Archives for January 2015

Anger: A Normal Emotion for Alzheimer’s Caregivers

Dear Readers:

The following blog is written by Angela Lunde, a dementia education specialist in the education core of Mayo Clinic’s Alzheimer’s Disease Research Center at the Abigail Van Buren Alzheimer’s Disease Research Clinic in Rochester, Minn.

Angela is just fantastic and has written many wonderful blogs that have created a lot of interest and support for AD caregivers.

You can visit her blog at Expert Blog for more information.

~ Jennifer

(Mayo Clinic) Doug and so many of you wrote about the perplexing nature of acceptance.  Many of you agreed that accepting your situation as it is offers up room for ease and coping, but nevertheless isn’t easy.

As Doug wrote, “accepting is not a onetime process…it is a work in progress”. And Joy wrote, “Sometimes we just get tired out and have to holler.” How true those statements are!

Acceptance isn’t the same as liking it, and acceptance doesn’t mean we aren’t allowed to get angry. You, as caregivers, have every right to feel all of your emotions and to let them out. You’re entitled to bad days — no judgment or apology necessary.

Although Joy recognizes her anger, not all caregivers can see it in themselves. Often you may not be in tune with your emotions because you’re immersed in someone else’s needs and consumed with the tasks at hand.  Yet you live in extraordinary circumstances and have understandable reasons to be angry.

You take on difficult and unpleasant tasks and often feel unappreciated. You have little time for yourself and less time for friends and personal relationships. In addition, you often set unrealistic expectations for yourself and often believe it’s a sign of weakness to ask for help, or believe that no one can do the job quite like you can.

It’s common to feel anger toward the one you’re caring for.  Sometimes, the anger may be a symptom of the fear most caregivers experience when faced with such an ambiguous loss. Undoubtedly, caregivers are at risk for feeling angry. However, feeling angry isn’t the real problem. As caregivers you’re entitled to (and should) feel anger if that’s what you feel. The problem comes with not knowing what to do or how to relieve the anger.

An excellent booklet titled “Pressure Points — Alzheimer’s and Anger”, from the Duke Family Support Program at Duke University Medical Center, states that anger is a normal and expectable emotion. The booklet offers ways of responding that support the caregivers’ well-being and that of the person they’re caring for.

I’m going to highlight some of the ways to manage anger in my next blog. But for now, I want to leave you with an excerpt from the booklet and ask that you offer some thoughts on your own anger triggers (or pressure points) and what, if any, helpful ways you respond when you get angry.

“Anger is an emotional response to a grievance, real or imaginary, in the past, present or future. The pain of anger is very real. If we don’t know how to relieve it the right way, we will react to it in ways that make things worse instead of better.”

— Mitchell Messer as cited in the booklet “Pressure Points — Alzheimer’s and Anger”


By Angela Lunde

© 1998-2015 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “,” “EmbodyHealth,” “Enhance your life,” and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.


Activities for People with Alzheimer’s Disease

(American Association of Retired Persons) Melanie, a music therapist, regularly played live classical music for a Chicago woman who was in the late stages of Alzheimer’s. The woman used to frequent the opera and classical music venues, but for some reason, the songs did not seem to resonate with her. Melanie then played a Frank Sinatra CD. Immediately, the woman’s eyes lit up. Frank’s crooning, instead of the live sounds of the flute and guitar, really moved her.

For people with Alzheimer’s disease, a successful activity, whether it’s listening to music or playing a game, helps create meaning and pulls from past interests, says Cameron Camp, Director and Senior Research Scientist, Myers Research Institute of Menorah Park Center for Senior Living. Activities allow the person to be part of a family and community and gives him or her the chance to be more engaged with life.

“The biggest thing to remember with a person with dementia is that they’re a person with dementia,” says Camp.

There will always be part of that individual who wants to help, participate, and succeed. Although as the caregiver you will want to find activities that take in account lost abilities, you should always focus on the person and not the disease. Even if your loved one does not remember the activity, the joy he feels from taking part in a project, big or small, leaves a positive effect and contributes to an overall sense of happiness.

Why Activities Help

Although they don’t necessarily slow the progression of Alzheimer’s, activities do improve your loved one’s quality of life. Games, housework, and the other activities listed below can lessen agitation and depression. Activities can also help maintain motor skills that aid daily tasks such as buttoning a shirt or recognizing household objects. Projects that match a person’s skill level also give her a sense of ownership and independence. And when your loved one completes an activity, she gains a sense of accomplishment.

Activities also help relieve a caregiver’s frustration by keeping the loved one stimulated and by fostering emotional connection and self expression.

General Guidelines

  • Create meaningful activities. This is not about filling the day – no busy work. Try for activities that your loved one used to do and enjoy.
  • Assess skills. Can they sort objects by size or color? Can they button shirts and zip up jackets? Can they follow written commands? Modify activities to make them more or less challenging to fit the skills of your loved one.
  • Play up past interests. People with Alzheimer’s often maintain old habits and abilities. Try adapting these skills into smaller and more manageable components. Create games based on their interests.
  • Make activities failure free. If your loved one is involved and happy, don’t correct him. The goal is to engage the person with dementia and encourage a sense of success.
  • Keep activities simple. Too many decisions may frustrate people with Alzheimer’s. Keep crowds and noise to a minimum.
  • Give both verbal and visual instruction. Feel free to tell and to show. If your loved one is accepting, even guide his arms gently as you instruct.
  • Do activities that let your loved one manipulate materials. For people with advanced dementia, avoid small objects that might be swallowed.
  • Select the best time of day for your loved one. More energy in the morning? Go for a walk. More focused in the afternoon? Try an art project.
  • Keep the work area safe. Work with unbreakable plastics; keep the surface clean, uncluttered and well lit.
  • Be prepared with alternate activities. If your loved one doesn’t connect with an activity, be sure to have another ready. Through trial and error, you’ll find activities that best suit your loved one.
  • And don’t be afraid to try something new, to see if it arouses curiosity.
  • Repeat favorite activities, and establish a routine. Note the activities your loved one enjoys. Although the patient may not remember them the next time, she may repeat the processes instinctively. While doing familiar activities, such as sorting objects, keep the procedures the same, but try different content from day to day to keep it fresh for her and for you.

Activities to Try

  • Simplify old hobbies. For those who liked to knit, try a simpler pattern. If they enjoy crossword puzzles, try a jigsaw puzzle with large pieces.
  • Garden together. Basic, repetitive tasks such as raking may fulfill your loved one, especially if he gardened in the past. Use herbs or other nontoxic plants that arouse multiple senses.
  • Find her inner artist. Paint with watercolors, draw with crayons. People with Alzheimer’s may not judge themselves as harshly as they once did, so they may finally free their inner artists.


Exercise helps everyone, including people with dementia, to maintain a healthy appetite, get a good night’s sleep and achieve a happy, endorphin-boosted outlook.

  • Take a walk.
  • Go for a swim.
  • Participate in a yoga or tai chi class at your local community center. Simplify by picking only a couple of moves to try, or watch a yoga tape together.
  • Visit a therapeutic garden. These provide walking paths, bird feeders accessible to those in wheelchairs, and sturdy furniture for older adults. Gardens provide a safe environment to reconnect with nature, get a little exercise and absorb some vitamin D.


  • Sorting games. Sort objects by color, shape or design. Infuse the game with your loved one’s favorite hobbies. For example, baseball fans can sort cards by team or position. If your loved one enjoyed carpentry, have him match tools with their names.
  • Play ball. Use balloons or large, soft balls to play catch.
  • Shopping scavenger hunt: Collect sales ads from newspapers with your loved one. While you travel the aisles with your loved one, give her a list of items to search for in the grocery store. Up the ante and search for items with the lowest cost.
  • Solve puzzles. Create jigsaw puzzles from family photos. Cut them into two or three large pieces to start. You can divide the photo into more pieces to make the activity more challenging.
  • Shuffle a prayer. Type lines of their favorite prayer on separate pieces of paper for re-ordering.

Daily Tasks and Chores

  • Read together. Read the paper or book with large print. Take turns, and have fun.
  • Bake together. Pick simple recipes for cookies, muffins and pancakes. Put him in charge of part of the recipe or an easier task, such as stirring.
  • Clean up together. Ask your loved one to help you around the house. By doing simple tasks such as wiping off the table, sweeping the patio, washing the silverware, folding towels or simply holding open the trash bag as you put things into it, she becomes part of a team. Remember that she may not perform the tasks to perfection, but it is the process that is important.

Help Others

By helping others, you can help your loved one combat feelings of uselessness.

  • Start a food drive. Collect canned goods and other nonperishable items from your neighbors or grocery store. Get your loved one involved, whether she selects the items or helps you load the bags.
  • Participate in a toy drive. Collect, wrap and take the toys together to a women’s shelter or orphanage.


  • Talk about old times. Encourage your loved one to remember a favorite summer, first day of school or wedding day. Keep in mind, though, that painful memories may also resurface.
  • Watch family videos. Pull out old movies or make a new one where family members discuss their fondest memories of your loved one.
  • Go through photo albums. Old pictures can trigger pleasant memories.
  • Watch a favorite movie or TV show from their past.
  • Go through a box of trinkets from their life.
  • Write down family stories. Keep a book of the memories your loved one has related, and ask her to read it to the grandchildren.


Some music therapists have found that adults with advanced Alzheimer’s often respond to music, and especially music from their past. In fact, researchers have found that the ability to process music remains intact into the late stages of the disease.

  • Trigger old memories. Play their favorite hymn, music from their youth or well-known popular songs of their day. Make a CD of their favorite songs.
  • Dance. If they enjoyed dancing, they probably still do, or at least will respond to the sight of others dancing. You could attend a dance class and sit in the audience.
  • Sing along. People with Alzheimer’s often retain melodies and words to popular songs. Print out the words to a song and sing along with a CD. Or sing with a group while someone plays a piano or guitar.


Here’s a source of unconditional love. Pets convey their needs in ways that everyone, including people with Alzheimer’s, easily understands, and they provide comfort. Relax by watching birds from a window or fish in an aquarium.


Remember that as Alzheimer’s advances, your loved one will retain all of his or her senses.

  • Talk to him. While your loved one may not respond, this doesn’t mean that he is not aware of your presence.
  • Comb her hair.
  • Moisturize her skin.
  • Shave his face.
  • Give her a manicure or a hand massage with scented oil.
  • Give her dolls with zippers and buttons to play with or soft teddy bears, textured cloth, or fur to stroke.

© 2003, 2004, 2007 AARP. All rights reserved.


Voices of Alzheimer Caregivers on Positive Aspects of Caregiving

Gerontologist. 2015 Jan 21. pii: gnu118. [Epub ahead of print]

Voices of Alzheimer Caregivers on Positive Aspects of Caregiving.

Cheng ST1, Mak EP2, Lau RW3, Ng NS2, Lam LC4.



To discover positive gains as constructed by family caregivers of relatives with Alzheimer‘s disease.


Fifty-seven Hong Kong Chinese primary caregivers provided 669 diary recordings over an 8-week period, describing daily events and experiences in which positive gains were achieved. The diaries were analyzed independently by two researchers using thematic analysis.


Ten themes related to positive gains were identified: (a) insights about dementia and acceptance of the condition, (b) a sense of purpose and commitment to the caregiving role, (c) feelings of gratification when the care-recipient (CR) was functioning relatively well, (d) mastering skills to handle the CR, (e) increased patience and tolerance, (f) cultivating positive meanings and humor amidst difficult circumstances, (g) letting go of things, such as when the CR’s qualities had been lost or personal agenda had become unrealistic, (h) developing a closer relationship with the CR, (i) finding support, and (j) feeling useful helping other caregivers.


In addition to treating negative outcomes such as depression, practitioners and researchers should, identify means to promote positive gains. Strategies mentioned in the caregivers‘ diaries, such as reframing stressful situations in a more positive light, may provide input into the design of such interventions.

© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail:

Nasal Spray with Insulin Equivalent Shows Promise as Treatment for Adults with Mild Cognitive Impairment, Alzheimer’s Dementia

(Wake Forest Baptist Medical Center) A man-made form of insulin delivered by nasal spray may improve working memory and other mental capabilities in adults with mild cognitive impairment and Alzheimer’s disease dementia, according to a pilot study led by researchers at Wake Forest Baptist Medical Center.

The study’s subjects were 60 adults diagnosed with amnesic mild cognitive impairment (MCI) or mild to moderate Alzheimer’s dementia (AD). Those who received nasally-administered 40 international unit (IU) doses of insulin detemir, a manufactured form of the hormone, for 21 days showed significant improvement in their short-term ability to retain and process verbal and visual information compared with those who received 20 IU does or a placebo.

Additionally, the recipients of 40 IU doses carrying the APOE-e4 gene – which is known to increase the risk for Alzheimer’s – recorded significantly higher memory scores than those who received the loser dosage or placebo, while non-carriers across all three groups posted significantly lower scores.

Previous trials had shown promising effects of nasally-administered insulin for adults with AD and MCI, but this study was the first to use insulin detemir, whose effects are longer-lasting than those of “regular” insulin.

“The study provides preliminary evidence that insulin detemir can provide effective treatment for people diagnosed with mild cognitive impairment and Alzheimer’s-related dementia similar to our previous work with regular insulin,” said Suzanne Craft, Ph.D., professor of gerontology and geriatric medicine at Wake Forest Baptist and lead author of the study, which is published online in advance of the February issue of the Journal of Alzheimer’s Disease.

“We are also especially encouraged that we were able to improve memory for adults with MCI who have the APOE-e4 gene, as these patients are notoriously resistant to other therapies and interventions.”

The researchers also sought to determine if the insulin detemir doses would cause any negative side effects, and found only minor adverse reactions among the subjects.

The study’s overall results support further investigation of the therapeutic value of insulin detemir as a treatment for Alzheimer’s and other neurodegenerative diseases, Craft said.

“Alzheimer’s is a devastating illness, for which even small therapeutic gains have the potential to improve quality of life and significantly reduce the overall burden for patients, families and society,” she said. “Future studies are warranted to examine the safety and efficacy of this promising treatment.”

The research was support by National Institute of Aging grants P50 AG05136 and T32 AG000258 and the Department of Veteran Affairs.

Co-authors are Laura Baker, Ph.D., Wake Forest Baptist; Amy Claxton, Ph.D., Angela Hanson, M.D., Emily H. Trittschuh, Ph.D., Amy Morgan, R.N., Maureen Callaghan, M.D., and Colin Behl, B.S., Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine; Brenna Cholerton, Ph.D., University of Washington School of Medicine; and Matthew Arbuckle, Oregon Health Sciences University.


© Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157. All Rights Reserved.


First Evidence of Potential Efficacy of Tau Aggregation Inhibitor Therapy in Alzheimer’s Disease

(Journal of Alzheimer’s Disease) The Journal of Alzheimer’s Disease has published today the results of the first clinical trial of a Tau Aggregation Inhibitor (TAI) in Alzheimer’s disease (AD). This Phase II clinical trial, conducted by TauRx Therapeutics Ltd (a Singapore incorporated spinout from the University of Aberdeen), provided the basis and rationale for subsequent Phase III clinical trials of a TAI in AD currently in progress.

The double-blind dose-finding Phase II clinical trial involved 321 patients in 16 clinical research centres in the UK and one centre in Singapore and tested three doses of the drug. The study met its predefined primary efficacy endpoint at 24 weeks on the standard scale most commonly used to measure cognitive decline in clinical trials (ADAS-cog) at the 138 mg / day dose.

The primary result was also supported by benefit on two other clinical scales. The effect sizes seen were statistically significant and clinically meaningful in moderate subjects at 24 weeks. The clinical results were also supported by brain scan evidence of arrest of decline over the same period in mild subjects at the same dose. The beneficial effect was sustained to 50 weeks in both mild and moderate subjects at this dose, with 90% reduction in the rate of cognitive decline overall.

This is the first ever clinical trial which has attempted to target directly the hallmark neurofibrillary tangle pathology of AD. Tangles were originally discovered by Alois Alzheimer in 1906 and this discovery gave the disease its name. Tangles were found to be composed of abnormal filaments largely made up of a short fragment of the protein Tau in 1988 by Professor Claude Wischik (co-founder of TauRx Therapeutics Ltd) and colleagues in Cambridge, UK. The spread and density of tangles in the brain are known to be highly correlated with the clinical severity of dementia.

They are also correlated with the extent of abnormal aggregation of Tau protein and loss of neuronal function seen on brain scans in those brain regions where tangles typically form. Wischik and colleagues went on to report in 1996 that the chemical substance methylthioninium (MT), used in medicine for the last 100 years, dissolves tangle filaments isolated from the human brain by selectively blocking a critical step in the process required to form the rogue filaments.

The encouraging efficacy signals seen in the TauRx trial at the minimum effective dose of 138 mg / day were first announced in a preliminary form at the Alzheimer’s Association International Conference on Alzheimer’s Disease in Chicago, USA, in July 2008. However, the surprising observation that the top dose of 228 mg /day had reduced efficacy has taken TauRx scientists a further 4 years to unravel. The results of these studies have also been reported in parallel in the Journal of Pharmacology and Experimental Therapeutics [2].

The form of MT that has been used in medicine for the last 100 years (a chloride salt of the oxidised MT+ form of the molecule, denoted MTC, and commonly known as “methylene blue”) is poorly tolerated without food, so taking it with food has been recommended traditionally.

However, TauRx scientists discovered that MTC suffers from dose-dependent impairment in absorption when taken with food. This is due to the fact that the oxidised MT+ form needs to be actively converted to the reduced LMT form in the gut before it can be absorbed as LMT. In other words, MTC is a pro-drug for LMT, and food interferes with the conversion and absorption process.

Since MTC was given with food in the Phase II trial to maximise tolerability for patients, only 109 mg / day of the intended 228 mg dose was available for absorption. Therefore, the minimum effective dose of 138 mg / day identified in the trial was simply the highest available dose tested.

In order to go forward into Phase III testing, TauRx scientists have developed an entirely new form of the molecule which keeps MT in the LMT form and therefore permits it to be absorbed directly without need for active conversion in the gut. This new form is denoted LMTX® for the present and is better absorbed and tolerated than MTC. This has enabled Phase III trials to test whether an even higher level of efficacy can be achieved without significant loss of tolerability and safety.

The ongoing trials are testing MT delivered as LMTX® in the dosage range of 150 – 250 mg / day. The full results now published in the Journal of Alzheimer’s Disease were previously available only as reports supporting regulatory filings for global confirmatory Phase III clinical trials in 22 countries.

These trials are now fully recruited and the first results are expected in the first half of 2016. If the Phase III clinical trials confirm a level of efficacy and safety similar to that seen in the Phase II trial reported in the Journal of Alzheimer’s Disease, a treatment targeting the Tau aggregation pathology of AD could be on the market as early as 2017.


Copyright © 2015 Journal of Alzheimer’s Disease


Preventing Loss of Independence through Exercise in Adults with Dementia

Aging Ment Health. 2015 Apr;19(4):353-62. doi: 10.1080/13607863.2014.935290

Preventing Loss of Independence through Exercise (PLIÉ): qualitative analysis of a clinical trial in older adults with dementia.

Wu E1, Barnes DE, Ackerman SL, Lee J, Chesney M, Mehling WE.



Preventing Loss of Independence through Exercise (PLIÉ) is a novel, integrative exercise program for individuals with dementia that combines elements of different conventional and complementary exercise modalities (e.g. tai-chi, yoga, Feldenkrais, and dance movement therapy) and focuses on training procedural memory for basic functional movements (e.g., sit-to-stand) while increasing mindful body awareness and facilitating social connection. This study presents analyses of qualitative data collected during a 36-week cross-over pilot clinical trial in 11 individuals.


Qualitative data included exercise instructors’ written notes, which were prepared after each class and also following biweekly telephone calls with caregivers and monthly home visits; three video-recorded classes; and written summaries prepared by research assistants following pre- and post-intervention quantitative assessments.

Data were extracted for each study participant and placed onto a timeline for month of observation. Data were coded and analyzed to identify themes that were confirmed and refined through an iterative, collaborative process by the entire team including a qualitative researcher (SA) and the exercise instructors.


Three overarching themes emerged: (1) Functional changes included increasing body awareness, movement memory and functional skill. (2) Emotional changes included greater acceptance of resting, sharing of personal stories and feelings, and positive attitude toward exercise. (3) Social changes included more coherent social interactions and making friends.


These qualitative results suggest that the PLIÉ program may be associated with beneficial functional, emotional, and social changes for individuals with mild to moderate dementia. Further study of the PLIÉ program in individuals with dementia is warranted.



Higher Dementia Risk Linked to More Use of Common Drugs

(Group Health Research Institute) A large study links a significantly increased risk for developing dementia, including Alzheimer’s disease, to taking commonly used medications with anticholinergic effects at higher doses or for a longer time. Many older people take these medications, which include nonprescription diphenhydramine (Benadryl). JAMA Internal Medicine published the report, called “Cumulative Use of Strong Anticholinergics and Incident Dementia.”

The study used more rigorous methods, longer follow-up (more than seven years), and better assessment of medication use via pharmacy records (including substantial nonprescription use) to confirm this previously reported link. It is the first study to show a dose response: linking more risk for developing dementia to higher use of anticholinergic medications. And it is also the first to suggest that dementia risk linked to anticholinergic medications may persist—and may not be reversible even years after people stop taking these drugs.

“Older adults should be aware that many medications—including some available without a prescription, such as over-the-counter sleep aids—have strong anticholinergic effects,” said Shelly Gray, PharmD, MS, the first author of the report, which tracks nearly 3,500 Group Health seniors participating in the long-running Adult Changes in Thought (ACT), a joint Group Health–University of Washington (UW) study funded by the National Institute on Aging.

“And they should tell their health care providers about all their over-the-counter use,” she added.

“But of course, no one should stop taking any therapy without consulting their health care provider,” said Dr. Gray, who is a professor, the vice chair of curriculum and instruction, and director of the geriatric pharmacy program at the UW School of Pharmacy.

“Health care providers should regularly review their older patients’ drug regimens—including over-the-counter medications—to look for chances to use fewer anticholinergic medications at lower doses.”

For instance, the most commonly used medications in the study were tricyclic antidepressants like doxepin (Sinequan), first-generation antihistamines like chlorpheniramine (Chlor-Trimeton), and antimuscarinics for bladder control like oxybutynin (Ditropan). The study estimated that people taking at least 10 mg/day of doxepin, 4 mg/day of chlorpheniramine, or 5 mg/day of oxybutynin for more than three years would be at greater risk for developing dementia.

Dr. Gray said substitutes are available for the first two: a selective serotonin re-uptake inhibitor (SSRI) like citalopram (Celexa) or fluoxitene (Prozac) for depression and a second-generation antihistamine like loratadine (Claritin) for allergies. It’s harder to find alternative medications for urinary incontinence, but some behavioral changes can reduce this problem.

“If providers need to prescribe a medication with anticholinergic effects because it is the best therapy for their patient,” Dr. Gray said, “they should use the lowest effective dose, monitor the therapy regularly to ensure it’s working, and stop the therapy if it’s ineffective.”

Anticholinergic effects happen because some medications block the neurotransmitter called acetylcholine in the brain and body, she explained. That can cause many side effects, including drowsiness, constipation, retaining urine, and dry mouth and eyes.

“With detailed information on thousands of patients for many years, the ACT study is a living laboratory for exploring risk factors for conditions like dementia,” said Dr. Gray’s coauthor Eric B. Larson, MD, MPH.

“This latest study is a prime example of that work and has important implications for people taking medications—and for those prescribing medications for older patients.”

Dr. Larson is the ACT principal investigator, vice president for research at Group Health, and executive director of Group Health Research Institute (GHRI). He is also a clinical professor of medicine at the UW School of Medicine and of health services at the UW School of Public Health.

Some ACT participants agree to have their brains autopsied after they die. That will make it possible to follow up this research by examining whether participants who took anticholinergic medications have more Alzheimer’s-related pathology in their brains compared to nonusers.


Journal Reference:

  1. Shelly L. Gray, Melissa L. Anderson, Sascha Dublin, Joseph T. Hanlon, Rebecca Hubbard, Rod Walker, Onchee Yu, Paul K. Crane, Eric B. Larson. Cumulative Use of Strong Anticholinergics and Incident Dementia. JAMA Internal Medicine, 2015; DOI: 10.1001/jamainternmed.2014.7663

© 2015 Group Health Research Institute


Dietary and Lifestyle Guidelines for the Prevention of Alzheimer’s Disease

Neurobiol Aging. 2014 Sep;35 Suppl 2:S74-8. doi: 10.1016/j.neurobiolaging.2014.03.033. Epub 2014 May 14.

Dietary and lifestyle guidelines for the prevention of Alzheimer‘s disease.

Barnard ND1, Bush AI2, Ceccarelli A3, Cooper J4, de Jager CA5, Erickson KI6, Fraser G7, Kesler S8, Levin SM9, Lucey B10, Morris MC11, Squitti R12.


Risk of developing Alzheimer‘s disease is increased by older age, genetic factors, and several medical risk factors. Studies have also suggested that dietary and lifestyle factors may influence risk, raising the possibility that preventive strategies may be effective. This body of research is incomplete.

However, because the most scientifically supported lifestyle factors for Alzheimer‘s disease are known factors for cardiovascular diseases and diabetes, it is reasonable to provide preliminary guidance to help individuals who wish to reduce their risk.

At the International Conference on Nutrition and the Brain, Washington, DC, July 19-20, 2013, speakers were asked to comment on possible guidelines for Alzheimer‘s disease prevention, with an aim of developing a set of practical, albeit preliminary, steps to be recommended to members of the public.

From this discussion, 7 guidelines emerged related to healthful diet and exercise habits.


Alzheimer’s disease affected an estimated 4.7 million Americans in 2010, and its prevalence is expected to nearly triple in coming decades (Hebert et al., 2013). Several factors contribute to the risk of developing late-onset Alzheimer’s disease, including older age, genetic factors (especially the presence of the APOEε4 allele), family history, a history of head trauma, midlife hypertension, obesity, diabetes, and hypercholesterolemia (Bendlin et al., 2010).

In addition, recent prospective studies have shown that certain dietary and lifestyle factors, including saturated fat intake, vitamin E intake, and physical exercise, among others, are associated with Alzheimer’s risk, suggesting that prevention strategies may be applicable for these factors.

In each of these areas, scientific evidence is less than complete. Nonetheless, individuals at risk for Alzheimer’s disease make decisions about dietary and lifestyle on a daily basis and need to act on the best evidence available to them, even when scientific consensus may not have been achieved.

In toxicology, the “precautionary principle” is invoked in situations in which there is a substantial basis for concern regarding the health consequences of an exposure and for which available data preclude a comprehensive evaluation of risk (European Commission, 2000).

A similar approach can be applied to nutritional and other lifestyle-related exposures, particularly for conditions, such as cancer or Alzheimer’s disease, for which there may be a long latency period between exposure and disease manifestation and for which randomized controlled trials are impractical or are, for whatever reason, not rapidly forthcoming.

Some have argued that the level of evidence required for making dietary recommendations for disease prevention may be different from that required for establishing the efficacy of medical treatments, such as pharmaceuticals (Blumberg et al., 2010).

At the International Conference on Nutrition and the Brain, Washington, DC, July 19-20, 2013, evidence regarding the influence of dietary factors, physical and mental exercise, and sleep on aspects of cognition was reviewed, and conference speakers were asked to comment on possible dietary and lifestyle guidelines for Alzheimer’s disease prevention, with an aim of developing a set of practical steps to be recommended to members of the public.


The following principles were applied to the development of guidelines:

  1. Guidelines were to be based on substantial, although not necessarily conclusive, evidence of benefit.
  2. Implementation of guidelines should present no reasonable risk of harm.
  3. The guidelines were to be considered to be subject to modification as scientific evidence evolves.


Seven guidelines emerged and are as follows:

  1. Minimize your intake of saturated fats and trans fats. Saturated fat is found primarily in dairy products, meats, and certain oils (coconut and palm oils). Trans fats are found in many snack pastries and fried foods and are listed on labels as “partially hydrogenated oils.”
  2. Vegetables, legumes (beans, peas, and lentils), fruits, and whole grains should replace meats and dairy products as primary staples of the diet.
  3. Vitamin E should come from foods, rather than supplements. Healthful food sources of vitamin E include seeds, nuts, green leafy vegetables, and whole grains. The recommended dietary allowance (RDA) for vitamin E is 15 mg per day.
  4. A reliable source of vitamin B12, such as fortified foods or a supplement providing at least the recommended daily allowance (2.4 mg per day for adults), should be part of your daily diet. Have your blood levels of vitamin B12 checked regularly as many factors, including age, may impair absorption.
  5. If using multiple vitamins, choose those without iron and copper and consume iron supplements only when directed by your physician.
  6. Although aluminum’s role in Alzheimer’s disease remains a matter of investigation, those who desire to minimize their exposure can avoid the use of cookware, antacids, baking powder, or other products that contain aluminum.
  7. Include aerobic exercise in your routine, equivalent to 40 minutes of brisk walking 3 times per week.


The rationale for each of these guidelines is briefly discussed as follows.

  1. Minimize your intake of saturated fats and trans fats.

As reviewed elsewhere in this supplement, several (although not all) prospective studies have indicated an association between intake of saturated or trans fats and incident Alzheimer’s disease (Barnard et al., 2014; Morris, 2014). Saturated fat is found especially in dairy products and meats; trans fats are found in many snack foods.

In the Chicago Health and Aging Project, individuals in the upper quintile of saturated fat intake had twice the risk of developing Alzheimer’s disease during a 4-year study period, compared with participants in the lowest quintile (Morris et al., 2003).

In the Washington Heights-Inwood Columbia Aging Project in New York and the Cardiovascular Risk Factors, Aging, and Dementia study in Finland, Alzheimer’s disease risk was positively, but nonsignificantly, associated with saturated fat intake (Laitinen et al., 2006; Luchsinger et al., 2002).

A number of well-controlled studies of cognitive decline have found that high saturated fat intake increases the rate of decline in cognitive abilities with age (Beydoun et al., 2007; Devore et al., 2009; Eskelinen et al., 2008; Heude et al., 2003; Morris et al., 2006b; Okereke et al., 2012).

Increased saturated fat intake is associated with risk of cardiovascular disease and type 2 diabetes (Mahendran et al., 2013; Mann, 2002), which, in turn, are associated with increased risk of Alzheimer’s disease( Ohara et al.,2011;Puglielli et al.,2003).

A large study of Kaiser Permanente patients showed that participants with total plasma cholesterol levels_240mg/dL in midlife had a 57% higher risk of Alzheimer’s disease 3 decades later, compared with participants with cholesterol levels <200 mg/dL (Solomon et al., 2009).

Additional evidence of mechanistic associations between saturated or trans fat intake and Alzheimer’s risk comes from the fact that the APOEε4 allele, which is strongly linked to Alzheimer’s risk, produces a protein that plays a key role in cholesterol transport (Puglielli et al., 2003) and from the observation that high-fat foods and/or the increases in blood cholesterol concentrations they may cause may contribute to beta-amyloid production or aggregation in brain tissues (Puglielli et al., 2001).

  1. Vegetables, legumes (beans, peas, and lentils), fruits, and whole grains should replace meats and dairy products as primary staples of the diet.

Vegetables, berries, and whole grains provide healthful micronutrients important to the brain and have little or no saturated fat or trans fats. In both the Chicago Health and Aging Project and the Nurses’ Health Study cohorts, high vegetable intakes were associated with reduced cognitive decline (Kang et al., 2005; Morris et al., 2006a).

Legumes and fruits merit emphasis, not because of an association with reduced Alzheimer’s disease risk, but because, like grains and vegetables, they provide macronutrient nutrition that is essentially free of saturated and trans fats and are part of a dietary pattern associated with reduced risk of cardiovascular disease, weight problems, and type 2 diabetes (Fraser, 2009; Tonstad et al., 2009), which, in turn, have critical influences on brain health.

Many plant-based foods are rich in several B-vitamins. Folate and vitamin B6 are noteworthy in that, along with vitamin B12, they act as cofactors for the methylation of homocysteine; elevated homocysteine levels are associated with higher risk of cognitive impairment in some studies (Morris, 2012; Smith et al., 2010; Vogel et al., 2009).

Nonetheless, the efficacy of B-vitamins is not yet settled; in an Oxford University study of older individuals with elevated homocysteine levels and mild cognitive impairment, supplementation with these 3 vitamins maintained memory performance and reduced the rate of brain atrophy (de Jager et al., 2012; Douaud et al., 2013; Smith, 2010). Healthful sources of folate include leafy green vegetables, such as broccoli, kale, and spinach, beans, peas, citrus fruits, and cantaloupe.

The RDA for folate acid in adults is 400 mg per day. Vitamin B6 is found in green vegetables in addition to beans, whole grains, bananas, nuts, and sweet potatoes. The RDA for adults up to age 50 is 1.3 mg per day. For adults >50 years older, the RDA is 1.5 mg for women and 1.7 mg for men.

  1. Vitamin E should come from foods, rather than supplements. Healthful food sources of vitamin E include seeds, nuts, green leafy vegetables, and whole grains.

The RDA for vitamin E is 15 mg per day. In the Chicago Health and Aging Project, higher intakes of vitamin E from food sources were associated with reduced Alzheimer’s disease incidence (Morris et al., 2005). Similarly, in the Rotterdam study, high vitamin E intake was associated reduced dementia incidence (Devore et al., 2010).

Vitamin E occurs naturally in the form of tocopherols and tocotrienols and is found in many foods, including mangoes, papayas, avocadoes, tomatoes, red bell peppers, and spinach, and particularly in high quantities in nuts, seeds, and oils. The RDA for adults is 15 mg. A small handful of typical nuts or seeds contains 15 mg of vitamin E.

Vitamin E from supplements has not been shown to reduce Alzheimer’s disease risk. Many common supplements provide only α-tocopherol, and most do not replicate the range of vitamin E forms found in foods. A high intake of α-tocopherol has been shown to reduce serum concentrations of γ- and δ-tocopherols (Huang and Appel, 2003).

  1. A reliable source of vitamin B12, such as fortified foods or a supplement providing at least the recommended dietary allowance (2.4 mg per day for adults) should be part of your daily diet.

Vitamin B12 is essential for the health of the brain and nervous system and for blood cell formation. The RDA for adults is 2.4 μg. It is found in supplements and fortified foods, such as some breakfast cereals or plant milks.

Vitamin B12 is also found in meats and dairy products, although absorption from these sources is limited in many individuals, particularly those older than 50 years, those with reduced stomach acid production, those taking certain medications (e.g., metformin and acid blockers), and individuals who have had gastrointestinal surgery (e.g., bariatric surgery) or who have Crohn disease or celiac disease.

The US Government recommends that vitamin B12 from supplements or fortified foods be consumed by all individuals older than 50 years. Individuals on plant-based diets or with absorption problems should take vitamin B12 supplements regardless of age. However, dietary sources and even vitamin B12 supplements may not be sufficient to sustain adequate blood levels. Some individuals require vitamin B12 injections. Every middle-aged or older adult should have his or her vitamin B12 status checked on a regular basis.

Have your blood levels of vitamin B12 checked regularly as many factors, including age, may impair absorption. Vitamin B12 is essential for the health of the brain and nervous system and for blood cell formation. The RDA for adults is 2.4 mg. It is found in supplements and fortified foods, such as some breakfast cereals or plant milks. Vitamin B12 is also found in meats and dairy products, although absorption

  1. If using multiple vitamins, choose those without iron and copper and consume iron supplements only when directed by your physician.

Iron is essential for formation of hemoglobin and certain other proteins, and copper plays an essential role in enzyme functions among many other aspects of health. However, some studies have suggested that excessive iron and copper intake may contribute to cognitive problems for some individuals (Brewer, 2009; Squitti et al., 2014; Stankiewicz and Brass, 2009).

In recent meta-analyses (Schrag et al., 2013; Squitti et al., 2013; Ventriglia et al., 2012), circulating non-protein-bound copper was associated Alzheimer’s disease risk.

Other aspects of the diet may play a modulating role in the relationship between metals and cognitive effects. In the Chicago Health and Aging Project, individuals with a high intake of saturated fat along with a high copper intake were found to have cognitive decline equivalent to 19 additional years of aging (Morris et al., 2006b).

Most common multivitamins contain both iron and copper, sometimes exceeding the RDA (Physicians Committee for Responsible Medicine, 2013). However, most individuals in the United States meet the recommended intake of these minerals from everyday foods and do not require supplementation.

The RDA for iron for women older than 50 years and for men at any age is 8mg daily. For women of age 19-50 years, the RDA is 18mg. The RDA for copper for men and women is 0.9 mg per day. For individuals who use multiple vitamins, it is prudent to favor products that deliver vitamins only, unless specifically directed by one’s personal physician.

Some authorities also suggest specific clinical testing (e.g., to measure levels of non-ceruloplasmin copper) before initiating diet changes (Squitti et al., 2014).

  1. Although aluminums role in Alzheimers disease remains a matter of investigation, those who desire to minimize their exposure can avoid the use of cookware, antacids, baking powder, or other products that contain aluminum.

Aluminum’s role in Alzheimer’s disease remains controversial. Some researchers have called for caution, citing aluminum’s known neurotoxic potential when entering the body in more than modest amounts (Kawahara and Kato-Negishi, 2011) and the fact that aluminum has been demonstrated in the brains of individuals with Alzheimer’s disease (Crapper et al., 1973, 1976).

Studies in the United Kingdom and France found increased Alzheimer’s prevalence in areas where tap water contained higher aluminum concentrations (Martyn et al., 1989; Rondeau et al., 2009). However, because of the limited number of relevant studies, most experts regard current evidence as insufficient to indict aluminum as a contributor to Alzheimer’s disease risk.

Because aluminum plays no role in human biology, it may be prudent to avoid aluminum exposure to the extent possible, although its role in cognitive disorders remains under investigation. Aluminum is found in some brands of baking powder, antacids, certain food products, and antiperspirants.

  1. Include aerobic exercise in your routine, equivalent to 40 minutes of brisk walking 3 times per week.

Observational studies have shown that individuals who exercise regularly are at reduced risk for Alzheimer’s disease (Erickson et al., 2012). Adults who exercised in midlife were found to be less likely to develop dementia after age 65, compared with their sedentary peers (DeFina et al., 2013).

In controlled trials, aerobic exercisedsuch as brisk walking for 40 minutes 3 times per weekdreduces brain atrophy and improves memory and other cognitive functions (Hotting and Roder, 2013).

In addition to the foregoing guidelines, other steps merit further investigation for possible inclusion in future iterations of prevention guidelines. These could include recommendations as follows:

  1. Maintain a sleep routine that will provide an appropriate amount of sleep each night, approximately 78 hours for most individuals.

It is important to evaluate and treat any underlying sleep disorders, such as obstructive sleep apnea. Sleep disturbances have been associated with cognitive impairment in older adults (Blackwell, 2011; Lim et al., 2013; Tworoger et al., 2006; Yaffe et al., 2011).

  1. Engage in regular mental activity that promotes new learning, for example, 30 minutes per day, 45 times per week.

Several studies have suggested that individuals who are more mentally active have reduced risk for cognitive deficits later in life (Curlik and Shors, 2013; Hotting and Roder, 2013; Robertson, 2013; Stern, 2012; Tucker and Stern, 2011).


Although current scientific evidence is incomplete, substantial evidence suggests that, a combination of healthful diet steps and regular physical exercise may reduce the risk of developing Alzheimer’s disease. These lifestyle changes present additional benefits, particularly for body weight, cardiovascular health, and diabetes risk, and essentially no risk of harm. As investigations into Alzheimer’s disease bear additional fruit, these guidelines should be modified accordingly.


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