News From Alzheimer's Conference

Here are some updates from the International Conference on Alzheimer's Disease.  The first article is is about improving communication with those suffering from Alzheimer's., the second article about the relationship between physical fitness and brain health.  I think the first is especially important for caregivers and the loved ones of those suffering from the disease.  Everyone wants to be treated with dignity, like an adult, and Alzheimer's sufferers are no different.

Respectful Adult Communication Improves Quality of Care in Alzheimer's

- New research says don't talk to them like children -

Chicago, July 28, 2008 – Adults with Alzheimer's in nursing homes who are talked to like children are more resistant to care, according to new research reported today at the 2008 Alzheimer's Association International Conference on Alzheimer's Disease (ICAD 2008) in Chicago.

As effective pharmaceutical treatments and prevention for Alzheimer's remain elusive, some researchers are focusing their efforts on improving quality of life and care – including communication. One study determined that there is a correlation between how nursing home staff communicates with residents who have dementia and the residents' subsequent resistance to care. Another investigated how families work to maintain normalcy and coherence during dinner time conversation when a family member with Alzheimer's is included.

"The style of communication that we use with people with Alzheimer's influences how they feel about themselves and how well they respond to those providing care," said Sam Fazio, PhD, Director, Medical and Scientific Relations at the Alzheimer's Association. "With the growing prevalence of Alzheimer's, it will be increasingly important for healthcare providers, caregivers and families to understand the effect Alzheimer's has on communication and, perhaps more importantly, the impact their communication may have on the individual's quality of life."

"Elderspeak" and Resistance to Care Among People with Alzheimer's
The growing population of adults with Alzheimer's presents complex challenges to care providers. Kristine Williams, RN, PhD, and colleagues at the University of Kansas School of Nursing explored the relationship between how nursing home staff communicates with those with dementia and subsequent behaviors that disrupt care, or resistiveness to care (RTC). Specifically, the study examined whether nursing staff "elderspeak" affected RTC behaviors.

The researchers defined elderspeak as overly caring, controlling, and infantilizing communication, similar to "baby talk." Common features are simplified grammar and vocabulary, substitution of collective pronouns, and overly intimate endearments.

RTC increases nursing staff stress, time needed to provide care, and costs of care. At the same time, RTC may actually indicate unmet needs that the person with Alzheimer's is unable to communicate in a conventional way.

Twenty (20) nursing home residents with dementia were filmed during bathing, dressing, oral care, and other care activities (2005-2006) and the sequences subsequently analyzed (2006-2008, and ongoing) for nursing staff communication (normal talk, elderspeak, or silence) and resident behavior (cooperative, resistive to care, or neutral). Residents and staff in Special Dementia Care Units in three skilled nursing facilities in Kansas were used for the study. The mean age of residents in the sample was 82.9 years, with a range of 69 to 97. Cognitive test scores indicated a relatively homogeneous sample in the moderate stage of dementia. Staff participants were primarily (78%) certified nursing assistants. The remaining staff participants included nurses, therapists, and social workers who were involved in direct care.

The probability of RTC behavior varied significantly with the type of nursing staff communication. Residents with dementia were more likely to resist care when nursing staff used elderspeak communication; they were more likely to cooperate with care when normal adult communication was used.

The Resistiveness to Care Scale (RTCS) is a measure of the occurrence of and intensity of behaviors of persons with dementia including those that disrupt care. It assesses 13 behaviors including grabbing objects, saying no, adduction [holding the arms or legs tight against the body], grabbing a person, pulling away, clenching teeth, crying, screaming, turning away, pushing away, hitting/kicking, threatening, and moving the body in the opposite direction from staff. Each occurrence of the 13 RTC behaviors was scored by duration and intensity. The total RTC score was the sum of multiplying the duration of each incident by its observed intensity providing a weighted score within a possible range of 0 (no resistiveness) to 156 (maximum resistiveness).

When elderspeak communication was used, the probability of RTC was .55 (CrI = .44 - .66). In contrast, the probability of RTC was .26 (CrI = .12 - .44) when staff used normal adult communication. Silence resulted in a probability of .36 (CrI = .21-.55) for RTC.

"This study suggests that there is an association between communication style and resident behaviors," Williams said. "This may significantly impact nursing care and how nursing home staff should best be trained to communicate with residents with Alzheimer's. Future research is needed to test whether interventions that reduce nursing staff elderspeak communication will contribute to greater cooperation with care for persons with dementia."

Family Communication Patterns Altered When Person with Alzheimer's Is Present
Over their years together, family members often develop assumptions and expectations about their conversational roles and responsibilities. With the onset and progression of Alzheimer's, the person with dementia becomes less able to speak as others have always expected him or her to. Impaired word finding is often the first, most noted difficulty. Shortened attention span and/or impaired recent memory results in the individual no longer being able to follow another speaker's retelling of the day's events. In an attempt to participate in the conversation, the person with dementia may say something that shows confusion or misunderstanding. He may initiate an unrelated topic because he cannot remember what had just been discussed. These responses are not normally anticipated and may leave caregivers in a momentary quandary as to how to continue conversations.

Jeanne Katzman, CPhil, CCC/SLP of the University of California Los Angeles, examined the effects of Alzheimer's on family conversation at dinnertime. Thirty (30) families in which one member had recent onset of Alzheimer's participated in the three-year study, which began in 2001. Each family had two videotaped dinner conversations which were later transcribed and analyzed for both verbal and gestural communication. The goal was to document ordinary family communication based on naturally occurring conversation and to analyze problematic sequences.

According to Katzman, responses of healthy family members to utterances of the Alzheimer's individual were found to follow certain predictable patterns. When a response was unexpected and disrupted the normal flow of conversation, healthy family members often were observed to continue their talk almost if the person with Alzheimer's had not spoken. The healthy family members tended to pause – a sign that the utterance was indeed heard – but did not respond verbally. In such sequences, the healthy speaker's lack of response framed the Alzheimer's individual as a non-participant.

Katzman found that other families responded to each problematic utterance. In extended, multigenerational families (n=7), a healthy family member might respond with an explanation of the utterance and then speak for the person with Alzheimer's. Conversations between families with only two members (n=21) organized problematic talk in a greater variety of ways. Responses often took the form of rewording; the healthy speaker suggested what the other wanted to say, expanded upon it, and brought the contribution of the family member with Alzheimer's to a close.

"This initial research leads to an improved understanding of daily communication between people with Alzheimer's and their families. This will be used to develop new training programs that focus on facilitating conversation between family members," said Katzman. "The goals are for caregivers to have the opportunity to adjust their conversation with the changing communicative and cognitive abilities of their loved ones and for people with Alzheimer's to experience healthier participation in family discussions."

About ICAD
The 2008 Alzheimer's Association International Conference on Alzheimer's Disease (ICAD 2008) is the largest gathering of international leaders in Alzheimer research and care ever convened. At ICAD 2008, more than 5,000 researchers from 60 countries will share groundbreaking information and resources on the cause, diagnosis, treatment and prevention of Alzheimer's and related disorders. As a part of the Association's research program, ICAD serves as a catalyst for generating new knowledge about dementia and fostering a vital, collegial research community. ICAD 2008 will be held in Chicago at McCormick Place, Lake Side Center from July 26–31.

About the Alzheimer's Association
The Alzheimer's Association, the nonprofit world leader in Alzheimer's research and support, is the first and largest U.S. voluntary health organization dedicated to finding prevention methods, treatments and an eventual cure for Alzheimer's. For more than 25 years, the donor-supported Alzheimer's Association has provided reliable information and care consultation; created supportive services for families; increased funding for dementia research; and influenced public policy changes. For more information, call (800) 272-3900 or visit www.alz.org.

New Research Shows That People With Better Physical Fitness Have Less Brain Atrophy in Alzheimer's

- Other studies show physical activity improves physical function and quality of life in people with Alzheimer’s and their caregivers -

CHICAGO, July 27, 2008 – People with early Alzheimer’s disease who had better fitness ratings had less atrophy in key brain areas associated with memory, according to research reported today at the 2008 Alzheimer's Association International Conference on Alzheimer’s Disease (ICAD 2008) in Chicago.

This is the first time that MRI brain imaging has been used to demonstrate the connection between cardiorespiratory fitness and Alzheimer’s-related brain changes in the hippocampus, an area of the brain important for memory and spatial navigation. In Alzheimer's, the hippocampus is one of the first regions of the brain to suffer damage.

Another report from ICAD 2008 showed that a home-based exercise program could reduce falls, improve balance, and maintain independence and quality of life in people with dementia.

"These studies reinforce the need for increased awareness and education about the importance of living a brain-healthy lifestyle, including staying physically active," said William Thies, PhD, vice president of Medical and Scientific Relations for the Alzheimer’s Association. "Growing evidence shows that physical exercise does not have to be strenuous or require a major time commitment. It is most effective when done regularly, and in combination with a brain-healthy diet, mental activity and social interaction."

Physical Fitness Preserves Brain Volume in Alzheimer’s
Exercise and physical fitness have been shown to moderate age-related regional brain volume changes in healthy older adults. However, little is known about the relationship of fitness to Alzheimer’s disease-related brain changes, particularly in areas that are predominantly affected early in the course of the disease, such as the hippocampus.

Robyn A. Honea, PhD, and colleagues from the University of Kansas Medical Center, Kansas City, Kansas investigated the relationship between cardiorespiratory fitness and regional brain volume in healthy older adults and those with early Alzheimer’s using MRI and a new neuroimaging analysis technique called voxel-based morphometry.

Nondemented (n=56) and early-stage Alzheimer’s subjects (n=63) aged 60 and over had MRI scans and fitness assessments based on peak oxygen consumption during a treadmill test. The researchers found that people with early Alzheimer’s in the study, and not healthy elderly, had a significant relationship between the size of key brain areas associated with memory (hippocampal and parahippocampal volume) and cardiorespiratory fitness, such that those with better fitness ratings had less atrophy and those with worse fitness ratings had more atrophy.

"We found that, in early-stage Alzheimer’s, cardiorespiratory fitness is correlated with regional brain volumes in key areas affected by the disease," said Honea. "This suggests that maintaining cardiorespiratory fitness may positively modify Alzheimer’s-related brain atrophy."

"A previous study by our group looked at whole brain volumes and fitness, giving us a clue that there was some relationship. This is the first study to get an inside look into specifically where these changes occur in the brain – we're able to locate the changes associated with fitness to the actual memory region, the hippocampus, which is a key area for Alzheimer’s-related atrophy," Honea added.

Caregiver-Directed Home Exercise Program Reduces Falls and Improves Quality of Life for People with Dementia
According to researchers Megan J. Wraith, PhD, and colleague R. Arthur Criddle, MD, FRACP, from Western Medicine, Nedlands, Western Australia, one-third of older people living in the community fall each year; people with dementia fall up to three times more than those who have no cognitive impairment. The aim of their study was to examine whether a home-based exercise program combined with good geriatric management could reduce falls, improve balance and maintain independence and quality of life in people with dementia over a 12-month period.

The researchers involved caregivers in the delivery of the program so they could prompt their loved ones into completing the exercises. The level of participants’ dementia ranged from mild to severe. People were chosen for inclusion in the study if they had a live-in caregiver or someone who visited most days.

Patient/caregiver dyads were enrolled into either a group receiving usual care (control group, n=12) or an exercise group (n=21). All patients were seen for a full geriatric assessment at baseline including measures of balance, daily activities, independence and quality of life. An occupational therapist made recommendations that would reduce the risk of falling at home.

Caregivers in the exercise group were taught a tailored set of exercises and were shown how to prompt their loved ones to do them. The exercise program focused primarily on promoting good balance as this has been previously shown to have the greatest impact on reducing falls. Particular emphasis was put on embedding the exercises into everyday routines to increase the likelihood that the exercises would be carried out. All participants received eight home visits in the first six months of the study. The usual care group was engaged in conversation and completed some tasks that measured their communication abilities.

Fall Reduction
The researchers found that people in the exercise group fell significantly less often than people in the control group in the first six months. In the second six months there was no difference between the groups. The investigators concluded that the home visits in the first six months were important in keeping people motivated to do the exercises and this may have had an impact on how often they fell. The study also showed that people in the exercise group improved their balance over 12 months while the usual care group showed some deterioration in their balance over this time.

"The results of this study were encouraging," said Wraith. "Falls have a negative impact on a person’s quality of life, often resulting in nursing home placement, increased mortality and significant costs to the community. Targeting this high risk group may be a relatively cost effective way of having a significant impact on the overall rate of falling in the elderly."

Improved Quality of Life
A significant problem with increasing frailty and problems with balance is that the person with Alzheimer’s becomes less independent due to the fear of falling. People in the exercise group showed no significant increase in fear of falling over 12 months, while the usual care group became more fearful. As anticipated by the researchers, this led to a decrease in the usual care group’s independence and in the range of activities in which they were involved. In contrast, the people in the exercise group maintained their level of independence and continued to be involved in daily activities to the same degree as they were at the beginning of the study, despite the progression of their dementia.

In addition, the study showed that the quality of life was maintained for both the caregiver and the person with dementia in the exercise group, but that it deteriorated for participants in the usual care group.

"As people become increasingly affected by the changes in their memory and thinking, and as the risk of falls becomes greater, quality of life can deteriorate," said Wraith. "This study is small and is just a beginning, but maintaining quality of life at the same level in the context of deteriorating cognitive abilities is an achievement. The results are sufficiently encouraging to pursue this approach and develop a caregiver focused home-based exercise program on a larger scale."

About ICAD 2008
The 2008 Alzheimer’s Association International Conference on Alzheimer's Disease (ICAD 2008) is the largest gathering of international leaders in Alzheimer research and care ever convened. At ICAD 2008, more than 5,000 researchers from 60 countries will share groundbreaking information and resources on the cause, diagnosis, treatment and prevention of Alzheimer’s and related disorders. As a part of the Association’s research program, ICAD serves as a catalyst for generating new knowledge about dementia and fostering a vital, collegial research community. ICAD 2008 will be held in Chicago at McCormick Place, Lake Side Center from July 26–31.

About the Alzheimer’s Association
The Alzheimer's Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s. For more information, visit www.alz.org.

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• Robyn A. Honea – "Physical fitness preserves brain volume in Alzheimer’s disease." (Funders: National Institute on Aging, National Institute on Neurological Disorders and Stroke)
• Megan J. Wraith – "Reduction in falls found for people with dementia from carer-directed home exercise program" and "Carer-directed home exercise programs maintain quality of life for people with dementia over 12 months." (Funders: Sir Charles Gairdner Research Foundation, Hollywood Private Hospital Research Foundation)