Month: January 2018

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How to Detect Alzheimer’s: 10 Tests of Varying Accuracy

How to Detect Alzheimer’s: 10 Tests of Varying Accuracy

There are a number of things that can be meant by “detecting Alzheimer’s Disease.”

For one, Alzheimer’s progresses (or regresses) in stages. It may not take much to “detect” the condition once it is sufficiently advanced. A series of simple questions might ferret out the truth. (For more on the utility of such widely employed tests, read further on.) However, by the time the patient is far-gone enough to fail such a “mini-cognitive” test, the result could be of little use in terms of intervention and treatment – except perhaps as an official, doctor’s confirmation of an already obvious diagnosis.

On the other hand, a diagnosis in an early stage of Alzheimer’s could be quite important, therapeutically speaking (albeit emotionally devastating and unwelcomed). Such a diagnosis could serve as a warning and encourage the implementation of lifestyle (for example, to diet [see HERE] and sleep [see HERE and HERE]) and medical changes that could potentially slow down the degenerative process.[1]

At present, though, there simply is no one test that can definitively establish that a person is in early stages of Alzheimer’s.[2] Unfortunately, only an autopsy can confirm, 100%, that a person has Alzheimer’s telltale “amyloid plaques.” Once again, however, by the time an autopsy is relevant, the patient has presumably already succumbed to the disease.[3]

Nevertheless, there are a several tests available. Although they may or may not detect Alzheimer’s in any given instance, they are (collectively and individually) they best that we have for the time being.

Here is my list of ten such tests, in no particular order.[4]

  1. Olfactory: “Peanut-Butter Smell” Test

This particular item came across my desk in late 2015. Numerous news sources ran with phrases like “peanut-butter smell test.” Designed by one Jennifer Stamps,[5] a graduate student in neurology at the University of Florida, the test requires only a dollop of peanut butter and a ruler. It is motivated by the thought that Alzheimer’s patients typically have lost or severely compromised senses of smell.

This point was made vividly for me during one family get-together years ago. At the time, I dabbled in making home-made, flavored liqueurs. I passed around a few samples for some relatives to smell (and, yes, taste!). I recall that my dad, Jim, literally ended up with one of his nostrils pressed firmly around the rim of a bottle. We knew his condition. But I just thought that the culprit was lost motor skills or messed-up spatial awareness. Heck, I even entertained the notion that he might have just lacked the requisite tact for the occasion. In hindsight, I feel confident saying that he simply couldn’t smell the concoction, and so he kept trying to get his nose closer and closer.

The test is administered one nostril at a time. The subject is instructed to close his or her eyes, mouth, and one nostril. The tester then opens and raises a jar (or other container) of peanut butter, positions a ruler vertically under the open nostril, and tracks the peanut butter upwards along the ruler. The test ends when the subject declares that he or she can smell the peanut butter.

It is not entirely clear to me whether how researchers interpret their results. Presumably, they hope eventually to hash out a range of measurements to wield for diagnostic purposes.

Some articles applaud the test and suggest that fine points, like alleged differences in a single patient’s nostril sensitivity, may be explained in virtue of which side of the brain is Alzheimer’s-affected. Other articles are thoroughly skeptical. Still others advise that while the “smell test” might serve a purpose in confirming a diagnosis of Alzheimer’s, it is not well-evidenced enough to be relied upon by itself.

So…can Alzheimer’s be detected by such a crude test? Let’s say that the jury is still out.

It certainly seems possible to approximate this test yourself. Peanut and measuring sticks are easily obtained. The downside, however, is that you will likely have trouble interpreting your results. It’s probably best to stick (no pun intended) with the experts.

  1. Proprioceptive: “One-Leg” Balance Test

In 2009, Science Daily published an article titled “Simple Balance Test May Predict Cognitive Decline in Alzheimer’s Disease.”[6] In it, the author unpacked a somewhat quirky test in which the subject was instructed to try to maintain his or her balance for as long as possible, while standing on one leg.

From grade-school anatomy classes, I recall that the cerebellum is the brain structure credited with the primary role in regulating balance. Indeed, there is evidence that “frontotemporal” dementia affects the cerebellum. (What areas of the brain are affected? See HERE.)

Five seconds seems to be the important threshold. If a person is unable to hold themselves up on one leg for at least five seconds, then their balance is labeled “abnormal.” Although this test is even easier than the previous one to replicate at home, it is possible that balance can be negatively affected by causes other than Alzheimer’s Disease.

Intuitively, certain earaches and headaches might throw your balance off kilter. Additionally, the low blood-sugar conditions experienced periodically by diabetics may render a person unable to maintain his or her balance. Finally, leg or join pains of various sorts might make you physically (or mechanically) incapable of standing on one leg, even if you would be capable from a “mental” (or “proprioceptive”) perspective.

  1. Spatial Acuity: The “Four Mountains” Test

Simply put, the Four Mountains or 4MT test is a test of spatial memory. During the examination, testers present a subject with a digital topographical map that looks like it is a snapshot from an environment in a video game. As the name implies, this landscape sports four “mountain” formations. The subject is then shown four additional images. One of these subsequent images represents the same four-mountain terrain – albeit from a slightly different point of view. The other three images are simply representations of different computer-generated mountain clusters.

According to test creators, 4MT is dependent upon this core idea. “Allocentric spatial memory is a key function of the hippocampus, one of the earliest brain regions to be affected in Alzheimer’s disease (AD) and impairment of hippocampal function predates the onset of dementia.”[7]

Designers maintain, therefore, that the 4MT test is capable of distinguishing “mild cognitive impairment” (MCI) due to Alzheimer’s, from MCI that is caused by other forms of dementia.

  1. Mental Status: Six-Item Cognitive-Impairment Test, “Mini-cog” (Mini Mental-State Examination), and Other Short-Term Memory Tests

These tests are commonly administered by doctors’ offices, insurance companies, and the like. For the former, the objective may be to evaluate a patient’s memory and reasoning abilities without having to be physically invasive.[8] Similarly, insurers are looking to estimate an individual’s risk for needing long-term care due to cognitive issues.

In employing tests of this sort, administrators are looking to gauge a person’s cognitive abilities by asking a series of simple questions.

In one version of the test, a person is given a short list of words (3 to 10) and is then asked to perform a simple task, such as positioning clocks to a certain position. Once the task is complete, the interviewer asks the subject to repeat the list of words. There are numerous variations of this test.

In another permutation, published by the British newspaper Daily Mail, an individual is asked a handful of questions. Example questions include: What is the year? What’s the month? What time is it? (With or without looking at a clock face.) Can you count down from [n]? (N is some number, say 25.) Can you name the months of the year – in reverse?

Such tests also include some component designed to test short-term memory. For instance, a name or address might be given to the target at the beginning of the test. At the end, the administrator would ask the person if he or she recalls the given information.

Commonly, incorrect answers are awarded points. The number of points is then tallied and, if it exceeds some (presumably experimentally established) threshold, then it is deemed to be clinically significant.

  1. Visual: Eye Tests

There are a couple of options when it comes to eye tests. One basic test has to do with changes in visual acuity. Specifically, some researchers believe that early stages of Alzheimer’s might be detectable by tracking certain perceptual “color changes” using a device called a hyperspectral endoscope. The idea is that amyloid deposits will change the way the eye receives and processes light, resulting in measurable wavelength shifts that may be an early indicator of Alzheimer’s.

A second sort of test relies upon techniques for assessing the thickness of a cluster of neurons termed “macula.” It turns out that thinning macula are correlated with diminishing cognition. State-of-the-art optometric imaging machines may therefore be able to warn of impending Alzheimer’s by peering into a subject’s eyes.

  1. Hematologic: A Blood Test for MCI

Mild cognitive impairment, or MCI, is a condition that attends early-stage Alzheimer’s Disease. However, it is also associated with other sorts of dementia and with pathologies, including multiple sclerosis and Parkinson’s Disease. In 2016, news broke concerning the possibility that a blood test could both detect MCI and distinguish Alzheimer’s-related MCI from other types.

According to one of the test’s designers, “it is possible to use a small number of blood-borne autoantibodies to accurately diagnose early-stage Alzheimer’s.”[9] Researchers devised a panel of 50 “autoantibody biomarkers” that, they believed, were highly correlated with Alzheimer’s. 

It appears that this test is still in an experimental phase. But it holds the promise of being able to detect Alzheimer’s Disease years before it manifests its giveaway symptoms.

For the latest on blood tests, see my video:

  1. Genetic: DNA Test
An at-home DNA test is available.
The company 23AndMe offers a saliva-based genetics test for Alzheimer’s.

Whereas blood testing purports to reveal when a person has early-stage Alzheimer’s, genetic testing supposedly can disclose your risk before any clinical signposts are present. The California-based firm 23AndMe, already widely known for its ancestry analyses, has released a DNA test that predicts one’s risk level for Alzheimer’s dementia. At least, that is the claim.

Like its ethnicity test, the disease test begins with the collection of a person’s saliva. The company then tests the saliva for the “E4 variant” of the “Apolipoprotein E” (or APOE) gene.

Apparently, processing once took around two months. Now you frequently receive your results in about two to three weeks. 

23AndMe acknowledges that environmental and lifestyle factors may affect a person’s overall Alzheimer’s risk. Furthermore, the test only looks at one specific genetic factor. There might even be other genetic factors that are relevant to overall risk, but that are ignored by the test.

It is important to note that the test does not “diagnose” a person with Alzheimer’s – it merely indicates one factor that is presently believed to increase a person’s genetic risk.

In fact, designers maintain that the test can disclose predispositions toward nine other diseases, in addition to Alzheimer’s, including coeliac disease, and Parkinson’s.

The price includes laboratory-testing fees. So, after you purchase your package, and receive a saliva-collection kit, all you have to do is send your sample back to the company. You will then get a stack of genetic reports – the company numbers them at “75+.”

Of all the tests covered in this post, this one is probably the best value, in terms of both accessibility and scientific credibility. It’s not invasive, and it gives genuinely important and pertinent information about your risk level. But it is certainly not the final word.

Although it is far from clear that health providers will be recommending this sort of test, I can tell you that I am interested enough to take it myself. I will be reporting on my own experience in a later post. (UPDATE: See the video, below, for a start.)

  1. Cerebrospinal: Lumbar Puncture

The collection of cerebral-spinal fluid (CSF) begins another test with encouraging results when it comes to the early detection of Alzheimer’s dementia. Specifically, the relevant test evaluates two amyloid proteins, labeled beta and tau, that are prevalent in the brain deposits and plaques that are characteristic of an Alzheimer’s-riddled brain. Alzheimer’s patients customarily have elevated levels of these proteins in their CSF.[10]

Various CSF tests are commercially available. However, they are definitely “invasive.” The participant must submit to a collecting procedure that is variously termed “lumbar puncture” or the evocative (and, dare I say, heavy-metal-ly) “spinal tap.” A small needle is inserted into the spinal area and some fluid is removed for analysis.

There is a constellation of side effects that can accompany spinal-tap procedures. The most common of these is a bad headache. This is so widely experienced that numerous resources refer to this as a “post-lumbar puncture headache.” There can also be unspecified pains as well as dizziness, nausea, and vomiting.

  1. Brain Imaging: Amyloid PET Scan

Just the facts: Positron Emission Tomography uses radioactive sugar (e.g., fluorodeoxyglucose, or FDG) to give doctors a peek at a person’s brain tissue.[11]  PET scans, as they are called, “…[measure] important body functions, such as blood flow, oxygen use, and sugar (glucose) metabolism, to help doctors evaluate how well organs and tissues are functioning.”[12] Their benefit is that they reveal the amyloid plaques that announce the presence of Alzheimer’s Disease.

So, an upside is that this test is reliable.

A downside is that it radioactive.

My opinion: I am a bit leery. Healthcare workers typically insist that “low doses” of radiation have “no known” lasting negative (or adverse) effects.[13] But, as an article on MedLine Plus discloses: “…The risk of cancer depends on the dose and begins to build up even with very low doses. There is no ‘minimum threshold.’…”[14]

This makes sense when we consider the canonical description of how cancer originates. In the words of the editorial board at Cancer.net: “All cancers begin when one or more genes in a cell are mutated, or changed.”[15] One or more.

Of course, when we are considering a person who is suspected of having Alzheimer’s, it may well be worth the risk of cancer (however high or low it might be) to “risk” the radioactivity of the PET scan.[16]

On a personal note, my dad (read “Jim’s Story”), had two surgeries prior to reaching “advanced” stages of Alzheimer’s. He had a triple bypass for his heart and a colectomy to remove a cancerous portion of his bowel. In hindsight it is tempting to think that he may have had less miserable experience dying of cancer than of Alzheimer’s. But, as one instructor put it once (concerning counterfactual statements): There is no way to get an answer, and nothing to do with the answer even if you could get it.

  1. Autopsy

A final “test” is not really a test in the same sense as the previous nine entrants on this list. An autopsy,[17] of course, is a port-mortem medical examination – that is, one performed on a deceased person’s body. According to the Alzheimer’s Association: “While the diagnosis of A[lzheimer’s] D[isease] can now be up to 90% accurate, it can only be positively confirmed through autopsy.”[18]

Apparently, some autopsies still collect brain material for purposes of scientific study. Others are performed to confirm the diagnosis of Alzheimer’s, which, since it enhances the detail of the medical record, can benefit other family members down the road.

The Alzheimer’s Association stresses the need to plan and to coordinate such an undertaking with the funeral home, hospital, primary-care doctor, and nursing home. (It’s morbid, but a brain autopsy must be performed prior to the embalming process.)

The next of kin (usually a surviving spouse or adult child) must sign a permit. Autopsies cost anywhere from $0 to a few thousand dollars, depending on the circumstances and facilities involved.

Notes:

[1] As one New York Times writer put it: “Alzheimer’s …starts a decade or more before people have symptoms. …[B]y the time there are symptoms, it may be too late to save the brain. …[T]he hope is to find good ways to identify people who are getting the disease, and use those people as subjects …in studies of drugs that may slow or stop the disease.” (Gina Kolata, “In Spinal-Fluid Test, an Early Warning on Alzheimer’s,” Aug. 9, 2010, <http://www.nytimes.com/2010/08/10/health/research/10spinal.html>.)

[2] Developing tests is tricky business. The tests have to meet various criteria, reliability perhaps foremost. But tests also have to be available – both to doctors and patients – and affordable (or at least “covered” by health insurance). The ten tests (or categories of test) surveyed herein are each at different developmental stages. Not all of them are equally accessible, affordable, or reliable.

[3] Of course, a person could die at any time from a variety of causes – both natural and non-natural. It is possible for a person’s Alzheimer’s to be detected during an autopsy that was performed after a death unrelated to dementia. But I am ignoring that possibility, here.

[4] Full disclosure: I had intended to try to “rank” the tests in terms of accuracy. But since I am neither a clinical researcher nor physician, I lack the requisite qualifications to carry out such a task. Moreover, a quick glance at the popular-level literature suggests that there may be no fact-of-the matter about this sort of hypothetical ranking. Alternatively, even if there is an answer, objectively speaking, it could be unknowable – at least given the current state of the relevant science. So, even though my list might look like a “ranking,” I’m sticking to my story: It isn’t!

[5] Stamps apparently worked at least partially under the direction of Professor Kenneth Heilman, in the University of Florida’s College of Medicine.

[6] Mar. 13, 2009, <https://www.sciencedaily.com/releases/2009/03/090310104744.htm>.

[7] Neil Burgess, Dennis Chan, Laura Marie Gallaher, Kuven Moodley, Ludovico Minati, and Tom Hartley, “The 4 Mountains Test: A Short Test of Spatial Memory with High Sensitivity for the Diagnosis of Pre-dementia Alzheimer’s Disease,” Journal of Visual Experiments, no. 116, 2016, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5092189/>.

[8] Several authors refer to these sort of cognitive tests as “invasive.” Surely, this is not true in a physical sense. Still, it is obvious sense that being unable to answer basic questions (like “what year is it?”) is embarrassing. There may be some sense, then, in which these tests are “emotionally invasive.”

[9] Cassandra DeMarshall, quoted in “New Blood Test Helps Detect MCI Stage of Alzheimer’s Disease,” June 8, 2016, <https://www.news-medical.net/news/20160608/New-blood-test-helps-detect-MCI-stagec2a0of-Alzheimers-disease.aspx>.

[10] The New York Times cited a study in which 75% of people with MCI displayed increased amyloid levels in their CSF; while 33% of “normal” people did as well. The Times author added that researchers suspected the 33% were in a “pre-symptomatic” stage and would ultimately develop Alzheimer’s. Another study apparently found that the signature CSF elements were identified in 100% of Alzheimer’s patients tested. See Kolata, loc. cit.

[11] Other types of imaging are available. Writers at Alz.org remind that an important part of a doctor’s procedure in diagnosing Alzheimer’s (or any condition) is a general review of the patient’s case. This will include family and personal medical history as well as other facets of a “routine” examination. To this end, CT (computed tomography) and MRI (magnetic resonance imaging) may be employed “to rule out other conditions that may cause symptoms similar to Alzheimer’s…,” “Tests for Alzheimer’s Disease and Dementia,” <https://www.alz.org/alzheimers_disease_steps_to_diagnosis.asp>.

[12] “Positron Emission Tomography – Computed Tomography (PET/CT),” Radiology Info, lasted updated Jan. 23, 2017, <https://www.radiologyinfo.org/en/info.cfm?pg=pet>.

[13] For just one example, see the Canadian Cancer Society’s article “Positron Emission Tomography (PET) Scan,” n.d., <http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/positron-emission-tomography-pet-scan/?region=on>.

[14] Eric Perez, et al., “Radiation Sickness,” MedLine Plus, Feb. 1, 2013, <http://www.nlm.nih.gov/medlineplus/ency/article/000026.htm>.

[15] “The Genetics of Cancer,” Cancer [dot] net, Aug., 2015, <https://www.cancer.net/navigating-cancer-care/cancer-basics/genetics/genetics-cancer>.

[16] There are hypothetical questions about the use of PET scans in routine-screening procedures. Maybe there is a fruitful comparison to be made with mammography. Again, I quote the New York Times: “A 17-year study has concluded that screening mammography — in which all women in certain age groups are routinely screened for breast cancer — does not reduce the incidence of advanced tumors, but does increase the diagnosis of lesions that would never have led to health problems.” Nicholas Bakalarian, “The Downside of Breast Cancer Screening,” Jan. 11, 2017, <https://www.nytimes.com/2017/01/11/well/live/the-downside-of-breast-cancer-screening.html>.

[17] The word “autopsy” is interesting. It has Greco-Roman roots and is basically has two components: autos, meaning “self,” and opteuō, meaning “I see.” The sense of autoptēs was “seeing with one’s own eyes” and sometimes conveys the idea of being an “eyewitness.” See William Arndt, Walter Bauer, Frederick Danker, and Felix Gingrich, A Greek-English Lexicon of the New Testament and Other Early Christian Literature, 3rd ed., Frederick Danker, ed., Chicago: Univ. of Chicago Press, 2000, p. 152. There is an intriguing quasi-religious angle. A similar etymology, tracing the word to autopsia, is given by Albert Mackey in “Autopsy,” Encyclopedia of Freemasonry, Robert Clegg, ed., vol. 1, Chicago: Masonic History Co., 1956, p. 113. The Online Etymology Dictionary concurs and adds: “Sense of ‘dissection of a body to determine cause of death’ is first recorded 1670s, probably from the same sense in French autopsie (1570s).” Douglas Harper, “Autopsy,” <https://www.etymonline.com/word/autopsy>.

[18] Cited in the now-dated “Autopsy Update,” Sept.-Oct., 1991, <https://www.alz.org/alzwa/documents/alzwa_resource_eol_autopsy_update.pdf>. I note, though, that the Daily Mail (out of Great Britain) repeats this claim as recently as 2015. “There is no definitive test for dementia. The only way to know for sure if someone has had it is after death, in an autopsy.” Keith Souter, “Six Questions That Could Show if You’re at Risk of Dementia,” Mar. 23-24, 2015, <http://www.dailymail.co.uk/health/article-3008253/Dementia-Six-questions-risk-dementia.html>.

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Alzheimer’s and Sleep: Herbs, Spices, and Other Supplements

Alzheimer’s and Sleep: Herbs, Spices, and Other Supplements

This Is Part 2 of a Two-Part Series on Alzheimer’s and Sleep

How Can We Improve our Caliber of Sleep?

There are a lot of questions that remain unanswered. Given all of what we know about the importance of sleep (see HERE), we can draw certain theoretical conclusions from the data. However, I am more interested in the practical side of things. What can I do – concretely – to try to Alzheimer’s-proof myself?

For me, I am betting on the need for good quality, nightly sleep. A secondary practical question then presents itself. How can I be better rested? Here are some things that I have tried, or plan on trying soon.

Reduce Your Light Exposure

Avoid blue-lighted gizmos at bedtime.

Light of any kind can interfere with the production of the “sleep chemical” melatonin.[1] But especially harmful is the blue light emitted from electronic devices.

An obvious culprit, depending on the time of day that you hit the hay, is sunlight. While it is important to keep your vitamin-D levels up, and while the most natural (and inexpensive!) way to keep your vitamin-D levels up is to ensure that you have adequate exposure to sunlight, you want to taper off this exposure once you near your bedtime. If you are stuck in a position of having to get some shuteye while the sun is still a factor, then your best bet is to try to make your sleep area as dark as possible.

Light-blocking curtains can be of great assistance. In my own case, I have doubled up on the window treatments, creating a layered effect that can be more effective than a single curtain alone. However, depending on such things as color and density, some curtains may not be adequate even if you “stack” them on top of each other.

If you are serious about keeping light out of your room, then you should buy “blackout” curtains. As expected, they come in various colors, to match, as they say, almost any decor.

If you usually go to sleep after dark, then sunlight won’t be your biggest problem. However, light from street[2] and other outside lighting[3] can also inhibit your body’s melatonin production and frustrate your ability to fall asleep. Again, selecting the right window treatments can mean the difference between getting a good night’s sleep and being awakened by the neighbor’s motion-sensing porch lamp.

It’s been suggested that people stop using electronic devices (including cell phones, computers, tablets, televisions, etc.) at least one hour before bedtime. The light emitted by video screens can make just as much mischief for your melatonin levels as the other sorts of lighting just discussed.

I also suggest that you turn off completely any LED displays (particularly blue lights), because even those little lights can deprive your brain of the requisite time for accumulation of the melatonin needed to sleep. For those appliances that cannot (or should not) be switched off, a bit of electrical tape over the LED could do the trick. Additionally, you can turn the alarm clock away from you or otherwise place it out of sight. (More on melatonin, below.)

If you absolutely must keep working, then you might consider acquiring special, blue-light-blocking glasses. Some manufacturers claim that their products help avoid eyestrain, perhaps by given us an assist in the refocusing department.

I have tried the Gunnar brand gaming and screen eyeglasses with some success. These are yellow-tinted glasses that are designed to block blue-shifted light. Although they do not state this, it appears that my Gunnars have a slight magnification. (I am not an eye specialist. Although it seems likely that this is far less than 1x, it is still noticeable.)

Eliminate Background Chatter or Add White Noise

For those who are either easily awoken by background sounds, or who have trouble falling asleep when it’s “too quiet,” there are devices that can help. For years, I slept with the aid of an old “SleepMate” machine, manufactured by the company Marpac.

I notice that they have updated their product line. In general, I can vouch for the fact these little appliances really seem to help. Other options include HoMedics’s “Sound Spa” and iHome’s “Zenergy” sound maker. (More on iHome’s offerings in the aromatherapy section, below.)

For one thing, these machines mask background sounds quite effectively. (Typical offerings include volume controls and can be adjusted to your sound-floor preferences.) Moreover, I have discovered that focusing on the noise can have a relaxing effect. To some extent the noise can “drown out” the mental chatter that keeps my mind going some nights and prevents me from drifting off to sleep.

Work out

Exercise is great,[4] and it is positively correlated with improved sleep, but should be done no later than a few hours before you retire. Unfortunately, my schedule is such that I am routinely in a position of having to decide between working out right before bed, or not working out at all. To be sure, this is a difficult call to make. In my case, I decide on a case-by-case basis. If I am feeling unwell or if I am sleep-deprived, I may skip the weights for the day. If I am feeling well-rested and energetic, then I will probably go for it. Just know that if you go for it, also, it might result in a less restful night than you would have had otherwise.

On the subject, however, some “fitness trackers” can pull double duty as sleep monitors. As of this writing, one big “name” in the industry is FitBit. As for me, I have been eyeballing the Charge 2, because it’s less bulky (and less expensive) than items such as FitBit’s Ionic SmartWatch.

When it comes to Alzheimer’s patients, of course, it is probably somewhere between difficult and useless to attempt to fit them with a sleep monitor. However, for those who are still in the position of trying to avoid Alzheimer’s, such a monitor might be worth the investment. For one thing, just getting in the habit of wearing one might make it more likely that I would continue to wear it in the unfortunate event that I am display signs of dementia. But also it might enable me to tweak my sleeping routine now so as to help me avoid Alzheimer’s in the future.

Avoid These Things

Caffeine is obviously counterproductive to the goal of getting to sleep. So, lay off the stuff well (some say as many as six hours, but at least four) before hitting the hay. (If your dietary goals call for you ramping up your metabolism, you might try a non-caffeinated supplement. I have tried MET-4 by Dietetic Advantage and am happy with it.[5])

There are other reasons that you might want to incorporate some alcohol, for example in the form of a glass or two of red wine, into your diet.[6] But from the perspective of maximizing your sleep potential, steer clear of the stuff toward bedtime.

Other substances, like alcohol, might give the impression of being relaxation aids. But, under the surface, they actually interrupt healthy body rhythms and can impede sleep. At least, they can prevent the brain from entering, or enjoying the benefits of, the sort of deep, restorative sleep that (I earlier suggested) benefits cognition. To put it bluntly, passing out from alcohol is not the same thing as getting a good night’s sleep.

It may be surprising, but similar warnings attend the use of nicotine. While it may seem to provide a tranquilizing effect, nicotine also has stimulant properties.

Instead, Try Some of These

There are many natural sleep aids available. In fact, there are vitamins and minerals that support the body’s ability to sleep and could therefore be thought of as “sleep aids” in a broad sense. For some people, getting a better night of rest may be as simple as elevating your levels of these compounds by supplementing with a multivitamin. For those who desire a bit more specificity, let’s look at a handful (or a few handfuls, hands full) of options.

Herbal Tea

Relax with a book, a cup of herbal tea, a warm bath, or some combination. (Don’t get your book wet.)

Nowadays, herbal teas come in a variety of packages. There are a plethora of distributors offering everything from single-herb teas to blends. For example, chamomile (as well as catnip), which is a solid reputation among herbalists as a calming herbal tea, can be obtained by itself or in various sleep-aid concoctions.

Celestial Seasonings’ “Sleepytime” mixture is a personal favorite of mine. The classic version is a composite of chamomile, spearmint, west Indian lemongrass, tilia flowers, blackberry leaves, orange blossoms, hawthorn and rosebuds.

Recently, Celestial Seasonings introduced a “Sleepytime Extra” offering that adds valerian into roughly the same mix of chamomile, tilia flowers, spearmint, lemongrass, and hawthorn.

Incidentally, valerian (root) is also available singly. Alvita, for instance, sells Valerian Root tea. In my opinion, based on my own (admittedly uncontrolled) experiments, it can be quite effective,[7] but it is also an acquired (and slightly “pine-needly”) taste.

For a more flavorful treat, you might consider Bigelow’s “Sweet Dreams” that, similarly to Celestial Seasonings’ products, combines chamomile, hibiscus, peppermint leaves, rose blossoms, spearmint leaves, (unspecified) spice, and orange blossoms.

Actually, almost any (non-caffeinated) tea can be sipped for relaxation and general enjoyment. Two of my all-time favorites are Celestial Seasonings Bengal and Gingerbread Spice blends. Find something that you like and make it part of your nightly, wind-down routine.

Herbal Capsules

If you’re not much of a tea drinker, then you might prefer just popping some herbal “pills” instead. Here is my own master list, broken down into four categories.

Category 1: Herbs Recommended for Insomnia by “Commission E”

“Commission E” refers to the German-based Bundesinstitut für Arzneimittel und Medizinprodukte.[8] The group is essentially the German equivalent of the American Food and Drug Administration (FDA). Formed in 1978, Commission E weighed scientific evidence for the approval (or disapproval) of various substances and products previously used in traditional, folk and herbal medicine. Here are four herbs listed by Commission E as recommended sleep aids.

  • Hops (Humulus lupulus)[9] Hops was one of the herbs expressly “approved” by Commission E for the treatment of insomnia.
  • Lemon Balm (Melissa officinalis) Also packaged as “Melissa,” it’s approved by Commission E for both nervousness and sleeplessness, my PDR for Herbal Medicines lists no known adverse reactions or contraindications. It might be a good choice (but see the footnote) for those wanting to begin with a mild herbal sedative.[10]
  • Passion Flower (Passiflora incarnata) Likewise Commission-E approved for anxiety and insomnia, it appears to be generally safe if taken as indicated on the label.
  • Valerian (Valerian officinalis)[11] Valerian was approved for nervousness and insomnia. It is potentially powerful, but readers should be aware of two things. Firstly, sometimes, albeit rarely, people display signs of valerian allergy.[12] Secondly, valerian can have a stimulating effect on some people. (See, again, footnote #7.)

If you don’t have ambition enough to select (and take) herbals individually, you could also try one or more of the various sleep-formulated blends on the market. (Just don’t try multiple formulas all in the same night!) I have tried, and include in my regimen, Solaray Sleep SP-17 and Nature’s Way Silent Night. However, there are a million alternatives (e.g., this, and this, and that, etc.), so find one that works for you.

Category 2: Generally Safe Herbs With “Unproven”[13] Folk Reputations as Sedatives

Besides the specific plants receiving Commission E’s herbal-medical seal of approval, there are a number of other offerings that I have considered, sampled, or worked into my nightly, supplement repertoire. Here are nine.

  • Birch (Betula lenta)[14] Although I have yet to try birch myself, it has a good reputation and is purportedly safe and potentially effective for some people.
  • Catnip (Nepeta cataria)[15] I use catnip frequently. I usually “cycle” my nighttime herbs. To put it differently, I change up what I take so that my body doesn’t get too accustomed to any particular one.
  • Chamomile (German: Matricaria chamomilla or recutita)[16] I also use German chamomile – both in capsule and tea form.
  • Fennel (Foeniculum vulgare)[17] Often suggested for digestion or menstruation pains, fennel may also have mild sedative properties. You might already have some on your kitchen spice rack. (Another kitchen spice is saffron, which may have dementia-fighting properties.)
  • Lady’s Slipper (Cypripedium calceolus) Also called “nerve root,” Lady’s Slipper has a folk reputation for relieving nervousness and tension. It also crops up on lists – like this one! – for herbal insomnia treatments.
  • Poppy (California: Eschscholtzia californica) It’s simply listed in some resources as an “unproven” herbal insomnia treatment.[18]
  • Poppy (Red: Papaver rhoeas) Also known as “corn poppy,” it appears to be generally considered safe. In fact, at least one source[19] recommends it for children.[20]
  • Skullcap[21] (Scutellaria lateriflora) Another fairly widely listed herbal sedative, it seems (in the literature that I consulted) to be largely without adverse-reaction warnings. I use skullcap regularly.
  • Wood Betony (Betonica or Stachys officinalis) It has a reputation among herbalists as a treatment for anxiety and insomnia, “unproven” though it may be. Like Lady’s Slipper, it is supposedly mostly safe, without any remarkable contraindications or warnings.

Category 3: More Potentially Dangerous Herbs With Reputed Sedative Properties

Some herbals appear on various sleep-aid lists, but strike me as a bit riskier than the plants just surveyed. Out of the following four, I have taken ginseng, but I am a bit gun-shy about the others.

  • Ginseng (Panax ginseng) Ginseng is something of a puzzle. It can have stimulating effects and has been reported to cause sleeplessness in people who “overuse” it. Nevertheless, sometimes it finds its way onto lists of herbal sedatives. I disfavor trying ginseng for purposes of supporting sleep since, similarly to black cohosh, it apparently has estrogen-like actions.[22]
  • Kava Kava (Piper methysticum) Although it was “approved” by Commission E for anxiety and nervousness, the U.S. Food and Drug Administration (FDA) advises that kava kava may increase your risk of severe liver damage or toxicity, particularly if used in conjunction with alcohol. So much for my kava-kava shooter recipe! Not a few web sources suggest – often in heated terms – that you stay well away from it. If I could be persuaded to give it a whirl, it would only be in consultation with, and under the supervision of, a qualified naturopath or equivalent.[23]
  • Lobelia (Lobelia inflata) Part of lobelia’s folk-medical reputation has it that the stuff possesses sedative properties. However, because it is supposed to be potentially fatal in high-enough dosages (and therefore has a lot of “street cred”), I have never had the gumption to try it. It is usually found in homeopathic preparations and in small amounts.[24]
  • Wild Lettuce (Lactuca virosa) It’s also a folk remedy for cough, bronchitis, and whooping cough (so it’s included in the next section). However, it is supposedly possible to “overdose” on wild lettuce. Another name for it is “poison lettuce”! Still, I don’t find that it is as potentially harmful as lobelia; it’s sometimes eaten in salads.

Category 4: Cold-Remedy Herbs With Secondary Sedative Effects

You might consider these herbals if you’re sleepless because of some upper-respiratory junk.

  • Black Cohosh (Actaea or Cimicifuga racemosa)[25] I have tried black cohosh. I usually reserve it for times when I am under-the-weather – usually with a respiratory virus – and need to sleep. I do not prefer black cohosh since I am male, and it is often associated with menstruation-related conditions and is possibly estrogen-enhancing.
  • Elder Flower (European: Sambucus nigra)[26] I love elder – elderberries and elder flowers. However, I do not turn to it first as a sleep aid. Similarly to black cohosh, I find myself going to elder when I am sick with a cold or flu.
  • Linden (Tilia tomentosa, inter alia) Linden is actually Commission-E approved for bronchitis and cough. Sources[27] suggest that Linden is mostly safe when used as directed, but its purported sedative effects may be qualified as “unproven.” I have it, but like black cohosh and elder, I typically reserve it for times when I am sick.
  • Vervain (Verbena officinalis) A few lists designate vervain, also known as “Enchanter’s Plant,” as mildly sedating. However, it is more commonly thought of as a folk cold remedy (or palliative). Thus, I would lump it together with black cohosh, elder, linden, and wild lettuce.
  • Wild Lettuce (Lactuca virosa) Wild lettuce is not without some rather striking warnings, so see the comments in the previous section. However, since it is regarded as an effective folk treatment for chest congestion (among other things), it is in somewhat the same class as the other herbs in this subcategory.

Essential Oils (For Aromatherapeutic / External Use)

Oils can be released into the air using a diffuser. If you want to try to soothe several of your senses with one machine, iHome’s Zenergy-Aroma combines the functions of an essential-oil diffuser and a sound machine (for more on which, see above). added to a carrier oil like almond, coconut, or  jojoba (to create a concoction that can be massaged onto your feet and body), or just included in the water of your warm bath (a few drops should do it). Another option for bath time is the employment of what is evocatively termed a “bath bomb.”

With essential oils, the selection is likewise variegated. Here are a few widely used scents.

“Sleep Pillows”

A subcategory under “aromatherapy” should make mention of so-called “sleep pillows.” These can be as simple as bits of fabric that are stuffed with dried herbs and tied shut. Some herbs of choice include:

With a bit of fabric, some string, and a pinch of dried herbs, you can make your own.

More Exotic Supplements

There are a few other things that you might be able to throw into the mix as you try to develop, maintain, or support your body’s healthy sleep patterns. One category of substance is the amino acid. Constituents of proteins, amino acids are used by our bodies for an enormous range of purposes. Of importance to us here, obviously, is the role that some aminos play in aiding sleep.

Amino Acids

By far the best-known sleep-aiding amino acid is l-tryptophan.

L-Tryptophan – Found in poultry, especially turkey (but chicken, also); other meats (from the commonplace beef, lamb, and pork to the less common goat and rabbit); fish (e.g., cod, halibut, mackerel, salmon, trout, and tuna); shellfish (for instance clams, crabs, crayfish, lobsters, oysters and scallops); some fruits (apricots, bananas, cashews, dates, figs, grapefruits, etc.); nuts and seeds (including almond, chia, flax, hazel, pistachio, pumpkin, cashew, sesame, and sunflower); dairy (including milk, yogurt, and cheeses like cheddar, mozzarella, parmesan, and swiss); and certain wholegrains (buckwheat, oat bran, oats, wheat bran, and even whole-grain crackers).

Of course, aminos like l-tryptophan can be taken in capsule form. It’s best to supplement with them on an empty stomach, because this is supposed to aid with absorption. So make the capsule the last thing that you take at night, a good 30-60 minutes after your nighttime snack.

However, tryptophan is not the only game in town. Other amino acids that promote restfulness or sleep, include:

5-HTP – 5-Hydroxytryptophan, generally referred to as “5-HTP” (but also sometimes called oxitriptan), is an amino acid and l-tryptophan by-product that acts, in part, as a precursor for the neurotransmitter[28] serotonin. 5-HTP is routinely employed as a sleep-aid due to its supposed ability to increase serotonin production. It is believed to have a calming effect and is therefore also used to treat “mood disorders” like over-anxiety and depression.

GABA – Many of these amino supplements are mouthfuls to say, and gamma-aminobutyric acid is no exception in that regard. Like serotonin, GABA is a neurotransmitter. Apparently, while some neurotransmitters amplify or enhance nerve-signals, GABA has an opposite effect. It is perceived to perform an attenuating or dampening action on nerve impulses. Thus, like 5-HTP and many other compounds surveyed in this post, GABA is reputed to have a sedative effect.[29]

Glycine – I recently ran across an article,[30] available on the National Institutes of Health website, discussing the positive effects of glycine on regular sleep patterns. So, you might consider supplementing with it to keep your body at optimum levels. 

Hormones

Melatonin – By now, this nighttime sleep aid has become fairly widely used. It is made by the body under low-light conditions, which is one reason why blocking light (as discussed above) is crucial to sleep success. Still, I confess that I keep 1mg, 3mg, and 5mg versions on my shelf.

However, I sometimes cut the 1mg capsule into quarters, and take 0.25mg instead of a full dose. (Use something like this.) At any rate, I have read that “overuse” (whatever that comes to) of melatonin can cause your body to shut down it’s own natural production of the stuff – a less-than-desirable state of affairs, to be sure. 

Less Exotic Supplements

We have run through a wide assortment of herbals and other things. But, amazingly (to me, anyway), it turns out that you can support your body’s sleeping abilities just by keeping your vitamins at recommended daily levels. So, I’ll end this post with some more common supplements.

Vitamins and Minerals

Calcium – According to nutritionist Phyllis Balch, calcium “[h]as a calming effect.”[31] She recommends it in its chelated form. Vitamin D assists the body in the absorption of calcium. Several products, like this one, therefore combine calcium with vitamin D. Remember, also, that vitamin D is important in its own right as a possible Alzheimer’s-prevention supplement. (See HERE.)

Magnesium – Calcium is apparently “counterbalanced” by magnesium, presumably in a similar way that potassium and sodium interact in the body. Magnesium is also supposed to possess muscle-relaxant properties. There are many forms of magnesium, as discussed in another post. Presently, I use magnesium citrate and malate. But you might also consider magnesium glycinate, orotate, or threonate.

Vitamin C – Insofar as sleeplessness can be precipitated by stress, it is crucial to include antioxidants in your diet. As it happens, emotional stress is believed to increase the number of “free radicals” wandering around the body. Antioxidants like vitamin C can counteract these free radicals and, in theory, help mend your body from the effects of stress.

Zinc – A final mention should be given to zinc. Again, Ms. Balch informs us that it “[a]ids in the recovery of body tissues while sleeping.”[32]

In general, you might benefit from taking a multivitamin supplement that is tailored to your particular activity level, age, sex, etc. (Your actual daily vitamin needs are dependent on factors such as age, sex, and activity level.)

Notes:

[1] On the other hand, you absolutely want to ensure that you are getting at least some sunlight exposure during the day.

[2] These lights typically utilize mercury, neon, or sodium.

[3] Commonly available lighting types are compact fluorescent, traditional fluorescent, halogen, and incandescent.

[4] You should always consult with your healthcare provider or physician before beginning any exercise program. Moreover, you would want to start off small, with light weights or simple movements.

[5] Over the years, I have become sensitive to caffeine. Even a little bit gives me awful “jitters.” At first, I was a bit skeptical that it was “caffeine-free” given its inclusion of green tea extract. But I have had no ill effects from MET-4, which leads me to believe that it really is non-caffeinated after all. Still, I am no dietician. Consult with an expert if you have any concerns about your own tolerance levels.

[6] One commonly mentioned reason is to benefit from resveratrol.

[7] Caveat emptor: According to the possibly unreliable weblog Tree of Light, for some people, valerian may actually have a stimulant-like effect. (Steven Horne, “Valerian [Valerian officinalis],” May 31, 2012, <http://www.treelite.com/articles/articles/valerian-(valerian-officinalis).html>.) This comports with the herb’s reputation in the 19th century, if the National Institutes of Health’s Office of Dietary Supplements is to be believed. See its article on valerian, here: <https://ods.od.nih.gov/factsheets/Valerian-HealthProfessional/>.

[8] “Federal Institute for Pharmaceuticals and Medical Products.”

[9] Hops is contraindicated for pregnant women and those suffering from clinical depression. It should also be avoided, or used only under medical supervision, by persons with breast cancer. It should not be mixed with other central nervous system (CNS) depressants and it may react adversely with various barbiturate drugs and estrogen.

[10] It is best to fact-check my claims for yourself. Once again, I am incompetent to recommend herbal medicines to anyone. I offer this information solely from my own personal experiences and untutored research, as-is, for illustrative and informative purposes only. You must consult a health professional for personalized advice.

[11] It should be avoided while breastfeeding or pregnant. Some sources also caution that overuse, often in conjunction with other “hepatoxic agents,” could result in liver damage. When taking valerian, steer clear of alcohol, barbiturates, benzodiazepines, iron, loperamide, and opioid analgesics.

[12] See, again, footnote 11.

[13] I put “unproven” in scare quotes because I have reservations about the phrase. One sometimes reads that herbal remedies are “unproven” when what is usually meant is that they have not been positively established as effective by some (for example) FDA-approved trial. This might make them “unproven” in a narrow, or strict, scientific sense. But, really, hundreds of years of folk traditional testimony arguably counts as evidence in a broad, or looser, sense. Thus, I take umbrage at the idea that herbal remedies “have no evidence” in their support. As a matter of fact, they have quite a bit of evidence; it’s simply that we are talking about “evidence” in a sense that is less rigorous than how the word is used in scientific contexts.

[14] Birch is contraindicated for heart or kidney problems.

[15] Avoid during pregnancy.

[16] Do not take German chamomile is you have hay fever or ragweed allergies. Also, persons with known sensitivities to arnica (Arnica montana), feverfew (Tanacetum parthenium), mugwort (Artemisia vulgaris), tansy (Tanacetum vulgaris), or yarrow (Achillea millefolium).

[17] Avoid this herb if you are allergic to celery or pregnant. Do not administer to children.

[18] Avoid during pregnancy.

[19] Julie Bruton-Seal and Matthew Seal, Backyard Medicine, New York: Castle Books, 2012, pp. 144-145.

[20] Still the herbal PDR, cautions that it is not without some risk. (Joerg Gruenwald, et al., eds., PDR For Herbal Medicines, 4th Ed., Montvale, N.J.: Thomson Healthcare, 2007, p. 230.)

[21] It’s also sometimes spelled “scullcap.”

[22] Caution is needed for those with diabetes or cardiovascular disease. It might also interact poorly with anticoagulants, insulin, diuretics, estrogen, monoamine oxidase inhibitors, nifedipine, and albendazole.

[23] It is contraindicated for breastfeeding mothers, people with mood/neurological disorders (especially depression), and pregnant women.

[24] Not to be used while pregnant. Probably best to use only under the supervision of a qualified herbalist, naturopath, or physician.

[25] Black cohosh is often used to treat premenstrual syndrome and may have abortifacient properties. Hence, it should not be used by pregnant women. Additionally, there are adverse-reaction warnings associated with black cohosh in conjunction with the following drugs: azathioprine, cyclosporine, antihypertensive medications, iron-containing pills, and tamoxifen.

[26] Unripe berries can be mildly toxic. Do not use, except under medical supervision, if you are diabetic. Should not be taken alongside any iron-containing supplement.

[27] For details, see the various footnotes.

[28] A “neurotransmitter” is a chemical that is produced, secreted, or otherwise released by a nerve cell. This chemical release is precipitated by (electrical) nerve impulses and it assists in the passing of signals between nerve fibers, or between nerve and muscle cells, and so on. Suffice it to say that neurotransmitters are important for nervous-system function.

[29] According to writers at the University of California – Berkeley, some pharmaceutical “[s]leeping pills such as zolpidem [marketed under names like Ambien, Edluar, and Intermezzo] and eszopiclone [Lunesta] work by improving the ability of GABA to bind to receptors in the brain…” (“Can Supplements Help You Sleep?” Berkeley Wellness, Oct. 1, 2013, <http://www.berkeleywellness.com/supplements/other-supplements/article/can-supplements-help-you-sleep>.)

[30] Makoto Bannai, Nobuhiro Kawai, Kaori Ono, Keiko Nakahara, and Noboru Murakami, “The Effects of Glycine on Subjective Daytime Performance in Partially Sleep-Restricted Healthy Volunteers,” Frontiers in Neurology, vol. 3, no. 61, Apr. 18, 2012; <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3328957/>.

[31] Phyllis A. Balch, “Insomnia,” Prescription for Nutritional Healing, 5th Ed., New York: Avery; Penguin, 2010, p. 539.

[32] Ibid.

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Alzheimer’s and Sleep: Too Little, Too Much and Just Right

Alzheimer’s and Sleep: Too Little, Too Much and Just Right

Part 1 of a Two-Part Series on Alzheimer’s and Sleep

Dementia can run the gamut in terms of sleep disturbances. From excessive sleep, in often late-stage patients (see further on), to insomnia, Alzheimer’s patients may experience some sort of disordering of their slumber.

What’s Wrong With Not Getting Enough Sleep?

Lack of adequate sleep is correlated with mood disorders such as anxiety and depression. It’s linked with obesity. It’s associated with premature aging – no wonder some call it “beauty rest.” In relation to the present topic, though, I note that not getting enough sack time can also have a pronounced and negative effect on cognitive function.

If it is anything, Alzheimer’s Disease is a condition characterized by suboptimal brain function. It is tempting, therefore, to think that something that, when missing, drives down your cognition will also ramp up your risk of dementia. Contrariwise, if getting plenty of rest helps you to maintain optimal mental functionality, then it is reasonable to think (or hope!) that it might lower your risk of Alzheimer’s.

As I have stated elsewhere, I do not suggest that this is, without exception, a true causal statement. I think of this rather as a bet. Let me put it this way. Personally, I am betting on my health and trying to avoid Alzheimer’s. If I think that there is even the slightest chance that I can stack the deck in my favor by making a little lifestyle tweak, then I will do it! So, if something is correlated with optimal brain function, and the lack of that same thing is correlated with substandard function, then that’s good enough to prompt me to bet on that thing – whatever it is.

And there’s just such a correlation with sleep.[1]

Why Might Sleep Be Important for Dealing With or Avoiding Alzheimer’s?

But the inability to get some restful shuteye can afflict almost anyone. And one concern is that this inability could be a possible dementia risk factor. Still thinking in terms of placing wagers, then, I am interested in treating seriously – and addressing – my own, periodic sleep interruptions.

To put it directly and simply, sleep is important for healthy brain function. It seems to relate especially to how nerve cells communicate.

Despite outward appearances, our brains and bodies are active even when we are sleeping. Recent studies lend credence to the idea that the body repairs, and cleans out toxins from, the brain while we are asleep.[2] Some scientists believe that this “drainage” or elimination system fixes the wear and tear on the brain that due to the stresses of daily living. It supposedly restores our neural command center to peak performance.[3]

The brains of Alzheimer’s sufferers tend to display accretions of amyloid plaques, proteins and other junk. It is intriguing to consider the possibility that these telltale indications of a dementia-plagued brain accumulate, in part, due to something as basic as a breakdown in the sufferer’s power to sleep.

What Is Sleep?

It sounds like a silly question. But, as one recent news headline put it: sleep is a bona fide mystery.[4] Obviously, sleep is more than just lying down and closing your eyes. Some of you can perhaps to relate to the frustrating experience of doing both of those things – maybe for hours on end – without ever actually falling asleep. Delving into the information available on these topics, I read that there are two main “types” of sleep: Non-rapid-eye-movement sleep and rapid-eye-movement sleep. The former is termed non-REM and the latter REM.

Apparently, we go from “deep” sleep into “lighter,” or REM, sleep, in approximately 90-minute cycles. Presumably, each of us may have cycles of varying lengths. Moreover, it may be that an individual’s cycles vary depending on health and other factors. In light of this, the 90-minute interval is probably best thought of as an average. On average, people sleep in cycles of an hour and a half.

The deep-sleep period is, at least according to one prominent sleep theory,[5] supposedly the restorative time. This deeper sleep, however, is claimed to occur more at the beginning of the night[6] than at the end. As the sleeper proceeds from cycle to cycle, REM becomes more frequent and longer-lasting, climaxing in the predawn hours.

Sidebar: Sleep Affects Learning

Since sleep is vital for proper brain function, it is unsurprising (indeed, virtually tautological) that every brain activity is affected by the quantity and quality of sleep that we get.

Consider, for instance, our ability to learn. It seems obvious that dementia sufferers eventually lose this fundamental human power. Yet our capacity for learning is intimately connected to the caliber of our sleep.

On one simple model, the learning process (at least in behavioral terms) may be imagined as consisting of three distinct functions.[7]

  1. Acquisition – Or the period during, and process by, which the brain “takes in” some emotion or piece of information. In more computational terms, “acquisition” is a data-input operation.
  2. Consolidation – “Consolidation” is a word for the interim stage when the brain converts certain bits of data (emotional, informational, what have you) into long-term, recoverable memories. Thinking along the lines of a computer analogy, perhaps we can say that this second learning function is akin to the act of “saving” data on a hard drive or other storage device.
  3. Recall – This is the time at, or means by, which the brain retrieves a piece of stored information or acts upon an associated emotional (or other) state. Crudely carrying forward our PC comparison, we might envision “recall” as an “output” mechanism.

Acquisition and recall are accomplished while we are awake. However, consolidation, which is the somewhat mysterious time when our brain forms ideational and neural connections[8] (some of which we term “long-term memories”), happens while we sleep. (Or so it seems to some researchers.)

Why Does My Alzheimer’s-Affected Relative Sleep So Much?

The thrust of a lot of research on sleep, and certainly a main point of what has been written herein, is that – on average – we need more sleep than we get. It’s easy to think that we should grab as many “winks” as we can.

But a fair number of people who have spent time around Alzheimer’s patients might wonder: Why do many dementia-afflicted persons sleep so much? Why would this be, if sleep is restorative and helpful for maintaining brain function? Would an Alzheimer’s sufferer be chronically sleep-deprived?

Answering these questions presents us with many difficulties. There are several complexities that arise.

Firstly, it is far from obvious that all Alzheimer’s patients do sleep a lot. True, many frequently seem to be asleep. But others – e.g., the so-called “Sundowners” – appear to be awake at all hours of the night.

Secondly, getting restful, restorative sleep involves more than merely reclining with your eyes closed – even if you don’t respond to your name being called. And this exposes another problem: many Alzheimer’s patients are elderly people whose auditory (and other) sensory abilities have dulled. Do grandma or grandpa not react because they are in deep sleep, or because of a lack of awareness that you are trying to communicate? Or is it somewhere in between?

Thirdly, and relatedly, sleep studies[9] (like studies of many other sorts) depend crucially on self-reporting. For example, a person’s nighttime sleep might be monitored and then, upon waking, the person many be asked how rested he or she feels. Thus, the researchers associate being rested or tired with particular patterns of observed sleep behavior (at least partially) on the basis of what the test subject reports.[10]

Once Alzheimer’s is far enough advanced, however, it is apparent that it would be futile to ask the sufferer much of anything, meaningfully. Either the patient’s language capabilities have eroded to a point that makes any verbal communication difficult to impossible, or else the patient’s cognition and memory have decline below the threshold of reliability.

In other words, either the dementia patient can say nothing, or nothing that they say can be accepted at face value. But this bodes ill for the success of any sleep study based on the collection of self-reports.[11]

Despite these difficulties, we may be on at least semi-solid ground if we speculate along the following lines. It certainly seems that some Alzheimer’s sufferers sleep a lot. Several possible explanations are available.

One is that this initial appearance is (at least sometimes) deceptive. Although the dementia-afflicted person might appear to be asleep a lot, this is (again, at least sometimes) not the case. I grant that this suggestion might seem far-fetched at first blush. However, given that we are dealing with often aged individuals whose sensory faculties have diminished and who often revert to childlike (or childish) states of mind, I submit that it cannot be ruled out. If the Alzheimer’s-afflicted person is (at least sometimes) not actually sleeping at all, this would explain why he or she is not getting the restorative benefits of sleep.

But if you don’t care for that possibility, here is another. We have seen that “sleep” is a generic term. There are (at least) two subtypes of “sleep.” Let’s call them deep sleep and shallow sleep. Therefore, even if an Alzheimer’s patient is observed to be “asleep,” it doesn’t follow that the person is cycling from deep to shallow sleep as he or she should. It remains possible that dementia sufferer is “stuck,” as it were, in shallow sleep. This would explain why the person could be observed to be “sleeping” but also why the person is not enjoying the restorative benefits. Restorative benefits only attend to deep sleep, and, for some reason, the Alzheimer’s sufferer only manages to sleep shallowly.

Finally, it must be kept in mind that the brain of an Alzheimer’s patient is basically damaged at a neural-physical level. This damage affects cognition, memory, reasoning, and so on. It is possible, then, that while the restorative process that we sketched above is associated with, or occurs during, deep sleep, it is handled by an isolated or separate “mechanism” within the brain. It may be something like this. The Alzheimer’s sufferer can manage “deep” sleep but, unfortunately, some other neural mechanism is essential for restoration and that mechanism has already been destroyed.

Any of these three suggestion may help explain why some Alzheimer’s patients are, or seem to be, asleep without showing signs of sleep’s purported restorative benefits.[12]

What’s the Right Amount of Sleep?

So, proceeding on the assumption that sleep is both good and restorative, the next obvious question has to do with the amount. This is quite an important question, both for Alzheimer’s sufferers and for anyone who desires to keep his or her body in healthy condition.

We have all heard the proverbial eight-hours-per-day recommendation. And, indeed, this is a good rough-and-ready figure to gauge whether your “hibernation” time is in the ballpark of adequacy.

But…what’s the precise “right” amount of sleep? The answer is: it depends.

It depends on your age. Children require much more sleep than do adults.[13] As we will see in a moment, elderly adults typically get less sleep than younger adults. Whether this is an indicator of a lesser “need” is, however, another question.

The amount of sleep that you need also depends on your health.[14] If you are ailing, you may well need a lot more sleep than you would need if you were healthy. Sleep seems to help our bodies fight infections and recover from illnesses. Moreover, people under stress might require more sleep than they would otherwise. If you’re changing jobs, moving, or going through a divorce, you might catch a few more “Zs” than usual. Likewise, women may sleep more often while pregnant than they do when not pregnant since pregnancy puts inordinate pressures on women’s bodies.

How Much Sleep Does an Alzheimer’s Patient Need?

In general, older adults tend to need between 6 to 8 hours of sleep each night. In general. But these numbers typically assume that we’re talking about older adults with more or less “normal” (for their age) health. When we focus on Alzheimer’s sufferers in specific, we hit another bumpy patch. (Why can’t anything ever be simple?!)

One immediate problem is somewhat indelicate. If John has a cold, we might say: “John, you need more rest.” But that phrase is some what elliptical. To put it another way, “you need more rest” is kind of a shorthand way to tell John that he “needs more rest so that he can get better.” Or again, when Jane is pregnant, we might tell her to go ahead and sleep more. What we mean is usually something like this: “Go ahead and sleep more so that your body can get through this pregnancy and deliver a healthy baby.”

As things currently stand, the first problem, then, is that a person with Alzheimer’s is not going to recover. If Bob suffers from Alzheimer’s and we notice that he’s only sleeping six hours a night, we can’t really say “You need more sleep” in the same way that we did to John and Jane. The clause following the word “so” isn’t curative. After all, the prevailing view is that Alzheimer’s is not like a cold virus that will pass it you just get more rest, eat right, and stay hydrated. Similarly, having Alzheimer’s is not like being pregnant. It’s not a temporary state-of-affairs that puts additional stress on your body, but will be over at a predictable time in the future.

Still, we might think that getting sufficient rest could help Bob (or his caretakers) to better manage his care. Maybe getting more sleep might even improve Bob’s mental clarity to some degree. True, he may never fully recover, but perhaps his decline can be slowed. Thus, there is something that we can put after the “so.” We can say something like, “Bob, you need to get more rest so that you can better cope with your condition.”

Here, we run into the second problem. It’s a practical matter of getting Bob to alter his behavior. If I tell John that he needs more rest, he may or may not agree. He may or may not try to get more rest. But whatever he does, presumably, will be a conscious decision on his part to either ignore or heed my advice. The case is similar with Jane. However she modifies her schedule (or not!) is presumably going to have been her own willful choice. Again, Bob is relevantly different.

Alzheimer’s patients may not be able to comprehend the idea of getting more sleep. It is debatable whether Bob will grasp what we are suggesting to him. Dementia clearly affects the brain’s linguistic abilities. Depending upon the Alzheimer’s stage that he is in, he may not understand part or any of the statement. Even if he does grasp the words, he may be unable to resolve to change his behaviors. For Alzheimer’s also effects a person’s volitional faculties.

Going further, in the case of a person who apprehends and resolves to do what is said, he or she may not remember to follow through with the necessary changes. The most obvious fact about Alzheimer’s is that it severely undercuts memory.

In light of these considerations, we may just have to shrug our shoulders and let Bob sleep as little or as much as he happens to do. The administration of relaxation and sleeping drugs to Alzheimer’s patients arguably has as much (if not more) to do with making the caretaker role more manageable than it does with making the patient more comfortable. It’s a bit of an ethical pickle. If Bob is awake at all hours of the night, is it really “bad” for Bob? Or is it just an inconvenience on his custodian?

It’s not my intention to definitely answer these questions as much as it is just to bring them to the surface. Speaking in broad terms, the human body seems to require between 6-10 hours of sleep, with 8 being the average. Insofar as a person’s nighttime sleep amount is less than 6 hours, it is probably a good bet that encouraging, recommending, suggesting, or otherwise supporting them to get more sleep would benefit their overall health. But for dementia patients, the process of “encouraging,” “recommending,” “suggesting,” and “supporting” might be fraught with practical difficulties or result in outcomes that offset or undermine the hypothetical advantages. The upshot? It might be better to let sleeping patients lie, and let awake patients just roam – focusing, of course, on ensuring that they have a safe environment in which to do so.

But…for those of us who take at least some of these sleep recommendations to heart, or for those early-stage patients who have an interest in enhancing up their own sleep experience, what can be done?

We turn to that question in part 2. See HERE.

Notes:

[1] Numerous online sources highlight diet and sleep as two of the most important health categories to start with for to try to maintain – or improve – your neurological health, both now and in the future. Diet requires its own separate treatment, which you can find here: “Alzheimer’s-Proof Your Diet, Part 1” and “Alzheimer’s-Proof Your Diet, Part 2.”

[2] The National Institutes of Health report that toxins are “flushed” during sleep. See “How Sleep Clears the Brain,” Oct. 28, 2013, <https://www.nih.gov/news-events/nih-research-matters/how-sleep-clears-brain>.

[3] Interestingly enough, I encountered one article that stated sleeping on your side facilitated this drainage and cleansing better than sleeping on your back. On August 4, 2015, Stony Brook University’s online Newsroom posted this suggestion under the heading “Could Body Posture During Sleep Affect How Your Brain Clears Waste?” The article, itself a summary of findings published in the Journal of Neuroscience by researchers Helene Benveniste, Hedok Lee, et al., describes the role of something termed the “glymphatic pathway” – named after the body’s “glial” cells – in “the clearance of amyloid from the brains” under scrutiny. The study, which was performed on mice and is admittedly speculative, nevertheless suggested to investigators that sleeping on your side is superior, for waste-removal purposes, to sleeping on your back or front. For the full report, see: Helene Benveniste, Hedok Lee, Rashid Deane, Tian Feng, Hongyi Kang, Jean Logan, Maiken Nedergaard, Mei Yu, and Lulu Xie, “The Effect of Body Posture on Brain Glymphatic Transport,” Journal of Neuroscience, vol. 35, no. 31, Aug. 5, 2015, pp. 11034-11044; online at <https://doi.org/10.1523/JNEUROSCI.1625-15.2015>.

[4] See Sarah Klein, “The Mystery of Sleep,” Huffington Post, Oct. 27, 2013, updated Dec. 6, 2017, <https://www.huffingtonpost.com/2013/10/27/why-do-we-need-sleep_n_4149438.html>.

[5] Ibid.

[6] I am assuming that we are talking about sleeping at night and being awake during the day. I understand that for some people, due to scheduling demands, this is not the order of events. There is some evidence to suggest that human beings are “made,” so to speak, to be awake during the day and asleep at night. Pursuing this line of thought, you might read that if you go to bed once the nighttime is far advanced, or if you sleep during the day, then you may not be getting much of the sort of sleep that restores your brain and body. Some writers label specific times the “best hours for deep sleep.” One source suggested that this most-advantageous period may be 10 pm to 2 am.

[7] This is all simplistic. It may also be that this particular model is specific to certain branches of psychology. Again, my aim is not to teach a psychological course, but to simply avoid Alzheimer’s. Perhaps the point, then, is this: The brain is important in the learning process, and sleep is important to the brain. Conversely, we might say: Sleep is important in the learning process, and the learning process is important to the brain. I’m just going for intuitive plausibility. I think the statements have that much going for them.

[8] Those in the teaching profession attest to the importance, in improving the retention of newly learned information, of forming “connections.” However, these connections are arguably subsumed under the heading of “acquisition” in our threefold schema. To put it another way, acquisition of information can be enhanced when conscious emphasis is placed upon associations existing among the relevant pieces of information. The operative idea seems to be that these associations, or connections, encourage consolidation.

[9] At least sleep studies involving human beings.

[10] This is overly simplistic. Many studies could be designed to run subjects through various tasks. A subject’s time and accuracy in completing the tasks could then be used to draw conclusions about how rested or alert they are. Still, in Alzheimer’s patients, the nature of the affliction practically guarantees that assigned tasks may be done incorrectly – whether the subject is fully awake and alert, or not.

[11] It is arguable that even studies that utilize brain-scanning technology still bottom out, as it were, with self-reporting. This is more controversially, philosophically. But one attractive picture is that brain states and mental states “come apart.” A neurologist plausibly has direct access to your brain states – via imagining and scanning equipment. So, suppose that Dr. Alpha scans Miss Omega and observes that Region 1 of Miss Omega’s brain displays marked neural activity. Still, Dr. Alpha has only one way to know what is going on in Miss Omega’s private, mental state. He must ask her.

[12] Of course, there is a also the possibility that sleep doesn’t have restorative benefits. But this flies in the face of the empirical evidence surveyed above.

[13] Newborns may sleep upwards of 15 hours a day. This declines a bit to around 12 hours per day when children become toddlers. Even older children and teenagers might require between 9 and 11 hours of slumber every night.

[14] It is worth noting, at least for people who get into or believe in “biorhythms,” is worth noting that a person’s placement on the various (allegedly) cycles (e.g., physical, emotional, intellectual)

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Alzheimer’s-Proof Your Retirement: Long-Term Care Insurance

Alzheimer’s-Proof Your Retirement Savings With Long-Term Care Insurance

My dad, Jim, passed in 2016 at age 85 from Alzheimer’s-related complications. At the time, he had been in a nursing home for almost four years. (For more details, see “Jim’s Story.”)

Nursing-home costs vary by region. There are also price differences that depend upon offered amenities and services.  However, on average, it is not uncommon for nursing-home care to run in the ballpark of $75,000 to $150,000 annually.

At a middling $100,000/year level, a four-year stay (as my dad had) would come to $400,000. This could easily devastate your – or your surviving spouse’s – retirement plans. Additionally, once an estate is spent down, it can be difficult or impossible to leave a legacy to your children or grandchildren.

Sadly, my family discovered this all too well.

Jim’s Case

My dad retired from Sears (he always called it “Sears Roebuck”) after nearly forty-five years of service. At first, he worked in display. This was back when department-store displays were impressive and custom-assembled setups. Jim was trained in glass cutting and other skills that are now largely lost, in a time when what brick-and-mortar stores are left typically have pre-fabricated displays crated in from corporate headquarters.

Ultimately, he ended up in “maintenance.” A lot of the creativity was gone from the job that he had originally entered. Especially towards the end of his working life, he didn’t make much, salary-wise.

It’s probably safe to assume that he brought in around $20,000/year. At age 65, when he retired, Jim had around $300,000 from his Sears profit-sharing plan.

For illustration purposes, let’s think of this $300,000 as a well of money that can be drawn out a little at a time. There are ways of using the money (for example, to purchase an annuity) that do not consist in treating it as a pool. But we will put that to the side, presently.

Now, abstracting away from niceties like cost-of-living increases and supplemental incomes (like from Social Security), let’s consider three sample scenarios.

Three Hypothetical Situations

  • Firstly, imagine No-Change Jim. No-Change Jim wants his retirement years to be the same as his working years – no change in lifestyle. A conservative assumption would be that Jim needed most (if not all) of his $20,000/year income to pay expenses. So, drawing $20,000 from our well of money every year, No-Change Jim would deplete his $300,000 in fifteen years.

As stated, and in fact, the real Jim retired at 65 and died at 85. But, for the moment, put aside the fact that the real Jim got Alzheimer’s Disease around the age of 75.

Drawing off $20,000 every year, No-Change Jim would have had fifteen years of money. That would have allowed him to live, with “no changes,” to age 80. If No-Change Jim had lived to age 85, as the real Jim had done, he would have run out of money five years too early. This is even on a “best-case” scenario where No-Change Jim never needed any extra money for emergencies (like needing a new roof or needing nursing-home care). No-Change Jim cannot really have “no change” after all. He has major problems by age 80. Additionally, No-Change Jim was “locked” into the spending habits he had when he was working. $20,000/year would have kept him where he was at, financially, but would not have provided any funds for any retirement-specific activities (like, say, traveling to Europe). So, No-Change Jim can keep going for a while in the lifestyle to which he had been accustomed. But he can’t keep going until the end of his life. What will No-Change Jim do at age 80?

  • Let’s modify some of our assumptions. Think of a man that we’ll call “You-Only-Live-Once Jim.” YOLO Jim values enjoyment above being conservative. YOLO Jim wants to do some traveling with his new-found free time. To be sure, there are extreme versions of YOLO Jim where he takes the $300,000 in a lump sum, pays the taxes, and then blows the remainder on a few purchases. But let’s remain tethered to financial conservatism in some respects. Suppose that YOLO Jim simply wants to keep his overall lifestyle the same as it was while he was working, plus add on a $10,000 vacation each year (or build a “man cave” with a nice entertainment system, or whatever). To keep his pre-retirement lifestyle, we have seen that he requires $20,000/year. But to add on his desired vacation (or whatever), he needs an extra $10,000/year. That brings us to $30,000 each year. With $30,000 being drawn off every year, YOLO Jim’s $300,000 would have lasted him ten years. Again, holding fixed real Jim’s ages of retirement and death, YOLO Jim would have run out of money at age 75. YOLO Jim could have been “living large” for a while. But it catches up with him. How is YOLO Jim supposed to survive the last ten years of his life?
  • Maybe there’s a version of Jim that thinks through possibilities 1 and 2 and wishes to avoid them. This hypothetical Jim does not want to outlive his money. Let’s call this man “Frugal Jim.” Frugal Jim faces head-on the fact that he cannot spend money on retirement trips (or man caves). Moreover, Frugal Jim realizes that – spending-wise – he cannot even keep leading the life that he was leading prior to retirement. $20,000/year is too much to spend. Therefore, Frugal Jim gives himself a pay cut.

Now there are two subtypes of Frugal Jim that I want to look at. One can see the future with his crystal ball, and the other cannot.

Crystal-Ball Jim can be frugal, but can also minimize his pay cut. Still leaving the Alzheimer’s aside, Crystal-Ball Jim knows that he will die at age 85. Since he retires at 65, Crystal-Ball Jim knows that he needs income for the next 20 years. By simple division, Crystal-Ball Jim takes his $300,000 and divides it by the 20 years he knows that he will live, and arrives at the figure of $15,000/year.  So, he gives himself a $5,000/year pay cut. Presumably, this will mean that Crystal-Ball Jim needs to cut expenses somehow. But, suppose it’s possible. With $300,000, Crystal-Ball Jim could live out his life on $15,000/year.

But, clearly, few people would claim to have the requisite knowledge of the future. So, let’s envision a version of Frugal Jim without a crystal ball. Unaware Jim doesn’t know that he will die at 85 (we’ll continue to assume). Unaware Jim only worries that he will outlive his money and that believes that he needs to scale down his expenses in order to protect himself against that outcome. As with YOLO Jim, there are extreme versions of Unaware Jim who scale back so radically that they practically (or actually) end up living on the streets. But, once again, we will commit ourselves to minimalism, change-wise. Since he doesn’t know that he will die at 85, our version of Unaware Jim decides to plan to live until 90. So, our version of Unware Jim wants to ensure that he has income to live on for the next 25 years. $300,000 divided by 25 gives us the amount that Unaware Jim has to be able to live on: $12,000/year. Supposing that Unaware Jim manages to eke out an existence on $12,000/year, he spends $240,000 over the next 20 years, dies at 85, and leaves $60,000 as a legacy (of which, a portion will be paid in taxes).

How Much Money Do You Need to Retire?

What’s the “moral” of these various hypothetical case studies?

The first thing that jumps out at me is this: My dad didn’t have enough money to retire! Financially, retirement had been inadvisable for him.

Of course, there are seldom one-size-fits-all answers. Things like your assets, lifestyle preferences, location, and so on, all figure in any satisfying response. Your retirement goals (including your idea of what retirement consists in) plan a role as well. If your idea of retirement is to travel around the world, then you’ll probably need more money than someone whose idea of retirement has them living in a log cabin in an isolated part of the country. For an individualized answer, you should really address retirement-related questions in consultation with one or more trusted financial advisors – people to whom you feel comfortable disclosing your personal financial information.

However, general statements can be made. Current estimates suggest that the average worker needs upwards of $2 million to retire. The financial website TheStreet published an article in 2016 outline reasons for thinking that $2 million is the “new amount needed for retirement.” Previously, the baseline number was thought to be $1 million.

Citing the considered opinions of various investment and wealth managers, TheStreet author Ellen Chang contended that the $2 million figure is a “good goal” to aim at.

One Jon Ulin stated that each million saved could issue in an estimated income stream of between $30,000 to $40,000 per year.

It’s easy to see the difference that $2 million, or even $1 million, would have made to my dad’s case studies. Still thinking of the $1 million as a pool of money to be drawn upon (and not as the single premium on an annuity or as the base amount in an investment portfolio), we see that my dad could have drawn $25,000 each year and not outlived his money even if he would have lived to 100. Indeed, Jim could have lived on over $30,000/year and had enough to survive until the age of 90 – assuming that he never got Alzheimer’s Disease.

What About the Cost of Alzheimer’s?

By this point, you should be saying (and hopefully not screaming): “But he did get Alzheimer’s!”

And this is part of the point of going through the case studies. It’s hard enough to plan for a “normal” retirement. But even a person who had budgeted enough for him- or herself to carry a current lifestyle forward into retirement may find that Alzheimer’s blows that budget to smithereens. All the figures just covered assume everyday expenses only. We have not factored in the cost of Alzheimer’s care.

Given that male residents may spend between one to three years in a nursing home, and that females may spend between three and five years, estimated costs can be calculated for husband-wife pairs.

We said earlier that yearly nursing-home expensive range from $75,000 to $150,000. On the low end, if the husband spends one year in a $75,000/year home, and the wife spends 3 years at the same facility (whether concurrently or successively), that comes to $300,000. On the other hand, if a husband and wife spend three and five years, respectively, in a $150,000/year home, the total expense would be $1,200,000 (that’s 1.2 million dollars).

Of course, there are scenarios in which the husbands and wives spend more or less time and the facilities cost more or less than the costs sketched above. But this carves out a general estimated range for projecting Alzheimer’s-care expenses.

On average, we could say that total, estimated nursing-home expenses for Alzheimer’s-related care for a married couple run between $300,000 and $1.2 million.

Alzheimer’s is not the only danger to retirement funds. Any condition that results in the loss of two out of six “activities of daily living” (ADLs) or results in severe cognitive impairment can trigger the need for what is termed “long-term care.”

[See also “75 Questions to Ask a Doctor About an Alzheimer’s Diagnosis.”]

It is arguable, if not obvious, that my dad didn’t have the financial resources for normal, retirement-related expenses, let alone resources enough to afford long-term care.

In fact, Jim’s long-term care did cost around $75,000/year. This means that his care actually cost $300,000 over the four years that he ended up spending in a nursing home. He would have blown through his entire profit-sharing fund even if he had saved it, at its full value, until he needed full-time care in a facility.

A husband-wife pair with $1 million in retirement assets could reasonably plan to spend between $300,000 to $600,000 on long-term care, if they resolved only to utilize facilities that are on the low end of expenses, around $75,000/year. (As we have seen, 8 years of combined care in a facility costing $150,000/year costs $1.2 million.) This is between 30% and 60% of their available assets.

It may be a bit clearer why many writers are advising people to have $2 million put away for retirement.

A husband and wife with $2 million for retirement between the both of them might have to spend 15%-60% (if facilities cost upwards of $150,000) of those assets on Alzheimer’s, or other long-term, care.

Just working with $100,000/year, a married couple should probably budget $400,000 to $800,000 for their combined long-term care costs.

If you have around $2 million in retirement assets, could you afford to pay $400,000 to $800,000 for long-term care? Perhaps, if you could afford to pay for your other, pre-long-term care expenses with the remaining $1.2 or $1.6 million that remains.

However, there is another alternative.

Retirement Insurance

One alternative is to (try to) acquire long-term care (or “retirement”) insurance. There are different varieties of long-term care (LTC) insurance available. Presently, I will simply sketch a few of the basic concepts.

Two Main Types of Long-Term Care Insurance

In the main, there are two sorts of LTC policies. Number one, there are policies that only cover expenses occurred by an individual in a nursing home. Predictably, these sorts of policies are often designated nursing home only.

Number two, there are policies that cover a broader range of expenses. To understand this second sort of policy, usually referred to as a comprehensive plan, you should be aware of the range of possible care options (and attendant expenses).

  1. Adult Daycare – This is basically like a child day care. It is probably best described as a place offering custodial, recreational/social, and supervisory services to older adults who primary live at home, but are dropped off at the daycare center for limited periods of time. Not usually an option for people who require around-the-clock attention or are confined in some way, it may nevertheless be suitable for many families. For instance, if adult children take care of their aged moms or dads, but need a place to take them while going to work, then adult daycare may fit the bill.
  2. Assisted Living – Assisted-living facilities are a combination of senior housing and limited care services. You might take grandpa or grandma to an assisted-living home if he or she need some help with daily activities, but do not (yet) require skilled-nursing or 24-hour care.
  3. Home Health Care – As the name expresses, this option is for seniors who do not need institutional care because they are receiving help at their own (or someone else’s) home. The health plan may still include periodic visits from a skilled nurse who may perform various therapies and generally will be overseen by a physician.
  4. Hospice Care – During that unhappy time when the end draws near for a terminally ill individual, hospice-care personnel focus upon the comfort of the patient and the emotional wellbeing of the family. Nurses do not administer curative or remedial care, but try to minimize the patient’s pain. Hospice teams typically offer bereavement and counseling services as well.
  5. Nursing-Home Care – This is what may immediately come to mind when the subject of long-term care is broached. Nursing homes offer a mixture of custodial and skilled-nursing care. They are equipped to provide care 24 hours a day.

What Types of Care Do Long-Term Care Policies Cover?

The only type of care covered by long-term care insurance is custodial care. “Custodial care” refers to care administered in order to help people perform the activities of daily living or help people who suffer from debilitating cognitive problems (like severe memory and reasoning deficits). Custodial-care workers do not require medical training.

Skilled-nursing care, on the other hand, is only performed by a licensed nurse. The nurse will be depending upon an attending physician for the patient’s care plan. Usually, the phrase “skilled nursing” designates nursing care that is available around the clock, 24 hours a day, 7 days a week, 365 days a year. Long-term care policies do not cover skilled nursing care. It would be covered under health insurance, hospitalization policies, and Medicare.

On the other hand, neither healthcare plans nor Medicare cover custodial care! The only game in town for non-individual long-term care coverage is Medicaid. And Medicaid only covers people who are financially impoverished.

You might also run across the phrase “intermediate care.” This is also performed by a licensed nurse, under a doctor’s orders. However, this is less-than-24 care. It’s medical care, but it is not performed around the clock. Again, long-term care policies do not cover intermediate care. Health insurance, hospitalization policies, and Medicare cover intermediate care (which is often temporary, transitional, and ordered to support patient recovery).

Benefit Amount

Perhaps the most conspicuous consideration is the benefit amount. Generally, LTC benefits are paid on a dollar-per-day basis. So, your benefit amount might be $100/day, for example. Available benefit amounts typically range from $50 to $500 per day. Different companies will have different per-day maximums. Intuitively, the higher the per-day benefit, the higher the premium cost. All things being equal, the lower the per-day benefit, the lower the premium cost.

The average per-day cost for long-term care presently hovers around $200/day. At this rate, a $200/day benefit would cover 100% of expected costs, in today’s dollars, while a $100/day amount would could about half the anticipated costs. And so on. (Your own care experience may be very different. Again, this is for illustrative purposes only.)

Benefit Period

Another consideration is the benefit period. This is the period of time over which your benefit amount will be paid. Often, you can specify a benefit period something like 1, 3, 3, 5, or 10 years, etc. Similarly to what was said before, longer benefit periods translate into higher premium costs; shorter benefit periods generally mean lower premium costs.

Elimination Period

It was earlier briefly mentioned that long-term, or custodial, care has two “triggers”: one physical, one mental. Physically, LTC is triggered when an individual lacks the ability to perform two out of six activities of daily living. Mentally, LTC is trigged when an individual suffers cognitive impairment severe enough to require around-the-clock custodial supervision.

However, once one (or both) of these triggers is activated, the LTC benefit period does not begin until after the “elimination period” has been satisfied. An elimination period is sometimes characterized as a “time deductible.” It is the amount of time you must wait, after you are eligible for benefits, but before your benefit period begins.

Theoretically, the elimination period could be any arbitrary number of days.[1] It generally ranges from 30 days to 180 days. The shorter the elimination period, the higher the premium.

If your elimination period were 0 (zero) days, your premium payments would be extremely high. With a zero-day elimination period, your benefits would begin as soon as your need for long-term care is triggered.

If, to swing to the other extreme, your elimination period were 365 days (i.e., an entire year), your premium would be lower than it would be if you had selected a briefer elimination interval. However, your out-of-pocket costs would high. Essentially, a one-year elimination period means that you will be paying for your first year of nursing-home care out of your own assets or income. Since we already estimated one year of nursing-home care at between $75,000 and $150,000, these would be your expected out-of-pocket expenses before your long-term care benefit period begins.

Usually, people opt for something in the middle. 90 days is a commonly selected option. In this case, once you have triggered your need for long-term care, you would have to cover nursing-facility expenses out of your own pocket for three months and then your LTC insurance would begin paying your benefit amount.[2]

Three months of care at a $75,000/year facility would run $18,750. At a facility that costs double every year (or $150,000), your three-month cost would also double. In this case, that would be $37,500.

What Insurance Companies Offer Long-Term Care Insurance?

Here is a sample of companies that do, or did, offer long-term care insurance.[3]

Notes:

[1] There is also a finer-grained distinction between “calendar” and “service” days. When an elimination period is based on calendar days, the first day of a claim starts the clock and it runs continuously until the elimination period is complete. On the other hand, when an elimination period is based on service days, the clock begins when the claim is made and the individual actually receives care. If a given person only receives in-home care three days out of the week, then only three days per week will be counted toward the fulfillment of the elimination period.

[2] Note that you may still have out-of-pocket expenses even after the benefit period begins. In any case where your contractual per-day benefit amount is less than your actual per-day cost of care, you will have to pay the difference out of your own assets/income.

[3] I have done my best to report accurate financial-strength ratings (as of this writing). However, I offer this list for informational purposes only and make no guarantees or warranties. I encourage anyone who is considering the purchase of a long-term care policy to do his or her own research into a company’s financial strength and philosophy before making a purchase. Moreover, a would-be purchaser may find that Company A offers a better policy than Company B for your individual needs. In this case, it may make sense to favor A over B, even if B has a higher financial rating. You should seek professional advice.