Tag: Elderly

How to Drive Safely When You’re an Older Driver

Safe driving is possible for many people in their 70s, 80s and beyond, provided they take steps to maintain their skills.

Nursing Homes Face Dilemma: Vaccinate Staff or Don’t Get Paid.

A new policy from President Biden will require all nursing home workers to be vaccinated against Covid. Facilities that fall short could be penalized or lose federal funding.

How an Unproven Alzheimer’s Drug Got Approved

Though some of its own senior officials said there was little evidence of benefit for patients, the F.D.A. nonetheless greenlighted Biogen’s Aduhelm, or aducanumab.

The Secrets of ‘Cognitive Super-Agers’

By studying centenarians, researchers hope to develop strategies to ward off Alzheimer’s disease and slow brain aging for all of us.

One of my greatest pleasures during the Covid-19 shutdowns was having the time to indulge in hourlong phone conversations with friends and family whom I could not see in person. Especially uplifting were my biweekly talks with Margaret Shryer, a twice-widowed 94-year-old Minneapolitan.

I met Margaret in Minneapolis in 1963, six months after her first husband was killed by a drunken driver. With four small children to support, this young widow wasted no time getting qualified to teach German to high school students. Margaret and I are kindred spirits who bonded instantly, and despite living half a country apart since 1965, we’ve remained devoted friends now for 58 years.

My conversations with Margaret are substantive and illuminating, covering topics that include politics, poetry, plays and philosophy as well as family pleasures and problems. I relish her wisdom and sage advice. I especially delight in the fact that she seems not to have lost an iota of her youthful brain power. She’s as sharp now as she was when we first met decades ago.

Recent findings about the trajectories of human cognition suggest that if no physical insult, like a stroke, intervenes in the next six years, Margaret is destined to be a cognitively sharp centenarian.

Fewer than 1 percent of Americans reach the age of 100, and new data from the Netherlands indicate that those who achieve that milestone with their mental faculties still intact are likely to remain so for their remaining years, even if their brains are riddled with the plaques and tangles that are the hallmarks of Alzheimer’s disease.

Findings from the Dutch study may eventually pave a path for many more of us to become “cognitive super-agers,” as researchers call people who approach the end of the human life span with brains that function as if they were 30 years younger.

One day everyone who is physically able to reach 100 may also be able to remain mentally healthy. By studying centenarians, researchers hope to identify reliable characteristics and develop treatments that would result in healthy cognitive aging for most of us. Meanwhile, there is much we can do now to keep our brains in tiptop condition, even if reaching 100 is neither a goal nor a possibility.

These hopeful prospects stem from the study of 340 Dutch centenarians living independently who were tested and shown to be cognitively healthy when they enrolled. The 79 participants who neither died nor dropped out of the study returned for repeated cognitive testing, over an average follow-up of 19 months.

The research team, directed by Henne Holstege at Vrije University in Amsterdam, reported in JAMA Network Open in January that these participants experienced no decline in major cognitive measures, except for a slight loss in memory function. Basically, the participants performed as if they were 30 years younger in overall cognition; ability to make decisions and plans and execute them; recreate by drawing a figure they had looked at; list animals or objects that began with a certain letter; and not becoming easily distracted when performing a task or getting lost when they left home.

Even those with genes linked to an elevated risk of developing Alzheimer’s disease were able to perform well on the tests.

Nearly a third of the participants agreed to donate their brains after death. Brain autopsies of 44 of the original centenarians revealed that many had substantial neuropathology common to people with Alzheimer’s disease although they had remained cognitively healthy for up to four years beyond 100.

Dr. Thomas T. Perls, a geriatrician at Boston University who directs the New England Centenarian Study who wrote an accompanying editorial, said in an interview that the Dutch participants represented “the crème de la crème” of centenarians who had averted the onset of Alzheimer’s disease by at least 20 to 30 years. They seemed to be either resistant to the disease or cognitively resilient, somehow able to ward off manifestations of its brain-damaging effects. Perhaps both.

Resistance, Dr. Perls explained, may reflect a relative absence of brain damage conferred by a person’s genes or lifestyle. Or they may have “protective biological mechanisms that slow brain aging and prevent clinical illness,” he said.

Resilience, on the other hand, characterizes people with normal cognitive abilities even though their brains may have damage typical of Alzheimer’s, the leading cause of dementia. In addition to plaques and tangles, such changes include loss of neurons, inflammation and clogged blood vessels.

People with cognitive resilience are able to accumulate “higher levels of brain damage before clinical symptoms appear,” the Dutch team reported.

Yaakov Stern, neuropsychologist and director of cognitive neuroscience at Columbia University College of Physicians and Surgeons, said that while resistant individuals may be spared much of the brain pathology typical of Alzheimer’s disease, resilient individuals have what researchers call a cognitive reserve that enables them to cope better with pathological brain changes.

Many studies have revealed that a variety of lifestyle factors may contribute to resilience, Dr. Stern said. Among them are obtaining a higher level and better quality education; choosing occupations that deal with complex facts and data; consuming a Mediterranean-style diet; engaging in leisure activities; socializing with other people; and exercising regularly.

“Controlled trials of exercise have shown that it improves cognition,” he said. “It’s not just a result of better blood flow to the brain. Exercise thickens the cerebral cortex and the volume of the brain, including the frontal lobes that are associated with cognition.”

Dr. Perls said, Alzheimer’s disease is not an inevitable result of aging. Those genetically predisposed can markedly delay it or show no evidence of it before they die by doing the things we know are healthful: exercising regularly, maintaining a healthy weight, not smoking, minimizing red meat in the diet, and doing things that are cognitively new and challenging to the brain, like learning a new language or a musical instrument.”

Also important is to maintain good hearing, said Dr. Perls, a 60-year-old who wears a hearing aid. “I can’t emphasize enough how important it is for people to optimize their ability to hear,” he said. “There’s a direct connection between hearing and preserving cognitive function. Being stubborn about wearing hearing aids is just silly. Hearing loss results in cognitive loss because you miss so much. You lose touch with your environment.”

Vision, too, is important, especially for people who already are cognitively challenged. “Poor vision makes cognitive impairment worse,” Dr. Perls said. As his brain-challenging activity, he’s taken up birding, which requires both good hearing and good vision.

For her part, my friend Margaret reads, writes and recites poetry and occasionally acts in a relative’s films.

Looking to Tackle Prescription Overload

Older adults often take more medications than they need, or than is safe. Increasingly, geriatric experts and their patients are exploring the benefits of “deprescribing.”

The last straw, for Leslie Hawkins, was her mother’s 93rd-birthday gathering in 2018.

Her mother, Mary E. Harrison, had long contended with multiple health problems, including diabetes and the nerve pain it can cause; hypertension; anxiety; and some cognitive decline. She was prone to falling.

Still, she had been a sociable, churchgoing nonagenarian until Ms. Hawkins, who cared for her in their shared home in Takoma Park, Md., began seeing disturbing changes.

“She was out of it,” recalled Ms. Hawkins, 57. “She couldn’t hold a conversation or even finish a sentence.” On her mother’s birthday, she said, “A bunch of us went to Olive Garden, and Mommy sat there asleep, slumped over in her wheelchair. I decided, nope.”

Ms. Hawkins and one of her brothers took their mother to see a geriatrician at Johns Hopkins Hospital, where she could supply only three correct answers on the 30-question test commonly used to assess dementia. “She didn’t really participate,” said the geriatrician, Dr. Stephanie Nothelle.

Fortunately, Ms. Hawkins had brought a list of the 14 medications Ms. Harrison was taking, several of which alarmed her new doctor. “I started chipping away at them,” Dr. Nothelle said.

She recommended stopping oxybutynin, prescribed to treat an overactive bladder, because “it’s notorious for precipitating delirium and causing confusion in older adults,” she said. She also suggested eliminating the pain medication Tramadol, which has similar effects and contributes to unsteadiness and falls.

At their next visit in three months, Dr. Nothelle told the family, they would discuss stopping several more drugs, including gabapentin for neuropathy; a diabetes medication that lowered Ms. Harrison’s blood sugar to unnecessary levels; and a reflux drug that nobody could remember her needing.

The follow-up visit did not happen as scheduled. Ms. Harrison fell and broke her hip, requiring surgery and six weeks in rehab.

Still, her daughter had gotten the message: Her mother’s many drugs might be harming her. “I went online and looked everything up and I started questioning her doctors,” Ms. Hawkins said.

Fourteen prescriptions? “Unfortunately, that’s pretty common” for older patients, Dr. Nothelle said. The phenomenon is called polypharmacy, sometimes defined as taking five or more medications, as two-thirds of older people do.

More broadly, polypharmacy refers to an increasing overload of drugs that may not benefit the patient or interact well with one another, and that may cause harm including falls, cognitive impairment, hospitalization and death. It has sparked interest in “deprescribing”: the practice in which doctors and patients regularly review medication regimens to prune away risky or unnecessary drugs.

For older patients, the most commonly prescribed inappropriate medicines include proton pump inhibitors like Nexium and Prilosec, benzodiazepines like Xanax and Ativan, and tricyclic antidepressants, according to an analysis of Medicare data published last year. Over-the-counter products and supplements can also prove problematic.

“We spend hundreds of millions every year to bring meds to market and figure out when to start using them, and next to nothing trying to figure out when to stop them,” said Dr. Caleb Alexander, an internist and epidemiologist at the Johns Hopkins University School of Medicine. Yet among older people, adverse drug reactions account for one in 11 hospital admissions.

Ms. Hawkins began investigating the various drugs her mother was on. “I went online and looked everything up and I started questioning her doctors,” she said.Rosem Morton for The New York Times
With her daughter’s help and a new doctor, Ms. Harrison has reduced her number of medications, and she is now getting physical therapy to improve her mobility.Rosem Morton for The New York Times
Ms. Hawkins with a box of her mother’s medications. Her mother’s new doctor helped her prune her medications to four drugs, from 14.
Ms. Hawkins with a box of her mother’s medications. Her mother’s new doctor helped her prune her medications to four drugs, from 14.Rosem Morton for The New York Times

Hence the Drive to Deprescribe campaign, launched last month by the Society for Post-Acute and Long-Term Care Medicine, known as AMDA, which represents medical directors and administrators of long-term care facilities, where polypharmacy is particularly prevalent.

The initiative calls for a 25 percent reduction in medication use within a year, with AMDA monitoring the results. “An ambitious goal,” said Dr. Sabine von Preyss-Friedman, co-chair of the Drive to Deprescribe work group. “But if you do a little here and a little there, you don’t move the needle.”

To date, 2,000 facilities have enrolled, along with three major consulting pharmacies that serve them. That represents a fraction of the nation’s 15,000 nursing homes, with several large chains unrepresented, but “we are still recruiting,” Dr. von Preyss-Friedman said.

Another milestone in the polypharmacy battle: the U.S. Deprescribing Research Network, established in 2019 and funded by the National Institute on Aging. So far, it has awarded nine grants to test effective deprescribing strategies.

“Stopping a medication is not just the reverse of starting one,” said Dr. Michael Steinman, a geriatrician at the University of California, San Francisco, and co-director of the network. “It’s often much harder.”

The barriers reflect a fragmented health care system, in which a patient’s endocrinologist, for example, pays scant attention to what her cardiologist or neurologist has prescribed, while her primary care doctor hesitates to overrule any of them.

Deprescribing discussions also require time, a luxury during a brief office visit with a senior who may have many competing needs.

“There’s a general bias toward doing things in medicine,” said Dr. Ariel Green, a geriatrician and researcher at Johns Hopkins. “If we prescribe something, that’s seen as a positive action. If we stop something, or don’t start it, that’s not.”

So inertia can easily take over, with prescriptions being refilled year after year without anyone exploring why they were initially written, whether one drug duplicates another or whether the medications remain necessary or effective.

Most older adults say they are willing to reduce their medications, according to a 2018 study published in JAMA Internal Medicine — yet paradoxically, participants also said that all their medications were necessary.

Seniors may resist deprescribing, unwilling to see a drug routine they have been accustomed to for years as dangerous. “How do we talk about taking fewer medications without it looking like we’re withdrawing care, or like the person isn’t worthy of treatment?” Dr. Green said. Her own studies indicate that older patients respond well to discussions focusing on drugs’ possible side effects.

A dispiriting number of interventions aimed at deprescribing have had little impact, according to a review of 38 studies published last year. But one recent Canadian clinical trial showed significant results.

The study enlisted pharmacists, who handed or mailed patients a deprescribing brochure before refilling certain risky prescriptions. The pharmacists also contacted the prescribing doctors with forms explaining why the drugs might be harmful, providing safer alternatives and allowing doctors to change or eliminate prescriptions by simply checking a box.

Although Ms. Harrison still needs assistance, her condition has vastly improved over the last two years, and she scored far better on a cognition test. “It was night and day,” her doctor said.Rosem Morton for The New York Times

Within six months, 43 percent of those using sedative-hypnotic drugs (benzodiazepines and the related “Z-drugs” like Ambien) were able to discontinue them. So were 30 percent of the patients using the older diabetes drug glyburide and 57 percent of those using nonsteroidal anti-inflammatories, or NSAIDs.

“It was spectacular,” said Dr. Cara Tannenbaum, a geriatrician at the University of Montreal and senior author of the study. Now, she added, “How do we scale it up and get it out of research projects and into everyday practice?”

One way is for patients themselves to combat polypharmacy, by regularly asking their doctors to reassess their medications — sometimes bringing every pill bottle, including supplements, to an appointment for a “brown bag review.” A short list of potentially inappropriate drugs, published by the American Geriatrics Society, can help them spot problems.

That is essentially what Leslie Hawkins did for her mother, Dr. Nothelle said. “Every time she had a health care interaction, she asked, ‘Do we need this? Can we lower this? Can we stop this?’”

Ten months passed before Ms. Harrison could see her geriatrician again, and by then, “she was a completely different person,” Dr. Nothelle said. “She was awake, she answered my questions. It was night and day.”

Ms. Harrison’s score on the 30-question cognition test jumped from three to 25. She is starting physical therapy to improve her mobility. And she is taking four drugs — insulin, a blood pressure medication and two anti-depressants — instead of 14.

Ms. Harrison, now 95, still needs considerable assistance. But at her 94th-birthday celebration in a downtown Washington, D.C., restaurant, with 20 family members including great-grandchildren, “She was the life of the party,” her daughter said. “We had a ball.”