You may already know that not getting enough good sleep can cause daytime sleepiness, an inability to make good decisions, car and other accidents, unhealthy food choices, weight gain, depression, high blood pressure, diabetes and a host of other health problems. But could poor sleep increase your risk of Alzheimer’s, too? Three recent studies are pointing us in that direction.
In this issue of The ElderCounselor, we will look at the finding of these studies and the latest advancements in the treatment and prevention of Alzheimer’s.
Boston University School of Medicine
This study, conducted by a team from Boston University School of Medicine, was published in the journal Neurology. They determined that even a small loss of the dreaming phase of sleep, called REM or rapid eye movement sleep, can increase the risk of Alzheimer’s.
The Boston team studied 321 people over age 60 who volunteered for a sleep study in the 1990s. Over the next 12 years, 32 developed dementia and of those, 24 were diagnosed with Alzheimer’s. Those who had just a little less REM sleep during the sleep test were more likely to be in the dementia group later. The difference in REM sleep was indeed slight—those who later developed dementia had only 3% less REM sleep than those who did not develop dementia. Most did not even notice the difference in their sleep.
It is not clear if the disordered sleep is a cause or an early effect of the dementia process. One of the leaders of the study, Matthew Pace, commented that, “Sleep disturbances are common in dementia but little is known about the various stages of sleep and whether they play a role in dementia risk. Our findings point to REM sleep as a predictor of dementia. The next step will be to determine why lower REM sleep predicts a greater risk of dementia.”
Washington University in St. Louis
In the second study, published in the journal Brain, a team from Washington University in St. Louis reported that sleep disruption raised levels of amyloid, the protein that clogs the brains of Alzheimer’s patients. They believe that interrupted sleep may allow too much of the compounds, amyloid and tau, to build up and that sleep might help the body clear them away.
In this study, the team allowed their group of 17 healthy adults to sleep a normal amount of time but half were prevented from getting deep sleep, called slow-wave sleep. In the mornings, their spinal fluid was analyzed. Those who had their slow-wave sleep disrupted had an increase in their amyloid levels by about 10%. The volunteers also wore sleep monitors to measure their sleep at home. Those who slept poorly for a week at home had measurably higher levels of a second Alzheimer’s associated protein called tau.
Amyloid is naturally produced in the brain and researchers know it can cause clogs called plaques. People with more plaques often have memory and thinking problems and dementia but not always, so the amyloid link is not yet entirely clear.
Dr. Yo-El S. Ju, who led this study, thinks that interrupted sleep leads to increased brain activity and increased amyloid production. Amyloid is released by brain cells all the time when they fire their synapses, but they don’t release the amyloid when they rest. Dr. Ju thinks the brain may clear out excess levels of amyloid during deep sleep.
“When people are in a nice, deep sleep, they get a period of time when, with the normal clearance mechanisms working, the levels of amyloid decrease. If levels are increased over years, they are more likely to cause the clumps, called plaques, which don’t dissolve.”
Studies in mice show it takes only an excess of about 10 percent of amyloid to cause amyloid plaques to form. This study showed that just one night of interrupted sleep can increase amyloid levels by 10 percent.
Dr. Ju’s team will next study whether treating obstructive sleep apnea, a common cause of sleep disruption, will improve people’s slow-wave sleep and affect amyloid levels.
New York University School of Medicine, Rutgers School of Public Health
In this study, published in the journal Neurology, researchers at New York University School of Medicine and Rutgers School of Public Health found that sleep apnea can lead to mild cognitive impairment (MCI) nearly 10 years earlier than in those who don’t suffer from breathing problems during sleep. And those with sleep apnea were diagnosed with Alzheimer’s an average of five years earlier than those without sleep issues.
Sleep apnea is common in older adults, affecting more than half of all men and a quarter of all women. But many go undiagnosed until they are in a car accident because they are sleepy, they develop high blood pressure or they have a stroke.
People with sleep apnea have periods during the night when their throats close up and they briefly stop breathing. Itis caused by a blockage of the airway, usually when the soft tissue in the back of the throat collapses during sleep and briefly closes the throat until the person partially awakens, gasping for air. Other symptoms are loud snoring, choking and snorting while sleeping. Breathing pauses can last from a few seconds to minutes and can happen as many as 300 to 400 times a night, but the person often doesn’t wake up enough to even be aware it is happening. Instead, they wake up in the morning feeling tired.
The team reviewed the medical histories of 2,470 people aged 55 to 90 who had participated in an earlier study designed to look for markers of Alzheimer’s disease. They found that sleep apnea was associated with a much quicker decline in cognitive function. But they also found that people who got treatment declined at the same speed as people who didn’t have apnea at all. Treatments can include machines that help people breathe better as they sleep (called CPAP devices), dental appliances (for mild cases) and weight loss.
Sleep apnea leads to drops in oxygen levels, which can affect various organs in the body differently and can damage parts of the brain. Dr. Andrew Varga, an Adjunct Instructor in Medicine at New York University and co-author of the study, noted that certain neurons in the hippocampus, where much of Alzheimer’s is thought to start, are very sensitive to drops in oxygen, and sleep apnea may stress out those neurons. Also, as mentioned earlier, the disrupted sleep may prevent the brain from cleaning out the amyloids that can turn into plaques.
Recent Developments in Treating Alzheimer’s
Currently, more than 5 million Americans have Alzheimer’s. That number is expected to grow to 28 million by 2050 as our population ages. There is no cure. There are a handful of drugs on the market—Aricept, Namenda and Exelon— that were approved more than a decade ago. They can treat symptoms for a while, but they do not affect the disease itself.
There are, however, some new drugs in the works that aim to clear amyloid proteins out of the brains of Alzheimer’s patients in hopes of slowing the disease. But they are not even close to being a cure or even being on the market. The three drugs highlighted at the Alzheimer’s Association International Conference are solanezumab, aducanumab and gantenerumab.
Solanezumab, made by Eli Lilly, was first released in 2012 and didn’t seem to help patients. But developers continued to follow those in the trials and discovered that those who got the drug early seemed to be doing better, while those who got the drug later could not seem to catch up. Test scores showed very modest changes but could add to more days living at home for those treated very early. Lilly has started a phase III clinical trial, the last stage before seeking FDA approval. Results are more than a year away.
Aducanumab, made by Biogen, appears to be clearing the amyloid from the brains of patients and there is some evidence of improving test scores in patients who got the highest doses. Biogen has also started a phase III clinical trial and will test it in people who have very early Alzheimer’s disease or have mild cognitive impairment.
Gantenerumab also failed in tests, but it may be that people were not given enough of it. An analysis did show it was affecting tau protein, but higher doses have caused brain inflammation (which could indicate the drugs are working), headaches, dizziness and, in other drug trials, death.
Researchers want to offer hope, both for patients and for investors so they will continue to support the development of new drugs. But they caution that real noticeable progress in patients is still years and many dollars away. The Alzheimer’s Association is also asking Congress to fund more government research.
Can We Prevent Alzheimer’s?
There is no evidence that anything can prevent Alzheimer’s. But there are some things we can do to help slow memory loss and cognitive impairment. These include improving sleep quality, getting regular exercise, controlling blood pressure, engaging in cognitive training and changing eating habits.
Improve Sleep Quality:If you, your sleeping partner or a roommate suspect you have sleep apnea, get tested and follow through with any recommended treatment. Other sleep disrupters include restless leg syndrome, insomnia, jet lag, sleepwalking, night terrors, and stress. If your sleep suffers from any of these, talk to your doctor or a sleep specialist about steps you can take to start getting restful sleep.
Get regular exercise:Moderate aerobic exercise, like brisk walking, can have an effect on reducing cognitive impairment later in life. Experts say to aim for 150 minutes a week (30 minutes five times a week). Exercise increases the blood flow to all parts of the body, including the brain, improves physical conditioning and lifts your spirits.
Lower your blood pressure:Controlling blood pressure helps prevent heart disease. There is also evidence it can reduce the risk of memory loss and dementia because high blood pressure damages delicate blood vessels in the brain.
Engage in cognitive training:According to Dr. Ronald Peterson, an Alzheimer’s expert at the Mayo Clinic, this doesn’t mean crossword puzzles or Sudoku, although those won’t hurt. Instead, he suggests working on memory improvement techniques, called mnemonic techniques. These can include finding a new way to remember a list of grocery items; figuring a tip in your head instead of using a calculator; using new strategies that will help you process and locate information more quickly and efficiently; and working on techniques that will help you remember names and other vital information.
Dr. Peterson cautions that most “brain games” have done little more than show they make people better at playing them. He also encourages people to get out and do things, instead of sitting and watching television for hours.
Clean up eating habits:You probably know that sugary foods are not good for you. But did you also know that carbs turn into sugar in your body? And did you know that both can have devastating effects on your brain? Dr. David Permutter is a renowned neurologist. His book, Grain Brain, may provide some insights that just might change your life for the better.
Alzheimer’s is a devastating disease. There is no cure. Current medicines, when started early, only help with symptoms for a while and have no real effect on the disease itself. Therefore, we owe it to ourselves, our families, and those we serve to do everything we can to protect our brains from Alzheimer’s for as long as possible and to educate others about how to do so.
If we can be of assistance to you or the seniors you work with, please don’t hesitate to reach out.
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Most Americans do not know, or refuse to accept, the facts surrounding their potential need for long-term care and the costs associated with it. This was reconfirmed recently in a telephone survey of 1,735 Americans over the age of 40, funded by the SCAN Foundation and conducted by the Associated Press (AP) – NORC Center for Public Affairs Research (“survey”). This survey highlights many of the misconceptions Americans have about long-term care, including: the potential that a loved one may need some sort of long-term care within the next five (5) years; lack of knowledge of the positive impact of “person-centered care” practices; lack of understanding of coverage of long-term care services by Medicare, Medicaid and private insurance; and an increase in lack of concern over failure to plan for the costs associated with long-term care.
Who Will Need Long-Term Care
According to the Genworth Cost of Care Survey of 2015 (“Genworth Survey”), seventy percent (70%) of Americans over the age of sixty-five (65) will eventually need some type of long-term care. In addition, by the year 2040, twenty-two percent (22%) of the population will be over the age of sixty-five (65), which is a ten percent (10%) increase from the year 2000. Yet, this survey showed an increasing number of people over the age of forty (40) refusing to believe they will ever need long-term care.
Quality of Long-Term Care
The survey defined person-centered care as “an approach to health care and supportive services that allows individuals to take control of their own care by specifying preferences and outlining goals that will improve their quality of life.” This approach points to the consideration of coordinated care. Coordinated care involves communication among various medical providers to reduce overlap, misdiagnosis or other medical oversights. Because many people are avoiding thinking about their golden years, they are missing out on the benefits provided by this approach and the survey shows a lack of appreciation for the improved quality of life it can provide.
According to the survey, over sixty-five percent (65%) of adults over the age of forty (40) have two or more doctors that they see on a regular basis. Twenty-nine percent (29%) of those report that their providers do not communicate well or at all. Further, the lack of understanding of the person-centered care approach is evident in that twenty-three percent (23%) of those individuals who don’t participate in it reported that it would not improve their quality of care.
Cost of Long-Term Care
The study showed a lack of understanding by many of coverage for long-term care by Medicare, Medicaid and private health insurance. The truth is that Medicare does not pay for ongoing long-term care (although it will pay for intermittent stays at nursing facilities). Yet, thirty-four percent (34%) surveyed thought Medicare would pay for long-term care while twenty-seven percent (27%) were unsure. Furthermore, Medicare doesn’t typically pay for care in the home. However, thirty-six percent (36%) of those surveyed thought it would and twenty-seven percent (27%) reported that they were unsure.
As for private insurance, most health insurance plans will not cover long-term services like a nursing home or ongoing care provided at home by a licensed home health care aide. Yet, eighteen percent (18%) of Americans age 40 and older believe that their insurance will cover the costs of ongoing nursing home care. While, twenty-five percent (25%) believe their plan will pay for ongoing care at home. About 1 in 5 people surveyed were unsure of the coverage provided for these types of long-term care services.
Medicaid is the largest payer of long-term care services. Medicaid is a federally and state funded needs-based benefit that will provide for various types of long-term care depending on the state’s regulations. In 2013, Medicaid paid for fifty-one percent (51%) of the national long-term care bill totaling $310 billion. However, fifty-one percent (51%) of Americans age 40 and older reported that they don’t expect to have to rely on Medicaid to help pay for their ongoing living assistance expenses as they age.
The actual costs for long-term care are staggering. The Genworth Survey reported that, nationwide, the average bill for a nursing home is approximately $80,300 and for home health care, approximately $44,616 with a variety of options among and in between these levels of care.
Planning for Long-Term Care
Despite the availability of this information, most Americans are unprepared for the costs associated with long-term care. For example, the results of the survey showed that only one-third of adults were “very or extremely confident” in their ability to pay for long-term care. Fascinatingly, while many individuals reported being concerned over leaving family with debt or becoming a burden on loved ones, many do little to alleviate their concern in the way of planning. In fact, just over thirty percent (30%) of those over the age of sixty-five (65) reported being concerned with this. And, finally, two-thirds of Americans over the age of forty (40) reported doing no planning for long-term care.
The survey results lead to the conclusion that many Americans are reluctant to face the possible loss of independence related to aging. Apparently, this plays a role in the unwillingness to plan for the possibility of needing assistance later in life. As an example, there was an interesting difference in the number of people surveyed who had planned, or talked to loved ones about, their funeral arrangements (nearly sixty-five percent (65%)), in those who had discussed care preferences with family (about forty-two percent (42%)) and in those who had saved money for long-term care (approximately thirty-three percent (33%)). Some things, including how we want to be memorialized are just easier to think about than how we may end up dependent on others.
Although not a popular topic among Americans over the age of forty, long-term care is an increasingly important one. We are in the business of providing options for people in planning for their potential long-term care needs. If you, a loved one or a client needs help figuring out their options, please think of us. We can help and we are always happy to hear from you.
On June 11, the Department of Veterans Affairs passed a major milestone with the introduction of a telehealth system known as “anywhere-to-anywhere.” This system allows qualified practitioners to access the VA’s telehealth system and provide care to patients across the nation. This issue of The ElderCounselorwill take a closer look at this telehealth system, which is part of the VA Mission Act.
One facet of the recently passed VA Mission Act is to provide protections for VA telehealth services. The law extends regulatory protections to VA telehealth providers and blocks states from interfering with providers who are part of the VA telehealth network, even if they do notcomply with state regulations.
A major advantage of this system is that it gives physicians the ability to determine if the patient needs to receive care at one of the already crowded VA facilities, or if care would be better receivedat home or a community care center. Inside the VA clinics, the telehealth system allows patients and local caregivers to connect digitally with physicians and specialists across the VA system. There is another option that launched June 2017, known as the VA Video Connect application. VA Video Connect is a desktop and mobile application that allows patients to connect with physicians and specialists without ever leaving their home. So far, this application has connected over 22,700 veterans with 4,500 unique VA providers—this is especially effective for rural patients who have to travel long distances to their nearest VA health center.
Another area where the VA is making strides in telehealth is for Veterans in need of mental health care. Generally, patients will connect with physicians through video conferencing technology which allows the patient to seeand hear the physician but eliminates the need for travel that could be disruptive or costly. Thisis especially important for patients with severe cases of post-traumatic stress disorder because it allows them to receive the care they need in a controlled environment in which they feel comfortable.
While the VA currently treats dozens of conditions via telehealth services and has plans to add more in the future, (you can view a complete listhere) the VA specializes in four main telehealth services:
Polytrauma:The polytrauma telehealth services allow the VA to link their four Polytrauma Rehabilitation Centers along with the 17 Polytrauma Network Sites together to congregate all of the expertise across the VA network into one place. Patients receive multiple opinions from care providers and the physicians can consult each other in real-time to determine the best path of care for their patients.
TeleMental Health: As mentioned previously, another area the VA is specializing in is caring for mental health patients through the telehealth system. One in three Veterans suffer from mental health disorders, and this service has been effective in providing a safe and comfortable environment for Veterans to receive care.
TeleRehabilitation:This service allows patientswho are recovering from a stroke to be linked to a speech pathologist to begin the rehabilitation process. The VA also uses TeleRehabilitation to connect with Veterans and monitor their functional status and equipment needs.
TeleSurgery:The main use for this service is for surgeons to receive specialist consultation in remote sites, before operating on a patient. The VA also uses this service to provide patient and staff education and pre/post-operative assessment.
With over nine million patients served each year, it is integral that the VA does everything possible to ensure Veteransreceive quality care in a reasonable amount of time. One of the ways they are accomplishing this is through the telehealth system.
If youhave any questions, please do not hesitate to contact our office.
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