Among the many unfortunate side-effects or symptoms of Alzheimer’s (and other forms of dementia) is the susceptibility of the afflicted individual to false beliefs and inaccurate perceptions. This was made painfully evident to our family in dealing with my dad, Jim. I mention a few specific illustrations of this further on. For more detailed accounts, read “Jim’s Story.”
But, Jim was hardly unique in this regard. So, as I have said numerous times in this weblog: what follows is the resource that I wish I had had when I was managing occurrences of paranoia in my dad’s house. I hope that it can help you and your family dealing with what is an extremely difficult aspect of the disease.
Definitions
Hallucinations
Medically, a hallucination is defined as follows. “The apparent, often strong subjective perception of an external object or event when no such stimulus or situation is present; may be visual, auditory, olfactory, gustatory, or tactile.”[1] So, an Alzheimer’s-afflicted person may perceive insects, pests or the like of that, where there in fact are none. (But check the claims out first! See Tip # 3.)
Delusions
Similarly, a “delusion” is “[a] false belief or wrong judgment, sometimes associated with hallucinations, held with conviction despite evidence to the contrary.”[2] Delusions are far more common than hallucinations. There are many relevant sorts of delusion. As recounted elsewhere, Jim falsely believed that my children (then around the ages of 6 and 8) were stealing from him and leaving their toys in his personal space. Now, there’s no question that kids leave toys around. And my kids were no exceptions. But my mom used to teach kindergarten-age children. And what my dad falsely believed were my kids’ toys, were actually learning games (and so on) that my mom was storing at home.
Tips
Remain calm. You will only worsen the situation by loosing your cool. Additionally, Alzheimer’s sufferers (among others) pick up on – and feed off – your own emotional state. So, try to keep your reactions in check. It’s easier said than done, I realize. But it’s importance cannot be understated. It is a key point.
Draw near to your loved one. There is something to be said for just “being there.” Sometimes maintaining proximity can by itself defuse the situation. It’s said that people’s three favorite words are “please,” “thanks,” and our own names. On the assumption that this bit of psychology is not rendered worthless by the Alzheimer’s, try trading on it. If they don’t respond to the usual forms of address (“it’s okay, mom”; “I’m here, grandpa”; etc.), then see if their given name will snap them out of it.
Investigate the claims. Sure, your loved one’s cognition is “off.” We know this is true. It is not uncommon for a cognitively impaired individual to experience perceptual difficulties. However, as the saying goes: Even a blind rooster picks up some corn. The fact that mom or grandpa is prone to false beliefs does not mean that every utterance is false. So, before you just assume that there really is no spider on the bed, it’s probably best to check to make sure.
Express concern, empathy, reassurance, understanding. For dementia patients, it’s not always what you say, but how you say it. You may have to modify your approach depending on the person’s level of function. But, some suggestions include statements such as: “I’m so sorry that you are having such a [bad, painful, scary] experience,” “I can’t imagine what you are feeling right now,” or “I cannot fully relate to what you are experiencing, but you should know that I am here for you.” While you’re investigating – or while you are following any course of action – say encouraging or comforting things.
Distract/redirect. After you have investigated and decided that the relevant claim (whatever it was) is baseless, then you can put some energy into trying to help your loved one get the uncomfortable thought out of his or head. There are several tacks that you could try. Maybe it’s close to time for a meal – or at least for a glass of water. You could also try turning on some music. (See “Can Music Calm an Alzheimer’s Patient?”) Along similar lines, you could try switching on the television. Or perhaps you could draw his or her attention to some old photographs, read out of a book or newspaper article, or take him or her on a walk.
Turn off background noise. Of course, the previous suggestions assume that the radio or television are not already on. If dad’s delusions or grandma’s paranoia arouse amidst some level of background din, then consider quieting things down. Lower volume controls or power off electronic devices entirely.
Take your loved one to the doctor for a checkup. Granted that Alzheimer’s can issue in delusory beliefs and hallucinatory perceptions, it is a fact that other conditions may cause similar symptoms. For example, a urinary-tract infection (or any ailment that makes a person feverish) can derail a person’s belief-forming mechanisms. The bottom line is this: Just to be sure about the etiology, have your loved one evaluated by a medical profession. Prescriptions may be another factor. If there has recently been a dosage or script change, these alterations could be relevant to the behaviors that you are dealing with.
Don’t take any negative reactions personally. The fact that an Alzheimer’s sufferer has a proclivity to react badly needs to be kept clearly in mind. Take it in stride. My dad owned a baseball encyclopedia that he purchased in 1969, when he was around 39 years old. When I was about 13, he bought an updated version for me. I had in in my possession for decades. At one point, when we were all dealing with his dementia, he took the updated book off my shelf and claimed that it was his. He insisted that I return it. Truthfully, it hurt my feelings because his giving it to me had been a special memory. I felt that it must not have been important to him. But this reaction, while understandable, was unfair. His brain was being ravaged by a disease that was, to put it somewhat artfully, “deleting” memories from his hard drive. Yes, he had confused his book and mine. But he did not do this spitefully. His own book had meant something to him, and this memory (crossed up as it was) had been what he acted upon.
Keep to the daily routine (as much as possible). If your loved one is anxious or scared, familiar behaviors or objects can be a great comfort. When paranoia strikes, try to steer your charge back to the usual activities. If it’s time for dinner, then set the place settings as you normally would. Leverage the schedule to help “reset” things and calm everyone down.
Note patterns. If grandpa becomes agitated or confused after morning coffee, then try switching to decaf.[3] If mom gets skittish in the evening hours, then you might be contending with an ancillary condition known as “sundowners.” Perhaps grandma is set off when the postal truck passes by the window. Or it might be that dad’s episodes begin after visits from one particular nurse. Perhaps events occur during the grogginess that lingers after an afternoon nap; or maybe they happen following a sleepless night.[4] Any of this information could help you to understand, anticipate, and deal with the relevant delusions. Plus, it will give you further detail to disclose to medical professionals.
Let them take their time. You want the delusional or hallucinatory experience to conclude. Toot sweet. And I get it. But, don’t rush them. It’s irritating, scary or uncomfortable for you loved ones as well. It’s important to “de-stress” the circumstance, not inflame matters. Placing them under time constraints – whether explicit or implicit – will therefore be counterproductive. The ramp up in pressure typically will not go unnoticed. It will merely increase the felt frustration by all parties and prolong the event.
Of course, these suggestions are not magical. The paranoid incident will pass with time. The best that you can do sometimes is simply to be present and loving. But also bear in mind that persistent or recurring delusions/hallucinations may require pharmaceutical (or other) interventions. So, your loved one’s physician should be kept in the loop. (See, again, Tip #7.)
Step 1: Ensure That You Have a Source of Lifetime Income
As retirement expert Tom Hegna has argued, in order to retire happy, you need a basic level of guaranteed, lifetime income. At a the most fundamental level, this sort of income is provided by Social Security (on which, more below).
However, Social Security should not be the sum and total of your retirement plan. For one thing, there are grave doubts about the solvency of the Social Security system. For another thing, many people find that their benefits under Social Security are insufficient – in and of themselves – to provide them with the sort of retirement that they would like to have.
If you are lucky enough to have been employed by a company that still has a defined-benefit plan, then this will be another piece of your retirement plan. These defined benefits, or pensions, are literally gold for those who have them. However, in today’s work environment, they are (unfortunately) a bit like the fabled chimera.
In most cases, therefore, it is necessary to create your own pension by purchasing one or more annuities. Simply put, an “annuity” is a financial instrument that protects a person against living too long. It is any vehicle – like pensions and Social Security – that have a pay-in period (during which a person puts money into the annuity) followed by a pay-out period (during which a person receives payouts – possibly for the rest of his or her life).
There are numerous sorts of annuities: fixed, equity-indexed, and variable. Each type has its own potential risks and benefits. But the long and short of it is that one essential piece of the happy-retirement puzzle is not having to worry about your income stream. And annuities, of one kind or other, play a huge part in delivering that sort of peace of mind.
To really explore what products and solutions might be right for your situation, you will need to consult with a licensed insurance agent in your area.
For more general information, see Tom Hegna’s print book, Paychecks and Playchecks (Boston: Acanthus, 2011), or his audio book of the same title.
Step 2: ‘Buy out’ Your Heirs… Early
There are two main worries that people have about spending all of their money during retirement. Some people worry about spending all their money because then they’ll run out of it for themselves! Pretty straightforward. This is where the idea of guaranteed lifetime income comes into play (see above).
But others worry about spending all their money because they want to be able to leave something on to their kids or grandkids.
So, as Tom Hegna humorously puts it: These people don’t buy the boat, join the country club, take the vacation, etc. And, indeed, they manage to leave some money on to their kids. And what do the kids do? They promptly buy the boat, join the club, take the vacation…!
Does this mean that you should not leave a legacy? Absolutely not! By all means, leave a legacy. But do it smart. Don’t leave cash; leave life insurance.
The reason is a simple matter of dollars and cents. Literally. Cash left on is dollar-for-dollar, at best. This means that if you put one dollar aside for your heirs, they will get one dollar – in the best-case scenario. In the more usual scenario, for every $1.00 you leave on in a tax-qualified account, like an IRA, your heirs will get about $0.75 (assuming a 25% tax bracket). So if you leave $100,000 in your 401(k), your tax liability would be in the vicinity of $250,000.
But life insurance can be purchased for pennies on the dollar (when you consider premium outlay versus death benefit). Put it this way: for every $1.00 you spend on life insurance premium, your heirs might get $1.50, or $2.00, or $3.00 – depending on your age, health, and overall risk classification.
With life insurance, your dollars go further. But, that’s not all. Life-insurance proceeds are also tax-free to your beneficiaries.
Consider a hypothetical case. Suppose that you’re dead and that you’re surviving spouse later dies, leaving $100,00 of unspent money in an IRA. The kids are the designated non-spousal beneficiaries. Let’s make an assumption and say that they’re in the 25% tax bracket. This means that, of the $100,000, the Internal Revenue Service will take $25,000 right off the bat, leaving only $75,000 to go to the kids. While few people would turn their noses up at $75,000, still, you had to leave $100,000 in order to give them $75,000.
With life insurance, you have two options. Maybe you want to hold fixed the fact that you have $100,000 taxable dollars to spend on your legacy. So, after tax, you take your $75,000 and purchase a single-premium life-insurance policy. Conservatively (and the details depend on your age, health, and overall risk classification), that $75,000 deposit will likely buy you between $100,000 and $175,000 in death benefit. And the death benefit is tax-free to your beneficiaries.
On the other hand, if you wanted to hold fixed that your heirs actually received $75,000. In this case, you might put $35,000 to $60,000 into a life policy and expect that you could get the desired $75,000 death benefit. But, contrast this outlay of money with the IRA illustration. In the case of the IRA, recall, you had to leave $100,000 in the account in order to give your kids $75,000. With life insurance, you might only have to spend between $35,000-$60,000 to give them the same $75,000. So, the obvious question is: Would you prefer to spend $100,000 to get $75,000 to your kids, or would you rather spend $35,000 to $60,000 to accomplish the same end?[1]
Think of life insurance as a legacy-building “coupon.”
Step 3: Maximize Social Security and Medicare
For some people who are fully paid into Social Security (SS), the payable benefits throughout retirement could approach $500,000 (for a single person).[2] That’s a considerable chunk of change. Do you know how to maximize and protect your SS benefits?
You need to learn about – and, as I said, learn to maximize – your SS benefits.
For example, for a lot of people, SS payouts double between the ages of 62 and 70. It can really pay (literally) to wait to elect benefits – especially for the primary breadwinner.[3]
But, do you have the financial resources to wait until 70 to elect SS benefits? Wouldn’t that mean that you would have to postpone retirement until age 70? It depends.
The Two Bridges strategy might be the answer.
It is possible to plan so that you have an alternative stream of income from 62 to 70. So, suppose you retire at 62. You’re no longer earning income through regular employment. But, you also realize that you should wait until 70 to elect your SS benefits.
The first bridge is a way to get you from 62 to 70, without your having to take your SS payments early (thus leaving a lot of money on the table). If you had an annuity in place – with, say, an 8- to 10-year payout schedule – you could live off the annuity while you waited to collect your full retirement benefit from SS.
Note carefully that, for a married couple, only the greater of the two SS payouts is retained after one person’s death. The lesser payout is lost.
The second bridge, therefore, has to do with getting from the death of the first spouse to the death of the other. What do you need? You may have guessed it: another annuity. Though, this one will have to have longer than a decade-long payout schedule. This one is going to have to be a big one – to provide you with guaranteed income for the remainder of your life.
Do you see a recurring theme? You cannot depend on SS alone. And, as Hegna stresses, it’s not about your assets, per se. It’s about guaranteed lifetime income. If you’re lucky enough to retire from a company that still has a defined-benefit (or pension) plan, fabulous! But, if you’re like a growing number of retirees, pensions are like dinosaurs. They don’t exist anymore. It’s up to you.
Step 4: Make a Provision for Private, Long-Term Care Coverage
To protect yourself against the possibility that Alzheimer’s Disease might decimate your retirement savings requires that a few more pieces be put into place.
You need to have some sort of provision for long-term care (LTC). I have written about this at greater length, HERE. But, suffice it to say that LTC isn’t cheap. If you wonder how you can afford LTC insurance, I’d submit that you should give at least some thought to how you could afford not to have it.
After all, LTC costs can average $100,000 per year, nationwide. Nursing home residents might stay between 2-4 years, on average. That means that the average cost of care could run between $200,000 to $400,000 – per person. A married couple, both of whom need care, might spend upwards of $400,000 to $800,000. Memory care often costs significantly more. And these are just averages.
There are only three ways to pay for nursing-home expenses. You either: “private pay” from your own resources; go through the dreaded “spend down” in order to qualify for Medicaid; or utilize long-term-care insurance.
Neither health insurance nor Medicare cover long-term or “custodial” care costs. Both health insurance and Medicare cover doctor, hospital, and skilled-nursing costs – up to certain limits.
But what is envisioned by “long-term care” is what you will need when you can no longer toilet by yourself, or if you were unable to transfer in and out of bed by yourself.
If you are able to perform any of these “Activities of Daily Living” (ADLs), on your own power, then you would require long-term – that is, custodial – care.
What’s your plan for that?
If you are counting on your children caring for you, the obvious first question is: Have you had that conversation yet? Wiping your butt or feeding you is a lot to put on a child – who might have other dependents of his or her own. God forbid that there is a memory or behavioral problem in addition. I speak from experience.
I was sometimes in the unhappy situation of having to correct or restrict my dad, Jim (read his story, HERE), when he would engage in an activity that posed a danger for him or others. Unfortunately, usually, he remembered that he used to perform these activities. He also remembered that he used to discipline me. So, he resented my efforts and resisted them – at every turn – as unwelcomed intrusions.
He and I would clash, therefore. And the dynamic – especially since I was also caring for two young (4- / 6-year-old) children – cast a pall over the home environment. I was physically ill several times because of the stress.
And I had no one to turn to. The Alzheimer’s Association representative recommended that I call the police when my dad got out of hand. On one occasion, I did so. The police were dumbfounded as to why I had called them and asked, plainly vexed, “What do you want us to do?” I confess that I had no good answer.
But my family had no back-up plan. When Jim became too difficult to deal with, and when his meager financial resources were depleted, Medicaid was the only game in town.
The government took everything that my dad had – including his Social Security check – and forced my mom to spend down her own retirement account to virtually nothing (about $30,000).
My dad’s experience with Alzheimer’s was harrowing. But my mom is the one who now has to live with the financial repercussions. As of this writing, she is 66 years old and has insufficient resources to retire – period. Realistically, she will have to work until she dies, or need long-term care herself.
There’s a saying that it is well to bear in mind. “People seldom plan to fail; they fail to plan.” There are no two ways about it. You need some provision for long-term care.
[1] On the assumption that you came in between $40,000 and $60,000 for a $100,000 death benefit, you would be free to spend the remaining $60,000 to $40,000 yourself. And you would have still secured the $100,000 legacy. That’s the power of buying your heirs out early.
[2] That’s around $1,000,000 for a married couple.
[3] The reason is the larger of the two payouts will be retained after the death of one spouse. So, as Tom Hegna puts it, in effect, the larger payout will cover “two lives” – the life of the primary breadwinner during retirement, and the life of the surviving spouse after one person’s death.
Do Alzheimer’s-Afflicted Drivers Cause More Crashes Than Other Drivers Do?
“There are more than 40 million licensed drivers ages 65 and older in the U.S. And while driving can help with mental sharpness and independence, 16 older adults are killed in crashes every day.”[1]
Between “4.5 million” and 5.5 million people – over “…10 percent of those over 65 years and nearly 50 percent of those over 85 years [–] suffer from … [Alzheimer’s] disease).”[2]
Introduction: The Short Answer
There is no question about it: the U.S. populations is aging. Moreover, there are some not-so-rosy projections about the number of people expected to develop Alzheimer’s over the next several decades. All of this has the makings of a real traffic disaster, if it is the case that Alzheimer’s sufferers are more dangerous than other drivers. But are they more dangerous?
One public-information liaison advised: “…cognitive impairment from Alzheimer’s (or any other cause) is associated with an increased risk of traffic crashes[,] but the specifics have been hard to pin down for a lot of reasons, including that the disease is progressive.”[3] On the other hand, according to a Maine-based medical-review coordinator, Mild Cognitive Impairment, or MCI, “…statistically …carries no increased crash risk.”[4]
A Bit More Information
Things get even trickier, because: “In the US, there is no method for following patients with dementia over the long term while simultaneously following their driving record. As the disease progresses, patients and their families self-police whether the person should be driving or under what conditions they may drive [For an overview of the usual process, see HERE] – this means their exposure may decrease, particularly for night driving, highway driving, etc. This makes determining the risk for a given patient even more complex. The large part of the data on the topic comes from the medical literature.”[5]
When I wrote to the National Highway Traffic Safety Administration, a representative replied that “NHTSA does not have any info on driver health issues in our crash data systems. If you have any further questions regarding crash data, please feel free to email the National Center for Statistics and Analysis directly.”[6]
Likewise, the National Transportation Safety Board (NTSB) responded: “We do not keep these stats.”[7]
However, the NTSB’s media point man offered a little more detail.
He stated that “[t]he NTSB has not recently (last 6 years) investigated an accident involving a driver with dementia.” But, he said, NTSB “did complete a study quite some time [i.e., about 14 years] ago…,” as of this writing.[8]
National Transportation Safety Board Data
In the research results, a smattering of references were made to dementia in general, or Alzheimer’s in specific. In what follows, I will excerpt some of those references.
Firstly, the report stated: “Researchers have attempted to estimate the increased crash risk for medically high-risk drivers.[9] A comprehensive longitudinal study of restricted and unrestricted drivers with high-risk medical conditions[10] found that medically high-risk drivers generally had a higher rate of at-fault crashes when compared with matched controls, but that the relative risk differed greatly depending on the condition… For example, unrestricted drivers with cardiovascular disease had an at-fault accident risk equal to that of drivers in a comparison group, whereas unrestricted drivers with learning, memory, or communication deficits (such as Alzheimer’s disease and mental retardation) were 3.32 times more likely to cause an accident than drivers in a comparison group. The authors recommended that licensing authorities place greater consideration on the functional ability categories that show a higher risk of crashes (such as learning and neurological and episodic conditions) or that comprise a greater number of drivers.”[11]
The report further acknowledged the obvious point that “[s]ome high-risk medical conditions, such as Parkinson’s and Alzheimer’s disease, change over time, necessitating regular followups. [sic] Studies show that drivers over 65 with degenerative medical conditions do self-regulate to a limited extent, but that many continue to drive despite poor health.”[12]
Are patients generally honestly appraising their own diminishing driving abilities? Unfortunately, it appears that they are not. “A study of patients with Alzheimer’s disease found that although …[some] patients tended to restrict their driving habits, many continued to drive despite their caregivers’ perception that they should discontinue driving altogether. …[A]ttention deficits were significantly associated with an absence of self-imposed driving restrictions. Witnesses at the Safety Board’s hearing favored an active role by physicians and close associates in determining the driving fitness of a medically high-risk individual.”[13]
Finally, as I have written about elsewhere: “Every State has laws that regulate the driving privileges of medically high-risk drivers. Many place license restrictions on these drivers in an attempt to lessen the risk to all road users while granting the medically high-risk drivers some mobility. Disagreement currently exists among experts and in the literature regarding the merits of restricted licenses. The data in table 248 suggest that drivers on restricted licenses still present a hazard to the motoring public.”[14]
Hence, currently, the processes being advanced as solutions are all state-specific. However, not all states have the same sorts of interventions or procedures. For instance: “Agencies from [only] nine States noted that they have specific courses or educational material to train officers in identifying symptoms of Alzheimer’s disease.”[15]
Tentative Conclusion
Hence, more data is surely needed. However, from the limited information that is available, it appears that the intuitive answer is the case. Cognitively impaired drivers (for example, those with Alzheimer’s or other forms of dementia) cause more accidents and are therefore more dangerous than non-cognitively impaired drivers.
Additional Resources:
For a general introduction to the legalities of driving with some form of dementia, see:
For ALZHEIMERSPROOF’s guide to State laws concerning driving with Alzheimer’s Disease, non-specific dementia, or Mild Cognitive Impairment, click below:
[2] National Institute on Aging, Progress Report on Alzheimer’s Disease, 1999, NIH Publication No. 99-4664, Bethesda, MD: National Institute on Aging, 1999; quoted in Medical Oversight of Noncommercial Drivers, Highway Special Investigation Report, Washington, D.C.: National Transportation Safety Board, 2004, p. vii.
[3] Christopher T. O’Neil, Chief of Media Relations, National Transportation Safety Board. Emphasis supplied.
[4] According to Thea Fickett, Medical Review Coordinator, Maine Bureau of Motor Vehicles.
[9]Medical Oversight of Noncommercial Drivers, Highway Special Investigation Report, Washington, D.C.: National Transportation Safety Board, 2004, p. 13; citing T.D. Koepsell, M.E. Wolf, L. McCloskey, D.M. Buchner, D. Louie, E.H. Wagner, and R.S. Thompson, “Medical Conditions and Motor Vehicle Collision Injuries in Older Adults,” Journal of the American Geriatric Society, vol. 42, no. 7, 1994, pp. 695-700; G. McGwin, R.V. Sims, L. Pulley, and J.M. Roseman, “Relations Among Chronic Medical Conditions, Medications, and Automobile Crashes in the Elderly: A Population-Based Case-Control Study,” American Journal of Epidemiology, vol. 152, no. 5, 2000, pp. 424-31; and C. Owsley, G. McGwin, and K. Ball, “Vision Impairment, Eye Disease, and Injurious Motor Vehicle Crashes in the Elderly,” Ophthalmic Epidemiology, vol. 5, no. 2, 1998, pp. 101-13.
[10] Ibid., citing E. Diller, L. Cook, E. Leonard, J. Reading, J.M. Dean, and D. Vernon, Evaluating Drivers Licensed
With Medical Conditions in Utah, 1992-1996, DOT-HS-809-023, Washington, DC: NHTSA, 1999, n.p.
[12] Ibid., p. 15; citing Testimony of Dr. Dana Clarke, Chairman of the Utah Medical Advisory Board and Director of the University of Utah Diabetes Center, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003 and A. Dobbs and B. Dobbs, The Unsafe Older Driver: Identification, Assessment and Minimizing the Negative Consequences of Loss of Driving Privileges, Continuing Education Seminar sponsored by the Canadian Psychological Association and the American Psychological Association, 2003.
[13] Ibid., p. 16; citing V. Cotrell and K. Wild, “Longitudinal Study of Self-Imposed Driving Restrictions and Deficit Awareness in Patients with Alzheimer Disease,” Alzheimer Disease and Associated Disorders, vol. 13, no. 3, 1999, pp. 151-6.
[14] Ibid., p. 16; citing Diller, et al., Evaluating Drivers Licensed With Medical Conditions in Utah, op. cit.
We’ve heard for a while now that red wine is good for our hearts. In 2002, the London School of Medicine’s Dr. Roger Corder declared: “Moderate consumption of red wine is likely to prevent heart disease.”[1] Moreover, in the same year, the prestigious journal The Lancet published a study with the following description: “Light-to-moderate alcohol consumption reduces the risk of coronary heart disease and stroke. Because vascular disease is associated with cognitive impairment and dementia, …[researchers] hypothesized [sic] that alcohol consumption might also affect the risk of dementia.”[2] Their finding? “Light-to-moderate drinking (one to three drinks per day) was significantly associated with a lower risk of any dementia …and vascular dementia… .”[3]
However, even though some investigators do maintain that occasionally having a drink isn’t too bad, some of the same researchers also hasten to add that excessive drinking can lead to alcohol-related dementia. For example, in 2018, a group of scientists “aimed to examine the association between alcohol use disorders and dementia risk, with an emphasis on early-onset dementia…”.[4] They concluded that, of the “cases of early-onset dementia” that they examined, “…most were either alcohol-related by definition …or had an additional diagnosis of alcohol use disorders… . Alcohol use disorders were the strongest modifiable risk factor for dementia onset…”.[5] The study was summarized by a staff writer from the British newspaper The Guardian. The journalist reported: “Heavy drinkers are putting themselves at risk of dementia… [P]eople who drink enough to end up in hospital are putting themselves at serious risk of vascular dementia and Alzheimer’s disease.”[6]
The author goes on the speculate that the study “…will also raise questions for moderate drinkers about …possible long-term consequences…”.[7] It is commonplace at these conjunctures to interject the oft-heard lament: More study is needed. Surely this is true. But, let’s consider some of the data that is presently available.
Personal Background
My dad, Jim, died from Alzheimer’s complications in 2016. It is safe to say that I have a family history of dementia. And, yes, I enjoy an occasional whiskey – or several. (Ahem.) So, the question of whether to drink or not has more than academic relevance for me. (For more about my dad’s story, see HERE.)
To be fair, when I was younger, I didn’t see my dad drink much. The most he would ever have was at a holiday gathering. We would invite my grandparents over for Thanksgiving and Christmas Day. My mom would decorate the table and set out fancy china, silverware and glasses. There would be a seasonal arrangement in the middle although, as we got older, it was replaced by a delicious cake or fancy iced cookies. The grownups got wine in the fancy glasses – and we got juice, or sometimes soda.
Honestly, my dad didn’t really drink after he and my mom were married. However, he did drink alcohol more frequently before he met my mom, usually meeting people at a bar after work. Was he drinking a moderate or an excessive amount? Search me! Was Alzheimer’s already beginning to insinuate itself into his brain? In Jim’s case, we’ll never know the answer to that, either.
How Does Alcohol Affect Your Body
What researchers do claim to know, however, is the constellation of possible effects that alcohol can have on your body and, by extension, on your mind also. Spoiler alert!! Drinking, especially in excess, can eventually take a toll on your health. Big surprise, there, right?
Let’s rehearse the reasons. (I know, I am turning into a party pooper.) Enumerating just a few of the relevant bits of information, it is clear that alcohol can have pronounced effects upon the heart, liver, pancreas, and immune system. Although none of these is certain to occur, any of the following may happen – whether by themselves or together.[8]
Possible Negative Effects on the Heart from Excessive Alcohol:
Cardiomyopathy – that is, the stretching and “drooping” of the heart muscle
Arrhythmias – Irregular heart-beating patterns
Strokes
High Blood Pressure
As every elementary-school student knows, the heart’s job is to pump blood to all parts of our body. Any of the above conditions could make that job more challenging. Additionally, blood flow especially to the brain, is one of the important factors to check periodically in order to stave off dementia – according to Dr. Daniel Amen’s “BRIGHT MINDS Protocol.”[9]
Possible Negative Effects on the Liver from Excessive Alcohol:
Fatty liver
Alcoholic Hepatitis
Fibrosis
Cirrhosis
The liver’s main function is to process nutrients and purify and detoxify the blood. As we reported elsewhere, some researchers have speculated that (some variants of) Alzheimer’s may, in fact, be due to exposure to environmental toxins. If this is so, then it is possible that suboptimal liver function may allow for the buildup of toxins in the body and, finally, result in brain toxicity or dementia.
Possible Negative Effects on the Pancreas from Excessive Alcohol:
Pancreatitus.
Alcohol causes production of toxins in the pancreas that can lead to pancreatitus. This is the inflammation and swelling of blood vessels that prevents proper digestion.
Possible Negative Effects on the Immune System from Excessive Alcohol:
Depressed immune system.
Alcohol weakens the immune system, thus making a person susceptible to any disease to which they may be exposed. Alcoholics are more likely to come down with pneumonia than nondrinkers.[10] Drinking too much, on even a single occasion, hinders – for at least 24 hours – your body’s ability to ward off infections. That’s a sobering thought.
Even though, as alluded to above, a few studies have brought to light possible benefits with drinking wine, keep in mind that the recommended amount is often said to be only around two (2!) glasses a week. (Though, I have seen reports claim three [3] or more.) And the recommended beverage is usually quality red wine – not bourbon, scotch or beer. (Sorry, John Lee Hooker and George Thorogood.) Additionally, some experts also question whether the increase in cognitive function is actually the result of the red wine’s resveratrol, or merely a byproduct of other incidental factors, for instance (however implausibly), the stimulating conversations that you might be having in social situations![11] (Assuming that you’re not imbibing in a loud,smoke-filled bar watching the ball game.)
Possible Negative Effects on the Brain from Excessive Alcohol
This litany of negative possibilities strongly suggests, though, that the brain doesn’t get a “pass.” If alcohol can be a detriment to the heart, liver, and pancreas, then – probably – it can be a detriment to the brain as well. (Well, do you want it straight, or not?)
Short Term Effects
The new idea of brain “plasticity” has it that the brain changes every day, for better or for worse. Alcohol interferes with communication pathways affecting how the brain looks and works. This disruption in communication is caused by the slowing down of the production of GABA and can alter your mood and actions, thus possibly causing problems for clear thinking or coordination. Alcohol also speeds up production of Dopamine, resulting in a feeling of pleasure in the brain’s reward center which can lower inhibitions. No news there. But, binge drinking also affects the cerebellum – the part of the brain that regulates balance – as well as the cerebral cortex – the part that helps you pay attention. The Hippocampus is the part of the brain that creates new memories. If this is compromised it can result in memory loss.
Decreased attention. Undermined memory. Physical imbalance. Deficits in reasoning and coordination. Does this sound like any disease that we know?
Long Term Effects
One of the first long term effects that could occur is that you would build up a tolerance to your alcohol intake. So, then you must continually increase the amount consumed to get the same effect. Higher consumption, in turn, could mean greater cellular damage to the body generally and to the brain specifically. The classic “wet brain” refers to a form of dementia caused by a deficiency of thiamine. Alcohol hinders its absorption.[12]
A study in the 2014 Journal of Neurology concluded that excessive alcohol consumption in men was associated with faster cognitive decline compared to light or moderate drinkers.[13] Another study from the same journal, but in 2018, showed that alcohol consumption also was associated with a disturbance in the REM sleep cycle.[14] Inadequate sleep, that is sleep without going through all of the cycle including REM, has been reported to be important in dealing with or preventing Alzheimer’s. (For more information, see HERE.)[15]
Confusingly, a study published in the Journal of Alzheimer’s Disease in July 2017 found that moderate to heavy drinkers were more likely to live to 85 years old and have no dementia.[16] However, another – even “bigger” – study, published in June 2017, concluded that even moderate drinking resulted in hippocampus degeneration. The hippocampus is responsible for memory and its atrophy is an early specific marker for Alzheimer’s Disease.[17]
Dr. Ayesha Sherzai is a neurologist and, along with her husband, Dean, is co-director of the Brain Health and Alzheimer’s Prevention Program at Loma Linda University. Dean and Ayeasha Sherzai go so far as to claim that alcohol is a neurotoxin that is a prime cause of cellular damage. In their 2017 book, The Alzheimer’s Solution, they list “alcohol” as one of the top ten foods to avoid.[18] In the same book, they agree with Amen (et al.) that alcohol disrupts sleep patterns and, on page 209, they cite a review found in a 2005 journal article[19] that states that sleep loss negatively affects executive functioning. The lapses were reported to be reflected in measurable ways in the frontal and parietal lobes, revealed during neuroimaging.[20]
Conclusion
We’re not healthcare professions and can give neither dietary nor general medical advice. But, I’m thinking that if I want a drink, it’s probably best to keep it on the moderate and occasional side of the fence. And it’s probably also a better idea to enjoy a glass of red wine, than to indulge in cocktails, mixed drinks, or shots. But life is a gamble, n’est-ce pas? (For other dietary changes that you can make that will possibly mitigate your risk of dementia, see HERE and HERE.)
But, before I wrap things up, let me briefly consider a companion question.
Can a person with Alzheimer’s drink alcohol?
The short answer is: No. According to an article published in July 2012 by CNN, alcohol and Alzheimer’s don’t mix.
Although the article goes on to state that the effects of alcohol on a person with Alzheimer’s aren’t completely understood new studies have found that binge drinking once a month of a person with Alzheimer’s can lead to a 62% decline in cognitive function.
Add to that fact the possibility that they won’t remember how many drinks they have had or what reactions they might experience because of medication interactions, and you have a recipe for potential disaster. One must also bear in mind that Alzheimer’s engenders confusion. Alcohol’s ability to further impair awareness and perception could exacerbate an already bad situation.
Beth Kallmyer, the vice president of constituent services at the Alzheimer’s Association, suggests that if a person with Alzheimer’s asks for a drink, caretakers should try distractions to keep them occupied so that they forget about their request. They certainly do not need to be intoxicated.[21]
Notes:
[1]Southern Illinoisan (Carbondale, Illinois), Jan. 1, 2002, p 13.
[2] Annemieke Ruitenberg, John C van Swieten, Jacqueline Witteman, Kala Mehta, Cornelia van Duijn, Albert Hofman, and Monique Breteler, “Alcohol Consumption and Risk of Dementia: The Rotterdam Study,” Lancet, vol. 359, no. 9303, Jan. 26, 2002, pp. 281-286, <https://doi.org/10.1016/S0140-6736(02)07493-7>.
[4] Michaël Schwarzinger, Bruce G Pollock, Omer Hasan, Carole Dufouil, and Jürgen Rehm, “Contribution of Alcohol-Use Disorders to the Burden of Dementia in France 2008–13: A Nationwide Retrospective Cohort Study,” vol. 3, no. 3, Mar. 2018, pp. e124-e132, <https://doi.org/10.1016/S2468-2667(18)30022-7>.
[12] Amanda MacMillan, “What Really Happens to Your Brain When You Drink Too Much Alcohol,” Health, Apr. 2018.
[13] “Alcohol Consumption and Cognitive Decline in Early Old Age,” Journal of Neurology, Jan. 15,2014.
[14] “Alcohol Consumption and Probable REM Sleep Behavior Disorder: Community-Based Study,” Journal of Neurology, Apr. 2018.
[15] Sleep was shown to be of significant value as to be included in “The Protocols of the aforementioned Dr. Daniel Amen and Dr. Teitlbaum, as well as in lectures of Dr. Michael Breus, who talks about our innate circadian rhythms. See HERE.
[16] “Alcohol Intake and Cognitively Healthy Longevity in Community Dwelling Adults,” Journal of Alzheimer’s Disease, Jul. 2017.
[17] Anya Topiwala, “Moderate Alcohol Consumption as a Risk Factor for Adverse Brain Outcomes on Cognitive Decline: Longitudinal Cohort Study,” The BMJ (formerly the British Medical Journal), Jun. 2017, <https://www.bmj.com/content/357/bmj.j2353>.
[18] Ayesha Sherzai and Dean Sherzai, The Alzheimer’s Solution: A Breakthrough Program to Prevent and Reverse the Symptoms of Cognitive Decline at Every Age, San Francisco: Harper One, 2017.
Listening to music or sharing art can be soothing. Relatedly, creativity is a powerful capacity that all humans share. Unfortunately, for those suffering from cognitive impairments, the utilization of this capacity can be frustrated. However, with a healthy dose of – you guessed it! – creativity, caretakers can enable Alzheimer’s patients (even ones who are far advanced in their declines) to use the arts to express themselves and to realize some of the benefits previously noted. My dad’s case afforded me a glimpse into this fascinating and emotionally salubrious process.
For a bit more detail, you can read about my father, Jim, HERE. Suffice it to say that music and art were two of his many interests. He liked to listen to music and sketch people from the covers of TV Guides. Later, as his disease progressed, but while he was still residing at home, he became unable to plan and execute his own projects. Still, he used to sit with my mom as she made cards. Jim was able to help by brushing color on a background papers or performing rudimentary “stamping” operations with a sponge. As his disease worsened, he started a “music therapy” program in his nursing home. The overseers developed a play list of his favorite songs and fed it into an iPod. It was bittersweet to see him smiling and sometimes even humming along. But a key takeaway is that this therapy also helped to calm him.
In addition to the in-house efforts, the nursing home hired a musician to come about once a month to the main visiting area. Residents were encouraged to clap or sing along. Jim seemed to enjoy listening to the oldies. As he was fond of saying, during happier times in his life, they are “oldies, but goodies.”
Music and movement (like dancing) seems to make people with Alzheimer’s feel happier and more like socializing, thus creating a calmer environment. This could result in a decrease in anxiety and depression levels which, in turn, could possibly reduce the reliance on certain medications.
But being in a new area and seeing others respond to the music also helped to stimulate responses in him.
Art Has Effects That Go Beyond Mere Pacification
According to Generations Healthcare: “[I]n 2013 there were neurological studies done that revealed that artists with dementia could still draw familiar people, places and objects from memory.”[1] Art is also surmised to help build feelings of accomplishment and purpose.
Moreover, there is good reason to suppose that the arts might be able to reduce feelings of loneliness. In an article by the Chicago Bridge on Building Community Through the Arts, the author notes that older adults experience social isolation for a variety of reasons. Some experience it due to diminishing physical capabilities, such as loss of hearing. Similarly, others may find that their own voices become too weak for most people to hear without above-average concentration. Still others develop mental problems, like “aphasia” (i.e., comprehension or language impairment), a common difficulty arising with various forms of dementia.
Language abilities are a complex tapestry of mental powers. For instance, many discrete cognitive faculties contribute to, and constitute, the ability to keep up with a conversation’s flow and to initiate a response. Alzheimer’s sufferers become deficient in many of these relevant processes and can only follow a normal discussion with great effort (if at all).
However, the arts in general, and perhaps music in particular, has the unique ability to touch human beings in a direct and intuitive way that is almost, dare I say, magical.[2] Thus, the creative outlets just sketched give Alzheimer’s-afflicted persons a way to connect even when communication is difficult (or practically impossible).
Dr. Natalie Rogers, an art therapist, described this creative connection quasi-poetically as “a process in which one art form stimulates and fosters creativity in another art form, linking all of the arts to our essential nature. Using the arts in sequence evokes inner truths which are often revealed with new depth and meaning.”[3] This “art connection” arguably supports a total integration of a person’s mind and body, fosters deeper relationships with others, and may even facilitate greater awareness of oneself. Or, where the requisite understanding is lacking, as it is in Alzheimer’s Disease, if not self-awareness, at least a certain self-acceptance or personal peace.
How Do the Arts Help?
Art, dance, and music engage regions of the so-called “non-verbal” parts of the brain. People who have trouble with verbal communication can still connect with others through the kinds of creative activities that, in a way, bypass the neurological roadblocks that are erected by dementia.[4] (For an overview of the literal “plaques” and “tangles” plaguing the brains of Alzheimer’s sufferers, see HERE.)
Alzheimer’s makes it hard for people to handle too much sensory input. Music, somewhat counterintuitively, seems to be able to help patients process sensory stimuli better.[5] Specifically, art appears to have a “strengthening” effect on memory, supporting the brain’s ability to recall associations that have been made with certain sounds and sights.
Investigators theorize that art and music are able to activate areas of the brain that Alzheimer’s has “turned off.” Music is especially potent because it is supposed to be processed in many different areas of the brain.[6] Further, musical memories are believed, so to say, to be more “deeply entrenched” in the brain than even language. Musical recollection sets the limbic system in motion because of the tie between melodies and emotions.
Neurologist Oliver Sacks has gone so far as to opine that human beings listen to music “with our muscles.” Although this is a somewhat cryptic comment, he seems to have in mind the fact that sound processing starts in the primal brainstem and then registers in the root structures called the “basal ganglia” – which, along with the thalamus, control voluntary motor movements and routine behaviors.
Thus, we see that Sacks’s statement highlights the importance of movement. Muscle movement, locomotion, and the like stimulate circulation – specifically, blood flow to the brain.[7]
Tips for Your Own Caregiving Environment
All of this theory is well and good. But how can you implement general art, dance and music in your own caregiving environment – whether at home or in an assisted-living facility or nursing home?
Art
Begin with simple projects – maybe abstract watercolor painting. But note well that, although projects should be simple, they should not be childish.
Build conversation into whatever activity you select. Talk about what they are doing.
Don’t rush anything. Let the person take his or her time.
Recognize that you might have to help the person get started (for example, by moving the brush) to show them what to do.
Movement
Again, don’t place arbitrary or unnecessary time limitations on the activity. Let them take the time they need – or desire.
Play music (for more on which, see below).
As before, you might need to jumpstart your loved one’s motions (in this case, by clapping with or for them, or tapping his or her feet, etc.)
Of course, movement can be rudimentary and still be benefit. This could range from dancing or just swaying, to pacing or walking, or even exercising. Hey, if it gets them moving, call it a win.
Music
Play music that is familiar to, or a favorite of, your loved one.
Tranquil music can calm, while a faster beat can boost the spirits. Mix it up.
Don’t play it too loud. Loud noise might cause agitation. On the other hand, remember that aging adults or dementia sufferers might have auditory difficulties on top of whatever other cognitive problems they have. So, be ready with the volume knob or remote in order to regulate the volume as needed.
Try to get commercial-free music in your play list. Commercials might confuse them. Additionally, commercials just break the mood and will tend to undercut the sustained effects that you are trying to achieve.
Encourage clapping, dancing, humming, or singing along.
Final Thoughts
Art therapy covers a lot of areas – dance/movement, drawing, improvisation, music appreciating, painting, sculpting, singing, and even (for those still higher functioning) writing. A common undercurrent is their engagement of the senses. For someone whose faculties are failing, these activities become rich avenues of information gathering. If a person’s vision and hearing are not as sharp as they once were, they may now rely on touch, taste and smell. So, don’t be afraid to add such pastimes as tasting or smelling different foods, looking at pictures, listening to rain, massage or aromatherapy.
Elaine Perry is a professor of Neurochemical Pathology at the Institute for Aging and Health – Newcastle University that is currently working on a study of aromatherapy for people suffering with Alzheimer’s and agitation. In one of her papers, she cites specific research that shows that certain essential oils are useful for elevating mood and calming agitation.[9] In several clinical tests using lavender and lemon balm as a natural treatment for residents having advanced dementia, it was found that there was a decrease in negative behavior. Geranium, rosemary and peppermint oils have also been tried with some success. Interestingly enough, the best delivery was in a lotion that was applied to the skin. The physiological effect is alleged to be present even if the person has lost their ability to smell (on which, see HERE).
For Further Research
Kate Gfeller and Natalie Hanson, Music therapy for Alzheimer’s and Dementia Individuals, Iowa City, Iowa: Univ. of Iowa, School of Music, 1995.
Notes:
[1] See the article titled “The Amazing Effect of Art and Music Therapy on Alzheimer’s,”
[3] Natalie Rogers, The Creative Connection: Expressive Arts as Healing, Palo Alto, Cal.: Science and Behavior Books, 1993.
[4] This has given way to the suggestion that cognitive skills may not be inextricably intertwined with the memory, as is presently the dominant view.
[5] It’s counterintuitive in the sense that music itself seems to be a kind of “sensory input.” Then why is it that music doesn’t seem to add to the feelings of overwhelm experienced by the Alzheimer’s sufferer? Perhaps the answer is something like this: the rhythm of the music may provide a kind of structure or “beat” to the afflicted person’s otherwise increasingly chaotic and unstructured thoughts. But this is just sheer speculation on my part.
[6] This is because the various elements involved in music – like pitch, rhythm and melody – are all processed by subtly different brain components.
[7] Oliver Sacks, Musicophilia, New York: Vintage Books, 2008. Sacks wrote: that there is “no single music center in the human brain, but the involvement of a dozen scattered networks throughout the brain.” He also credits the 19th-century German philosopher Friedrich Nietzsche with the thought that “Listening to music is not just auditory and emotional, it is motoric as well …[W]e listen to music with our muscles.”
Blood flow is one of the important factors in brain health according to Dr. Daniel Amen and his BRIGHT MINDS protocol. Exercise was also stressed by Dr. Jacob Teitelbaum’s program that highlights five areas for energy and brain health called SHINE. For more information on these matters, see HERE.
[9] Elaine Perry, “Aromatherapy for the Treatment of Alzheimer’s Disease,” Journal of Quality Research in Dementia, No. 3, n.d., (cached HERE).
The question of whether to drive or not is perhaps one of the most pressing to face dementia-afflicted patients. Basically, a person is licensed to drive when he or she is shown (usually by testing) to have mastered the mechanics and rules of driving as well as to be of legal age and of normal mental competence. Impairments of any sort might jeopardize mechanical mastery, obedience to and retention of the rules of the road, or general mental function. These factors, by themselves or together, may put the affected driver at risk (to him- or herself, or to others). However, a mere diagnose of Alzheimer’s Disease may not signal gross deficiencies in any relevant area. There are really two main facets to the query. One is: Is It Safe to Drive? I have covered this topic more fully elsewhere. (See HERE.)
It will have to suffice here to say (as was noted in my article on safe driving) that Alzheimer’s (and related dementias) affects coordination, cognition, concentration, decision-making, emotion, focus, memory, perception, reaction time, spatial awareness, understanding, and much else besides. Consequently, an Alzheimer’s sufferer might get “lost” more frequently than a non-sufferer; he or she may “misjudge” distances and turns; and such a person might “forget” (or neglect) good driving practices (otherwise known as the “rules of the road”). While these things tend to render a person with Alzheimer’s indisputably unsafe behind a wheel, the second question remains: what are the relevant legalities? I will tackle this, presently.
(For our State-specific guide to the relevant laws, see HERE.)
Does Alzheimer’s Mean Automatic License Revocation?
First and perhaps most obviously, does a diagnosis of some sort of dementia (including Alzheimer’s Disease) automatically entail license revocation? The short answer is: No – not necessarily.
Number one, remember that most forms of dementia – chiefly, for our purposes, Alzheimer’s – come in degrees or stages. (For a primer, see HERE.) Early-stage patients may still be able to drive even if, by middle stage, most sufferers are generally unsafe behind the wheel.[1]
While, again, this is not an article about safety, the present point is that unless a given driver is demonstrably unsafe, there are few grounds on which to base a case for revocation.[2]
Having said that, diagnoses of dementia may be grounds for license restriction.
What Is the Usual Process?
Different states tackle this differently. (For a State-specific guide to the relevant laws, see HERE.) But, speaking only in general terms, what typically happens is something like the following.
A person goes in for his or her license renewal. The renewal application has a question something like: “Do you suffer from a medical condition that could or does impair your ability to drive safely?” If a person answers “yes,” then that person would be medically evaluated straight away. (Possible results of this process are enumerated, below.) If, on the other hand, a person answers “no,” then he or she would have to undergo the usual renewal tests (driving, knowledge, vision, etc.), if any. If the applicant passes the tests, and has no impairments that are severe enough to be observed by the bureau/department of motor vehicle (BMV/DMV) employee, then the license will be renewed.
If the applicant’s license is renewed, then the entire process becomes reactive. To put it another way, the driver will be allowed to operate a motor vehicle with no restriction/oversight unless or until he or she is brought to the attention of the BMV/DMV. This might occur when the person’s doctor reports him or her for some medical reason. A handful of states have mandatory-reporting laws. (See the last paragraph of the next section for a list of said states.) Most states do not have such a requirement. However, physicians may report people for ethical reasons, to mitigate the attendant liability risks, or for other reasons.
A driver may also be reported by a court of law or by a law-enforcement officer. For example, these sorts of reports might occur after a traffic accident, traffic hearing, or traffic stop.
Finally, a person may be reported by a family member, caretaker, or even (in some jurisdictions) by concerned citizens or neighbors. Many times, these reports are treated as affidavits and must be dated, notarized, and properly signed. Typically, anonymous reports are rejected. However, a few states (including Florida, Ohio, South Dakota, and Washington, D.C.) treat reports as confidential. The concern with anonymous or strictly confidential reporting is twofold. Number one, for obvious reasons, states wish to avoid nuisance or revenge reporting (i.e., people reporting drivers for reasons of personal vengeance and the like). Number two, Western legal systems usually have provisions for enabling accused persons to confront their accusers.
(Again, to see the laws and regulations that are specific to your State, click HERE.)
Who Ultimately Decides Whether a Person May Drive?
Doctor’s evaluations usually settle the question either way. In a few states, physicians are actually required by law to report a diagnosis of Alzheimer’s (among other conditions) to various governmental bodies and, ultimately, to the department that oversees licensing or motor vehicles (such as the state BMV/DMV). (To get a sense of the myriad state-specific differences that arise at this point, see below.)
Even in states that do not mandate doctor reporting, there are usually mechanisms in place that allow other concerned or interested individuals (e.g., chiefly doctors, but also law-enforcement officials, relatives, or others) to file a report. In fact, most states are reactive in this way.[3] To put it slightly differently, the usual state of affairs is to leave licensed drivers alone unless or until one of more of the following occurs.
A person discloses that he or she suffers from some cognitive impairment, dementia, seizure disorder, etc. (that is, the afflicted person reports him- or herself);
The driver is brought to the attention of the licensing body via multiple accidents or other incidents; or
The Alzheimer’s sufferer is reported to the licensing agency by family members, law-enforcement personnel, or (mainly) physicians.
When any one of these “triggers” is tripped, the licensing or motor-vehicle department typically initiates a review process. This is the process by which the driver in question is put under scrutiny in an effort to ascertain his or her actual competency.
The individual’s driving and medical records may be examined. It is not uncommon for the licensing/motor-vehicle evaluators to send a letter to the targeted driver indicating that he or she is under review and giving said individual the opportunity to obtain the written opinion of his or her own doctor.[4] The review process may also involve requalifying the individual for a driver’s license by way of administering driving, vision, and written retesting.
In the end, for most states, the final word is given to competent medical personnel. Physicians evaluations are awarded immense weight. Additionally, “[s]ix States [California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania] currently require physicians to report certain types of impairments to the State licensing agency.”[5]
What Are the Main Outcomes of the Review Process?
Renewal – If a person obtains a favorable evaluation from his or her physician, then his or her license will likely be renewed. However, the licensing body may require more frequent reevaluations.
Restriction – Alternatively, a person could have his or her driver’s license renewed, but with certain provisos or restrictions. For example, someone might be limited to driving in a particular area, or to driving only during certain times of day (say, being required to avoid driving at night).
Revocation – If the person in question fails the retesting outright, or if the physician statement is unfavorable (from the point of view of renewal), then the license probably will not be renewed. Depending upon the state, there might be an appeals process or even the possibility of reexamination.[6]
What Are Possible Legal Repercussions From Driving While Cognitively Impaired?
Let’s face it, a main concern has got to be exposure to legal liability. If a licensed Alzheimer’s sufferer has an accident, is he or she open to a lawsuit? As I have stated elsewhere, I am incompetent to provide legal advice, but, intuitively, the short answer this time is surely yes. For one thing, almost anyone involved in an accident might be open to a legal action. Observe, also, that Alzheimer’s (and other dementias) are far from the only sorts of driving impairments. (Driving while under the influence of alcohol or drugs would also be impairments in the relevant sense.)
However, there is much more nuance than a mere “yes.” The fact that an Alzheimer’s-afflicted driver might open him- or herself up to a lawsuit in the event of an accident does not, by itself, imply that the Alzheimer’s Disease is necessarily a factor – let alone the deciding factor – in such a case.
Several issues are important. Number one, the Alzheimer’s-affected driver would have to be the one at fault. Number two, the Alzheimer’s Disease (or other dementia) would have to have been determined to be a causal factor.[7] To put a finer point on it, the available evidence would have to show (to any pertinent legal standard) that the afflicted driver’s impairment contributed to the occurrence of the accident.
However, there are circumstances that can create serious liability issues for Alzheimer’s sufferers, their families, and their physicians.
For instance, there could be severe legal consequences if there is good reason to believe that an afflicted person, his or her family, or his or her physician ignored or failed to adequately address signs that the relevant driver was unsafe behind the wheel. A person who ought to voluntarily submit to medical evaluation or who ought to disclose a cognitive impairment, but who does neither, could be legally liable. Of course, sometimes Alzheimer’s impacts self-awareness. In cases where this awareness deficit exists, it may be that the sufferer’s culpability is mitigated. But, presumably, this would have to be determined by a court or judge of competent jurisdiction. The intuitive point is that if a person knowingly and willingly operates a motor vehicle while impaired, then he or she might have to face legal consequences.
Similarly, family members or physicians who allow persons under their care to drive while impaired could also face legal actions. Of course, there are complications and subtleties to these questions. A key phrase is such cases is “good faith.” The driver and his or her caretakers (if any) are expected to act in good faith and with reason and experience, jointly applied.
Once again, these considerations are supplied merely for illustrative purposes. They are neither meant to be exhaustive nor applicable to every situation. If you or a loved one is suffering from some form of dementia, then you should seek professional advice. Doctors and lawyers both have their own spheres of competence, and both sorts of professional may have something relevant to say on this issue.
State-Specific Complications
Legalities pertaining to drivers’ licensing are handled by the individual U.S. States. Each state has its own procedures. (For a list of State-specific laws, see HERE.) Indeed, each state has its own departmental structures.
In sixteen (16) states (such as Arizona, Delaware, Hawaii, Idaho, Iowa, Kentucky,[8] Maryland, Massachusetts, North Carolina, North Dakota, Oregon, Pennsylvania, Vermont,[9] West Virginia, Wisconsin, and Wyoming), drivers’ licensing is overseen by a Department of Transportation.
In other states, the Department of Transportation merely deals with the building and maintenance of public highways and roads and licensing is managed elsewhere.
It could be under the auspices of a Department of Revenue (as it is in Colorado, Kansas, Missouri, and Rhode Island).
Sometimes (as is the case in Alabama, Florida,[10] Minnesota, Mississippi, New Hampshire, Ohio, Oklahoma, South Dakota, Tennessee,[11] Texas, and Utah) licensing is directed by a Department of Public Safety.
The Secretary of State’s Office facilitates licensing in Illinois, Maine, and Michigan.
A handful of states have one-of-a-kind departments. In Montana, drivers are licensed by the Department of Justice; Arkansas seemingly has a hybrid Department of Finance and Administration; whereas, in Washington State, there is literally a Department of Licensing.
In Georgia, it’s called Driver Services. (The same phrase crops up in other states, too. But in Illinois, Pennsylvania, Tennessee, and Wyoming, “Driver Services” is a subset of some larger, overarching, agency.)
Then there is another layer of terminological difference. Most states (i.e., by my count, Alaska, Arizona, Colorado, Idaho, Kansas, Kentucky, Montana, New Hampshire, New Mexico, North Carolina, North Dakota, Oregon, Rhode Island, Utah, West Virginia, and Wisconsin) refer to their motor vehicles agencies as “Divisions.”
Similar units are called “Departments” in California, Connecticut, Washington D.C., Maryland, Nebraska, Nevada, New York, South Carolina, Vermont, and Virginia.
On the contrary, “Bureaus” carry out licensing functions in Indiana, Maine, and Ohio.
And usual, some states have sui generis labels (in Louisiana, there is an “Office” of Motor Vehicles; in Massachusetts, it’s called the “Registry” of Motor Vehicles; and it’s a Motor Vehicle “Commission” in New Jersey.) Still other states use combination terms. Iowa and Minnesota both have composite names such as the Division of Motor Vehicles and Driver Services.
[1] One wrinkle, here, is that persons with even advanced dementia may have “good” days during which they seem to lucid and able to reason. These good days will be sprinkled in the midst of “bad” days where the person’s cognitive abilities are subpar. Even though this variability is well known, it is likely that, as far as driving is concerning, the safest course is to make licensing decisions based upon a person’s worst days, rather than their best ones. The reason is that an Alzheimer’s sufferer has little to no power over whether a day will be “bad” or “good.” Therefore, any given driving outing is left to chance. If the Alzheimer’s-afflicted individual has declined to the point where he or she would be unsafe driving on “bad” days, then it’s probably time to hand the license over.
[2] It is not enough That a given driver with early-stage Alzheimer’s or Mild Cognitive Impairment will, given the natural course of the disease, eventually become unsafe is not enough.
[3] That is, the majority of states do not seem to proactively restrict Alzheimer’s patients. Instead, most states wait until a credible concern is filed, and then the driver in question is subjected to scrutiny.
[4] In some cases, of course, the family doctor may be the person who referred the individual to the licensing body for medical review in the first place. Whenever a physician is involved, the licensors will elicit the physician’s considered opinion of the patient’s ability to drive safely.
[5] Here is an illustration of the authority given to healthcare professionals. One reference, for the state of Nebraska, states: “If the guidelines …indicate that [a] driv[ing] test need not be administered, but if [a] physician indicates on the …Physician [Statement] that one should be administered, follow the physician’s recommendations.” On the mandatory-reporting laws, see Medical Oversight of Noncommercial Drivers, Highway Special Investigation Report, Washington, D.C.: National Transportation Safety Board, 2004, Appendix E, p. 69. “California Lapses of consciousness and Alzheimer’s Disease severe enough to be likely to impair a person’s ability to operate a motor vehicle [;] Delaware Loss of consciousness due to diseases of the central nervous system[;] Nevada Epilepsy[;] New Jersey Recurrent convulsive seizures, recurrent periods of unconsciousness, or recurrent impairment or loss of motor coordination due to conditions such as epilepsy[;] Oregon Loss of consciousness or control. Cognitive and functional impairments that are severe and/or uncontrollable to a degree that may preclude safe operation of a motor vehicle and are not correctable by medication, therapy, surgery, driving device, or technique[; and] Pennsylvania Lapses of consciousness or other mental or physical disabilities affecting the ability of a person to drive safely[.]” Ibid.
[6] Again, however, if a driver is evaluated as unsafe because he or she is having one is his or her “bad” days, then this probably should be taken as an indication that the condition has advanced to the point where the driver is not reliably safe. A person should probably not be licensed just because he or she might be safe, but because he or she is predictably safe. While they may enjoy periods of lucidity, at a certain point in their decline, Alzheimer’s patients are no longer predictably safe. Therefore, unfortunately, they are not reliably safe, and probably should not be licensed. Another issue is the cost. Although some states may not charge for the initial review, if the outcome is contested, then the affected driver may end up having to pay for any requested reevaluations.
[7] Even if were not the only factor. It is arguable that many (if not most) accidents have complex causes.
Can an Alzheimer’s Patient Have Sexual Intercourse?[1]
This was the question fired at me from my two teenaged boys. My background is in philosophy, so I was able to talk a bit about issues of autonomy and consent (on which, see further on). But the total answer is, perhaps predictably, complex. Dr. Bruce Miller describes a study done “[a]round 1995” when nurses affiliated with the University of California – San Francisco “did a survey on [Dr. Miller’s] Alzheimer and frontotemporal dementia patients regarding sexual activity. The majority [of surveyed patients] had decreased sexual activity[;] some maintained activities similar to before [contracting] the disease[;] and …around 8% [actually] had increased activity.”[2] So, can we say anything, in general?
“[A] quick, general answer” comes to us by way of Dr. Victor Henderson, director of Stanford University’s Alzheimer’s Disease Research Center. He writes that “[i]n mild and moderate stages of their illnesses, many – and perhaps most – men with Alzheimer’s disease, and virtually all women with Alzheimer’s disease [AD], would be able to engage in sexual intercourse.”[3]
Dr. Gregory Jicha, “Dr. J,” of the University of Kentucky Alzheimer’s Disease Center, adds: “Sexuality and intimacy remain an important part of one’s life as they age. It is no different in AD.”
However, a lot turns on just how one understands the word “able” – in Dr. Henderson’s statement that Alzheimer’s sufferers are “able to engage in” sex. Let’s dig a bit deeper.
Physical Issues
Dr. Allan Levey puts it succinctly when he says, “There are no physiological reasons …why a person with Alzheimer’s disease would be unable to have sexual activity, except until late stages of the disease.”[4] Dr. J concurs, stating: “There are no physical impediments to engage in sexual activity that develop in Alzheimer’s disease until the very end stage when even walking is affected.”
“Alzheimer’s,” Dr. Caleb Finch remarks, “differs widely between individuals and …the parts of the brain usually damaged do not involve physical function in early stages.”[5]
However, Dr. Swerdlow reminds “…that people with Alzheimer’s are often older, may be frail, and frequently have other comorbid medical issues.” The Mayo Clinic’s Lunde expands on this by saying: “most individuals living with the disease are older adults and so age-related issues such as menopause, decreased sperm count, arthritis, hormonal changes, Erectile Dysfunction, illness, medications and depression are often factors related to sexual arousal and/or function.”
To put it slightly differently, even if Alzheimer’s itself does not destroy sexual functionality, said functionality may be diminished by other physical ailments or conditions that attend the aging process.[6] Dr. Mary Sano adds that the “stage of disease may relate to ability to be aroused or want to be aroused as well as to be sexually functional.” (More on this angle, below.)
On the other hand, Dr. James “Jim” Brewer relates that he is “aware of several AD patients whose physical state is outstanding[,] and there would be no physical impediments to [their engaging in] sexual activity.”[7]
A final consideration comes by way of Dr. Eric Reiman who notes that “effects of medications” might also affect sexuality – whether physically, emotionally or otherwise.
As Dr. Hank Paulson helpfully summarizes: “Sexual function is a complicated matter, of course, and many things beyond physiology contribute.”
Emotional Issues
Angela Lunde helpfully frames this part of the discussion, writing that “…the issues have more to do with changes in sexual feelings, desire, and behavior…” than with anything physical, per se. We might say that this constellation of concerns is broadly “emotional.”
Most relevantly, Dr. Marek-Marsel Mesulam notes that, “[g]enerally, Alzheimer’s decreases libido.”[8] Lunde hastens to say, though, that some Alzheimer’s-afflicted individuals actually suffer from an opposite problem, specifically “hyper-sexuality.” We may say, therefore, even if everything is physically operational (so to speak), without sexual desire the arousal mechanisms may be impaired.
“[M]any patients do lose interest in sex – but [it’s not] that the disease [by itself] imposes peripheral physiological challenges to sexual intercourse.” So reports the aforementioned Dr. Miller.
Dr. J, professor of neurology and part of the University of Kentuck-based Sanders-Brown Center on Aging, and his colleagues “studied changes in sexuality and intimacy in normal aging as well as in those with AD and their spouses. …What we …[found] was a general feeling of emotional estrangement in spousal caregivers, with their needs for intimacy and sexuality not being met. The person with AD was almost universally oblivious to this and felt that their needs were met and that the relationship was intact.” Dr. Reiman makes the point that “much of …[this] will depend on the couple.”
Again, Dr. J: “While our study did not further explain the ‘WHY?’ for this [phenomenon], we can postulate that it may be socially or culturally mediated, i.e. a feeling that it is not ‘right’ to engage in intimacy or sexual conduct with an impaired person[.] It could also be due to a reduction in emotional depth that could occur as part of the loss of cognitive processes in AD[.]”[9]
Along similar lines, Dr. Finch (quoted earlier) again remarks that “[s]ocial sensitivity …may be impaired in early stages.” It may therefore be that the Alzheimer’s afflicted individual no longer recognizes sexual “cues” from his or her partner.
Again, I turn to Dr. Sano. “When we talk about capacity, we falsely think it is the same as cognition and it is not. …[W]hile a person may not be able to ‘rationally report what they want’ they may still want a sexual life.” Unfortunately, we cannot peer into the afflicted person’s thoughts. “Additionally, as a person becomes more impaired, they may not be able to understand what another person wants.”
Ethical Issues
Of course, Alzheimer’s Disease undermines cognitive function. But, along with diminishing cognition comes diminishing capacity to consent. As Dr. Mary Sano relates: “Many things depend on the stage of dementia (with our assumption that milder patients have greater cognition and greater capacity to make decisions for themselves).”
In terms of ethics, specifically, there are several considerations that loom large when it comes to any discussion about sexual intercourse. One relevant notion (of many that could be mentioned) is that of autonomy, and another is informed, mutual consent. The two issues converge – and come apart – in interesting ways.
Autonomy is a Greek-derived word meaning, roughly, “self-law.” The idea is that an “autonomous person” is one who chooses (e.g., courses of action, values, etc.) for oneself. A mental competent[10] person (who has attained the age of majority and not forfeited his or her freedom, through imprisonment, military service, or whatever) has the right to determine his or her own courses of action – within the limits of the law. Other free agents have duties or obligations[11] to honor the choices of competent persons.
Similarly, “consent” has to do with agreement or compliance. In order for agreement to be fully “consensual,” the relevant agreement has to be “informed.” So, roughly, “informed consent” happens when a competent person has adequate information to make a responsible decision.
Requiring informed, mutual consent before engaging in sexual activities with another person is one way that person’s autonomy is properly respected. So, for example, a prospective, sexual partner much be made aware of my intentions as well as crucially relevant background information that might affect his or her decision (for instance, my sexual-health status). The other person needs then to be given the space to decide, free from bullying, coercion, or threats of any kind.
The obvious difficulty comes by virtue of the fact that, at certain stages of the disease at any rate, an Alzheimer’s sufferer is not mentally competent.[12]
Alzheimer’s and related dementias are by no means the conditions or situations that present challenges to informed consent. To get a flavor for this, think about a case in which a set of people with normal cognitive functioning volunteer for medical or scientific studies. Suppose that we’re talking about studying the effects of a migraine pharmaceutical. The researchers might disclose certain statistics relating to possible benefits (eliminating the migraine in 15 minutes, for instance). But they will also have to apprise potential participants of the pertinent risks (maybe stroke).
However, persons with “normal” brain functions will not necessarily be able to interpret benefit and risk statistics. It is well known that scientific-study participants sometimes do not (seem to) understand some of the relevant background information. For example, a person may believe that he or she will be receiving an actual dose of some drug, without giving appropriate weight to the possibility that it will be a placebo instead. Or a person might hear various probabilities for some adverse medical event (like the aforementioned possibility of stroke), without appreciating the actual risk that he or she faces.
Of course, Alzheimer’s sufferers are in an even worse position.
Think back to Dr. J’s comments regarding marital sexuality. A husband and wife share sexual experiences and strive for intimacy. Alzheimer’s patients may desire continued intimacy but be unable to express their desires. Alternatively, certain patients may lack the desire. But, from the point of view of the spouse/potential sexual partner, without the expression, it’s dicey business to just dive right in, so to say.
For we already rehearsed the idea that informed consent is the bedrock of respect for personal autonomy. The trick, therefore, is to understand what the Alzheimer’s-afflicted person’s wishes are, and to try to honor them. But this is obviously more easily said than done, since Alzheimer’s is – eventually – partially characterized by the inability to express one’s wishes (and, possibly, by the absence of concrete wishes of certain sorts).
In closing, though, it is well to bear in mind the words of Dr. Nathaniel Chin: “People with dementia can still appreciate human contact, emotional love, and have feelings of love, even if they cannot express it.” This seems plausibly true. And, even if it isn’t true, it is probably more responsible (and charitable) to behave as if it were true, than to behave as though it were not.
Final Remarks
I cannot hope to resolve every issue in this brief treatment. Hopefully, however, what has been said suffices to give you an apprehension of the some of the range of relevant issues.[13]
[1] In an email exchange, Dr. Gregory Jicha, Robert T. & Nyles Y. McCowan Endowed Chair in Alzheimer’s Disease in the University of Kentucky’s neurology department, called the question “fascinating” lamenting that it “has not been fully explored” but opining that it “certainly deserves more attention.”
[2] Angela Lunde, education program manager for the prestigious Mayo Clinic, comments that “overall, there is no single pattern of sexual change in person living with AD.” Miller’s research seems to bear this out.
[3] He notes further: “Some of the other forms of dementia do affect the ability of men to engage in intercourse.”
[4] This was echoed by numerous other experts, including Dr. Russell Swerdlow, who added: “The AD would not be expected to profoundly directly impact a person’s sex organs. So physically there would not be [any predictable negative] …effect [sexually]. …Alzheimer’s in and of itself would not have a profound impact on the function of the sex organs.” Angela Lunde puts it this way: “Alzheimer’s disease alone does not generally impede one’s physical capacity and/or sexual function and reproduction.” Dr. May Sano demurs, however. She expresses doubts “that anyone has answers” to these questions.
[5] Understanding stages is crucially important to understanding Alzheimer’s. As Dr. Nathaniel Chin reports: “A person with dementia due to AD can still have sexual intercourse but it will depend on the stage. As the dementia worsens a person’s sexual drive as well as their physical ability to have sex can become impaired. Additionally, mood becomes affected and medications used to treat mood can interfere with a person’s emotional and physiological drive to have sex. Early in the disease there may not be any physical impairment to sexual function. Dynamics in relationships may change but a person with dementia physiologically can still have desires for sex.” More on these emotional angles, below.
[6] Dr. Hank Paulson adds: “Alzheimer’s does not typically lead to major changes in the physiology of sexual function, although some other neurodegenerative diseases can, such as multiple system atrophy.”
[7] He adds these thoughts: “The disease has a lot of sad components, and I often find myself thinking what a shame it is when a patient’s brain fails so much earlier than the body. It seems to me that these individuals would have lived a long, healthy life, if it weren’t for their brain condition.”
[8] It may increase “inhibition,” in Lunde’s words.
[9] He adds: “My guess is that this is a common problem that is simply not discussed often for a variety of social and cultural reasons. … Our ultimate goal would be to develop an intervention to help maintain emotional and physical intimacy given its importance to us as humans throughout our lifespan.”
[12] I.e., he or she is generally regarded as non compos mentis.
[13] Dr. Reiman notes that interested readers can find more information online, for example from the British Alzheimer’s Alzheimer’s Society, e.g., <https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/factsheet_sex_and_intimate_relationships.pdf>. Sarah Brisebois, Research Study Coordinator at the Alzheimer’s Disease Center on the campus of the University of Texas’s Southwestern Medical Center – Dallas, points us to several articles on the Alzheimer’s Association’s website: <https://www.alz.org/national/documents/topicsheet_sexuality.pdf>, <https://www.alz.org/oregon/images/microsoft_word_-_intimacy_and_sex-feb_08.pdf>, <https://www.alz.org/library/downloads/sexandintimacy_rl2015.pdf>.
When Is a Person With Alzheimer’s Too ‘Far Gone’ to Drive Safely? Can Someone Drive With Mild Cognitive Impairment?
These are very sensitive issues and should be discussed with the afflicted person (if possible) along with the attending physician, family members, legal advisers, and so on. Although this website cannot and does not provide specific advice (whether legal or otherwise), we will lay out – for conversational and informational purposes only – some general, practical guidelines.
The first and most obvious point is that Alzheimer’s varies according to stages. (For a brief introduction, see HERE.) In early stages, Alzheimer’s may not significantly impair a person’s driving ability.[1] As the sufferer declines, regrettably, cognitive and reasoning functions, memory, and physical reflexes will inevitably diminish to the point that safe driving will no longer be possible. The main question is when, precisely, this tipping point occurs.[2]
In order to prepare for the virtually unavoidable conclusion, but before the relevant problems surface, it is wise to consider – and plan for – means of transportation that can serve as driving substitutes. In most cases, and for short trips, these alternatives (depending on the area) will be things such as buses, personal drivers, shuttles, taxis, trains, and the like.
(Although cycling, walking, and other similar activities may be options early on [and for more on their benefits, see HERE], numerous factors – such as physical enfeeblement and inclement weather – might remove them as recourses – whether permanently or temporality.[3])
If possible, you may want to test these (and other) options out, as well as consult with family members and friends who already utilize them, to help determine the one that best meets your loved one’s needs.
How do I keep driving safely? Pre- and Early-Stage Alzheimer’s
While your or your loved one’s ability to drive represents independence, it also may jeopardize his or her safety and that of other drivers on public roads. Therefore, again, these tips should be taken as general rules of thumb, but not as universally applicable – or even universally advisable. Consult pertinent healthcare providers for more insight and for case-specific recommendations. Keep in mind that some areas may have laws that govern some of these issues. It may therefore also be necessary or prudent to seek legal advice from a competent attorney.
That said, it is still true that simple measures may help to extend your or your loved one’s time behind the wheel. There are a few relevant categories. Here are a few things to consider.
Vision Considerations
Schedule regular eye and vision examinations. This is one of the staples of general, preventative medicine in any case. But it is of vital importance when it comes to keeping a person safely operating a motor vehicle. (Did you know, some eye tests can actually detect Alzheimer’s? See HERE.)
Update eyeglass or contact-lens prescriptions. This is really an extension of the previous point. Corrective lenses only function correctly if they are suitable.
Periodically replace windshield wipers and, in general, keep the car’s mirrors, windows and windshield clean. Maintain headlamps in proper working condition and adjust the brightness on the vehicle’s instrument panel for optimal visibility.
Broader Health Considerations
Schedule periodic wellness checkups. If cognitive-impairment is suspected, ensure that you or your loved one disclose all relevant concerns to a qualified healthcare provider. Tests such as the Mini Mental-State Exam might be usefully employed. (For more on this test and others, see HERE.)
Your or your loved one’s life – as well as the lives of others – is more valuable than having a few more outings behind a steering wheel. Be sure to honestly bring driving-related questions to your physician.
In certain cases, and for particular conditions, occupational or physical therapy may assist a driver in maintaining or rehabilitating skills that are essential for safe motor-vehicle operation.
Other Vehicle Considerations
It may be worth replacing a car or truck with a vehicle that is more suitable for your or your loved one’s condition or life station. Although some of the following are, by now, nearly universal, here are some general things that might get you thinking in the relevant direction.
Automatic transmissions are usually easier to operate than manual transmissions.
Power brakes and power steering should be available and properly functioning.
Instrument panels should be easy-to-read and without extraneous or confusing information.
Doors and seats should facilitate ease of vehicle entry and exit.
Commensensical Driving Dos and Don’t
Avoid distracting your loved one or competing for his or her attention. Don’t let your own mind wander. Minimize noise and reduce disturbances! Here are a few (fairly obvious) tips that might apply to some situations. If there is a common undercurrent, it would be: Exercise an abundance of caution and focus.
Avoid driving in inclement weather, during high-traffic (“rush-hour”) times, or in the dark.
Observe all rules of the road, including: checking traffic and signaling properly when changing lanes, looking twice before reversing, maintaining sufficient vehicle distance, and so on.
Limit or postpone having conversations until out of the vehicle.
Turn down music, podcasts, radio programs, and so on. In other words, concentrate on the road!
Set air-conditioner or heater controls before the vehicle is in operation.
Map routes and plan trips ahead of time and select roads for their drivability and not necessarily for their drive times.
If you or your loved one drives infrequently, skills may slip. Keep in practice. Depending upon your area, it may also be possible to enroll in continuing-education courses in order maintain (or enhance) skills, in addition to acquiring strategies for coping with dementia or disabilities.
Finally, as hard as it may be to read, it is a good practice to have competency assessed periodically – both through physicals administered by a healthcare provider as well as via relevant tests (driving, vision, and written).
When to Give up the License/Signs of an Unsafe Driver
You or your loved one may need to have significant restrictions imposed (up to and including license revocation) if certain warning signs surface. Here are things to look for. Your loved one:
Has difficulty discerning the gas pedal from the brake pedal.
Sometimes confuses turning right with turning left – or vice versa.
Declines, forgets, or refuses to use turn signals (or displays other poor decision-making faculties).
Changes lanes in a dangerous manner, does not yield correctly, or weaves in his or her lane.
Has obvious trouble recognizing road signs.
Routinely disregards or otherwise fails to obey traffic signals (e.g., not stopping at red; stopping on green; etc.).
Cannot hear sirens from emergency vehicles.
Cannot see or focus on the road.
Does not seem to notice other cars on the road.
Believes that most other drivers are going “too fast.”
Believes that other drivers go “too slow.”
Has had accidents, actual moving violations, “close calls” or “warnings” more and more frequently.
Misjudges distances, as evidenced in virtue of erratic turning (turning too widely and veering out of a lane, or too narrowly and running onto the shoulder or a curb) or following other vehicles improperly (giving too much distance, or not enough).
Has physical difficulties with the mechanics of driving. [4]
Gets (inappropriately) angry, confused, or frustrated driving.
Forgets how to navigate to or from familiar places.
Feels fatigued or overwhelmed after brief periods of driving.
If children, other family members or friends become worried about someone’s driving ability, then this should be taken as an immediate and obvious red flag. Bear in mind that some Alzheimer’s-afflicted persons may be self-aware enough to accurately assess their own driving abilities and to honestly catalog their limitations. Other dementia patients do not display this sort of insight (or honesty) and, therefore, require much closer attention from doctors, family, friends, or other professionals.
Check Yourself!
AAA once published a self-assessment test under the title “Drivers 55 Plus: Self-Rating.”[5] The assessment included questions about whether you or your loved one:
Habitually signals when changing lanes.
Properly and regularly wears seat belts.
Has difficulty navigating through four-way stops or otherwise busy intersections.
Has trouble merging into congested highway traffic.
Perceives himself or herself to be “slower” in terms of cognition, perception, reflexes, and the like of that.
Has difficulty separating him- or herself from emotional states or becomes easily angered by high-traffic situations.
Cannot stop his or her mind from wandering.
Sees general practitioners and specialists (like eye doctors) regularly to ensure that overall health, prescriptions, and vision are optimal.[6]
[1] Of course, other conditions – for instance, those that result in blackouts, dizziness, or seizures – might undercut driving abilities. But these, except insofar as they are byproducts of dementia, lie beyond the scope of the present article.
[2] Bear in mind that there may be a transitional period during which the patient alternates between lucidity and confusion.
[3] At a certain point, it is likely that the patient will need full-time care. For a discussion of long-term care – with an emphasis on the attendant costs – see HERE.
[4] For example, maybe grandma has a problem shifting pressure between pedals. Perhaps grandpa’s arthritis prevents him from controlling the steering wheel or changing gears. It might be that dad cannot turn his head to check his blind spots. Maybe mom’s prescriptions are causing her to become sleepy and inopportune times.
Besides its not-inconsiderable practical burdens, Alzheimer’s also has numerous theoretical burdens as well. Chief among these are that we know neither precisely what causes Alzheimer’s, nor do we have any curative treatment available.
However, there is much speculation on both alleged causes and prospective cures. Readers can get a flavor for this by attending to the recent Awakening From Alzheimer’s “summit.” This presentation has given me hope, since doctors and researchers believe that they are making progress toward giving us explanations of, and possible solutions to, this dreadful disease.
The first of the many fascinating ideas that I encountered was the notion that our brains are akin to living organisms. On the face of it, this is trivially true, since our brains are part of our bodies and our bodies are, quite obviously, alive. The revelation really comes at the level of analysis, where a more organic view of brain is replacing a more computational/mechanical model.
Various research has convinced some investigators that healthy brains rejuvenate and change on almost a daily basis. But our brains need whole-body support to perpetuate these changes and to keep them going in a positive direction. Too often, poor diet and bad lifestyle choices lead to cognitive decline. (In a way, this is the theme of the entire weblog.)
The “Bredesen Protocol”
The prevailing opinion is that “amyloid plaque” causes Alzheimer’s Disease. An interesting alternative has been proposed by Dr. Dale Bredesen. He believes that the amyloid plaque is actually a reaction of the body to protect the brain from the underlying real cause. This real cause ties into Dr. Bredesen’s primary thesis: there are, in his estimation, different types of Alzheimer’s.
If Dr. Bredesen is correct, then we have some idea of why pharmaceutical companies have heretofore been unsuccessful at devising chemical interventions. They are on the wrong track. One pill cannot cure everyone (nor even slow down the progression of the disease); one size does not fit all, when it comes to dementia. Things are far more complicated than that. (For the received view, see HERE.)
He believes that there are multiple causes of multiple variations of Alzheimer’s. Therefore, we need multiple remedies.
The doctor’s entire schema, as well as his recipe for treatment, is termed the “Bredesen Protocol.” It rests on the posit that there are three different types of Alzheimer’s.
Type 1 – Inflammation Alzheimer’s. Type 1 is characterized by initial memory loss and is supposed to be caused variously by diets high in sugar and processed food or unspecified infection. This sort is generally of late onset.
Type 2 – Nutrient-Deficiency Alzheimer’s. Dr. Bredesen thinks that Type 2 is precipitated when the brain or nervous system lack essential nutrients – termed “trophic supports.” Like Type 1, Type 2 is late-onset and starts with memory loss.
Type 3 – Brain-Toxicity Alzheimer’s. This third sort is early onset and begins with the disruption of executive functioning, as opposed to mere memory loss. Dr. Bredesen believes that the relevant brain toxicity is caused by exposure to specific heavy metals like mercury, or to biotoxins like mold.
BRIGHT MINDS
Another worthy mention is Dr. Daniel Amen, who summarized his BRIGHT MINDS program. The name is an acronym in which the letters stand for factors pertinent to overall brain and cognitive health. Dr. Amen recommends that each factor be checked out and, if need be, issue in a dietary change or lifestyle modification.
In order, the elements are as follows.
Blood Flow – Ensure that your brain has adequate blood flow. Substances like caffeine can restrict blood flow. (On the other hand, some herbs like ginkgo and hawthorn are supposedly salubrious – see HERE.)
Retirement – Don’t just sit around; keep learning! (For some pointers, see HERE.)
Inflammation – Dr. Amen advises: Increase omega-3 levels, by using flaxseed oil, fish oil, and the like. (Additionally, turmeric is a potent, natural anti-inflammatory. For more, see HERE.)
Genetics – This underlines the obvious datum that you are believed to be at greater risk for Alzheimer’s if the disease runs in your family. (On available testing – including genetic testing – see HERE.) What can you do? Dr. Amen recommends that you drink green tea and supplement with vitamin D. (For more on vitamin D, see HERE.)
Head trauma – Dr. Amen colorfully likens our brains to “soft butter.” Protect your brain! Yes, it’s probably a bad idea to bicycle without a helmet or to ride in a car without a seatbelt.
Toxins – Like Dr. Bredesen, Dr. Amen points out that there appears to be a link between neurological degeneration and things such as alcohol, carbon monoxide, drugs of various kinds, mold, and so on.
Mental health – Get help dealing with anger, depression, stress, and the like.
Immunity and infection – Again, in common with Dr. Bredesen, Dr. Amen warns against the possible negative, systemic effects of unchecked infection. Boost your immunity naturally with vitamins C and D as well as probiotics. (Again, see HERE and HERE.)
Neurohormonal deficiency – Hormones should be at optimal – not just adequate – levels.
Diabetes – Cease and desist with the sugar, already! And, yes, we’re looking at you too, breads and pastas. Do you have to cut these yummy treats out entirely? Perhaps not. But, for your brain’s sake, cut down. Eat nutrient-dense foods such as asparagus, berries (like blueberries and strawberries), carrots, cruciferous veggies (e.g., arugula, broccoli, brussels sprouts, cauliflower, cabbage, collard greens, kale), fish (like salmon), lentils, sweet potatoes, and tomatoes.
Sleep – We generally need between 7 and 9 hours of sleep. And yes, you need those 7 hours (minimum) of shuteye each night. (For much more on sleep, see HERE and HERE.)
Get in Step With Your Circadian Rhythm
Dr. Michael Breus talked about our innate circadian rhythms, and how our brains are more receptive to certain types of activities at certain times of the day. For example, he alleges that, for many people, the brain is readier to learn new information in the morning after breakfast, and it’s more creative in the afternoon after lunch.
Dr. Breus speculates that this is because mental clarity and focus peak early in the circadian cycle, as opposed to creativity, which climaxes later. He also recommends that we venture outdoors to soak up some of the natural light – because, in his estimation, “light is medicine.” (See HERE.) So, on the advice of Dr. Breus: Take a walk!
Movement is also important. (We touched on this topic and the dangers of a sedentary lifestyle, HERE.) After lunch, when you feel your energy waning, go outside and get the blood flowing again. (There’s that Blood Flow, again – as mentioned by Dr. Amen.)
Dr. Brues gave a couple of tips on how to get to sleep. He stated that you want your cortisol levels to be low at night because cortisol is a hormone that indicates being stressed. On the other hand, you want high levels of melatonin because that hormone accompanies or marks states of relaxation. (Thus, it helps you get to sleep.) Other helpful tips include turning off computers (and other electronic gadgets) at least one hour before bed – as blue light inhibits (or “turns off”) melatonin production. (For much more on these and other matters, see my sleep articles, HERE and HERE.)
SHINE on, You Sane Diamond
Another method or system – the so-called “SHINE Protocol” – was explicated by Dr. Jacob Teitelbaum. Dr. Teitelbaum’s sketches five areas that are key to developing optimal energy and neurotransmitter functionality. Fine-tuning your nervous system enables your chemical messengers to carry their information from the nerve cells in the brain to other parts of the body in the most efficient manner feasible.
“SHINE” stands for:
Sleep – Not enough sleep can leave you tired and foggy. (Are you starting to get the picture? It’s like old computer-programming adage “garbage in, garbage out.” Many of our problems seem to stem from the fact that we don’t care for ourselves at the most basic levels.) Dr. Teitelbaum recommends 8-9 hours. (Again, see HERE and HERE.)
Hormones – Any kind of deficiency, here, can leave you achy, irritable, tired, and, if Dr. Bredesen is correct, possibly struggling with Type-2 Alzheimer’s. (For more on this, search “hormone” HERE.)
Immunity and infection – Gas and bloating can be a sign of a Candida infection. This, in turn, can be a sign of certain suboptimalities that can spell disaster for brain health.
Nutrition – Mainly watch the levels of your vitamins A, B12, C, and D, as well as of the mineral magnesium. These are easily depleted. (See HERE for more information.)
Exercise (as able) – Start slowly and with light weights. Increase speed and weight and your endurance and strength increase – under the guidance of a competent fitness or medical professional, of course.
Wait, You Want Me to Increase My Fat Intake?
Well, be careful with this one. But consider the words of one Dr. David Perlmutter. The doctor made the astounding statement that our brains are powered (that is, get their needed energy from) by fat – not sugar, as one might immediately think.
Dr. Perlmutter said that, in fact, the higher the blood sugar, the greater the risk for dementia. On the other hand, people who eat diets higher in (good) fat have a 44% risk reduction. Along this line, the best foods to eat for memory retention are avocados, beef (grass-fed), and coconut oil – of which he adds one tablespoon to his coffee every morning to help him feel full for hours.
Coffee also receives a high rank because it helps relieve oxidative stress and protect against neuro-degenerative diseases with a 65% risk reduction. However, presumably, this must be weighed against Dr. Amen’s warning that caffeine is a vasodilator and can restrict blood flow to the brain. (For the skinny on fats – as well as some other good info – see HERE.)
