheimer?s or some other form of dementia. By 2040, that number 'will probably increase to 7 million as baby-boomers age,' says APA Past President Norman Abeles, PhD, a geropsych-ologist at Michigan State University.

During his presidency, Abeles formed a task force that established guidelines on 'The Assessment of Dementia and Age-Related Cognitive Decline.' Anxiety about the disease is likely to increase, he says, as thousands of sensitized but otherwise normal elders cringe inwardly with every forgotten phone number.

But led by Abeles, psychologists are improving their strategies to deal with people?s often unwarranted fears of getting Alzheimer?s. A second task force established by Abeles during his APA presidency recently published a brochure 'What practitioners should know about working with older adults.'

Based on a heightened understanding of why such fears exist, psychologists are recommending:

? Through testing, screen out those who really have Alzheimer?s from those afflicted with the normal muzzying of the mind that many mistake for dementia.

? Promote education about the common influence of depression and anxiety on memory loss in the elderly.

? Offer grief counseling to assist older people in accepting their new role with its attendant lessening of physical and mental acuity.

? Stress the positive effects of exercising one?s mind for sustained mental sharpness.

Beyond the symptoms

Alzheimer?s is often tough to confirm in the very early stages and is frequently misdiagnosed at the family physician level, say experts like Alfred Kaszniak, PhD, a University of Arizona neuropsychologist. In fact, technically, the only foolproof way to confirm Alzheimer?s is by autopsy?looking for the telltale plaques and tangles in brain neurons. But at larger, specialized centers, diagnostic accuracy rates are high, says Kaszniak, reaching 90 percent or more.

Among those who worry about getting Alzheimer?s are those suffering from the anxiety of aging and those who are depressed. Thus, experienced professionals go far beyond the symptoms of lost keys or forgotten names in making their diagnosis, says Michael Hazlewood, PhD, director of geropsychology the VA Medical Center, Little Rock, Ark.

They look for tell-tale behavior patterns. For instance, those suffering from Alzheimer?s show great difficulty in learning new things, says Hazlewood. And they demonstrate a rapid rate of forgetting, of the type where the use of mental cues to bring back a memory doesn?t work anymore.

Even then, he says, diagnosis can be complicated, 'especially with someone who functions at a high level to begin with.' Such as the 82-year-old retired banker whose wife told Hazlewood 'Something?s different here.' When he asked what, specifically, was different, 'she said he didn?t shave as frequently, didn?t seem as cheerful, stayed in the house more and forgot things.'

Hazlewood and colleagues interviewed the man at length, ruling out depression, then administered batteries of cognitive tests, with some keyed to dementia. Occupational therapists rated the man?s ability to carry out typical life tasks. Hazlewood then took a medical history, while the man had blood work, for infections, and MRI and CT scans. After that, he had a thorough neurological exam. The result? 'He was still within the norms for someone his age, ' says Hazlewood, 'though some things were at the high end.'

Last winter, says Hazlewood, 'the man?s wife called to tell me her husband couldn?t remember how to build a fire, something he?d done every year at the first cold snap. And we saw the pathology clearly for the first time.' It confirmed his belief, he said that 'dementia isn?t a test score; it?s a type of behavior.'

The influence of depression

Often, though, close examination of a patient will show that depression and not a permanent dementia, is behind memory loss.

'I frequently hear older adults complain about their memories,' says Abeles. 'They?ll say, ?I?m worried my mind?s going. I can?t focus on anything.?' But studies, he says, show no clear relationship between complaints and brain disease. 'So you first search elsewhere for an explanation. I first look for depression, which may count lack of concentration and memory problems among its symptoms.'

Abeles believes that depression combined with anxiety makes an especially potent thought-disrupter. 'The two may sidetrack memory by diminishing attention,' he says. And, by losing your attention, he adds, information doesn?t stick in memory.

Adults with a major depression may have noticeable cognitive problems, or dementia syndrome of depression, he says. These people 'test out with clear memory losses,' says Abeles, but 'you can treat them with medication or psychotherapy or both, and it all goes away.'

Sensory losses, such as hearing or vision impairments, when added to older people?s normal slips in thinking, can heighten their anxiety, says geropsy-chologist Martita Lopez, PhD, at Chicago?s Rush-Presbyterian-St. Luke?s Medical Center. 'Hearing is the worst offender,' she says, 'because its loss may be subtle, and folks don?t put two and two together.'

'Sometimes,' says Hinrichsen, 'helping such patients is as simple as education. You explain the nature of normal changes with age and help them get a better handle on how to manage anxiety.'

The nature of those changes is now better understood by psychology, says Alan Zonderman, PhD, a researcher with the

National Institute on Aging (NIA) in Baltimore. 'You may see, for example, some change in memory in the late 50s or early 60s, often related to word-finding. People may be slower to find nouns in particular. Recalling becomes more difficult than recognizing. And reaction time seems to slow, gradually.'

And because these older people are slower to process information, he says, learning rates may be slower?though the ability?s still there. 'Just because someone can?t find the car keys, that doesn?t mean dementia.'

If patients aren?t clinically depressed or anxious, their concern may signal something more intangible, says Hinrichsen. These people have often been high-achievers in their jobs or recreation, and in aging they?re sensitive to their losses. 'Their worries about mental ability,' says Hinrichsen, 'become the proxy for all their grief about aging?their loss of control and general body changes. I know patients who, when younger, could read The New York Times and recount every article. But now that they can?t quite do that, they mourn and shift that mourning into fear of Alzheimer?s disease.'

Victor Molinari, PhD, who directs geropsychology at the Houston VA Medical Center, suggests a structured approach to what he sees, essentially, as grief counseling.

'First you get people to recognize the losses that trouble them most: a loss of physical ability, perhaps, or the loss of esteem that comes from holding a job,' he says. 'Some grieve the loss of their role as parents or the loss of prestige when Western society counts them out as productive members.'

Next, says Molinari, encourage patients to focus on the positive aspects of age, like gaining in wisdom or having time to savor beauty. 'You emphasize the value of substituting golf for football, or hiking for marathon-running,' he says. 'And you do this in groups, so people can be models for each other in expressing their grief and can brainstorm together on replacement activities.'

Counseling aside, some studies suggest many normal cognitive changes of age, such as memory loss, spring from disuse. In a landmark study in 1986, for instance, Penn State psychologists K. Warner Schaie, PhD, and his colleague Sherry Willis, PhD, showed that losses in two simple mental abilities?spatial orientation and the ability to reason inductively?could be turned around in many of their 60-plus aged subjects with short periods of training using simple exercises such as figuring out how often a bus runs by reading a schedule.

Since then, the two researchers have shown that brief booster sessions of training also helps memory 'stick.'

Even small gains can have an impact, Schaie believes. 'A lot of older people function marginally,' he says. 'They?re still making it, paying bills and participating, even though they?re frail. The issue isn?t making old people young again, but it?s extending their independent years.'

For a copy of the booklet 'What the Practitioner Should Know About Working With Older Adults,'call APA at (800) 374-3120. A consumer version is also available.

Marjorie Centofanti is a writer in Severna, Md.