A Practical Guide to the Dying Process for End-Stage Alzheimer's Patients

An Annotated Bibliography on Dying for Caregivers of Alzheimer’s Patients

Evelyn E. Smith

M. S. in Library Science, University of North Texas (2012)

Addendum, January 28, 2016

First a Personal Note:  I originally thought about writing this post as I watched Mother die a few months ago, jotting down terms the hospice nurse used to describe the physical process of dying. Cindy Frasier of Providence Hospice, patiently answered all my questions, pointing out exactly what was happening and why.  This helped me more actively participate in Mother’s palliative care: On Mother’s last day, for example, I wiped secretions from the inside of her mouth when she started to emit a death rattle, duly noted the mottling in her feet and lower legs, traipsed down the hall to the nurse’s desk  at Wesley Woods Alzheimer's Center to ask for medications to relieve her pain, counted each second between breaths in what is known as Cheyne-Stokes Respiration, talked myself hoarse (Cindy reminded me that hearing is the last sense to go), sang most of the hymns in an old hymnal several times, read aloud all of Mother’s favorite Bible verses again and again, and urged Mother and myself to be brave while I prayed for strength for the both of us.  March 19, 2014, was the hardest day of my life, but I wouldn’t trade any minute of it.

Beginning with Elizabeth Kübler-Ross’ On Death and Dying (1969), social psychiatrists and physicians have broken down dying into a two or three-step physical process and an up to a five-stage emotional process, although critics quibble about the emotional acceptance of death in patients who are fully cognitive.  For the most part, however, Alzheimer’s patients don’t receive the attention that they should, although most authorities counsel that they too need to say goodbye.  Thus, during Mother’s last few days, some of Mother’s close friends dropped in, and fellow church members provided spiritual, emotional, and practical support; for instance, a friend brought me lunch, and the assistant pastor sat with Mother when I needed to go back home to let out the dog. 

This short bibliography also offers a warning:  Although hospice care of the dying is usually less traumatic than hospital care, if Mother’s dying process is any indication, a late-stage Alzheimer’s patient may experience pain that can be eased without losing consciousness.  Writing about a loved one's death also certainly provides some closure, so readers should feel free to post about how they coped with their loved one's passing.

End of Life.   (2014, April 16).  Alzheimer’s Society Canada.  Retrieved from http://www.alzheimer.ca/en/About-dementia/Alzheimer-s-disease/Stages-of-Alzheimer-s-disease/End-of-Life

In this most helpful Web page, the Alzheimer’s Society of Canada cautions that a caregiver should focus on the quality of the patient’s life rather than lengthening life span.  In most instances, this palliative care occurs in an institutional setting rather than at home (Alzheimer’s Society Canada, para. 1 & 2, 2014, April 16).  The Canadian Alzheimer’s Society then lists common symptoms as well as possible strategies to comfort the dying individual.  Thus, a loved one keeping vigil might massage the patient’s feet and hands if they are cool to touch, relieve skin pressure by strategically placing pillows, and moisten a patient’s lips when he or she no longer accepts food and drink.  The caregiver also needs to watch for signs of pain, so he or she can alert the hospice nurse (Alzheimer’s Society Canada, para. 3, 2014 April 16).

As the dying patient’s senses start to change as evidenced by sensitivity to noise and light, he or she will still respond to touch and sound.  That means speaking “soothingly” and “reassuringly”, and perhaps arranging a pastoral visit, thus, giving the patient “permission to go” (Alzheimer’s Society Canada, para. 3, 2014, April 16).  Finally, the Alzheimer’s Society urges the caregiver to take care of him or herself as  he or she “works through grief” (para. 4-7, 2014, April 16).

Hospice Patients Alliance. (n. d.).  Signs and symptoms of approaching death.  Retrieved from http://www.hospicepatients.org/hospic60.html

Hospice Patients Alliance breaks down the dying process into a “pre-active phase of dying” that may last up to two weeks as well as an active phase of dying that lasts approximately three days (n. d., para. 5). Most of the characteristics of the pre-active period can apply to end-stage dementia patient: Decreased intake of food and fluids, pauses in breathing or apnea, inability to heal, and increased swelling or edema (n. d., para. 6).   However, a late-stage Alzheimer’s patient usually is beyond the point of withdrawing from social activities, for since he or she can no longer speak, it's impossible to carry on a conversation with already departed relatives or announce that he or she is dying (Hospice Patients Alliance, n. d., para. 6).

Apart from making such pronouncements, “active dying” symptoms apply to all those facing death since the dying patient enters a semi-coma state while exhibiting cyclic changes in breathing as respiratory congestion increases. He or she now breaths through a wide open mouth and may not be able to speak even if awake.  In addition to these breathing difficulties, the patient isn’t able to swallow any fluids.  The end-stage hospice patient is now incontinent, although urinary output is greatly decreased and is now red or brown in color.  During this stage, blood pressure  drops drastically, systolic blood pressure dipping below 70, and diastolic blood pressure plummets to below 50, although if the patient is in hospice, the only way to find out these readings is to ask the hospice nurse.  At this point, the patent’s hands, arms, feet, and legs are cold to touch, so a purple or bluish mottling may appear in the lower legs, feet, and hands. Upon death, the jaw drops, and the body is rigid (Hospice Patients Alliance, n. d. para. 7). 

Even with all these signs of approaching death, no one can predict exactly when the individual will die until it happens (Hospice Patients Alliance, n. d., para. 9), but because hearing is the last sense to go, Hospice Patients Alliance encourages keeping up a one-sided conversation at the patient’s bedside (Hospice Patients Alliance, n. d., para. 10).

Late stage care. (2014). Alzheimer’s Association New York City.  Retrieved from http://www.alz.org/nyc/in_my_community_17737.asp

New York City’s Alzheimer’s Association provides a very long laundry list of characteristics of late stage dementia, offering tips for family members.  Even though most of these symptoms don’t necessarily apply to the actual dying process, some of them should sooth the dying Alzheimer’s patient.  For example, caregivers, focusing of what the patient might still enjoy rather than what he or she cannot do, can provide comfort through touch, smell, and hearing (Alzheimer’s Association New York, 2014, para. 33-39).  The Alzheimer’s Association additionally cautions that at this stage the patient needs only palliative care.  Thus, if he or she refuses to eat or drink, “it’s ethically permissible to withhold nutrition and hydration artificially administered by vein or gastric tube” (2014, para. 52).

The last stages of life. (2009). Kokua Mau. Retrieved from http://kokuamau.org/resources/laststages-life

Even though medical professionals speak of “dying trajectories”, each individual goes through the dying process at a different rate and exhibits variations in symptoms.  Even so, Kokua Mau, a Hawaiian hospice, notes some common physical traits that the dying pass through and offers suggestions for palliative care as the patient becomes less responsive to voice and touch.  Here, the caregiver is supporting the person, giving him or her permission “to let go” (Kokua Mau, 2009 para. 8).

As the patient loses interest in food and drink and is unable to swallow, forcing food may be harmful or painful, and urging him or her to drink may result in choking or force liquid into the lungs.  A caregiver, however, may wet the patient’s lips and apply lip balm (Kokua Mau, 2009, para. 12-15).

Constipation caused by lack of mobility and decreased fluid intake will accompany incontinence as the bowel and bladder muscles relax, so adult diapers are now necessary for every hospice patient.  Tea-colored urine at this point is highly concentrated (Kokua Mau, 2009, para. 16-19).

Reduced oxygen to the brain and dehydration may cause restlessness and agitation, so family members keeping vigil may need to alert hospice staff that the patient needs increased pain medications.  Meanwhile,  the caregiver should always identify him or herself when talking and speak in a gentle voice, giving lots of reassuring touches (Kokua Mau, 2009, para. 23).

Pooling secretion in the lungs and an inability to cough up this mucus the breath must pass through may cause a death rattle (Kokua Mau, 2009, para. 24).  The dying patient will most probably also have longer and longer periods of not breathing at all, followed by deeper and more frequent breaths, a condition known as Cheyne-Stokes respiration (Kokua Mau, 2009, para. 25).  Although using a syringe to suction the mucus rarely helps, a caregiver may gently wipe out the mouth with a clean cloth (Kokua Mau, 2009, para. 27).

As the blood moves from the legs and arms to protect the vital organs, a purplish mottling may appear when blood collects (Kokua Mau, 2009, para 28).  The caregiver may also cool fevered skin with a cool, damp washcloth and cover the patient with a blanket if he or she feels cold.   Since physical pain can be controlled, alert hospice nurses if the patient needs medication  Meanwhile a caregiver’s presence not only provides “loving kindness” but also “practical help” (Kokua Mau, 2009 para. 29-34).

Morrow, Angela. (2010, December 27).  The journey towards death: Recognizing the dying process.  Caregiver Revolution.  Retrieved from http://www.thecaregiverwebsite.com/2010/12/the-journey-towards-death-recognizing-the-dying-process-by-angela-morrow-rn-about-com-guide/

Morrow cautions that death is a personal journey, so each dying patient doesn’t always stop at every milestone.  Nevertheless, health professionals have documented three distinct phases that share common characteristics (2010, para. 1-4).

Between one to three months before death, the dying patient withdraws from his or her surroundings, even if the late-stage dementia patient will not be able to verbalize the “five tasks of dying”: asking for forgiveness, offering forgiveness, giving thanks, showing love, and saying goodbye, so the only outward signs that death is approaching may be that he or she is eating less and sleeping more (Morrow, 2010, para. 6).   Then between one to two weeks before death, the patient will start to show definite physical changes: A lowering of body temperature and blood pressure, an irregular pulse, increased perspiration, pale and bluish lips and nail beds, rapid and labored breathing, and a rattling breathing sound (Morrow, 2010, para. 9).  He or she may also show an increased state of agitation, possibly picking at sheets or clothing (Morrow, 2010, para. 9).

As the patient edges closer to death, breathing slows and becomes irregular, therefore entering a Cheyne-Stokes breathing cycle, while a blotchy and purplish mottling may work its way up the arms and legs, and the eyes, although open, may be unresponsive (Morrow, 2010, para. 12).  When breathing ceases, the heart stops (Morrow, 2010, para. 13). Because the dying can still hear, however, Morrow recommends that caregivers “sit and talk to the dying” (Morrow, 2010, para. 12).

Profeta, Louis, M. D. (2016, January 19). How we used to die, how we die now.  Exopermaculture. Retrieved from http://exopermaculture.com/2016/01/19/how-we-used-to-die-how-we-die-now/

Although  Dr. Profeta may be romanticizing dying within a home setting, he effectively argues for hospice care for the dying. 

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Terms Describing the Dying Process

Cheyne-Stokes Respiration: Also known as periodic respiration, Cheyne Storkes respiration alternates breaths of increasing depth and frequency with increasing periods of apnea, or not breathing.

Cheyne-Stokes and abnormal periods of respiration.  (n. d).  Patient.co.uk. Retrieved from http://www.patient.co.uk/doctor/Cheyne-Stokes-and-Abnormal-Patterns-of-Respiration.htm

Last days of life (PDQ): Supportive care—health professional information [NCI] care during final hours.  Cancer Health Center.  Web M. D. Retrieved from http://www.webmd.com/cancer/tc/ncicdr0000543592-care-during-the-final-hours

Death Rattle:  Also known as End-Stage Wet Respiration, Terminal Respiration Secretion, and Noisy Breathing, this ominous sound occurs when a dying patient cannot clear the throat through coughing or swallowing, so secretions of mucus build up, causing a rattling sound when air forces its way through the airway.  An Australia Palliative Care Consortium notes that the median survival rate for patients after the first death rattle occurs is less than 24 hours.

End of life care: Management of respiratory secretions. (2013, June). Eastern Metropolitan Region Palliative Care Consortium [Victoria, Australia].  Retrieved from http://centreforpallcare.org/assets/uploads/EMRPCC-%20EOLRS%202013.pdf

Morrow, Angela.  (2014, May 21).   The death rattle: Recognizing and treating end-stage wet respirations.  Dying, Funerals, & Grief.  About.com.  Retrieved from http://dying.about.com/od/symptommanagement/a/death_rattle.htm

Cynosis:  A bluish color to the skin caused by lack of oxygen.

Skin-discoloration—bluish.  (2013, April 21).  Medline Plus.  National Institutes of Health.  Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003215.htm

Mottling: Reduced blood circulation in the legs results in a distinctive purple, reddish, or bluish blotches first seen in the soles of the feet and later seen in the legs and arms (Scott, p. 4).

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(http://www.proprofs.com/quiz-school/story.php?title=end-of-life-care_1)

Scott, Paula Spencer.  (2014). Swelling in feet, coolness in fingers and toes, and mottled veins before death.  Caring.com.  Retrieved from http://www.caring.com/articles/mottling-and-signs-of-death

Signs of dying. (n. d.).  Compassion and Support.org.  Retrieved from https://www.compassionandsupport.org/index.php/for_patients_families/death_dying/signs_of_dying

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Explaining Physical Symptoms 

Hagberg, Bob.  Hospice aide: Common signs of approaching death.  Retrieved from http://www.youtube.com/watch?v=5uRBPxNC1iA (23:12 minutes).

Jarkovich, Joan. (2012, January 14).  Death, dying, and hospice care.  The Joan Jarkovich Show.  Retrieved from http://www.youtube.com/watch?v=GkHQtJ_FRCo (57:50 minutes).

Signs and symptoms of dying—Cheyne-Stokes breathing.wmx. (2010 September 21). Midwife 2 the soul.  Retrieved from http://www.youtube.com/watch?v=bDebRCRVN08 (9:25 minutes).

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Just a reminder: 

 If you have been a caretaker of any extended period of time, make sure that you look after yourself. Case in point: When I went to the ophthalmologist the last week in December 2015, I got a scolding for not going to the eye doctor's for the last four years, although because I have had two detached retinas, in the past I scheduled an appointment twice a year. My doctor updated my prescription, and I see much more clearly and in greater detail. 

Using Keyword Searches to Find Treatments for Mild Cognitive Impairment

Nicotine Patches May Slow the Decline of Mild Cognitive Impairment into Alzheimer’s

Evelyn E. Smith

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

Family members of patients diagnosed with Mild Cognitive Impairment may wish to ask a neurologist about the advisability of outfitting their loved one with a daily nicotine patch at least on a trial basis, perhaps replicating the results of a six-month trial published in 2012 that proved that wearing a nicotine patch under a physician’s supervision for six months eases some of the loss of cognitive functioning of MCI.  Although caretakers will also need to weigh this against the increased anxiety that often accompanies a heightened  awareness of memory loss, I can certainly testify that family members often try all sorts of alternative cures—from Vitamin E to blueberries and coconut oil--to slow the approach of dementia. 

A few years later, what would the family trade for six extra months of relative normality?  Mother was diagnosed with MCI in August 2000 and is now completing her ninth-month in hospice care for Frontaltemporal Dementia, so looking at her increasingly emaciated body and often expressionless face, I know that I would certainly call her neurologist about this finding.

On February 9, 2014, Scientific American published the following excerpt from Dan Hurley’s book, Smarter: The New Science of Building Brain Power (2013), which elicited a hunt for vetted research backing up its claims that nicotine patches can safely ameliorate some of the memory loss brought about by MCI:

Hurley, Dan.  (2014, February 9).  Will a Nicotine Patch Make You Smarter? [Excerpt].  Scientific American.  Retrieved from  http://www.scientificamerican.com/article/will-a-nicotine-patch-make-you-smarter-excerpt/?&WT.mc_id=SA_MB_20140212

Smarter: The New Science of Building Brain Power (2013)  details how dozens of human and animal studies published during the last five years have shown that nicotine in the form of chewing gum or a transdermal patch may treat or prevent a wide variety of neurological disorders, including Parkinson’s, Mild Cognitive Impairment (MCI), Attention Deficit Hyperactivity Disorder (ADHD), Tourette’s, and schizophrenia as well as bring about weight loss with “few known safety risks” (2014, February 9, para. 1).

The one area where nicotine patches, however, prove ironically ineffective is quitting smoking since heavy smokers who use nicotine replacement therapy have the same long-term relapse rate as those who don’t use nicotine patches, gum, inhalers, or nasal spray (Hurley, 2014,  February  9, para. 2).

Yet for all of nicotine’s medical usefulness, scientists can’t disassociate it from smoking (Hurley, 2014, February 9, para. 3 & 5). Even so, the first serendipitous hint of nicotine’s possible health benefits came from a report published in 1966 by the National Institutes of Health that revealed while smokers were far more likely to die from various cancers than nonsmokers, nonsmokers were three times more likely to die from a neurodegenerative disorder, marked by a loss of dopamine-producing neurons in midbrain (Hurley, 2014, February 9, para. 8).  During the 1970s, neuroscientists went on to learn that nicotine molecules guarded against cognitive disorders by fitting into receptors for the neurotransmitter acetylcholine (Hurley, 2014, February 9, para. 9). 

Research now hints that nicotine may protect against the early stages of Alzheimer’s or Mild Cognitive Impairment:  In a recent trial, 67 patients diagnosed with MCI well-tolerated nicotine treatment and found “significant nicotine-associated improvements in attention, memory, and psychomotor speed” (Hurley, 2014, February 9, para. 12).   Paul Newhouse explains, “What we saw was consistent with prior studies showing that nicotinic stimulation in the short run can improve memory, attention, and speed.” Although Newhouse admits that the results of  these exceedingly small studies weren’t necessarily replicated in larger ones, participants suffered absolutely no withdrawal symptoms or any abuse liability when using the nicotine  patch (Hurley, 2014, February 9, para. 13-14).

As for the risk of addicting nicotine patch wearers to nicotine, while nicotine when smoked is one of the most addictive substances known, “in animal models nicotine appears to be a weak reinforcer”.  To be addictive, tobacco therefore needs other chemical ingredients to keep smokers hooked (Hurley, 2014, February 9, para. 15-17).

Thus, during the past six years, researchers in Europe as well as Paul Newhouse in the United States have published more than a dozen studies verifying that nicotine temporarily improves visual attention and working memory.  For example,  Jennifer Rusted, of the University of Sussex, has published a series of reports proving that nicotine increases by about 15 percent “prospective memory”, or the ability to remember and put into effect an objective, shutting out irrelevant stimuli and focusing attention on relevant matters (Hurley, 2014, February 9, para. 20-21).

Even with these studies, however, physicians and neuroscientists discourage using a nicotine patch for anything other than its intended use—to quit smoking (Hurley, 2014, February 9, para. 22).

Using this Scientific American  article as a basis for a keyword search verifies that Hurley is just jumping on the nicotine patch band wagon since Time Magazine published a similar article in January 2012.

Szalavitz, Maia. (2012, January 9). Nicotine Patch May Improve Memory. Aging.   Health & Family. Time.  Retrieved from http://healthland.time.com/2012/01/09/nicotine-patch-may-improve-memory/

A study led by Dr. Paul Newhouse of Vanderbilt University and published in Neurology has determined that the nicotine found in cigarettes may treat mild cognitive impairment (MCI), a precursor to Alzheimer’s and other dementias, as shown by the results of a randomized, controlled trial of 74 individuals diagnosed with MCI.   Six months of treatment with nicotine patches restored some long-term memory to 46 percent of normal in non-smoking patients while a control group treated with a placebo experienced a 26 percent decline in cognitive functioning.  Approximately half the participants were previous smokers (Szalavitz, 2012, January 9, para. 1-2).

Participants receiving nicotine patches experienced improved attention, memory, and reaction time on several objective tests while the patients themselves as well as their family members also noted their partial recovery. Nicotine’s positive effects didn’t decline over time.  However, clinical experts didn’t see a significant difference between the behavior in the patients outfitted with nicotine patches and their controls (Szalavitz, 2012, January 9, para. 3).

Wearing a nicotine patch had the most effect on individuals with two copies of the APOE4 gene, which increases the risk of Alzheimer’s by a factor of 20 or higher.  Since the brains of Alzheimer’s patients have a reduced number of nicotine receptors, some evidence indicates that nicotine could possibly protect these neurons even as other research suggests that nicotine might increase the cancer-causing properties of other substances (Szalavitz, 2012, January 9, para. 4).

Proof thus exists for nicotine-induced cognitive improvement in MCI patients; however, additional, larger studies are needed to determine if this partial recovery of memory, attention span, and reaction time is “clinically important”(Szalavitz, 2012, January 9, para. 5).  However, the research funded by the National Institute on Aging, the pharmaceutical industry, and the tobacco company Philip Morris found no problematic side effects or withdrawal symptoms, although patients did lose some weight.  Pfizer supplied the nicotine patches (Szalavitz, 2012, January 9, para. 6).

All of which lead to Google Scholar and PubMed searches for clinical trials that verify the results touted by the Time and Scientific American articles:

Newhouse, Paul A., Potter, Alexandra, & Singh, Abhay.  (2004). Effects of nicotinic stimulation on cognitive performance.  Current Opinion in Pharmacology, 4, 36–46.  Retrieved from http://www.gwern.net/docs/nicotine/2004-newhouse.pdf

Newhouse and his fellow researchers certainly prove that using nicotine patches to ameliorate the effects of MCI and Alzheimer’s isn’t new if the dates of the clinical trials they mention are any indication.  In this 2004 article, which serves as a basis for further research, they emphasize that successful trials of nicotine treatment in Alzheimer’s patients preceded trials of nicotine patches for patients diagnosed with Mild Cognitive Impairment (Newhouse, 2004, p. 38).  The articles referenced in this article also clearly show that that medical science  has long recognized the short-term positive effect of nicotine patches for treating memory loss and dementia:

White, H. K. and Levin, E. D.  (2004, February).  Chronic transdermal nicotine patch treatment effects on cognitive performance in age-associated memory impairment.  Psychopharmacology, 171(4):465-71.  [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14534771

This double-blind, placebo-controlled, cross-over study determined the clinical and neuropsychological effectiveness of chronic transdermal nicotine for treating Age Associated Memory Impairment (AAMI), otherwise sometimes known as Mild Cognitive Impairment.  Participants wore a nicotine patch for 16 hours daily, dispensed and tested in an outpatient setting.  A two-week washout period followed the wearing of the patch (White, 2004, para. 1-3).  Individuals diagnosed with AAMI wore Nicotrol patches dispensing 5 milligrams of nicotine during the first week, 10 milligrams of nicotine during the second week, and five milligrams of nicotine during the third week (White, 2004, para. 4).

Using the Clinical Global Impressions Questionnaire, the Conners’ Continuous Performance Test (CPT), and a computerized neuropsychology battery, known as the Automated Neuropsychological Assessment Metrics (ANAM), researchers determined that nicotine “significantly improved” the participants’ clinical Global Impressions Questionnaire scores as well as their attention function and decision reaction time, but it didn’t improve motor and memory function (White, 2004, para. 5-6).  Researchers concluded that transdermal nicotine treatment of AAMI patients resulted in sustained improvement of clinical symptoms, thereby supporting further investigation (White, 2004, para. 7). 

However, before clinical trials fitted nicotine patches on MCI patients, researchers first administered intravenous injections of nicotine to Alzheimer’s patients in 1988 and first outfitted them with nicotine patches in 1995 and 1999:

Newhouse, P. A., Sunderland, T., Tariot, P. N. et al. (1988).  Intravenous nicotine in Alzheimer’s disease: A pilot study. Psychopharmacology, 95, 171-175. [Abstract and first page only].  Retrieved from http://link.springer.com/article/10.1007/BF00174504#page-1

Six-non-smoking Alzheimer’s patients with the mean age of 66.8 received three successive amounts of low (0.125 kilograms), middle (0.25 kilograms), and high (0.5 kilograms) intravenous nicotine or a placebo over an unspecified period of time [that didn’t appear in the abstract or the first page] whereupon they took cognitive tests that showed a decrease in intrusion errors.  However, an increase in anxiety and depression accompanied this increase in cognitive function.

Wilson, A. Lynn, Langley, L.K., & Monley, J., et al. (1995, June-July).  Nicotine patches in Alzheimer's disease: Pilot study on learning, memory, and safety. Pharmacology Biochemistry and Behavior, 51(2-3), 509-514.  doi: 10.1016/0091-3057(95)00043-V.  [Abstract only].  Retrieved from http://www.sciencedirect.com/science/article/pii/009130579500043V

This double-blind, placebo-controlled trial evaluated the effects of sustained nicotine administration on behavior, cognition, and physiology in six patients diagnosed with Alzheimer’s, who were exposed to seven days of a placebo, eight days of wearing a nicotine patch, and seven days of washing out its effects respectively while daily sessions evaluated their learning, memory, and behavior,  and physicians also monitored their global cognitive functioning, rest and activity levels, cardiac activity and blood levels.  Researchers found the participants improved learning skills while they wore the nicotine patch, and this enhanced ability to learn continued through the washout period.  However, nicotine didn’t significantly affect memory, behavior, and global cognition.  Administration of nicotine over the week appeared to be safe, although participants showed a significant decrease in sleep. 

White, H. K. and Levin, E.D. (1999, April).  Four-week nicotine skin patch treatment effects on cognitive performance in Alzheimer's disease. Psychopharmacology (Berl), 143(2):158-65. [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10326778

White and Levin undertook a four-week, double-blind, placebo-controlled cross-over study to evaluate the clinical and neuropsychological effects of chronic transdermal nicotine in eight otherwise healthy Alzheimer’s patients since although researchers knew that nicotine injections improved attention, they didn’t know much about the effects of the use of chronic nicotine.  For sixteen hours a day, patients wore a Nicotrol patch containing five milligrams of nicotine for the first week, a 10 milligram nicotine patch during the second and third week, and a five milligram patch during the four week. 

Wearing a nicotine patch significantly improved attention span, errors of omission, and reaction time for correct responses as measured by the Conners’ Continuous Performance Test (CPT). But it didn’t improve motor and memory function.  The participants' sustained attention encouraged researchers, but nicotine’s inability to influence other cognitive and behavioral domains as well as the modest size of the study left the positive effects of using nicotine patches as a treatment for Alzheimer’s open to question.  Nevertheless, White and Levin suggested that higher doses of nicotine, the possible use of other nicotine ligands, or nicotine treatment combined with other therapies might produce more comprehensive therapies.

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These references, in turn, leads to the most recent clinical trial conducted by Newhouse and colleagues:

Newhouse, P., Kellar, K., Aisen, P., et al.  (2012, August 11). Nicotine treatment of mild cognitive impairment: A 6-month double-blind pilot clinical trial.  Neurology, 78;91. doi: 10.1212/WNL.0b013e31823efcbb.  Retrieved from http://www.gwern.net/docs/nicotine/2012-newhouse.pdf

Newhouse and his fellow researchers randomly administered 15 milligrams of transdermal nicotine daily to non-smoking trial participants diagnosed with amnestic Mild Cognitive Impairment over a six-month period.  Of the original 39 participants wearing nicotine patches, 34 completed the study while 33 of the 35 participants wearing placebo patches finished it.  Those wearing the nicotine patches showed signs of nicotine-induced improvement in attention, memory, and psychomotor speed but no enhanced cognitive functioning measured by the Clinical Global Impressions Questionnaire.  The researchers thus concluded that attention, memory, and mental processing improve when non-smoking MCI patients are outfitted with transdermal nicotine patches.

Stay tuned to further results by regularly searching PubMed with the keywords “mild cognitive impairment” AND “nicotine”; but in the meanwhile, nicotine patches just might prove beneficial:

Cooper,  C., Li,  R.,  & Lyketsos, C, et al. (2013). Treatment for mild cognitive impairment: systematic review.  The British Journal of Psychiatry, 203-255-65. doi: 10.1192/bjp.bp.113.127811.  [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24085737

Cooper and associates reviewed 41 studies, assessing their validity and determined that cholinesterase inhibitors have proved ineffective in preventing dementia.  However, preliminary evidence suggests that heterogeneous psychological group interventions enhance thinking skills over a six-month period, Piribedil, a dopamine agonist, augments cognition over three months, and Donepezil betters brain functioning over 48 weeks.  Clinical trials have also shown that nicotine improves attention for six months.  Equivocal evidence also indicates that Huannao Yicong capsules boost cognition and social functioning.  Nevertheless, no replicated evidence existed that any intervention was effective.

 

Bottom Line: Nicotine patches may be another tool in an increasing set of pharmaceutical options that improves cognitive functioning and delays the onset of Alzheimer’s and other dementias.

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