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  1. 1. Live Well, Live Long: Steps to Better Health Health Promotion and Disease Prevention for Older Adults Strategies for Cognitive VitalityChapter 2. Problem AnalysisTable of Contents Introduction: Why is Cognitive Vitality Important? What Factors Contribute to Cognitive Complaints? Clinical Depression What is depression? What causes depression? How does depression affect memory? How does depression differ from Alzheimer’s disease? What prevention activities can reduce or eliminate depression? Multiple Minor Strokes What is stroke? What causes stroke? How does stroke affect memory? How does stroke differ from Alzheimer’s disease? What prevention activities can reduce stroke? Avoiding Damaging Health Behaviors Lack of Physical Activity How Exercise Works Poor Nutrition How Nutrition Affects the Brain Stress How Stress Affects the Brain Sleep Irregularity How Sleep Affects the Brain Medication Misuse How Medications Affect the Brain Alcohol Consumption How Alcohol Affects the Brain Tobacco Use How Cigarette Smoking Affects the Brain Lack of Mental Stimulation How Mental Stimulation Affects the Brain Emotionally Deprived Environments How Are Different Populations Affected? Caucasians African Americans Latinos Asians and Pacific Islanders
  2. 2. Native Americans How Diverse Cultures View Dementia African Americans Latinos Asians and Pacific Islanders Native Americans Lesbian, Gay Bisexual and Transgender (LGBT) What Are the Barriers to Reaching Target Audiences? General Population Diverse Populations Rural Populations Who Is the Target Audience? Selected by Cognitive Status Selected by Specific Population Selected by Geographic Factors ReferencesIntroduction: Why Is Cognitive Vitality Important?As the boomer population ages, dementia and Alzheimer’s become a looming communityproblem. The National Institute on Aging predicts that by 2010, as many as 10 millionolder adults will lack the ability for self-care because of Alzheimer’s disease.Alzheimer’s strikes about one-third to one-half of those ages 85 and over. Predictions ofincreased longevity, doubling the number of older adults ages 85 and over, suggest anincreased need for care and increased cost. Even now, the estimated cost per individualis a formidable $659,000.In addition to costs, formal care systems struggle to find and retain care workers for olderadults with dementia. Informal care provided by relatives or partners often requires themto sacrifice personal retirement security, either by forcing them to leave employment orprovide out-of-pocket expenses that diminish their savings.Two elements can potentially slow the increasing number of cognitively impaired elders.Researchers estimate that delaying the onset of symptoms, by even five years, can dropthe incidence of Alzheimer’s disease in half.1 The delay of symptoms and slowedprogression of the disease means that death from other causes may occur before theserious functional disabilities of Alzheimer’s set in.This chapter introduces some of the most current thought on research exploring improvedcognitive vitality through treatment and lifestyle recommendations. Much discussion anddebate is still forthcoming. The background provided in this chapter should help youunderstand some of the new discoveries and debates that will emerge.1 Margolis, S., and Rabins, P. (2001) The Johns Hopkins White Papers: Memory. NewYork: Medletter Associates, Inc.Live Long, Live Well: Steps to Better Health 2Strategies for Cognitive VitalityChapter 2
  3. 3. This chapter will: • Discuss factors contributing to cognitive vitality and decline • Describe the target audience for messages about health promotion • Develop strategies for reaching that audienceNote:The Blueprint for Health Promotion module included in this series of health promotiontools provides extensive information on reaching target audiences and creating healthmessages. Some sections of this chapter will refer to this Blueprint module for effectiveplanning of your health promotion campaigns.What Factors Contribute to Cognitive Decline?Three major factors contribute to reversible or preventable cognitive decline: • Clinical depression Depression, often brought on by injuries, illness, losses, financial pressures or life events, accounts for 1 to 5 percent of memory disorders. • Multiple minor strokes Multiple strokes account for 20 percent of cases of cognitive impairment. • Damaging health behaviors Damaging health behaviors contribute to another 20 percent of the total cases of cognitive impairment. These behaviors include physical inactivity, poor eating habits, smoking and sleep irregularities.Clinical DepressionWhat is depression?Almost everyone periodically feels a little down. In clinical depression, however, thesadness and lack of zest for life persist every day for more than two weeks. Thedepressed older adult can: • Express hopelessness • Show lack of interest in things that were once enjoyable • Feel worthless • Have trouble sleeping or eating • Experience persistent physical symptoms unresponsive to treatment • Lack energyLive Long, Live Well: Steps to Better Health 3Strategies for Cognitive VitalityChapter 2
  4. 4. • Seem irritable or restless • Difficulty concentrating or indecisivenessEstimates from the National Mental Health Association indicate that 30 percent of peopleover the age of 65 will suffer from depressive symptoms at least once.2What causes depression?Both at the biological level and within their social environment, older adults arevulnerable to depression. Biological • Changes in the neurotransmitters and hormones Neurotransmitters are chemicals that play a key role in transferring information from one neuron to another. An electrical impulse that carries information moves from the neuron center down the axon. To make the jump between the neurons, neurotransmitters are released to carry the information. Decreased activity of the neurotransmitter norepinephrine stems in part from our body’s diminishing production of this chemical as we age. When there are inadequate levels of norepinephrine present in the limbic system—the part of the brain most responsible for emotion and memories —the older person becomes biologically at risk for depression. Long-term stress also contributes to shutting down neurotransmitters within this system. Synapse Dendrites Cell Body Axon2 National Mental Health Association (1999) Overcoming Depression in Later Life.Alexandria, VA: National Mental Health Association.Live Long, Live Well: Steps to Better Health 4Strategies for Cognitive VitalityChapter 2
  5. 5. • Medications Many medications, including those that treat Parkinson’s disease, have depression as a side effect. • Accompanying illnesses Clinical depression often accompanies chronic diseases such as diabetes, stroke and heart disease. Social Environment • Losses Death of a spouse or life partner, loss of a job or friends can cause clinical depression. An older person moving from a longtime residence may grieve over the change. Giving up driving can represent loss of independence as well as loss of mobility, a reduction in activities and less contact with the world. • Stress Living on a reduced income, navigating an unsafe neighborhood, or taking the caregiving role for a loved one may cause stress that leads to depression.How does depression affect memory?Memory loss is a common complaint of clinical depression. Short-term memory loss is atypical symptom of depression.3People learn what interests them and disregard the extra information presented. Thissystem of sorting the important data from the mass of stimulation we encounter dailysaves us from overload. At the same time, when we are depressed, our interest in theworld around us declines. Depressed people are not able to allocate as much effort tocognitive processes as the external world demands. They have a deflated pool ofattention capacity, and therefore absorb less new information and create fewer newmemories.Additionally, the production of norepinephrine decreases even more during depression,which slows the efficiency with which new memories are established.3 Woodruff-Pak, D.S. (1997) The Neuropsychology of Aging. Oxford, UK: BlackwellPublishers.Live Long, Live Well: Steps to Better Health 5Strategies for Cognitive VitalityChapter 2
  6. 6. How does depression differ from Alzheimer’s disease?Symptom-related Factors Depression Alzheimer’s DiseaseOnset There is an uneven There is a progression over progression over a an extended time relatively short periodTime of day Symptoms are usually more Symptoms increase later in evident in the morning the day due to fatigueAwareness of memory loss Those suffering from Alzheimer’s victims in later depression complain about stages may deny memory memory loss lossSelf-medication Depressed people are more This is less likely in likely to turn to alcohol or Alzheimer’s cases drugs for reliefWhat prevention activities can reduce or eliminate depression?Many difficult situations and losses encountered by older people are unavoidable andmay activate low moods that can develop into clinical depression. However, clinicaldepression is not a part of normal aging. Treatment, either through counseling and/ormedications, is successful in 80 percent of older adults.Social support from families, friends, partners and the community significantly increasesthe older person’s ability to negotiate difficult situations. Meaningful activities and asense of purpose also contribute to a zest for life.Multiple Minor StrokesWhat is stroke?Sometimes called a “brain attack,” a stroke injures the brain when the supply of blood toan area of the brain shuts off long enough to damage or kill cells. Sometimes the braincompensates for damaged cells, but cell death is irreversible. Brain cells survive onlyone or two minutes without oxygen or glucose, which are transported by blood.What causes stroke?Disruption of this vital blood supply takes place in three ways: • Most frequently, blood vessels become blocked by arteriosclerosis, the buildup of plaque, or waste material in blood that cause clots to form • Blood seeps into the brain through a rupture in a blood vessel hardened from arteriosclerosis • A blood clot formed in another part of the body breaks loose and travels in the bloodstream to clog a crucial artery to the brainLive Long, Live Well: Steps to Better Health 6Strategies for Cognitive VitalityChapter 2
  7. 7. Major strokes occur when large arteries affect a vast portion of the brain, and can resultin death. Strokes affecting more localized blood vessels damage only small areas of thebrain.How does stroke affect memory?Strokes affecting small areas of the brain may cause cognitive impairment. The cells nolonger function and cannot pass information to other brain cells in their network ofconnections. An accumulation of dead areas from stroke may mimic the symptoms ofearly Alzheimer’s disease.How does stroke differ from Alzheimer’s disease?Because of the difficulty in detecting the difference between stroke (resulting in vasculardementia) and Alzheimer’s disease, healthcare professionals may attribute cognitivedecline to the presence of Alzheimer’s. The subtle difference between the two is shownbelow: Symptom-related Factor Stroke-related Dementia Alzheimer’s DiseaseRate of progression There is a sudden decline There is gradual after stroke diminishing of cognitionCardiovascular risk factors High blood pressure, high Not a major factor concentrations of LDL cholesterolOlder adults may have both Alzheimer’s disease and vascular dementia, but determiningthe primary cause of impairment affects treatment options.What prevention activities can reduce stroke?The risk of stroke can be reduced by: • Maintaining proper blood pressure • Avoiding high levels of fat in the diet • Exercising adequately • Avoiding tobaccoLive Long, Live Well: Steps to Better Health 7Strategies for Cognitive VitalityChapter 2
  8. 8. Damaging Health Behaviors • Lack of Physical Activity Of the U.S. population over age 50, 34 percent are sedentary. Thirty-three percent of men and 50 percent of women ages 75 and older do not participate in leisure-time physical activity. How Physical Activity Works Physical activity increases direct blood flow to the brain and lowers the level of harmful stress hormones called cortisol. It also activates neurological and endocrinological secretions, one of which is norepinephrine. Norepinephrine is a neurotransmitter that carries the electrical stimulation that creates new memories, and plays a significant role in moving memories from short-term to long-term storage. Norepinephrine is also involved in the regulation of pleasure pathways and mood. Physical activity increases the supply of this mood-enhancing neurotransmitter, helping to dispel depression. Physical activity is also a stress buffer. Active people decrease their vulnerability to stress. Many people experience an elevated mood for as long as four hours after physical activity. For people who have primarily physical reactions to stress, this is an especially effective benefit, because it not only provides relaxation via mood enhancement, but also increases blood flow to the brain. • Poor Nutrition The National Institutes of Health (NIH) directly relates 30 percent of deaths from cardiovascular disease to diet. As indicated above, vascular disease contributes to cognitive decline. The American diet consists of 58 percent sugar and fat. This high percentage results in increased caloric intake and reduced healthy nutritional content. Generally, eating five or more servings of fruits or vegetables per day will help provide the needed nutrition for maintaining body function. Only 9 percent of Americans follow this recommended five-a-day eating routine. How Nutrition Affects the Brain Within the brain, poor nutrition can cause impairment of blood circulation important in supplying neurons (brain cells) with the “building materials” they require for proper function. Damage to blood vessels’ interior lining caused by normal wear and tear, or injury from stress and elevated blood pressure, increases significantly with high concentrations of fatty acids in the bloodstream. The fatty acids, sugars and starches work their way intoLive Long, Live Well: Steps to Better Health 8Strategies for Cognitive VitalityChapter 2
  9. 9. tears underneath the thin blood vessel lining. By sticking underneath this thin layer, this concentration, called plaque, causes thickening of the walls of the blood vessel, decreasing its flexibility and gradually closing the passageway. The decreased flow of blood results in slow starvation of brain cells and, in the extreme, blockage that causes stroke. Good nutrition also plays a crucial role in a healthy brain by providing the fuel to repair damage caused by stress-induced steroid hormones called glucocorticoids. Recommended Health Habits To counter the increase of plaque that narrows the blood vessels, health professionals recommend a heart-healthy diet: • Increasing fiber such as oat bran, legumes and fruit • Reducing saturated fat intake. Harmful saturated fats, which include butter, whole milk, cheese, ice cream, red meat, and palm, coconut, and cottonseed oils raise the level of harmful LDL cholesterol • Reducing cholesterol by avoiding egg yolks and organ meats (kidney, brain and liver) • Adding moderate amounts of Omega 3 fatty acid found in walnuts and salmon, which appear to potentially stabilize the structure of the brain, since the brain consists of 60 percent fat • Increasing physical activity to increase HDL, the “good” cholesterol that scavenges plaque • Stress Stress increases the risk of getting diseases by weakening the body’s ability to fight off disease. Since individuals respond quite differently to a given situation, statistically documenting the sources of stress is difficult. We do know that a lower socioeconomic level is a major indicator of health status among American older adults. Inadequate financial income affects access to: o Higher education (another factor related to good health) o HealthcareLive Long, Live Well: Steps to Better Health 9Strategies for Cognitive VitalityChapter 2
  10. 10. o Adequate housing o Fresh foods All these factors can create more stress for poor older adults. How Stress Affects the Brain The hormone glucocorticoid, also called cortisol, produced as a reaction to stress, damages the brain over a sustained period of strain by: o Interfering in the brain’s supply of glucose—the fuel that powers the brain. New memories become difficult to lay down and the retrieval of existing memories slows considerably o Interfering with the function of neurotransmitters—chemicals that transmit information from one neuron to another. The interference blocks messages the brain needs to sort information or determine appropriate reactions o Triggering an overinflux of calcium into the brain cells. Over an extended period of time, continued intake of calcium leads to the creation of free radicals, unstable molecules that rob electrons from stable molecules. When free radicals come into contact with the protective sheath, called myelin, that insulates neurons, it degrades. At first, loss of this insulating sheath reduces the speed of the electrical signals. Free radicals contacting the neurons’ branch receptors of electrical signals, called dendrites, also thin their density. With fewer receptors, fewer signals find their path and consequently must detour around an area, which takes more time. This instability causes a breakdown in the brain cells, which eventually kills the cells. The affected neurons are usually concentrated in the hippocampus, the primary “sorting and shipping” area for memories Recommended Health Habits To counter stress, increase physical activity. This will activate the neurotransmitter norepinephrine, which carries the electrical stimulation that creates new memories and decreases cortisol. • Sleep Irregularity One hundred years ago, adults living in the U.S. slept an average of nine hours each night. In 2001, adults average less than seven hours. Compounding this reduction in sleep, the quality of deep sleep, which refreshes the mind, and the ability to fall asleep and stay asleep, both decrease with age. Lack of sleep impairs mental function.Live Long, Live Well: Steps to Better Health 10Strategies for Cognitive VitalityChapter 2
  11. 11. How Sleep Affects the Brain Normal sleep will cycle between deep and the lighter dreaming sleep. The deepest stages of sleep regulate the release of human growth hormones that possibly regenerate cells, including brain cells. These growth hormones may counteract the effects of the stress-produced hormone, cortisol. As the hours of deep sleep decrease in late life, levels of cortisol increase. Reduced numbers of human growth hormones and increased cortisol are thought to compound the aging effects on the brain and body. Recommended Health Habits To promote normal sleep cycles: • Reduce napping during the day, especially in the early evening • Avoid caffeine such as coffee, chocolate and black tea in the later part of the day • Increase physical activity to at least 30 minutes each day • Medication Misuse Older adults take more medicines than any other age group. They consume 30 percent of all prescription drugs, although only 12 percent of the population is considered within this age group. The average older person consumes five prescription medications and three over-the-counter drugs each day. Older people also experience slowed organ function, which increases the time it takes to eliminate some drugs from the body. Increased use of drugs, and reduced efficiency in flushing them out, in turn increase: o The risk of side effects o The possibilities for interactions among the drugs o The likelihood for overmedication How Medications Affect the Brain Medication side effects can mimic symptoms of Alzheimer’s disease. The combination of frequent use of medications and the decreased ability of the liver to break down and eliminate certain drugs may promote confusion and drowsiness, potentially impairing the memory performance of older adults. The following are some of these medications:Live Long, Live Well: Steps to Better Health 11Strategies for Cognitive VitalityChapter 2
  12. 12. o For treatment of anxiety and sleeping problems  Benzodiazepines such as Valium (diazepam), Halcion (triazolam), Xanax (alprazolam), Dalmane (flurazepan), Seraz (oxazepam) and Tylenol P.M. (diphenhydramine)  Tranquilizers such as Miltown (meprobamate) o For treatment of depression  Trycyclic antidepressants such as Asendin (amoxapine), Elavil (amitryptyline) and Pamelor (nortryptyline) o For treatment of agitation or psychotic disorders  Antipsychotics such as Haldol (haloperidol) and Mellaril (thioridazine) o For treatment of high blood pressure, angina and some forms of heart failure  Beta blockers such as Inderal (propranolol)  Central agonists such as Aldomet (methyldopa) o For treatment of pain  Opiods or narcotic analgesics such as MS (morphine sulfate), Vicodin (hydrocodone/acetaminophen), Darvon (propoxyphene), Percodan (oxycodone/aspirin) o For treatment of heartburn and ulcers  Histamine-2 blocking agents such as Tagamet (cimetidine), Pepcid (famotidine), Zantac (ranitidine) Recreational drugs such as cocaine cause a sharp increase in neurotransmitters, followed by a sharp drop. With the depletion of neurotransmitters, consolidation of new memories comes to a halt. Marijuana interferes with the production and utilization of the neurotransmitter acetylcholine Recommended Health Habits • Check with your healthcare provider about medication interactions and memory problems • Make sure that healthcare providers are aware of all over- the-counter medications and herbal remedies and teas that you ingestLive Long, Live Well: Steps to Better Health 12Strategies for Cognitive VitalityChapter 2
  13. 13. • Alcohol Consumption The popular press and scientific studies acknowledge the growing evidence that drinking wine in moderation may contribute to improved heart and brain health. Moderate consumption may ward off mental decline by increasing “good cholesterol,” HDL, and helping to thin the blood—both of which ensure a healthy supply of blood to the brain. Yet researchers hesitate to recommend either drinking for health or starting to drink.4 Since older adults consume 30 percent of the prescription drugs in America, the likelihood of their combining alcohol with medications increases. The combination of alcohol and medications can severely affect health. In multiple research studies, heavy drinkers—those who consume four or more drinks in a day—perform poorly on memory tests. It is estimated that 2.5 million older adults have problems due to alcohol. The related healthcare costs top $60 billion per year. How Alcohol Affects the Brain Chronic overconsumption of alcohol causes a deficiency in vitamin B1, also called thiamine. Extended deficiency results in a neurological disease called Korsakoff’s psychosis, defined by extensive memory loss, the diminishing of other cognitive functions, including judgment, and by the changed structure of the neuron. Each time alcohol enters the bloodstream, it temporarily shuts down the protective mechanism that surrounds all the capillaries in the brain to prevent infiltration by harmful substances. The temporary lifting of the protective shield opens the brain to toxins that can cause additional free radical development. Years of alcohol abuse degrade the covering that insulates nerve fibers. The exposing of nerve fibers interrupts the passage of stimulus information between neurons, resulting in a shortage of recorded sensations.4 Mukamal, K.J., Longstreth, Jr., W.T., Mittleman, M.A., Crum, R.M., Siscovick, D.S.,and Bereczki, D. (2001) “Alcohol Consumption and Subclinical Findings on MagneticResonance Imaging of the Brain in Older Adults: The Cardiovascular Health Study.”Stroke 32:1939-46.Live Long, Live Well: Steps to Better Health 13Strategies for Cognitive VitalityChapter 2
  14. 14. Recommended Health Habits Researchers and clinical professionals recommend: • Reducing drinking of alcoholic beverages to no more than 7 standard drinks per week. (One standard drink is 12 ounces of beer or ale, 1.5 ounces of spirits, 5 ounces of wine, or 4 ounces of sherry, liqueur or aperitif) • If you don’t drink, don’t begin • Ask your healthcare provider about interactions between your medications and alcohol. If serious side effects are possible, avoid alcohol • Tobacco Use Tobacco is the addictive drug most abused by older adults. In 1998, the prevalence of daily cigarette smoking was 36.7 percent among Medicare enrollees ages 55-64, 15.1 percent for people ages 65-74, 9.1 percent for the 75-84 group and 4.5 percent among people ages 85 and older. Each year, $50 to $75 billion dollars are spent on healthcare for tobacco-related illness. How Smoking Affects the Brain Smoking constricts and damages the blood vessels that supply oxygen and nutrients to the brain. The shortage of oxygen in the brain slows cognitive processing, reduces energy and impairs memory consolidation and retrieval. Over many years, lack of oxygen contributes to the death of millions of cells. One recent research study of people over the age of 65 living in England, indicated that a total of 5.7 percent of all participants free of cognitive impairment at the beginning of the study showed some signs of impairment at end of one year. Sixty-seven percent of these impaired participants were smokers. The researchers believe that smoking may play a significant role in development of cognitive impairment after age 65.55 Cervilla, J.A., Prince, M., and Mann, A. (2000) “Smoking, Drinking and IncidentCognitive Impairment: A Community-Based Study Included in Gospel Oak Project.”Journal of Neurology, Neurosurgery and Psychiatry 68(5):622-26.Live Long, Live Well: Steps to Better Health 14Strategies for Cognitive VitalityChapter 2
  15. 15. Recommended Health Habits • Avoid tobacco • Lack of Mental Stimulation Intellectual stimulation promotes brain growth in animals and protects against cognitive decline in humans. In animal studies, brains can shrink if deprived of thought-provoking toys and enriched environments. These results lead researchers to infer that in humans, age-associated memory loss could be partly attributed to lack of mental stimulation. Older adults watch an average of four hours of television each day. The passive consumption that most TV programs afford does not stretch the mental capabilities of the mind. How Mental Stimulation Affects the Brain Neurons develop throughout life by extending fibers like tree branches from the neuron’s cell body to other neurons. Dendrites receive the electrical impulse that jumps from another neuron’s axon, a long thin trunk extending from the cell body. This gap that the signal jumps is called a synapse. The more dendrites a neuron grows, the more likely the receptor neuron will successfully catch the transmitted impulse over the synapse. Synapse Dendrites Cell Body Axon Therefore, learning requires creating new, branched dendrites to reach out to other neurons. The first five branches do not grow longer with mental enrichment, but, finally, at the sixth branch, the dendrite increases in length as a response to stimulation. The six-branched dendrites are 86 percent longer in older animals that have spent their final 30 days in an enriched environment. This cutting-edge research suggests that gatheringLive Long, Live Well: Steps to Better Health 15Strategies for Cognitive VitalityChapter 2
  16. 16. knowledge and developing creativity can ensure learning at any age. This is referred to as fluid intelligence, the measure of the efficiency with which the brain works through its networks, rather than the number of facts stored there.6 Recommended Health Habits Educators and researchers recommend: • Developing a habit of continuous learning through books, public talks, museum, or faith-based study • Use the basic processes of thinking daily. These include: o Observing with your five senses o Communicating an important idea verbally or in writing o Organizing by making lists, or ordering the events of the day o Inventing new ways to accomplish a task and experimenting with how that can be accomplished • Emotionally Deprived Environments Ongoing research into mental well-being and the importance of social supports has resulted in contrary findings on their value and meaning. In animal studies, though, environments rich in human affection and attention stimulate the growth of the brain, especially in the limbic system, the part of the brain responsible for emotions. Additionally, the animals lived longer.76 Conner, J.R., Melone, J.H., Yuen, A.R., and Diamond, M.C. (1981) “Dendritic Lengthin Aged Rats’ Occipital Cortex: An Environmentally Induced Response.” ExperimentalNeurology 73:8127-30.7 Diamond, M.C. (2001) “Good News About the Aging Brain.” Presentation at the FirstJoint Conference of the American Society on Aging and the National Council on Aging,New Orleans, LA.Live Long, Live Well: Steps to Better Health 16Strategies for Cognitive VitalityChapter 2
  17. 17. Hippocampus Recommended Health Habits • Associate with friends and loved ones on a regular basis • Create a network of caring people through faith-based communities, social clubs, civic groups, creative communities, physical activity associations, volunteer activities, or senior centersHow Are Different Populations Affected?Personal lifestyle, which is affected by one’s environment, the cultural norms of societyin general, and cultural community beliefs and practices, can have an impact on cognitionand can change the course of impairment.Caucasians • Fifty-three percent of all Caucasian adults ages 85 and older are diagnosed with Alzheimer’s disease, a higher percentage than any other group8 • Twenty percent of the dementia cases among Caucasian older adults are caused by vascular dementia and 3 percent are attributable to alcoholAfrican Americans • Thirty-one percent of diagnosed cases of dementia among African Americans are attributed to vascular dementia (due to stroke), a higher percentage than all other ethnic and cultural groups98 Yeo, G., and Gallagher-Thompson, D. (1996) Ethnicity & the Dementias. Washington,DC: Taylor and Francis.9 Ibid.Live Long, Live Well: Steps to Better Health 17Strategies for Cognitive VitalityChapter 2
  18. 18. • Forty-six percent of all African American dementia cases receive a diagnosis of Alzheimer’s disease and 3 percent of the diagnosed dementia cases are alcohol-related • African Americans with a parent, sister or brother who has Alzheimer’s disease are at a higher risk for dementia than Caucasians with similar family relationships • African Americans experience a lower rate of dementia related to Parkinson’s disease than Caucasians • Older adults may be prone to misdiagnoses of dementia because of the cultural and socioeconomic biases of some cognitive tests. Culture-related information or unfamiliar facts may affect the test results. For example, some tests call for ordering a sequence of pictures depicting an activity that may be unfamiliar to the person tested10Latinos • Of the Latino population with dementia, 47 percent are diagnosed with Alzheimer’s disease, 18 percent with vascular dementia, and 5 percent with dementia related to alcohol11 • Some older adults may be misdiagnosed with dementia because of the cultural and socioeconomic biases of some cognitive testsAsians and Pacific Islanders • A higher percentage of Asians and Pacific Islanders (26 percent) are diagnosed with vascular dementia than Caucasians (20 percent)12 • Of all cases of dementia in this population, 45 percent are attributed to Alzheimer’s and 1 percent to alcohol Japanese • In studies of Japanese Americans, the range of older adults diagnosed with Alzheimer’s is 12-40 percent of all those with dementia. The range for vascular dementia is 50-70 percent13 Chinese • Among Chinese American elders with dementia, 60 percent have Alzheimer’s. Vascular dementia appears in 28 percent.10 Ibid.11 Ibid.12 Ibid.13 Ibid.Live Long, Live Well: Steps to Better Health 18Strategies for Cognitive VitalityChapter 2
  19. 19. Native Americans • The diversity among American Indians must be noted. There are over 500 federally recognized nations, tribes, bands and Alaskan Native villages14 • Dementia occurs with low frequency. The combined number of Alzheimer’s disease and vascular dementia diagnoses represent only 0.0008 percent of all diagnoses within the entire Indian Health Service and affect only 0.001 percent of veterans discharged from California Veterans Affairs hospitals15 • Diagnoses of dementia may increase as the life expectancy of the Native American population grows • In a 1995 study of Pueblo elders, the median age for impaired memory or judgment was 84 years of age. More men than women were affected (65.4 percent)16How Diverse Cultures View DementiaAfrican Americans • In some communities in the South, a higher value is placed on physical function than on cognitive. Therefore, older adults with mild cognitive impairment can maintain a sense of value because they continue to perform a role in the familyLatinos Mexican Americans Beliefs about dementia vary depending on the region of the country, cultural background and acculturation. The following are examples of how dementia may be viewed by some families, but should not be assumed to exist in all Mexican families: • Health is the result of balance among one’s faith, nutrition and how one has lived his or her life. The family may deny that an elder suffers from dementia if this person has led a balanced life • Dementia is considered punishment from God for “improper behavior.” The will of God also has the power to alter the illness. Therefore, the family must continue proper care as preparation for forgiveness and the resulting change in cognitive condition14 Ibid.15 Ibid.16 Hennessy, C.H., and John, R. (1995) “The Interpretation of Burden among PuebloIndian Caregivers.” Journal of Aging Studies 9:215-29.Live Long, Live Well: Steps to Better Health 19Strategies for Cognitive VitalityChapter 2
  20. 20. • Memory impairment is a temporary condition caused by nerves which folk healers (curanderos) can cure • The brain dries up in old age, leading to childlike behavior Cuban and Puerto Rican Families As with Mexican Americans, Cuban and Puerto Rican families differ in beliefs and customs throughout the country. A field staff member of an Alzheimer’s care organization in Florida noted: • Dementia behaviors that fall outside of social conventions place a social stigma on the person with dementia and the family. The fear of losing an impeccable community image may isolate caregivers and elders in their own homes • Dementia is seen as a punishment on the family for past sins of caregivers17Asians and Pacific Islanders Chinese • The most common response to memory problems in Chinese cultures is acknowledging the behavior as a normal consequence of growing old • The community may see odd behavior from dementia as a sign of mental disorder. It is especially true in cases where the person with dementia experiences hallucinations, paranoia and disorientation, which may also be found in people with mental disorders. The association of cognitive decline with mental illness causes families shame, because mental illness is viewed as retribution for the misdeeds of ancestors or immediate family • Interpretations of causes of dementia include fate, imbalance of energy in the body or disharmony in natural forcesNative Americans Pueblo of New Mexico • Caregivers and communities show respect for elders whether they remain cognitively alert or display inappropriate behaviors17 Yeo, G., and Gallagher-Thompson, D., op. cit.Live Long, Live Well: Steps to Better Health 20Strategies for Cognitive VitalityChapter 2
  21. 21. Choctaw of Oklahoma • Dementia is considered part of normal aging. It serves as a means to communicate with the afterlife during the transition to the next worldLesbian, Gay, Bisexual and Transgender (LGBT) • A biological propensity for dementia is based on genetics, ethnicity and gender rather than sexual orientation • LGBT people may fear dementia for the following reasons: o Dementia may reduce past guarded behavior that could cause the individual to reveal his or her sexual orientation, resulting in poor care from agencies or estrangement from family o Dementia may reduce past guarded behavior that could also result in identification of a partner who must remain discreet about sexual orientation because of a job, housing situation or family relationships o Guardianship and ownership of property may be disputed between a partner and a biological family when dementia progresses to the point of mental incapacity o Families may exclude a healthy partner from care of the partner with dementiaWhat Are the Barriers to Reaching Target Audiences?General Population • A belief that dementia is universal and inevitable Many people believe that declines in memory ability are both universal and inevitable with aging. The federal Administration on Aging reports that about 75 percent of people ages 50 and older have reported some sort of memory problem over the past year. Older adults are more likely than younger people to believe that they can do nothing to improve their memory. Yet the facts do not match this belief. Moderate or severe memory impairment exists in a very small percentage of the population up to age 85. Even then, cognitive impairment affects about a third of the population. Cognitive impairment is not inevitable.1818 Federal Interagency Forum on Aging-Related Statistics (2000) Older Americans 2000:Key Indicators of Well Being. Washington, DC: U.S. Government Printing Office.Live Long, Live Well: Steps to Better Health 21Strategies for Cognitive VitalityChapter 2
  22. 22. Age % Moderate or % Severe Only Severe Impaired 65 to 69 4.4 .9 70 to 74 8.3 2.1 75 to 79 13.5 5.2 80 to 84 20.1 7.6 85 or older 35.8 18.3 • Fear o Fear of Alzheimer’s The Administration on Aging also reports that reactions to forgetting or losing things differ in older people and younger adults. Older people tend to see lapses as a sign of memory decline or Alzheimer’s. They blame themselves, while younger adults who forget or misplace things are more likely to blame someone else, or rationalize that they are too busy or preoccupied. o Fear of institutionalization For older people, loss of memory means an end to independent living. Fear of losing their independence often deters older adults from discussing memory deficits.Live Long, Live Well: Steps to Better Health 22Strategies for Cognitive VitalityChapter 2
  23. 23. Example—Fear of Institutionalization The Bryan Alzheimer’s Disease Center Douglas Mason at the Bryan Alzheimer’s Disease Research Center at Duke University Memory Clinic reported that participants in clinical research frequently included people complaining of memory problems but testing in the “normal” limits of memory performance. They exhibited a tone of fear and anxiety in their complaints, indicating that the emotional component was fueling their forgetfulness. How: Psychologists Douglas Mason and Michael Kohn created a memory- training group, providing strategies for encoding information and addressing the emotional component associated with memory loss. Mason and Kohn’s model of memory enhancement strategies includes clear explanations of the mechanism of memory creation and recall, appreciation of present capabilities and celebrations of accomplishments. Evidence of accomplishment: Observing the initial negative tone, the facilitators watched the group change over a course of four weeks. By sharing memories and memory problems, coupled with memory retrieval techniques, group members demonstrated confidence in their newly learned abilities and pride in sharing past memories with others. Resources: Mason, D.J., and Kohn, M.L. (2001) The Memory Workbook. New Harbinger Publications, Oakland, CA. Setting: Memory clinic support groupDiverse Populations • Lack of trust Although populations differ significantly in their cultural traditions and beliefs, one essential ingredient when approaching older community members with health information is trust. Ethnic or cultural communities must believe the person providing the information. A trusting relationship opens the door to older people’s acceptance of information and interventions.Live Long, Live Well: Steps to Better Health 23Strategies for Cognitive VitalityChapter 2
  24. 24. Example—Lack of Trust in Ethnic Communities Self Help For the Elderly Alzheimer’s Day Care Resource Center How: The Self Help for the Elderly Alzheimer’s Day Care Resource Center opened its doors to the Chinese community in 1990. Two groups showed the greatest lack of trust. Community members steeped in traditional beliefs that dementia is a mental disorder or is a natural part of aging were predictably reluctant to participate in dementia support groups. What perpetuated the mystery and stigma of dementia were Chinese physicians practicing Western medicine who conveniently diagnosed any memory complaint as senility. This second group proved a more difficult sub-community to approach. Caregivers with traditional beliefs and verification from Western- medicine-based authorities simply would not believe the messages that dementia presents a complex interplay of factors, some reversible and some adaptable to behavior management. A two-year campaign headed by Darrick Lam, present director of the San Francisco Office on the Aging, addressed the Chinese community through radio talk shows, television appearances, conferences and educational sessions for the community. The visibility of the dementia support program and its partnership with a well-respected community organization, Self Help for the Elderly, began to open channels for outreach. Parallel to the publicity campaign, the center staff attended community functions, conducted assessments after the normal 9 a.m.-5 p.m. business hours to accommodate working families. Staff sensitive to family taboos about revealing secrets, discussing sexuality or requiring private financial information also made inroads slowly into the trust of families desperately needing respite and assistance. Three critical elements were present: 1. Partnership with a trusted community organization 2. Cultural sensitivity to traditions and etiquette of the community 3. Persistence in developing visibilityLive Long, Live Well: Steps to Better Health 24Strategies for Cognitive VitalityChapter 2
  25. 25. In reaching Chinese physicians, it was important to find allies within the healthcare community to whom the doctors would listen. Second, persistent meetings over meals promoted educational sessions presented by other medical professionals, such as UCSF researchers, and eventually the professional social workers directly involved in the lives of caregivers. Evidence of accomplishment: After two years, the community of elders and family caregivers responded to the outreach efforts. Adult day program attendance increased, requests for respite care grew and support groups maintained an attendance comparable to local Alzheimer’s support groups of predominately Caucasian caregivers. After four years, the Chinese physicians began to diagnose suspected Alzheimer’s cases and recognize and treat other dementias. Contact: Darrick Lam Office on the Aging City and County of San Francisco 25 Van Ness Ave., Suite 650 San Francisco, CA 94102 E-mail: Example—Lack of Trust in Cultural Communities Lavender Seniors of the East Bay In its initial attempt, Lavender Seniors was unsuccessful in conducting educational outreach programs in local senior centers for older adults. Because of fear of identification and lack of attendance by Lesbian, Gay, Bisexual and Transgender (LGBT) elders in senior centers, Lavender Seniors then revamped its outreach by developing coalitions with more multicultural service and political groups, such as Latino service and advocacy groups. Building coalitions with disenfranchised groups has created more visibility for Lavender Seniors within informal helping venues, where its target audience seeks assistance. Contact: Joyce Pierce Lavender Seniors of East Bay Phone: 510-667-9655Live Long, Live Well: Steps to Better Health 25Strategies for Cognitive VitalityChapter 2
  26. 26. Example—Trust Cleveland Alzheimer’s Association The Cleveland Alzheimer’s Association successfully founded a support group for LGBT partners in their community. Located on a campus of multiservice organizations, the Cleveland Alzheimer’s Association fits naturally into many service-providing networks and task forces, like the Gay Pride Interagency Task Force on LGBT Aging. The support group, led by a gay man, continues with the same effectiveness as the other local Alzheimer’s support groups. The group’s strength lies in its distinction as a nonjudgmental place for partners and caregiving relatives of LGBT elders. Although many of the discussions resemble those of other Alzheimer’s support groups, issues of sexual orientation, especially “coming out of the closet,” are also talked about. Contact: Alzheimer’s Association, Cleveland Area Chapter Helpline Phone: 1-800-441-3322Rural PopulationsCertain elements are common throughout rural life in America, and can become obstaclesthat rural communities face in dealing with dementia: 1. Isolation 2. Fewer economic and human resources than urban areas 3. Low population density 4. Access to services due to geographical distances from metropolitan areas 5. Close social ties, which may stigmatize an individual or family 6. A culture of self-sufficiency • Availability, distance and access to services In many rural areas, the healthcare service delivery system is impoverished and fragmented. o The health, mental health, and social services cannot support people with Alzheimer’s disease or related disorders. Many services do not exist outside of a county seat o Professionals with the diverse skills necessary for caring for older adults with dementia may be in short supply or nonexistent o Because of distance and the low volume of use, services are expensive, especially for people who live in economically distressed communitiesLive Long, Live Well: Steps to Better Health 26Strategies for Cognitive VitalityChapter 2
  27. 27. Example—Availability and Service DeliveryFriendly ConnectionsHow: Friendly Connections reaches isolated older adults through the Telephone GroupProgram. The program, free to participants, uses a conference call system for up to 18older adults to participate in classes, discussion, support and recreation groups.Facilitators may receive training, depending on their past experience in facilitatinggroups.Participants learn of the program through word of mouth and information distributedthrough flyers and newsletters to community agencies, including the home-deliveredmeals program. Friendly Connections is funded through private and corporate donationsfrom organizations like United Way.Evidence of accomplishment: The program has operated since 1996 with over 200participants currently enrolled.Contact: Michelle YodisFriendly ConnectionsFamily Centers, Inc.20 Bridge St.Greenwich, CT 06830Phone: 201-661-4378E-mail: myodis@familycenters.orgWeb: • Values and attitudes The importance of self-reliance in rural America limits older adults’ use of services and openness about memory deficits. Confidentiality in rural communities is difficult because of the familiarity community members have with each other. Fear of exposing problems deters many people from seeking help.Who Is the Target Audience?Selected by Cognitive StatusA realistic approach in targeting the older adult population and family membersconcerned about cognitive health would be to reach those who: • Wish to maintain cognitive vitality • Have little demonstrated cognitive decline or only mild impairmentLive Long, Live Well: Steps to Better Health 27Strategies for Cognitive VitalityChapter 2
  28. 28. • Are at risk of stroke but can minimize their risk through health behavior changePrevention programs for these populations result in dramatic cost savings both for thecommunity and the individual.Selected by Specific PopulationIf the target audience is a specific population, focus on the characteristics of thataudience. For example, since African Americans experience a higher rate of dementiaassociated with stroke than all other groups, emphasis on stroke prevention in materialsmay more significantly affect them.Families play a more significant role in some populations than in others. Targeting thisaudience may mean reaching family members through the workplace, religiousorganizations, and schools or other community groups and associations.Selected by Geographic FactorsSince 23 percent of the older adult population lives in rural areas, it is crucial to reach thislarge segment of the aging population. In the South, 43 percent of older adults live innon-metropolitan areas, and in the Midwest, the figure is 32 percent. States in theseregions with high percentages (24 to 26 percent of the total population) of people ages 60and over include Arkansas, Florida, West Virginia, North Dakota and South Dakota.Reaching these geographically isolated people can greatly improve the quality of theirlives.The lack of health resources in rural areas presents an even more convincing argumentfor maintaining cognitive vitality.Live Long, Live Well: Steps to Better Health 28Strategies for Cognitive VitalityChapter 2
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