Given the research we do for this channel, I am no stranger to surprising, sometimes controversial—and occasionally disgusting—claims regarding Alzheimer’s disease.
In a previous video, we explored how something as mundane as earwax buildup—or, more technically, cerumen impaction—could lead to hearing loss and, by extension, cognitive decline.
Today, we’re looking at a physical habit.
It’s often dismissed as a minor social faux pas—and was even the subject of jokes in an old Seinfeld episode. But recent research suggests this common behavior might create a pathway for certain pathogens to reach the brain.
We’re talking about nose-picking—and its potential link to late-onset dementia.
For the companion video, see here:
The Griffith University Study
A team of researchers at Griffith University in Australia published a 2022 study in the journal Scientific Reports. They focused on a bacterium called Chlamydia pneumoniae.
This common airborne bacterium—sometimes called the Taiwan Acute Respiratory Agent—is primarily known for causing bronchitis and pneumonia. However, it has also been detected in a significant number of human brains affected by late-onset dementia.
Using mouse models, the researchers tracked how this bacterium travels. What they found was striking: it can move along the olfactory nerve—from the nasal cavity directly into the brain.
In these models, infection reached the central nervous system within 24 to 72 hours. Once inside, it triggered amyloid-beta deposition—the same protein associated with Alzheimer’s plaques.
One interpretation is that amyloid-beta may function as part of the brain’s immune response to infection. However, if that infection becomes chronic or repeatedly facilitated—potentially through damage to the nasal lining—this process could contribute to neurodegeneration.
In short: this research suggests that certain behaviors might make it easier for pathogens to access the brain.
Connection: The Earwax Analogy
You may remember from our earwax discussion that conductive hearing loss involves a physical obstruction—something like earwax blocking sound transmission.
In a similar way, the nasal epithelium acts as both a physical and immunological barrier.
The Griffith University study found that when this barrier was damaged, infections in the mice became significantly more severe.
Think of the nasal lining as a security checkpoint: if it’s intact, most threats are stopped. If it’s compromised, things can slip through.
Just as we cautioned against inserting objects into the ear canal, scientists now warn that picking—or plucking nose hairs—can damage this delicate lining. That damage may give pathogens a clearer route to the brain.
Why This Matters
As geriatrician Maria Carney noted in our earwax discussion, “most people don’t even realize that they have an issue.”
That lack of awareness is a recurring theme in both Alzheimer’s prevention and detection.
While nose-picking is often associated with children, it remains common in adults. In fact, one study found that about 91% of people admit to it.
I’m curious how that compares with this audience—so I’ve put up an anonymous poll if you’d like to weigh in.
As many viewers know, age alone—especially over 65—significantly increases Alzheimer’s risk.
If we add environmental exposures, such as introducing pathogens through repeated nasal damage, this could represent an additional, potentially modifiable risk factor.
Caveats and Disclaimers
To be clear: this is early-stage research conducted in mice. We do not yet have direct evidence that this pathway operates the same way in humans.
Human trials would be needed to confirm whether a similar mechanism is at work.
And of course, Alzheimer’s disease likely involves multiple contributing factors—including acetylcholine loss, plaque formation through other mechanisms, neurofibrillary tangles, and nutritional or metabolic influences.
So yes—this hypothesis may sound farfetched.
But it is being seriously explored, and it may be worth paying attention to.
Practical Advice and Conclusion
One of the core goals of the Alzheimer’s Proof project is prevention. And unfortunately, there is no single solution—no magic bullet.
What we can do is try to stack the odds in our favor.
Protect the Barrier
Avoid plucking nose hairs and minimize behaviors that could damage the nasal lining. Chronic irritation may increase vulnerability.
Use Safer Alternatives
If needed, consider electric trimmers for grooming. For congestion, saline sprays or nasal irrigation may help. If using a neti pot, always use distilled or properly purified water.
Keep It Clean
If you must manually clear your nose, ensure your hands are clean—before and after. Also keep fingernails trimmed and smooth to reduce the risk of micro-injury.
Stay Aware
Consult a healthcare provider if you experience persistent irritation, bleeding, or signs of infection.
The key takeaway here isn’t panic—it’s awareness.
Small habits, repeated over time, can shape long-term brain health.
And if reducing Alzheimer’s risk comes down—even in part—to eliminating preventable factors, then even small changes may be worth considering.
Anu Chacko, Ali Delbaz, Heidi Walkden, Souptik Basu, Charles W. Armitage, Tanja Eindorf, Logan K. Trim, Edith Miller, Nicholas P. West, James A. St John, Kenneth W. Beagley, and Jenny A. K. Ekberg, “Chlamydia pneumoniae can infect the central nervous system via the olfactory and trigeminal nerves and contributes to Alzheimer’s disease risk,” Scientific Reports, vol. 12, no. 2759, February 17, 2022, <https://www.nature.com/articles/s41598-022-06749-9>.
What if a simple sleeping pill could help the brain wash away the very proteins linked to Alzheimer’s disease? A surprising new study suggests that an already FDA-approved insomnia medication may do exactly that.
Researchers have found that a common, Food-and-Drug-Administration-approved sleeping pill might actually reduce the buildup of toxic proteins linked to Alzheimer’s disease.
Today, we’re diving into the reportage of the science behind this discovery. And we’ll discuss a bit about what it could mean for the future of dementia prevention.
The Study
First thing’s first: The study we’re concerned with was written up in an article titled “Suvorexant Acutely Decreases Tau Phosphorylation and Aβ in the Human CNS,” which was published online in the March, 2023 edition of the scientific journal Annals of Neurology. And it was printed in a hard-copy version in July of the same year.
To understand the study, we first need to understand how the brain ‘cleans’ itself (quote, unquote) during sleep.
While we sleep, our brain uses something called the “glymphatic system.” Think of it like a biological dishwasher. It flushes out metabolic waste that builds up while we’re awake.
Two of the most dangerous types of “trash” cleared out by this glymphatic system are amyloid-beta and tau proteins.
Of course, viewers of this channel — not to mention anyone with a basic familiarity of Alzheimer’s — probably won’t fail to recognize these words.
After all, it’s these proteins that, when not cleared effectively, clump together into the notorious “plaques and tangles” that constitute the hallmarks of Alzheimer’s disease.
This is one reason why chronic sleep deprivation is often cited as a major risk factor — alongside advanced age, of course — for cognitive decline.
Suvorexant
Enter a drug called suvorexant, known by the brand name “Belsomra.”
It’s a type of drug known as an “orexin-receptor antagonist.” Oversimplifying, orexin is a molecule in the brain that keeps us awake and alert.
The idea is that, by blocking orexin, the drug suvorexant may encourage the brain to transition into sleep.
Researchers at Washington University School of Medicine in St. Louis, Missouri wanted to see if using this specific drug to “promote” or “enhance” sleep could help to lower the levels of the aforementioned toxic proteins.
To this end, and as scientific studies typically do, they took a group of thirty-eight healthy volunteers, aged 45 to 65, and gave them either a dose of suvorexant or a placebo before bedtime. Researchers then monitored the participants’ cerebrospinal fluid over the next 36 hours.
What Happened?
To hear them tell it, the results were striking.
In the subset of participants who took the higher-than-usually-prescribed dose of suvorexant, levels of amyloid-beta dropped by 10 to 20 percent, compared to the placebo group.
Even more significantly, the same group saw a drop in “phosphorylated tau” — a form of the tau protein that is particularly closely linked to brain-cell death and Alzheimer’s- disease progression.
What makes this exciting is that it wasn’t just “better sleep” clearing the brain (in some vague sense); it was a specific intervention that seemed to target the very precursors of Alzheimer’s pathology.
Caveats
However, before we get too ahead of ourselves, there are some major caveats.
This was a very small study, and it only lasted for two nights. Therefore, researchers cannot yet say if taking this medication, long-term, will actually “prevent” dementia, or if the protein levels will stay low once the medication is stopped.
The researchers themselves prefer to refer to this as something more like a “proof-of-concept.”
Of course, we would want to see much longer trials to decide if the observed reduction in proteins actually translates into a predictable — and reliable — reduction in cognitive decline.
That said, this study confirms that the intersection of sleep medicine and neurology is one of the most promising frontiers in medicine. And it suggests that we might eventually treat sleep not just as a lifestyle habit, but as a clinically significant tool that may help us to maintain brain health as we age.If you’re interested in the full details of the study, click for the ScienceAlert article or for the original paper. We hope you rest a little easier tonight!
The easy – and probably unhelpful – answer is: “Sure, it’s possible.” – said, of course, with suitable emphasis on the final word!
After all, anything is supposed to be possible. Right?
But what we’re really asking is: Can I manage it? Will it work in my situation?
And the frustrating reality is, I don’t know.
What I can do is speak from my own experience and research.
But after it’s all said and done, you’ll have to look at this picture, talk it over with family and trusted advisers, and decide whether it would be feasible and realistic for you.
Perhaps the least useless thing I can do is to try to paint a picture of what solo caretaking might look like in the hope that it will give you a framework for your own decision making.
So, strap in, and we’ll start to think through the question: Can you be a caretaker all by yourself?
Preface
I’ll be speaking broadly. I’ll talk about a way solo caretaking could look, drawn from when I was the at-home caregiver for my dad, who died from Alzheimer’s Disease in 2016. I started caring for him in 2008. But we’ll also talk about caregiving variations, based on my research.
The main thing I want to do is to provide you with a blueprint for having a conversation. You will want to talk about possible caregiving scenarios – and pitfalls – with family, friends, and trusted advisers. So, my hope and expectation is that you’ll take what you find useful and leave the rest.
As an “assist,” I’ve prepared a step-by-step guide that you can feel free to download. It’s possible that you can simply Google “Alzheimer’s Proof Caretaker’s Guide.”
But, search engines can be a bit dicey sometimes. So, you can always just point your web browser to AlzheimersProof.com and navigate to it that way.
Introduction
This video was prompted by a viewer-submitted question. As I reflected on the viewer’s situation, one thing I realized is that it is extraordinarily difficult – bordering on being practically impossible – to be entirely solo as a caretaker.
As we move along, it’ll become apparent why I say this. But, what I sincerely hope is that you may also discover, upon reflection, that you’re not actually all by yourself. Or, at least, if you are genuinely alone, then I hope you may come to a deeper understanding of the challenges that lay ahead of you. Not to compound your worries! But simply to enable you to better plan for, and adapt to, circumstances as they arise.
Caretaking Rôle vs. Household Composition
First thing’s first. We should try to clarify what we’re talking about. You’d think that “solo caregiver” is fairly self-explanatory. But I think there are subtleties that need to be made explicit.
What does it mean to be “solo”? There are at least two senses.
‘Solo’ in a Caretaking Sense
Firstly, there’s a caretaking sense. By “caretaking,” I mean assisting your loved one with the Activities of Daily Living (ADLs) – which I explain in a dedicated video – or supervising a cognitively impaired individual, or both.
Just for reference, the basic “ADLs” are: bathing, dressing, eating, maintaining continence, toileting, and transferring (e.g., in and out of bed).
Under the category of “caretaking,” we can further distinguish a primary caretaker from a solo caretaker. Taking the latter first, if you’re a solo caregiver – in a strong sense – then you are the only game in town (or the only player, as it were). It’s entirely and totally up to you – and absolutely no one else – to implement every aspect of your loved one’s care plan.
If you’re a primary caretaker, by contrast, then you have some people in relieving or supportive roles – even if only minimally. Consider a few examples.
Let’s say you have four siblings. One of your siblings drives mom to the doctor’s office. Another buys and delivers her diet-specific groceries and medicine. A third takes her to church on Sunday and spends the day with her. And a fourth can usually be relied upon to fill in for you if you have something come up.
Even so, mom lives in your house. You administer her medicines, prepare her meals, and otherwise tend to her daily needs. You watch her for the majority of the week. The bulk of caretaking duties fall upon you. We might say that you are mom’s primary caretaker.
On the other hand, suppose three of your four siblings live out of state. The other one declines or refuses to help you with any facet of mom’s care. Here, you’re more of a solo caretaker.
Granted, there are cases that are harder to classify. More on that in a moment.
But… it’s not as important to classify the cases as it is simply to recognize that there are different levels of expected responsibility falling on you in each case.
Questions
One of the most pressing questions is: Which case is – or would be – closest to your situation?
Can you expect help with the actual caretaking responsibilities?
At this point, I’m thinking about unpaid help: assistance you’d get from family and (possibly) friends. We’ll consider the role of professionals in a few minutes.
If you’re closer to a primary caretaker, then your questions are things like the following.
How dependable are the secondary caregivers?
Do you have someone who can step in for you in an emergency?
When you get sick, for example, is someone willing to come into your place?
Bear in mind that an Alzheimer’s sufferer may have difficulty adjusting to a new environment. Often, they have enough trouble getting around a familiar place. If the place is comparatively strange, they can be especially difficult to manage.
Do you have a family member willing to be around you when you might be contagious?
Will someone take your loved one to their place for a week?
Remember that the care environment may need to be safeguarded and secured in various ways. I’ve spoken in other videos about many aspects of this. You may need to install childproof locks on cabinets (to prevent your loved one from accessing dangerous chemicals or objects), change thumb-turn locks to double-keyed deadbolts (to reduce the risk of “elopement,” which is the caregiver’s term for when your loved one wanders away from the care environment), install closed-circuit cameras (to monitor them while you do other, necessary work), etc.
Even if you do have a family member who is willing to take dad for a week, it may be necessary for them to prepare their home for this eventuality well in advance.
And if you have no one, how will you function as a caretaker if you are not feeling 100%? What if you become disabled? Etc.
For that matter, how will you sleep? Many of you may realize that Alzheimer’s, and other forms of cognitive impairment and dementia, often interrupt normal sleeping patterns. Usually, this results in an insomnia-type situation at night. Your loved one may have difficulty falling – and remaining – asleep. Sufferers who wake up in the middle of the night may wander. And, unless their environment is entirely free of potential hazards, this nighttime wandering can’t be ignored.
Related questions include: How will you cook or otherwise prepare meals? Similar problems with wandering may appear during the day. If you need time in the kitchen, it may be possible to entice your loved one to join you – possibly by assigning them an easily accomplished or harmless task. But if they refuse to cooperate, or if they start to walk away, you’ll need to make sure they’re not getting into anything dangerous. And that can be easier said than done – especially if the timer’s going off and that dish in the oven is about to burn.
Now… some of these problems lead into another topic.
‘Solo’ in a Housekeeping Sense
Remember I said that there were two relevant senses of the word “solo.” The first was the caretaking sense. The second sense is related – and possibly overlapping.
And that’s the general question of whether you’re alone in your household. Apart from your afflicted loved one, are you literally the only other person in the home?
From this standpoint, we’re talking about whether you’re single, married, or otherwise “partnered”; whether you have kids; whether you have a roommate; or even, in some cases, whether there’s another aging adult that you care for already.
The basic questions, here, are: Are you being helped in running the household? And do you have other people – besides your afflicted loved one – for whom you are responsible?
I want to keep the phrase “running the household” a little vague. After all, this is not a channel about good housekeeping. But, just so we’re on roughly the same page, I have in mind anything – and everything – that goes into making sure the house isn’t condemned and the people inside it don’t starve. Doing chores, paying bills, performing maintenance, and …whatever else.
There are too many household variations to list them all. But we can gesture toward four (4) broad types, under two overarching factors: whether the other people are helping you, or if they’re needing help from you.
Of course, there’s a sense in which any group of people thrown together under the same roof will sometimes help one another and sometimes need help from one another.
But, for this exercise, what you want to ask yourself is: Are the other people in the household helping you in a consistent and meaningful way? Relatedly, you want to ask: Are the other people in the house needing substantial help from you on a regular basis?
We’re going to assume simple “yes” and “no” answers can be given. Real-life cases may involve “maybe” and “sometimes” answers. But… this uncertainty may help you decide what to do.
After all, if your household is already a “question mark” – before you bring in an Alzheimer’s-afflicted loved one – then you might have serious concerns about the viability of a plan that complicates your living situation further.
Ignoring those complexities for the time being, we can arrange the following possible answers.
One case is where you both give help to – and can expect help from – the people in your house. We might think, here, of two married or “partnered” people, for example.
Another is where you provide help, but can’t expect or rely on any in return. An example of this would be a case where you also have young children in the house.
A third is where you don’t really need to provide help, but you still get help. Maybe it’s your house, but one of your grown children lives with you. They pay their own way, as it were, but also do the dishes, maintain your car, mow the grass, etc.
Finally, we can imagine a case where you don’t need to provide much help, but you don’t get much back either. Perhaps you have teenagers. Maybe they’re in college and working part time. They’re starting to pay for necessities and you don’t have to do much for them day to day. But they’re not around much. And they aren’t really contributing to the household.
Some of this will dovetail with financial considerations, which I will say something about in a moment. But, for the time being, and at the risk of harping on the obvious, we can expect that it would be much easier to take on caregiving responsibilities in a household where you’re getting help than one where you’re not getting help.
Likewise, it would be harder to be a caretaker for someone with dementia if you’re also having to provide help to other people already (for example, children).
Still, for all that, it may be possible to add an Alzheimer’s-afflicted loved one into any of the four scenarios. And this is because there are so many factors at play.
For instance, it would make a huge difference if your afflicted loved one presently is in an early-stage – or has a mild form – of dementia as opposed to something more severe.
‘Early’ vs ‘Middle’ vs ‘Late’ Stages
I don’t want this to be a video about Alzheimer’s various stages. I’ve gotten into that topic before – and it may be good to do so again in the future.
At the same time, we can’t avoid touching on the subject, here. But my remarks will be cursory and shouldn’t be taken as a detailed accounting of the progression of dementia.
What I want to highlight is that caretaking challenges are not static. They can and do change – sometimes dramatically, frequently, and unpredictably.
Caveats notwithstanding, we can say that so-called “Early-Stage” Alzheimer’s is characterized by mild difficulties. Memory and reasoning are beginning to be impaired. But this impairment may go unnoticed – even by family and trained physicians.
Possible “comorbidities” aside, your loved one may be able to maintain a large amount of independence. For example, they might be able to cook for themselves, handle basic finances, maintain good hygiene, etc. They might even still be able to drive. Though, this poses special problems and carries risks, as I discuss elsewhere.
From a caregiving perspective, it may not pose insurmountable or even especially difficult challenges to take in a loved one who is in an early stage of cognitive decline. In other words, caregiving – even solo – could potentially be sustained throughout the early stage of dementia.
That said, there are important qualifications. Firstly, given the subtlety of the symptoms, Alzheimer’s may not be diagnosed in its earliest stage. So, families may not be presented with the question of home care until after the dementia becomes more advanced.
I didn’t come in until my dad – by all accounts – was already in Middle-Stage Alzheimer’s.
Secondly, given the current state of the medicine – and enough time – the disease will (unfortunately) progress. This has numerous consequences. Chief among them, for this discussion is that, even if you are able to be a solo caretaker for a while – while symptoms are mild – you have to understand that symptoms will not be mild forever.
If you have a good reason for suspecting that your loved one’s dementia will not become more complicated, that’s one thing. For example, let’s say that your mom is simultaneously (and tragically) diagnosed both with Early-Stage Alzheimer’s and some form of advanced, inoperable cancer. Suppose that her physicians expect her death within 12 to 24 months and they think it likely that she’d still be suffering from only mild dementia during that interval. In that specific case, you’d have good medical reasons for worrying less about how to handle advanced Alzheimer’s than about how best to deliver so-called “palliative care.”
Even so, you may feel more comfortable with a backup plan. After all, the exact progression of the cancer and the dementia are, to some extent, left to the educated guesswork of the doctors. And they are not all-knowing or inerrant.
One final word, here. If Alzheimer’s (or some other dementia) is recognized in an early stage, it may provide a prime opportunity to involve the afflicted loved one in the development of a sustainable, long-range plan for their care. If you simply take them in – and figure you’ll deal with any worsening of their condition later – you may foreclose on that possibility.
Not only this, but if they do live long enough for the dementia to progress, then caregiving will become more complicated. And that is what you can expect by “Middle Stage.”
It’s arguable that Middle Stage is the most difficult, from the standpoint of caregiving in general, and at-home caregiving in particular. Be that as it may, Middle Stage is characterized by a worsening of the pertinent condition. You’ll be dealing with a person who may still be mobile, but who is no longer reliable in terms of decision-making, memory, reasoning, etc.
To put it bluntly: It can be a bit like dealing with a child who has the physical abilities of an adult.
Middle Stage is also often the longest stage. Possibly this is due to the fact that Early Stage may not be detected immediately. Bear in mind that the beginning of “Middle Stage” may not be much worse than the end of “Early Stage.” This might point to the clumsiness or inadequacy of the three-stage view. But my point is that the relevant degeneration and transition can be gradual. The home situation could be fine and manageable until… it’s not.
And – especially if you’re all by yourself – you need to have some awareness of this progression so you can plan accordingly. After all, if it became necessary for you to look into nursing homes, it’s not clear how you would be able to manage visiting and applying to facilities while you’re buried in daily caretaking tasks. And nursing homes almost always have waiting lists.
And while the progression of dementia is somewhat predictable, there are numerous variations.
For instance, Early Stage is usually said to last 1 to 2 years. Fair enough. But you should know that, occasionally, people report a precipitous decline in their loved-one’s cognitive function.
This might occur after a major surgery, for example. My dad took a significant turn for the worse following a triple bypass and a colectomy (spaced out by several months). I’ve seen comments where other people have shared similar stories. It may happen that your loved one is compliant or reasonable one day; then – almost suddenly – they’re obstinate or uncontrollable.
If you can make it all the way to “Late Stage,” you might find that a lot of the Middle-Stage difficulties have subsided. For example, your loved one’s mobility will be drastically diminished. And at a certain point, they will have a near-total impoverishment of their communication ability.
The huge caveat, here, is that Late Stage comes with brand new difficulties. Dealing with a bed- or wheelchair bound person is by no means effortless. They have to be bathed or wiped, changed, fed, hydrated, turned to prevent bed sores. Etc.
When you imagine having to lift an immobile person and help them transfer, you may see why this stage can be extremely physically demanding.
And speaking of those challenges, let’s talk about another set of considerations.
Able-Bodied vs Disabled
Let’s go back to the beginning of the home-care-decision process. Whether the cognitively impaired adult is able-bodied will also matter. Although, this consideration cuts in two directions.
If your loved one has mild-cognitive impairment, then – all other things being equal – it would probably be easier to care for them if they were able-bodied rather than disabled. As stated, many early-stage Alzheimer’s sufferers can perform a lot of daily activities on their own. And while they will need some measure of monitoring and reminding, these kinds of assistance may be “low-impact” and might be manageable by a caretaker who has many other responsibilities.
On the other hand, if your loved one has more severe dementia, then – somewhat paradoxically – it might be easier to care for them (overall) if they were also physically disabled. This sounds bad, but it’s to say that an able-bodied person with significant dementia may be an elopement risk (meaning that they have a tendency to leave the safety of the care environment without the knowledge of the caretaker); or they may otherwise require constant supervision.
I’ve told many stories – in other videos – of times that my dad created messes or safety hazards (whether for himself, for others, or both) in virtue of the fact that he was still ambulatory and mobile, but had lost his ability to recognize perils or to make good decisions.
That said, a severely impaired person who is also disabled may be at increased risk for other things – such as falling. They might fall out of bed, out of a chair or wheelchair, or – God forbid – down a flight of stairs or off the front porch.
To make all this even more complicated, it’s also predictable that – again, all things being equal – a physically disabled person would be more difficult to care for than one who is able-bodied. This is due to the obvious point that a person who is physically disabled will require help getting around, whether to the bath, shower, or toilet; in and out of chairs or bed; or whatever.
Support Network
You also need to consider your – or your loved one’s – support network. And, here, let’s further develop the point – made earlier – that some cases are difficult to classify.
For example, let’s say you’re caring for mom or dad in your home, but that you have siblings who live in the same city. Suppose that they don’t usually assume caretaking responsibilities.
Still, if they could or would assume some responsibilities in the event that you had a personal emergency, you would want to know this – and get that commitment – in advance of needing it.
Is this a case where you’re a primary caregiving, or solo? Once again, and obviously, it doesn’t really matter what you call it. What matters is what help you can rely upon!
I am working on a separate video on talking and planning with family. The best practice is to have hard conversations before emergencies arise. Try to agree on a workable plan in advance.
See, again, the “Caretaking Guide” at AlzheimersProof.com.
Paid vs Unpaid Support
Family can be – and often is – a valuable resource. However, it has its limitations.
What happens if your sister is out of town when you fall ill? She promised to help in the case of an emergency, but she’s just not around.
In such cases, you may need to augment your family network by paying for professional services. So, let’s round out our discussion by picking up the thread I laid down earlier.
There are numerous types of paid services. There may be home-care providers in your area. Some of these may require applications and approvals in advance. This is especially likely if your loved one requires skilled-nursing care, or if you will be – wholly or partially – relying on long-term-care insurance, medicaid, or medicare.
I have a few videos sketching the basics of these. If you would be interested in more, please leave me a comment.
Of course, other options might include changing the care environment altogether. On this wavelength, there are Assisted-Living Facilities and Nursing Homes.
A somewhat middle-of-the-road option would be an Adult Daycare. This is a facility you might be able to utilize alongside home care. For example, maybe you take your loved one to a nine-to-five daycare program Mondays, Wednesdays, and Fridays, but care for them at home the remainder of the week.
A final recourse (still thinking about maintaining homecare) is called Respite Care. Respite Care is designed to give the primary caregiving a short break. But, if the respite provider comes to the home, this may only be for a day or so. If you take your loved one to a respite facility, the respite interval may be a week at most.
For some of the differences in care environments, see my dedicated video. Admittedly, it’s an older video. It might be time to remake it. Feel free to share your opinion in the comments.
Nursing Home
The thrust of this presentation is the feasibility of solo, at-home caregiving. But, what if you determine that it’s simply not feasible?
We should say, emphatically, that it’s not necessary to look at it as an either-or situation.
What I mean is, you shouldn’t think that either you care for your loved one in the home, or else you’re just not involved at all.
When my family made the decision to get my dad admitted to a nursing home, we saw – up close – the level of involvement that he and other patients received from the families.
And it was definitely a spectrum. On the tragic end were those people who received no visits from loved ones. Whether this was because they had no living relatives or because their relatives were unable or unwilling to come, I can’t say. And it probably depended on the case.
In the middle were those people who received regular visits from family members. Maybe it was the same day every week, or always on weekends, or whatever. But these patients had family members who remained involved in their lives.
On the other extreme, there were family members who – barring emergencies and illnesses – came to the nursing home every single day. These devoted folks – whether children, spouses, or whatever – maintained their role as caretakers, despite the change of care environments.
And here’s the crux. You may not be able to accommodate your loved one in your home (or in their home) all by yourself. But you could potentially still be involved as a caregiver – even daily.
I say “potentially,” because (as always) there are complications. For example, it would be an obstacle to daily visits if you had to make a four-hour drive to get to the nursing home. Obviously, all the income-specific considerations are still pertinent, here.
And there are ancillary factors as well. Unless you trust the staff implicitly, or you’re on site frequently, it’s a good idea to vary the days and times of your visits. I will have to get into more detail in another video.
But, in the same vicinity, nursing homes are often understaffed. What staff there is, may be overworked. This may lead to a situation – usually unspoken – where the staff depend upon you to deliver basic care to your loved one. And, well… there’s no delicate way to say this, but: You pay the same for the nursing home whether you are performing caretaking duties or the staff is.
It may come down to the question of whether it matters more to you that your loved one is properly cared for, or whether you get what you (or someone) is paying for.
Financial Considerations
Of course, professional home care, Adult Daycare, Respite Care and the like are not free services. Daycare and homecare can cost several thousands of dollars every month. And if you admit your loved one into a nursing home, the average expected monthly costs start at $4,000.
You or your loved one might qualify – or be able to qualify – for Medicaid. But you should know that not all nursing homes accept Medicaid. Of those they do accept Medicaid, they may not accept it for every available bed in the facility. That is, Medicaid beds may be in short supply.
So the prospect of having – or electing – to pay for care (of any kind) leads immediately into a discussion of finances. …For which – once again – I have dedicated videos.
But… At the most basic level, the question is: What is your financial situation? Among the prominent “sub” questions, here, would be: What is your source of income?
We’d be at it all day if I tried to list all the possible combinations. So, let’s just make a few obvious, summary remarks. If you have to leave the house to go to a 9-to-5 job, then assuming caretaking responsibilities may not be sustainable for you in the long run.
Things might be fine as long as your loved one has mild impairment, is in an early stage, or does not require constant physical assistance or supervision.
But what happens when the dementia advances and becomes more severe? What happens if a fall around the house confines them to a wheelchair? Would you be around them enough every day to notice the sometimes-subtle signs of worsening dementia?
Financially speaking: Could you manage to keep your current job and still be a caretaker?
If your income depends on you commuting to a business, then necessary in-home caregiving will have to be provided by someone else when the time for that comes. Either that or you will have to change your job, take an extended “leave,” or utilize some care facility. As mentioned, Adult Daycare could come into play.
But, what would you do if your loved one is ill and can’t be taken to daycare? Or, what happens if (or when) their dementia advances and they become hard to control or they become ineligible for daycare? Or, what would you do if, as my dad did, your loved one flat refuses to go?
You may be able to cover limited periods of time with paid time off or family medical leave. But at a certain point, your employer may become less understanding. Or corporate policies might demand your termination – regardless of the good will of your immediate supervisor.
If your job is more flexible, or if you work from home, you might have an easier time in some respects. However, even here: How will you ensure that you can devote the necessary time to your job? How will you make sure you have a sufficiently quiet environment in which to work?
It’s not always as simple as giving your loved one an arts-and-crafts project, or hoping they find something to do for a couple hours. What if they become agitated? Would you notice if they wandered off? Do you have some way of monitoring them? – All questions for “9-to-5’ers.”
Finally, a problem may arise more broadly for anyone thinking of taking an extended leave or quitting their current job to be a caretaker. If you’re not actively employed, you might find that some of your benefits – such as your health insurance – will be canceled or suspended. And if you ever found it necessary to rejoin the workforce or to try to get your previous job back, you might find that the position has been eliminated or filled. You might lose seniority. If you have access to a pension, its calculation might be negatively affected by the “lost” years.
There are cases where income may not be an issue for you. One might be if your partner or spouse is the primary breadwinner. Assuming they’re on board with the decision to take in your loved one, then – the idea is – you’d continue relying on their income. No changes. In theory.
Of course, you’ll want to consider whether home care would negatively – and predictably – affect your spouse’s ability to earn a living. If your partner works from home but mom or dad’s raucousness keeps your partner from being able to uphold their job obligations, then things could get messy. What if your loved one has chronic insomnia and their nightly wanderings disturb the whole household? Would your spouse find it difficult to get to the office on time?
Even if things started off “okay,” you’ll want to ask: What happens if the home care starts to interfere with the day job? Will you err on the side of continuing care? Or preserving the job?
These are all genuinely difficult questions.
Other cases of stable income might be ones in which you are able to live off a truly passive income stream – such as guaranteed pensions, royalties, or trust funds.
However, not all “passive income streams” are equal. Some may require periodic tending. Could devote enough time to this maintenance if you were also an at-home caretaker?
Probably the most common case where you may have quasi-dependable income is if you’re fully (not “partly”) retired, and you have unfettered access to all relevant funds (including distributions from 401ks, IRAs, Roth IRAs, dividends, and Social Security).
These can have complications of their own. And it’s beyond the scope of this video to tease out every aspect of relevance. But, if you’re not at least 59 ½, then you likely do not have unrestricted access to retirement funds. And if you’re not at least 62, then you wouldn’t be able to collect Social Security – assuming you’ve qualified for SSA retirement benefits.
Even if you can withdraw money from retirement funds without penalty, you still have to keep an eye on your tax situation. And if distributions from your retirement account depend at all on market performance, then the next economic downturn could upend your ship.
Eventually, if you’re not already doing so, you’ll be forced to take money out of qualified retirement plan accounts by way of the so-called “Required Minimum Distribution.”
The point is that even if you think your finances are “taken care of,” it may not be best thought of as a case of “set it and forget it.”
If you’re living off government assistance, you’ll want to be careful about altering the number of people in the household. Sometimes this can jeopardize your eligibility for some programs.
I can’t and won’t speak to this in any detail, here. Except, I will say that you should consult with experts before finalizing or implementing any changes. And you can see some of my other videos for basic overviews of some relevant programs like Medicaid and Medicare.
It’s worth pointing out that there are a few programs under which you might qualify for government subsidies as a family caretaker. I believe that Medicaid has such a program, sometimes falling under the umbrella of “Consumer Direction.”
Once again, it’s beyond the present scope to detail such a program.
And, of course, eligibility for government programs isn’t the only concern. The amount of assistance you qualify for may change depending on your household’s total financial picture. In some cases, if you change the makeup of the household, you’ll also change that picture.
Obviously, the amount of income is also important for you to reflect on, regardless of its source.
A question would be: Is your current income level sufficient to pay for home-care services – on top of the other, usual household expenses? If not, then it will probably need to be augmented.
Now you might think that if you’re living – or thinking about living – in the same house as your afflicted loved one, then you would have access to their income as well as your own.
And sometimes this is true. But, there are complexities.
I don’t want to make this a video about the relevant ins and outs. However, I could do so if there’s interest. I’m simply trying to bring to the surface issues that may be of relevance.
In that vein, let me just gesture toward some big considerations. As mentioned a moment ago…
Firstly, if your loved one’s income partly consists of government assistance, and is predicated on their living situation, then changing the situation could change the level of assistance. (Boldface, italicize, and underline the word “could.”)
Secondly, be aware that most financial institutions – for example, banks, brokerages, insurance companies, investment houses, retirement-management firms, etc. – are on the lookout for anything that smacks of elder abuse.
If dad’s social-security check suddenly starts getting deposited into daughter’s account; or if mom’s financial adviser or life-insurance agent gets an out-of-the-blue request to “cash out” this or that account or policy; you will probably have to answer some questions before your request or transaction is executed.
This isn’t to say that you’re trying to do anything questionable! Nor is it to say that these kinds of financial requests can’t be honored. But you should be aware that there are levels of legislative protection that have been built into financial regulations over recent decades. And these result in legal “hoops” that sometimes have to be cleared before you can “pool” resources.
Best-case scenario? You’re able to involve your loved one in making all necessary – or desired – changes before their legal or mental competence is undermined (or even called into question).
This might include cashing out or closing some types of account, filling out beneficiary-designation forms, giving you durable or “springing” powers of attorney, opening joint accounts, transferring control or ownership of a financial holding or instrument, and so on.
Once your loved one loses his or her ability to make sound financial decisions, then many – even most (or all!) – of the necessary financial moves you would need to make wouldn’t be advisable (or realizable) without outside authorization. The chief avenue for this would be a conservatorship hearing in a court of proper jurisdiction.
However, appointment as conservator will almost certainly carry restrictions and require reporting to the court. At a basic level, this means that separate bank accounts will have to be maintained, funds shouldn’t be “comingled,” assets can’t be disposed of without court approval, etc. Additionally, conservatorship generally terminates upon the death of the person who was subject to it – so… your loved one. (The subject would be called a “conservatee” or “ward.”)
If your loved one is still able – right now – to converse, decide, and think lucidly on these matters, then you could look into trying to arrange the asset picture in advance of any worsening of their condition. For example, if it is their wish that their financial resources be pooled with yours or otherwise used at your discretion then there is not a moment to lose.
Extremely important caveat! If your loved one is no longer legally or mentally competent, then they are unable to consent to changes to their financial situation. You might face serious – even criminal – consequences even if your loved one’s competency is questionable. All this is beyond me. You’d be wise to consult with legal and medical professionals to ensure that everything is above board. Just to be clear: What I’m saying is for general informational purposes only and should not be construed as any kind of advice.
Suffice it to say… You still do need to be careful with any consolidating moves.
Another point, here. If it’s even possible (that is, conceivable) that your loved one would eventually need Medicaid to help pay for the cost of care, then you have to take great care when assigning, disposing of, gifting, pooling, retitling, selling, or otherwise transferring assets. Because, once again, there are severe repercussions for not following Medicaid’s requirements to a “T.” It took me three dedicated videos just to scratch the surface of Medicaid-related issues.
A Word on Emotions
I’ve been ignoring emotional factors because these are sometimes especially difficult to describe or quantify – partly because they are so bound up with who we are as unique individuals. But, they’re no less an important part of our lives.
You need to consider the emotional impact on – and emotional makeup of – everyone involved.
On the one hand, this means your loved one’s emotions. A diagnosis of dementia would be depressing to anyone with the wherewithal to understand it. It can also be bound up with or give rise to anger, hostility, and resentment.
Alzheimer’s is a mysterious disease. The effects that it can have on emotions are sometimes as puzzling as they are devastating. There is no formula that I am aware of that will predict exactly what you’ll get.
Before his decline, my dad was friendly, likable, and somewhat extroverted. He was also easygoing and, to a large extent, unflappable.
As his cognitive faculties eroded, he became aggressive, belligerent, and combative – with everyone around him. It’s not exactly clear how to understand what occurred.
Did the dementia – so to speak – cause his emotions to “invert”? Did it cause an awakening and overemphasis of dormant negativity? Or did it destroy who he was and, in effect, leave us with someone new?
The other side of the coin, in a solo-caretaking situation, is your emotional tendencies.
If you are mellow and don’t get your feathers ruffled easily, you might be able to take caretaking challenges in stride. On the other hand, if you’re irritable and impatient – like I can be, for sure – then you’re in for an especially tough time.
These considerations need not be determinative or final. Alzheimer’s is always a wild card. And we’re often capable of rising to a challenge. So don’t sell yourself short. Don’t “ostrich” either.
For those who are interested, I dive more into emotional factors in the companion video “Is It Hard to Be a Caretaker?”
Summary Remarks
Okay… this has been a long and bumpy road. Let’s try to take stock.
We started by thinking about what it means to be a “solo” caretaker. We distinguished being a primary caregiver, where others – whether family members or professionals – assist you in backup, respite, and various secondary roles; and being truly solo, where you’re literally handling all caretaking duties by yourself.
But we also noticed that being a solo caretaker doesn’t necessarily mean you’re alone in your home – not counting your afflicted loved one, of course.
It’s difficult to be a caretaker at any level of involvement. It could be a challenge to take dad or grandma for the afternoon, let alone invite them into your house 24/7/365.
If you’re truly going it alone – both as a care provider and as a homemaker – then you’re in for major difficulties. Assuming you have your financial bases covered, however, and you just have to focus on caretaking, I don’t want to say it’s impossible.
Still, you’ll need to have a plan for necessities like cooking, sleeping, and showering – just for yourself. And you’ll probably want to have some sort of lifeline in place if (for instance) you fall ill or become injured. This highlights the need for a viable short-term back-up plan.
This includes numbers for prospective, in-home professional caregivers, Adult Daycares, etc.
Looking farther into the future, you’ll want to have a plan – even if only provisional – for finding a nursing home should that route become unavoidable. This is part of a long-term backup plan.
If you’re more in the primary-caretaker camp, then some pressure might be off of you. But, even so, emotional, medical, and other factors might arise that make it infeasible (or ill-advised) to continue with in-home care.
Additionally, worsening of your loved one’s dementia is, for all intents and purposes, inescapable. Though, of course, it’s possible that a comorbidity might arise and further complicate an already complex situation.
Regardless of your circumstances, you’ll almost certainly run into a situation – probably many – where you’ll need or want professional advice. This could be legal, medical, nutritional, psychological, whatever. You’d be well-served by trying to develop a network of connnexions before your need for expert guidance becomes urgent.
Okay. As difficult as it was to make this video, the really hard part is up to you. You have to reflect on these factors and make the decision. Then you have to put that choice into effect.
Please understand that the Alzheimer’s Proof project – both this channel and the associated website – were designed and intended to help you.
I hope you can turn to some of my resources and find some assistance and value in them.
Finally, let me remind you that I have a second video – written in tandem with this one – which you might find a useful supplement. And don’t forget to check out and download the free workbook that I prepared to walk you through reflecting and choosing a path for your family.
If you’d like to ask follow-ups to me, personally, you can type your comments below or email me at AlzheimersProof@gmail.com.
For legal reasons, I cannot give specific advice. But if there are general concerns, I may be able to speak to them in a future presentation.
Please know that I wish you all the best in this confusing and painful process. Thank you for watching.
There are really only three (3) ways to pay for long-term care expenses and nursing costs.
The first general way is with the proceeds from insurance policies. These might be long-term care policies, whether they are qualified policies or non-tax-qualified policies. It could be through short-term care policies; it might even be through hybrid, life-insurance / long-term care combinations.
For people who do not have insurance policies to cover their long-term care costs, the remaining payment options are, second, privately paying from your own income and assets and – for people who do have insufficient income or assets to pay for their care – the final option, third, is applying for government aid. Of course, the most relevant government-aid program is Medicaid.
So, the questions then become: How does one specifically qualify for Medicaid? Or, to put it another way: How does Medicaid determine eligibility?
Caveats
It is important to bear in mind that this is a complex conversation, in part because Medicaid-eligibility requirements are going to vary slightly (and, in some cases, significantly) from state to state. Because of this, you’re going to want to consult with an expert who is knowledgeable about your particular state.
Note: This post tracks along with a YouTube video I have on the same subject.
Medicaid Eligibility
There are two overarching considerations.
Number one, there are financial qualifications.
Number two, there are medical-eligibility requirements.
Most of what I’m going to say is going to have to do with the financial eligibility requirements (because they are so complicated). But let me say a bit about the medical requirements just right off the bat.
Medical Requirements
Generally speaking, Alzheimer’s-level cognitive impairments are going to be enough to qualify you – provided, of course, that they are sufficiently advanced in their severity.
In some literature, you will encounter phrases like “nursing-home-level care.”
The specifics of this are going to vary from state to state. So, once again, you need to seek advice.
However, often, this nursing-home level of care is going to be calibrated to the type of supervision that a person requires, if they have cognitive impairments. Or, it may be calibrated to the various Activities of Daily Living (ADLs) that they are lacking.
Financial Requirements
But what I’m mainly going to be concerned with is going to be the financial eligibility. That’s essentially determined by two (2) calculations or “tests”: an asset test, and an income test.
The question of assets is going to preoccupy us in this article. In a subsequent article, I’ll talk about the income test. (They are both intricate conversations, and so it is probably best to break the conversation up into two pieces.)
Why Are There Financial Qualifications?
The basic reason that these tests exist at all hearkens back to the stated purpose of Medicaid – as I sketched, previously. (For my written article, see HERE; for the companion YouTube video, see HERE.)
In a nutshell, Medicaid provides financial assistance, to help pay medical expenses for people who are impoverished.
And so, the obvious follow-up question is: Who qualifies as “impoverished”?
The answer to that question is determined by these two tests. Basically, the idea is if a person’s assets fall below a certain level, and their income falls below a certain level, then they count as impoverished.
So, as I said: Let’s now consider assets.
Medicaid Asset Requirements
Quick Answer
Essentially, a person has to have $2000 or less in order to qualify for Medicaid, from an asset standpoint.
Two Types of Assets
Now assets themselves are classified into two (2) categories.
The first are “countable assets,” or those that are nonexempt. The second are exemptassets, or those that are not “countable.”
The precise scope of the exemptions and countability will vary from state to state. So, once again, this underscores the need for you to have a conservation with an expert in your area.
Typical Exempt (Non-Countable) Assets
But, usually, an exempt asset is going to be something like these: basic pieces of property, such as the Medicaid recipient’s primary residence,[1]a car, and so on.
Another Caveat
You have to bear in mind that Medicaid can cover people of various ages; it’s not just for people who have Alzheimer’s Disease, dementia, and other cognitive impairments. Medicaid is more broadly applicable than that.
So, for example, it might happen that a 30-year-old Medicaid recipient has a primary residence, has a car, and can get around with no problem.
Now, while it is unlikely – not to say, ill-advised – for a person with advanced Alzheimer’s to be living alone or have a car, those restrictions are not imposed by Medicaid. They are simply result of the advancement of their disease.
What About the Non–Afflicted Spouse?
But the real question occurs when an Alzheimer’s afflicted individual has a spouse who has no affliction. What happens with the assets in that case?
The answer is that the non-afflicted spouse – sometimes referred to as the “noninstitutional spouse,” or the “community spouse” – will also have some assets that are usually going to be exempt.
Those exempt assets will be similar to what was just surveyed for the recipient him- or herself and will usually include a primary residence[2] and a single vehicle.
Medicaid May Seek ‘Recovery’
You should be mindful of the fact that Medicaid will sometimes claim reimbursement for the sale of the home after the Medicaid recipient has died.
You should also be aware that Medicaid is supposed to seek recovery from money that it spends on a recipient’s care.
Because of its strict monetary eligibility requirements, a Medicaid recipient is unlikely to have had any property apart from a home. For this reason, Medicaid often becomes a lien holder against the primary residence, and it may seek to collect money that was generated from the sale of the home.
In a few cases, a home may be required to be sold in order to settle with Medicaid.
However, there are many exceptions to this. In some cases where the noninstitutional spouse or minor child or some other dependent is still living in the home, Medicaid may either be unable or unwilling to seek recovery.
This is complicated territory and, not to sound like a broken record, but you will need to discuss your situation with licensed professionals who are familiar with these kinds of cases.
Countable (Non-Exempt) Assets
For the most part, assets beyond personal effects – like furniture and clothing – will be counted. This includes cash and banking assets, whether they are liquid or “semi-liquid.”
For example, it will include unsettled annuities, bank accounts (like checking accounts, money markets, and savings accounts), as well as certificates of deposit, (or CDs).
Countable assets will also include brokerage and other investment accounts as well as myriad “funds” (such as ETFs, hedge funds, mutual funds, and so on).
It will include cash-value life insurance (whether adjustable life, universal life, whole life, variable life, etc.).
And, importantly, it will include retirement accounts – including 401(k)s and other employer-sponsored defined contribution plans like 403(b)s, 457(b)s, and other employer-sponsored, defined-contribution-type plans. But it will also include Individual Retirement Accounts / Annuities – such as the Traditional IRA and the Roth IRA.
Real-estate and other property, beyond the primary residence and the main vehicle, are also generally non-exempt.
For example, if you have a family cabin or vacation home, then that would be a countable asset.
If you have a boat or a recreational vehicle (RV), then these would be countable assets as well in most cases.
$2,000 Limit
And as I said before, a person having more than $2000 in countable assets will usually be considered (asset) ineligible for Medicaid – although some states like New York have set other asset limits.
What About Property Owned Jointly?
How does it work if assets are shared in common with the spouse?
There are two (2) sorts of state: a “50%” state and a “100%” state.
Each of these types of estates handles assets a little bit differently and I will run through each of these, in turn.
My unofficial count was that approximately 35 states are of the 50-percent type. So, I’ll start with that.
‘50-Percent’ (50%) States
Although the details vary, usually, it happens something like this: All the countable assets are totaled.
So, consider a married couple. Let’s call them “John and Jane.”
The couple’s countable assets will include (1) those that are owned entirely by John, (2) assets owned entirely by Jane, as well as (3) assets that they own together.
The current values or Fair Market Values (FMVs) for these are summed, and then the result is divided by two – hence the name, “50-percent state.”
In general, the non-Afflicted spouse is going to be able to keep half – that is, 50% – of the total, within certain limits.
Two (2) limits are of greatest pertinence: a lower asset limit (or, minimum amount), and the upper asset limit (or, maximum amount).
Minimum & Maximum Asset Limits
These amounts are likely to vary year to year, just like the Internal Revenue Service (IRS) varies the amount of tax deductions, or varies the amount of retirement contributions that you can make.
In 2020, the lower limit was $25,728, and the upper limit was $128,640.[3]
In theory, a person could ask Medicaid to keep an amount outside of those limits. This would be established through a Medicaid “Fair Hearing.” But, in practice, the stated limits are usually final.
50%-State Examples
Case #1
This is complicated stuff, so an example or two might be helpful. I will run through three different scenarios, just for illustration purposes.[4]
Let’s take a middle-of-the-road example to begin.
Step One
Total the assets. Let’s suppose that John’s assets and Jane’s assets, together, are worth $100,000.
Step Two
In a 50% state, we just learned that we take that total and divide it by 2 which (of course) gives us $50,000.
Step Three
Compare the answer to that division problem (the quotient) to the lower and upper limits.
Results
Since our quotient – $50,000 – falls somewhere between the lower limit of $25,xxx, and the upper limit of $128,xxx, in this case, the noninstitutional spouse would get to keep all $50,000.
(This is because $50,000 is less than the maximum-allowable amount, and more than the statutory minimum.)
On the other hand, the institutional spouse, can only have $2000. So, he or she would need to “spend down” $48,000 (on this example), in order to qualify for Medicaid.
(Warning: This is only considering assets! There’s also an income test, as well.)
Case #2
Let’s consider a case now where the assets are a little bit more substantial.
Step One
Let’s suppose that Jane and John both together have $300,000 in assets.
Step Two
Once again, applying the 50% calculation we would take $300,000 and divide it by two. The resultant amount is $150,000.
Step Three
Comparing $150,000 to our stated limits, we notice that it exceeds the 2020 upper limit of $128,640.
Results
This means that, in our second example, the noninstitutionalized spousewillonly be able to keep up to the limit, or $128,640.
As always, the institutionalized spouse can only keep $2000. So, once again, the institutional spouse must spend down the rest of his or her “half.” So… that’s $148,000 (or, $150,000 – $2,000).
But, all the money that is over the limitmust bespent down.
In this case, even the noninstitutional spouse was not permitted to keep the entirety of his or her “half” of the money. So, the noninstitutional spouse must also spend down the remainder of his or her share of the couple’s assets. Here, that amounts to $21,360 (or, $150,000 – $128,640).
Therefore, in this second case, the total spend-down amount is $169,360.
($148,000 from the institutional spouse plus $21,360 from the noninstitutional one).
Case #3
For our third example, let’s consider a case where the assets are far less significant.
Step One
Suppose that Jane and John have a total of $30,000 to their names.
Step Two
When we divide that number by two, we get $15,000.
Step Three
Comparing it to our limits, we observe that $15,000 is less than the minimum amount of $25,728.
Results
That means, in a 50% state, the noninstitutional spouse will get to keep all $25,728, despite the fact that that amount exceeds 50% of the asset total.
On the other hand, since the institutional spouse can only keep $2000, the remaining $2,272 would have to be spent down.
($30,000 of total assets minus $25,728 kept by the noninstitutional spouse minus $2,000 kept by the institutional spouse.)
Takeaway
We see that there is an asset “spend down” that occurs when one’s countable assets exceeds the allowable amounts.
100% States
As I said, not all states operate on a 50% basis. Some are what are called “100% states.” In these states, the noninstitutional spouse may keep all the assets, up to the prescribed limit.
100%-State Examples
In some cases, the practical difference is very slight.
Case #4
Step One
For example, again suppose that Jane and John have $300,000 of total assets.
Step Two
Compare the total assts to stated limits.
Results
In a 100% state, the noninstitutional spouse keeps up to the maximum-allowable amount. In 2020, this is $128,640.
Therefore, the noninstitutional spouse will keep $128,640. This is the same amount that the noninstitutional spouse got to keep in the comparable 50%-state example.
As always, the institutional spouse keeps $2,000, and the rest is spent down.
Case #5
On the other hand, if the assets are less significant, the 100% state approach starts to make a bigger difference.
Step One
So, suppose that Jane and John had a total of $100,000 of assets.
Step Two
$100,000 is less than the 2020 limit of $128,640.
Result
Therefore, in a 100% state, the noninstitutional spouse would keep all $100,000.[5]
Case #6
Step One
Similarly, suppose the assets totaled $30,000.
Step Two
$30,000 is less than the $128,640 limit.
Result
In a 100% state, the noninstitutional spouse would keep all $30,000.
Takeaway
Essentially, in a 100% state, the noninstitutional spouse gets to keep all the assets up to the limit, which is $128,640 in the year 2020.
‘Spend Down’ Doesn’t Mean ‘Give Away’!
Here we run into a potential pitfall.
Upon learning about Medicaid’s austere requirements, and upon surveying their financial situation, couples might be tempted to start giving away assets – whether it be to relatives, to friends or to charities.
This would be a bad idea and very dangerous course of action!
Medicaid’s ‘Penalty Period’
We’ll need to be exceptionally careful.
Medicaid asset transfer rules are every bit as stringent as its other requirements.
Running afoul of Medicaid asset transfer regulations can result in the imposition of what is termed a “penalty.” This is a period of time when the applicant would be ineligible for Medicaid because of procedural violations.
You should also be aware that the penalty period only begins once the applicant would otherwise qualify for Medicaid and often once the applicant is already in a long-term care environment and receiving care.
That means that the Medicaid applicant would be in need of the assistance but would be unable to get it because they are being penalized. In other words, you would be up a creek without a paddle!
The ‘Look-Back Period’
In general, at least for long-term-care scenarios, Medicaid can – and will – review an applicant’s financial history and financial reports going back a full 60 months, or five years.
This “scrutinizing interval” is referred to as the “Medicaid look back.”
What are they looking for?
Medicaid is looking for transfers that are inadmissible from the standpoint of its regulations.
Improper Gifting
Illicit transfers might include things that you might call “improper gifting” and also inappropriate sales.
Illicit gifting would be giving gifts apart from what would be reasonable to celebrate usual occasions (like birthdays and anniversaries) or beyond what would be expected and reasonable in terms of holidays (that is, holidays that your family normally observes).
So, for example, giving little Johnny $50 on his birthday, or buying him a video game might not raise any red flags. (Although, if you are in the process of Medicaid planning, you need to consult with an attorney about every move that you make!)
On the other hand, giving the family cabin to your brother and calling it “an Arbor-Day gift” will almost certainly land you in hot water.
So, don’t make that kind of a mistake!
But, seriously, even inadvertent violations of asset-transfer requirements can be penalized severely.
Your best bet is to consult with an attorney who is knowledgeable about Medicaid transfers.
Firstly, lawyers are liable for the advice that they give to you.
And secondly, it’s against federal law to advise anybody to make asset transfers in such ways to try and hide assets or to cheat Medicaid. If a person’s advice results in the imposition of a penalty, the person giving the advice can be criminally liable.
Caveat
Naturally, this article is not intended to be construed as advice of any kind. It is for general informational, or entertainment, purposes only. You need to consult with experts in your area – perhaps more in this case than others. This is because qualifying for Medicaid is serious business.
Improper Selling
You can get in a lot of trouble, even if you aren’t gifting assets, but if you’re selling them incorrectly.
This is especially the case if the sale price is below the fair market value (FMV) of whatever the item is.
For example, if your car’s blue book value is $10,000. You sell it to your granddaughter for 25 bucks.
This is going to do more than just raise eyebrows. It could get you into a lot of trouble!
Is Every Asset Transfer Illicit?
Now, that isn’t to say that no asset transfers or sales are permissible.
This is an important point because it’s to be expected that a person is transitioning into a new era of their life when going into a long-term care facility, or a nursing home, and they are going to be downsizing, and they’re going to be getting rid of some of their property almost for sure.
The point is that you would be far better getting competent advice when you make these changes, than you would be otherwise.
Permissible asset transfers might include: retitling the home in the name of a spouse or in the name of a caretaking child, or selling items at their fair market value – provided, of course, that the proceeds from the sales are duly noted, tracked, and then reported as part of the countable asset calculation.
Once again, asset transfer rules are state specific, and any Medicaid planning and preparation should be done only under the express advice of an attorney.
Life Insurance
The real difficulty with life insurance is the cash value.
Not every life-insurance policy has cash value. This is going to apply (mainly) to policies that are built on a whole-life or universal-life chassis.
Most term-life policies[6] have no cash value and can (generally) be retained at any face amount.
The “face amount” is the big dollar amount written on the front page of most life-insurance policies. It’s the amount that you would expect to the beneficiary to receive in the event of the insured person’s death.
On the other hand, permanent policies are usually the ones that have cash values. These policies must be limited to $1,500 face values.
That means they can pay out $1,500, at most, in the event that the insured dies. If the face value is $1500, then the cash value is expected to be less than that.
Any contract exceeding these values most likely will need to be “surrendered,” or “cashed out.” (But do not do anything without consulting a competent Medicaid expert or planner!)
Cash-value policies also need to be tracked carefully, even if they are retained.
So, if a policy falls under that $1,500 threshold, it is still going to need to be carefully tracked because: (1) the cash value is still part of the countable assets, and (2) if the policy’s cash value increases or changes year to year, or if the face value goes up, then the policy may qualify this year but not qualify next year.
Final Words
Take a deep breathe.
Because… the income requirements are every bit as complex as the asset requirements!
[1] You should also be aware that there are sometimes limits imposed in terms of how much equity can be inside the house and whether this is applicable or not often depends on whether it is the Medicaid recipient him or herself, who is in the home or whether it is the noninstitutional spouse where equity limits do apply. They tend to vary year to year. In 2020, the amount of allowable equity in a home is about $600,000. Technically about $595,000. In some states it can go all the way up to closer to $900,000 or about $893,000 in 2020.
Intuitively, the reason for the equity limit is so that a person sitting on a $2 million mansion could not qualify for Medicaid when the sale of the home would be enough to discharge both their medical expenses and more modest housing costs. Cases where the spouse is willing in the home equity.
Limits may or may not apply. Consult your Medicaid planner.
[3] These limits may have changed, though; so, don’t too get too hung up on the specific amounts. Just try to get a grasp of the concepts. Your trusted Medicaid expert or planner will be “up” on the relevant limits.
[5] Conceivably, the institutional spouse could keep $2,000 and the noninstitutional could retain $98,000. Consult your Medicaid planner.
[6] Term insurance is usually regarded as “temporary,” since it is purchased for intervals called “terms.” Intervals may be 1 year, 10 years, 20 years, 30 years, etc. The insurance expires if the insured hasn’t died during the interval.
[7] I want to stress that this has been my good-faith effort to provide people with an accessible summary of the contours of Medicaid asset eligibility. However, I make no claims to completeness or expertise. I do not warrant that this information is accurate, error-free, or up to date. So, please, consult with a qualified expert to help you!
A news item crossed my radar screen a couple weeks ago. This actually goes all the way back to August 2019, and was published in the Neurology, which is an academic journal, and subsequently was picked up by various news outlets.
I saw this through a press release from Washington University School of Medicine which is located in St. Louis, Missouri. The report focused on a new blood test that’s available for Alzheimer’s Disease.
Currently, it’s in testing phases. But, it has been developed, and researchers think that it holds great promise, and let me explain why that is.
So, first of all:
What does the test do?
I have both an ARTICLE and a YouTube VIDEO on some of the possible causes for Alzheimer’s disease. One of the causes that’s often referenced is the accumulation, in the brain, of various protein “gunk.”
There are two different types of protein that are implicated in this. The first is called beta-amyloid and the second is called tau. The two of these, together, account for the various “plaques and tangles” that Alzheimer’s patients’ brains seem to be riddled with.
The 100% definitive test for this is going to be an autopsy. (For these assortment of Alzheimer’s “tests,” see – again – either my other written work, e.g., HERE, or the companion, video presentation, HERE.)
There is very little use, obviously, for an autopsy to play in terms of preventative medicine or even in treatment, while somebody’s alive. It can give you the accurate cause of death only after the fact. But it’s not going to be too good for medicinal purposes.
Now comes a blood test that promises, or at leads holds the promise, of being able to detect levels of beta-amyloid in the blood during a person’s life.
Two kinds of beta-amyloid protein are being focused upon. And those are designated “Number 40” and “Number 42.”
My layman’s “take” on this is that there is an array of these beta-amyloid’s, but that 40 and 42 somehow play particularly important roles in the pathological accumulation of these deposits in an Alzheimer’s-afflicted brain.
I should say the test has actually been going on for couple years.
What researchers have hypothesized, and has since been borne out – at least, in early stages – is that levels of beta-amyloid in the blood suggest an accumulation of the beta-amyloid in the brain.
Why is the test important?
I mentioned that autopsies are the definitive test for Alzheimer’s. But, of course, autopsies are no good for diagnostic purposes so long as the patient is alive.
So, the most accurate test a living person can get right now is a so-called “Pet Scan,” which is shorthand for the more forbidding “positron-emission-tomography scan.”
A pet scan is essentially the best test that’s available.
But… pet scans are both expensive and time-consuming to perform. Therefore, this blood test holds out the hope for being able to be administered on a much wider scale and at far less of a cost.
Those are two points in its favor.
In theory, a blood test of this kind would be able to be given in a doctor’s office – instead of, for example, having to send the patient to an imaging center.
How Accurate Is the Blood Test?
What researchers discovered, when they compared the blood-test results against the pet-scan results, was that the blood test was 88% correlated with the pet scan.
What this seems to suggest is that, if for every 100 pet scans displaying evidence of Alzheimer’s, a blood test would detect Alzheimer’s in 88 of those cases.
At least… that’s the way I’m reading the article. (Disclaimer: I am not a medical professional! This is simply my untutored commentary on the situation. For advice, seek a healthcare expert who is familiar with your personal history.)
So, the test was (provisionally) determined to be 88% effective, in the above respect.
What Other Risk Factors Were Considered?
It’s worth pointing out that when they coupled the blood test with a couple of other risk factors – for example, age – the effectiveness increased.
It’s widely accepted that a person’s Alzheimer’s risk goes up with age. In fact, it’s said that your risk actually doubles every five years after age 65.[1]
Also, they factored in genetic predisposition. So, if you have the APO-E4 variant gene in your genetic makeup – as I myself do (see my video testimony, HERE) – then you have a higher (3 to 5 times higher actually!) chance of developing Alzheimer’s sometime in your life.[2]
Another risk factor – believe it or not – is sex. We talked about this in other places. (My AlzheimersProof.com post is HERE and my video is HERE.) Sex may not be its own risk factor. It may simply be that women live longer and therefore are more likely to manifest symptoms of Alzheimer’s and other dementias because of their longevity. But it is sometimes said that two out of three Alzheimer’s sufferers are female.[3]
When researchers incorporated age and genetic predisposition, they found that the test was 94% effective in terms of matching up to the pet scan.
What’s the Practical Benefit of an Alzheimer’s Blood Test?
But what they found, in addition to that, was that when some of the blood tests came up positive for people who had not yest been pet scanned, those people eventually came up positive on the pet scan as well.
This suggested to researchers that the test might actually be even more accurate than the pet scan, and able to detect Alzheimer’s in its very earliest stages.
Recall, also, that Alzheimer’s disease manifests in symptoms. But researchers believe that the underlying brain changes may take place as far back as a decade or more prior to the onset of symptoms.
One of the benefits obviously of early detection is they want to be able to treat people in presymptomatic stages. They feel like once memory changes, and other changes manifest in the brain, then that brain is already so damaged that it is basically beyond help.
In possibly being able to find people in the earliest stages of Alzheimer’s, another potential benefit of the blood test is that it might help with constructing clinical trials for developing interventions.
An early version of this test goes back to 2017 or even 2016. At that time, some of the articles referenced “autoimmune antibodies,” also called “autoantibodies.” The idea was that the immune system’s response to the accumulation of beta-amyloid protein might be able to be gauged. But, upon closer inspection of these articles now, in retrospect, they also seem to be describing a blood test that focuses on some of these beta-amyloid protein variants.
The fundamental idea is to try to catch Alzheimer’s disease in its very earliest stages.
Sometimes this “preclinical” stage is referred to variously as Very Mild Cognitive Impairment (especially on the so-called 7-Stage-Dementia view – about which, see HERE and HERE) or Mild Cognitive Impairment, often better known simply by the abbreviation “MCI.”
Note, however, that not all cases of MCI develop into Alzheimer’s disease. For one thing, there are other sorts of dementia (e.g., Lewy-Body Dementia, Multi-Infarct Dementia, Parkinson’s Disease, etc.) and there are traumatic brain injuries and other conditions that also might be prefaced by mild cognitive impairment. (For the difference between “Alzheimer’s Disease” and “dementia,” see my video, HERE.)
“Mild Cognitive Impairment” is, in a sense, just a catchall phrase for a certain level of mental diminishment as well as for the impoverishment of other perceptual and reasoning capabilities.
Concluding Reflection
There’s little doubt, though, that this blood test is fascinating. Even though it still has some way to go before you can expect it at a physician’s office near you, it holds promise.
Number one, it’s less expensive than the pet scan. Number two, it is able to be administered more widely, and in more environments – like doctors’ offices, and other places (such as out-patient clinics and “urgent-care” centers) – whereas the pet scan is obviously limited to an imaging center. Number three, it’s possibly more accurate than the pet scan. And, number four, it’s certainly superior to the autopsy in the sense that it holds out promise for being able to help treat and diagnose people while they are still alive – which is, quite obviously, advantageous.
Within the United States and Canada there are laws that require a physician to report a patients with neurological or cognitive disorders to a licensing agency, as those patients may be a danger behind the wheel of a vehicle.
This type of reporting is not mandatory across the entire United States. Currently, there are only six (6) states that mandate a physician to report on a patient’s ability to operate a motor vehicle. These six states include:
California
Delaware
Nevada
New Jersey
Oregon
Pennsylvania
Not all mandatory states direct their reporting law toward those who are afflicted with Alzheimer’s Disease or, indeed, any sort of dementia whatsoever. Below are some specifics around each mandatory state and what is defined in their law.
If you want to see and hear me present the material, feel free to watch the YouTube video that I prepared, here:
California
The state of California is the first that I will discuss. It’s a prime example of a state in which (a.) there is mandatory reporting, and (b.) that reporting is at least partially concerned with Alzheimer’s Disease expressly.
The California Legislative Information website (leginfo.legislatures.ca.gov) references chapter 3 – Disorders Characterized by Lapses of Consciousness [103900-103990].
103900 states: “Every physician and surgeon shall report immediately to the local health officer in writing, the name, date of birth, and address of every patient at least 14 years of age or older whom the physician and surgeon has diagnosed as having a case of a disorder characterized by lapses of consciousness.”
This law specifically includes Alzheimer’s Disease as a disorder that involves the requisite “lapses of consciousness.”
In Delaware, the focus is on conditions that are characterized by “losses of consciousness.” In this respect, Delaware’s statutory language is similar to the “lapses of consciousness” verbiage present under California law.
Title 24 of the Delaware Code Online – Professions and Occupations Chapter 17, Medical Practice Act states: “Every physician attending or treating persons who are subject to losses of consciousness due to disease of the central nervous system shall report within 1 week to the Division of Motor Vehicles the names, ages and addresses of all such persons unless such person’s infirmity is under sufficient control to permit the person to operate a motor vehicle with safety to person and property.”
Again, for further reading, scroll down to “Delaware’s entry, HERE.
Nevada
Nevada is a good example of a state in which, while there is mandatory-physician reporting, it is not directed towards cognitive impairments such as dementia (of which, as we know, Alzheimer’s Disease is the most common variety). (On two ways of understanding the difference between Alzheimer’s Disease and dementia, see my YouTube video, HERE.)
According to the Bradley, Drendel & Jeanney law firm: “…Nevada laws can regulate the driving rights of individuals with epilepsy. In fact, doctors in our state are required to report epileptic seizures to the state’s Department of Motor Vehicles…”
You might be picking up on a recurring theme, here, but… for additional information, click down to “What does Nevada State Law say about Driving with Alzheimer’s?” in my 50-State Guide, HERE.
New Jersey
The New Jersey Academy of Ophthalmology, states, “NJ Law (N.J.S.A. 39:3-10.4) requires all physicians to report patients to the Motor Vehicle Commission within 24 hours after determining that a patient experiences any of the following: Recurrent convulsive seizures, recurrent period of unconsciousness or impairment, or loss of motor coordination due to conditions such as, but not limited to epilepsy in any of its forms which persist or recur despite medical treatment.”
Even so, New Jersey appears to be one of those states in which physicians could potentially be held liable, legally, if they don’t report potentially dangerous drivers.
While New Jersey law has established an elective reporting system for drivers with vision deficiencies and mandatory process for reporting specific neurological dysfunctions, there is no statute that protects a physician from liability if they have failed to report a patient that may cause injuries to a third party due to a condition known by the physician.
Given this, you might think that a New Jersey doctor will err on the side of reporting. And, I may be inclined to agree.
For more info, where do you think I’ll send you? My state guide, of course! Find it, HERE.
Oregon
The Oregon Driver & Motor Vehicle Services states: “Most medical professionals are required to report drivers who can no longer drive due to impairment.”
It is required of medical professionals to report on a patient’s impairment, even if that patient has agreed to give up driving.
The Oregon Secretary of State website similarly states: “…mandatory reporting by physicians and health care providers of those persons with severe and uncontrollable cognitive or functional impairments affecting a person’s ability to safely operate a motor vehicle.”
Cognitive impairments as specified in Oregon include: attention, judgement and problem solving, reaction time, planning and sequencing, impulsivity, visuospatial, memory and/or loss of consciousness or control.
Intuitively, this list is expansive enough to range over various cognitive impairments like dementia and Alzheimer’s Disease, even if they are not singled out for special or explicit attention.
See: “What does Oregon State Law say about Driving with Alzheimer’s?” which is a subsection of my longer, and more comprehensive (but certainly not exhaustive) reference, elsewhere on this website.
Pennsylvania
According to Schemery Zicolello Law Firm, the Pennsylvania Medical-Reporting Law requires health care personnel to report to the Pennsylvania Department of Transportation the full name, date of birth and address of every person over 15 years of age that is diagnosed as having a disorder or disability that could impair his/her ability to drive. In the list of reportable medical conditions, the attorneys specifically call out dementia.
That’s good enough for me.
If you want a bit more detail, scroll down to “Pennsylvania,” on my article, HERE.
Utah
Utah was mentioned in an article by National Center for Biotechnology Information (NCBI) as a reporting state. However, in the Fact Sheet for Patients and Families provided for Utah drivers, the indication for mandatory reporting by physicians is not present.
The document does state that the patient is expected to report and disclose their impairments to the department of motor vehicles.
So… I don’t find that Utah is actually a mandatory-reporting state.
Bear in mind that just because a state does not have mandatory-reporting laws, it should not be assumed that physicians won’t report anyway.
In the first place, a doctor might believe that it is his or her ethical duty to report a potentially dangerous driver – regardless of whether state law strictly requires that he or she do so.
Additionally, the physician’s other professional entanglements – for instance, his or her affiliation with a medical group or his or her professional-liability insurance – might have stricter requirements governing action steps in relevant cases.
Mandatory Medical Reporting Law States: In some states, physicians are required to report patients who have specific medical conditions (e.g., epilepsy, dementia) to their state Department of Motor Vehicles (DMV). These states generally provide specific guidelines and forms that can be obtained through the DMV.
Physician Reporting Law States: Other states require physicians to report ‘unsafe’ drivers to their state DMV, with varying guidelines for defining ‘unsafe.’ The physician may need to provide (a) the patient’s diagnosis and (b) any evidence of a functional impairment that can affect driving (e.g. Results of neurological testing) to prove that the patient is an unsafe driver.
Physician Liability States: Case law illustrates situations in which the physician was held liable for civil damages caused by his/her patient’s car crash when there was a clear failure to report an at-risk driver to the DMV prior to the incident.
On the NHTSA’s website, a survey of medical review practices can be found that indicate while all 51 jurisdictions accept reports of potentially unsafe drivers from physicians, only 6 jurisdictions require physicians to report drivers to the motor vehicle agency.
Another helpful article on NHTSA’s website is ‘Current Screening and Assessment Practices’. This article summarizes the legal requirements in each of the six mandatory reporting states.
Another helpful resource is the National Center for Biotechnology Information, the website for which can be found, here: https://www.ncbi.nlm.nih.gov.
National Library of Medicine, National Institutes of Health contains an article within the Journal of General Internal Medicine (abbreviated “J Gen Intern Med”). Of interest is an article titled “Reporting by Physicians of Impaired Drivers and Potentially Impaired Drivers,” which mentions that virtually all states have established policies for the identification of drivers with physical or mental impairments, however, the reporting is voluntary with the exception of specific states.[1]
Additional references on AlzheimersProof.com include:
This is a resource regarding the legalities of driving with Alzheimer’s or another cognitive disorder. This is not legal advice, simply research and research leads presented in a comprehensive article to assist in locating additional sources for further information. You can find additional information and important aspects specific to your state within my 50-State legal guide, HERE.
The above article, also on my website, goes into a discussion about a number of factors that may impact a person’s ability to drive, given their cognitive or mental state. This not only addresses that Alzheimer’s Disease occurs in stages (for more on which, see HERE), but also addresses some concerns around other cognitive impairments.
I also have an article – and a companion video (see my YouTube channel, HERE) – talking specifically about considerations of driving safety, apart from an explicit discussion on any legal requirements.
Now, if it gets to the point where you have to actually restrict your loved one’s access to the vehicle (and I sympathize with you if this happens), then you might find something of use in the above resource.
The final piece that I’ll note, here, is a general article that I did on the question of how to “Alzheimer’s Proof” a car. Recall that Alzheimer’s Proofing is akin, in this context, to baby proofing or childproofing. For more on this, see HERE.
Disclaimer
Please note – this article should not be treated as providing legal or medical advice, but purely as a reference that provides general information in regards to the laws that require a physician contact a licensing bureau in regards to a patient’s ability to operate a vehicle. This post is given as-is; I do not warrant that the information is accurate or complete. But I provide the information in good faith and I believe, to the best of my knowledge, that it is reliable.
Notes:
[1] As noted in the main text, the article’s list of states includes Utah, while in other references, Utah is not mentioned as a mandatory state.
Alzheimer’s Disease is a progressive, neuro-degenerative illness that presents itself in stages. While there is some debate over the precise number of stages (for more on which, see my ARTICLE or companion VIDEO), for present purposes, we can say that there are three: early, middle and late. Because cognitive degradation is just what it is to have some form of dementia, the fact is, at some point, an Alzheimer’s sufferer will become unsafe behind the wheel of a car.
In the early stage of Alzheimer’s, memory impairments may be mild affording a person the ability to safely drive. A larger concern occurs during the transition from the early to middle stage of the illness.
During the middle stage of Alzheimer’s, memory impairments may become more severe. You or your loved one may be doing fine one day, but have a lapse in memory or judgement, causing challenges the next day. These lapses, or deterioration in memory, can make a person with Alzheimer’s more of a danger to themselves or others, especially when driving.
By the time a person reaches the late stage of Alzheimer’s, he or she will have lost so many abilities (including language, mobility, responsiveness, etc.) that driving will be virtually inconceivable. Generally, by that time, the level of physical disability alone makes operating a motor vehicle practically impossible.
But before that threshold is reached, it may be somewhat difficult to identify the precise time at which a person becomes an unsafe (or at least unreliable) driver. Here is a breakdown of some early signs or symptoms that may indicate it is no longer safe for a person with this illness to operate a vehicle.
(These signs may be noticed by the person themselves, a loved one, vehicle caretaker or an outside party such as a neighbor, physician, police officer, etc. Additionally, it is important to assess behaviors and signs relative to a person’s “baseline.” In this context, a baseline is the starting point for comparison. It’s basically the way a person acted or the degree of functionality they possessed for most of their adult life – at a point when they were obviously not impaired in the relevant sense.[1])
Emotional Changes
A person with a mild demeanor may become more aggressive, hostile, or otherwise difficult. These changes in behavior could potentially be due to a mood disorder or other neurological problem. However, these behavioral changes can also occur in a person with Alzheimer’s Disease or some other form of dementia.
If you notice that you or a loved one becomes unable to control anger or depression, becoming so overcome with emotional fits or episodes, it may be an indicator of Alzheimer’s or some other serious condition. Whatever the cause, these emotional changes will increase the dangers and risks of being behind the wheel of a car.
Anger – Your loved one may become agitated or irate with little or no apparent provocation, or beyond what a normally functioning person would think of as justified or reasonable.
Anticipation – In this case, the pathological component may be another outgrowth of memory loss. If you loved one seems or professes to expect or hope for an imagined or past event, it may be a sign of worsening dementia.
Disgust – An Alzheimer’s patient may have difficulty masking emotions and might display naked aversion, distaste, loathing, revulsion, etc. even in inappropriate contexts or directed toward things that they previously felt fondly toward.
Fear – On a low level, this might result in an increasing level of anxiety. It could be apparent through spoken language, but it may only become apparent to people who notice subtler signs or body language (e.g., in facial expression or posture) or habit (such as hand wringing or nail biting). Alternatively, fear may manifest in more extreme ways, for instance, through indications of a pathologically paranoid or suspicious turn of mind.
Joy – We all like to see our loved ones content and happy. But, in some cases, the level of jubilation or excitement may exceed what is appropriate to or warranted for the occasion. For instance, your loved one may not exercise due restraint. Alternatively, it may appear strike you as inappropriate in the sense that he or she seems to be taking pleasure in something that ought to elicit a different emotional reaction.
Sadness – A dementia-afflicted people might suffer from apathy or depression, or from some other related sort of unrelenting melancholy. They may tend to brood or become removed or withdrawn from family or other social circles.
Surprise – Look for evidence or amazement or bewilderment that seem out of place. Astonishment or shock could be a result of affected judgment or reasoning. But it also could be a function of increasing forgetfulness and impaired memory.
Trust – This may be related to fear and paranoia in the sense that your loved one may begin to suspect family members of plotting against them. Contrariwise, it might be expressed in an inappropriate or unwise willingness to follow or receive instructions from strangers.
Memory Changes
Some Alzheimer’s-afflicted individuals may have issues with short-term memory loss but are able to remember things that occurred further back in time. Vehicle operations can be broken up into “before,” “during” and “after” categories to determine if memory changes impact or undercut safe driving. Here’s what I mean.
Before Getting Into the Vehicle, Ask…
Do you or your loved one have an issue finding the keys?
Is it consistently a challenge to remember where the vehicle is parked? Or…
Is it hard to recall which vehicle belongs to you?
Everyone misplaces things from time to time. Obviously, when it is sporadic, this is not necessarily an indicator of Alzheimer’s Disease or some other form of cognitive impairment or dementia. However, the issue occurs when this becomes more of a pathological condition where memory loss is more frequent than normal, or when its occurrence undermines safety.
While Inside of the Vehicle, Ask…
Do you or your loved one have trouble remembering which pedal is the accelerator and which is the brake?
Is there confusion on what traffic signs or signals are indicating?
Do you or your loved one regularly forget where you are going, or how to get there?
Beyond the perceptual diminishment that often accompanies normal aging, cognitive impairments may erode sensory faculties. Does the driver have reduced sensory-processing capabilities? (See further below.)
Do the A/C or radio controls confuse you or distract you from the road?
A person with this illness may not understand signs to where they inadvertently drive through a construction zone. They may also forget where they are going or how to get where they are going, even if the route is familiar.
After Exiting the Vehicle, Ask…
Are there dents or scratches that cannot be accounted for?
Is parking haphazard or erratic?
Are items forgotten inside the car inadvertently?
Are keys routinely left in the vehicle?
Is the car left running unintentionally?
Have you or your loved one begun to receive mailed traffic citations? Or…
Is the driver being pulled over more frequently than before?
A person afflicted with this some form of dementia or other cognitive difficulty may not remember how a particular dent or scrape appeared on the vehicle.
All these items are warning signs or indicators that something else may be going on beyond normal forgetfulness.
Motor-Skill Changes
Cognitive disabilities are only half of the picture, though. Driving also places physical demands on a person. Therefore, various physical impairments can also undermine safe-driving abilities.
Similarly to the previous category, these changes can also be evaluated by looking at requirements that impose themselves before, during, and after using a vehicle.
Before Getting Into the Vehicle, for Example…
Changes in motor skills or reductions in physical strength may hinder a person from doing something as simple as opening or closing a vehicle door.
You or your love done may struggle with opening or closing the hatch or trunk.
It may become difficult or practically impossible properly open or close the hood of a vehicle.
It is true that memory may come into play here as well. And there’s little question but that forgetting how to do these minor tasks may be an indicator of Alzheimer’s.
But diminished motor skills can be serious problems on their own. And, when determining a person’s driving fitness, physical abilities need to be assessed alongside cognitive ones.
While Inside of the Vehicle, for Example…
A person with diminished motor abilities may have difficulty turning the wheel.
He or she may have trouble physically depressing the pedals or shifting gears.
Someone might find it physically taxing to keep the car in the correct lane.
Parking the vehicle may begin challenging, especially if the individual has limited abilities to turn their body or head.
Sensory impairments such as hearing or vision loss can also undercut the ability to safely operate a car or truck.
After Exiting the Vehicle, for Example…
Do you or your loved one have difficulties just physically getting in and out of the house, opening entry or garage doors, carrying groceries, and so on?
Of course, people often drive in order to assist them with the functional activities of life – such as shopping. While general impairments may not specifically speak to the question of safety behind the wheel, they do speak to the issue of whether driving is beneficial or necessary. If you or your loved one can no longer perform or engage in other life activities – like shopping – then it may be that driving is no longer helpful. This suggests that it may pose a risk that outweighs any potential benefit.
Additionally, the loss of non-driving-specific abilities indicates a general physical decline any may suggest either that driving-related abilities may soon erode or that further cognitive impairment is on the horizon.[2]
Clearly, being unable to physically control a vehicle, while not an Alzheimer’s-specific problem, may be an indicator that you or your loved one can no longer reliably or safely operate a vehicle.
Perceptual Difficulties
The normal aging process can cause perceptual difficulties. However, Alzheimer’s can exacerbate these issues.
Perceptual difficulties may impact visual-spatial abilities such as being able to judge distance or peripheral vision. Being spooked by shadows or not noticing cars or pedestrians next to you may be a result of diminished perception.
There may also be an inability to see traffic signs, signals, or other drivers (for example, people braking in front of them or merging into the same lane).
Perceptual difficulties may also include a decreasing ability to hear sirens or horns. This poses an obvious danger – especially, though not exclusively, if it is coupled with memory impairments. Forgetting what emergency-vehicle sounds indicate or require in terms of courses of action can lead to accident, injury, or death.
Reasoning Changes
A deviation from a normal route may cause confusion for a person with Alzheimer’s, as they may not be able to react or think through an alternate route. They may also have issues navigating around accidents or construction sites.
A person with this disease, or some other form of cognitive impairment or dementia, may have a reduced reaction time that, in turn, undermines their ability to react to unexpected changes within their route. These include such things as closed roads and bridges, etc., which could potentially lead to accident, and certainly engender confusion.
Deviations and detours can also result in you or your loved one becoming lost.
Concluding Remarks
As difficult as this can be for the afflicted individual, there will come a point where having them behind the wheel of a car or truck will become more of a danger than a benefit.
For more information, please see my companion YouTube video, HERE.
Postscript
In addition to these safety considerations, there may also be legal implications and potential liabilities in regards to a person driving with Alzheimer’s Disease.
While I am not a lawyer or legal expert, I do have several, relevant resources available on AlzheimersProof.com.
[1] Of course, some persons may have lifelong afflictions or disabilities. These will have to be factored in as well. Doing so is beyond the scope of this article. Consult a healthcare or medical professional for personal evaluations or recommendations.
“Custodial care” is nonmedicalhelp with the Activities of Daily Living (like bathing and eating). “Skilled care” is medical care, such as giving medications and shots, dressing wounds, drawing blood, and so on.
The phrase “long-term care” can be confusing, since custodial care is sometimes used as a synonym for custodial care, and sometimes it’s used for the combination of custodial and skilled care that a person might receive in a nursing home.
I would like to spell these things out as simply as I can.
So, let’s first think, on a very basic level, about what we mean by long-term care.
A Personal Example: My Dad
As I have written elsewhere, my dad, Jim, passed from Alzheimer’s disease in 2016. I took care of him in his own home for four years. And then he was in a nursing home for four years after that.
That means that he suffered obviously from Alzheimer’s for at least eight years. In fact, it was longer. We can reasonably conclude this for two reasons.
Firstly, I started caring for him was because it was becoming increasingly apparent that he needed help. So, we are justified in believing that he was suffering from some cognitive impairment before I assumed the role of his daytime caregiver.
Secondly, scientists inform us that the brain degeneration of Alzheimer’s begins before any symptoms manifest themselves. Therefore, we can infer that Jim had the very beginnings of Alzheimer’s prior to anyone noticing that something was wrong with him.
But, once we became aware, we observed that he needed help with the basic tasks of everyday life.
Help With Everyday Activities
Called “Activities of Daily Living,” or “ADLs,” these include things like bathing, dressing, eating, maintaining continence, toileting by yourself, and transferring in and out of bed.
These are things we all need to do each day. That’s 24/7/365, as it were.
That’s the intuitive definition of “long-term care.” It’s help with the ADLs, delivered over a fairly long period of time.
So, what’s in view here is a person who has a chronic condition, disease, disability, or whatever and who is going to require everyday care over a long period of time.
Probably Also Need Extended Medical Care
It turns out that many conditions that will prompt this level of care are also terminal conditions. (I go into greater depth on terminal illnesses HERE and HERE. And I have a video on the topic, HERE.)
A personal who is so severely incapacitated that he or she needs daily assistance with the basic activities of living most likely also requires some kind of ongoing medical care.
Think about my dad, again. He had Alzheimer’s Disease. He required both medical care and nonmedical care. He needed supervision and medication, for instance.
As noted previously, one way of using the term “custodial care” is applying it to nonmedical care. But, a person – like my dad – who has a chronic and debilitating illness may very well also require medical care (e.g., pharmaceutical interventions, speech therapies, and so on). When we say “skilled care,” then, we’re thinking of this latter sort of care.
Possible Word Confusion: ‘Long-Term Care’
Once again, the intuitive difference between custodial care and skilled care is going to be that custodial care is essentially nonmedical / supervisory care, whereas skilled care is going to be medical.
Now there are a few different ways of kind of getting more clear on what the differences are, and I’m going to talk about what the actual care is in terms of (1) what is involved, (2) who provides the care, (3) where the care is provided, and (4) how you pay for it.
But before I do that, let me just say one another word about long-term care.
Sometimes, often in everyday speech, the word “long-term care” is used to encompass both custodial and skilled care. In this loose sense, long-term care basically means “whatever your loved needs over an extended period of time.”
A person may think about a relative who’s in a nursing home – like my dad was. My dad received both types of care in the nursing home. So, it’s tempting to think that my dad’s long-term care had medical and nonmedical elements. He needed both – over the long term.
Other times, the word “long-term care” is essentially used as a synonym for custodial care. This use is common in billing applications, healthcare insurance, long-term-care insurance, Medicare, Medicaid, etc.
The upshot is: understand the context of the word use. And, when you hear it, be sure that you know which definition of the word is operative!
‘Qualifying’ for Long-Term Care
What I mean, here, is essentially this: What are the diagnostic triggers that would prompt a doctor to say, “This person needs long-term care”?
This is an important consideration, especially – but not exclusively – for people who may have private nursing-home and other pertinent insurance policies. Long-term-care insurance generally “kick in” once the insured person is certified as being in need of long-term care.
2 Triggers
Physical
This is measured in terms of the “Activities of Daily Living,” or ADLs. In most materials, you’ll find six of these listed. I mentioned them, above: Bathing, dressing, eating, transferring, toileting, and controlling bodily functions.
From the physical point of view, to be “long-term-care certified” essentially means that you lack two out of six of these activities. So, if you’re incontinent and unable to feed yourself, then that would count. Or, if you’re unable to dress yourself and get in and out of bed by yourself, that would count also.
Your needs will have to be evaluated and documented by a licensed healthcare professional, chiefly, a physician.
Cognitive
But there’s also a cognitive or mental trigger.
You may also be certified as in need of long-term care if you have a cognitive impairment to a significant enough degree that you would require more or less constant supervision in order not to hurt yourself or other people.
Sometimes this trigger is pulled at the same time as the physical one, and other times the two are quite separate. In my dad’s case, for instance, he was physically able-bodied (in terms of the ADLs). He had no physical difficulties.
His problem, initially, was purely cognitive. Of course, as the disease progressed, his condition worsened and then he met the long-term-care qualification “tests” multiple times over. This is not uncommon.
Lacking Activities of Daily Living = Custodial Care
When you think of these Activities of Daily Living – bathing by yourself, dressing, feeding, and so on – think custodial care. Likewise, think of custodial care when you think about severe cognitive impairment that necessitates supervision.
Custodial care is going to be that kind of care that assists a person in receiving and in performing the Activities of Daily Living or providing the needed supervision.
Medicines, Medical Tests, Therapies, Etc. = Skilled Care
But my dad’s Alzheimer’s Disease also required certain pharmaceutical interventions. He was on put on the drug Aricept, for example. And it had to be administered to him at various times.
Of course, family members are able to administer that kind of medication at home. But in an institutional care situation, you wouldn’t want a person who doesn’t have proper licensing and proper credentials to administer drugs to your loved one.
But, as of this writing, people don’t need to be licensed to help bathe your loved one, or to help feed him or her.
Therefore, a second distinguishing feature of custodial care is that the care practitioners do not need to be licensed.
On the other hand, skilled care, as the medical portion of care, does require special training and licensing. In fact, that is one of the reasons it is referred to as skilled care.
Nursing Homes Provide Custodial & Skilled Care
In certain care environments, you are going to see a combination of these needs being met. So, for instance, a nursing home is a place that is going to provide both custodial and medical care for its residents. It’s a one-stop shop, so to speak.
One of the reasons why these definitions get a bit mixed up is because of the fact that we see our loved ones in this kind of composite care environment. It’s therefore natural to assume that everything going on in that environment is appropriately called “long-term care.”
Possible Care Environments
Of course, other care environments exist beside the nursing home.
Home Care
Number one, a person could receive care in his or her own home, or in the home of a friend or relative. Certainly, you can have people come into the home to provide the kinds of custodial supports that a person might need. And, generally speaking, if you’re receiving care in the home the professional care is probably going to be a supplement to a familial caregiver.
When my dad was living in the home, it was my mom and who were giving the supports that were necessary for him to get through the day. But, if we needed additional help, then we might call somebody else to the house.
This extra support could be skilled – like a visiting nursing – or unskilled/custodial. But, for the most part, we handled the custodial portion of the care ourselves.
Assisted Living
An assisted-living facility is a place that’s going to help people who are starting to have difficulty with the Activities of Daily Living. Such facilities try to emphasize and encourage independence. Seen from a different perspective, these facilities actually require a fair degree of independence – since they are generally not licensed or staffed to provide the level of care available in nursing homes.[1]
Nursing Home
But, for present purposes, the third main care environment is a nursing home.[2]
A nursing home is going to provide a level of care that’s a notch above an assisted-living facility in terms of comprehensiveness.
Whereas an assisted-living facility is equipped to provide low-level help with some daily activities, a nursing home is able to provide full-blown custodial care.
And whereas an assisted-living facility likely has a nurse or doctor on call, a nursing home always has medical practitioners on the premises. Skilled care is part of the overall care provided by the home.
To put it slightly differently, nursing homes provide comprehensive care services.
Billing of Services
Why are these distinctions so important?
Well, the distinctions become important largely when it comes time to pay the bill!
As usual, this discussion can become nuanced and detailed. But here’s the bottom line.
There are three main ways to pay for long-term care services, broadly construed.
Private Pay
“Private paying” is where you pay for yourself. You’ll likely do this out of your own assets (e.g., checking, money market, savings accounts; emergency funds; retirement vehicles; etc.) or your own income (for instance, annuities, pensions, rental payments, social security, and so on).
While you pay for yourself, you can go wherever you can afford. You can have whatever accommodations and services you like. At least, you can have all this so long as your money holds out.
At the level of nursing-home care, your bill is likely going to be a composite of skilled nursing services and custodial services. But if you’re paying entirely out of pocket for your care, then it doesn’t matter which sort you’re being billed for. You pay for everything yourself, regardless of what type of care it is.
So, in the private-pay scenario, the custodial/skilled distinction really doesn’t matter from the standpoint of your checkbook.
Government Aid
Medicaid
Once you “spend down” your assets to a particular – and low – level, you may be eligible for Medicaid. This is a government-assistance program that is geared towards helping impoverished people pay for necessary medical expenses.
For qualifying individuals, Medicaid pays for (portions of) both custodial and skilled care. However, there are strict asset and income tests that are applied.
Moreover, your preferred facility may not be able to accommodate you. Some facilities have no or few “Medicaid beds.” Others require that you have lived at the facility under private-pay arrangements for a specified period (not infrequently one or more years) before you can claim a Medicaid bed. Others have long waiting lists.
Typically, the relevant beds are in semi-private rooms with at least one other occupant. Additionally, Medicaid usually segregates its recipients by sex.
Medicare
What about Medicare?
For purposes of this post, let’s just say that Medicare is a government program that provides healthcare coverage for seniors (i.e., people over the age of 65).
In principal, then, Medicare is available to cover at least some of the medical-related, skilled-care portion of the nursing-home bill. Now, there are several caveats.
One of these is that Medicare only really covers hospital bills and short-term skilled-nursing costs.
Additionally, there are requirements that the skilled nursing, to be covered, must follow a hospital stay.[3]
Curative Vs. Palliative Care
Finally, Medicare is geared toward what is called “curative care.” In basic terms, this sort of care is supposed to (help to) restore a person back to good health.
“Palliative care,” on the other hand, merely relieves symptoms – it doesn’t “cure” a patient.
You run headlong into trouble, here, when you start to consider conditions, like Alzheimer’s Disease, that have no cures.[4]
Elsewhere, I have discussed the question of whether Alzheimer’s is a “terminal illness.” (For a written article, see HERE. For a video touching the issue, see HERE.)
But suffice it to say that Medicare doesn’t generally cover palliative care – except in end-of-life, hospice situations.
The Upshot
The long and short of it is this, then.
Medicare only covers short-term skilled care and curative care.
Custodial and palliative care is generally not covered by Medicare at all.
Medicaid may cover these – is a person is eligible based on asset and income qualifications.
But that means that if a person is receiving both custodial and skilled care in a nursing home, and even if Medicare is paying for some of the medical/skilled portion of their bill, they cannot rely on Medicare to pay for any of the help they get with Activities of Daily Living. And they cannot hope to get Medicaid assistance until their own assets are spent down.
Long-Term-Care Insurance
Besides paying out of your own assets and spending your own assets down until you qualify for Medicaid, really the only other payment option is to use proceeds from a long-term-care insurance policy.
Such policies have a high application-decline rate, partly because people generally wait so long to try to purchase them.
Now I get more in depth into long-term care in other places. But, essentially, long-term-care insurance is the kind of insurance that’s going to help you to pay for the nonmedical portion of your bill. Long-term-care policies pay benefits when you need custodial care.
So, if you are getting help getting paying for the medical or skilled-care portion of your bill via your health insurance or via Medicare, then a long-term care insurance policy is able to pay for the custodial-care portion.
Of course, you have to be long-term-care eligible in order to collect payouts from this type of policy.
Basically, “eligibility” comes to this. You have to lack two of six of the aforementioned Activities of Daily Living, or you have to be cognitively impaired to such an extent that you require supervision.
But, once a physician “certifies” you as long-term-care eligible in one or both of these ways, then your long-term-care policy is supposed to pay out.
Only a few policies these days have lifetime benefits. So, you should be aware that is it possible to exhaust the proceeds of such a policy. But, it does constitute a third possible funding option, and can delay or avoid exhaustion of your personal assets.
Confusions Summarized
One confusion arises with respect to the fact that “long-term care” is a phrase that can be used for both types of care, together, or as a strict synonym for custodial care only.
A second confusion comes from the fact that both kinds of care – custodial and skilled – are delivered side-by-side, in the same environments. For example, and as discussed, you may get both medical and non-medical care in a nursing home.
Thirdly, there are confusions with respect to how care is billed. What you have to realize is that nursing-home bill is going to be a conglomeration of items, some of which are going to count as custodial services, and others of which are going to be skilled. Who pays – and what kind of insurance or assistance is relevant (e.g., health or long-term-care insurance, Medicare, or Medicaid) – is going to depend in part on this classification.
The Major Issue Restated
For most people, the main point of learning the distinction between custodial and skilled care is to gain clarify and insight into the question of how the relevant types of services can be paid for.
Who pays for a particular care service and for how long is, in part, a function of whether the service is classified as “custodial” or “skilled.”
Custodial services – like help bathing, dressing, and eating – can be provided by unlicensed and non-skilled care providers. These services may be delivered in a variety of care environments – from your own home, to adult daycares, to nursing homes – but, ultimately, these services are not covered by health insurance or Medicare.
So, you’re stuck paying for these privately (that is, out of your own pocket), through Medicaid (after you’ve exhausted your own assets), or through long-term-care insurance.
Skilled care – that is, the sort of care that is provided by licensed and skilled medical professionals – may be covered by health insurance and Medicare. But this is not always the case because of Medicare’s rules and because it only really covers “curative” interventions – as discussed, above.
Notes:
[1] In terms of whether or not a person would be safe to reside in an assisted living facility, or whether they require a higher level of care, sometimes people talk about various requirements. These are things such as being able to get to an exit by yourself, being able to get around without mobility aids, and so on. I’ll get into greater depth on these questions in subsequent posts or videos.
[2] There are also adult-daycare, hospice, and respite facilities. But I will get into those in another place. See my video presentation, HERE.
[3] Getting into detail about the precise rules, here, is beyond the scope of this article.
Halloween can be a fun time for young and old alike. For many, it’s their favorite time of the year. But, for the cognitively impaired, Halloween can present special challenges.
Caveat
Some of these tips are and have pros and cons.
There’s going to be a sense in which let’s say for example turning off the lights in order to dissuade trick-or-treaters might be an increased risk for tripping inside the home and it might be an invitation to vandalism or burglary. You may need to adapt some of these tips for your specific situation.
Two Main Concerns
Firstly, Halloween presents dangers for your Alzheimer’s-afflicted or dementia-stricken loved one. Secondly, people who are cognitively impaired may present challenges for others – not least, youthful trick or treaters.
Problems for Dementia Sufferers
Alzheimer’s Disease and other forms of cognitive impairment may result in anxiety, agitation, confusion, and numerous other emotional changes.
In general, these affective, cognitive, and physical difficulties are made worse during a holiday like Halloween.
One primary reason for this is that the normal trappings of Halloween can add to, magnify, or trigger negative states such as confusion and disorientation. It can exacerbate emotional problems like anxiety, agitation, and fear.
Additionally, Halloween can present certain physical dangers that go beyond what you would experience in the normal course of Alzheimer’s Disease.
Fire
There are burning hazards from candles, bonfires, jack-o-lanterns, and other things.
Choking
Depending on the stage of your loved one’s condition, you may have to contend with choking hazards from candy and other kinds of treats that are left out.
Falling and Tripping
Normal, age-related mobility issues are made worse by cognitive impairments. But the low-lighting conditions that often accompany Halloween can lead to increased risks of falls and trips.
Criminal Activity
In addition, and unfortunately, there are those people who are looking to take advantage of elderly people. People who are cognitively impaired (for example, who might be in early or middle stages), but who are still able to live alone part of the time, can be targeted and victimized in an array of ways.
On the severe end of the spectrum there are things like assaults and burglaries. On the less serious side, things like pranks, vandalism, and scams may escalate during holidays,
Cognitively impaired individuals may misperceive threats in a couple of different ways.
Number one, they may misperceive a person who is really an innocent trick-or-treater as a threat.
Number two, they might misperceive a person is actually a threat, as not being a threat.
Disorienting Factors
Doorbells and Knocking
Think about the amount of time the doorbell might ring during the evening. Or consider the effect that repeated knocks on the door might cause.
These can be startling at best. But they can actually be panic inducing at worst.
Of course, the actual effect will depend on the nature of your loved one’s affliction.
The geographical area and crime rate also play large roles, here.
Costumes and Masks
Another aspect of disorientation is the costumes and masks worn by party goers and revelers.
In the first place, some of these can be downright scary.
But, in the second place, they might make it even more difficult than usual for a cognitively impaired person to identify someone else – even if that person is (or should be) known or recognizable.
Alzheimer’s and other dementia-afflicted persons react poorly and even unpredictably to unfamiliar situations.
Masks and other kinds of costumes are going to obviously make it difficult to recognize a person. Predictably, this is going to increase the level of confusion that might be felt by some sufferers – or their caretakers.
Decorations
Halloween decorations can range from the grotesque and the off-putting to the downright terrifying. Be mindful of the effect these might have.
Horror Movies
Television, and other kinds of movies and “programming” can be horrifying and extremely scary, especially for young children and – again – those who are cognitively impaired.
Bear in mind that hallucinations and even paranoia are a couple of symptoms that typically go along with dementia. (For my article on this, see HERE.)
And these perceptual maladies are just a normal part of Alzheimer’s! Halloween just can make these kinds of things a little bit worse.
Cognitive and emotional difficulties are compounded by numerous factors.
Dim, Flickering, or Strobing Lights
There are often lighting changes.
So, for example, lights are often turned down low. This dim lighting might make it difficult for a dementia-affected person to perceive his or her surroundings or navigate the living environment.
This, in turn, can lead to falls and trips.
Some lighting might be flickering or strobing, which can also be disorienting. It might also cause seizures in individuals who are prone to epileptic-type fits.
Other changes might include candles and bonfires. These present numerous hazards.
Firstly, as previously mentioned, they may cause burns and house fires.
Secondly, they may give off smoke (and set off agitating smoke alarms) or even deadly carbon-monoxide gas. (For more on these dangers, and how to alleviate them, see HERE and HERE and HERE.)
Thirdly, they can also lead to an increased risk for tripping and falling inside the house. The flickering and uneven light can be just as disorienting as many novelty lamps or black lights.
Strange Sounds
Sounds might be loud.
Or they might be just plain eerie. And that can be unnerving.
Miscellaneous Dangers
Additionally, knives and other paraphernalia (for instance, those that may be used to carve pumpkins or set decorations) could be left lying around.
Dos and Don’ts
So, what can you do? (An abbreviated version of this list is online HERE.)
Don’ts
Hopefully it goes without saying, but don’t put your fun over your loved one’s well-being. Many people love Halloween and are ready to go all out. But remember, if you’re dealing with somebody who’s got a cognitive impairment. They may require special and a particular amount of love and care, especially during a time like this. You may have to sacrifice a few of your decorations and so on.
Don’t bring love ones to disorienting environments – out to malls (if there are any remaining!), to parties, or in general to places where there is bound to be lots of boisterousness or commotion.
Don’t leave Alzheimer’s suffers alone.
Don’t leave carving equipment lying about.
Don’t alter lighting beyond what would be safe.
This one is a bit tricky because, on the one hand, you’re going to want to leave lighting on inside the home for the purpose of helping your loved one to navigate the home environment. But, on the other hand, leaving the light on inside can signal to trick-or-treaters that you actually have a house that is worth visiting.
So, there can be some pressure to turn the lights down low in order to dissuade people from coming up to your door.
If you have good window treatments on the outside of the house or on the inside of the house, then you can turn the lights on inside without having to worry about that light penetrating to the outside.
If not, it might be better to retreat to an inner portion of the house where perhaps you can turn those lights on and leave the outermost lights off.
Don’t leave exterior or porch lights on, as it can signal the trick-or-treaters that yours is a house that you might that they might want to approach. (But, per my caveats, if you are in a burglary- or vandalism-prone area, then you may want to leave the lights on after all.)
Don’t over-decorate the house.
Don’t over stimulate your loved one. This can even include the opening and shutting of the doors.
If you are passing out candy, don’t overwhelm your afflicted relative with guests or parties inside the home (or outside of it, for that matter).
Dos
Do keep a careful watch over your loved one.
Do emphasize the lighthearted over the horrifying.
Do keep interiors well enough lit for safe passage.
Do remove the car from the driveway, if feasible. Placing it into the garage so that the house does not appear to be occupied.
HOWEVER… As I started off the video by saying, some of these tips have pros and cons. This is one such tip.
If you live in an area where you think that the house would be construed as vacant if it didn’t show signs of presence inside; or, relatedly, if you think that the lack of light or a vehicle might make the home more of a risk for a burglary attempt; then you obviously want to mitigate that risk by modifying or disregarding these sorts of tips.
So, again, you may have to adapt some of these tips for your own situation.
It’s also worth a discussion about whether your household should pass out candy or not. Obviously, if it’s going to disrupt the evening or if it’s going to disturb your Alzheimer’s-afflicted relative or loved one, then it’s probably not a good idea.
Some people advise placing candy outside, maybe in a bowl, and putting a sign on it that says, “Go ahead; take one; don’t ring the doorbell.”
Other people say, “No, you shouldn’t do that,” because candy left outside could be tainted or manipulated or stolen. Again, the sign could be interpreted as an indication that no one is home, which – depending on the area that you’re in – might be an invitation to criminals.
This is something you’ll have to figure out by yourself, given your situation.
Depending on your level of comfort, you might consider having someone else pass out candy for you. He or she could remain outside, provided that the weather is agreeable. If that person has whatever he or she needs, then this would reduce or eliminate the need to have to enter and exit the home very often. This would be a big help in terms of minimizing agitation. The question is: is it worth all that just to appease trick or treaters?
Do respond to signs of upset – whether this be due to overstimulation or agitation.
Some helpful tips are do set up some sort of a safe environment inside the house – a safe space, a room that’s especially quiet. You should have some quiet activities planned out and ready to go. These can be simple puzzles or photo albums. They could be familiar movies, music, and so on, or familiar books – something that you would be able to read to your afflicted relative.
Do reassure if necessary.
And do remove problematic decorations.
You might also consider just not being in the home (especially if you think you’re in a high traffic area). Different neighborhoods vary in this regard. Sometimes the neighborhood could be completely quiet and other times it might be extremely filled with activity.
Not to sound like a broken record but weigh the benefits of leaving against liabilities – for example if you think an unoccupied home would be a target. On the other hand, it might be a good idea to permanently relocate your loved one if they live in a high-crime area. Though, this is often easier said than done – especially if money is tight.
Disclaimers: First of all, there is no substitute for watchfulness any of the tips that I may provide are not supposed to be a substitution for diligently and vigilantly watching your loved one. Number two I am not a lawyer. I am not a doctor. I cannot give you specific advice I can give you specific Promises that any of the things that we will discuss will prevent injury and that is why watchfulness is so important.
Alzheimer’s is a degenerative brain disease that causes diminution of cognitive abilities, including memory, perception, and reasoning. As of this writing, Alzheimer’s Disease afflicts between 5.5 and 5.8 million people in the United States and between 44 and 47 million people in the world. It’s possible causes – discussed HERE – are not well understood. (There are widely mentioned RISK FACTORS.)
Various researchers, however, have suspected that at least some of the blame for Alzheimer’s can be placed on controllable things like diet/nutrition and exercise – both mental and physical. The general idea is that if you don’t “use it” (i.e., your brain), you might “lose it”![1] To that end, several sources have posited a slew of activities that are geared toward keeping you cerebrally fit. I’’ take a sort of “cocktail” or “grab-bag” approach.
Here is my list of the top twelve ways you might be able exercise your brain to prevent Alzheimer’s Disease. (See “Caveats,” below.)
Board and Card Games
An article in the British newspaper Independent related that “playing board games …could help” with mental decline – perhaps to an even greater extent than working crossword puzzles (about which, more in a moment).[2]
According to the results of one study that looked at brain scans: “Middle-aged people who [are] avid game players …[tend] to have bigger brains than people who [do] not play games…”.[3]
These more massive brains can confer a big advantage. Some people refer to this as “cognitive reserve.”[4]
Brain Teasers
“Brain teasers” are a type of game, usually consisting of problems, riddles, and the like of that that are solved usually for amusement. But what if they could serve a more useful purpose?
Numerous news outlets have reported on the possibility that various brain teasers, mathematics puzzles, and mysteries might help to enhance your cognitive health.
In the article “How to Outsmart Alzheimer’s,” Wall Street Journal columnist Amy Marcus reported that “quizzes and other cognitive challenges” might push back the onset of Alzheimer’s – “perhaps indefinitely.”[5]
So, reach for those puzzles and put your mind to work!
Chess
Chess is a two-player strategy game that has been around for hundreds of years. It’s played on a board composed of 64 squares of alternating colors. In total, there are 16 pieces per side (32 in all): eight pawns, 2 knights, 2 bishops, 2 rooks, 1 queen, and 1 king. Each type of piece has different rules governing its legal moves. The overall objective of the game is to “corner” (or “checkmate”) the opponent’s king in such a way as to leave it with no counterattack or means of escape.
Chess can be a very involved game with lots of subtlety and variety. It has competitive and social aspects (on the further benefit of which, see further on). But, on the other hand, it can be played over the internet without you (or your loved one) having to leave home.
Once again, some researchers suggest that “playing chess helps stave off the development of dementia.”[6] In fact, one study showed that playing chess “resulted in an almost 30% reduction in” dementia risk.[7]
Checkers
A two-player game, checkers is similar in some respects to the aforementioned chess. For instance, the board consists of 64 alternately colored – or “checkered” – squares.
Checkers is, however, played with 12 pieces per side instead of 16. Each piece is the same at the beginning of the game: simply a small, circular disk. The object of checkers is to “capture” or remove all (or at least most) of your opponent’s pieces or to leave him or her without any legal moves.
Although checkers has less variety in terms of pieces and moves, it is plenty rich in terms of move combinations and traps.
“Studies show games like checkers can boost your brain strength.”[8]
Crosswords
Admit it: Here’s the one you’ve probably been waiting for!
Simply put, a “crossword” is a kind of word puzzle. It is usually presented as a sort of grid with a combination of “empty” boxes and shaded boxes. The object of a crossword is to answer questions or use clues to fill in the empty boxes with words. Often, the words crisscross and interconnect in interesting ways – usually by sharing letters – which accounts for the name of this puzzle type.
Some investigations have suggested that working crosswords can boost mental ability and function.
Whether these activities affect age- or Alzheimer’s-related cognitive decline is an open question.
However, the National Center for Biotechnology Information, part of the National Institute of Health, published a study revealing that doing crossword puzzles delayed cognitive impairment – specifically, memory decline – by an average of two and a half years.[9]
Language
There’s a joke that goes something like this.
Question: What do you call a person who speaks three languages? Answer: Trilingual. Question: What do you call a person who speaks two languages? Answer: Bilingual. Question: What do you can a person who speaks only one language? Answer: American!
A quick Google search suggests that around 80-85% of Americans are monolingual.[10] Similar percentages apply in Canada. And the United States and Canada have some of the highest rates of Alzheimer’s Disease. For instance, it is the sixth leading cause of death in this country.
This is compared to approximately 45% of Europeans who are monolingual.[11]
Some research suggests that being bilingual can delay the onset of dementia.[12] For example, a 2013 article from CBS News is titled “Learning Another Language May Help Delay Dementia.”[13]
The article reported on a scientific study of various subpopulations in India. The suggestion was that speaking another language can push Alzheimer’s onset back an average of four to six years.
However, a key word is delay. Many people Belgium and Iceland are multilingual. However, both of those countries are in the top ten of nations with high percentages of Alzheimer’s dementia – according to WorldAtlas.com
In fact, Finland is the nation with the highest affliction rate. And a preponderance of the population appears to be bilingual to one degree or other.
Still, it seems reasonable to talk about a “protective effect of bilingualism.”[14]
Music
I have written a bit about how musical therapy can be a helpful intervention to explore when it comes to treating Alzheimer’s sufferers. (See my article “Can Music Calm an Alzheimer’s Patient?”)
A few studies have also led investigators to conclude that things like “playing musical instruments” can be better than working crossword puzzles or doing Sudoku. In fact, some suggest that this can “significantly reduce” a person’s risk.[15]
But for a more complete look at risk factors, see my video dedicated to that topic.
Puzzles
For those who weren’t introduced to these as children, jigsaw puzzles are basically jumbles of irregularly cut pieces (originally of wood, but now largely cardboard or plastic) that must be assembled in the correct order to reveal a pattern or picture. Pieces range in size from large (for small children or Alzheimer’s sufferers) to small (for people of normal to high cognitive function who may be looking for a challenge).
This deep into the article, you can probably predict what I’ll say next. “[J]igsaw puzzles …can help keep the mind active and a little sharper.”[16] (There are numerous kinds available. For my suggestions, see HERE.)
Reading
Some researchers believe that simply reading (books, magazines, etc.) frequently can have a protective and supportive effect on our brains. This could honestly be as mundane as picking up the daily newspaper. Or, for people who are more electronically inclined, visiting your favorite news website.[17]
If you walk to your local library, you could add a bit of exercise into the mix as well!
Social Interaction
According to a report from National Public Radio: “social interaction may be a better form of mental exercise than brain training,” where “brain training” refers to exercises designed to enhance processing speed and promote reasoning.[18]
Just “being around” other people can be of great benefit to Alzheimer’s sufferers.
Still, it is well to recall that causal direction is difficult to establish. Is it that social withdrawal leads to Alzheimer’s, or that Alzheimer’s leads to social withdrawal?
Sudoku
Here’s another – and more arithmetical – sort of puzzle: Sudoku. This Europe-originated puzzle with the Japanese name is essentially a reworked “magic square” in which numbers are inserted into a 9×9 grid. The object of the number game is to fill paper so that every column, row, and embedded 3×3 grid contains all numerals from 1 to 9.
One scientist stated: “…doing Sudoku isn’t probably going …to prevent you from developing Alzheimer’s disease” by itself.[19] Still, there’s little doubt from many investigators that “regular use of word and number puzzles” – like Sudoku – “helps keep our brains working better for longer.”[20] At least one scientific “study has identified a close relationship between frequency of number‐puzzle use and the quality of cognitive function in adults aged 50 to 93 years old.”[21]
If numbers are in your wheelhouse, give it a shot. If letters are more your thing, feel free to see our section on “crosswords,” above!
Working
You read that correctly. We’re talking about going to work.
Before you complain about your job, consider that, for many people, their job provides their “daily cognitive training.”[22]
This is to say that just going to work can have some neural-protective value.
Many jobs are going to present workers with daily brain challenges. These may include having data to enter, information to process, items to remember, things to multi-task, questions to answers, and so on.[23]
Now, if your nine-to-five has you on the verge of a panic-induced coronary, then you might want to seek stimulation elsewhere. But if your day job isn’t overly stressful or soul-sucking, then realize that it might be giving your brain an assist.
Caveats
When it comes to Alzheimer’s prevention, there are three divergent perspectives on the efficacy of mental exercise. These are as follows. (1) Mental exercise is possibly helpful. (2) Mental exercise is likely neither helpful not harmful. (3) Mental exercise is potentially harmful.
Objections
The third position – that mental can be potentially harmful – suggests a few objections to the strategies outlined above.
False Hope?
Firstly, some investigators worry that these considerations might give a person “false hope.” The idea, here, is – presumably – that someone might form beliefs such as that doing crossword puzzles has the power to confer some sort of magical protection against dementia, or that doing them could even reverse the disease. Sadly, these don’t seem to be the case.
But it seems to me that the solution is to have realistic expectations, rather than abandoning the idea of doing mental exercises.
Ineffective?
Secondly, and relatedly, some people object that these interventions are just plain ineffective. For example, in some studies – like regarding bilingualism – participants ended up getting Alzheimer’s anyway.
But this shouldn’t mean that the interventions are without value. It may be that we have to clarify what we mean by “effective.” If “effective” has to mean 100% protection against Alzheimer’s, then we might have to confess these interventions to be “ineffective.” But could mental exercises be “effective” at delaying Alzheimer’s?
Delaying onset of a disease seems valuable in and of itself. For example, if you can maintain a higher quality of life longer, wouldn’t you want to do it?
So, maybe playing checkers or working won’t guarantee that I never get Alzheimer’s. But if they (and other things) can help me to push onset back 2 years, 4 years, 6 years… it’s worth it to me.[24]
However, some people mention another facet of this objection. To put it directly, it’s possible that “incipient” or as-of-yet undetected dementia might prompt people to withdraw from social situations and to cease engaging in mentally stimulating activities.
On this picture, it’s not so much that you should exercise your brain to ward off Alzheimer’s. It’s more that once you reduce your level of mental engagement, it’s likely that you have Alzheimer’s – latently – already.
Of course, it is true that I don’t have any special insight into the mechanics or direction of the causation – if any – between mental exercise and dementia. It could be that dementia causes a lack of mental exercise; it could be that a lack of brain engagement causes dementia; it could be that they both have a third, presently unknown cause; or it could be that they are causally unrelated.
Still… only one of those possibilities suggests any direct way for me to influence my mental health positively. In the absence of some impelling reason for me to think that brain exercise isn’t at least possibly beneficial to me, I’ll continue to operate as though it might.
Counterproductive?
Thirdly, some commentators have spoken (or written) in such a way as to suggest that brain exercises could actually be harmful! A few titles make statements such as that mental training can “speed up dementia.” A few acknowledge that mental stimulation might buy time, but that it also accelerates decline once it begins.
There are a few things to be said.
Number one, insofar as these statements make it seem as if someone could be worse off for having exercised their brains, these summaries are a bit misleading. The “acceleration” of the decline can be explained as a simple matter of mathematics, provided only that the dementia is at least partially a matter of biology or physiology.
What I mean is this. Mental exercises almost certainly help boost or preserve cognitive function. But Alzheimer’s involves literal, physical damage to the brain. So, ultimately, mental exercises cannot undo physical damage.
However, through things such as by increasing “cognitive reserve,” they may be able to stave off the noticeable effects of the condition. But this means that once the effects of the condition do become noticeable, the disease may be “compressed,” and the decline may appear to be more rapid or steeper than it would have been otherwise.
Mathematically, this means that the decline is “quicker” either in that it happens over a shorter time, or that it occurs from a higher “starting point” – or both. This can be seen fairly readily from a simple curved-line graph.
In the graph, I show four different trajectories, all ending at age 80.
Red line: no exercise
The red line represents a person who doesn’t exercise at all, and whose decline begins at age 70. The decline concludes at age 80 – as it will for each of the four imagined scenarios.
Blue line: exercise preserves brain function
The blue line represents a person whose exercise preserves their cognitive function an extra five years. So, their decline begins at age 75. It still concludes at age 80.
Orange line: exercise increases, but doesn’t preserve
The orange line represents a person for whom exercise gives their brain function a boost. I didn’t also assume that this boost bought them any additional time. So, you see their decline begins at the same point as the person who doesn’t exercise at all: age 70. This is the person who has a “higher starting point.” The decline also ends at age 80.
Green line: exercise increased brain function
Finally, the green line represents the person for whom exercise both gives a boost to brain function and preserves it. Obviously, this is the best-case scenario. Since the brain function is boosted, the starting point is higher. Since it is preserved, I have their decline begin at age 75. Like everyone else, it stops at age 80.
Analysis
In this toy model, I have envisioned four scenarios, representing four possible combinations. (1) No boost to brain function and no preservation of brain function;[25] (2) preservation of brain function with no boost; (3) no preservation of function, but some boost; and (4) both preservation and boost.
In each of the four cases, we’re looking at people between the ages of 65 and 80. I have assigned arbitrary “brain-function points” between 100 and 400.[26] Furthermore, I have supposed that people start to decline beginning at age 70 or 75, depending on whether there is preservation or not.[27]
(You could either see these as representing four different, but relevantly similar, people. Or you could see it as representing four different possible trajectories for one and the same person. I prefer the latter.)
The four resulting combinations are as follows.
No boost, no preservation
The red line depicts a person who doesn’t engage in any mental exercise at all. The decline begins at level “300” (just an arbitrary number) and ends at level “100.” This is a difference of 200 points. It takes ten years, which means that they lose twenty points a year.
No boost, preservation
The blue line buys the person an extra five years of preservation. Since they hit the same level – level “100” – at the end, their decline occurs twice as fast as for the person who didn’t exercise. They drop 40 points per year, which is twice the rate of decline. This is because the same amount of decline (as occurred with red) is compressed into half the time.
Boost, no preservation
The orange line shows a person with a bit of a boost (getting them to 400), but no extra time before decline begins. They start higher, but end in the same place, dropping 300 points in ten years. This yields a rate of 30 points per year. The amount of decline (compared with red) is 1.5 times greater (150%) but is stretched over the same length of time (as red).
Boost, preservation
The green line shows a person with both boost and preservation. This person bought an extra five years before visible decline. But they also have the extra “100 points” of function. So, their decline starts at a later age (compared to red) – age 75 – and from a higher starting point (again, compared with red) – 400 points. Since they decline 300 points over five years, their rate of decline is 60 points per year.
Conclusion
That we see “higher rates” of decline in the exercisers is due to either (or both) of two factors.
Factor 1: The decline happens over a shorter span of time (as with blue and green); or…
Factor 2: The decline happens from a higher starting point (as with orange and green).
I said earlier that the explanation for the higher decline rates was mathematical. When a predetermined amount of decline happens over a shorter time frame, the rate of decline is increased. This is mathematical in this sense. Take some number, n. n divided by 5 is going to be bigger than n divided by 10.
Moreover, when a predetermined endpoint of decline is reached from a higher beginning point, the slope of the line representing that decline is steeper.[28] This is also mathematical, since the slope of a line is merely a value (m) in the equation representing that line. So, if the cognitive “drop off” is steeper, all we’re saying is that the value of slope (m) for that drop off is a bigger number than it is if the drop off were not as steep.
At the end of the day, for me, I would rather have my cognitive function preserved for as long as possible – and boosted as high as possible – even if I experience an eventual decline.[29]
Curiously, you could even argue that having a “quicker” or “higher” rate of decline is preferable to a slower rate in that it likely saves caretaker energy as well as money devoted to care!
Training Is Parochial
Fourthly, you may read that certain forms of “brain training” are very limited in terms of what they accomplish. Even where certain mental exercises may be worthwhile, their impact may be restricted. To put it another way, specific benefits may not generalize to other areas of your daily or mental life.
For example, reading books may help boost your processing speed, but maybe doesn’t help enhance your memory. (It’s just an illustration; I don’t know whether it does or doesn’t.)
Somewhere I read a researcher giving the following analogy. Some brain exercises can be likened to working out physically by doing only one or two exercises. These exercises – like bicep curls – may strengthen a single muscle (the biceps), but they are unlikely to impact the overall health of the body much.
A few things may be said in reply. Number one, you can make the case that doing a few exercises is better than doing none. A person who does biceps curls may not be as fit or healthy as a person who trains his or her whole body. But he or she may well be more fit or healthy than he or she would be if they did nothing at all.
Number two, whether a given exercise has broad or narrow impact may depend on the sort of exercise being done. In physical training, there are differences between compound and isolation exercises. It’s one thing to do bicep curls or grip strengtheners all day long. It’s another to do deadlifts or squats. The former may only affect one or two muscles; the latter might well affect the entire body. It is doubtful that we know enough about “brain training” to really understand the broader impact of a lot of the mental exercises discussed here. For example, is playing chess more than doing bicep curls, or more like doing squats? I’m not sure. And I’m not sure that anyone else is sure, either!
Blame the Victim?
Yet another objection, fifthly, is that talking about mental exercise may lead to sufferers being “blamed” for their Alzheimer’s. The idea here is that some people might conclude that if John Doe has dementia, then he must have been mentally inactive or lazy.
Sometimes you may read comparisons to smoking. People who smoke are at higher risk of lung cancer. So, if a smoker gets lung cancer, then he or she assumes some of the responsibility for that condition.
By way of response, I should first remind readers that Alzheimer’s risk almost certainly has a – probably a significant – genetic component. (See my video about risk factors HERE; or read the article on the same topic HERE.) To put it differently, some people are simply more at risk than others of developing it.
Having said that, I will simply repeat what I have mentioned many times in my written and video-graphic work: I am trying to stack the odds in my favor. I realize that if I smoke, I’ll be at increased risk for lung cancer. Although the data may not be as clear cut for the relationship between mental exercise and dementia, I’ll say that for me personally I’d rather exercise, and have it avail me nothing, than not exercise and have it turn out that it would have helped me.
If other people value other things over exercising, then I would suggest that it is their prerogative to do so. In the first place, the data in favor of mental exercise is not so compelling as to make it undeniable that it helps preserve or boost cognitive function or that it can ward off Alzheimer’s.
But even if the data were that compelling, it’s not clear that someone has to value preserving or boosting cognitive function or must value warding off Alzheimer’s, over not doing any of these. I confess that such a position would be foreign to my own thinking. But it’s not something that moves me to start throwing words like “blame” around.
I suppose you could put my answer this way. If a person doesn’t perform mental exercises, it’s either because they don’t think it will help or they don’t care if it helps or not. If they don’t think it will help, then their choice not to exercise is rational. They have discharged their rational duty and it’s not obvious to me that there’s anything to blame them for.
If they don’t care, then the choice itself may be irrational (i.e., not rational). But it’s not clear why a person choosing irrationally in this way wouldn’t care if exercising helps but would care if they’re “blamed” for not caring. It seems to me more likely (or at least more consistent) if they didn’t care about either one. So, even if the choice is blameworthy, it doesn’t appear to have the result the objector is worried about. It seems that the concern in the objection is centered on the perceived hurt feelings of the person being blamed. But, to reiterate: for all we know, the person who doesn’t care about not exercising wouldn’t care about being blamed for not exercising. If this is so, then it’s not obvious that there would be any hurt feelings for us to worry about.
Conclusions (Tentative)
One article ventured the opinion “that lifestyle choices may even counteract genetic predisposition for Alzheimer’s.” If true, that’s huge.[30] And it would put a lot of control in our hands.
Here are a few takeaways.
Train the Whole Brain
But staying mentally fit and sharp may really come down to neural recruitment: using multiple parts of your brain, not just a few.
Be Consistent
It’s also going to involve consistency. Many reports mention the need to engage in stimulating activities regularly – say two or more times weekly – not just every blue moon.
Try Something New
Another key element is novelty. Sometimes trying something new may be more valuable than doing the same things over and over. There may be two “levels” of novelty. Think about some of the things on this list. For example, chess or reading. Every game of chess you play has the possibility of being different from every other game. And if you read new articles or books every day, you are adding some variety. However, we might call this low-level variety. A higher level of variety can be attained if you learn a new language or musical instrument, for example. Interestingly, there may be a kind of middle level as well. For example, a person could switch from reading fiction to nonfiction, or from reading prose to reading poetry.
Act as Though It’s ‘Use It Or Lose It’
As the Independent put it: “use it or lose it” idea may just “give a person a ‘higher starting point’ from which to decline.” But this still seems advantageous.
Realize: ‘Better Late Than Never’
Some commentators express the message that its always “better late than never.” But you should probably take the position that it’s desirable to start now! This applies to you whether you are a sufferer or a person looking to avoid the condition altogether.
No Silver Bullets
Still, neither I nor most other researchers are suggesting that any of these measures amounts to a “cure.”
Aim to Have a Healthy Lifestyle
Additionally, these mental activities almost certainly need to be situated in a larger context – a “lifestyle package,” as it were. Genetic predisposition notwithstanding, if you really want to stack the odds in your favor, you’ll need to address your blood pressure, body mass, cholesterol, diet, level of physical exercise, and sleep patterns.
I can tell you that I’m implementing a number of these measures today. Most of the items on this list are cheap (or free) and easy to obtain. And after all that’s been said, I think it’s reasonable to maintain that they can’t hurt. And some of them just might help. So…go on: give your brain a good workout!
[4] See, e.g., Margaret Gatz, Educating the Brain to Avoid Dementia: Can Mental Exercise Prevent Alzheimer Disease?” Public Library of Science, vol. 2, no. 1, Jan. 25, 2005, p. e7, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC545200/>.
[9] According to Jagan Pillai, Charles Hall, Dennis Dickson, Herman Buschke, Richard Lipton, and Joe Verghese, “Association of Crossword Puzzle Participation with Memory Decline in Persons Who Develop Dementia,” Journal of the International Neuropsychological Society, vol. 17, no. 6, Nov., 2011, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885259/>.
[21] Helen Brooker, Keith Wesnes, Clive Ballard, Adam Hampshire, Dag Aarsland, Zunera Khan, Rob Stenton, Maria Megalogeni, and Anne Corbett, “The Relationship Between the Frequency of Number‐Puzzle Use and Baseline Cognitive Function in a Large Online Sample of Adults Aged 50 and Over,” International Journal of Geriatric Psychiatry, vol. 34, no. 7, publ. in print Jul. 2019, pp. 932-940, publ. online Feb. 11, 2019, <https://onlinelibrary.wiley.com/doi/abs/10.1002/gps.5085>.
[22] “A Brain Scientist Who Studies Alzheimer’s Explains How She Stays Mentally Fit,” loc. cit.
[24] Again, onset detection is not a little tricky.
[25] Both ideas – “boosting brain function” and “preserving brain function” – are a little vague and would need to be sharpened to be of greater use. However, my model is merely trying to show that the “higher rates of decline” spoken about in some articles might well be nothing to worry about. So, I have abstracted away from some of the details because I don’t think they’re necessary for the point.
[26] This raises the issue of how we would actually be able to measure cognitive ability. There are various assessment tests. But it is possible that these assessments fail, for one reason or other, to paint a true or complete picture of a person’s cognitive situation. This is simply a model.
[28] I realize that I opted to display the graph with curved lines. This was simply an esthetic choice since when I used straight lines, the lines overlapped in places and couldn’t be easily distinguished. The information is simply sample and hypothetical data for illustrative purposes only. It could be represented with straight lines. And if it were represented this way, then the resulting lines would have calculable slopes in the usual sense.
[29] As a side note, the red line also represents a case in which a person exercises, but it fails to boost their brain function or preserve it at all. So, you’ll notice that if the exercises are utterly ineffective, you’re no worse off than you would be had you not exercised at all. You might think that you would have wasted your time. I suppose this boils down to whether you find any of the exercises enjoyable – or potentially enjoyable – or not. But even still, personally, it strikes me as improbable that mental exercises would do nothing whatsoever. Readers may think differently.
[30] More scientific study and philosophical reflection is needed, however. Some studies abstract away from possibly relevant data, including economic, educational, genetic, intelligence, and sociological factors.
