Archives for September 2013

Sibling Squabbles Over Mom? 7 Tips for Getting Along

(AARP with Sally Abrahams) Relationships with siblings can be solid and fulfilling, yet when there are issues regarding aging parents, even the sweetest situations can turn strained or worse.

Hot-button issues are almost always around money (your parents’, caregiving expenses and who pays), family possessions, Mom and Dad’s independence and safety, living arrangements or medical decisions. You know what they say about too many cooks in the kitchen….

Or not enough. Your brother and sister might be delighted to leave the caregiving to you. They might not do their fair share, live so far away that their presence is minimal, or lack the time, money or interest to contribute to your parents’ care. They may also passionately disagree with doctors, you or your parents.

Sometimes squabbling relates less to the present situation and more to the past. “You were always Mom’s favorite” or “a know-it-all.” “You’ve been selfish your whole life.” It can be hard to tease out issues from emotions.

Aging parents and bickering siblings have spawned an industry of elder mediators. These professionals help families make decisions in the parents’ best interest, trying to replace vitriol with reason and preserve sibling relationships.

For those at wit’s end or hoping to avert a blowout, elder mediation can be a way to involve a trained outsider. Rather than the see-you-in-court route where a judge is The Decider, with mediation, decisions are made by consensus. They’re confidential and nonbinding.

The price tag, often shared by siblings or paid for by the parents — typically $150 to $500 an hour for a few hours — is a fraction of what litigation can cost. Community mediation centers may charge a nominal fee. (No guarantee you’ll be locking fingers at the end and singing “Kumbaya,” of course.) Mediators typically talk to all family members individually, including the parents when it’s feasible.

Don’t want an elder mediator? There are strategies that work regardless. Most important, says Crystal Thorpe, a mediator trainer and cofounder at Elder Decisions in Norwood, Mass., is to “keep in mind the wishes of parents. Their primary goal is that their children don’t fight. You’ll want to make parents proud and honor those wishes.”

Ask yourself:

  1. What do my parents want? (This is why you need to have The Talk about their medical and other wishes when they’re still healthy.) Are their wishes realistic? For instance, if they have dementia, or are in a house with steep stairs, are they safe to live alone?
  2. If it makes sense, can you agree on what your parents want and if not, can you work out something that will satisfy them? That could be a paid caregiver, aging in place technology like a Medic Alert-type device or something to reassure the family that they’re okay.
  3. Plan a family meeting, preferably in person, but if impossible, on a conference call, to discuss caregiving — finances, responsibilities, logistics. Follow these up with regular discussions.
  4. What are your siblings’ strengths? If one is tech-savvy, can she set up a secure family website (or consider a site like that is already up and running)? If one isn’t contributing time but can afford it, can she kick in some money for extra help?
  5. One sib will probably be the primary caregiver. Decide how the others can take the pressure off him. Visits to spell him and accompany Dad to the doctor? Pay for respite care? Pay the bills online? Research community resources? Be the liaison with health care providers?
  6. When siblings disagree, listen and ask them why they feel the way they do. Is their perspective valid?
  7. Remember that bad communication and ill will can sever family relationships after your parents are gone. Do you want that?

An excellent book on the topic is Francine Russo’s They’re Your Parents, Too!

Interested in elder mediation? Try, and the National Association for Community Mediation.


By Sally Abrahms. She writes about caregiving, boomer and senior housing and 50+ work. Follow her on Twitter.

Copyright 2013 AARP


The Experience of Early-Stage Alzheimer’s

(BrightFocus Foundation) As persons with early-stage Alzheimer’s are speaking out—online, in support groups, and in publications—we are learning more about what they are experiencing—physically, cognitively, emotionally, socially, and spiritually. How great it is that they have a “voice,” but also it is helpful for everyone to be able to understand Alzheimer’s disease better from an inside perspective.

Different Presentations

We generally know about the symptoms of Alzheimer’s (confusion, memory loss, difficulty concentrating, and functional changes, such as difficulty following directions, laxness in self-care, and loss of interest in social events). However, we are becoming more aware of how each person initially shows different degrees of symptoms. For example, one person’s primary symptom might be expressive language—being able to say what one wants to say—whereas another person’s may be short-term memory loss. There is a saying nowadays that if you have met one person with Alzheimer’s, then you have met one person with Alzheimer’s. In other words, each person has a unique set of symptoms. Thus, we are cautioned not to generalize about the person and not to expect the person will act like every other person with this brain disease. We are encouraged to respond to what the person says or does rather than what we think the person may be experiencing; to view this person as unique, just as we did before the person had the disease.

Core of the Person

When speaking out, persons with early-stage Alzheimer’s emphasize their “personhood” or humanness. Just as cancer or heart disease does not make the person, Alzheimer’s does not define the person.   People living with the disease will always keep their core personality and spirit, which make them who they are. They hope we will continue to see and connect with the essence of the person they have always been—who is so much more than a set of symptoms.


While persons with early-stage Alzheimer’s hope we will see beyond the Alzheimer’s and remember the persons they are, we know they are grappling with their new and changing sense of self. As one person who was recently diagnosed explained, “It’s the loss of oneself while one is still alive.” We see people who have felt pride in their skills such as woodworking who have lost the ability to handle tools and instructions capably. They experience a profound sense of loss when they realize they have lost their competencies. They are left struggling with the existential question of “Who am I?” especially if they have been more self-defined by their job, what they do, or their accomplishments.

At the same time this is happening, people in the early stage of Alzheimer’s may also be losing the ability to navigate around their community, on foot, or in the car. Things become unfamiliar to them. It is as if the ground underneath them is shifting. Can you imagine how unsettling and even frightening this could be? It could feel like being lost in a forest without a compass. To complicate this, the course of Alzheimer’s is unpredictable: a person can have good days and bad days. One day a person may remember if he has taken his medication, the next day he is unsure. This uncertainty, confusion, and vulnerability may result in a person becoming restless, irritable, frustrated, and/or anxious.

In general, in the early stage of the disease, people describe a growing loss of control they feel. They no longer feel like they are the “captain of their ship” because they lack the information and skills to make decisions and take action. They feel more dependent on the people close to them for household tasks, finances, and following doctors’ orders, for example.

People in the early stage may begin to withdraw socially because they are unsure what may happen, what is expected of them, or have difficulty following a conversation. At the same time, friends and family members may begin to pull back socially because they are having a difficult time adjusting to the change in the person with early-stage Alzheimer’s. This may result in the people with the disease feeling lonelier and more isolated. As importantly, however, this social isolation negatively affects the spouse or partner who needs social interaction and emotional support.

Positive Response

It seems the people with early-stage Alzheimer’s who are speaking out are people who are more self-assured. They seem to be tackling this disease as they would any other life challenge. They want to learn as much about the disease as possible so they are better able to respond to situations and prepare for the future. They seek out community resources that would be useful now and down the road for themselves and their spouses or partners. They are asking for support groups so they can meet people who are on the same journey as they. When they meet these people, they gain solace that they are not alone and that others understand what they are experiencing and feeling. They gather strength from being able to talk about their changes and worries in a safe setting free of judgment.

What is amazing is what the people in the early stage are saying. Sure they are grieving their losses—of jobs, sense of self, friends, skills, and independence. But overriding these feelings are statements full of hope and optimism. They have not taken the diagnosis of Alzheimer’s as a death sentence. Rather, they have recognized they still have so much living to do.  We hear them discuss how they enjoy each day, perhaps more than when their lives were so busy. They use their five senses more to appreciate the little things in life, such as a butterfly flitting on the flowers in the garden. We hear them explain how they might have simplified their lives to make it more manageable and feel more secure. We listen to their gratitude for the love and support they receive from loved ones. And we listen to them laugh—not just at a good joke but also at some of the silly things they do or say. What a blessing they have kept their sense of humor. What a gift they have to be able to laugh at themselves.

These folks may have some rocky days ahead, but somehow they will manage well because of their resilience. They have taken the “bull by the horn” and decided “I’m going to deal with this.” They have been proactive and positive.

Early Pioneers

These “early-stage pioneers” are courageous. Just as the pioneers in the U.S. were in the 1800’s, to a great extent, these folks are forging into uncharted territory with few resources or comforts and many unknowns. What they are leaving for those coming behind them are more community or emotional “maps” about lies ahead and how to navigate the land.

They are speaking out to fulfill their own needs, but we will all benefit from their actions. They are raising awareness among the public, policymakers, and legislators about their needs and issues. They are advocating for increased research and services with a passion unparalleled by professional lobbyists. They are informing health care professionals on how to treat them. They are buttressing the infrastructure for spouses, partners, family, and friends to build a support network. We are grateful to these early pioneers and wish them well.


© 2000 – 2013 BrightFocus Foundation. All rights reserved.


Effectiveness of Exercise on Cognitive Impairment and Alzheimer’s Disease

Int J Gen Med. 2013 May 24;6:387-91. doi: 10.2147/IJGM.S35315. Print 2013.

Effectiveness of exercise on cognitive impairment and Alzheimer’s disease.

Balsamo S, Willardson JM, Frederico Sde S, Prestes J, Balsamo DC, Dahan da CN, Dos Santos-Neto L, Nobrega OT.


Graduate Program in Medical Sciences, School of Medicine, University of Brasília, Brasília, Brazil ; Rheumatology Division, University of Brasília Hospital, Brasília, Brazil ; Department of Physical Education, Euro-American University Center, Brasília, Brazil ; GEPEEFS (Strength Training and Health Research Group), Brasília, Brazil.


Physical activity has a protective effect on brain function in older people. Here, we briefly reviewed the studies and results related to the effects of exercise on cognitive impairment and Alzheimer’s disease. The main findings from the current body of literature indicate positive evidence for structured physical activity (cardiorespiratory and resistance exercise) as a promising non-pharmacological intervention for preventing cognitive decline. More studies are needed to determine the mechanisms involved in this preventative effect, including on strength, cardiorespiratory, and other types of exercise. Thus, the prevention of Alzheimer’s disease may depend on healthy lifestyle habits, such as a structured physical fitness program.


PMID: 23737675 PubMed PMCID:PMC3668090

National Center for Biotechnology Information, U.S. National Library of Medicine


CB1 Cannabinoid Receptor Agonist Protects Neurons and Reduces Cognitive Impairment in Mice

J Alzheimers Dis. 2012;30(2):439-59. doi: 10.3233/JAD-2012-111862.

CB1 agonist ACEA protects neurons and reduces the cognitive impairment of AβPP/PS1 mice.

Aso E, Palomer E, Juvés S, Maldonado R, Muñoz FJ, Ferrer I.

Institut de Neuropatologia, Servei d’Anatomia Patològica, IDIBELL-Hospital Universitari de Bellvitge, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain.


The present study shows that chronic administration of the cannabinoid receptor type 1 (CB1) receptor agonist arachidonyl-2-chloroethylamide (ACEA) at pre-symptomatic or at early symptomatic stages, at a non-amnesic dose, reduces the cognitive impairment observed in double AβPP(swe)/PS1(1dE9) transgenic mice from 6 months of age onwards. ACEA has no effect on amyloid-β (Aβ) production, aggregation, or clearance.

However, ACEA reduces the cytotoxic effect of Aβ42 oligomers in primary cultures of cortical neurons, and reverses Aβ-induced dephosphorylation of glycogen synthase kinase-3β (GSK3β) in vitro and in vivo. Reduced activity of GSK3β in ACEA-treated mice is further supported by the reduced amount of phospho-tau (Thr181) in neuritic processes around Aβ plaques.

In addition, ACEA-treated mice show decreased astroglial response in the vicinity of Aβ plaques and decreased expression of the pro-inflammatory cytokine interferon-γ in astrocytes when compared with age-matched vehicle-treated transgenic mice.

Our present results show a beneficial effect of ACEA at both the neuronal, mediated at least in part by GSK3β inhibition, and glial levels, resulting in a reduction of reactive astrocytes and lower expression of interferon-γ.

As a consequence, targeting the CB1 receptor could offer a versatile approach for the treatment of Alzheimer’s disease.


National Center for Biotechnology Information, U.S. National Library of Medicine


Cannabinoids for the Treatment of Dementia

Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007204. doi: 10.1002/14651858.CD007204.pub2.

Cannabinoids for the treatment of dementia.

Krishnan S, Cairns R, Howard R.

Mental Health of Older Adults, Maudsley Hospital, Denmark Hill, London, UK, SE5 8AZ.



Following the discovery of an endogenous cannabinoid system and the identification of specific cannabinoid receptors in the central nervous system, much work has been done to investigate the main effects of these compounds. There is increasing evidence that the cannabinoid system may regulate neurodegenerative processes such as excessive glutamate production, oxidative stress and neuroinflammation. Neurodegeneration is a feature common to the various types of dementia and this has led to interest in whether cannabinoids may be clinically useful in the treatment of people with dementia. Recent studies have also shown that cannabinoids may have more specific effects in interrupting the pathological process in Alzheimer’s disease.


To determine from available research whether cannabinoids are clinically effective in the treatment of dementia.

Search Strategy

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 11 April 2008 using the terms: cannabis or cannabinoid* or endocannabinoid* or cannabidiol or THC or CBD or dronabinol or delta-9-tetrahydrocannabinol or marijuana or marihuana or hashish. The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many clinical trials registries and grey literature sources.

Selection Criteria

All double-blind and single (rater)-blind randomized placebo controlled trials assessing the efficacy of cannabinoids at any dose in the treatment of people with dementia.

Data Collection and Analysis

Two reviewers independently examined the retrieved studies for inclusion according to the selection criteria. They then independently assessed the methodological quality of selected trials and extracted data where possible.

Main Results

Only one study met the inclusion criteria. The data in the study report were presented in such a way that they could not be extracted for further analysis and there was insufficient quantitative data to validate the results.


This review finds no evidence that cannabinoids are effective in the improvement of disturbed behaviour in dementia or in the treatment of other symptoms of dementia. More randomized double-blind placebo controlled trials are needed to determine whether cannabinoids are clinically effective in the treatment of dementia.



Helping People with Alzheimer’s Disease Stay Physically Active

(National Institute on Aging) Regular physical activity has many benefits for people with Alzheimer’s disease. Exercise helps keep muscles, joints, and the heart in good shape. It also helps people stay at a healthy weight and can improve sleep. Caregivers can help people with Alzheimer’s disease be more active and stay safe:

  • Be realistic about how much activity can be done at one time. Several 10-minute “mini-workouts” may be best.
  • Help get the activity started or join in to make the activity more fun.
  • Find time in the morning for exercise.
  • Break exercises into simple, easy-to-follow steps.
  • Choose comfortable clothes that are suitable for the weather and appropriate shoes that fit well.
  • Make sure both you and the person with Alzheimer’s drink plenty of water when exercising.

Some physical activities to try:

  • Take a walk together.
  • Do simple tasks around the house, such as sweeping and raking.
  • Work in the garden.
  • Play music and dance.
  • Exercise with videos made for older people. Try the sample workout on NIA’s free Go4Life DVD.
  • Throw a soft rubber exercise ball back and forth.
  • Lift weights or household items such as soup cans.
  • Use resistance bands, which you can buy in sporting goods stores. Be sure to follow the instructions.

Go4Life is a registered trademark of the U.S. Department of Health and Human Services.

National Institute on Aging


Trial of Rivastigmine Patch for Patients with Severe Alzheimer’s Disease

CNS Neurosci Ther. 2013 Aug 7. doi: 10.1111/cns.12158. [Epub ahead of print]

A 24-Week, Randomized, Controlled Trial of Rivastigmine Patch 13.3 mg/24 h Versus 4.6 mg/24 h in SevereAlzheimer’s Dementia.

Farlow MRGrossberg GTSadowsky CHMeng XSomogyi M.

Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.



The 24-week, prospective, randomized, double-blind ACTION study investigated the efficacy, safety, and tolerability of 13.3 versus 4.6 mg/24 h rivastigmine patch in patients with severe Alzheimer’s disease (AD).


Patients had probable AD and Mini-Mental State Examination scores ≥3-≤12. Primary outcome measures were as follows: Severe Impairment Battery (SIB) and AD Cooperative Study-Activities of Daily Living scale-Severe Impairment Version (ADCS-ADL-SIV). Secondary outcomes were as follows: ADCS-Clinical Global Impression of Change (ADCS-CGIC), 12-item Neuropsychiatric Inventory (NPI-12), and safety/tolerability.


Of 1014 patients screened, 716 were randomized to 13.3 mg/24 h (N = 356) or 4.6 mg/24 h (N = 360) patch. Baseline characteristics/demographics were comparable. Completion rates were as follows: 64.3% (N = 229) with 13.3 mg/24 h and 65.0% (N = 234) with 4.6 mg/24 h patch.

The 13.3 mg/24 h patch was significantly superior to 4.6 mg/24 h patch on cognition (SIB) and function (ADCS-ADL-SIV) at Week 16 (P < 0.0001 and P = 0.049, respectively) and 24 (primary endpoint; P < 0.0001 and P = 0.025). Significant between-group differences (Week 24) were observed on the ADCS-CGIC (P = 0.0023), not NPI-12 (P = 0.1437).

A similar proportion of the 13.3 mg/24 h and 4.6 mg/24 h patch groups reported adverse events (AEs; 74.6% and 73.3%, respectively) and serious AEs (14.9% and 13.6%).


The 13.3 mg/24 h patch demonstrated superior efficacy to 4.6 mg/24 h patch on SIB and ADCS-ADL-SIV, without marked increase in AEs, suggesting higher-dose patch has a favorable benefit-to-risk profile in severe AD.


Combined Impact of Smoking and Heavy Alcohol Use on Cognitive Decline in Early Old Age

Br J Psychiatry. 2013 Aug;203:120-5. doi: 10.1192/bjp.bp.112.122960. Epub 2013 Jul 11.

Combined impact of smoking and heavy alcohol use on cognitive decline in early old age: Whitehall II prospective cohort study.

Hagger-Johnson G, Sabia S, Brunner EJ, Shipley M, Bobak M, Marmot M, Kivimaki M, Singh-Manoux A.



Identifying modifiable risk factors for cognitive decline may inform prevention of dementia.


To examine the combined impact of cigarette smoking and heavy alcohol consumption on cognitive decline from midlife.


Prospective cohort study (Whitehall II cohort) with three clinical examinations in 1997/99, 2002/04 and 2007/09. Participants were 6473 adults (72% men), mean age 55.76 years (s.d. = 6.02) in 1997/99. Four cognitive tests, assessed three times over 10 years, combined into a global z-score (mean 0, s.d. = 1).


Age-related decline in the global cognitive score was faster in individuals who were smoking heavy drinkers than in non-smoking moderate alcohol drinkers (reference group). The interaction term (P = 0.04) suggested that the combined effects of smoking and alcohol consumption were greater than their individual effects. Adjusting for age, gender, education and chronic diseases, 10-year decline in global cognition was -0.42 z-scores (95% CI -0.45 to -0.39) for the reference group. In individuals who were heavy alcohol drinkers who also smoked the decline was -0.57 z-scores (95% CI -0.67 to -0.48); 36% faster than the reference group.


Individuals who were smokers who drank alcohol heavily had a 36% faster cognitive decline, equivalent to an age-effect of 2 extra years over 10-year follow-up, compared with individuals who were non-smoking moderate drinkers.