The Role of Resilience in Alzheimer's Dementia

Editor’s Note: This text is a transcript of the course, The Role of Resilience in Alzheimer's Dementia, presented by Teresa Fair-Field, OTD, OTR/L.

Learning Outcomes

After this course, participants will be able to:

• List the Top 5 resilience factors with an impact on cognitive health.
• Identify the evidence-based best approach to exercise for older adults with dementia.
• Describe the sleep factors that are linked to dementia, based on recent literature

Current Scope of Dementia

To start, I want to discuss the current scope of what we know about dementia.

• Alzheimer’s dementia
• Vascular dementia
• Lewy body dementia (DLB)
• Frontotemporal dementia (FTD)
• Normal pressure hydrocephalus
• Mixed dementia
• Syndrome related dementias

First, there is Alzheimer's dementia. Next is Vascular dementia which can be the result of strokes or TIAs. It might impact judgment and problem solving a bit more than memory, depending on what areas of the brain are affected. Next is Lewy body dementia (LBD), which is the result of microformations of proteins that are in the cerebral cortex. Presentations of Lewy body dementia might vary from person to person.

Frontotemporal dementia, or FTD, is cellular damage in the lobes of the brain which are responsible for executive functions. Executive functioning deficits, even more so than memory, are implicated with FTD. For example, inhibitory control or word finding.

At times, some aspects of motor movement are affected and we're discovering more and more diagnoses that have a component of FTD attached or associated.

Normal pressure hydrocephalus (NPH) is the result of fluid buildup in the ventricles of the brain without a measurable increase in intracranial pressure. The pressure remains normal while that fluid is building up.

There are also mixed type dementias which are a combination of any two types in the above bulleted list. The most common mixed type of dementia is Alzheimer's dementia along with a vascular type.

Finally, some syndromes are related dementias.  Many have dementia as a component, such as Parkinson's disease, which also contains Lewy bodies. However, not all individuals with Lewy body dementia have Parkinson's or Huntington's disease, etc.

For the purposes of this course, we will focus on the most common form of dementia, which is Alzheimer's. Sixty to eighty percent of dementia is an Alzheimer's type and in the absence of other co-occurring events or diagnoses that may explain the dementia, Alzheimer's is the most likely.

Age

The age of the individual is still the most common risk factor for Alzheimer's disease. But of course, not everyone who ages is diagnosed with Alzheimer's disease. Further, not everyone who is diagnosed with Alzheimer's is equally affected.

What are some of the factors that affect these differences? Most symptoms appear after age 60 with the risk increasing the older you get. That's not including early-onset, which is earlier than age 60 and remains relatively rare.

Age-related Alzheimer's incidents rates are expected to double as the aging population increases. Incidence rates are expected to be 13.9, almost 14 million people, by the year 2060. That's less than 40 years away.

There are some racial disparities in Alzheimer's that should be discussed. Blacks and African Americans have the highest incidence of Alzheimer's disease with 13.8% of the population 65 and older. It is 12.2 in individuals identifying as Hispanic, 10.3 in those identifying as non-Hispanic white, 9.1 in American Indian (AI) or Alaskan native (AN), and 8.4 in Asian and Pacific Islander populations.

In a comprehensive study by Babulal et al., which is in your references, a geographically and racially diverse team of more than 20 researchers examined factors affecting these numbers. They specifically examined reserve, resilience, and protective factors and how those are impacted by socioeconomic status.

Vocabulary & Progression

I want to provide a basic understanding of what researchers are using to identify Alzheimer's in its brain formation. Plaques are the abnormal clusters of protein fragments (i.e., beta-amyloid) that build up between nerve cells. Tangles are twisted strands of tau protein that interrupt normal cellular communication. It's important to note that both beta-amyloid and tau contain purposeful functions in the healthy brain. Beta-amyloid only becomes problematic when abnormal levels of the protein begin to cause formation of the plaques.

Similarly, tau binds to and stabilizes microtubules, which guide the flow of nutrients and molecules from the cell body down to the axons and dendrites. In Alzheimer's, abnormal changes occur causing the tau to detach from its normal location on the microtubules and attach to each other. That creates the tangle and that tangle, of course, disrupts the normal flow the tau is supposed to be managing.

Researchers identified that it's not just a case of those mechanisms incurring in isolation. It’s an interplay of factors that cause the buildup of beta-amyloid to actually reach a tipping point, which then causes the tau to rapidly spread throughout the brain. So, there is some interconnection there.

That first phase of Alzheimer’s disease appears to occur with the beta-amyloid cascade as that first event.  Neuronal injury due to the tau protein seems to follow after this initial accumulation of beta-amyloid. That's based on current understanding. Therefore, any discussion of resilience and prevention needs to address the possibility of preventing that initial buildup of beta-amyloid.

Cognitive Reserve Theory

Cognitive reserve theory has been in the literature for some time, although our understanding of it has grown over the years. Cognitive reserve theory suggests that individual differences in brain health and cognition can have an effect on the expression and severity of Alzheimer's dementia. These findings are emerging in the literature and represent the best current wisdom on the topic of resilience.

Let's talk about those current findings and what they might mean for your practice, as well as your own life. The theory suggests that at any level of severity, an individual with higher preexisting cognitive capital could support greater levels of brain pathology without demonstrating the same debilitating deficits as someone with lower cognitive capital.

This dates back to the 1980s when we were identifying Alzheimer's from autopsies. Researchers completed autopsies and identified individuals with no apparent symptoms of dementia who were found to have brain pathology consistent with advanced Alzheimer's disease. They theorized that these individuals had no apparent symptoms because they had a large enough cognitive reserve to offset the debilitating effects of the damage. It's not that the damage didn't occur, it's that their baseline was higher to compensate for the loss.

Besides post-mortem analysis, what else could support this theory and how has it progressed since that time? One particular study, with an N of 70 newly diagnosed individuals with Alzheimer’s disease, showed lower levels of beta-amyloid in individuals with higher levels of education.  In their sample, 70 subjects had a lumbar puncture to examine their cerebral spinal fluid for the presence of both beta-amyloid and tau protein. The results of the study showed an inverse association, meaning when the years of education went up, the presence of beta-amyloid went down. There was no such relationship between education and tau. There was only a connection with the beta-amyloid.

These findings support the cognitive reserve theory in the first period of clinical evolution when Alzheimer's disease is first identified as MCI, mild cognitive impairment. However, that inverse relationship between education and tau disappears in the advanced phases of the disease. This means the individual may have more cognitive reserve in those initial phases, but once they progressed to later phases of Alzheimer's, individuals progressed at the same rate. So, they may have had a longer period upfront, but once that cascade began, the relationship disappeared as deficits increased.

Brain Reserve Theory

How does this differ from brain reserve theories? Brain reserve theories hypothesize that individual differences in brain volume can have an effect on the expression and severity of Alzheimer's.  This is not referring to just education or cognitive reserve, but actual brain tissue reserve.  It's hypothesized with brain reserve theory, that with a more robust volume, one could support greater loss before reaching the same threshold for clinical symptoms.  In a study by Liu et al. (2012), brain thickness was measured via structural MRI analysis, in which sections of the brain were examined and compared with demographic and performance of the subjects. The researchers based this hypothesis on years of schooling but also controlled for intracranial volume, age, gender, country of origin, cognitive status, and several testing events.

Results show that in the age-matched healthy control group, there was no significant correlation between years of schooling and cortical thickness or volume. However, some isolated brain regions were found to be significantly larger in subjects with more education (i.e., about 13 years, plus or minus three years) versus less than six years of education. So, overall, there were no significant findings amongst the control group, relative to brain thickness.

In the MCI group, which is not yet qualifying for a diagnosis of Alzheimer's, there were also no statistical differences relative to brain thickness.  In the Alzheimer's group, it was found that those with higher rates of education demonstrated greater cortical loss than those with less education at the same functional level. Again, with greater education, they experienced greater loss of brain tissue while maintaining a similar education level. So, individuals with more education may be able to mitigate the effects of greater cortical loss while retaining function which supports the reserve theory as well. But those findings aren't particularly current any longer.  

Conflicting research even suggests that though the early stages of Alzheimer's disease might be mitigated by higher levels of education, when the later stages do come, individuals may advance even more swiftly. This would essentially equalize any early benefits.  The individual may, in later stages, progress more rapidly even though they had a longer runtime before those noticeable effects of the disease and deterioration.

Resilience

Alzheimer's disease, while lacking a dramatic breakthrough, has benefited from various refinements in the many research projects that are currently ongoing. One of those refinements is the progression of the cognitive reserve theory, which now very closely resembles a model of resilience that we can begin to follow in our daily activities. A more recent study published in 2018 supposes that cognitive reserve might be less related to brain volume or the presence or absence of protein than it is related to a network efficiency model.  There was no relationship between education and the CSF biomarkers in a sample of only 14 individuals with mild Alzheimer's, 28 with MCI, and 28 control participants.  Again, no relationship was present between education level and the biomarkers they were investigating. They did find that education was related to higher neural network efficiency in all groups. That those in the control group, the MCI sample, and the Alzheimer's disease group all had more highly efficient neural networks based on educational level. They also determined that abnormal levels of beta-amyloid and the tau proteins were related to more highly efficient networks in the sample that had mild Alzheimer's.  This confirms that while education might not protect one from the onset of Alzheimer's, it may insulate the individual from the effects of pathology. There's resilience within the system. That opens the door for us, as speech and language pathologists, to the benefit of cognitive stimulation to slow age-related cognitive decline.  That's particularly exciting for our work in both older adult and community health settings.

Another considerable factor is stress reduction. If we consider the level of cortisol as the measure of stress associated with the accumulation of the tau protein, then higher cortisol levels correlate with faster progressions of the disease. So, the more cortisol within the system, the higher the level of baseline stress resulting in faster progression of the accumulation of tau.

Protective Factors

Cognitive Reserve

Whatever the mechanism, cognitive reserve remains a strong protective factor in all of the identified studies and not only as the number of years of education but rather the adoption of a lifelong learning approach. Thinking about that finding regarding neural efficiency, we train our brains to work around areas that may be challenging. We train ourselves to find multiple ways to get to our destination.  That is cognitive flexibility.  When we take on new skills or tasks, we are engaging in new learning.

Cognitive reserve is building those intergenerational relationships. Those things that keep our elders connected with young people and learn new techniques, new systems, new ways of thinking.

Physical Fitness/Exercise

Also hitting the literature is physical activity and exercise. There are multiple sources that cite physical fitness as a protector of cognitive health. Active older adults do have lower incidences of dementia.  Some studies commonly cite aerobic fitness for its cardiovascular benefit. But new findings support an approach of both aerobic fitness and strength training has the greatest benefit. Essentially the best fitness approach is the one that the elder will perform consistently.

Environment

Of course, there are effects of the environment. We definitely have the ability to shape with our sensory and stimulation programming, the variability of the environment, and in some of our clinical settings we have the ability to vary what the individual is exposed to. Whether that's indoors, outdoors, amount of light, amount of activity. These are all factors that we can shape with activities and engagement.

Socialization

Socialization is of particular concern to us, as SLPs. There are some studies that show that daily casual relationships may benefit the individual as much as close friendships. For example, communication and interaction with somebody even at the grocery store or the coffee shop can be beneficial.  A consistent plan for social interaction may have the same protective benefits as somebody that has close interpersonal relationships.

Socialization does have an unclear mechanism. There are a lot of hypotheses. But one factor is that it has an effect on mood and connectedness, that feeling of connection with our surroundings. And, of course, these factors can reduce the baseline level of stress and baseline level of cortisol within our system.

Sleep

Another factor is sleep.  New research indicates that sleep has a powerful and unprecedented role in tidying up the brain. Additionally, disrupted sleep and wakefulness lead to both increased beta-amyloid production and decreased beta-amyloid clearance.  That accumulation results in disturbed sleep cycles which is a vicious cycle.  There are very, very high incidences of disturbed sleep in individuals with Alzheimer's dementia.

Acute sleep loss also causes an increase in tau levels. Those are the tangle levels that are found in the cerebral spinal fluid.  Chronic sleep loss accelerates the tau spread in the neural network. If sleep loss is persistent over time, you can see that throughout the individual system. So, there's a significant relationship between sleep disturbances and beta-amyloid aggregation.

Sleep hygiene is an activity of daily living that we need to address. We see that “changes in sleep efficiency and quality seem to precede the onset of cognitive decline in Alzheimer's patients and progress in parallel with cognitive dysfunction and the progression of Alzheimer's pathology” (Wang & Holtzman, 2020).

Below are some specific numbers:

• >7 hours of sleep = lowest amyloid burden
• >6 to < 7 hours = intermediate amyloid burden
• < 6 hours = greatest amyloid burden

Greater than seven hours of sleep may have the lowest amyloid burden. Greater than six hours and up to seven hours is an intermediate amyloid burden. Less than or equal to six hours of sleep has the greatest amyloid burden.

There are some very, very recent findings that have found that the longer you spend in bed that may increase some of your cognitive impairments. But there are so many confounding factors that you have to investigate how sleep was measured. Just because an individual spends a longer period of time in bed, does not necessarily mean that they are getting the deep quality sleep that cleans out these processes. Therefore, it is interesting to note that participants that have preclinical amyloid pathology, meaning a buildup of the beta-amyloid, exhibit increased napping.  They're potentially not getting consolidated sleep during the night so they're napping throughout the day, which is generally lighter levels of sleep that don't have the same clean-out effect.

Sleep Factors

There are definitely changes in sleep in normal aging.  There is a decrease in non-REM, short wave sleep, and more time spent in lighter sleep stages as we age. There is also an increase in sleep fragmentation, meaning we get sleep in chunks rather than as one consolidated night's sleep.

But in Alzheimer's risk, there are some other unusual factors. One factor is sleep-disordered breathing or untreated sleep apnea. There is even greater fragmentation, meaning smaller usable chunks of sleep over the night, shorter overall sleep duration, and lower sleep quality. We also see excessive daytime sleepiness and napping in those individuals during the day. These are individuals who are up and wandering the hallways at night as well.

Protective Factor Programming

What can we do as clinicians to engage some of these protective factors with our clients? Let’s look at some programming.

The “Awe” Walk Study

This study is interesting because it targets perspective-taking and pro-social emotions paired with a walking activity. This work came out of the state of California, with researchers at UCSF, Berkeley and San Francisco State (2020).  They identified that awe was a positive emotion in the presence of something vast, that we cannot immediately understand. They identified the experience of awe occurring in nature, art, at times in music, and sometimes in collective action or acts of courage. The study identifies that it causes a decrease in anxiety, depression, and lowers cortisol levels. It decreases inflammation throughout the body and reduces cardiovascular risk.

It is thought that feelings of awe can be nurtured and cultivated in the individual. Feelings of awe diminish our sense of self-importance, which interestingly makes us feel smaller in the grand scheme of things but also more connected. This could elevate feelings of compassion, admiration, gratitude, engagement, empathy for others; things that are identified as pro-social.

In this group design, there were 28 participants in a control group and 24 participants in the Awe Walk group. They had an 80% power analysis and used a two-sample T-test for this study. Volunteers were recruited between the ages of 60-90 years old and were participants in a healthy aging network. Participants were randomly assigned to one of two groups.

The control walk group was tasked with completing at least one 15-minute outdoor walk weekly for eight weeks. The Awe Walk group completed the same task. The control group received no additional instructions, while the Awe Walk group received additional instructions, which are available in your handouts.

The walks had to be outside and they used a mobile phone to take pictures as part of the study in the Awe Walk group. But other than taking photographs, the participants needed to minimize their phone usage while on the walk. This is a factor that's going to be more and more relevant as our generation ages.  The task was to take three pictures of yourself - one before the walk, one during the walk, and one after the walk. Then to take one picture of something else, such as the most interesting thing that you saw; or potentially, the source of “awe”.

Interestingly and surprisingly to the researchers, the control group walked twice as often as the study group. So, they had more frequent walks. The expectation, again, was at least one 15-minute walk per week over the eight weeks of the study.

The Awe Walk group completed the minimum number assigned, which was about seven and a half to eight walks on average. The control walk group walked much more frequently than that, with 18.9 walks over the eight weeks. All participants were blinded to the group assignment.

It's hypothesized that without additional instructions as to the purpose of the walk, the control group may have assumed that their fitness or their frequency was being tested. As a result, the control group spent more time walking. Whereas the Awe Walk group, which received specific instructions and a specific task, did not perform more or less than what was required for their participation.  There was no significant difference in speed, duration, or distance of the walk between the two groups. The only difference was in frequency.

The participants measured something called self-size which is where the photographs came into play. They measured their self-size as the number of pixels devoted to the person themselves in the selfie versus the background to measure the aspect of awe that may cause us to feel smaller, but more connected. 

The Awe Walk participants reported greater increases in feeling a part of something larger than themselves during the walk, compared with the control group. Though neither group reported feeling in the presence of something vast.  That may be more a reflection on the environment than the personal perspective and could speak to the environment where the individual is walking.

The effects don't appear to be related to which group a participant was assigned, but were relative to effects over time. So, the differences between a participant in the control walk group versus the Awe Walk group, when looking at just one walk, were not noticeable. Whereas a participant that engaged in the practice consistently over time, showed greater gains in all of the positively measured areas - the pro-social positive emotions (e.g., emotions of awe, compassion, admiration, appreciation, joy, pride) and they also showed an increase in their smile intensity over time in their selfies. Remember that they're doing a before and an after selfie and they actually measured the pixilation of the smile, as one of the objective measures of pro-social emotion.

The Balanced Life Group

The Balanced Life Group had a purpose to inspire and promote balance in overall awareness. This was a research pilot that was presented to older adults who were hospitalized for psychiatric disorders.  Though with the effects on resilience and protective factors, it's worth looking at this study for this context as well.

The study was developed by a multi-disciplinary team at a state facility. The group design included nine topic areas. They ran 45 minutes sessions, twice a week for 11 weeks.  It used a strengths-based approach with open-ended questions. Each topic addressed new material in the first session of the week. The second session of the week was facilitation to personalize that to the self. The wrap-up was a wellness plan describing the strengths of the individual and identifying one area that they wish to continue to improve in each domain.

The group modules were spirituality, physical self, metabolic syndrome (specific to the hospitalized population), emotional health, intellectual health, social factors, occupational health, environmental factors, and sexuality.

The final topic summary was to develop a balanced life plan with strengths in each area. For example, “My strengths in spirituality are___________.” “One thing I would like to do or continue to do is______________.”  Each area asked similar questions to help the individual identify strengths as well as one habit or routine that they would like to incorporate.

Participant feedback included comments such as, “The group reminded us that we're still human beings.” That is a very powerful qualitative statement. Another comment was, “Look at the whole picture of your life and try to improve.” One thing that speaks to me is the sense of having a locus of control over some aspect of the individual's life.

Sensory Memory Workshop for Dementia

Another excellent programmatic option for the SLP/OT team is addressing sensory memory. This particular workshop suggested that paired cognitive and sensory stimuli may improve engagement, and reactivate memory and connection post-isolation.  The group design was a very small group of men with mild to moderate Alzheimer’s (N=5).  But since we don't have many resources for male clients specific to this group, even though it's a small sample size, it's very good evidence to focus on.

The group had seven meetings focused on the specific sensory organ paired with cognitive stimulation. This was coordinated by occupational therapy but could be delivered either as a team or by speech-language pathologists, depending on the environment.

The session plans included, first, a coming together or orientation of what was going to be taking place. Planning occurred in the second session. Then the third session focused on the very deep brain sense of smell. One thing I love about this intervention is that it can be customized to the cultural makeup of your population. The study used lemon, oregano, parmesan, vinegar, mint, popcorn which all had meaning for this specific group.  But these could be swapped out for smells appropriate to the foods of the cultural makeup of your particular group. The participants were tasked with making a match between a laminated picture of the item and the smell. They were concentrating initially on the sensory aspects.

Session four was focused on taste with a fruit salad activity. The participants had to recall what fruits went into a fruit salad (i.e., cognitive engagement), and then prepared the fruit salad in the kitchen with OT.

The fifth session was on hearing.  The group listened to music and discussed/recalled memories from the musical piece, followed by watching the video for visual effects as well as hearing the music. This created dual sensory input.

The sixth session was a conversation. The participants discussed the perception of the experience and how we use our senses in the community.

Finally, the seventh session was a group-designed party celebration to close the cycle and build connections between the group members.

DREAMS-START

This is another excellent programmatic option for an SLP/OT team addressing sleep hygiene. This is work by a team from the University College of London, the NHS Foundation Trust and the Alzheimer's Society of the UK.  They provide a toolbox of sleep strategies which are always interesting since they affect the Alzheimer's population.

The model contains a manual of six sessions with cognitive-behavioral approaches, components of education, and light therapy. The hope is to potentially establish a new sleep-wake cycle, aspects of behavioral activation, relaxation and readiness for sleep, as well as coping skills.  

The first session addresses the connection between sleep and dementia.  It also focuses on the importance of sleep in cognitive performance, lifestyle factors, and habits.

Session two is making a plan for sleep. The plan focuses on increasing natural and artificial light exposure, which is a significant factor in our production of melatonin. It looks at standardizing mealtimes for the individual, which also affects melatonin production. There may need to be some changes to bed and rise times in order to get the individual on a more typical schedule.  There may also need to be a reduction in daytime naps to build up sleep pressure. Additionally, adjustments to the bedtime routine, Lightbox therapy, and increasing the light exposure of the individual are also considerations for a sleep plan.

The third session focuses on the daytime activities of the person specifically looking at sleep hygiene strategies and the role of exercise.  We want patients to get up and get moving, particularly during that wake maintenance zone in the late afternoon when many of our elders are nodding off at three, four, and five o'clock. That is the time of day when they really need to be staying awake in order to build up enough sleep pressure for later night sleep. Scheduling and activity logging can really help with this issue and is something that the SLP and patient can do together. 

The fourth session focuses on difficult nighttime behaviors such as wandering in the hallways and the fifth session focused on caregivers. This would include sleep strategies for the caregiver to ensure they are getting high-quality sleep for their readiness to provide care. Finally, session 6 addresses strategies for the future (i.e., How do we incorporate the successes that were detected and developed over the sessions?)

Results of the program showed that the caregivers reported decreased stress and burden for the individuals they were caring for.  The qualitative interview of caregivers reported that the person with dementia they were caring for was less restless at night, they were more awake during the day and had few caregiver disruptions. That directly translates to a reduced burden of care because the individual disrupted the caregiver less often during the day.

They also seemed happier or in an improved mood. However, this was difficult to measure because they were unable to determine if, objectively, the individual actually slept longer. Tools used back in 2019 had difficulty distinguishing the individual being stationary or still in bed, versus fully asleep. Tools that are available now for sleep technology, including watches, rings, etc. have improved considerably since then. So, at the time of this study, they were unable to determine if the individual actually spent more time sleeping versus just lying quietly. The measurement tools were even less able to distinguish between quietly staying in bed and not moving versus being fully asleep the older the individual is. Additionally, they were unable to measure daytime sleepiness or feeling of sleepiness and function.

In summary, our top five protective factors are cognitive reserve, physical activity and fitness, the role of the environment, the role of socialization and the importance of sleep.

The last section focuses on some of the aspects of exercise. With an audience of SLPs, I'm not going to spend a lot of time addressing fitness and exercise, but I wanted to include the content because it may be helpful information for elders in your personal life or to pass along to team members in your work site.

Questions and Answers

Does taking melatonin or herbal supplements help expedite REM or just help us get to sleep, even during the time when we naturally start to lose our quality sleep?

Melatonin, which naturally occurs in our system, declines as we age. An individual may benefit from melatonin supplementation. But, on its own, it may not be able to accommodate for the loss because those other things that naturally stimulate melatonin also tend to be missing in our older adults. Things like daylight exposure, and routine mealtimes are also beneficial. These zeitgebers, meaning time givers, tells our body clock what's happening next. As the individual loses structure in their routine, that contributes to that loss of melatonin. That being said, there's a lot of exploration of supplementation that isn't melatonin. I'm not going to speak to those since the evidence is still outstanding, but there are a number of supplements that are being explored naturopathically for their ability to kind of dispel some of the stress in the system, some of the cortisol levels. It's definitely an exciting space to watch, but melatonin supplementation is certainly not a cure-all.

What was the environment or the setting for the Balanced Life Group?

The Balanced Life Group was in a psychiatric hospital environment.

You mentioned that you highly recommend we read an article on sleep in its entirety. Could you point out the article that that one was?

'Local Sleep and Alzheimer's Disease Pathophysiology’ by BA Mander (2020) and also the article by Wang and Holtzman (2020), Bidirectional Relationship Between Sleep and Alzheimer's Disease; Role of Amyloid Tau and Other factors.'

As you were talking about some of these programs that were looked at in these studies,  how do folks who perhaps see patients in a home health setting, or at least in individual outpatient therapy, do these group activities? Do you think that many of them could be adapted to one on one?

Yes, absolutely. The Awe Walks study is one that the individual can complete even with a distant family member. That would be a great intergenerational activity. They could even send their photographs to each other for a social component.

It could be in coordination with your PT or OT cohort in a home health setting. Are they safe and able to ambulate in the community? Are there issues of balance that you need to be aware of?  That could definitely be delivered in combination as either a treatment or an educational component for an individual and their caregiver. Again, whenever we can provide caregivers with a specific activity that they can do with the person in their care, that increases the quality of their day and the quality of their interactions. So, that program lends itself to a variety of environments and was actually delivered in a community population.

The pandemic has been so detrimental to people who are in this stage where they need to be working on their social connections, they need to be working on exercise out in the community, or going to their gym or whatever it might be. They're just being prevented from doing that by the nature of all these restrictions that have been going on. They need to protect their health, yet these other things are very important for them. I'm wondering, do you think that there are researchers looking at what has happened over these past two years now?

Oh absolutely, and I apologize for not addressing that earlier. I was reading a study, looking at how we are seeing an increase in frailty with a reduction in life space. So, as our life becomes smaller and more isolated, we see frailty factors increase.  The study was specifically on COVID, and it was earlier in the COVID process. The study was stating that the effects of the COVID lockdowns, isolations, et cetera, were equivalent to an individual's reduction in life space after a total hip replacement. Which I thought was significant.

We're locked up inside the house, or even in one room inside the house.

Exactly. We are interacting with the same individuals each day. We know the effect that a total hip can have on our elders and the research was saying that the reduction of life space of COVID was essentially equivalent to that. Even our active older adults were at increased risk of frailty caused by that life space. This is where digital readiness does make a difference. We can have some social interaction on the internet if we have those skills. Our elders who don't have those skills, or who are disadvantaged in their access, are particularly affected.

How are the level of beta-amyloid and tau proteins detected?

They use cerebral spinal fluid.

References

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Center for Disease Control and Prevention (2018, September 20). U.S. burden of Alzheimer’s disease, related dementias to double by 2060. CDC Newsroom. https://www.cdc.gov/media/releases/2018/p0920-alzheimers-burden-double-2060.html

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