Listening to music or sharing art can be soothing. Relatedly, creativity is a powerful capacity that all humans share. Unfortunately, for those suffering from cognitive impairments, the utilization of this capacity can be frustrated. However, with a healthy dose of – you guessed it! – creativity, caretakers can enable Alzheimer’s patients (even ones who are far advanced in their declines) to use the arts to express themselves and to realize some of the benefits previously noted. My dad’s case afforded me a glimpse into this fascinating and emotionally salubrious process.

For a bit more detail, you can read about my father, Jim, HERE. Suffice it to say that music and art were two of his many interests. He liked to listen to music and sketch people from the covers of TV Guides. Later, as his disease progressed, but while he was still residing at home, he became unable to plan and execute his own projects. Still, he used to sit with my mom as she made cards. Jim was able to help by brushing color on a background papers or performing rudimentary “stamping” operations with a sponge. As his disease worsened, he started a “music therapy” program in his nursing home. The overseers developed a play list of his favorite songs and fed it into an iPod. It was bittersweet to see him smiling and sometimes even humming along. But a key takeaway is that this therapy also helped to calm him.

In addition to the in-house efforts, the nursing home hired a musician to come about once a month to the main visiting area. Residents were encouraged to clap or sing along. Jim seemed to enjoy listening to the oldies. As he was fond of saying, during happier times in his life, they are “oldies, but goodies.”

Music and movement (like dancing) seems to make people with Alzheimer’s feel happier and more like socializing, thus creating a calmer environment. This could result in a decrease in anxiety and depression levels which, in turn, could possibly reduce the reliance on certain medications.

But being in a new area and seeing others respond to the music also helped to stimulate responses in him.

Art Has Effects That Go Beyond Mere Pacification

According to Generations Healthcare: “[I]n 2013 there were neurological studies done that revealed that artists with dementia could still draw familiar people, places and objects from memory.”[1] Art is also surmised to help build feelings of accomplishment and purpose.

Moreover, there is good reason to suppose that the arts might be able to reduce feelings of loneliness. In an article by the Chicago Bridge on Building Community Through the Arts, the author notes that older adults experience social isolation for a variety of reasons. Some experience it due to diminishing physical capabilities, such as loss of hearing. Similarly, others may find that their own voices become too weak for most people to hear without above-average concentration. Still others develop mental problems, like “aphasia” (i.e., comprehension or language impairment), a common difficulty arising with various forms of dementia.

Language abilities are a complex tapestry of mental powers. For instance, many discrete cognitive faculties contribute to, and constitute, the ability to keep up with a conversation’s flow and to initiate a response. Alzheimer’s sufferers become deficient in many of these relevant processes and can only follow a normal discussion with great effort (if at all).

However, the arts in general, and perhaps music in particular, has the unique ability to touch human beings in a direct and intuitive way that is almost, dare I say, magical.[2] Thus, the creative outlets just sketched give Alzheimer’s-afflicted persons a way to connect even when communication is difficult (or practically impossible).

Dr. Natalie Rogers, an art therapist, described this creative connection quasi-poetically as “a process in which one art form stimulates and fosters creativity in another art form, linking all of the arts to our essential nature. Using the arts in sequence evokes inner truths which are often revealed with new depth and meaning.”[3] This “art connection” arguably supports a total integration of a person’s mind and body, fosters deeper relationships with others, and may even facilitate greater awareness of oneself. Or, where the requisite understanding is lacking, as it is in Alzheimer’s Disease, if not self-awareness, at least a certain self-acceptance or personal peace.

How Do the Arts Help?

Art, dance, and music engage regions of the so-called “non-verbal” parts of the brain. People who have trouble with verbal communication can still connect with others through the kinds of creative activities that, in a way, bypass the neurological roadblocks that are erected by dementia.[4] (For an overview of the literal “plaques” and “tangles” plaguing the brains of Alzheimer’s sufferers, see HERE.)

Alzheimer’s makes it hard for people to handle too much sensory input. Music, somewhat counterintuitively, seems to be able to help patients process sensory stimuli better.[5] Specifically, art appears to have a “strengthening” effect on memory, supporting the brain’s ability to recall associations that have been made with certain sounds and sights.

Investigators theorize that art and music are able to activate areas of the brain that Alzheimer’s has “turned off.” Music is especially potent because it is supposed to be processed in many different areas of the brain.[6] Further, musical memories are believed, so to say, to be more “deeply entrenched” in the brain than even language. Musical recollection sets the limbic system in motion because of the tie between melodies and emotions.

Neurologist Oliver Sacks has gone so far as to opine that human beings listen to music “with our muscles.” Although this is a somewhat cryptic comment, he seems to have in mind the fact that sound processing starts in the primal brainstem and then registers in the root structures called the “basal ganglia” – which, along with the thalamus, control voluntary motor movements and routine behaviors.

Thus, we see that Sacks’s statement highlights the importance of movement. Muscle movement, locomotion, and the like stimulate circulation – specifically, blood flow to the brain.[7]

Tips for Your Own Caregiving Environment

All of this theory is well and good. But how can you implement general art, dance and music in your own caregiving environment – whether at home or in an assisted-living facility or nursing home?

Art

• Begin with simple projects – maybe abstract watercolor painting. But note well that, although projects should be simple, they should not be childish.
• Build conversation into whatever activity you select. Talk about what they are doing.
• Don’t rush anything. Let the person take his or her time.
• Recognize that you might have to help the person get started (for example, by moving the brush) to show them what to do.

Movement

• Again, don’t place arbitrary or unnecessary time limitations on the activity. Let them take the time they need – or desire.
• Play music (for more on which, see below).
• As before, you might need to jumpstart your loved one’s motions (in this case, by clapping with or for them, or tapping his or her feet, etc.)
• Of course, movement can be rudimentary and still be benefit. This could range from dancing or just swaying, to pacing or walking, or even exercising. Hey, if it gets them moving, call it a win.

Music

• Play music that is familiar to, or a favorite of, your loved one.
• Tranquil music can calm, while a faster beat can boost the spirits. Mix it up.
• Don’t play it too loud. Loud noise might cause agitation. On the other hand, remember that aging adults or dementia sufferers might have auditory difficulties on top of whatever other cognitive problems they have. So, be ready with the volume knob or remote in order to regulate the volume as needed.
• Try to get commercial-free music in your play list. Commercials might confuse them. Additionally, commercials just break the mood and will tend to undercut the sustained effects that you are trying to achieve.
• Encourage clapping, dancing, humming, or singing along.

Final Thoughts

Art therapy covers a lot of areas – dance/movement, drawing, improvisation, music appreciating, painting, sculpting, singing, and even (for those still higher functioning) writing. A common undercurrent is their engagement of the senses. For someone whose faculties are failing, these activities become rich avenues of information gathering. If a person’s vision and hearing are not as sharp as they once were, they may now rely on touch, taste and smell. So, don’t be afraid to add such pastimes as tasting or smelling different foods, looking at pictures, listening to rain, massage or aromatherapy.

Elaine Perry is a professor of Neurochemical Pathology at the Institute for Aging and Health – Newcastle University that is currently working on a study of aromatherapy for people suffering with Alzheimer’s and agitation. In one of her papers, she cites specific research that shows that certain essential oils are useful for elevating mood and calming agitation.[9] In several clinical tests using lavender and lemon balm as a natural treatment for residents having advanced dementia, it was found that there was a decrease in negative behavior. Geranium, rosemary and peppermint oils have also been tried with some success. Interestingly enough, the best delivery was in a lotion that was applied to the skin. The physiological effect is alleged to be present even if the person has lost their ability to smell (on which, see HERE).

For Further Research

• Kate Gfeller and Natalie Hanson, Music therapy for Alzheimer’s and Dementia Individuals, Iowa City, Iowa: Univ. of Iowa, School of Music, 1995.

Notes:

[1] See the article titled “The Amazing Effect of Art and Music Therapy on Alzheimer’s,”

[2] Maybe the more apt word would be Orphic.

[3] Natalie Rogers, The Creative Connection: Expressive Arts as Healing, Palo Alto, Cal.: Science and Behavior Books, 1993.

[4] This has given way to the suggestion that cognitive skills may not be inextricably intertwined with the memory, as is presently the dominant view.

[5] It’s counterintuitive in the sense that music itself seems to be a kind of “sensory input.” Then why is it that music doesn’t seem to add to the feelings of overwhelm experienced by the Alzheimer’s sufferer? Perhaps the answer is something like this: the rhythm of the music may provide a kind of structure or “beat” to the afflicted person’s otherwise increasingly chaotic and unstructured thoughts. But this is just sheer speculation on my part.

[6] This is because the various elements involved in music – like pitch, rhythm and melody – are all processed by subtly different brain components.

[7] Oliver Sacks, Musicophilia, New York: Vintage Books, 2008. Sacks wrote: that there is “no single music center in the human brain, but the involvement of a dozen scattered networks throughout the brain.” He also credits the 19th-century German philosopher Friedrich Nietzsche with the thought that “Listening to music is not just auditory and emotional, it is motoric as well …[W]e listen to music with our muscles.”

Blood flow is one of the important factors in brain health according to Dr. Daniel Amen and his BRIGHT MINDS protocol. Exercise was also stressed by Dr. Jacob Teitelbaum’s program that highlights five areas for energy and brain health called SHINE. For more information on these matters, see HERE.

[9] Elaine Perry, “Aromatherapy for the Treatment of Alzheimer’s Disease,” Journal of Quality Research in Dementia, No. 3, n.d., (cached HERE).

The question of whether to drive or not is perhaps one of the most pressing to face dementia-afflicted patients. Basically, a person is licensed to drive when he or she is shown (usually by testing) to have mastered the mechanics and rules of driving as well as to be of legal age and of normal mental competence. Impairments of any sort might jeopardize mechanical mastery, obedience to and retention of the rules of the road, or general mental function. These factors, by themselves or together, may put the affected driver at risk (to him- or herself, or to others). However, a mere diagnose of Alzheimer’s Disease may not signal gross deficiencies in any relevant area. There are really two main facets to the query. One is: Is It Safe to Drive? I have covered this topic more fully elsewhere. (See HERE.)

It will have to suffice here to say (as was noted in my article on safe driving) that Alzheimer’s (and related dementias) affects coordination, cognition, concentration, decision-making, emotion, focus, memory, perception, reaction time, spatial awareness, understanding, and much else besides. Consequently, an Alzheimer’s sufferer might get “lost” more frequently than a non-sufferer; he or she may “misjudge” distances and turns; and such a person might “forget” (or neglect) good driving practices (otherwise known as the “rules of the road”). While these things tend to render a person with Alzheimer’s indisputably unsafe behind a wheel, the second question remains: what are the relevant legalities? I will tackle this, presently.

(For our State-specific guide to the relevant laws, see HERE.)

Does Alzheimer’s Mean Automatic License Revocation?

First and perhaps most obviously, does a diagnosis of some sort of dementia (including Alzheimer’s Disease) automatically entail license revocation? The short answer is: No – not necessarily.

Number one, remember that most forms of dementia – chiefly, for our purposes, Alzheimer’s – come in degrees or stages. (For a primer, see HERE.) Early-stage patients may still be able to drive even if, by middle stage, most sufferers are generally unsafe behind the wheel.[1]

While, again, this is not an article about safety, the present point is that unless a given driver is demonstrably unsafe, there are few grounds on which to base a case for revocation.[2]

Having said that, diagnoses of dementia may be grounds for license restriction.

What Is the Usual Process?

Different states tackle this differently. (For a State-specific guide to the relevant laws, see HERE.) But, speaking only in general terms, what typically happens is something like the following.

A person goes in for his or her license renewal. The renewal application has a question something like: “Do you suffer from a medical condition that could or does impair your ability to drive safely?” If a person answers “yes,” then that person would be medically evaluated straight away. (Possible results of this process are enumerated, below.) If, on the other hand, a person answers “no,” then he or she would have to undergo the usual renewal tests (driving, knowledge, vision, etc.), if any. If the applicant passes the tests, and has no impairments that are severe enough to be observed by the bureau/department of motor vehicle (BMV/DMV) employee, then the license will be renewed.

If the applicant’s license is renewed, then the entire process becomes reactive. To put it another way, the driver will be allowed to operate a motor vehicle with no restriction/oversight unless or until he or she is brought to the attention of the BMV/DMV. This might occur when the person’s doctor reports him or her for some medical reason. A handful of states have mandatory-reporting laws. (See the last paragraph of the next section for a list of said states.) Most states do not have such a requirement. However, physicians may report people for ethical reasons, to mitigate the attendant liability risks, or for other reasons.

A driver may also be reported by a court of law or by a law-enforcement officer. For example, these sorts of reports might occur after a traffic accident, traffic hearing, or traffic stop.

Finally, a person may be reported by a family member, caretaker, or even (in some jurisdictions) by concerned citizens or neighbors. Many times, these reports are treated as affidavits and must be dated, notarized, and properly signed. Typically, anonymous reports are rejected. However, a few states (including Florida, Ohio, South Dakota, and Washington, D.C.) treat reports as confidential. The concern with anonymous or strictly confidential reporting is twofold. Number one, for obvious reasons, states wish to avoid nuisance or revenge reporting (i.e., people reporting drivers for reasons of personal vengeance and the like). Number two, Western legal systems usually have provisions for enabling accused persons to confront their accusers.

(Again, to see the laws and regulations that are specific to your State, click HERE.)

Who Ultimately Decides Whether a Person May Drive?

Doctor’s evaluations usually settle the question either way. In a few states, physicians are actually required by law to report a diagnosis of Alzheimer’s (among other conditions) to various governmental bodies and, ultimately, to the department that oversees licensing or motor vehicles (such as the state BMV/DMV). (To get a sense of the myriad state-specific differences that arise at this point, see below.)

Even in states that do not mandate doctor reporting, there are usually mechanisms in place that allow other concerned or interested individuals (e.g., chiefly doctors, but also law-enforcement officials, relatives, or others) to file a report. In fact, most states are reactive in this way.[3] To put it slightly differently, the usual state of affairs is to leave licensed drivers alone unless or until one of more of the following occurs.

1. A person discloses that he or she suffers from some cognitive impairment, dementia, seizure disorder, etc. (that is, the afflicted person reports him- or herself);
2. The driver is brought to the attention of the licensing body via multiple accidents or other incidents; or
3. The Alzheimer’s sufferer is reported to the licensing agency by family members, law-enforcement personnel, or (mainly) physicians.

When any one of these “triggers” is tripped, the licensing or motor-vehicle department typically initiates a review process. This is the process by which the driver in question is put under scrutiny in an effort to ascertain his or her actual competency.

The individual’s driving and medical records may be examined. It is not uncommon for the licensing/motor-vehicle evaluators to send a letter to the targeted driver indicating that he or she is under review and giving said individual the opportunity to obtain the written opinion of his or her own doctor.[4] The review process may also involve requalifying the individual for a driver’s license by way of administering driving, vision, and written retesting.

In the end, for most states, the final word is given to competent medical personnel. Physicians evaluations are awarded immense weight. Additionally, “[s]ix States [California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania] currently require physicians to report certain types of impairments to the State licensing agency.”[5]

What Are the Main Outcomes of the Review Process?

1. Renewal – If a person obtains a favorable evaluation from his or her physician, then his or her license will likely be renewed. However, the licensing body may require more frequent reevaluations.
2. Restriction – Alternatively, a person could have his or her driver’s license renewed, but with certain provisos or restrictions. For example, someone might be limited to driving in a particular area, or to driving only during certain times of day (say, being required to avoid driving at night).
3. Revocation – If the person in question fails the retesting outright, or if the physician statement is unfavorable (from the point of view of renewal), then the license probably will not be renewed. Depending upon the state, there might be an appeals process or even the possibility of reexamination.[6]

What Are Possible Legal Repercussions From Driving While Cognitively Impaired?

Let’s face it, a main concern has got to be exposure to legal liability. If a licensed Alzheimer’s sufferer has an accident, is he or she open to a lawsuit? As I have stated elsewhere, I am incompetent to provide legal advice, but, intuitively, the short answer this time is surely yes. For one thing, almost anyone involved in an accident might be open to a legal action. Observe, also, that Alzheimer’s (and other dementias) are far from the only sorts of driving impairments. (Driving while under the influence of alcohol or drugs would also be impairments in the relevant sense.)

However, there is much more nuance than a mere “yes.” The fact that an Alzheimer’s-afflicted driver might open him- or herself up to a lawsuit in the event of an accident does not, by itself, imply that the Alzheimer’s Disease is necessarily a factor – let alone the deciding factor – in such a case.

Several issues are important. Number one, the Alzheimer’s-affected driver would have to be the one at fault. Number two, the Alzheimer’s Disease (or other dementia) would have to have been determined to be a causal factor.[7] To put a finer point on it, the available evidence would have to show (to any pertinent legal standard) that the afflicted driver’s impairment contributed to the occurrence of the accident.

However, there are circumstances that can create serious liability issues for Alzheimer’s sufferers, their families, and their physicians.

For instance, there could be severe legal consequences if there is good reason to believe that an afflicted person, his or her family, or his or her physician ignored or failed to adequately address signs that the relevant driver was unsafe behind the wheel. A person who ought to voluntarily submit to medical evaluation or who ought to disclose a cognitive impairment, but who does neither, could be legally liable. Of course, sometimes Alzheimer’s impacts self-awareness. In cases where this awareness deficit exists, it may be that the sufferer’s culpability is mitigated. But, presumably, this would have to be determined by a court or judge of competent jurisdiction. The intuitive point is that if a person knowingly and willingly operates a motor vehicle while impaired, then he or she might have to face legal consequences.

Similarly, family members or physicians who allow persons under their care to drive while impaired could also face legal actions. Of course, there are complications and subtleties to these questions. A key phrase is such cases is “good faith.” The driver and his or her caretakers (if any) are expected to act in good faith and with reason and experience, jointly applied.

Once again, these considerations are supplied merely for illustrative purposes. They are neither meant to be exhaustive nor applicable to every situation. If you or a loved one is suffering from some form of dementia, then you should seek professional advice. Doctors and lawyers both have their own spheres of competence, and both sorts of professional may have something relevant to say on this issue.

State-Specific Complications

Legalities pertaining to drivers’ licensing are handled by the individual U.S. States. Each state has its own procedures. (For a list of State-specific laws, see HERE.) Indeed, each state has its own departmental structures.

In sixteen (16) states (such as Arizona, Delaware, Hawaii, Idaho, Iowa, Kentucky,[8] Maryland, Massachusetts, North Carolina, North Dakota, Oregon, Pennsylvania, Vermont,[9] West Virginia, Wisconsin, and Wyoming), drivers’ licensing is overseen by a Department of Transportation.

In other states, the Department of Transportation merely deals with the building and maintenance of public highways and roads and licensing is managed elsewhere.

It could be under the auspices of a Department of Revenue (as it is in Colorado, Kansas, Missouri, and Rhode Island).

Sometimes (as is the case in Alabama, Florida,[10] Minnesota, Mississippi, New Hampshire, Ohio, Oklahoma, South Dakota, Tennessee,[11] Texas, and Utah) licensing is directed by a Department of Public Safety.

The Secretary of State’s Office facilitates licensing in Illinois, Maine, and Michigan.

A handful of states have one-of-a-kind departments. In Montana, drivers are licensed by the Department of Justice; Arkansas seemingly has a hybrid Department of Finance and Administration; whereas, in Washington State, there is literally a Department of Licensing.

In Georgia, it’s called Driver Services. (The same phrase crops up in other states, too. But in Illinois, Pennsylvania, Tennessee, and Wyoming, “Driver Services” is a subset of some larger, overarching, agency.)

Then there is another layer of terminological difference. Most states (i.e., by my count, Alaska, Arizona, Colorado, Idaho, Kansas, Kentucky, Montana, New Hampshire, New Mexico, North Carolina, North Dakota, Oregon, Rhode Island, Utah, West Virginia, and Wisconsin) refer to their motor vehicles agencies as “Divisions.”

Similar units are called “Departments” in California, Connecticut, Washington D.C., Maryland, Nebraska, Nevada, New York, South Carolina, Vermont, and Virginia.

On the contrary, “Bureaus” carry out licensing functions in Indiana, Maine, and Ohio.

And usual, some states have sui generis labels (in Louisiana, there is an “Office” of Motor Vehicles; in Massachusetts, it’s called the “Registry” of Motor Vehicles; and it’s a Motor Vehicle “Commission” in New Jersey.) Still other states use combination terms. Iowa and Minnesota both have composite names such as the Division of Motor Vehicles and Driver Services.

Additional Resources:

U.S. Laws on Driving with MCI and Alzheimer’s Disease

Canadian Laws on Driving with MCI and Alzheimer’s Disease

See, also, our “Car-Modification Recommendations,” here:

Recommended Products

Notes:

[1] One wrinkle, here, is that persons with even advanced dementia may have “good” days during which they seem to lucid and able to reason. These good days will be sprinkled in the midst of “bad” days where the person’s cognitive abilities are subpar. Even though this variability is well known, it is likely that, as far as driving is concerning, the safest course is to make licensing decisions based upon a person’s worst days, rather than their best ones. The reason is that an Alzheimer’s sufferer has little to no power over whether a day will be “bad” or “good.” Therefore, any given driving outing is left to chance. If the Alzheimer’s-afflicted individual has declined to the point where he or she would be unsafe driving on “bad” days, then it’s probably time to hand the license over.

[2] It is not enough That a given driver with early-stage Alzheimer’s or Mild Cognitive Impairment will, given the natural course of the disease, eventually become unsafe is not enough.

[3] That is, the majority of states do not seem to proactively restrict Alzheimer’s patients. Instead, most states wait until a credible concern is filed, and then the driver in question is subjected to scrutiny.

[4] In some cases, of course, the family doctor may be the person who referred the individual to the licensing body for medical review in the first place. Whenever a physician is involved, the licensors will elicit the physician’s considered opinion of the patient’s ability to drive safely.

[5] Here is an illustration of the authority given to healthcare professionals. One reference, for the state of Nebraska, states: “If the guidelines …indicate that [a] driv[ing] test need not be administered, but if [a] physician indicates on the …Physician [Statement] that one should be administered, follow the physician’s recommendations.” On the mandatory-reporting laws, see Medical Oversight of Noncommercial Drivers, Highway Special Investigation Report, Washington, D.C.: National Transportation Safety Board, 2004, Appendix E, p. 69. “California Lapses of consciousness and Alzheimer’s Disease severe enough to be likely to impair a person’s ability to operate a motor vehicle [;] Delaware Loss of consciousness due to diseases of the central nervous system[;] Nevada Epilepsy[;] New Jersey Recurrent convulsive seizures, recurrent periods of unconsciousness, or recurrent impairment or loss of motor coordination due to conditions such as epilepsy[;] Oregon Loss of consciousness or control. Cognitive and functional impairments that are severe and/or uncontrollable to a degree that may preclude safe operation of a motor vehicle and are not correctable by medication, therapy, surgery, driving device, or technique[; and] Pennsylvania Lapses of consciousness or other mental or physical disabilities affecting the ability of a person to drive safely[.]” Ibid.

[6] Again, however, if a driver is evaluated as unsafe because he or she is having one is his or her “bad” days, then this probably should be taken as an indication that the condition has advanced to the point where the driver is not reliably safe. A person should probably not be licensed just because he or she might be safe, but because he or she is predictably safe. While they may enjoy periods of lucidity, at a certain point in their decline, Alzheimer’s patients are no longer predictably safe. Therefore, unfortunately, they are not reliably safe, and probably should not be licensed. Another issue is the cost. Although some states may not charge for the initial review, if the outcome is contested, then the affected driver may end up having to pay for any requested reevaluations.

[7] Even if were not the only factor. It is arguable that many (if not most) accidents have complex causes.

[8] The Transportation Cabinet.

[9] Agency of Transportation.

[10] Technically, here, it is the Department of Highway Safety and Motor Vehicles.

[11] Safety and Homeland Security.

Can an Alzheimer’s Patient Have Sexual Intercourse?[1]

This was the question fired at me from my two teenaged boys. My background is in philosophy, so I was able to talk a bit about issues of autonomy and consent (on which, see further on). But the total answer is, perhaps predictably, complex. Dr. Bruce Miller describes a study done “[a]round 1995” when nurses affiliated with the University of California – San Francisco “did a survey on [Dr. Miller’s] Alzheimer and frontotemporal dementia patients regarding sexual activity. The majority [of surveyed patients] had decreased sexual activity[;] some maintained activities similar to before [contracting] the disease[;] and …around 8% [actually] had increased activity.”[2] So, can we say anything, in general?

“[A] quick, general answer” comes to us by way of Dr. Victor Henderson, director of Stanford University’s Alzheimer’s Disease Research Center. He writes that “[i]n mild and moderate stages of their illnesses, many – and perhaps most – men with Alzheimer’s disease, and virtually all women with Alzheimer’s disease [AD], would be able to engage in sexual intercourse.”[3]

Dr. Gregory Jicha, “Dr. J,” of the University of Kentucky Alzheimer’s Disease Center, adds: “Sexuality and intimacy remain an important part of one’s life as they age. It is no different in AD.”

However, a lot turns on just how one understands the word “able” – in Dr. Henderson’s statement that Alzheimer’s sufferers are “able to engage in” sex. Let’s dig a bit deeper.

Physical Issues

Dr. Allan Levey puts it succinctly when he says, “There are no physiological reasons …why a person with Alzheimer’s disease would be unable to have sexual activity, except until late stages of the disease.”[4] Dr. J concurs, stating: “There are no physical impediments to engage in sexual activity that develop in Alzheimer’s disease until the very end stage when even walking is affected.”

“Alzheimer’s,” Dr. Caleb Finch remarks, “differs widely between individuals and …the parts of the brain usually damaged do not involve physical function in early stages.”[5]

However, Dr. Swerdlow reminds “…that people with Alzheimer’s are often older, may be frail, and frequently have other comorbid medical issues.” The Mayo Clinic’s Lunde expands on this by saying: “most individuals living with the disease are older adults and so age-related issues such as menopause, decreased sperm count, arthritis, hormonal changes, Erectile Dysfunction, illness, medications and depression are often factors related to sexual arousal and/or function.”

To put it slightly differently, even if Alzheimer’s itself does not destroy sexual functionality, said functionality may be diminished by other physical ailments or conditions that attend the aging process.[6] Dr. Mary Sano adds that the “stage of disease may relate to ability to be aroused or want to be aroused as well as to be sexually functional.” (More on this angle, below.)

On the other hand, Dr. James “Jim” Brewer relates that he is “aware of several AD patients whose physical state is outstanding[,] and there would be no physical impediments to [their engaging in] sexual activity.”[7]

A final consideration comes by way of Dr. Eric Reiman who notes that “effects of medications” might also affect sexuality – whether physically, emotionally or otherwise.

As Dr. Hank Paulson helpfully summarizes: “Sexual function is a complicated matter, of course, and many things beyond physiology contribute.”

Emotional Issues

Angela Lunde helpfully frames this part of the discussion, writing that “…the issues have more to do with changes in sexual feelings, desire, and behavior…” than with anything physical, per se. We might say that this constellation of concerns is broadly “emotional.”

Most relevantly, Dr. Marek-Marsel Mesulam notes that, “[g]enerally, Alzheimer’s decreases libido.”[8] Lunde hastens to say, though, that some Alzheimer’s-afflicted individuals actually suffer from an opposite problem, specifically “hyper-sexuality.” We may say, therefore, even if everything is physically operational (so to speak), without sexual desire the arousal mechanisms may be impaired.

“[M]any patients do lose interest in sex – but [it’s not] that the disease [by itself] imposes peripheral physiological challenges to sexual intercourse.” So reports the aforementioned Dr. Miller.

Dr. J, professor of neurology and part of the University of Kentuck-based Sanders-Brown Center on Aging, and his colleagues “studied changes in sexuality and intimacy in normal aging as well as in those with AD and their spouses. …What we …[found] was a general feeling of emotional estrangement in spousal caregivers, with their needs for intimacy and sexuality not being met. The person with AD was almost universally oblivious to this and felt that their needs were met and that the relationship was intact.” Dr. Reiman makes the point that “much of …[this] will depend on the couple.”

Again, Dr. J: “While our study did not further explain the ‘WHY?’ for this [phenomenon], we can postulate that it may be socially or culturally mediated, i.e. a feeling that it is not ‘right’ to engage in intimacy or sexual conduct with an impaired person[.] It could also be due to a reduction in emotional depth that could occur as part of the loss of cognitive processes in AD[.]”[9]

Along similar lines, Dr. Finch (quoted earlier) again remarks that “[s]ocial sensitivity …may be impaired in early stages.” It may therefore be that the Alzheimer’s afflicted individual no longer recognizes sexual “cues” from his or her partner.

Again, I turn to Dr. Sano. “When we talk about capacity, we falsely think it is the same as cognition and it is not. …[W]hile a person may not be able to ‘rationally report what they want’ they may still want a sexual life.” Unfortunately, we cannot peer into the afflicted person’s thoughts. “Additionally, as a person becomes more impaired, they may not be able to understand what another person wants.”

Ethical Issues

Of course, Alzheimer’s Disease undermines cognitive function. But, along with diminishing cognition comes diminishing capacity to consent. As Dr. Mary Sano relates: “Many things depend on the stage of dementia (with our assumption that milder patients have greater cognition and greater capacity to make decisions for themselves).”

In terms of ethics, specifically, there are several considerations that loom large when it comes to any discussion about sexual intercourse. One relevant notion (of many that could be mentioned) is that of autonomy, and another is informed, mutual consent. The two issues converge – and come apart – in interesting ways.

Autonomy is a Greek-derived word meaning, roughly, “self-law.” The idea is that an “autonomous person” is one who chooses (e.g., courses of action, values, etc.) for oneself. A mental competent[10] person (who has attained the age of majority and not forfeited his or her freedom, through imprisonment, military service, or whatever) has the right to determine his or her own courses of action – within the limits of the law. Other free agents have duties or obligations[11] to honor the choices of competent persons.

Similarly, “consent” has to do with agreement or compliance. In order for agreement to be fully “consensual,” the relevant agreement has to be “informed.” So, roughly, “informed consent” happens when a competent person has adequate information to make a responsible decision.

Requiring informed, mutual consent before engaging in sexual activities with another person is one way that person’s autonomy is properly respected. So, for example, a prospective, sexual partner much be made aware of my intentions as well as crucially relevant background information that might affect his or her decision (for instance, my sexual-health status). The other person needs then to be given the space to decide, free from bullying, coercion, or threats of any kind.

The obvious difficulty comes by virtue of the fact that, at certain stages of the disease at any rate, an Alzheimer’s sufferer is not mentally competent.[12]

Alzheimer’s and related dementias are by no means the conditions or situations that present challenges to informed consent. To get a flavor for this, think about a case in which a set of people with normal cognitive functioning volunteer for medical or scientific studies. Suppose that we’re talking about studying the effects of a migraine pharmaceutical. The researchers might disclose certain statistics relating to possible benefits (eliminating the migraine in 15 minutes, for instance). But they will also have to apprise potential participants of the pertinent risks (maybe stroke).

However, persons with “normal” brain functions will not necessarily be able to interpret benefit and risk statistics. It is well known that scientific-study participants sometimes do not (seem to) understand some of the relevant background information. For example, a person may believe that he or she will be receiving an actual dose of some drug, without giving appropriate weight to the possibility that it will be a placebo instead. Or a person might hear various probabilities for some adverse medical event (like the aforementioned possibility of stroke), without appreciating the actual risk that he or she faces.

Of course, Alzheimer’s sufferers are in an even worse position.

Think back to Dr. J’s comments regarding marital sexuality. A husband and wife share sexual experiences and strive for intimacy. Alzheimer’s patients may desire continued intimacy but be unable to express their desires. Alternatively, certain patients may lack the desire. But, from the point of view of the spouse/potential sexual partner, without the expression, it’s dicey business to just dive right in, so to say.

For we already rehearsed the idea that informed consent is the bedrock of respect for personal autonomy. The trick, therefore, is to understand what the Alzheimer’s-afflicted person’s wishes are, and to try to honor them. But this is obviously more easily said than done, since Alzheimer’s is – eventually – partially characterized by the inability to express one’s wishes (and, possibly, by the absence of concrete wishes of certain sorts).

In closing, though, it is well to bear in mind the words of Dr. Nathaniel Chin: “People with dementia can still appreciate human contact, emotional love, and have feelings of love, even if they cannot express it.” This seems plausibly true. And, even if it isn’t true, it is probably more responsible (and charitable) to behave as if it were true, than to behave as though it were not.

Final Remarks

I cannot hope to resolve every issue in this brief treatment. Hopefully, however, what has been said suffices to give you an apprehension of the some of the range of relevant issues.[13]

[1] In an email exchange, Dr. Gregory Jicha, Robert T. & Nyles Y. McCowan Endowed Chair in Alzheimer’s Disease in the University of Kentucky’s neurology department, called the question “fascinating” lamenting that it “has not been fully explored” but opining that it “certainly deserves more attention.”

[2] Angela Lunde, education program manager for the prestigious Mayo Clinic, comments that “overall, there is no single pattern of sexual change in person living with AD.” Miller’s research seems to bear this out.

[3] He notes further: “Some of the other forms of dementia do affect the ability of men to engage in intercourse.”

[4] This was echoed by numerous other experts, including Dr. Russell Swerdlow, who added: “The AD would not be expected to profoundly directly impact a person’s sex organs. So physically there would not be [any predictable negative] …effect [sexually]. …Alzheimer’s in and of itself would not have a profound impact on the function of the sex organs.” Angela Lunde puts it this way: “Alzheimer’s disease alone does not generally impede one’s physical capacity and/or sexual function and reproduction.” Dr. May Sano demurs, however. She expresses doubts “that anyone has answers” to these questions.

[5] Understanding stages is crucially important to understanding Alzheimer’s. As Dr. Nathaniel Chin reports: “A person with dementia due to AD can still have sexual intercourse but it will depend on the stage. As the dementia worsens a person’s sexual drive as well as their physical ability to have sex can become impaired. Additionally, mood becomes affected and medications used to treat mood can interfere with a person’s emotional and physiological drive to have sex. Early in the disease there may not be any physical impairment to sexual function. Dynamics in relationships may change but a person with dementia physiologically can still have desires for sex.” More on these emotional angles, below.

[6] Dr. Hank Paulson adds: “Alzheimer’s does not typically lead to major changes in the physiology of sexual function, although some other neurodegenerative diseases can, such as multiple system atrophy.”

[7] He adds these thoughts: “The disease has a lot of sad components, and I often find myself thinking what a shame it is when a patient’s brain fails so much earlier than the body.  It seems to me that these individuals would have lived a long, healthy life, if it weren’t for their brain condition.”

[8] It may increase “inhibition,” in Lunde’s words.

[9] He adds: “My guess is that this is a common problem that is simply not discussed often for a variety of social and cultural reasons. … Our ultimate goal would be to develop an intervention to help maintain emotional and physical intimacy given its importance to us as humans throughout our lifespan.”

[10] In legal speak, compos mentis.

[11] At least, prima facie.

[12] I.e., he or she is generally regarded as non compos mentis.

[13] Dr. Reiman notes that interested readers can find more information online, for example from the British Alzheimer’s Alzheimer’s Society, e.g., <https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/factsheet_sex_and_intimate_relationships.pdf>. Sarah Brisebois, Research Study Coordinator at the Alzheimer’s Disease Center on the campus of the University of Texas’s Southwestern Medical Center – Dallas, points us to several articles on the Alzheimer’s Association’s website: <https://www.alz.org/national/documents/topicsheet_sexuality.pdf>, <https://www.alz.org/oregon/images/microsoft_word_-_intimacy_and_sex-feb_08.pdf>, <https://www.alz.org/library/downloads/sexandintimacy_rl2015.pdf>.

 

 

When Is a Person With Alzheimer’s Too ‘Far Gone’ to Drive Safely? Can Someone Drive With Mild Cognitive Impairment?

These are very sensitive issues and should be discussed with the afflicted person (if possible) along with the attending physician, family members, legal advisers, and so on. Although this website cannot and does not provide specific advice (whether legal or otherwise), we will lay out – for conversational and informational purposes only – some general, practical guidelines.

The first and most obvious point is that Alzheimer’s varies according to stages. (For a brief introduction, see HERE.) In early stages, Alzheimer’s may not significantly impair a person’s driving ability.[1] As the sufferer declines, regrettably, cognitive and reasoning functions, memory, and physical reflexes will inevitably diminish to the point that safe driving will no longer be possible. The main question is when, precisely, this tipping point occurs.[2]

In order to prepare for the virtually unavoidable conclusion, but before the relevant problems surface, it is wise to consider – and plan for – means of transportation that can serve as driving substitutes. In most cases, and for short trips, these alternatives (depending on the area) will be things such as buses, personal drivers, shuttles, taxis, trains, and the like.

(Although cycling, walking, and other similar activities may be options early on [and for more on their benefits, see HERE], numerous factors – such as physical enfeeblement and inclement weather – might remove them as recourses – whether permanently or temporality.[3])

If possible, you may want to test these (and other) options out, as well as consult with family members and friends who already utilize them, to help determine the one that best meets your loved one’s needs.

How do I keep driving safely? Pre- and Early-Stage Alzheimer’s

While your or your loved one’s ability to drive represents independence, it also may jeopardize his or her safety and that of other drivers on public roads. Therefore, again, these tips should be taken as general rules of thumb, but not as universally applicable – or even universally advisable. Consult pertinent healthcare providers for more insight and for case-specific recommendations. Keep in mind that some areas may have laws that govern some of these issues. It may therefore also be necessary or prudent to seek legal advice from a competent attorney.

That said, it is still true that simple measures may help to extend your or your loved one’s time behind the wheel. There are a few relevant categories. Here are a few things to consider.

Vision Considerations

• Schedule regular eye and vision examinations. This is one of the staples of general, preventative medicine in any case. But it is of vital importance when it comes to keeping a person safely operating a motor vehicle. (Did you know, some eye tests can actually detect Alzheimer’s? See HERE.)
• Update eyeglass or contact-lens prescriptions. This is really an extension of the previous point. Corrective lenses only function correctly if they are suitable.
• Periodically replace windshield wipers and, in general, keep the car’s mirrors, windows and windshield clean. Maintain headlamps in proper working condition and adjust the brightness on the vehicle’s instrument panel for optimal visibility.

Broader Health Considerations

• Schedule periodic wellness checkups. If cognitive-impairment is suspected, ensure that you or your loved one disclose all relevant concerns to a qualified healthcare provider. Tests such as the Mini Mental-State Exam might be usefully employed. (For more on this test and others, see HERE.)
• Your or your loved one’s life – as well as the lives of others – is more valuable than having a few more outings behind a steering wheel. Be sure to honestly bring driving-related questions to your physician.
• In certain cases, and for particular conditions, occupational or physical therapy may assist a driver in maintaining or rehabilitating skills that are essential for safe motor-vehicle operation.

Other Vehicle Considerations

It may be worth replacing a car or truck with a vehicle that is more suitable for your or your loved one’s condition or life station. Although some of the following are, by now, nearly universal, here are some general things that might get you thinking in the relevant direction.

• Automatic transmissions are usually easier to operate than manual transmissions.
• Power brakes and power steering should be available and properly functioning.
• Instrument panels should be easy-to-read and without extraneous or confusing information.
• Doors and seats should facilitate ease of vehicle entry and exit.

Commensensical Driving Dos and Don’t

Avoid distracting your loved one or competing for his or her attention. Don’t let your own mind wander. Minimize noise and reduce disturbances! Here are a few (fairly obvious) tips that might apply to some situations. If there is a common undercurrent, it would be: Exercise an abundance of caution and focus.

• Avoid driving in inclement weather, during high-traffic (“rush-hour”) times, or in the dark.
• Observe all rules of the road, including: checking traffic and signaling properly when changing lanes, looking twice before reversing, maintaining sufficient vehicle distance, and so on.
• Limit or postpone having conversations until out of the vehicle.
• Turn down music, podcasts, radio programs, and so on. In other words, concentrate on the road!
• Set air-conditioner or heater controls before the vehicle is in operation.
• Map routes and plan trips ahead of time and select roads for their drivability and not necessarily for their drive times.
• If you or your loved one drives infrequently, skills may slip. Keep in practice. Depending upon your area, it may also be possible to enroll in continuing-education courses in order maintain (or enhance) skills, in addition to acquiring strategies for coping with dementia or disabilities.
• Finally, as hard as it may be to read, it is a good practice to have competency assessed periodically – both through physicals administered by a healthcare provider as well as via relevant tests (driving, vision, and written).

When to Give up the License/Signs of an Unsafe Driver

You or your loved one may need to have significant restrictions imposed (up to and including license revocation) if certain warning signs surface. Here are things to look for. Your loved one:

• Has difficulty discerning the gas pedal from the brake pedal.
• Sometimes confuses turning right with turning left – or vice versa.
• Declines, forgets, or refuses to use turn signals (or displays other poor decision-making faculties).
• Changes lanes in a dangerous manner, does not yield correctly, or weaves in his or her lane.
• Has obvious trouble recognizing road signs.
• Routinely disregards or otherwise fails to obey traffic signals (e.g., not stopping at red; stopping on green; etc.).
• Cannot hear sirens from emergency vehicles.
• Cannot see or focus on the road.
• Does not seem to notice other cars on the road.
• Believes that most other drivers are going “too fast.”
• Believes that other drivers go “too slow.”
• Has had accidents, actual moving violations, “close calls” or “warnings” more and more frequently.
• Misjudges distances, as evidenced in virtue of erratic turning (turning too widely and veering out of a lane, or too narrowly and running onto the shoulder or a curb) or following other vehicles improperly (giving too much distance, or not enough).
• Has physical difficulties with the mechanics of driving. [4]
• Gets (inappropriately) angry, confused, or frustrated driving.
• Forgets how to navigate to or from familiar places.
• Feels fatigued or overwhelmed after brief periods of driving.

If children, other family members or friends become worried about someone’s driving ability, then this should be taken as an immediate and obvious red flag. Bear in mind that some Alzheimer’s-afflicted persons may be self-aware enough to accurately assess their own driving abilities and to honestly catalog their limitations. Other dementia patients do not display this sort of insight (or honesty) and, therefore, require much closer attention from doctors, family, friends, or other professionals.

Check Yourself!

AAA once published a self-assessment test under the title “Drivers 55 Plus: Self-Rating.”[5] The assessment included questions about whether you or your loved one:

• Habitually signals when changing lanes.
• Properly and regularly wears seat belts.
• Has difficulty navigating through four-way stops or otherwise busy intersections.
• Has trouble merging into congested highway traffic.
• Perceives himself or herself to be “slower” in terms of cognition, perception, reflexes, and the like of that.
• Has difficulty separating him- or herself from emotional states or becomes easily angered by high-traffic situations.
• Cannot stop his or her mind from wandering.
• Sees general practitioners and specialists (like eye doctors) regularly to ensure that overall health, prescriptions, and vision are optimal.[6]

[1] Of course, other conditions – for instance, those that result in blackouts, dizziness, or seizures – might undercut driving abilities. But these, except insofar as they are byproducts of dementia, lie beyond the scope of the present article.

[2] Bear in mind that there may be a transitional period during which the patient alternates between lucidity and confusion.

[3] At a certain point, it is likely that the patient will need full-time care. For a discussion of long-term care – with an emphasis on the attendant costs – see HERE.

[4] For example, maybe grandma has a problem shifting pressure between pedals. Perhaps grandpa’s arthritis prevents him from controlling the steering wheel or changing gears. It might be that dad cannot turn his head to check his blind spots. Maybe mom’s prescriptions are causing her to become sleepy and inopportune times.

[5] Read the publication online, HERE.

[6] For further reading, see HERE and HERE.