Should You Tell a Person with Alzheimer's...that a loved one has passed?

On the Alzheimer List (from Washington University ADRC) we have dealt with this many times and for people in many stages of the disease. Bottom line...there are a few rules:

  • We feel the patient always has the right to know

  • The patient may cry, grieve, or respond negatively...but it is their honest and desirable response to a significant loss.

  • If they ask for details, tell them; if they seem to forget, let it go. * Even is the final stages of AD patients are capable of comprehending at some level -- they tell us this during lucid moments.

  • Always treat the patient with simplicity, compassion, and honesty.

  • Tell the patient at their best time of day in a quiet place that is free of distractions, tv, and other people -- You would be amazed at the number of people who do this in a crowded room or with the tv on. Take the person's hand and don't be afraid to let them see you cry. The non-verbal expression of tears is a powerful communicator.

  • If the person is capable of moving, you may want to take them to the funeral depending on behavior and cultural preferences.

  • Reminisce with the patient about the person who has passed in order to establish the link..yet avoid saying, "You remember Mary, right?"

  • And finally, remember that telling the patient is something you need for YOU. The patient is a member of the family who you need for moral support. You would be amazed at how often even nonverbal patients will stroke your hand or murmur words of comfort so you can grieve. It is a pretty amazing phenomenon. When my husband's uncle died, his wife was living in a nursing home for several years following a brain tumor. My husband didn't want to tell his wife but I insisted. We went to her after her nap and both took her hand. She turned and faced me -- which she had not done in quite a while. I quietly told her that her beloved husband had died and that the funeral had been lovely and well attended. She took my hand and turned away. A week later she peacefully died. I think she knew and was waiting.

Think about it. If it was you who had dementia, wouldn't you want to know if your loved one had passed?

** Reprinted
Geri R. Hall
 is an advanced practice nurse who works in the department of neurology at the University of Iowa College of Medicine and at the Banner Alzheimer Institute in Phoenix, Arizona. She's also a speaker and author who since 1996 has facilitated the online support group for the Washington University, St. Louis, Alzheimer's Disease Research Center's Alzheimer List.

Anxiety and Agitation in Alzheimer's Patients

A person with Alzheimer's may feel anxious or agitated. He or she may become restless, causing a need to move around or pace, or become upset in certain places or when focused on specific details.

Possible causes of agitation

  • Anxiety and agitation may be caused by a number of different medical conditions, medication interactions or by any circumstances that worsen the person's ability to think. Ultimately, the person with dementia is biologically experiencing a profound loss of their ability to negotiate new information and stimulus. It is a direct result of the disease.
     

Situations that may lead to agitation include:

  • Moving to a new residence or nursing home

  • Changes in environment, such as travel, hospitalization or the presence of house guests

  • Changes in caregiver arrangements

  • Misperceived threats

  • Fear and fatigue resulting from trying to make sense out of a confusing world

Treating Behavioral Symptoms

Anyone experiencing behavioral symptoms should receive a thorough medical checkup, especially when symptoms appear suddenly. Treatment depends on a careful diagnosis, determining possible causes and the types of behavior the person is experiencing. With proper treatment and intervention, symptoms of agitation can be reduced.
 

Tips to help prevent agitation

To prevent or reduce agitation:
 

  • Create a calm environment. Remove stressors. This may involve moving the person to a safer or quieter place, or offering a security object, rest or privacy. Try soothing rituals and limiting caffeine use.

  • Avoid environmental triggers. Noise, glare and background distraction (such as having the television on) can act as triggers.

  • Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation. Make sure the room is at a comfortable temperature. Be sensitive to fears, misperceived threats and frustration with expressing what is wanted.

  • Simplify tasks and routines.

  • Provide an opportunity for exercise. Go for a walk. Garden together. Put on music and dance.

How to respond

Do: Back off and ask permission; use calm, positive statements; reassure; slow down; add light; offer guided choices between two options; focus on pleasant events; offer simple exercise options, try to limit stimulation.

Say: May I help you? Do you have time to help me? You're safe here. Everything is under control. I apologize. I'm sorry that you are upset. I know it's hard. I will stay with you until you feel better.
 

  • Listen to the frustration. Find out what may be causing the agitation, and try to understand.

  • Provide reassurance. Use calming phrases such as: "You're safe here;" "I'm sorry that you are upset;" and "I will stay until you feel better." Let the person know you are there.

  • Involve the person in activities. Try using art, music or other activities to help engage the person and divert attention away from the anxiety.

  • Modify the environment. Decrease noise and distractions, or relocate.

  • Find outlets for the person's energy. The person may be looking for something to do. Take a walk or go for a car ride.

  • Check yourself. Do not raise your voice, show alarm or offense, or corner, crowd, restrain, criticize, ignore or argue with the person. Take care not to make sudden movements out of the person's view.

  • See the doctor. See the person with dementia's primary care physician to rule out any physical causes or medication-related side effects.

    ** Reprint -Alzheimer’s Association

Tips on Caring for a Person with Alzheimer's or Dementia

Dressing is difficult for most dementia patients. Choose loose-fitting, comfortable clothes with easy zippers or snaps and minimal buttons. Reduce the person’s choices by removing seldom-worn clothes from the closet. It's common for people with dementia to continue layering on clothes even though they are fully dressed. To facilitate dressing and support independence, lay out one article of clothing at a time, in the order it is to be worn. Remove soiled clothes from the room. Don’t argue if the person insists on wearing the same thing again.

  • Hallucinations (seeing or hearing things that others don’t) and delusions (false beliefs, such as someone is trying to hurt or kill another) may occur as the dementia progresses. State simply and calmly your perception of the situation, but avoid arguing or trying to convince the person that their perceptions are wrong. Keep rooms well-lit to decrease shadows, and offer reassurance and a simple explanation if the curtains move from circulating air, or if a loud noise such as a plane or siren is heard. Distractions may help. Depending on the severity of symptoms, you might consider medication.

  • Sexually inappropriate behavior, such as masturbating or undressing in public, lewd remarks, unreasonable sexual demands, even sexually aggressive behavior, may occur during the course of the illness. Remember, this behavior is caused by the disease. Develop an action plan to follow before the behavior occurs, i.e., what you will say and do if the behavior happens at home, around other relatives, friends, or paid caregivers. If you can, identify what triggers the behavior.

  • Verbal outbursts such as cursing, arguing, and threatening often are expressions of anger or stress. React by staying calm and reassuring. Validate your loved one’s feelings and then try to distract or redirect his attention to something else.

  • “Shadowing” is when a person with dementia imitates and follows the caregiver, or constantly talks, asks questions, and interrupts. Like sundowning, this behavior often occurs late in the day and can be irritating for caregivers. Comfort the person with verbal and physical reassurance. Distraction or redirection might also help. Giving your loved one a job such as folding laundry might help to make her feel needed and useful.

  • People with dementia may become uncooperative and resistant to daily activities such as bathing, dressing, and eating. Often this is a response to feeling out of control, rushed, afraid, or confused by what you are asking of them. Break each task into steps and, in a reassuring voice, explain each step before you do it. Allow plenty of time. Find ways to have them assist to their ability in the process, or follow with an activity that they can perform.

  • Even with these many potential challenges, it’s important to remember that these behaviors are often coping tactics for a person with deteriorating brain function. There’s no question that dealing with these behaviors can make caregiving especially challenging.

Resources

Family Caregiver Alliance
National Center on Caregiving
(415) 434-3388 | (800) 445-8106
Website: www.caregiver.org
Email: info@caregiver.org
FCA CareJourney: www.caregiver.org/carejourney
Family Care Navigator: www.caregiver.org/family-care-navigator

Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Through its National Center on Caregiving, FCA offers information on current social, public policy, and caregiving issues and provides assistance in the development of public and private programs for caregivers. For residents of the greater San Francisco Bay Area, FCA provides direct support services for caregivers of those with Alzheimer’s disease, stroke, traumatic brain injury, Parkinson’s, and other debilitating health conditions that strike adults.

 

FCA Fact Sheets

A listing of all facts and tips is available online at www.caregiver.org/fact-sheets.

Dementia, Caregiving and Controlling Frustration
Taking Care of YOU: Self-Care for Family Caregivers
Hiring In-Home Help
Community Care Options

 

Other Organizations and Links

Alzheimer's Disease Education and Referral (ADEAR) Center
www.nia.nih.gov/alzheimers
A service of the National Institute on Aging that offers information and publications on diagnosis, treatment, patient care, caregiver needs, long-term care, education, and research related to Alzheimer’s disease.

Eldercare Locator
eldercare.acl.gov
A service of the federal Administration on Aging that offers information about and referrals to respite care, as well as other home and community services available through state and Area Agencies on Aging.

Alzheimer’s Association Safe Return Program
www.alz.org/care/dementia-medic-alert-safe-return.asp
A nationwide program that identifies people with dementia who wander away and returns them to their homes. For a fee, families can register their loved one in a national confidential computer database. Participants receive an identification bracelet or necklace and other identification and educational materials.

 

This fact sheet was prepared by Family Caregiver Alliance and was reviewed by Beth Logan, M.S.W, education and training consultant and specialist in dementia care. © 2004, 2008, 2016 Family Caregiver Alliance. All rights reserved.

 

Parkinson's Disease

Parkinson’s disease affects between 1 and 1.5 million Americans, with between 40,000 and 60,000 new cases diagnosed each year. The mean age of diagnosis is 62, although 5 to 10% of individuals with Parkinson’s disease have young-onset Parkinson’s, which manifests before the age of 45. Individuals may be diagnosed in the earlier or later stages of the disease, and symptoms may progress more rapidly in some people than others. However, there is a common pattern to the course of Parkinson’s disease, linked to the progressive loss of dopaminergic nerve cells in the brain and body.

The role of dopamine


Dopamine is a neurotransmitter, or a chemical that transmits messages between nerve cells. Parkinson’s disease is associated with the death of neurons (nerve cells) that produce dopamine, leading to decreased levels of dopamine in the brain and body. The death of these cells causes malfunctioning of pathways that rely on dopamine to carry messages, including the neural pathways controlling movement.
Some loss of dopamine cells in the brain is expected with normal aging, but with Parkinson’s disease the loss is accelerated and more pronounced.

The symptoms of Parkinson’s are related to dopamine cell loss
The timeline of Parkinson’s disease follows the pattern of loss in dopamine nerve cells. This progression in cell damage was translated into six stages of the disease by a researcher named Dr. Heiko Braak. In the Braak staging system, Stage 1 of Parkinson’s is a pre-symptomatic stage; at this point in the disease, cell loss is occurring but is not yet significant enough to cause any symptoms. In late Stage 1 and Stage 2, the first premotor symptoms appear. Loss of dopamine nerve cells in the olfactory bulb results in a diminished sense of smell, or hyposmia. Neuronal loss in the enteric plexus (nerve supply of the intestine) results in constipation. Loss of neurons in the sleep centers of the brain, including the reticular formation, may result in sleep disorders, including REM sleep behavior disorder.

Onset of the classic motor symptoms of Parkinson’s disease
It is only in Stage 3 that the classic motor symptoms of Parkinson’s disease, including tremor and dyskinesias, begin to appear. This may be many years after the onset of the disease, as measured by loss of dopamine nerve cells. Motor symptoms are related to the loss of dopamine-containing neurons in a specific part of the brain called the substantia nigra. It is estimated that 50% or more of these cells must be lost before the motor symptoms begin to manifest. The loss of these dopaminergic neurons disrupts the function of the striatum, a part of the brain controlling movement. By Stage 4, cell loss has spread to the mesocortex.

Advanced Parkinson’s disease


In Braak Stage 5 and 6, cell loss involves the higher cortical centers of the brain, which control functions such as cognition and emotion. The progressive loss of these neurons may lead to confusion and dementia. Approximately 50% of individuals with Parkinson’s disease suffer from frank dementia by the time they have reached 20 years living with the disease. Other neuropsychiatric disorders can include depression, anxiety, apathy and hallucinations. Sleep disorders, including insomnia and daytime sleepiness, are also common.

While the progression of Parkinson’s disease typically follows this pattern, starting outside of the brain and in the brainstem (base of the brain) and progressing to higher centers of the brain including the cerebral cortex, the speed at which that progression occurs and the specific symptoms associated with the dopamine cell loss can vary greatly between individuals. The Colorado Neurological Institute specializes in creating personalized treatment plans for individuals suffering from Parkinson’s disease.

Source: Parkinson’s Community website

New method enables accurate diagnosis of Alzheimer's disease.

Credit: Oskar Hansson

Diagnosing Alzheimer's disease can be difficult, as several other conditions can cause similar symptoms. Now a new brain imaging method can show the spread of specific tau protein depositions, which are unique to cases with Alzheimer's.

"The method works very well. I believe it will be applied clinically all over the world in only a few years," says Oskar Hansson. Hansson is a professor of clinical memory research at Lund University in Sweden who has led a major international study on the new method.

There are two proteins that are known to be linked to Alzheimer's disease -- beta-amyloid, which forms what is known as plaque in the brain, and tau, which forms tangles within the brain cells. Beta-amyloid spreads throughout the brain at an early stage, decades before the patient notices signs of the disease. Tau, on the other hand, starts to spread at a later stage, from the temporal lobes to other parts of the brain.

"It is when tau begins to spread that the neurons start dying and the patient experiences the first problems with the disease. If we scan a patient with memory difficulties and he or she proves to have a lot of tau in the brain, we know with a high degree of certainty that it is a case of Alzheimer's," says senior researcher Rik Ossenkoppele, Lund University and Amsterdam University Medical Center.

He is the first author, and Oskar Hansson the last author, of an article recently published in JAMA (Journal of the American Medical Association). The article presents a study of over 700 patients. Besides Lund-Malmö in southern Sweden, researchers from San Francisco and Seoul took part in the study, and the patients were diagnosed in memory clinics from these regions.

The presence of tau in the brain was revealed by a PET scanner, a medical imaging technology which uses radioactive markers that make their way to different areas in the body.

"We administer the special tau marker intravenously to the patient. If the patient has tau in certain parts of the brain, the marker will detect it. The result -- whether Alzheimer tau is present or not -- is very clearly visible on the PET images," says Oskar Hansson.

The international study showed that the new tau-PET method had both great sensitivity and specificity: it detected 90-95 per cent of all cases of Alzheimer's and gave only few false positive results in patients with other diseases. The tau-PET method had clearly superior diagnostic accuracy compared to MRI, and fewer false positive results than beta-amyloid PET, two methods that are routinely used today. Tau-PET should therefore be of great use in the investigation of patients with memory problems, as soon as the method is approved for clinical use.

"If you are found to have tau in the brain according to tau-PET, it is, with few exceptions, due to Alzheimer's disease. If you have normal tau-PET and mild to moderate dementia, your memory problems are most likely due to other neurological diseases," summarises Oskar Hansson.

Although there is currently no cure for Alzheimer's, it is still important for patients to receive the correct diagnosis. On the one hand, the patient can be given symptom-relieving medication, and on the other, physical activity, a good diet and a correct dosage of the patient's other medication can optimize cognitive ability. The tau-PET method could also be valuable in trials of new medication against Alzheimer's, as it can show whether new drugs have succeeded in preventing the spread of tau in the brain.

Story Source:

Materials provided by Lund UniversityNote: Content may be edited for style and length.

Exercise Your Brain!!!

Brain exercises help your mental health and fitness in the same way your body benefits from physical exercise.

And just as doing a variety of physical exercises like aerobics, strength training, and stretching is more beneficial than doing just one, so it is with doing different kinds of brain exercises too.

1. Switch Hands

If you are right-handed, try using your left hand to do things like brushing your teeth, eating, and using your computer mouse.

Using your non-dominant hand results in increased brain activity.

This can be very hard at first which is why it gives your brain a good workout.

2. Eat with Chopsticks

This will force you to eat mindfully which is good for your brain, digestion and calorie consumption. (If you’re already good at this, use your non-dominant hand instead.)

3. Do Chores with Your Eyes Closed

When taking a shower, washing your hair, or sorting laundry, try doing it with your eyes closed.

4. Do Things Upside Down or Backwards

No worries, you don’t have to stand on your head for this one.

Stimulate your brain by looking at things upside down.

An easy one to start with is wearing your watch upside down. 

This forces your brain to really think every time you glance at your watch.

You can also hang clocks or calendars upside down.

When you get used to that, you can graduate to using your phone, or whatever else you can imagine, upside down.

Or you can channel your inner Leonardo da Vinci and try mastering the art of writing backwards, known as mirror writing. 
 

5. Read Books Aloud

Take turns reading and listening to a book with your significant other, a friend, or a child.

If that’s not feasible, alternate reading with listening to audiobooks.

6. Take New Routes

On a routine commute, your brain is on autopilot and gets very little stimulation.

But taking an unfamiliar route activates the cortex and hippocampus. (9)

It has been said that Bill Gates would drive a different route on the way home from work each day to stimulate his brain, and look where that got him!

There’s no need to stick to driving.

You can take new routes when walking, biking, or riding public transportation.

7. Simultaneously Use All Your Senses

 Try activities that simultaneously engage all your senses.

Travel, camping, and gardening are high on Dr. Katz’s list of activities that utilize all your senses in new ways.

8. Try New Things

 Do things you’ve never done before.

Travel somewhere you’ve never been.

Check out an unfamiliar ethnic cuisine.

Try a hobby that is totally out of character for you.

If you are a couch potato, sign up for a dance class.

If you are athletic, try needlepoint.

Novel experiences trigger release of dopamine, the “motivation” neurotransmitter.

It also stimulates the creation of new neurons.

9. Challenge Yourself with Mastery

 Learning something new stimulates brain activity.

But as soon as you master it, the mental benefit stops because your brain becomes more efficient at the activity.

The only way to continue to stimulate your brain is to give it new challenges and stay out of your

 

 

 

 

 

 

Depression in Parkinson's Patients

 

Depression is one of the most common non-motor symptoms of Parkinson’s Disease, with up to 60 percent of patients being affected during the course of the disease.

Causes and symptoms of depression:

Depression is a mood disorder in which mixed feelings of sadness, loss, and hopelessness are experienced, interfering with quality of life. Depression can have different causes, including psychological, biological, and environmental. In people with Parkinson’s disease, the principal cause of depression is thought to be an imbalance in certain neurotransmitters that regulate mood.

Motor and cognitive symptoms of Parkinson’s disease may be intensified by depression and researchers have found that treating depression can improve the motor symptoms of the disease as well as the quality of life.

Different people may experience symptoms of depression in different ways and severity, from mild to severe. However, some are common, such as feelings of guilt, worthlessness or helplessness, thoughts of death or suicide, decreased interest or pleasure in activities, poor attention and concentration problems, sleep disorders, feeling slowed down or restless inside, pessimism or self-blame, changes in appetite, low energy or fatigue and ongoing aches and pains, headaches and/or digestive problems.

People with Parkinson’s disease also may experience

anxiety and stronger symptoms of pessimism and restlessness.

Managing depression in Parkinson’s disease

Some medicines may make people with Parkinson’s disease more prone to depression and some symptoms of the disease itself may overlap with the symptoms of depression.

People with Parkinson’s disease should be aware that depression may be a common symptom in the course of the disease, and be prepared to share their feelings with their healthcare providers.

As different people may experience different symptoms of depression, the best management solution is a tailored combination of medication, exercise, and social support.

Antidepressants are commonly used to help manage depression, and include selective serotonin reuptake inhibitors (SSRIs) .Different people may react differently to the same medication. Therefore, if a treatment does not work in one patient, another one, or a combination of two, may be indicated.

Counseling or psychotherapy is a treatment option for people with depression and is used in combination with medication and an inexpensive way to improve mood and  symptoms of depression. Yoga, Tai-Chi, stretching, and walking are examples of exercises that may be beneficial in people with Parkinson’s disease.

* Parkinson’s News Today – June 2017, Maria Joao Almeida

The Memory & Aging Center of NJ offers a research study to evaluate the effectiveness of an investigational drug pimavanserin as combined therapy in adults with Parkinson's disease whose depression is not adequately controlled with current treatments.

September is Alzheimer's Awareness Month

September is Alzheimer's Awareness Month.  In the United States, one person every 65 seconds is diagnosed with Alzheimer's Disease.   The Memory and Aging Center of New Jersey is offering free memory screenings.  Throughout the month, every Tuesday and Thursday between 10am-3pm, we will be offering free memory screenings at our office.   We are located at 20 Hospital Drive, Suite 12, Toms River, NJ 08755.   Please call 732 244-2299 to schedule your appointment.

Simple Eye Test Could Detect Alzheimer's

A team of researchers in the U.S. believe that a simple eye exam may be able to screen patients for Alzheimer’s disease long before they exhibit symptoms or signs of dementia.

“The eye can really serve as a model for studying neurodegenerative diseases,” Dr. Gregory Van Stavern, professor of ophthalmology and visual sciences at Washington University in St. Louis, told CTV News. “And we can access the eye a lot easier than we can access the brain.”

Scientists know that Alzheimer’s and dementia can begin to take root in the brain up to two decades before symptoms such as memory loss or mood changes become obvious. And while simple tests currently exist for the early discovery of diseases such as colon cancer and diabetes, there is nothing comparable when it comes to Alzheimer’s. Today, only tests such as spinal taps or PET scans can detect Alzheimer’s in its earliest stages.

“You can imagine those are invasive tests,” Van Stavern said. “They’re expensive and very difficult to apply to the general population.”

In a new study, Van Stavern and a team of researchers used a relatively simple exam to study the eyes of 30 seniors. Although none of their subjects exhibited symptoms of Alzheimer’s, PET scans and/or spinal taps had previously revealed that 17 of them were at risk of developing the disease in the future due to elevated levels of brain plaque.

Through the eye exams, which use a technology similar to what is already found in many eye doctors’ offices, the researchers discovered that those 17 had thinner retinas -- the part of the eye that converts images into signals for the brain -- as well as fewer blood vessels in their retinas than the other research subjects, signalling less blood flow in the eyes and brain.

Dr. Rajendra S. Apte, who also teaches ophthalmology and visual sciences at Washington University, co-authored the study.

“What we wanted to examine was whether we could use the eye as a window to the brain,” he told CTV News.

“The finding that there were abnormalities in the blood vessels in the eye so early in disease was very surprising,” he added. “So this tells us that there are things going on very early in disease that we should be looking for even in the brain.”

Although more research needs to be done to definitively prove a link between the state of one’s retinas and Alzheimer’s, if verified it could mean that the disease can be detected earlier and easier, thus improving treatment and patient outcomes.

“Since these pathologic changes in Alzheimer’s disease begin about 20 years before dementia develops, it means practically by the time someone develops dementia there is so much loss of neural tissue that the medications, the treatments are not very effective,” Van Stavern explained. “There’s a push now to start intervening early in the preclinical stage with medications… So the idea would be using a test like this, which is non-invasive, as a way of screening people who might be at risk for Alzheimer’s disease.”

Meanwhile in Canada, a Montreal-based company called Optina Diagnostics believes they have developed another test for detecting Alzheimer’s via a relatively simple, but somewhat different, type of retinal examination. The company, which is currently conducting clinical trials in collaboration with McGill University in Montreal and Sunnybrook Hospital in Toronto, is hoping to receive regulatory approval for its test in 2019.

The development of such quick, inexpensive and non-invasive eye tests are welcome news to Alzheimer Society of Canada CEO Pauline Tardif.

“Any disease modifying therapies that might be developed in the future will be most effective at the very, very early stages of the disease,” she told CTV News. “And if we can have… diagnostic tools such as this through the retina, that’s really exciting.”

CTV Medical News 8/29/18

LOWERING YOUR BLOOD PRESSURE COULD STAVE OFF DEMENTIA

 

For the first time in history, researchers have found medicine that can reduce the risk of memory loss and dementia in your golden years. Even better, most forms of the treatment are available in safe, inexpensive generic formulations.

The twist? These drugs have been around for decades, since they’re widely used to lower blood pressure and ward off heart disease.

As the population ages, the incidence of cognitive impairment and dementia has surged. One in six women over the age of 55 and 10 percent of men are expected to develop dementia before they die. Alzheimer's disease, the most common type, affects more than 5 million Americans and is the sixth leading cause of death in the country. And while the drug industry has spent billions of dollars trying to slow down memory loss once it begins, the efforts have been largely unsuccessful. Until now.

The Systolic Blood Pressure Intervention Trial, or Sprint, was begun in 2010 to see if aggressively lowering blood pressure would reduce a range of health complications, including heart disease and dementia. The heart disease portion was halted five years later because the benefits were overwhelming. Researchers continued to track the cognitive function of 9,361 participants in a separate analysis called Sprint Mind through June.

 

The results, presented at the Alzheimer’s Association International Conference in Chicago, found that those who initially received intensive blood pressure control were 19 percent less likely to develop mild cognitive impairment than those who had more relaxed hypertension goals. The risk of developing either cognitive impairment or dementia was 15 percent lower, while dementia rates alone weren’t significantly different in the study.

“People may do all the right things and still develop dementia, but this may give them more time.”

“What is good for your heart is not only good for your heart, but also good for your brain,'” said Jeff Williamson, the lead researcher and chief of gerontology and geriatric Medicine at Wake Forest School of Medicine.

The researchers weren’t particular about what drug regimen the patients used, as long as they got to their goals. Those in the intensive treatment arm were expected to get below 120 mmHg, the upper number in a blood pressure reading, while those in the standard treatment group aimed for 140 mmHg.

Williamson compared the findings to car tires: “You want to have the right pressure,” he said. “If it’s too high or too low, the tires can wear out quickly. With blood pressure, if it’s too high, the walls of the arteries can endure damage.”

The findings will allow people to take action in their own lives to lower their risk, with specific goals to aim for, said James Hendrix, director of global science initiatives at the Alzheimer’s Association. Many people aren’t at recommended blood pressure levels, he said, and evidence that better control helps the heart and the brain may push them into action.

“People may do all the right things and still develop dementia, but this may give them more time,” he said. “It may give another five or 10 years with a healthy brain.”

 

** BLOOMBURG

Alzheimer's disease greater in females, researchers speculate

Last week, at the Alzheimer's Association International Conference in Chicago, a group of researchers presented research findings on the gender differences in Alzheimer’s causation. They speculated that women might be getting Alzheimer’s and dementia more commonly than men and the reason behind this has not been clearly understood. Estrogen or the female hormone could be the key, the researchers state.

The authors state that there are 50 million people worldwide who are living with dementia and Alzheimer’s disease and most of these are women. In the United States, of the 5.7 million people with Alzheimer’s, two thirds are females. Alzheimer’s is a twice common diagnosis among women over 60 years rather than breast cancer, they add. Alzheimer’s is the sixth leading cause of death in the US and in the UK and Australia too, Alzheimer’s kill more women compared to heart disease.

One of the studies presented at the conference has noted that more number of births in a woman is associated with a lower risk of dementia. Women who have given birth thrice or more times have been found to have a 12 percent lower risk of cognitive decline compared to women who have given birth only once. The study looked at nearly 15,000 women before coming to this conclusion. The study from Kaiser Permanente however adds that women who have had failed pregnancies have a greater risk of cognitive decline with women who have had three or more miscarriages being at a 47 percent greater risk of dementia. The study looked at age of menarche, menopause, female hormones and their associations with dementias.

They accessed the women’s medical records between 1964 and 1973 and then again from 1996 to 2017. Not only births, miscarriages, menarche and menopause, they also obtained other data such as stroke, diabetes, high blood pressure, heart disease etc. explained Paola Gilsanz, a staff scientist at Kaiser Permanente who co-led the study. This fortified the study results she added. The results also showed that women who were fertile between ages of 21 and 30 years had a 33 percent higher risk of dementia compared to women who were fertile for a longer period. Late menarche beyond age of 16 years was tied to a 31 percent greater risk of cognitive problems compared to girls who started at 13 years, the study found. Authors caution that this was an observational study and it really does not tell one how the female hormones might be affecting the brain yet.

University of Illinois psychology and psychiatry professor Pauline Maki is presenting the latest study at the conference. She said that age has been the biggest Alzheimer’s predictors till date and it has been thought that women are more at risk of dementias because they tend to live longer. She added, “No one was paying attention to what was going on in the female brain throughout a woman's life.” Presenter Carey Gleason of the Wisconsin Alzheimer's Disease Research Center added that they found it difficult to obtain research grants to look at effects of estrogen on Alzheimer’s. This has changed over the years they note.

Another study presented by Gleason explored the recent studies that looked at cognitive functions in women who were getting a hormone replacement therapy (HRT) after menopause. Earlier studies conducted in large number of women has shown that HRT containing estrogen and progesterone can raise the risk of stroke, blood clots, breast cancer and dementia among the women. The Women's Health Initiative after their initial discouraging results on HRT came up with new interpretations after a decade saying that they had initially included only elderly women. According to Gleason, younger women taking HRT may not be at risk of dementia but the elderly women on the drugs definitely are. Diabetics of any age however are at a greater risk. She explains that concrete conclusions are still awaited with HRT and dementia risk.

According to numbers from the Alzheimer’s Association, in 2018, Alzheimer’s along with other forms of dementia could cost the United States $277 billion in direct costs and this includes $186 billion in Medicare and Medicaid payments. The organization says that by 2015 the cost would rise to $1.1 trillion with one in every three Medicare dollar being spent on this condition.

Source:

https://www.alz.org/aaic/releases_2018/AAIC18-Mon-women-dementia-risk.asp

 

Helping People with Dementia Stay Physically Active

 

ACTIVITIES FOR ANY DAY - 6 HEALTHY TIPS to help you stay active with Alzheimer's, along with physical activities to do.

Caregivers can help people with dementia be more active and stay safe:

  1. Be realistic about how much activity can be done at one time. Several 10-minute "mini-workouts" may be best.
  2. Help get the activity started or join in to make the activity more fun.
  3. Find time in the morning for exercise.
  4. Break exercises into simple, easy-to-follow steps.
  5. Choose comfortable clothes that are suitable for the weather and appropriate shoes that fit well.
  6. Make sure both you and the person with dementia 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.

Quick Tip

Try being active together. Physical activity and exercise are good for caregivers, too!

Go4Life:
Everyday Fitness Ideas from the National Institute on Aging at NIH
Helping People with Dementia Disease Stay Physically Active


SOURCE:
National Institute on Aging
National Institutes of Health
U.S. Department of Health & Human Services
Go4Life is a registered trademark of the U.S. Department of Health

These Lifestyle Changes May Help Protect the Brain As You Age

1. SHORE UP YOUR HEART - Of all things you can do, reducing the risk of heart disease has the strongest evidence of benefits for the brain.  That means treating hypertension, high lipids, cholesterol, obesity and Type 2 diabetes.

2. EMPHASIZE EXERCISE - Physical activity reduces the risk and severity of cognitive decline.  Aerobic exercise has been shown to grow the volume of certain brain regions that tend to shrink during aging.

3. LEARN NEW THINGS - Engaging intellectually with the world across a lifetime, through activities like writing letters and reading, has been linked in brain autopsies to better cognitive health in old age.

4. BE SOCIAL - Richer social lives are associated with higher levels of cognition.  Loneliness, conversely, is connected with poorer brain health.

5 TREAT DEPRESSION - Depression is middle age - which is when it is most prevalent - is linked to twice the risk of cognitive decline, though its not clear if that's a cause or an effect.

6. SLEEP WELL  Studies have found a relationship between poor sleep and cognitive decline and Alzheimer's.  Improved sleep may reduce these risks.

 

Source:  TIME MAGAZINE- THE SCIENCE OF ALZHEIMER'S - WHAT IT IS HOW IT TOUCHES US - HOPE

Parkinson's Disease Dementia

Parkinson's Disease Dementia

Parkinson's disease dementia is an impairment in thinking and reasoning that eventually affects many people with Parkinson's disease.

About Parkinson's disease dementia

The brain changes caused by Parkinson's disease begin in a region that plays a key role in movement. As Parkinson's brain changes gradually spread, they often begin to affect mental functions, including memory and the ability to pay attention, make sound judgments and plan the steps needed to complete a task.

The key brain changes linked to Parkinson's disease and Parkinson's disease dementia are abnormal microscopic deposits composed chiefly of alpha-synuclein, a protein that's found widely in the brain but whose normal function isn't yet known. The deposits are called "Lewy bodies".

Lewy bodies are also found in several other brain disorders, including dementia with Lewy bodies. Evidence suggests that dementia with Lewy bodies, Parkinson's disease and Parkinson's disease dementia may be linked to the same underlying abnormalities in brain processing of alpha-synuclein.

Another complicating factor is that many people with both dementia with Lewy bodies and Parkinson's disease dementia also have plaques and tangles— hallmark brain changes linked to Alzheimer's disease.

Parkinson's disease is a fairly common neurological disorder in older adults, estimated to affect nearly 2 percent of those older than age 65. The Parkinson's Foundation estimates that 1 million Americans have Parkinson's disease. It is estimated that 50 to 80 percent of those with Parkinson's disease eventually experience Parkinson's disease dementia. 

What percentage of people with Parkinson's develop dementia?

An estimated 50 to 80 percent of those with Parkinson's eventually experience dementia as their disease progresses. The average time from onset of Parkinson's to developing dementia is about 10 years.

Parkinson's disease dementia is a decline in thinking and reasoning that develops in someone diagnosed with Parkinson's disease at least a year earlier. Common symptoms include:

  • Changes in memory, concentration and judgment
  • Trouble interpreting visual information
  • Muffled speech
  • Visual hallucinations
  • Delusions, especially paranoid ideas
  • Depression
  • Irritability and anxiety
  • Sleep disturbances, including excessive daytime drowsiness and rapid eye movement (REM) sleep disorder

Please call the Memory & Aging Center for more information on our current Parkinson's study.

Memory and Aging Center of NJ Alzheimer's Symposium

Join us on Friday, September 29th from 10am-2pm at the Brick Township Public Library* for a complimentary symposium for caregivers and family members.  In conjunction with Alcoeur Gardens Assisted Living, Dr. Ashok Patel will discuss Normal Aging vs. Alzheimer's Disease as well about caring for an Alzheimer's patient along with the newest medical research being conducted on the disease. 

Free Brunch will be served.  Registration is free but is required by calling (732) 290-2273.

* Brick Township Library 301 Chambersbridge Road, Brick, NJ.

 

Using the Right Vocabulary with Dementia Patients

Sticks and stones may break my bones but names will never hurt me” – so goes the old saying, a child’s mode of defence against bullies in the playground.

But the fact is that words do hurt. Quite apart from obvious insults, language can be a subtle but insidious weapon – especially when it comes to older people.

19-year-old care worker: I hope perceptions of growing old will change

There is a stigma associated with old age, but I feel more comfortable around the people I care for than my fellow teenagers

People with dementia don’t always have the ability to make witty comebacks to a “sticks and stones” remark. All the more reason to equip ourselves with the right vocabulary in the first place. Here is my advice:

‘She’s a wanderer’

It may seem an innocuous word but it’s a label and, as such, is disrespectful, because it totalises the person being talked about. Other similar words to avoid are “poor feeders” and “wetters”.

‘He’s losing his marbles’

Again, this is considered a lighthearted remark, but put yourself in that person’s position. Is this a kind thing to say about someone who is experiencing memory loss, confusion and personality change? For the same reason, words like “dippy”, “mad” and “demented” are offensive.

‘How long has he been suffering from dementia?’

People with dementia aren’t “sufferers”. Of course they suffer at times, but they don’t want dementia to define them. Instead of describing someone as a “dementia sufferer” or “dementia patient”, try using “person with dementia” or, better still, “person living with dementia”.

‘She’s an empty shell’

Actually, she isn’t. Not only is there lots going in that brain, but this makes the assumption that people living with dementia can’t feel pain or emotion. They can.

‘Where are you from, love?’

Beware of apparently friendly conversation. Asking someone with dementia seemingly basic questions such as where they live, where they were born or whether they’re married can cause them a lot of distress if they can’t remember. Instead, let them take the lead and don’t be afraid to enter into their universe. If they talk about their deceased wife as if she’s still alive, go with the flow and turn it into a chat. And don’t patronise people, by calling them “love”, “dear” or any other term of endearment. Use their preferred name.

Kate Swaffer, who has written about her own journey with dementia, has a few more tips on her blog:

  • Don’t remind people with dementia of the death of a loved one or pet.
  • Don’t talk about them to someone else in front of them.
  • Don’t say “I’ve just told you that”.

The stigma of dementia is learned. Children are frequent visitors to care homes, often visiting relatives, and communication comes naturally to them. We find that children, with no prejudice or preconceptions, talk openly, patiently and respectfully.

How to care for a person with dementia

Whether it’s sticking to routines or working with positive memories, there are ways care workers can really help people with dementia, says Caroline Baker

 

Read more

For many of us, finding the right language to use around people with dementia – and other mental health conditions – is difficult. It’s so hard to negotiate that many people often don’t bother. But that’s not teaching anyone anything, nor is it building important bonds between people with dementia and their carers, care workers, friends and family.

One of my colleagues sums it up perfectly: “Labels are for tins, not people.”

Let’s start seeing the person, not the illness.

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Happy 241st Birthday America!!

The Story of the Fourth of July


The Declaration of Independence

We celebrate American Independence Day on the Fourth of July every year. We think of July 4, 1776, as a day that represents the Declaration of Independence and the birth of the United States of America as an independent nation.

But July 4, 1776 wasn't the day that the Continental Congress decided to declare independence (they did that on July 2, 1776).

It wasn’t the day we started the American Revolution either (that had happened back in April 1775).

And it wasn't the day Thomas Jefferson wrote the first draft of the Declaration of Independence (that was in June 1776). Or the date on which the Declaration was delivered to Great Britain (that didn't happen until November 1776). Or the date it was signed (that was August 2, 1776).

 

So what did happen on July 4, 1776?

The Continental Congress approved the final wording of the Declaration of Independence on July 4, 1776. They'd been working on it for a couple of days after the draft was submitted on July 2nd and finally agreed on all of the edits and changes.

July 4, 1776, became the date that was included on the Declaration of Independence, and the fancy handwritten copy that was signed in August (the copy now displayed at the National Archives in Washington, D.C.) It’s also the date that was printed on the Dunlap Broadsides, the original printed copies of the Declaration that were circulated throughout the new nation. So when people thought of the Declaration of Independence, July 4, 1776 was the date they remembered.

In contrast, we celebrate Constitution Day on September 17th of each year, the anniversary of the date the Constitution was signed, not the anniversary of the date it was approved. If we’d followed this same approach for the Declaration of Independence we’d being celebrating Independence Day on August 2nd of each year, the day the Declaration of Independence was signed!

 

How did the Fourth of July become a national holiday?

For the first 15 or 20 years after the Declaration was written, people didn’t celebrate it much on any date. It was too new and too much else was happening in the young nation. By the 1790s, a time of bitter partisan conflicts, the Declaration had become controversial. One party, the Democratic-Republicans, admired Jefferson and the Declaration. But the other party, the Federalists, thought the Declaration was too French and too anti-British, which went against their current policies.

By 1817, John Adams complained in a letter that America seemed uninterested in its past. But that would soon change.

After the War of 1812, the Federalist party began to come apart and the new parties of the 1820s and 1830s all considered themselves inheritors of Jefferson and the Democratic-Republicans. Printed copies of the Declaration began to circulate again, all with the date July 4, 1776, listed at the top. The deaths of Thomas Jefferson and John Adams on July 4, 1826, may even have helped to promote the idea of July 4 as an important date to be celebrated.

Celebrations of the Fourth of July became more common as the years went on and in 1870, almost a hundred years after the Declaration was written, Congress first declared July 4 to be a national holiday as part of a bill to officially recognize several holidays, including Christmas. Further legislation about national holidays, including July 4, was passed in 1939 and 1941.

Constitution.com



 

Tips for Dementia Caregiving

1) Start with a Good Feeling Each Day

Caregivers have a profound influence on the

emotional state of individuals with Alzheimer's.

A University of Iowa study further supports an inescapable

message: caregivers have a profound influence -- good or bad --

on the emotional state of individuals with Alzheimer's disease.

Patients may not remember a recent visit by a loved one or having been neglected by staff at a

nursing home, but those actions can have a lasting impact on how they feel.

The findings of this study are published in the journal, Cognitive and Behavioral Neurology.

UI researchers showed individuals with Alzheimer's clips of sad and happy movies. The patients

experienced sustained states of sadness and happiness despite not remembering the movies.

"This confirms that the emotional life of an Alzheimer's patient is alive and well," says lead

author Edmarie Guzmán-Vélez. Despite the considerable amount of research aimed at finding new

treatments for Alzheimer's, no drug has succeeded at either preventing it. Against this backdrop,

this study highlights the need to develop new caregiving techniques aimed at improving the wellbeing

and minimizing the suffering for the millions of individuals afflicted with Alzheimer's.

For this behavioral study, Guzmán-Vélez and colleagues invited 17 patients with Alzheimer's and 17

healthy participants to view 20 minutes of sad and then happy movies. These movie clips triggered

expected emotions: sorrow and tears during the sad films and laughter during the happy ones.

Five minutes after watching the movies, participants took a memory test to see if they could recall

what they had just seen. As expected, the patients with Alzheimer's retained significantly less

information about both the sad and happy films than the healthy people. In fact, four were unable to

recall any factual information about the films, and one patient didn't even remember watching any

movies.

Before and after seeing the films, participants answered questions to gauge their feelings. Patients

with Alzheimer's disease reported elevated levels of either sadness or happiness for up to 30

minutes after viewing the films despite having little or no recollection of the movies. Quite strikingly,

the less the patients remembered about the films, the longer their sadness lasted. While sadness

tended to last a little longer than happiness, both emotions far outlasted the memory of the films.

The fact that forgotten events continue to exert profound influences on patients' emotional life

highlights the need for caregivers to avoid causing negative feelings and to try to induce positive

feelings.

"Our findings should empower caregivers by showing them that their actions toward

patients really do matter," Guzmán-Vélez says. She suggests simple things that can have a

lasting emotional impact on a patient's quality of life and subjective well-being, such as:

Frequent visits

Social interactions

Exercise

Music

Dance

Jokes

Serving patients their favorite

foods.1

1 SOURCE: University of Iowa Health Care

Dementia: A Group of Symptoms

Dementia: A Group of Symptoms

By Rachel Schindler, MD | Sep 4, 2014

By now most people have heard of the word dementia. But do you know exactly what it is? It is a gradual loss of mental abilities such as memory, thinking, language, judgment, and usually accompanied by changes in behavior. Dementia isn’t simply occasional forgetfulness, but a problem in the brain that is severe enough to interrupt normal daily activities.

Where many people get confused is when they think dementia is a disease in and of itself. In fact, dementia is the result of a disease, brain disorder, or injury. It is not a disease, but a range of symptoms that tell us a disease or condition is causing physical changes in the brain.

A good way to think about this is to draw a parallel between dementia and another symptom like itching. This may seem odd at first, but the comparison is actually quite helpful. For instance, like dementia, itching can be mild or severe, can cause a minor problems at first or can turn out to be a very serious issue. Itching can be the symptom of a number of diseases or conditions that are treated very differently. For example, itching may be a symptom of psoriasis, allergies, kidney disease, poison ivy or even lymphoma. Each of the underlying causes is treated very differently from the others. Treatment of the symptom, in this case itching, may make it better.  But the goal is to discover and address the underlying cause. So, like itching, it can help to think of dementia as a cluster of symptoms that indicates something is happening in the brain, though it does not tell us exactly what.

Types of Dementia

There are several types of dementia, caused by different underlying conditions. The most well known types of dementia include Alzheimer’s dementia (AD), Parkinson’s disease dementia, and Lewy Body dementia. But there are also types of dementia caused by vascular disease (such as strokes) and Frontotemporal dementia, which is caused by the breakdown of nerve cells in particular regions of the brain.

Early Signs of Dementia

If you recognize any of the following early signs in yourself or a loved one, it is important to speak with your doctor. You can then work together to find out what is causing your symptoms, including obtaining some tests or possibly finding a doctor who specializes in diagnosing and treating dementia:

  • Forgetfulness that hinders your ability to get through the day: This can include asking about the same thing repeatedly, especially if it was just learned; this is  different from sometimes forgetting names or dates and remembering them at a later time
  • Growing challenges in planning or solving problems: This might include being unable to concentrate, focus, or follow directions.   The difficulties are ongoing, and not just occasional errors.  They might occur, for example,  when balancing a checkbook, paying the bills or following a familiar recipe
  • Difficulty completing tasks that used to be easy:  Examples include getting lost while driving on a familiar route or  needing help to use the settings on a microwave which were used independently before
  • Confusion about what season it is, or the passage of time: Forgetting the date, time and location can occur; this is different from temporarily thinking it is Wednesday when it is Thursday
  • New problems with words, speaking or writing to the point that joining a conversation is difficult: This is different from sometimes having trouble finding the “right” word

The very presence of any symptom, if it is more than just a minor, passing issue, means that it is time to get to a doctor to find out what is going on. There are different types of dementia with different causes.  Some are even reversible, for example as with certain vitamin deficiencies or hormonal imbalances.  In those not reversible, treatment may help with symptoms.   An earlier diagnosis may also help patients and families learn as much as they can about the illness and what needs and choices may be anticipated.

Rachel Schindler, MD is a physician/scientist who leads the strategy for Neurosciences in the Clinical Sciences group at Pfizer’s Global Innovative Pharmaceuticals Medicines Development Group.  She is the founder and former Director of the Neurobehavior and Memory Disorders Program at University Hospital at Stony Brook.

Alzheimer's Patients Are Not Zombies

I saw a woman lose her mind, right in front of me, and then get it back, right in front of me.

Just like that.

We were talking about her life, hertypical day, when I asked her about Doug. "Who’s Doug?" she replied. I didn’t answer but, like one of my patients, I repeated myself: "How's Doug?" Again she replied, “Doug?”

This time, I answered, “Doug, your husband.”

Open-mouthed, she was surprised, even scared, like she’d seen a ghost. “I have a husband?” He came back to her like an old friend. “Of course, Doug, my husband. Oh, my…” She’d forgotten him, right in front of me. She begged me not to tell him she had forgotten him.

I’ve been wondering if I should have pushed her. Or maybe I should have dropped my line of questioning. I could have gotten away with that. White-coated and armed with my clipboard in my exam room, I wield authority. I could’ve simply moved on to another topic and she’d have gone along to get along. I could have lied or created some kind of imaginary “Doug.”

There comes a stage of Alzheimer's disease when people no longer recognize the ones they love: their spouses, friends and children. They may ask for long-dead relatives. They may ask to go home, when in fact they are home. The crushing fear of this produces a dangerous metaphor for the disease: patients become a kind of living dead or, in a word, zombies.

This troublesome metaphor often has innocent origins, as researcher Susan Behuniak explains in her essay, “The living dead? The construction of people with Alzheimer’s disease as zombies.” It pervades the ways we think about Alzheimer’s; see, for example, this blog or the TV preacher Pat Robertson's argument that divorce from an Alzheimer's patient is acceptable because the patient is a living death. Well-meaning caregiving guidebooks use it. Professional journals have articles such as “Hospice care for the living dead.”

The problem with the zombie metaphor, with thinking about the patient as a living dead, is that it limits our repertoire of emotions. We feel fear and disgust, emotions that in turn cause stigma, which describes a deliberate distancing and dehumanizing of a person.

Jews in Germany, homosexuals everywhere and, more recently, undocumented residents in the U.S.—when we stigmatize a group of people, we cease to care. The stigmatized become a threat, a burden. They’re put in ghettos, deported, even eliminated.

Persons with Alzheimer’s disease are called a “silver tsunami” that will bankrupt America. They feel a distancing from others. The public’s negative emotions are driven by the decline expected with Alzheimer’s disease. We hope for a cure, but hope is not a plan, and horror stories are for teenagers. We—autonomous grown-ups—need other ways of thinking about the disease.

This other way isn’t some fairy tale of unicorns and rainbows. Alzheimer’s, like other diseases that progressively destroy our brains, disrupts our ways of being, because its earliest symptoms are a loss in our capacity to exercise a cherished ethic: autonomy. We need to grow up, and think I’ve found a way we can do this in the stories of Alice Munro.

In her “In Sight of the Lake,” we meet Nancy. She’s bothered by memory problems. After a visit to her doctor (she came on the wrong date), she’s referred to a memory specialist in a neighboring town. To prepare for the visit, to avoid arriving flustered and late, she decides to drive to the town the evening before the visit, locate the office and so return the next day at ease over where she needs to travel.

She reaches the town, but she cannot find the doctor’s office. In her wanderings, she’s self-conscious of the troubles she’s having. She feels her world is coming apart. A child rides backwards on a bicycle, clocks are broken, a jewelry store sells junk. She resists asking for help, fearful that, once she’s out of earshot, people will “speculate” about her.

At story’s end, Nancy is in another place, in a bed in a nursing home. Sandy, one of the aides, is struggling to get her dressed in her nightclothes (Sandy calls it a “nightie”). Nancy is agitated. It has all been a dream.

Sandy says she’s acting like a chicken afraid it’s going to be “’et for dinner,” a politer way of saying Nancy’s acting not like a person who’s had a bad dream, but like a mindless bird, a chicken with its head cut off.

Reprinted- Forbes - Jason Karlawish is a Professor of Medicine, Medical Ethics and Health Policy, and Neurology at the University of Pennsylvania.