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February 17, 2000

Help available for those struggling with relatives' problems of aging

Families taking care of Alzheimer's patients are the real heroes of this world, according to a Pitt professor of psychiatry.

"It's like raising a newborn, but they're not cute, they don't grow up and they only get worse," says Jules Rosen, who holds a faculty appointment at Western Psychiatric Institute and Clinic.

Rosen led a Feb. 8 Faculty/Staff Wellness Program seminar focusing on two problems prevalent among the elderly: late-life depression and dementia, which includes Alzheimer's disease (AD).

"These two issues alone result in a phenomenal amount of morbidity, hospitalization, nursing home placement and, ultimately, death among the elderly," Rosen says.

While depression usually is curable, Rosen notes, dementia is not reversible.

"But with proper behavior management and medication dementia can be manageable," he says. "Most people with dementia, including Alzheimer's, live at home. We can delay a patient's institutionalization and make that period of a patient's life more bearable. That's where caregiver education is so important. There is a tremendous amount of stress on the families of patients. That's why a lay person really needs expert professional help and guidance."

According to Rosen, the most common form of dementia is Alzheimer's disease (AD), which is a chronic, progressive disorder of the brain that can cause a variety of problems, including memory loss, impaired judgment, confusion and/or loss of language skills.

The Alzheimer's patient experiences problems with intellectual abilities severe enough to interfere with everyday activities.

Although most of those affected are age 65 or older, AD can strike much earlier.

Memory loss is a natural by-product of aging, Rosen says. But the elderly can usually compensate by writing things down or using other reminders. It is more an inconvenience than a problem. With AD, such compensation usually isn't enough. Alzheimer's causes brain cells to die at an accelerated rate. Memory is usually the first thing to go, especially short-term memory.

"But sometimes the memory is good, and social behavior is not, depending on which part of the brain is affected. AD might affect the ability to walk or swallow or communicate; each person progresses differently. But it is true that everyone with AD gets worse; eventually AD consumes the entire brain."

Rosen recommends that families coping with AD patients seek professional evaluation and diagnosis. "Pitt's Alzheimer Disease Research Center (ADRC) can be a very valuable local resource. The national Alzheimer Association is another." (For information on ADRC, call 692-2700.) Rosen says as many as 30 percent of AD patients might be helped by medication. "I can't say who'll respond. It's not a cure. But in those that respond the person can go from someone who doesn't want to shower and is fighting you to someone who can maintain social skills enough to go out to dinner."

AD strikes men and women about equally, although in real numbers there are more women with the disease because on average they live longer.

"The risk factor doubles every five years after 65, until by age 85 there's about a 50-50 chance of getting the disease," Rosen says.

Diagnosis is complicated by AD's gradual onset, the lack of a single, specific diagnostic test and the fact that some other diseases mimic AD.

For this reason, Rosen recommends that anyone with signs of mental deterioration undergo a thorough evaluation, including medical history, a physical examination, lab tests and neuro-psychological assessment.

Common symptoms of dementia include loss of memory, personality changes, loss of speech command, searching for words or using the wrong words and paying less attention to regular activities or hygiene.

Patients with dementia are commonly subject to depression, Rosen says. "Late-life depression is a serious public health concern," Rosen says. "Suicide, for example, is highest in white males over 65 — double the rate of the rest of the population — and the 6th or 7th leading cause of death in the elderly."

According to Rosen, doctors often miss depression, because patients "mask" it. "Some mask it by minimizing their despair. They say they feel all right, but they really don't. They are at very high risk if masked depression continues. It's like a time bomb."

Rosen says 70 percent of late-life suicides see their doctor within a month of the suicide; 5 percent within 24 hours.

"I have a success rate of over 90 percent treating depression," Rosen says. "Sometimes it takes three weeks. Sometimes three months. Sometimes, in severe cases, longer. But it has to be recognized. The biggest cause of failure is that depression is under-diagnosed and under-treated."

By depression, Rosen stressed, he did not mean the run-of-the-mill sadness everyone experiences. "Late-life depression is not characterized by a feeling of sadness. It's something else. They could be anxious; they could have feelings of helplessness. They may think their life is over or worthless. But the most common thing the elderly say is: 'I feel sick.' They're given so many tests. They're bounced from interns to hospitals to doctors to specialists, but they don't respond to treatment. They're frustrated. The doctors are bewildered."

That is why family intervention is crucial, Rosen says. "Family members should be there to say to the doctor, 'I don't know what it is, but something is wrong.'

"I've heard doctors say, it's cultural: Patients learn not to say how they really feel. But that is nonsense. Across all cultures, all societies, when the elderly say 'I feel sick' that means that they feel sick!"

Rosen uses the analogy of a flu sufferer: a person feels listless, fatigued, irritable, unable to concentrate and has no appetite or motivation.

"What I've described is the same as a major depressive episode, except with the flu, we know what the cause is. But it doesn't matter what the pathogen is, whether it's influenza or a bacterial infection, the feeling is the same."

Pitt's geriatric program integrates psychiatry with geriatric medical care. Rosen said that in the last 15 years there has been a tremendous improvement in the success rate of treating depression with a group of antidepressant medications called selective serotonin reuptake inhibitors — SSRIs, for short. "These drugs are so good, I sometimes wonder why we don't put them in our drinking water," Rosen says, although he cautions no drug is completely risk-free.

–Peter Hart

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