Disabilities Associated with Aging

Introduction

With increasing age comes increased likelihood of disability. This is because as people live longer and do not encounter fatal diseases, their illnesses are chronic instead. The association between increasing age and increasing disability has led to a negative image of aging.

According to the most recent US Census data, almost 35 million Americans are older than 65 years, which is equal to one in every eight persons, or approximately 12% of the population. Why is the number so large? Remember that people today are living longer than they did 15 to 20 years ago. Advances in medical care and preventive measures have been instrumental in this increased longevity.

Older patients frequently have physical disabilities and chronic medical conditions. They may be taking numerous medications for their illnesses. Providing effective treatment to this growing number of patients will require you to understand the issues related to aging and how you may have to modify some of your assessment and treatment approaches.

We should respect the wealth of knowledge that older patients have to offer. In many countries, the elderly are treated with reverence. In many other cultures, the elderly are seen as a valuable resource of history. In Japan, for example, there is a “Respect for the Aged Day.” this same degree of respect may not be shared by many people in the United States, but as a Recreation Therapist, you must remember to treat every patient the way you would want your loved ones to be treated.

Aging and Disability – What Does it Look Like?

It is important to note that one grows old gradually, one does not suddenly become old when they turn age 60 or 65 or 70. Physical health does decline with age; this does not necessarily mean that older adults are incapacitated, or, in the language of some, handicapped. Disability is usually defined in terms of restrictions in the ability to perform activities of daily living (ADL), or, the inability to function independently in terms of basic ADL or instrumental ADL. Mobility disability is particularly important because the ability to ambulate is critical to so many activities that allow us to be independent. The International Classification of Functioning, Disability and Health (WHO, 2001) defines disability as, "the result of complex relationships between an individual's health condition and personal factors, and of the external factors that represent the circumstances in which the individual lives". This latter definition is important because it points to a relational perspective often forgotten when simply diagnosing physical ability. In gerontology, it is popular to discuss 'the disablement process', a dynamic interaction intimately tied to cultural norms and socioeconomic status encompassing attitudes, emotions, stigma, accessibility or lack thereof of various services, wheelchair accessible buildings, etc.

The WHO (2003; 2006) estimates that 10% of the world's population has some form of a disability, 20% of those aged 70+, and 50% of those aged 85+. That is, with increasing age, disability increases and, among those who are elderly (age 65 and over), the old elderly are more likely to experience disability than are young elderly. For this reason, the WHO argues that in terms of disability, old age can be viewed as starting at age 75. It is noteworthy that the oldest old are the most rapidly growing segment of the population and it is among the oldest old that severe disability is the highest (Ferucci, et al., 1996). While recent reports of declining rates of disability in some countries have lead to optimism, the trend does not characterize all nations. For example, a declining trend in severe disability is evident in the U.S., Italy and the Netherlands but it is stable in Australia and Canada and is increasing in Sweden and Japan (OECD 2009; Manton 2008). Furthermore, it is as yet unclear as to whether any trend toward decreasing rates will continue or spread.

Part of the discrepancy between declining health, increasing disability and maintenance of high levels of overall well-being is probably attributable to the fact that not all disability leads to dependence. If the consequences of disability in terms of limiting individual autonomy and creating dependence can be reduced or eliminated altogether, its negative effects on quality of life can minimized. This leads to a discussion of the environment and improvements in lifestyle. Improvements in lifestyle and health behaviours include, for example, better nutrition, not or quitting smoking, less obesity, and greater physical activity (Fries 2002; Hubert et al. 2002) which can help prevent stroke, CHD, and diabetes, all of which are related to disability in later life. For example, benefits accrue from exercise even when begun later in life; it serves to postpone disability.

Quality of Life and Therapeutic Environments

Whether individuals with age-related disabilities reside in community or institutional dwellings, the physical environment serves as a valuable resource by which their remaining cognitive and physical abilities can be supported (Iwarsson 2005; Oswald et al. 2007). Verbrugge and Jette's (1994) disablement process model and Lawton and Nahemow's (1973) competence-environmental press model both examine the relationship between the physical environment and disability. Verbrugge and Jette (1994) distinguish between intrinsic ability (i.e., an individual's ability to perform an activity regardless of context) and actual ability (i.e., an individual's ability to perform an activity when supported by the physical or social environment). According to the model, the physical environment has the potential to help an individual overcome his or her intrinsic disability through either the removal of environmental barriers or the provision of environmental modifications.

While the disablement process model provides a framework for understanding the role of the environment in the disablement process, Lawton and Nahemow's (1973) competence-environmental press model offers insight into the mechanism by which the physical environment and disability outcomes are linked (Wahl et al. 2009). Environmental press refers to the demand that the environment makes on an individual, while competence represents the ability of an individual to respond adaptively to such demands. An individual's functional performance is the result of interactions between competence and environmental demand, a concept more commonly referred to as person-environment fit. Central to the model is the environmental docility hypothesis, which suggests that the effect of environmental press on an individual's behaviour and well-being becomes greater as personal competence diminishes. When competence is inadequate to respond to the demands of the environment, excess disability may result. By modifying the environment to more appropriately fit an individual's ability, adaptive behaviour is promoted. An individual's competency may therefore be enhanced through the provision of environmental modifications. For individuals with lower competence, even minor changes to the environment can potentially result in a positive outcome (Iwarsson 2005).

Many older adults express the desire to age-in-place, that is, to remain in their own home for as long as possible (Gitlin 2003). However, for individuals with age-related disabilities successful aging-in-place may be compromised by environmental hazards or barriers, common in the homes of older adults. For example, Gill et al. (1999) report two or more hazards in 59% of bathrooms and in 23%-42% of other rooms. The European ENABLE-AGE project (Enabling Autonomy, Participation and Well-Being in Old Age: The Home Environment as a Determinant for Healthy Ageing) finds the mean number of environmental barriers present to range from 37 in the U.K. to 66 in Germany (Nygren et al. 2007). Iwarsson (2005) reports similar findings in Sweden. While common barriers include dim lighting, shadows or glare, tripping hazards (cords, loose throw rugs/mats, curled carpet edges), the absence of a kitchen work surface at a height suitable for sitting, bathroom sinks designed to be used only when standing, and hardware or controls requiring suitable wrist flexibility to operate, it is the absence of grab bars at the shower/bathtub and/or toilet that can create the most problems with accessibility.

Methodological issues associated with the examination of therapeutic institutional environments centre upon the use of small sample sizes (typically less than 30 residents), the absence of comparison groups or the use of non-equivalent comparison groups, all of which influence the validity and generalizability of findings (Day et al. 2000). Also, the nursing home setting is complex; consequently, the physical environment cannot be examined in isolation from the social and organizational context. The challenge is how to "account and control" for such factors when examining the impact of design features (Calkins 2001). Nursing homes tend to include multiple design interventions (e.g., home-like finishes/furnishings , smaller unit size) which makes it difficult to identify which features are central to improving quality of life or how such features can support or detract from one another (Day et al. 2000). Given the cognitive impairment of many nursing homes residents, experiential information is rarely collected; however, examining the perceptions of residents in the early to middle stages of dementia may help improve the quality of research (Day and Calkins 2002).

Therapeutic environments, be they community or institutional in nature, should promote wellness and should support individuals in coping with the stresses that accompany age-related disability (Schwarz and Brent 1999). As demonstrated here, focusing on the physical environment as an intervention or treatment modality offers a means by which to help alleviate such stress and improve older adults' quality of life. Working together, health care professionals, researchers, designers and stakeholders can optimize the therapeutic nature of community and institutional dwellings.

Conditions Associated with Aging

Arthritis

The word arthritis comes from the Greek arthron meaning "joint" and the Latin itis meaning "inflammation". Arthritis is not a single disease - it is a term that covers over 100 medical conditions. Osteoarthritis (OA) is the most common form of arthritis and generally affects elderly patients. Some forms of arthritis can affect people at a very early age.

What Causes Arthritis?

In order to better understand what is going on when a person suffers from some form of arthritis, let us look at how a joint works. Basically, a joint is where one bone moves on another bone. Ligaments hold the two bones together. The ligaments are like elastic bands, while they keep the bones in place your muscles relax or contract to make the joint move. Cartilage covers the bone surface to stop the two bones from rubbing directly against each other. The covering of cartilage allows the joint to work smoothly and painlessly. A capsule surrounds the joint. The space within the joint - the joint cavity - has synovial fluid. Synovial fluid nourishes the joint and the cartilage. The synovial fluid is produced by the synovium (synovial membrane) which lines the joint cavity.

If you have arthritis something goes wrong with the joint(s). What goes wrong depends on what type of arthritis you have. It could be that the cartilage is wearing away, a lack of fluid, autoimmunity (your body attacking itself), infection, or a combination of many factors.

Types of Arthritis

There are over 100 types of arthritis. Here is a description of some common ones, together with the causes:

• Osteoarthritis - cartilage loses its elasticity. If the cartilage is stiff it becomes damaged more easily. The cartilage, which acts as a shock absorber, will gradually wear away in some areas. As the cartilage becomes damaged tendons and ligaments become stretched, causing pain. Eventually the bones may rub against each other causing very severe pain.
• Rheumatoid arthritis - this is an inflammatory form of arthritis. The synovial membrane (synovium) is attacked, resulting in swelling and pain. If left untreated the arthritis can lead to deformity. Rheumatoid arthritis is significantly more common in women than men and generally strikes when the patient is aged between 40 and 60. However, children and much older people may also be affected.
• Infectious arthritis (septic arthritic) - an infection in the synovial fluid and tissues of a joint. It is usually caused by bacteria, but could also be caused by fungi or viruses. Bacteria, fungi or viruses may spread through the bloodstream from infected tissue nearby, and infect a joint. Most susceptible people are those who already have some form of arthritis and develop an infection that travels in the bloodstream.
• Juvenile rheumatoid arthritis (JRA) - means arthritis that affects a person aged 16 or less. JRA can be various forms of arthritis; it basically means that a child has it. There are three main types:

1.     Pauciarticular JRA, the most common and mildest. The child experiences pain in up to 4 joints.

2.     Polyarticular JRA affects more joints and is more severe. As time goes by it tends to get worse.

3.     Systemic JRA is the least common. Pain is experienced in many joints. It can spread to organs. This can be the most serious JRA.

What are the Signs and Symptoms of Arthritis?

The symptoms of arthritis depend on the type of arthritis:

• Osteoarthritis - The symptoms develop slowly and get worse as time goes by. There is pain in a joint, either during or after use, or after a period of inactivity. There will be tenderness when pressure is applied to the joint. The joint will be stiff, especially first thing in the morning. The patient may find it harder to use the joint - it loses its flexibility. Some patients experience a grating sensation when they use the joint. Hard lumps, or bone spurs may appear around the joint. In some cases the joint might swell. The most common affected joints are in the hips, hands, knees and spine.
• Rheumatoid arthritis - The patient often finds the same joints in each side of the body are painfully swollen, inflamed, and stiff. The fingers, arms, legs and wrists are most commonly affected. Symptoms are usually worst on waking up in the morning and the stiffness can last for 30 minutes at this time. The joint is tender when touched. Hands may be red and puffy. There may be rheumatoid nodules (bumps of tissue under the skin of the patient's arms). Many patients with rheumatoid arthritis feel tired most of the time. Weight loss is common.
• The smaller joints are usually noticeably affected first. Experts say patients with rheumatoid arthritis have problems with several joints at the same time. As the arthritis progresses it spreads from the smaller joints in your hands, wrists, ankles and feet to your elbows, knees, hips, neck, shoulders and jaw.
• Infectious arthritis - The patient has a fever, joint inflammation and swelling. He will feel tenderness and/or a sharp pain. Often these symptoms are linked to an injury or another illness. Most commonly affected areas are the knee, shoulder, elbow, wrist and finger. In the majority of cases, just one joint is affected.
• Juvenile rheumatoid arthritis - The patient is a child. He will experience intermittent fevers which tend to peak in the evening and then suddenly disappear. His appetite will be poor and he will lose weight. There may be blotchy rashes on his arms and legs. Anemia is also common. The child may limp or have a sore wrist, finger, or knee. A joint may suddenly swell and stay larger than it usually is. The child may experience a stiff neck, hips or some other joint.

How will Arthritis Affect you?

Arthritis affects people in many different ways. How long the patient is affected and how severely it is depends on the type of arthritis. Arthritis sufferers will find there are good and bad days. Most patients with arthritis will suffer from discomfort, pain, stiffness and/or fatigue.

You may also feel frustrated that you are no longer able to grip things so well or get around like you used to. It is important to remember that if you suffer from arthritis this does not mean you have to give up having an active lifestyle. With some changes to your way of life there is no reason why you cannot continue being active.

Physical Therapy and Occupational Therapy for Arthritis

Physical therapy and occupational therapy help maintain joint mobility and range of motion. How much therapy you need, and what kind of therapy will depend on many factors, such as the severity and type of arthritis you have, your age, and your general state of health. This has to be decided by you with your physician and physical or occupational therapist.

People with arthritis will often avoid moving the affected joint because of the pain. A physical therapist can help the patient work out the joint stiffness without damaging it. In order to perform your daily activity the physical therapist will help you achieve a good range of motion. This may involve building strength in the muscles that surround the affected joint - stronger muscles help stabilize a weakened joint. You will also be taught the best way to move from one position to another, as well as learning how to use such walking aids as crutches, a cane or a walker, if you need one.

Occupational therapy can teach you how to reduce the strain on your joints as you go about your daily activities. The occupational therapist can help you modify your home and workplace so that your movements do not aggravate your arthritis. You may need a splint for your hands or wrists, as well as aids for dressing, housekeeping, work activities, driving and washing/bathing yourself.

An occupational and/or physical therapist can make an enormous difference to your quality of life if you suffer from arthritis. He/she will help you learn more about your arthritis, devise a dietary plan if you are overweight and overstressing the joints as a result, help you make better decisions about what shoes to buy if that part of the body is affected. You will learn how and when to rest - rest is crucial for treating inflammation and pain, especially when many joints are affected and you feel tired. Resting individual joints is very helpful too - custom splints can be made to rest and support affected joints.

Local pain can be relieved with ice packs or heating pads. Ultrasound and hot packs provide deep heat which relieves localized pain and relaxes muscle spasm around the affected joint. You may find that a warm bath/shower makes it easier for you to exercise afterwards.

Physical activity can improve arthritis symptoms - doctors warn that inactivity could harm the health of most patients with arthritis or some kind of rheumatic disease. Inactivity raises the risk of cardiovascular disease and diabetes type 2. Muscles become weaker with no exercise, joints become stiffer, and the patient's tolerance for pain decreases. Balance problems may also become worse.

The American College of Rheumatology offers the following tips for those wishing to embark on an exercise plan:

·      Check with your rheumatologist first

·      Ask your physical therapist for advice

·      Set realistic goals, both short- and long-term ones. Include rewards for each achievement

·      Plan ahead, so that you can identify pitfalls, obstacles or problems for your exercise program, and how to overcome them

·      For variety, create a range of physical activities and do them in different locations

·      Try starting off with friends or family members

·      Keep a log of what you do so that you are aware of your progress

Medications for Arthritis

·      NSAID (nonsteroidal anti-inflammatory drugs) are the most commonly prescribed drugs for arthritis patients. These may be either prescription or over-the-counter (OTC). At low doses NSAIDs help a vast range of ailments, from headaches, muscle aches, to fever and minor pain. At a higher dose - prescription dose - NSAIDs also help reduce joint inflammation. There are three main types of NSAIDs and they all work by blocking prostaglandins - hormone-like substances that trigger pain, inflammation, muscle cramps and fever:

·      Glucocorticoids are anti-inflammatory steroids and are very effective at combating inflammation and can be extremely helpful when used properly. The patient needs to consider the potential for undesirable side-effects with this type of drug.

·      Minocycline - an antibiotic that is sometimes used as antibiotic therapy for rheumatoid arthritis. Its use is controversial.

·      Cyclosporine - an immunosuppressant drug - it makes your immune system less aggressive. Cyclosporine is commonly used by transplant patients so that their bodies do not reject their transplanted organs. Cyclosporine is usually used in combination with methotrexate for arthritis patients. Although effective, this may be limited by its toxicity.

Depression

The changes that often come in later life—retirement, the death of loved ones, increased isolation, medical problems—can lead to depression. Depression prevents you from enjoying life like you used to. But its effects go far beyond mood. It also impacts your energy, sleep, appetite, and physical health. However, depression is not an inevitable part of aging, and there are many steps you can take to overcome the symptoms, no matter the challenges you face.

Depression is a common problem in older adults. The symptoms of depression affect every aspect of your life, including your energy, appetite, sleep, and interest in work, hobbies, and relationships.

Unfortunately, all too many depressed seniors fail to recognize the symptoms of depression, or don’t take the steps to get the help they need. There are many reasons depression in older adults and the elderly is so often overlooked:

• You may assume you have good reason to be down or that depression is just part of aging.
• You may be isolated—which in itself can lead to depression—with few around to notice your distress.
• You may not realize that your physical complaints are signs of depression.
• You may be reluctant to talk about your feelings or ask for help.

            Depression isn’t a sign of weakness or a character flaw. It can happen to anyone, at any age, no matter your background or your previous accomplishments in life. Similarly, physical illness, loss, and the challenges of aging don’t have to keep you down. Whether you’re 18 or 80, you don’t have to live with depression. Senior depression can be treated, and with the right support, treatment, and self-help strategies you can feel better and live a happy and vibrant life.

Causes of Depression

As you grow older, you face significant life changes that can put you at risk for depression. Causes and risk factors that contribute to depression in older adults and the elderly include:

• Health problems – Illness and disability; chronic or severe pain; cognitive decline; damage to body image due to surgery or disease.
• Loneliness and isolation – Living alone; a dwindling social circle due to deaths or relocation; decreased mobility due to illness or loss of driving privileges.
• Reduced sense of purpose – Feelings of purposelessness or loss of identity due to retirement or physical limitations on activities.
• Fears – Fear of death or dying; anxiety over financial problems or health issues.
• Recent bereavements – The death of friends, family members, and pets; the loss of a spouse or partner.

Depression in older adults and the elderly is often linked to physical illness, which can increase the risk for depression. Chronic pain and physical disability can understandably get you down. Symptoms of depression can also occur as part of medical problems such as dementia or as a side effect of prescription drugs.

Medical Conditions can cause Depression

It’s important to be aware that medical problems can cause depression in older adults and the elderly, either directly or as a psychological reaction to the illness. Any chronic medical condition, particularly if it is painful, disabling, or life-threatening, can lead to depression or make depression symptoms worse.
These include:

Parkinson’s disease stroke heart disease cancer diabetes

thyroid disorders Vitamin B12 deficiency dementia and Alzheimer’s disease lupus multiple sclerosis

Prescription Medications

Symptoms of depression are a side effect of many commonly prescribed drugs. You’re particularly at risk if you’re taking multiple medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because, as we age, our bodies become less efficient at metabolizing and processing drugs.

Medications that can cause or worsen depression include:

Blood pressure medication (clonidine) Beta-blockers (e.g. Lopressor, Inderal) Sleeping pills Tranquilizers (e.g. Valium, Xanax, Halcion) Calcium-channel blockers Medication for Parkinson’s disease

Ulcer medication (e.g. Zantac, Tagamet) Heart drugs containing reserpine Steroids (e.g. cortisone and prednisone) High-cholesterol drugs (e.g. Lipitor, Mevacor, Zocor) Painkillers and arthritis drugs Estrogens (e.g. Premarin, Prempro)

If you feel depressed after starting a new medication, talk to your doctor. You may be able to lower your dose or switch to another medication that doesn’t impact your mood.

Signs and Symptoms

Recognizing depression in the elderly starts with knowing the signs and symptoms. Depression red flags include:

Sadness Fatigue Abandoning or losing interest in hobbies or other pleasurable pastimes Social withdrawal and isolation (reluctance to be with friends, engage in activities, or leave home) Weight loss or loss of appetite

Sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness) Loss of self-worth (worries about being a burden, feelings of worthlessness, self-loathing) Increased use of alcohol or other drugs Fixation on death; suicidal thoughts or attempts

Depression without Sadness

While depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or worsening headaches, are often the predominant symptom of depression in the elderly.

Depression Clues

Older adults who deny feeling sad or depressed may still have major depression. Here are the clues to look for:

Unexplained or aggravated aches and pains Feelings of hopelessness or helplessness Anxiety and worries Memory problems Lack of motivation and energy

Slowed movement and speech Irritability Loss of interest in socializing and hobbies Neglecting personal care (skipping meals, forgetting meds, neglecting personal hygiene)

Dementia Vs. Depression

Never assume that a loss of mental sharpness is just a normal sign of old age. It could be a sign of either depression or dementia, both of which are common in older adults and the elderly.

Since depression and dementia share many similar symptoms, including memory problems, sluggish speech and movements, and low motivation, it can be difficult to tell the two apart. There are, however, some differences that can help you distinguish between the two.

Is it Depression or Dementia?
Symptoms of Depression	Symptoms of Dementia
Mental decline is relatively rapid	Mental decline happens slowly
Knows the correct time, date, and where he or she is	Confused and disoriented; becomes lost in familiar locations
Difficulty concentrating	Difficulty with short-term memory
Language and motor skills are slow, but normal	Writing, speaking, and motor skills are impaired
Notices or worries about memory problems	Doesn’t notice memory problems or seem to care

Whether cognitive decline is caused by dementia or depression, it’s important to see a doctor right away. If it’s depression, memory, concentration, and energy will bounce back with treatment. Treatment for dementia will also improve you or your loved one’s quality of life. And in some types of dementia, symptoms can be reversed, halted, or slowed.

Depression Treatment Options

Depression treatment is just as effective for elderly adults as it is for younger people. However, since depression in older adults and the elderly is often the result of a difficult life situation or challenge, any treatment plan should address that issue. If loneliness is at the root of your depression, for example, medication alone is not going to cure the problem. Also, any medical issues complicating the depression must be also be addressed.

Antidepressant treatment for older adults and the elderly

Older adults are more sensitive to drug side effects and vulnerable to interactions with other medicines they’re taking. Recent studies have also found that SSRIs such as Prozac can cause rapid bone loss and a higher risk for fractures and falls. Because of these safety concerns, elderly adults on antidepressants should be carefully monitored. In many cases, therapy and/or healthy lifestyle changes, such as exercise, can be as effective as antidepressants in relieving depression, but without the dangerous side effects.

Alternative medicine for depression in older adults

Herbal remedies and natural supplements can also be effective in treating depression, and in most cases, are much safer for older adults than antidepressants. However, some herbal supplements may cause interactions with certain medications or occasionally carry side effects, so always check with your doctor before taking them.

• Omega-3 fatty acids may boost the effectiveness of antidepressants or work as a standalone treatment for depression.
• St. John’s wort can help with mild or moderate symptoms of depression but should not be taken with antidepressants.
• Folic acid can help relieve symptoms of depression when combined with other treatments.
• SAMe may be used in place of antideppresants to help regulate mood, but in rare cases can cause severe side effects.

Counseling and therapy for older adults

Therapy works well on depression because it addresses the underlying causes of the depression, rather than just the symptoms.

• Supportive counseling includes religious and peer counseling. It can ease loneliness and the hopelessness of depression, and help you find new meaning and purpose.
• Therapy helps you work through stressful life changes, heal from losses, and process difficult emotions. It can also help you change negative thinking patterns and develop better coping skills.
• Support groups for depression, illness, or bereavement connect you with others who are going through the same challenges. They are a safe place to share experiences, advice, and encouragement.

Helping a Depressed Senior

The very nature of depression interferes with a person's ability to seek help, draining energy and self-esteem. For depressed seniors, raised in a time when mental illness was highly stigmatized and misunderstood, it can be even more difficult—especially if they don’t believe depression is a real illness, are too proud or ashamed to ask for assistance, or fear becoming a burden to their families.

If an elderly person you care about is depressed, you can make a difference by offering emotional support. Listen to your loved one with patience and compassion. Don’t criticize feelings expressed, but point out realities and offer hope. You can also help by seeing that your friend or family member gets an accurate diagnosis and appropriate treatment. Help your loved one find a good doctor, accompany him or her to appointments, and offer moral support.

Diabetes

Diabetes is a serious disease. People get diabetes when their blood glucose level, sometimes called blood sugar, is too high. Diabetes can lead to dangerous health problems, such as having a heart attack or stroke. The good news is that there are things you can do to take control of diabetes and prevent its problems. And, if you are worried about getting diabetes, there are things you can do to lower your risk.

Diabetes disproportionately affects older adults. Approximately 25% of Americans over the age of 60 years have diabetes, and aging of the U.S. population is widely acknowledged as one of the drivers of the diabetes epidemic.

Although the burden of diabetes is often described in terms of its impact on working-aged adults, the disease also affects longevity, functional status, and risk of institutionalization for older patients.

What is Diabetes?

Our bodies change the food we eat into glucose. Insulin helps glucose get into our cells where it can be used to make energy. If you have diabetes, your body may not make enough insulin, may not use insulin in the right way, or both. That may cause too much glucose in the blood. Your family doctor may refer you to a doctor who specializes in taking care of people with diabetes, called an endocrinologist.

Types of Diabetes

There are two kinds of diabetes that can happen at any age. In type 1 diabetes, the body makes little or no insulin. This type of diabetes develops most often in children and young adults.

In type 2 diabetes, the body makes insulin, but doesn't use it the right way. It is the most common kind of diabetes. You may have heard it called adult-onset diabetes. Your chance of getting type 2 diabetes is higher if you are overweight, inactive, or have a family history of diabetes.

Diabetes can affect many parts of your body. It's important to keep type 2 diabetes under control. Over time it can cause problems like heart disease, stroke, kidney disease, blindness, nerve damage, and circulation problems that may lead to amputation. People with type 2 diabetes have a greater risk for Alzheimer's disease.

Symptoms

Some people with type 2 diabetes may not know they have it. But, they may feel tired, hungry, or thirsty. They may lose weight without trying, urinate often, or have trouble with blurred vision. They may also get skin infections or heal slowly from cuts and bruises. See your doctor right away if you have one or more of these symptoms.

Managing Diabetes

        

Once you've been told you have type 2 diabetes, the doctor may prescribe diabetes medicines to help control blood glucose levels. There are many kinds of medication available. Your doctor will choose the best treatment based on the type of diabetes you have, your everyday routine, and other health problems.

In addition, you can keep control of your diabetes by:

§ Tracking your glucose levels. Very high glucose levels or very low glucose levels (called hypoglycemia) can be risky to your health. Talk to your doctor about how to check your glucose levels at home.

§ Making healthy food choices. Learn how different foods affect glucose levels. For weight loss, check out foods that are low in fat and sugar. Let your doctor know if you want help with meal planning.

§ Getting exercise. Daily exercise can help improve glucose levels in older people with diabetes. Ask your doctor to help you plan an exercise program.

§ Keeping track of how you are doing. Talk to your doctor about how well your diabetes care plan is working. Make sure you know how often to check your glucose levels.

Your doctor may want you to see other healthcare providers who can help manage some of the extra problems caused by diabetes. He or she can also give you a schedule for other tests that may be needed. Talk to your doctor about how to stay healthy.

Here are some things to keep in mind:

§ Have yearly eye exams. Finding and treating eye problems early may keep your eyes healthy.

§ Check your kidneys yearly. Diabetes can affect your kidneys. A urine and blood test will show if your kidneys are okay.

§ Get flu shots every year and the pneumonia vaccine. A yearly flu shot will help keep you healthy. If you're over 65, make sure you have had the pneumonia vaccine. If you were younger than 65 when you had the pneumonia vaccine, you may need another one. Ask your doctor.

§ Check your cholesterol. At least once a year, get a blood test to check your cholesterol and triglyceride levels. High levels may increase your risk for heart problems.

§ Care for your teeth and gums. Your teeth and gums need to be checked twice a year by a dentist to avoid serious problems.

§ Find out your average blood glucose level. At least twice a year, get a blood test called the A1C test. The result will show your average glucose level for the past 2 to 3 months.

§ Protect your skin. Keep your skin clean and use skin softeners for dryness. Take care of minor cuts and bruises to prevent infections.

§ Look at your feet. Take time to look at your feet every day for any red patches. Ask someone else to check your feet if you can't. If you have sores, blisters, breaks in the skin, infections, or build-up of calluses, see a foot doctor, called a podiatrist.

§ Watch your blood pressure. Get your blood pressure checked often.

Loss of Hearing

About one-third of Americans between the ages of 65 and 74 have hearing problems. About half the people who are 85 and older have hearing loss. Whether a hearing loss is small (missing certain sounds) or large (being profoundly deaf), it is a serious concern. If left untreated, problems can get worse.

 Hearing loss can affect your life in many ways. You may miss out on talks with friends and family. On the telephone, you may find it hard to hear what the caller is saying. At the doctor's office, you may not catch the doctor's words.

 Sometimes hearing problems can make you feel embarrassed, upset, and lonely. It's easy to withdraw when you can't follow a conversation at the dinner table or in a restaurant. It's also easy for friends and family to think you are confused, uncaring, or difficult, when the problem may be that you just can't hear well.

 If you have trouble hearing, there is help. Start by seeing your doctor. Depending on the type and extent of your hearing loss, there are many treatment choices that may help. Hearing loss does not have to get in the way of your ability to enjoy life.

 How to Identify Hearing Loss

 See your doctor if you:

·       Have trouble hearing over the telephone,

·       Find it hard to follow conversations when two or more people are talking,

·       Need to turn up the TV volume so loud that others complain,

·       Have a problem hearing because of background noise,

·       Sense that others seem to mumble, or

·       Can't understand when women and children speak to you.

What Causes Hearing Loss?

 Hearing loss can have many different causes, including the aging process, ear wax buildup, exposure to very loud noises over a long period of time,viral or bacterial infections, heart conditions or stroke, head injuries, tumors, certain medicines, and heredity.

 Types of Hearing Loss

·       Presbycusis (prez-bee-KYOO-sis) is age-related hearing loss. It becomes more common in people as they get older. People with this kind of hearing loss may have a hard time hearing what others are saying or may be unable to stand loud sounds. The decline is slow. Just as hair turns gray at different rates, presbycusis can develop at different rates. It can be caused by sensorineural (sen-soh-ree-NOO-ruhl) hearing loss. This type of hearing loss results from damage to parts of the inner ear, the auditory nerve, or hearing pathways in the brain. Presbycusis may be caused by aging, loud noise, heredity, head injury, infection, illness, certain prescription drugs, and circulation problems such as high blood pressure. The degree of hearing loss varies from person to person. Also, a person can have a different amount of hearing loss in each ear.

·       Tinnitus (tih-NIE-tuhs) accompanies many forms of hearing loss, including those that sometimes come with aging. People with tinnitus may hear a ringing, roaring, or some other noise inside their ears. Tinnitus may be caused by loud noise, hearing loss, certain medicines, and other health problems, such as allergies and problems in the heart and blood vessels. Often it is unclear why the ringing happens. Tinnitus can come and go, it can stop completely, or it can stay. Some medicines may help ease the problem. Wearing a hearing aid makes it easier for some people to hear the sounds they need to hear by making them louder. Maskers, small devices that use sound to make tinnitus less noticeable, help other people. Music also can be soothing and can sometimes mask the sounds caused by the condition. It also helps to avoid things that might make tinnitus worse, like smoking, alcohol, and loud noises.

Loss of Vision

Vision loss among the elderly is a major health care problem. Approximately one person in three has some form of vision-reducing eye disease by the age of 65. The most common causes of vision loss among the elderly are age-related macular degeneration, glaucoma, cataract and diabetic retinopathy. Age-related macular degeneration is characterized by the loss of central vision. Primary open-angle glaucoma results in optic nerve damage and visual field loss. Because this condition may initially be asymptomatic, regular screening examinations are recommended for elderly patients. Cataract is a common cause of vision impairment among the elderly, but surgery is often effective in restoring vision. Diabetic retinopathy may be observed in the elderly at the time of diagnosis or during the first few years of diabetes. Patients should undergo eye examinations with dilation when diabetes is diagnosed and annually thereafter.

The elderly population in the United States is increasing rapidly. By the year 2030, approximately 70 million Americans will be over 65 years of age. Loss of vision among the elderly is a major health care problem: approximately one in three elderly persons has some form of vision-reducing eye disease by the age of 65. Vision impairment is associated with a decreased ability to perform activities of daily living and an increased risk for depression.² This article reviews the four most common causes of vision impairment in the elderly: age-related macular degeneration, glaucoma, cataract and diabetic retinopathy.

Age-Related Macular Degeneration

 Age-related macular degeneration (AMD) is the leading cause of loss of vision in people over 65 years of age. AMD is characterized by degeneration of the macula, the area of the retina responsible for central vision. Risk factors for AMD include advancing age, family history of AMD and cardiovascular risk factors such as hypertension and cigarette smoking. AMD can be divided into two categories: nonexudative (or “dry”) AMD and exudative (or “wet”) AMD.

 Glaucoma

 Glaucoma comprises a group of disorders characterized by glaucomatous optic nerve damage and visual field loss. It is a significant cause of blindness in the United States and is the most common cause of blindness among black Americans. An estimated 1 million Americans over 65 years of age have experienced loss of vision associated with glaucoma, and approximately 75 percent of persons who are legally blind because of glaucoma are over the age of 65. The most prevalent form of glaucoma is primary open-angle glaucoma.

 Primary open-angle glaucoma is responsible for approximately 10 percent of cases of blindness in the United States. Primary open-angle glaucoma affects men and women equally. Common factors associated with primary open-angle glaucoma include a family history of glaucoma, increasing age, high degree of myopia, hypertension and diabetes.

 Primary open-angle glaucoma is a chronic, slowly progressive disorder. Persons with primary open-angle glaucoma are generally asymptomatic until late in the course of the disease, after suffering significant visual field loss. Primary open-angle glaucoma is bilateral but may be asymmetric. Medical therapy is usually the first line of treatment for primary open-angle glaucoma. Medications lower intraocular pressure.

Cataract

Cataract is a common cause of vision impairment in the elderly and the most common cause of blindness worldwide. In the United States, the potentially blinding effect of cataract among the elderly is dramatically reduced because cataract surgery is readily available, effective and safe. The prevalence of cataract increases with age from less than 5 percent in persons under 65 years of age to approximately 50 percent in those 75 years of age and older. Exposure to ultraviolet light may contribute to the progression of cataract formation.

 Although there is no universally accepted definition, “cataract” generally refers to lens opacities that interfere with vision function. Patients with visually significant cataracts may complain of blurred vision or glare. Cataract progression is typically slow, with gradual loss of vision over months to years. However, some types of cataract progress more rapidly.

Diabetic Retinopathy

 Diabetic retinopathy is the leading cause of new blindness among middle-aged Americans. It is also a significant cause of vision morbidity in the elderly population. The prevalence of diabetic retinopathy rises with increasing duration of diabetes. However, significant diabetic retinopathy may be observed in the elderly at the time of diagnosis or during the first few years of diabetes. Diabetic retinopathy is divided into two categories: nonproliferative and proliferative.

Since significant diabetic retinopathy may be present at the time of initial diagnosis of diabetes or shortly thereafter, elderly patients should undergo eye examinations with dilation at the time of diagnosis. Follow-up examinations should be performed annually in those with minimal or no retinopathy, or more frequently if significant retinopathy is detected.

Stroke

A stroke is the sudden death of brain cells due to lack of oxygen. It is also called “brain attack.” A stroke is usually defined as one of two types:

• Ischemic (caused by a blockage in an artery)
• Hemorrhagic (caused by a tear in the artery's wall that produces bleeding into or around the brain)

The consequences of a stroke, the type of functions affected, and the severity, depend on where in the brain it has occurred and the extent of the damage.

Blood Flow Blockage

Strokes are caused by either blood flow blockage to the brain (ischemic stroke) or the sudden rupture of an artery in the brain (hemorrhagic stroke). Brain cells require a constant supply of oxygen to stay healthy and function properly. Therefore, blood needs to be supplied continuously to the brain through two main arterial systems:

• The carotid arteries come up through either side of the front of the neck. (To feel the pulse of a carotid artery, place your fingertips gently against either side of your neck, right under the jaw.)
• The basilar artery forms at the base of the skull from the vertebral arteries, which run up along the spine, join, and come up through the rear of the neck.

The Circle of Willis is the joining area of several arteries at the bottom (inferior) side of the brain. At the Circle of Willis, the internal carotid arteries branch into smaller arteries that supply oxygenated blood to over 80% of the cerebrum.

Blockage of blood flow to the brain for even a short period of time can be disastrous and cause brain damage or even death.

Ischemic Stroke

Ischemic strokes are by far the more common type, causing nearly 90% of all strokes. Ischemia means the deficiency of oxygen in vital tissues. Ischemic strokes are caused by blood clots that are usually one of three types:

• Thrombotic stroke
• Embolic stroke
• Lacunar stroke

Thrombotic or Large-Artery Stroke and Atherosclerosis. The thrombotic stroke accounts for about 60% of all strokes. It usually occurs when an artery to the brain is blocked by a thrombus (blood clot) that forms as the result of atherosclerosis (commonly known as hardening of the arteries). These strokes are also sometimes referred to as large-artery strokes. The process leading to thrombotic stroke is complex and occurs over time:

• The arterial walls slowly thicken, harden, and narrow until blood flow is reduced, a condition known as stenosis.
• As these processes continue, blood flow slows. In addition, other events contribute to the coming stroke:
• The arteries become calcified, lose elasticity, and become susceptible to tearing. In this event, the thrombus (blood clot) forms.
• The blood clot then blocks the already narrowed artery and shuts off oxygen to part of the brain. A stroke occurs.

Embolic Strokes and Atrial Fibrillation. An embolic stroke is usually caused by a dislodged blood clot that has traveled through the blood vessels (an embolus ) until it becomes wedged in an artery. Embolic strokes may be due to various conditions:

• In about 15% of embolic strokes, the blood clots originally form as a result of a heart rhythm disorder known as atrial fibrillation.
• Emboli can originate from blood clots that form at the site of artificial heart valves.
• Patients with heart valve disorders such as mitral stenosis are at increased risk for clots when they also have atrial fibrillation.
• Emboli can also occur after a heart attack or in association with heart failure.
• Rarely, emboli are formed from fat particles, tumor cells, or air bubbles that travel through the bloodstream.

Lacunar Strokes. Lacunar infarcts are a series of very tiny, ischemic strokes, which cause clumsiness, weakness, and emotional variability. They make up the majority of silent brain infarctions and are probably a result of chronic high blood pressure. They are actually a subtype of thrombotic stroke. They can also sometimes serve as warning signs for a major stroke.

Silent Brain Infarctions. Many elderly people have silent brain infarctions, small strokes that cause no apparent symptoms. They are detected in up to half of elderly patients who undergo imaging tests for problems other than stroke. The presence of silent infarctions indicates an increased risk for future stroke, and are often contributors to mental impairment in the elderly. Smokers and people with hypertension are at particular risk.

Transient Ischemic Attacks (TIAs)

A transient ischemic attack (TIA) is an episode in which a person has stroke -like symptoms that typically last for a few minutes and usually less than 1-2 hours. Transient ischemic attacks (TIAs) are caused by tiny emboli (clots often formed of pieces of calcium and fatty plaque) that lodge in an artery to the brain. They typically break up quickly and dissolve but they do temporarily block the supply of blood to the brain.

TIAs do not cause lasting damage but they are a warning sign that a true stroke may happen in the future if something is not done to prevent it. TIA should be taken very seriously and treated as aggressively as a stroke. About 10 - 15% of patients who have a TIA have a stroke within 3 months, with half of these strokes occurring within 48 hours after the TIA.

Hemorrhagic Stroke

About 10% of strokes occur from hemorrhage (sudden bleeding) into or around the brain. While hemorrhagic strokes are less common than ischemic strokes, they tend to be more deadly.

Hemorrhagic strokes are categorized by how and where they occur.

• Parenchymal, or intracerebral, hemorrhagic strokes. These strokes occur from bleeding within the brain tissue. They are most often the result of high blood pressure exerting excessive pressure on arterial walls already damaged by atherosclerosis. Heart attack patients who have been given drugs to break up blood clots or blood-thinning drugs have a slightly increased risk for this type of stroke.
• Subarachnoid hemorrhagic strokes. This kind of stroke occurs when a blood vessel on the surface of the brain bursts, leaking blood into the subarachnoid space, an area between the brain and the skull. They are usually caused by the rupture of an aneurysm, a bulge in a blood vessel, which creates a weakening in the artery wall.
• Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins. If it occurs in the brain and ruptures, it can also cause a hemorrhagic stroke.

Risk Factors

New or recurrent strokes affect about 780,000 Americans every year. On average, someone in the United States has a stroke every 40 seconds. While age is the major risk factor, people who have a stroke are likely to have more than one risk factor.

People most at risk for stroke are older adults, particularly those with high blood pressure, who are sedentary, overweight, smoke, or have diabetes. Older age is also linked with higher rates of post-stroke dementia. Younger people are not immune, however. Many stroke victims are under age 65.

Symptoms

People at risk and partners or caretakers of people at risk for stroke should be aware of its typical symptoms. The stroke victim should get to the hospital as soon as possible after these warning signs appear. It is particularly important for people with migraines or frequent severe headaches to understand how to distinguish between their usual headaches and symptoms of stroke.      

Time is of the essence in treating stroke. Studies show that patients receive faster treatment for stroke if they arrive by ambulance rather than coming to the emergency room on their own People should immediately call 911 for emergency assistance if they experience any of warning signs of stroke:

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause

An easy way to remember the signs of stroke, and what to do, is by the acronym "F.A.S.T." If you think you or someone else is having a stroke, the National Stroke Association's F.A.S.T. test advises:

• (F)ACE. Ask the person to smile. Check to see if one side of the face droops.
• (A)RMS. Ask the person to raise both arms. See if one arm drifts downward.
• (S)PEECH. Ask the person to repeat a simple sentence. Check to see if words are slurred and if the sentence is repeated correctly.
• (T)IME. If a person shows any of these symptoms, time is essential. It is important to get to the hospital as quickly as possible. Call 9-1-1. Act FAST.

 Treatment

Until recently, the treatment of stroke was restricted to basic life support at the time of the stroke and rehabilitation later. Now, however, treatments can be beneficial when administered as soon as possible after the onset of the stroke. It is critical to get to the hospital and be diagnosed as soon as possible. There are several steps in the initial assessment and management of a person with a stroke.

Receiving treatment early is essential in reducing the damage from a stroke. The chances for survival and recovery are also best if treatment is received at a hospital specifically certified as a primary stroke center.

Treatment of Ischemic Stroke

Immediate treatment of ischemic stroke aims at dissolving the blood clot. Patients who arrive at the emergency room with signs of acute ischemic stroke are usually given aspirin to help thin the blood. Aspirin can be lethal for patients suffering a hemorrhagic stroke, so it is best not to take aspirin at home and to wait until after the doctor has determined what kind of stroke has occurred.

If patients arrive at the hospital within 3 - 4 hours of stroke onset (when symptoms first appear), they may be candidates for thrombolytic (“clot-buster”) drug therapy. Thrombolytic drugs are used break up existing blood clots. The standard thrombolytic drugs are tissue plasminogen activators (t-PAs). They include alteplase (Activase) and reteplase (Retavase).

The following steps are critical before injecting a clot-buster drug:

• Before the thrombolytic is given, a CT scan must first confirm that the stroke is not hemorrhagic. If the stroke is ischemic, a CT scan can also suggest if injuries are very extensive, which might affect the use of thrombolytics.
• Thrombolytics must generally be administered within 3 - 4 hours of a stroke to have any effect. Best results are achieved if patients are treated with 90 minutes of a stroke.
• According to 2009 guidelines from the American Heart Association and American Stroke Association, some patients may benefit from treatment with a thrombolytic within 4.5 hours after stroke symptoms begin. These patients include those who are younger than 80 years, are having a less severe stroke, do not have a history of stroke or diabetes, and do not take anticoagulant (bood-thinner) drugs. Patients who do not meet these criteria should not be treated with a thrombolytic after the 3-hour window.

Thrombolytics carry a risk for hemorrhage, so they may not be appropriate for patients with existing risk factors for bleeding.

Treatment of Hemorrhagic Stroke

Treatment of hemorrhagic stroke depends in part on whether the stroke is caused by bleeding between the brain and the skull (subarachnoid hemorrhage) or within the brain tissue (intracerebral hemorrhage). Both medications and surgery may be used.

Medications. Various types of drugs are given depending on the cause of the bleeding. If high blood pressure is the cause, antihypertensive medications are administered to lower blood pressure. If anticoagulant medications, such as warfarin (Coumadin) or heparin, are the cause, they are immediately discontinued and other drugs may be given to increase blood coagulation. Other drugs, such as the calcium channel blocker nimodipine (Nimotop) can help reduce the risk of ischemic stroke following hemorrhagic stroke.

Surgery. Surgery may be performed for aneurysms or arteriovenous malformations that are bleeding. The surgery may be done through a craniotomy, which involves making an opening in the skull bone. Less invasive techniques can be done by threading a catheter. A catheter is guided through a small cut in the groin to an artery and then to the small blood vessels in the brain where the aneurysm is located. Thin metal wires are put into the aneurysm. They then coil up into a mesh ball. Blood clots that form around this coil prevent the aneurysm from breaking open and bleeding. If the aneurysm has ruptured, a clip may be placed on it to prevent further leaking of blood into the brain

Dementia

Definition

Category	Possible points	Description
Orientation to time	5	From broadest to most narrow. Orientation to time has been correlated with future decline.[7]
Orientation to place	5	From broadest to most narrow. This is sometimes narrowed down to streets,[8] and sometimes to floor.[9]
Registration	3	Repeating named prompts
Attention and calculation	5	Serial sevens, or spelling "world" backwards[10] It has been suggested that serial sevens may be more appropriate in a population where English is not the first language.[11]
Recall	3	Registration recall
Language	2	Naming a pencil and a watch
Repetition	1	Speaking back a phrase
Complex commands	6	Varies. Can involve drawing figure shown.

            In Latin, Dementia means “Madness”. De- means “without” and -ment means “mind”. Dementia is the loss of brain cells and tissues. It is not a specific disease, but instead a broad term used to define a set of signs and symptoms that affect cognitive areas such as memory, attention, language, and problem solving. It can also affect basic motor skills. It is the loss of brain cells in someone that was not previously impaired. It can start out very basic, but become severe enough to interfere with daily life.

Dementia is commonly referred to as “senile”. This belief is incorrect and reflects the belief that old age brings a decline in mental ability. This widespread belief is incorrect. Though Dementia is most commonly found in the elderly, it is not a symptom of old age. Memory loss can be caused by old age, but does not mean that someone has Dementia. Stress and depression can also cause memory loss, as well as a brain tumor and vitamin deficiencies (neither are very common).  Dementia is most commonly found in people 60 years or older. But early onset Dementia does occur.

Diagnostic Testing for Dementia

            Diagnosing Dementia is not an easy task, because no two patients are the same. There are many different ways in which to diagnose, and there should always be more than one way used. Assessments can include a conversation with a physician, a physical examination, a mind test/memory test, and brain scans. 

            There are many different tests available. Some of the most common ones are as follows:

            Mini-Mental State Exam (MMSE): This exam is designed to test a range of everyday mental skills. A point system is used to determine how far the dementia has progressed. 20-24 reflects mild dementia, 13-20 reflects moderate, and less than 12 indicates severe dementia. A patient suffering from Alzheimer’s is expected to decline 2-4 points each year. Bellow are the questions ask on this examination.

            Mini-Cog: A Mini-Cog has two parts. During the first part you are given three words that you are told to remember, and repeat back at the end of the test. They are basic words. Examples of some that are used are: Banana, Sunrise, and Chair. For the second part of the exam you are asked to draw a clock. You are told to draw to face of the clock with all 12 numbers in the right locations and the hands showing a time specified by the examiner. This test is meant to show if further examination is necessary. Bellow is an example of the drawing of the clock, and how it changes as the disease progresses.

                Hodkinsons’s Abbreviated Mental Test score: The goal of this exam is to test mental abilities. Bellow are the questions asked on this Examination. The score is used to determine how far the patients Dementia have progressed.

Question [1]	Score
What is your age? (1 point)
What is the time to the nearest hour? (1 point)
Give the patient an address, and ask him or her to repeat it at the end of the test. (1 point) e.g. 42 West Street
What is the year? (1 point)
What is the name of the hospital or number of the residence where the patient is situated? (1 point)
Can the patient recognize two persons (the doctor, nurse, home help, etc.)? (1 point)
What is your date of birth? (day and month sufficient) (1 point)
In what year did World War 1 begin? (1 point) (other dates can be used, with a preference for dates some time in the past.)
Name the present monarch/dictator/prime minister/president. (1 point) (Alternatively, the question "When did you come to [this country]? " has been suggested)
Count backwards from 20 down to 1. (1 point)

 General Practitioner Assessment of Cognition: This test is meant to establish cognitive abilities. During this assessment the caregiver is interviewed, as well as the patient.

The MMSE is also administered. Here is an example of what the GPCOG would include:

 Name and Address for subsequent recall test

1. “I am going to give you a name and address. After I have said it, I want you to repeat

it. Remember this name and address because I am going to ask you to tell it to me

again in a few minutes: John Brown, 42 West Street, Kensington.” (Allow a maximum

of 4 attempts).

Time Orientation

2. What is the date? (exact only)

Clock Drawing – use blank page

3. Please mark in all the numbers to indicate

the hours of a clock (correct spacing required)

4. Please mark in hands to show 10 minutes past

eleven o’clock (11.10)

Information

5. Can you tell me something that happened in the news recently?

(Recently = in the last week. If a general answer is given,

eg “war”, “lot of rain”, ask for details. Only specific answer scores).

Recall

6. What was the name and address I asked you to remember

John

Brown

42

West (St)

Kensington

If patient scores 9, no significant cognitive impairment and further testing is necessary. If patient scores 5-8, then more information is required. Step two of the test would then be administered, the information system portion. The desired information would be as follows:

·      Does the patient have more trouble remembering things that have happened recently than s/he used to?

·      Does he or she have more trouble recalling conversations a few days later?

·      When speaking, does the patient have more difficulty in finding the right word or tend to use the wrong words more often?

·      Is the patient less able to manage money and financial affairs (e.g. paying bills, budgeting)?

·      Is the patient less able to manage his or her medication independently?

·      Does the patient need more assistance with transport (either private or public)?

Why is it important to be diagnosed?

There is no way to cure Dementia, or to reverse its effects. So why is it important to find out if you are suffering from Dementia? Here are a few reasons why it would be important.

·      Since Dementia has many symptoms that can be caused by other conditions, you are able to eliminate the conditions that could be treatable, and reversible. Such as depression, vitamin and thyroid problems, and brain tumors.

·      It is possible that other issues such as poor sight and hearing can cause confusion. As well as new medications or a combination of medications

·      It is important to have a support team to help you. It will allow you to seek out support groups, voluntary agencies, and social services to get help. It also helps your family and caregiver to understand what you are going through, and better assist you.

·      Allows you to make plans for the future.

Symptoms and Effects of Dementia

           

Dementia is a progressive disease that starts out slow, but progressively gets worse. Since Dementia is a term used to describe a broad spectrum of diseases, each will present its self in a different way. Symptoms vary depending on the part of the brain that is being affected. Each person affected by Dementia will experience it in a different way. But the most common symptoms are:

·      Loss of memory, reasoning, and communication skills

·      Confusion

·      Steady loss of abilities needed to complete daily tasks

There are many conditions that can cause symptoms of Dementia. These symptoms can be reversed. Examples of these conditions are thyroid problems, or vitamin deficiencies. Symptoms caused by these problems that can be reversed are memory, communication and language skills, ability to focus and pay attention, reasoning and judgment skills, and visual perception. They are often mistaken as Dementia, because they present themselves in a similar form.

What Causes Dementia?

        

Dementia is caused by the deterioration of brain cells. Damage done interferes with the ability for brain cells to communicate with each other. When brain cells cannot communicate normally, thinking, behavior and feelings can be affected.

Types of Dementia 

            There are many different types of dementia. A person can also have a mix of more than one type. This is considered mixed dementia. This happens when the brain is affected by more than one type of dementia. Mixed dementia has been found to be more common than previously thought. Following is a list of the most common forms of dementia:

Alzheimer’s Disease: This is the most common. It accounts for 60-80% of cases. Symptoms include trouble remembering, depression and apathy. Some of the more progressive symptoms include impaired judgment, disorientation, difficulty speaking, swallowing, and walking. We will go into greater detail about Alzheimer’s disease later on.

Vascular Dementia: This is thought to be the second most common form of Dementia. It is previously known as multi-infarct or post-stroke dementia. Initial symptoms include impaired judgment, and the ability to plan out steps to accomplish a task. These occur because of brain injuries such as microscopic bleeding and blockage within blood vessels. Where the injury is located within the brain will determine how the individuals thinking and physical functioning will be affected. Brain imaging has been found to be a good way to detect issues within blood vessels.

Dementia With Lewy Bodies (DLB): Symptoms are very similar to those of Alzheimer’s disease. People will experience memory loss and thinking problems. They are more likely to have initial or early symptoms of sleep disturbance, visual hallucinations, and/ or muscle rigidity. Lew Bodies are clumps of abnormal protein alpha-synuclien. They develop in parts of the brain which can cause dementia. This can be present with both Vacular Dementia, and Alzheimer’s disease.

Parkinson’s Disease: This type of dementia is similar to DLB or Alzheimers. Parkinson’s causes difficulty with movement. The brain has alpha-synuclein clumps in an area deep inside the brain called substantia nigra. The clumps cause nerve cells that produce dopamine to degenerate. We will go into greater detail about Parkinson’s Disease later on.

Frontotemporal Dementia (FTD): Primary progressive aphasia, pick’s disease and progressive supranuclear palsy. Symptoms include changes in personality and behavior and difficultly with language. It effects the nerve cells in the front and side regions of the brain. It is really difficult to distinguish the changes because they are microscopic abnormalities. It is usually developed around the age of 60, and people will survive for less years then those with Alzheimer’s.

            This chart shows the distribution of different types of Dementia. A lot of the charts I looked at calculated the percentages of types of dementia differently. This graph is the one that I found to be the most common.

 Alzheimer’s Disease

Definition

         Alzheimer’s is a type of dementia that causes memory, thinking, and behavioral problems. It starts out slowly and then progresses until it is too difficult to complete daily tasks. It is the most common form of Dementia. It accounts for 60-80% of those diagnosed. Alzheimer’s is not a normal part of aging, but it is a disease that affects 4.5 million adults. Age is the greatest risk factor in developing Alzheimer’s disease. Majority of people diagnosed are above the age of 65. But 5% of those that are diagnosed are in their 40’s-50’s. This is called early onset Alzheimer.

            Alzheimer’s disease is irreversible, and unstoppable. There is no cure. People diagnosed with this disease on average will live up to 8 years. It is possible to survive up to 20. The course of the disease depends on when it is diagnosed and the health conditions of the person.

Causes of Alzheimer’s

         Alzheimer causes the nerve cells and tissues to die, and connections between the cells to be lost. Over time the brain shrinks dramatically, affecting nearly all its functions. The cortex shrivels, which causes damage to thinking, planning and remembering. The hippocampus shrinks, which plays a key part in formation of new memories. The ventricles (fluid-filled spaces within the brain) enlarge.

            A healthy brain will have many more nerve cells and synapses than a brain suffering from Alzheimer’s. When brain tissue looked at under a microscope scientists can see the formation of plaques and tangles, which are believed to be causing the cells to die. Though it is unsure what causes the death of the cells, plaques and tangles are believed to play a significant role.

Plaques are abnormal clumps of protein fragments, called beta-amyloids that become stuck between nerve cells. It is thought that the beta-amyloids in smaller portions, not making up the plaques, can be a bigger issue. They can block cell-to-cell communication, and activate the immune system cells, which can cause inflammation and death to disabled cells.

Tangles are caused when the strands of protein inside of the nerve become twisted. This will interfere with cell transportation. In a healthy cell the protein strands are organized and separate. They create a path for key materials to travel on like a railroad track. A protein called tau is keeping the tracks straight and orderly. When the tau stops working strands become tangled. When the tracks cannot stay straight, they are destroyed. The key materials, such as nutrients and cell parts, can no longer travel along the path, and cells ultimately die.

It is possible to map where the brain will be affected as the disease progresses; which makes it possible to chart the symptoms that will be experienced as the disease progresses. The amount of time each stage takes will vary from person to person. In the earliest stages of Alzheimer plaques and tangles begin to form in the parts of the brain, which involve learning and memory, and thinking and planning. In the moderate stage the ability to speak and understand speech and your sense of self are affected. In the final stage almost the whole brain is damaged. This is when the brain shrinks dramatically. The person will lose the ability to communicate, recognize family and loved ones and to care for themselves.

Symptoms

        

The chief cause for symptoms suffered is the deterioration of brain cells. The type of medication used, environment changes, and other medical conditions can also cause symptoms, or worsen them. Alzheimer is considered to have three stages of symptoms.

1.     Early stage: Plaque and tangles begin to form in the brain. No outward symptoms can be detected at this time. There is no way to know what is happening, until the damage has been done. This can begin up to 20 years before diagnosed.

2.     Moderate symptoms: Feelings of apathy and depression. Has a difficult time remembering names and recent events. This stage usually lasts from 2-10 years.

3.     Advanced Symptoms: Impaired Judgment, disorientation, confusion, behavior changes and difficulty speaking, swallowing, and walking. Left completely helpless. This can last anywhere from 1-5 years.

Behavioral symptoms can also be a huge deterrent. Medications can cause many of these, as well as deterioration of brain cells, and living in an increasingly confusing world. I can only image how difficult it would be to function, when your mind is often playing tricks on you.

Behavioral symptoms:

In the early stages:

·      Irritability

·      Anxiety

·      Depression

In later stages:

·      Anger

·      Agitation

·      Aggression

·      Emotional distress

·      Physical or verbal outburst

·      Restlessness, pacing, shredding paper or tissues

·      Hallucinations (seeing, hearing, feeling things that are not really there)

·      Delusions (firmly help belief in things that are not true)

·      Sleep disturbance

There are different things that can trigger these different behaviors. These triggers should be eliminated as much as possible. There are some changes that are necessary, and cannot be eliminated. The best way to deal with these sudden behavioral symptoms is with patience and understanding.

Here are some common triggers:

·      Moving to a new house or nursing home

·      Changes in family or caregivers arrangements

·      Misperceived threats

·      Admission to a hospital

·      Being asked to bathe or change clothes

Treatments

         Someone that has been diagnosed with Alzheimer is looking at an average life expectancy of 8 years. There is no cure for Alzheimer, nor is there a treatment that can slow down the progression of the disease. However there have been some different techniques that have proven to help with symptoms.

Many clinical trials have been, and continue to be run to try and find a cure for Alzheimer. Right now there are over 100 clinical trials looking for volunteers to participate. It is through clinical trials that we will be able to one day find a cure. There is a need for at least 50,000 volunteers who have Alzheimer’s, and their caregivers, family members, and/or physicians to participate in these trials.

Alternative Remedies

Some people have found success with natural remedies, as opposed to medications. Here is a list of some of the natural remedies that have been discovered:

·      Caprylic acid and coconut oil

·      Coenzyme Q10

·      Coral calcium

·      Ginkgo biloba

·      Huperzine A

·      Omega-3 fatty acids

·      Phosphatidylserine

·      Tramiprosate

There have been concerns that have arisen from the use of alternative remedies. A drug will go through a rigorous process by the Food and Drug Administration (FDA) for approval. But home remedies are not required to go through the same process. There are several concerns that arise from this:

·      Whether or not it is effective, and safe. There is no requirement to the FDA to prove this.

·      Purity is unknown. There is no guideline for ensuring that the product contains the ingredients it claims to, or to make sure that products used are safe.

·      May not act well with prescribed medications.

Medications

            Different medications are used to improve some of the symptoms caused by Alzheimer. There is a medication called Cholinesterase inhibitors which can slow down the worsening of symptoms for up to 6-12 months. This medication is meant to support communication between nerve cells. It works for about 50% of the people who take it. It can cause nausea, vomiting, loss of appetite, and frequent bowel movements. But it is commonly well tolerated. There are three different kinds of Cholinesterase inhibitors that are most commonly prescribed.

·      Donepezil- treats all stages

·      Rivastigmine- treats moderate stage

·      Galantamine- treats moderate stage

Other medications that have improved some symptoms are:

·      High doses of vitamin E used for cognitive change

·      Antidepressants for mood

·      Anxiolytics for anxiety/restlessness

·      Antipsychotics for hallucinations

It is important to first try a non-drug approach. Therapeutic Recreation is a great alternative. The goal of Therapeutic Recreation is to help others experience a greater quality of life. Recreation can be a good outlet for those suffering from Alzheimer’s because it provides them with a distraction, it can be something they are familiar with, and it allows them to make choices and control their life.

 Parkinson’s Disease

 What is Parkinson’s disease?

Parkinson’s disease, which mostly affects older people but can occur at any age, results from the gradual degeneration of nerve cells in the portion of the midbrain that controls body movements. The first signs are likely to be barely noticeable -- a feeling of weakness or stiffness in one limb, perhaps, or a fine trembling of one hand when it is at rest. Eventually, the shaking worsens and spreads, muscles tend to stiffen, and balance and coordination deteriorate. Depression, cognitive issues, and other mental or emotional problems are common as well.

Parkinson's disease usually begins between the ages of 50 and 65, striking about 1% of the population in that age group; it is slightly more common in men than in women. Medication can treat its symptoms, and the disorder is not directly life-threatening.

What Causes Parkinson’s Disease?

Body movements are regulated by a portion of the brain called the basal ganglia, whose cells require a proper balance of two substances called dopamine and acetylcholine, both involved in the transmission of nerve impulses. In Parkinson's, cells that produce dopamine begin to degenerate, throwing off the balance of these two neurotransmitters. Researchers believe that genetics sometimes plays a role in this cellular breakdown. In rare instances, Parkinson's disease may be caused by a viral infection or by exposure to environmental toxins such as pesticides, carbon monoxide, or the metal manganese. But in the great majority of Parkinson's cases, the cause is unknown.

Parkinson's disease is a form of parkinsonism. This is a more general term used to refer to the set of symptoms that is commonly associated with Parkinson's disease but sometimes stems from other causes. The distinction is important because these other causes of parkinsonism may be treatable, while others do not respond to treatment or medication. Other causes of parkinsonism include:

Continue reading below...

·       An adverse reaction to prescription drugs.

·       Use of illegal drugs.

·       Exposure to environmental toxins.

·       Stroke.

·       Thyroid and parathyroid disorders.

·       Repeated head trauma (for example, the trauma associated with boxing).

·       Brain tumor.

·       An excess of fluid around the brain (called hydrocephalus).

·       Brain inflammation (encephalitis) resulting from infection.

Parkinsonism may also be present in persons with other neurological conditions, including Alzheimer's disease, amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease), Creutzfeldt-Jakob disease, Wilson's disease, and Huntington’s Disease.

What are the Symptoms of Parkinson’s Disease?

Parkinson’s Disease is a movement disorder that progresses slowly. Some people will first notice a sense of weakness, difficulty walking, and stiff muscles. Others may notice a tremor of the head or hands. Parkinson's is a progressive disorder and the symptoms gradually worsen. The general symptoms of Parkinson's disease include:

·       Slowness of voluntary movements, especially in the initiation of such movements as walking or rolling over in bed.

·       Decreased facial expression, monotonous speech, and decreased eye blinking.

·       A shuffling gait with poor arm swing and stooped posture.

·       Unsteady balance; difficulty rising from a sitting position.

·       Continuous "pill-rolling" motion of the thumb and forefinger.

·       Abnormal tone or stiffness in the trunk and extremities.

·       Swallowing problems in later stages.

Diagnosing Parkinson’s Disease

Diagnosing Parkinson’s Disease is often difficult, especially in its early stages. It has been estimated that nearly 40% of people with the disease may not be diagnosed, and as many as 25% are misdiagnosed. Even as the disease progresses, symptoms may be difficult to assess and may mirror other disorders. For example, tremor may not be apparent while a person is sitting or posture changes may be written off as osteoporosis or simply a sign of aging. Some doctors, who think that tremor is a requirement for diagnosis, may not realize that as many as a third of people with Parkinson’s Disease may not have tremor.

Furthermore, making the diagnosis is even more difficult since there are currently no sophisticated blood or lab tests available to diagnose the disease. Some tests, such as a CT Scan (computed tomography) or MRI (Magnetic Resonance Imaging) may be used to rule out other disorders that cause similar symptoms. Given these circumstances, a doctor may need to observe the patient over time to recognize signs of tremor and rigidity, and pair them with other characteristic symptoms. The doctor will also compile a comprehensive history of the patient's symptoms, activity, medications, other medical problems, and exposures to toxic chemicals. This will likely be followed up with a rigorous physical exam with concentration on the functions of the brain and nervous system. Tests are conducted on the patient's reflexes, coordination, muscle strength, and mental function. Making a precise diagnosis is essential for prescribing the correct treatment regimen. The treatment decisions made early in the illness can have profound implications on the long-term success of treatment.

Because the diagnosis is based on the doctor's exam of the patient, it is very important that the doctor be experienced in evaluating and diagnosing patients with Parkinson's disease. If Parkinson's disease is suspected, you should see a specialist, preferably a movement disorders trained neurologist.

What are the Treatments for Parkinson’s Disease?

Most Parkinson's disease treatments aim to restore the proper balance of the neurotransmitters acetylcholine and dopamine by increasing dopamine levels. Drugs are the standard way of doing this, but many patients, as their disease worsens, may be candidates for having a brain stimulator surgically implanted.

Conventional Medicine for Parkinson’s Disease

Symptoms of Parkinson’s disease can often be effectively controlled for years with medication.

Levodopa -- also called L-dopa -- is the drug most often prescribed. The body metabolizes it to produce dopamine. Giving dopamine directly is ineffective, though; the brain’s natural defense blocks it from being used by the body. To suppress nausea and other possible side effects, levodopa is often used in conjunction with a related drug called carbidopa.

But some patients cannot tolerate carbidopa and take levodopa alone. If you take only levodopa, it's important not to take it at the same time as food or vitamins containing vitamin B-6, which interferes with its effectiveness.

Continue reading below...

Most doctors try to postpone starting patients on levodopa as long as possible, because the drug tends to lose effectiveness over time. However, there is some controversy about waiting to begin treatment with levodopa because it can be so beneficial. Researchers have thus investigated ways to offset the loss of effectiveness.

COMT inhibitors such as tolcapone (Tasmar) and entacapone (Comtan) are drugs that are taken with levodopa. They prolong the duration of symptom relief by blocking the action of an enzyme that breaks down levodopa.

Stalevo is a combination tablet that combines carbidopa/levodopa with entacapone. While carbidopa reduces the side effects of levodopa, entacapone extends the time levodopa is active in the brain.

MAO-B inhibitors also block the action of an enzyme that breaks down dopamine. They may be taken alone early in Parkinson's disease or with other drugs as the disease progresses. MAO-B inhibitors include selegiline (Eldepryl) and rasagaline (Azilect).

Dopamine agonists are dopamine-like drugs that directly imitate dopamine's activity in the brain. Pramipexole, rotigotine, and ropinirole used alone or in combination with L-dopa treat the motor symptoms of Parkinson's disease.

Other medications prescribed for Parkinson's disease include apomorphine, benztropine, amantadine, selegiline, and anticholinergic drugs; all can help control various symptoms -- in some cases by releasing dopamine from nerve cells, in others by reducing the effects of acetylcholine, a neurotransmitter that can cause a drop in dopamine.

Surgical Procedures

Deep brain stimulation. In deep brain stimulation (DBS), surgeons implant electrodes into a specific part of your brain. The electrodes are connected to a generator implanted in your chest that sends electrical pulses to your brain and may help improve many of your Parkinson's disease symptoms. Your doctor may adjust your settings as necessary to treat your condition. Surgery may involve risks, including infections, stroke or brain hemorrhage.

Deep brain stimulation is most often a procedure to treat people with advanced Parkinson's disease who have unstable medication (levodopa) responses. DBS can help stabilize medication fluctuations, reduce or eliminate involuntary movements (dyskinesia), reduce tremor, reduce rigidity, and improve slowing of movement. DBS is very effective in controlling erratic and fluctuating responses to levodopa or for controlling dyskinesias that can't be controlled with medication adjustments. However, it's not helpful for treating problems that don't respond to levodopa therapy, apart from tremor (tremor may be controlled even if not very responsive to levodopa)

Healthy Eating

 Eat a nutritionally balanced diet that contains plenty of fruits, vegetables and whole grains. Eating foods high in fiber and drinking an adequate amount of fluids can help prevent constipation that is common in Parkinson's disease. A balanced diet also provides nutrients, such as omega-3 fatty acids, that may be beneficial for people with Parkinson's disease

If you take a fiber supplement, be sure to introduce it gradually and drink plenty of fluids daily. Otherwise, your constipation may become worse. If you find that fiber helps your symptoms, use it on a regular basis for the best results.

Walking with Care

 Parkinson's disease can disturb your sense of balance, making it difficult to walk with a normal gait. These suggestions may help:

·      Try not to move too quickly.

·      Aim for your heel to strike the floor first when you're walking.

·      If you notice yourself shuffling, stop and check your posture. It's best to stand up straight.

·      Look in front of you, not directly down, while walking.

 Avoiding Falls

 In the later stages of the disease, you may fall more easily. In fact, you may be thrown off balance by just a small push or bump. The following suggestions may help:

·      Don't pivot your body over your feet while turning. Instead, make a U-turn.

·      Don't lean or reach. Keep your center of gravity over your feet.

·      Don't carry things while you're walking.

·      Avoid walking backward.

Daily Living Activities

 Daily living activities, such as dressing, eating, bathing and writing, can be difficult for people with Parkinson's disease. An occupational therapist can show you techniques that make daily life easier.

Therapeutic Recreation Implications

“He who is of a calm and happy nature will hardly feel the pressure of age, but to him who is of an opposite disposition, youth and age are equally a burden.” Plato (427-346 B.C.)

           

Through Therapeutic Recreation we find a greater quality of life. The objectives are to promote overall accessibility, facilitate social interactions, provide leisure education, and encourage community reaction. It does not matter our age, or even our health. Everyone can find a greater quality of life through recreation. Sometimes those that are older have limitations that might deter them from certain activities. But recreation offers a wide variety of activities that even the most limited can do. Most activities are also able to be adapted to the person’s abilities and needs. Some possible activities would be:

·      Music therapy: listening to familiar music has been proven to help those with severe Alzheimer.

·      Art therapy

·      Reading them books or their personal histories

·      Bingo

·      Nature walks

·      Scrapbooking

·      Social games

·      Gardening

·      Golf

·      Painting

·      Swimming (adaptive)

·      Crafts

·      Attending Sport events

·      Fishing

·      Promenades

·      Cooking

·      Talent shows

·      Bowling

·      Story Time

·      BBQs and Picnics

·      Yoga

There are many disabilities associated with aging, and many different ways to help the elderly’s life feel more rewarding. Working with the elderly can be difficult but very rewarding. Here are some tips on how to work with the elderly:

•       Be patient, flexible and adaptable

•       Have empathy and be understanding

•       Allow for independence, allow them to feel in control

•       Encourage physical activities

•       Learn from them

•       Do not expect more than they can give

•       Create a routine- familiarity helps eliminate fears and confusion

•       One thing at a time

Resources

Alzheimer’s Society

http://www.alzheimers.org.uk

58 St Katharine's Way,

London E1W 1LB

Alzheimer's Association National Office

225 N. Michigan Ave., Fl. 17,

Chicago, IL 60601

http://www.alz.org

Leading voluntary health organization in

Alzheimer’s care, support and Research.

http://www.educationalservice.net

Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)

http://www.rdash.nhs.uk

Tel: 01302 796000

MNT

 2003-2013

PO Box 193, Bexhill-on-Sea, East Sussex,

TN40 9BA. United Kingdom.

http://www.medicalnewstoday.com

Pfizer

Corporate Office:
1-212-733-2323
235

East 42nd Street


New York, NY 10017

Experience. Knowledge. Options.

http://www.arthritis.com

American Diabetes Association

http://www.diabetes.orgs

1701 North Beauregard Street

Alexandria, VA 22311 

1-800-DIABETES (800-342-2383)

http://www.medicinenet.com

American Family Physician

11400 Tomahawk Creek Pkwy.


Leawood, KS 66211-2672


Telephone: 913-906-6205


Fax: 913-906-6086


E-mail: afpjournal@aafp.org

http://www.aafp.org

http://www.healthcentral.com

Mayo Clinic

http://www.mayoclinic.com/health/parkinsons-disease/