Monday, January 6, 2014

Correlating Studies in Vitamin E and High Blood Sugar with the Delay or Prevention of Dementia


High Doses of Vitamin E May Delay Alzheimer’s Patients Moving to a Nursing Home While High Blood Sugar Raises the Risk of Dementia





Evelyn Smith

MS in Library Science, University of North Texas (2012)

A study that appears in the January edition of the Journal of the American Medical Association has reaffirmed some earlier studies that taking high doses of Vitamin E supplements may prolong the period that patients suffering from mild to moderate Alzheimer’s may be able to perform the Activities of Daily Living, such as dressing themselves, and toileting, that may keep them out of a nursing home for about six months.  However, taking vitamin E supplements doesn’t prevent the onset of dementia in otherwise functionally cognitive older adults. 

Because taking Vitamin E supplements can cause possible health risks, patients in the early stages of dementia should consult a physician before undertaking this therapy and weight the risks of taking this alternative medicine.  However, a diet that includes vitamin E, when it is found in dark green and leafy vegetables, has proven beneficial in possibly delaying dementia, just as a diet that includes several servings of fatty fish, such as salmon or tuna, may reduce the chance of dementia .  In August 2013, research also showed that a diet high in blood sugars correlates with a higher incidence of dementia. Placing these most recent studies in a broader context, which includes current advice on  administering vitamin E to patients in the early stages of Alzheimer's, should help caregivers discuss whether or not they should include high doses of vitamin E as part of their therapy. Reading The New York Times regularly should help the general public keep up with the latest developments in the treatment of Alzheimer's.
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Dieting Advice to Prevent Dementia: 

  • Everyone should regularly eat their spinach and other dark green and leafy vegetables as well as include nuts in their diet to increase the intake of Vitamin E naturally;
  • They should also strive to maintain a healthy body weight and stay away from high caloric foods and  that produce high blood sugar;
  • Caretakers should consult a physician before administering vitamin E supplements to patients in the early stages of dementia, so they can jointly evaluate the risks and benefits of doing so.
  •  In the meanwhile, watch out for a decline in verbal fluency particularly among women. Reason:  If not remembering the right word goes along with a high blood sugar level, it can be reversed if caught in time.
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Popular & Vetted Studies on Vitamin E


, Pam.  (2013, December 31).  Vitamin E Slows Decline of Some Alzheimer’s Patients in Study. New Old Age. Health.  New York Times.  Retrieved from http://newoldage.blogs.nytimes.com/

Until most recently, research from clinical trials as to whether vitamin E can help Alzheimer’s patients have been mixed and cautionary since high doses might increase the risk of death.  The January edition of the Journal of American Medical Association, however, has released a study that indicates that over a little more than two years, high doses of vitamin E slowed the decline of mild to moderate Alzheimer’s by about six months (Belluck, 2013, December 31, para. 1-3).

While vitamin E doesn’t delay cognitive decline, it does enable individuals diagnosed with mild to moderate Alzheimer’s to perform activities of daily living for about six months longer.  These individuals also needed help from caregivers for two hours less per day (Belluck, 2013, December 31, para. 4-5).

Whether this research will still dramatically affect the lives of Alzheimer’s patients is still unclear, but it might improve their ability to bathe and dress themselves.  Perhaps more importantly, high doses of vitamin E appeared to be safe—a finding that goes against a 2005 analysis that suggested that high doses of vitamin E could increase the risk of death (Belluck, 2013, December 31, para. 5-6).

Even so, this doesn’t mean that everyone with dementia or everyone hoping to prevent it should take high doses of vitamin E since the study only found that it benefitted people with mild to moderate Alzheimer’s, echoing 1997 research that also found that vitamin E could delay cognitive decline for about seven months in patients with moderately severe Alzheimer’s (Belluck, 2013, December 31, para. 8-9).

Other studies have discovered that vitamin E doesn’t delay dementia in individual without symptoms or with mild cognitive impairment (Belluck, 2013, December 31, para. 10). Physicians thus caution against applying the results of this study to anyone without mild to moderate Alzheimer’s (Belluck, 2013, December 31, para. 11-14).

The research followed 613 mostly male veterans from 14 Department of Veterans Affairs hospitals who were already taking medications, like Aricept, prescribed for mild to moderate Alzheimer’s. One group received 2,000 I.U.’s daily while another group received memantine (Namenda), vitamin E plus memantine, or a placebo. While researchers hoped for a double benefit of taking vitamin E and memantine, only vitamin E proved beneficial.  Mematine was no better than a placebo at preventing cognitive decline (Belluck, 2013, December 31, para. 15-16).

Moreover, while vitamin E helped individuals retain their ability to perform the activities of daily living for a longer period of time, it didn’t stop cognitive decline.  Although the ability to perform daily functions might be more important to patients and their families, a truly effective Alzheimer’s treatment would improve their ability both to think and function (Belluck, 2013, December 31, para. 17-18). Experts also couldn’t explain why vitamin E would work in fully developed Alzheimer’s but not earlier.  Even so, caretakers should attempt to give 2,000 I.U.’s of vitamin E without a physician’s oversight (Belluck, 2013, December 31, para. 19-20).

Researchers questioned as to whether they would administer high doses of vitamin E to their Alzheimer’s patients responded that they would suggest it after trying other treatments as another option (Belluck, 2013, December 31, para. 21-23).

Study: Vitamin E may help Alzheimer's patients (2013, December 31). CNN  Health.  Retrieved from http://thechart.blogs.cnn.com/2013/12/31/study-vitamin-e-may-help-alzheimers-patients/

A new study just released by the Journal of the American Medical Association suggests that vitamin E might help improve the functioning of patients with mild to moderate Alzheimer’s, even though no cure for Alzheimer’s exists.  No vitamin or medicine can reverse the symptoms of memory loss and disorientation.  Researchers also caution that vitamin E isn’t always effective.  Nevertheless results are positive enough to call for more research to duplicate and confirm the findings even as researchers caution that no one should take vitamin E unless a physician approves of the dosage (CNN Health, 2013, December 31, para. 1-3).

Methods

The trial involved 613 patients with mild to moderate Alzheimer's disease, 97 percent of which were male.  All but one of the patients was already taking acetylcholinesterase inhibitors that slow Alzheimer's symptoms in some patients. One group received synthetic vitamin E; one group received memantine; one group received both vitamin E and memantine, a drug for moderate to severe Alzheimer’s, and one group received a placebo (CNN Health, 2013, December 31, para. 4-5). Researchers used the Alzheimer’s Disease Cooperate Study/Activities of Daily Living Inventory to measure functional ability as well as other assessments to evaluate cognitive skills, following the patients for 2.3 years (CNN Health, 2013, December 31, para. 6-7).

Results

Only participants in the vitamin E only group had a delay in the clinical progression of Alzheimers of 19 percent over a year when compared with the placebo group.  Upon measuring how  quickly Alzheimer’s was progressing in terms of daily living activities, the vitamin E only group saw a decline of 3.15 units less than those receiving a placebo.  This could determine whether the patient was still able to bathe or dress him or herself.  Activities of Daily Living rarely improve during clinical trials (CNN Health, 2013, December 31, para. 8-9).  Patients taking both vitamin E and memantine or memantine alone did not show any benefits, nor did any group do better on  cognitive tests than those patients taking placebos (CNN Health, 2013, December 31, para. 10).

Caveats

Researchers still don’t know why only taking vitamin E benefitted Alzheimer’s patients while taking vitamin E along with memantine didn’t.  They also don’t know why any group didn’t perform better than   the placebo group on cognitive tests. This recent study therefore underlines the need for replicating the study (CNN Health, 2013, December 31, para. 11-13).

Previous research has proved that vitamin E might possibly benefit Alzheimer’s patients, but some studies have raised safety concerns; for example, a 2011 JAMA study found that when cognitively health men take vitamin E, this increases their risk of prostate cancer However, vitamin E didn’t appear to increase the risk of mortality in this study (CNN Health, 2013, December 31, para. 14-15). 

Conclusions

Physicians might now consider recommending that some of their Alzheimer’s patients take vitamin E.  Medical science has yet to discover any other treatments that make “a significant difference in the well-being of Alzheimer’s patients”. However, “In the future there will be very little discussion when we have a clearer, yes-or-no answer” (CNN Health, 2013, December 31, para. 16-17). 
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Alternative medicine. (2013, January 19).  Alzheimer’s Disease.  Mayo Clinic.  Retrieved from  http://www.mayoclinic.com/health/alzheimers-disease/DS00161/DSECTION=alternative-medicine

Alzheimer's Care Giving 

A panel of experts convened by the National Institutes of Health found no evidence indicating that taking extra vitamin B, vitamin C, vitamin E, folic acid or beta carotene delayed or prevented Alzheimer’s (Alternative medicine, 2013, January 19, para. 1).

Omega-3 fatty Acids

However, “somewhat stronger data”—but no “definitive evidence” showed that the fatty acids in fish oil may prevent cognitive decline (Alternative medicine, 2013, January 19, para. 2).

Vitamin E

Earlier research indicates that vitamin E may delay the inability to carry out activities of daily living for a few months, however, subsequent research has associated taking vitamin E with an increased risk of death.  Consequently, no one should take vitamin E without medical supervision (Alternative medicine, 2013, January 19, para. 3).

Ginkgo

The NIH has found ginkgo has no effect in preventing or delaying Alzheimer’s (Alternative medicine, 2013, January 19, para. 4).

Since alternative supplements can interact with prescribed medication taken for Alzheimer’s or other medical conditions, patients and their caretakers should work closely with medical professions to create an individualized treatment plan (Alternative medicine, 2013, January 19, para. 5).

Medications for Memory (2014).  alz.org/Alzheimers Association.  Retrieved from http://www.alz.org/alzheimers_disease_standard_prescriptions.asp

No medications [or alternative supplements] can prevent or cure dementia, however, some medications may lessen the severity of symptoms for a limited time (Alz.org, 2014, para. 1).

Types of Drugs

The U.S. Food and Drug Administration (FDA) has approved cholinesterase inhibitors (Aricept, Exelon, Razadyne, Cognex) and memantine (Namenda) — to treat memory loss, confusion, and problems with reasoning.  Current medication may temporarily stabilize symptoms by affecting chemical involved in carrying messages to the brain’s nerve cells.  Physicians may prescribe both cholinesterase inhibitors and meantine either separately or simultaneously.  Some physicians also prescribe high doeses on vitamin E (Alz.org, 2014, para. 2-3).

Medications for Early to Moderate Stages

Cholinesterase inhibitors treat Alzheimer’s symptoms related to memory, thinking, language, and judgment in its early to moderate stages (Alz.org, 2014, para. 4).

Medication Safety

Both the patient’s physician and pharmacist should know all medications currently taken, including over-the-counter drugs and alternative preparations, before prescribing any medicine to prevent side-effects (Alz.org, 2014, para. 5).

Neurologists usually prescribe three cholinesterase inhibitors—Donepezil (Aricept), Rivastigmine (Exelon), and Galantamine (Razadyne)—to help prevent the breakdown of acetylcholine (a-SEA-til-KOH-lean), a chemical that supports communication among nerve cells, thus delaying the worsening of Alzheimer’s symptoms for about six to twelve months.  While normally “well-tolerated, they may result in nausea, vomiting, loss of appetite and frequency of bowel movement (Alz.org, 2014, para. 6-9).  While Rivastigmine and Galantamine address mild to moderate Alzheimer’s, Donepezil is approved for use in all stages of Alzheimer’s.  Physicians more rarely prescribe the first cholinesterase inhibitor, Tacrine (Cognex)  because it results in more serious side effects than the other cholinesterase inhibitors (Alz.org, 2014, para. 9).

Medication for Moderate to Severe Stages

Memantine (Namenda) treats moderate to severe Alzheimer’s either alone or with other Alzheimer’s treatments since some evidence exists that patients with moderate to severe Alzheimer’s might benefit from taking both Donepezil (Aricept) and memantine (Alz.org, 2014, para. 10-11).

Memantine

Memantine regulates glutamate, a chemical involved in learning and memory, thus temporarily delaying the worsening of symptoms.  Memantine’s possible side effects include headache, constipation, confusion, and dizziness (Alz.org, 2013, para. 12-14).

Tomorrow’s Treatments

Clinical trials pave the way to new treatments by recruiting patients with Alzheimer’s and Mild Cognitive Impairment as well as individuals with no cognitive problems as controls. Ultimately, the path to effective new treatments is through clinical trials (Alz.org, 2013, para. 15).  Volunteers can find out more about participating in free clinical trials through the Alzheimer’s Association TrialMatch service (Alz.org, 2013, para. 16).

Vitamin E

Although physicians may prescribe vitamin E to treat Alzheimer’s, no one should use vitamin E to treat Alzheimer’s without medical supervision (Alz.org, 2013, para. 17). Since vitamin E is an antioxidant, it may protect brain cells and other body tissues from “chemical wear and tear”. A 1997 study showed that high doses of Alzheimer’s helped delay the loss of activities of daily living for several months. Some subsequent studies, however, have found that high doses of vitamin E might marginally increase the risk of death from coronary artery disease (Alz.org, 2013, para. 18).

A helpful chart summarizing the benefits and risks of Alzhemier's medications, including vitamin E follows.

Vitamin E U.S. (2013, October 22).  Medline Plus. National Library of Medicine .U.S. Department of Health and Human Services National Institutes of Health.  Retrieved from  http://www.nlm.nih.gov/medlineplus/vitamine.html

Summary

Vitamin E found in foods might play an important role in delaying cognitive decline as well as preventing coronary heart disease, certain cancers, and age-related eye disorders.  However, the jury is still out as to whether taking Vitamin E supplements does more harm than good.  Thus, no one should take Vitamin E without the advice and consent of a physician who is fully informed of all the medications and supplements that a patient is taking.  

Since vegetable oils and margarine that contain trans fats are now deemed harmful to health, Vitamin E should come in the form of dark green and leafy vegetables and nuts. Vitamin E is an antioxidant that plays a role in immune system and metabolic processes. Good sources of vitamin E include vegetable oils*, margarine*, nuts and seeds, and leafy greens.  Vitamin E is also added to foods like cereals. Most people get enough vitamin E from the foods they eat. People with certain disorders, such as liver diseases, cystic fibrosis, and Crohn's disease may need extra vitamin E.  Vitamin E supplements may be harmful for people who take blood thinners and other medicines. Check with your health care provider before taking the supplements  Vitamin E U.S., 2013, October 22, para. 1).
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Dietary Supplement Fact Sheet: Vitamin E. (2013, June 5). NIH: National Institutes of Health Office of Dietary Supplements.  Retrieved from http://ods.od.nih.gov/factsheets/VitaminE-HealthProfessional/

The recommended Intake for for Vitamin E (Alpha-Tocopherol)  individuals fourteen years and older is 15 mg (22.4 IU) (Vitamin E U.S., 2013, October 13, para. 15).   

Sources of Vitamin E



Image result for vitamin e foods
Nuts, olive oil, and avocados are all good sources for Vitamin E.


Food

Nuts, seeds, and vegetable oils are the best sources for vitamin E, although it is also found in green leafy vegetables and fortified cereals.  [However, deriving vitamin e from vegetable oils may be changing because of a preliminary FDA ruling that finds trans fats as unsafe]* (Vitamin E U.S., 2013, October 22, para. 16).
Thus, readers should pay attention to Table 2, which notes that sunflower seeds, almonds, hazelnuts, peanut butter, peanuts, spinach, broccoli, kiwi, mango, tomatoes, and soybean oil all are sources of vitamin E. (Vitamin E U.S., 2013, October 22, para. 17).

Most vitamin-E-only supplements provide over 100 percent of the Recommended Daily Allowance  for the nutrient, although two national surveys found that the diet of most American is less than it should be and can be naturally increased by consuming more nuts, seeds, fruits, and vegetables (Vitamin E U.S., 2013, October 22, para. 18-19).

 Even so, true Vitamin E deficiency is rare.  Since the digestive system requires fat to absorb vitamin E, those with malabsorption disorders are more likely to be deficient in Vitamin E, although individuals diagnosed with Crohn’s disease, cystic fibrosis, or the inability to secrete bile from the liver may also be deficient in vitamin E (Vitamin E U.S., 2013, October 22, para. 20-21).

Vitamin E and Health

Because of Vitamin E’s role in anti-inflammation, preventing platelets from clumping, and enhancing immunity, many health claims have been made for the supplement involving heart disease, cancer, eye disorders, and cognitive decline (Vitamin E U.S., 2013, October 22, 22-23).

Coronary Heart Disease

In vitro studies have shown that Vitamin E slows oxidation of low-density lipoprotein (LDL) cholesterol.  Vitamin E may also help prevent the formation of blood clots leading to heart attacks and strokes. Observational studies have associated lower rates of heart disease with higher vitamin E intakes either when it is taken in supplements or found naturally in food (U.S. Vitamin E, 2013, October 22, para. 24-25).  Contrary to these findings, randomized clinical trials question the ability to prevent coronary heart disease (U.S. Vitamin E, 2013, October 22, para. 26-30).

Cancer

Antioxidents like vitamin E protect cells from damaging effects of free radicals that might help cancers to develop.  Vitamin E might also block the forming of carcinogenic nitrosamines formed the nitrates in food.  Human trials, however, have found that taking Vitamin E supplements isn’t beneficial in most instances (U.S. Vitamin E, 2013, October 22, para. 31-32), although among smokers and former smokers a study did find a significant deduction is the risk or advanced prostate cancer.  Moreover, studies found that a higher intake of Vitamin E decreased the incidence of colon and breast cancer (U.S. Vitamin E, 2013, October 22, para. 33-34).  Additionally, the American Cancer Society found that those adults who took Vitamin E supplements for a decade or longer were less likely to die from bladder cancer (U.S. Vitamin E, 2013, October 22, para. 35).  Paradoxically, however, large doses of Vitamin E supplements, taking 400 IU daily, may increase the risk of prostate cancer (U.S. Vitamin E, 2013, October 22, para. 36).

Eye Disorders

Vitamin E may help prevent or treat age-related macular degeneration (AMD) and cataracts:  Studies have shown that individuals with a relatively high dietary intake of vitamin E (30 IU/day) have an approximately 20 percent lower risk of developing AMD with those with a low intake of less than 15 IU of vitamin E daily, although supplements didn’t produce this same effect.  A large randomized clinical trial that studied at risk participants, however, found that they reduced their risk of developing advanced AMD by 25 percent by taking a daily supplement containing 400 IU of Vitamin E along with other supplements (U.S. Vitamin E, 2013, October 22, para. 37-38). Different studies that correlated the development of cataracts and the use of Vitamin E as a supplement resulted in “inconsistent findings” (U.S. Vitamin E, 2013, October 22, para. 39-40).

Cognitive Decline

A clinical trial of patients with moderate Alzheimer's found that taking 2,000 IU of Vitamin E delayed a move to a nursing home, although these individuals fell more than those taking a placebo (U. S. Vitamin E, 2013, October 22, para. 41). An additional study found that taking Vitamin E supplements or including foods high in Vitamin E in the diet could delay cognitive delay for at least three years in elderly adults who lived independently.  However,  another study found that taking a 600 IU supplement resulted in “no apparent cognitive benefits as did research that randomly assigned either a dosage of 2,000 IU/day, donepezil, or a placebo in patients diagnosed with mild cognitive disorder (U. S. Vitamin E, 2013, October 22, para. 42-43).

Health Risks from Excessive Vitamin E

No adverse effects come from consuming vitamin E in food, but research has shown that high doses of Vitamin E supplements can cause hemorrhages and interrupt blood coagulation as well as inhibit platelet aggregation (U.S. Vitamin E, 2013, October 22, para. 44).

Table 3, which gives “Tolerable Upper Intake Levels (ULs) for Vitamin E” shows that the upper limit of tolerable amounts is 1,000 mg for individuals 19 years of age or older (U.S. Vitamin E, 2013, October 22, para. 45).  However, one study found the increase of death might rise if the individual takes only a supplement of 150 IU daily (U.S. Vitamin E, 2013, October 22, para. 46).

Interactions with Medications

Vitamin E supplements also can interact with other medications, so this underlines the necessity of discussing with a physician the advisability of taking Vitamin E supplements (U.S. Vitamin E, 2013, October 22, para. 49).

Anticoagulant & Antiplatelet Medications

Taking 400 I.U. of Vitamin E can hinder the clumping of platelets and interfere with vitamin K-dependent clotting factors (U. S. Vitamin E, 2013, October 22, para. 50).

Simvastatin & Niacin

Taking vitamin E supplements with other antioxidants, like vitamin C, selenium, and beta-carotene, can reduce the rise in high-density lipoprotein (HDL) cholesterol levels, among patients treated with a combination of simvastatin (Zocor) and niacin (U. S. Vitamin E, 2013, October 22, para. 51).

Chemotherapy and Radiotherapy

Oncologists advise against taking antioxidant supplements during cancer chemotherapy or radiotherapy because doing so might inhibit cellular oxidative damage in cancerous cells (U.S. Vitamin E, 2013, October 22, para. 52).

Vitamin E & Healthful Diets

The 2010 Dietary Guidelines for Americans advises that “nutrients should come primarily from foods” in diets that feature a large variety of fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products.  Thus, consumers can find Vitamin E in green leafty vegetables, whole grains, and fortified cereals.  Nuts are also a good source of vitamin E (U.S. Vitamin E, 2013, October 22, para. 53-55).
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Trans-fat References


*Hayes, Ashley.  (2013, November 13).  Put down that doughnut. FDA takes on transfats.  CNN Health.  Retrieved from http://www.cnn.com/2013/11/07/health/fda-trans-fats/

*Smith, Evelyn Elaine. (2013, December 2). The Breast Cancer, High LDL Cholesterol, & Trans Fat Connection: The Skinny on Avoiding High LDL Cholesterol, Breast Cancer, & Trans Fats. McGregor, Texas, McGinley Memorial Public Library Books and Friends.   Retrieved from http://evelynelainesmith.blogspot.com/2013/12/the-breast-cancer-high-ldl-cholesterol.html
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High Blood Sugar Correlates with Dementia: Step away from the Cupcake


Image result for high blood sugar

Span, Paula. (2013, August 9). High Blood Sugar Linked to Dementia.  The New Old Age - Caring and Coping. Health.  New York Times.  Retrieved from http://newoldage.blogs.nytimes.com/2013/08/09/high-blood-sugar-linked-to-dementia/

A recent study has found that the risk of dementia was 18 percent higher in participants whose blood sugar averaged 115 milligrams per deciliter than among those at 100 mg/dL, which was only a little lower. Patients with diabetes with glucose levels of 190 mg/dL had a 40 percent greater risk of developing dementia than those whose blood sugar levels averaged 160 mg/dL (Span, 2013, August 9, para. 1).  The study, however, didn’t explain why higher blood glucose tends to correlate with dementia or if maintaining lower blood glucose levels acts as a protection against dementia (Span, 2013, August 9, para. 2).

Epidemiological studies can guide further research, but they don’t necessarily proof that changes in behavior that lower blood sugar decrease the risk of dementia (Spin, 2013, August 9, para. 3). Since these blood glucose levels aren’t big difference, they shouldn’t necessarily change a patient’s goals for managing the condition.  They also don’t inevitably mean that anyone whose blood glucose levels climb to 115mg/dL is more likely to develop dementia (Spin, 2013, August 9, para. 3). 

However, patients should adopt a healthy lifestyle and diet, exercising daily and maintaining a normal weight to lower their dementia risk (Spin, 2013, August 9, para. 4). This research, however, offers proof that high blood sugar can damage the brain, even though medical science is still trying to discover why this is so (Spin, 2013, August 9, para. 5).

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Addendum August 29, 2015

Poor Verbal Fluency in Women
Coupled with High Blood Sugar May Signify Cognitive Decline


Image result for talking

A Finnish study links higher insulin resistance with poorer verbal fluency in women, thus postulating that high insulin resistance particularly in women might signal cognitive decline years before the onset of Alzheimer’s.

Ekblad, Laura L., Rinnel, Juha, O., Pauli, J.  (2015, 10 July).  Diabetologia. Insulin resistance is associated with poorer verbal fluency performance in women.  doi: 10.1007/s00125-015-3715-4 [Full text]. 2015 Aug 15. [Epub ahead of print]. Retrieved from http://www.diabetologia-journal.org/files/Ekblad.pdf

After hypothesizing a relationship between insulin resistance and cognitive performance and speculating that gender and the APOE*E4 gene might modify this link, Finnish researchers undertook a nationwide population-based study of adults aged 30 to 97, testing cognitive function by way of word-list learning, word-list delayed recall, categorical verbal fluency and simple and visual-choice reaction time tests.  They then used linear regression to confirm a link between HOMA-IR (a. k. a. insulin resistance) and lower test results.  Higher insulin resistance corresponded with poorer verbal fluency in women but not in men as well as in APOE*E4 negative individuals but not in APOE*E4 carriers.  High insulin resistance levels also correlated with a slower reaction time for all individuals tested. The test results suggest that higher insulin resistance could be a marker for cognitive decline (Abstract, para. 1-2). 

Fetters, K. Aleisha. (2015, August 27). The surprising link between Type 2 diabetes and Alzheimer's Disease.  US News.  Retrieved from http://news.yahoo.com/surprising-between-type-2-diabetes-alzheimers-disease-165313401.html

Untreated insulin resistance that leads to excessively high blood sugar levels is possibly one of the first signs of cognitive decline especially among women (Fetters, 2015, August 27, para. 2). 

Testing language skills, semantic memory and executive function in 6,935 Finnish men and women aged 30 to 97, researchers at the University of Turku discovered a link between high levels of insulin resistance and poorer scores among women (Fetters 2015, August 27, para. 3). 

Study results lead to the hypothesis that women’s brains are “more vulnerable to the effects of insulin resistance than men’s brains are. Previous research has discovered that lesions in the brain are more common among individuals with metabolic problems, including insulin resistance, as well as among women (Fetters, 2015, August 27, para. 4). 

With insulin resistance, too much insulin circulates in the blood flow, which, in turn, reduces the flow of insulin and delivery of glucose to the brain.  Earlier studies show that reduced brain insulin levels further cognitive decline.  Additionally, diabetics have a greater risk of cardiovascular disease, and their elevated blood cholesterol levels can lead to vascular brain changes.  This link between diabetes and Alzheimer’s has even cause researchers at Albany University to suggest that Alzheimer’s is simply the last stage of Type 2 diabetes (Fetters, 2015, August 27, para. 5-6).


Know Your Blood Sugar Levels; 

Reduce Your Alzheimer's Risk



However, the most truly “alarming”-- but “potentially lifesaving”--idea culled from this study is a link between insulin resistance and poor cognition is present years before Alzheimer’s onset (Fetters, 2015, August 27, para. 7). More than one out of three U.S. adults can be classified as pre-diabetics because their blood sugar levels are too high, but not high enough to be classified as diabetics (Fetters, 2015, August 27, para. 8). 

This news necessitates that anyone who is overweight, has high blood pressure, or abnormal cholesterol levels to get his or her blood sugar levels checked (Fetters, 2015, August 27, para. 9).   Diabetics, however, can reduce or delay the onset of Alzheimer’s with proper management of their condition (Fetters, 2015, August 27, para. 10).  Unlike diabetes, pre-diabetes is reversible through diet and exercise, and these actions may help prevent Alzheimer’s Disease (Fetters, 2015, August 27, para. 11).




The medical links furnished on this Web page represent the opinions of their authors, so they complement—not substitute—for a physician’s advice.

Sunday, July 7, 2013

Weight Loss in End-stage Dementia



A Layperson’s Guide: Weight Loss in End-stage Dementia

Evelyn Smith


M. S. in Library Science (1995), University of North Texas


Summary: Most Alzheimer's patients need to be
encouraged to eat while frontal temporal
lobe dementia patients are "plate cleaners".



Several weeks ago, a rapid weight loss of 7.8 pounds (4 kg.) within a single month necessitated placing Mother, who was already confined to a wheelchair, in hospice care when this weight loss was coupled with other aggravating factors, so the reader should note that this blog entry is very much in response to a personal need to learn about weight loss in dementia patients and how it fits into the dying process.   This type of weight loss, however, is very different from the weight loss that occurs during the onset of Alzheimer's and when some patients simply lose interest in eating. Thus, this cathartic summary of sources available Online intends to give other caregivers an overview of what is happening once hospice care has started as well as an understanding of how weight loss fits into the dying process. 


Family members should also be forewarned that the wasting brought about by end-stage dementia is not pleasant to watch, but they can give their loved ones some small measure of comfort if they confer regularly with the hospice and/or nursing home staff.   For example, immediately after Mother was admitted to hospice care, her physician changed her multi-vitamin supplement to provide her with more nutrients.  However, since she had progressively had trouble swallowing this supplement, perhaps because the calcium included in it is granular, the search was on for another vitamin supplement that fit her progressive inability to swallow.  Eventually, all vitamin supplements stopped because it was simply too hard for her to swallow them.

Family members should also be cautioned that the weight loss caused by trouble swallowing as well as the ongoing shut down of the digestive system is a progression that each individual patient experiences differently.   Even so, it is comforting to know what to expect.


Alzheimer's Society & Popular Sources




Dementia information for carers, families and friends of people with severe and end stage dementia. (2007). 2nd ed. University of Western Sydney.  Palliative Care Dementia Interface: Enhancing Community Capacity Project.  Retrieved from http://catalogue.nla.gov.au/Record/4085461

In late-stage Alzheimer’s patients usually lose weight despite receiving adequate amounts of food and fluids because the progression of the disease causes complex physiological changes.  Patients also lose interest in eating and drinking, often refusing food and drink in the final weeks of the dying process (Dementia information, 2007, para. 21).

Eating in late-stage dementia. (2011, May 18).  Dementia-friendly environments: A guide for residential care.  Victorian Government Health Information.  Retrieved from http://www.health.vic.gov.au/dementia/strategies/assisted-eating.htm

Patients who lose interest in food and/or have trouble swallowing are more likely to lose weight, so caretakers should take the following steps to provide the highest quality of care:
  • Provide soft and pureed foods as long as patients can tolerate swallowing them;
  • Change food textures as needed;
  • Check weight loss regularly and make up for it with fortified foods and vitamin supplements or foods higher in calories.
(Eating in late-stage dementia, 2011, para. 1)
During the most severe stages of dementia, patients will no longer be able to eat.  Even so, care givers should not force patients to eat even as they moisten the mouth and continue to provide oral health care (Eating in late-stage dementia, 2011, para. 2).

Fernandez, F. (2011, March 15).  Final stages of dementia.  Livestrong.com.  Retrieved from http://www.livestrong.com/article/103819-final-stages-dementia/1

Advanced-stage dementia patients have trouble swallowing and choking.  Weight loss occurs, and the skin around the lips becomes very thin.  Additionally, they start to display grasping and sucking reflexes (Fernandez, 2011, para. 3).

Gordon, M. (2011, January 31).  Alzheimer’s disease/ Timeline for final stages in early-onset dementia.  AllExperts. Retrieved from http://en.allexperts.com/q/Alzheimer-s-Disease-1005/2011/1/Timeline-final-stages-early.htm


Signs that the end is nigh include wasting and weight loss, loss of interest in food and drink, sleeping more and responding less, not being able to sit up in a chair, a rise in contracting opportunistic infections, and a corresponding break down of the immune system.
 
Late stage and end-of-life care: Caregiving in the final stages of life.  (n. d.). Helpguide.org. Retrieved from http://www.helpguide.org/elde/alzheimers_disease_dementia_caring_final_stage.htm

As patients lose their appetites and experience a decreased need for food and fluid, care givers should let them choose if they need to eat or drink while moistening the lips with glycerin swabs and lip balm as well as supplying [thickened] water, or juice if they are still physically capable of swallowing (Late stage Help Guide, n. d., p. 15).

Late-stage care: Providing care and comfort during the late stage of Alzheimer’s disease. (2011). Alzheimer's Association. Retrieved from http://www.alz.org/national/documents/brochure_latestage.pdf

The Alzheimer’s Association warns care givers that while weight loss is common in end- stage dementia, it can also signal inadequate nutrition,undiagnosed illness, or the side effects of medication (Late-stage care, 2011, p. 6).

Late stages of dementia.  (2013). Alzheimer’s Society.  Retrieved from 
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=101

Even though most dementia patients lose weight in end- stage dementia, care givers should ensure they are receiving enough food and liquid.   Because muscles in the throat and the patients’ reflexes are not working properly, this causes choking problems that often result in chest infections [aspiration pneumonia].  Thus, as the occasion demands it, physicians [or hospice nurses] may need to periodically refer patients to speech therapists or nutritionists (Late stages, 2013, Alzheimer’s UK, para. 12-14).

Lynne, V. (2013).  Symptoms of advanced-Alzheimer’s.  Hub Pages. Retrieved from
http://virginialynne.hubpages.com/hub/Symptoms-of-Advanced-Alzheimers

Severe weight loss occasioned by the inability to eat and process food is one of the symptoms of advanced dementia (Lynne, 2013, para. 5).   Dealing with these patients necessitates the following suggestions: 1) Make sure patients are seated upright when eating [Mother’s nursing home makes sure she is in an upright position for thirty minutes after meals]; 2) feed them pureed food more slowly than they have previously done so, and 3) and stroke the neck to elicit a swallowing response (Lynne, 2013, para. 6).   Hospice attendants ordinarily encourage end-stage dementia patients to eat and drink, but they also allow them to refuse food and water since as the digestive process starts to shut down, the body cannot take in nourishment, and eating makes them increasingly uncomfortable (Lynne, 2013, para. 16). 

Vaughan, K. (2013, April 30).  Signs & symptoms of end-stage dementia. e-How. Retrieved from http://www.ehow.com/list_5787280_signs-symptoms-end_stage-dementia.html

End-stage dementia results in weight loss caused by 1) feeding apraxia, or loss of the ability to chew and to swallow, 2) depression, 3) weakened motor skills, and 4) increased risk of aspiration (Vaughan, 2013, para. 4).

Volicer, L. (2005).  End-of-life care for people with dementia in residential care settings. Alzheimer’s Association. Retrieved from http://www.alz.org/national/documents/endoflifelitreview.pdf

Volicer notes that forgetting to eat and a lessening of their ability to smell, intensive pacing, and poor-feeding practices causes weight loss in the beginning stages of Alzheimer's. Patients with frontotemporal dementia, by way of contrast, often suffer from hyperphagia, or excessive hunger (Volicer, 2005, p. 13).

As dementia progresses, however, all patients lose the ability to feed themselves without assistance whereupon care givers can hand feed them until the beginning of the dying process starts when the body begins to shut down. 

Observation of mentally-cognitive cancer patients indicates that the dying do not feel hunger and thirst.  Thus, when patients refuse all food and liquids, this will not result in pain or discomfort, and they will usually die a comparatively peaceful death within two weeks (Volicer, 2005, p. 13-14). 

Waller, E. (2001).  Lesson Thirteen—the death and dying process.  Gerontology 130: Working with the frail elderly.  Coastline Community College.  Retrieved from http://cvc3.coastline.edu/modelcvc3courses/elliswaller/lesson13.htm

Waller furnished a death-watch time line for elderly patients:  Older patients ordinarily decrease their food intake from between one to three months prior to death.  From one to two weeks before dying, their exhibit the following symptoms:  1) Refusal of food and drink, 2) decreased blood pressure, 3) increasing or decreasing pulse rate, 4) changes in skin color, 5) increased perspiration,  6) problems breathing, 7) [chest] congestion, 8) sleeping and not responding, and 9) fluctuations in body temperature.  10) Those who can communicate also complain that their body is tired and heavy.


Vetted & Research-based Sources




, P. N. (2010, October 27).  Palliative care in end stage dementia: Providing the right care for the right patient at the right time in the right place.  American College of Osteopathic Internists.  Retrieved from http://www.acoi.org/2010Convention/BrymanPalliativeCareAndAdvanced.pdf

Bryman identifies one of the symptoms of hospice eligibility as the inability to maintain sufficient fluid and caloric intake  so that a ten percent weight loss has occurred during the previous six months. Other symptoms include 1) serum albumin levels of less than 2.5 g. dL.  [Serum albumin is a globular protein commonly found in blood, the normal range of which is from 3 to 4 dl in adults]; 2) aspiration pneumonia, 3) pyelonephritis, or kidney infections, or other upper Urinary Tract Infections (UTI), 4) septicemia, or infections of the blood, 5) pressure ulcers, and 6) fever that recurs after antibiotic therapy (Bryman, 2010, slide 19).

Grundman, M., Corey-Bloom, J, Jernigan, T., Archibald, S. and Thal L. T.  (1996 June). Neurology, 46(6), 1585-91 (Medline Abstract).  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8649553

In a case study, Alzheimer’s exhibited significantly more brain atrophy in all regions of the brain other than the white regions than their controls did, although the Mesial temporal control region (MTC) remained the only brain region associated with dementia patients.  The study thus concluded that damage to the limbic system that controls swallowing correlates with weight loss in Alzheimer’s patients.

Hughes, J. C, Jolley, D., Jordan, A., and Simpson, E. L. (2007).  Palliative care in dementia: Issues and evidences. Advances in Psychiatric Treatment, 19 (4). doi: 10.1192/apt.bp.106.003442,  Retrieved from http://apt.rcpsych.org/content/13/4/251.full

United States Medicare funding for hospice care depends on the patient’s inability to survive less than six months, so complications caused by rapid weight loss have become just one of the indications that recommend dementia patients for hospice care.  Other Functional Assessment Staging or FAST variables include the following components:   

1) Hospice candidates suffering from dementia are ordinarily non-ambulatory; 2) they can no longer speak, and 3) they are entirely dependent upon others for all their activities of daily living. 4) Moreover, they may suffer from recurrent skin infections and pressure sores, 5) hip fractures, 6) [aspiration] pneumonia, and finally, 7) the need for artificial feeding—or the acceptance upon those who have medical power of attorney that life cannot be substantially prolonged or its quality improved by tubal feeding (Hughes, 2007, para. 16).

During the last stages of dementia, weight loss and the loss of muscle strength reflect reduced food intake, although the degree of weight loss in dementia patients may be greater than the refusal of food alone would indicate.  This is because a low metabolic rate and physical inactivity can bring about a state of physiological homeostasis, so that patients constantly lose weight and body mass, develop skin contractures, easily torn skin, and bed sores—all of which result from muscle atrophy and a poor diet that the trouble they have swallowing causes (Hughes, 2007, para. 16).

Additionally, advanced dementia and the lack of mobility that goes with it produce incontinence that threatens skin integrity and constipation that, in turn, leads either to impaction or overflow incontinence.  Constipation impedes bladder function and causes discomfort, pain, and toxicity whereupon patients may become confused or agitated, and may feel more comfortable being placed lying on their sides (Hughes, 2007, para. 17).

As this cycle continues, patients lose their appetites.   The loss of a need for regular meals causes coordination and sequencing problems involved with swallowing, so patients more easily choke on food and may develop aspiration pneumonia (Hughes, 2007, para. 26). 

Kovach, C. R. (2001).  Late-state dementia care. Marquette Elder Advisor, 2 (3).  Article 7, 48-56. Retrieved from http://scholarship.law.marquette.edu/cgi/viewcontent.cgi?article=1248&context=elders

Weight-loss in late-stage dementia is usually caused by swallowing problems as dementia patients lose the ability to coordinate the complex process involved in swallowing, and they are also less likely motivated to eat (Kovach, 2001, p. 50). As appetite decreases, the inability to swallow may lead to patients aspirate food, which in turn leads to fluid in the lungs (Kovach, 2001, p. 47).  

Pivi, G. A. K., Bertolucci, P. H. F. & Schultze, R.  (2012). Nutrition in severe dementia. Current Gerontology and Geriatrics Research.  doi: 10.1155/2012/983056 Retrieved from http://www.hindawi.com/journals/cggr/2012/983056/

Feeding problems and difficulty swallowing result in continuous weight loss as dementia progresses.  Most patients will eventually experience dysphagia, or the ability to coordinate all the steps in the swallowing process--a stage often associated with aspirate pneumonia (Pivi, 2012, para. 4-6).

Cachexia, or wasting away, and weight loss are common symptoms of end-stage dementia patients (Pivi, 2012, para. 13), and this weight loss correlates with higher rates of infection.  As this degenerative process increases, so do skin infections and ulcers, and body temperature eventually declines (Pivi, 2012, para. 13-15).  Pivi et al theorize that the continuing atrophy of the mesial temporal cortex corresponds with this drop in weight since the last stages of dementia also bring about a lowering of the Body Mass Index (BMI) in advanced dementia (Pivi, 2012, para. 18).

Sachs, G, A., Shega, J. W., & Cox-Hayley, D. (2004, October).  Barriers to excellent end-of-life care for patients with dementia.  Journal of General Internal Medicine, 19(1), 1057-1063.  doi:  10.1111/j.1525-1497.2004.30329.x.  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492583/

Sachs and his fellow researchers review the symptoms of end-stage dementia—a period preceded by the loss of all or most of the activities of daily living, any meaningful conversation, and a non-ambulatory status, weight loss of ten percent or more, recurrent infections, pressure sores, and possible hip fractures and/or [aspirant] pneumonia (Sachs, 2004, para. 18).  

Tsai, S. & Arnold, R. (n. d.).  #150 Prognostication in dementia.  End of Life/Palliative Education Resource Center.  Retrieved from http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_150.htm

Factors predicting a shortened-survival rate for patients with dementia include “male gender, old age, diabetes mellitus, CHF, COPD, cancer, cardiac dysrhythmias, peripheral edema, aspiration, bowel incontinence, recent weight loss, dehydration, fever, pressure sores, seizures, shortness of breath, dysphagia [or difficulty swallowing], low oral intake, not being awake most of the day, low Body Mass Index, and need for continuous oxygen” (Tsai, n. d., para. 2).  Six months after dementia patients are admitted to hospice care, over half have either succumbed to pneumonia compared with 13 percent of mentally cognitive hospice patients or have died from complications resulting from hip fractures compared with 12 percent of hospice patients not experiencing dementia (Tsai, n. d., para. 3).

____________

Postscript: A Personal Note


March 30, 2014

So how much weight does a patient lose during the end stage of dementia?  The answer obviously depends on the individual patient, but a wasting away isn't all that uncommon for all stages of Alzheimer's if medical intervention doesn't occur.  However, please let me cite my mother's case as an example:  Since inactivity and a craving for food experienced by frontotemporal dementia patients had originally caused Mother to gain approximately 40 pounds, or 64 kilograms, she differed from most Alzheimer's patients, who show no interest in food.  Mother originally stood five feet eight inches tall (173 cm.), and she weighed approximately 140 pounds (65 kg.)  at the time she started to lose her memory.  Since she had always been fashionably thin most of her adult life--she weighed 120 pounds (54 kg.) when she was wed in 1946.  Thus, she would have been pleased that a mortician was able to dress her in a size 14 Misses suit that was kept back for her funeral with only a little adjustment, for she had lost around 30 pounds (14 kg.) within the space of ten months, which is hard to do when confined to a reclining geriatric wheelchair. 

Fortunately, after Mother's initial weigh loss, after being placed in hospice care, her weight loss was gradual until the last week of her life when from Friday through Wednesday she refused all food, and from Tuesday onward she was unable even to swallow any liquid no matter how hard she tried.  Her food had been pureed for over three years and her water thickened as well.



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