Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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He did not indicate any issues with nutrition; scored a 1 out of 5 on the Geri-

atric Depression Scale, which indicates no signs of depression; and scored a 33

out of 60 on the Lubben Family Network Scale, in which he reported having rela-

tives that he felt at ease with to discuss personal matters. He identified only one

close friend. On the Mini-Cog, he scored a 3 out of 3 on the recall and a 3 out of 4

on the Clock Drawing Test, which indicated no signs of dementia, allowing him

to remain in the program. However, a 3 on the Clock Drawing Test does demon-

strate some concern with cognitive status and warrants further evaluation. He

showed concern with dealing with pain and fatigue, as they interfere with activi-

ties at times. There were no concerns with home or personal hygiene. In reference

to health resources, he reported attending regular fitness programs and focusing

on activities to help manage health concerns. Past medical history includes a head

injury. Medications include Ritalin and Hydrocodone. He reports taking Ritalin

to stay awake and not taking Hydrocodone because of unwanted side effects. He

also reports taking epidural injections for stenosis. In the Physical Therapist’s

Systems Review, he was not impaired in cardiovascular and integumentary sys-

tems. He was slightly overweight according to the Body Mass Index. His upper-

body strength was determined to be normal. On the functional reach test, his

average score was 7 inches, which placed him in moderate risk for falls. On the Sit

to Stand Test, he scored a 7 in 30 seconds, which indicated weakness in lower ex-

tremities. On the TUG or Get Up and Go Test, he took 11.5 seconds; this means he

was slightly impaired and indicated a decrease in agility, strength, and balance.

He also became short of breath for the Get Up and Go and Sit to Stand tests.

Raymond’s primary care physician was given a summary of the assessment results

and recommendations from the team working with him. After conducting a thor-

ough health history and evidence-based assessment, the team determined that Ray-

mond needed further evaluation for alcohol abuse or dependence. There was also

concern for continued assessment about his cognitive status, given the failed Clock

Drawing Test. He was provided with appropriate referral sources to obtain these ser-

vices. The social worker was careful to present these recommendations with tact and

sensitivity. He was referred to a local alcohol and drug counseling center that would

accept his insurance provider. The team also recommended an exercise program for

improvement of strength and cardiovascular endurance. A recommendation was

made to perform low back and abdominal exercises for spinal stenosis.

Raymond’s response to the recommendation by the social worker and physical

therapist was very positive, and he agreed to follow their recommendations. He

was to be reassessed in 12 weeks. Unfortunately, after 1 month of his involvement

with the plan of care, he had to have spinal surgery. Due to the requirements of

the research program that clients have no major surgeries in the prior 6 months,

he had to then be dropped from the program.

Raymond’s case provides a real-world example of an evidence-based interdis-

ciplinary assessment utilizing the CAGE to explore problematic alcohol use as

well as a brief intervention. The social work team member engaged Raymond

with rapport building and administered the CAGE in a nonthreatening, support-

ive manner. Raymond was forthcoming about feeling he needed to cut down on

his drinking, that he was annoyed at times by his wife’s concerns, and that he felt

guilty about his drinking. The social worker engaged Raymond in a brief inter-

vention by discussing the CAGE results, which were indicative of a need for fur-

ther evaluation and probable subsequent substance abuse treatment. The social

Substance Abuse 327

worker informed Raymond about the health risks associated with his drinking

and in combination with Ritalin and Hydrocodone. The social worker provided

handouts so that he could read further about these health risks. He was given a

referral for further evaluation with a local alcohol and other drug treatment cen-

ter. Raymond signed the plan of care and verbally agreed to these recommenda-

tions as well as other previously mentioned recommendations.

The advantages that the social worker had in this case was that Raymond volun-

tarily sought involvement in the research and service program, and he was inter-

ested in improving his health. Therefore, the skilled social worker and physical

therapist tailored their recommendations for the plan of care to his sincere con-

cern to improve his overall health. These types of brief, structured interventions

are used to ameliorate the substance abuse problem and perhaps interrupt the tra-

jectory of a more serious problem with alcohol dependence (DiClemente, Bellino,

& Neavins, 1999; Heather, 1995; O’Hare, 2005; U.S. Department of Health and

Human Services, 1997, 2000). Though brief, these interventions can be sufficient

in assisting the modification of substance use to forestall more serious problems.

EVIDENCE-BASED POLICY RECOMMENDATIONS

Implications for policy can be derived from the research literature to date. The

authors are currently working on the aforementioned Geriatric Evaluation and

Self-Management Services Project, which has begun to produce improved out-

comes in terms of health indicators and cost-benefit analysis. Receiving interdis-

ciplinary in-home assessments from social workers and physical therapists, older

adults are screened for alcohol abuse or dependence problems and a variety of

other health-related risk factors and can be given brief interventions to assist in

decreasing future substance abuse and other related health problems. These

types of projects need to be recognized by policy makers as interventions that can

and will make a significant contribution to the quality of life of the elderly as well

as to decrease the need for acute hospitalizations and other health-related costs.

Abrams (2002) discussed the vital need for increased education about and

awareness of substance abuse in the elderly to inform policy. She recommends

that policy be developed to improve prevention and detection of substance abuse

among older adults. The argument that school-age children have a greater need

for substance abuse prevention programs does not hold weight when the statistics

about the potential impact of the baby boom generation are considered. More

specifically, future cohorts of the elderly, who did not experience Prohibition and

who were involved in the Vietnam War and the drug culture of the 1960s, may

have more significant drug and alcohol issues than the current generation of the

elderly (Gurnack et al., 2002). Abrams (2002) also argued that it is only through

prevention, detection, and treatment of abuse that the substance abuser may es-

cape permanent physical and mental damage.

These points emphasize the importance of competency training for care

providers of the elderly to be able to identify those at risk and those who indicate

a problem with chemical abuse or dependence. Once proper training is obtained,

various disciplines of elder care providers can perform their unique roles in a

concerted successful effort to prevent, detect, and treat substance abuse among

the older population. Furthermore, it is crucial to develop a vocabulary to facili-

tate a dialogue about the substance abuse problem in older adults to move beyond

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thinking of the elderly person as a “drunk” or a “drug addict” and instead as a

person who has a disease that is very treatable.

There is also the important point about addressing the cost of substance

abuse treatment that needs to be considered in policy decisions. Cornelius

(2002) urges policy makers to find ways to pay for the provision of substance

abuse services as well as supporting treatment designs that reflect the diversity

of the clients involved.

In a data analysis of the National Household Survey on Drug Abuse in 1994 (N

= 10,158) and 1998 (N = 12,892), Oggins (2003) found that in alcohol or other drug

using samples of mixed-age groups, most paid for treatment out of pocket even de-

spite reported increases in employer-paid insurance. The results of this study em-

phasize that often the insured population is not well informed about the details of

their health insurance, specifically for alcohol or other drug treatment; many do

not realize that they have coverage and end up paying more than they have to. The

findings also recommend an expansion of no-cost treatment, with funds extracted

from increased taxation on liquor, cigarettes, tobacco settlements, and savings in

incarceration costs due to nonviolent offenders being sent to treatment.

With ongoing changes to the provisions of treatment services from inpatient to

outpatient and shifts in reimbursement structures, coverage of effective treat-

ment is of increasing concern. These changes in treatment provisions put much

emphasis on the need for ongoing research.

FUTURE DIRECTIONS FOR RESEARCH

Substance abuse among the elderly is a growing concern that threatens to pose se-

rious consequences for older adults and health providers. Efforts in the future need

to be focused on outcome studies for addiction treatment, such as Project MATCH

(Project MATCH Research Group, 1997), wherein individually delivered treat-

ments are evaluated for their effectiveness. Controlled trials of various models of

treatment addressing topics such as prescription drug dependence in the elderly

are very much needed (Finlayson, 1998). In addition, exploration of how the Min-

nesota model, 12-step facilitation, motivational interviewing, cognitive-behavioral

therapy, and other treatment models may need to be restructured in an effort to

meet the needs of the elderly substance abuser is also needed.

The Consensus Panel (CSAT, 1998) reported that future research with older

adults needs to address alcohol and other drug consumption in terms of varying

patterns of use along the life course, gender and ethnic differences, health care

cost comparisons between those maintaining abstinence and those who reduce

consumption, early and late onset of alcohol and drug problems, and the develop-

ment of valid screening instruments for illicit and prescription drug use. Other

recommended areas for research with older adults are treatment (e.g., prevention

and early intervention techniques, use of technology, efficacy of age-specific

treatment, older subgroups, and risk factors), biomedical (e.g., medication inter-

actions, medical consequences of moderate to heavy consumption of alcohol or il-

licit drugs), and behavioral and psychological (e.g., relationship between

demographics and alcohol and drug abuse, reasons for changing drinking pat-

terns, stress and coping in relation to substance abuse), as well as special issues

(e.g., homelessness, elder abuse and neglect, underrepresentation of older adults

in treatment facilities; CSAT, 1998).

Substance Abuse 329

Conducting rigorous research studies in the field of aging and substance abuse

needs to be a high priority. This type of evidence can provide vital knowledge to

inform health care providers, policy makers, older adults, and families in an ef-

fort to improve our response to the ever increasing aging population. An absence

of these types of investigations and related education will create enormous costs

to one of the most vulnerable and rapidly growing groups in society.

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333

CHAPTER 13

Alzheimer’s Disease

MASAHIRO SHIGETA and AKIRA HOMMA

OVERVIEW OF ALZHEIMER’S DISEASE

ISTORY AND

ROFILE OF

LZHEIMER

’

ISEASE

Alois Alzheimer (1864–1915), a psychiatrist and neuropathologist, reported the case

of a 51-year-old woman (Auguste D) with dementia that started with delusions of

jealousy. As memory impairment progressed rapidly, she lost her way when she

went out and she became unable to read and write. Sometimes she hid her belong-

ings, and her husband could not understand such behavior. She died 4.5 years after

the clinical onset. In the postmortem study of her brain, Alzheimer reported de-

posits of “peculiar substances” (plaques) distributed widely in the brain and “dense

bundles” (neurofibrillary tangles) within the nerve cells. There were subsequent re-

ports of several patients with similar features. Emil Kraepelin (1913) named the dis-

ease “Alzheimer’s disease” in the eighth edition of his textbook, Psychiatrie.

Alzheimer’s disease (AD) is the most common neuropsychiatric disorder. Pa-

tients with AD show progressive deterioration of memory and other cognitive

functions such as thinking, decision making, attention, reasoning, and calcula-

tion, and finally loss of mental and physical functions. Diagnostically important

symptoms of AD include aphasia, apraxia, agnosia, and disturbances in executive

function. Aphasia in AD is characterized by forgetting correct wording and the

inability to follow conversations. Apraxia is generally defined as loss of the abil-

ity to carry out purposeful movements in the absence of motor disorders such as

palsy, ataxia, and involuntary movement. Agnosia is generally defined as loss of

the power to recognize the importance of external stimuli: auditory, visual, olfac-

tory, gustatory, and tactile. Executive function involves the cognitive processes

used to complete complex tasks. Patients with impairment of executive function

cannot perform the series of procedures involved in a task.

Not only cognitive symptoms but also behavioral and psychological symptoms

are common in patients with AD. These symptoms are brought together as be-

havioral and psychological symptoms of dementia (BPSD). The BPSD are de-

fined as the symptoms of disturbed perception, thought content, and mood and

behavior that frequently manifest in patients with dementia. Some BPSD are

assessed at an interview of the patient or a relative; others are assessed by

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observing the patient’s behavior. The former symptoms include anxiety, de-

pressed mood, hallucinations and delusions; the latter symptoms: aggression,

screaming, restlessness, agitation, wandering, culturally inappropriate behav-

iors, sexual disinhibition, hoarding, cursing, and shadowing. The BPSD are more

or less stressful for caregivers, and their management is a critical issue in the

daily lives of the caregivers and their families.

Two forms of AD are clinically recognized in terms of age at onset: early onset

and late onset. Early-onset AD is relatively rare, and its symptoms begin to ap-

pear before age 65. Late-onset AD is the most common form and appears after age

65. It is known that there is a familial AD, which is a rare form, accounting for

fewer than 5% of all AD cases.

REVALENCE AND

NCIDENCE OF

LZHEIMER

’

ISEASE

Prevalence is defined as the percentage of the number of cases of a disease in a

statistical population at a specified time. Jorm, Korten, and Henderson (1987)

statistically analyzed the data from studies of the prevalence of dementia be-

tween 1945 and 1985. Variations in prevalence reflected differences in methodol-

ogy, such as screening design and diagnostic criteria, as well as in study site

characteristics (institutionalization and life expectancy; Katzman & Kawas,

1994). However, the relationship between prevalence and age was consistent

across the studies, with prevalence doubling every 5.1 years (Jorm et al., 1987).

This exponential rise in prevalence was observed especially in the 65- to 85-year

age range.

There are highly accurate diagnostic criteria for AD in the clinical setting, such

as the criteria specified by the National Institute of Neurological and Commu-

nicative Diseases and Stroke/Alzheimer’s Disease and Related Disorders Associ-

ation (NINCDS-ADRDA; McKhann et al., 1984). However, in field surveys,

differentiation of AD is sometimes difficult, because coexisting factors, such as

cerebrovascular factors, make the diagnosis ambiguous. Differential diagnosis

among AD with cerebrovascular disease, AD with vascular dementia, and vascu-

lar dementia is often unsatisfactory (Katzman & Kawas, 1994).

National differences in the relative prevalence of AD and vascular dementia

were reported from a meta-analysis (Jorm et al., 1987). Vascular dementia was

more common in Russian studies, AD in Western European countries, and no sig-

nificant difference was observed in American studies. The national differences

might be caused not only by the diagnostic procedures but also by the age struc-

ture of the population. With the rapid increase in the old-old population in Japan,

recent surveys there have reported that AD is now more common than vascular

dementia (Meguro et al., 2002; Nakamura et al., 2003; Shigeta, 2004).

The incidence is a number equal to the fraction of the population that con-

tracts a particular disease during a given period of time. It thus refers to the an-

nual diagnosis rate or the number of new cases of AD diagnosed each year. It

reflects differences in the time of the investigation and regional differences

more sensitively than prevalence. However, incidence studies have not been

performed as frequently as prevalence studies because of the need for repeated

surveys for the former. Several incidence surveys have been conducted in

Mannheim, Germany (Bickel & Cooper, 1994), southwestern France (Letenneur,

Alzheimer’s Disease 335

Commenges, Dartigues, & Barberger-Gateau, 1994), Cambridge, England

(Brayne et al., 1995), Rotterdam, Netherlands (Ott, Breteler, van Harskamp, Sti-

jnen, & Hofman, 1998), southern Taiwan (Liu et al., 1998), and Odense, Den-

mark (Andersen et al., 1999). The incidence of all dementias ranged from 1.07 to

2.95, according to these surveys. Many incidence data were distributed between

1% and 2%. On the other hand, the incidence of AD showed wider variation:

The lowest value was 0.54 (southern Taiwan), and the highest was 2.7 (Cam-

bridge). For epidemiological studies of dementia, the differential diagnoses

(causes of dementia) include not only AD, cerebrovascular dementia, and other

types of dementia, but also “unknown” or “uncertain” types of dementia. The

frequency or ratio of such unknown or uncertain types also varied among the

surveys, and could influence the frequency or ratio of AD. The incidence is also

affected by the screening method and the diagnostic procedures for the demen-

tia subtypes.

The cost of the management of patients with AD includes the physician’s visits,

laboratory testing, medications, nursing services, home care, day care, and more.

Alzheimer’s disease has thus become one of the most serious health economic is-

sues as well as a public health problem in advanced countries because of the

growing number of elderly people who are affected by AD.

AUSES AND

ISK

ACTORS OF

LZHEIMER

’

ISEASE

Alzheimer’s disease is now considered to be caused by a combination of genetic

and environmental factors. Familial AD of early-onset type is linked to at least

three genes: encoding the amyloid precursor protein (APP) on chromosome 21,

and genes for presenilin 1 and 2 on chromosomes 14 and 1, respectively. Prese-

nilin mutations are more frequent than APP mutations. However, altogether

these mutations account for only approximately 0.1% of all patients with AD, and

the cause of almost all sporadic cases of AD remains unknown.

Studies have been conducted to ascertain whether certain chemicals or other

toxins in the environment play a role in causing AD. Environmental factors that

have been proposed include aluminum, zinc, toxins in contaminated food, and

viruses. However, to date there is little solid evidence of their involvement, even

though the possibility cannot be excluded. Other hypotheses about the causes of

AD include oxidation damage, estrogen deficiency, and inflammation. These pos-

sibilities are under investigation.

Apolipoprotein E4 Gene Apolipoprotein E4 (ApoE4, chromosome 19) is a genetic

risk factor for late-onset AD (Strittmatter et al., 1993; Wisniewski, Golabek, Mat-

subara, Ghiso, & Frangione, 1993). People who have ApoE4 are at higher risk of

developing AD and are likely to develop AD earlier in life. However, it is not a

consistent cause: Some people with ApoE4 do not get AD, and some without

ApoE4 get AD. The development of late-onset AD is considered to be influenced

by more than one gene.

Age A number of factors that increase a person’s risk of developing AD have been

studied. One of the strongest risk factors for AD is age. The risk of AD increases

after age 65 and rises exponentially after age 75. While 1% of the population has