In fact, experts recommend trying behavior management first, and for good reasons: It tends to be more effective in the long run than “chemical restraints,” has no dangerous side effects, and leads to a better care relationship. But people often don’t know how to do this.
I’ve learned how.
I’ve lived through five close family members’ experiences with Alzheimer’s and other forms of dementia. Lots of trial and error, and insights from dozens of top dementia experts (whose brains I’ve been lucky to pick as a journalist and dementia educator), got me through regular scenes with…
My father-in-law, who needed a walker to move yet spent hour after hour for several days straight hauling all his clothes and toiletries from his room to our driveway, insisting that his (imaginary) new wife was about to pick him up
My dad, a formerly sharp dresser who wore the same shirt and pants every day no matter how dirty
My grandmother, who insisted on going “home,” when she was home
And other relatives, in dozens of similar scenes.
In this article, I want to share what I wish someone had explained to me early on: the “Why-This, Try-This” approach to dealing with difficult behaviors.
This is a mental framework that can help you get unstuck from unproductive responses that get you nowhere or make things worse.
It can bring calm -– to both of you — whether the issue is verbal or physical aggression, agitation, confusion, wandering, disinhibition, delusions, hallucinations, or a restless or repetitive behavior (like pacing, shadowing, rummaging). It also works well with milder irritants like repetitive questions and indecision.
Then, I’ll boil down the Why-This, Try-This concept to a 7-step process you can use every time. These “7 R”s give you a basic platform for responding to any frustrating behavior:
Reassure the person
Review the possible causes
Remove any triggers
Redirect behavior or attention
Review what happened
Reach out for help as needed
The “Why-This, Try-This” Approach
You can’t reason with the person to get out of these situations.
You need to look for the reason why it’s happening in the first place.
To turn things around, consider:
WHY This? There’s almost always a “WHY” behind a dementia behavior.
TRY This! Build off that insight to TRY different ways of shifting the behavior to something less intense, more appropriate, or more positive.
Believe it or not, there actually is a “why” behind nearly all dementia behavior. Often there are multiple reasons at once.
Fundamentally, a challenging behavior is a reaction to a set of circumstances, expressing something that the person may be otherwise unable to convey.
As cognitive and communication abilities wane, it becomes harder for a person with Alzheimer’s to say things like, “I’m confused” or “I’m feeling anxious” or “I just want to be left alone.”
The natural response to all these challenges is frustration, defensiveness, anger, anxiety, or fear. We all act on certain ways when we’re feeling uneasy, mad, insecure, frustrated and so on. These are magnified in someone with dementia, who is even less equipped to deal.
Certain types of dementia can bring added stressors. With Lewy body dementia, for example, visual hallucinations are common. With frontotemporal dementia, impulse control erodes, so you’re more likely to encounter problems like uncharacteristic cursing or sexual behaviors.
Just reminding yourself that there IS a “why” can help extend your empathy and patience.
There’s no single right way to respond to most situations. In many cases, several different things could work, depending on the person and the circumstances.
But here’s what pretty much never works: things like sharp words, attempting to reason with the person, or worse yet, using force.
Instead you’ll need words and actions that are more gentle, more loving – and yep, sometimes downright creative. Although you can’t always stop an irritating behavior, you often can make it less bothersome, safer, or more acceptable, and even over time lower its frequency.
Be ready to do some trial-and-error. If one response isn’t doing the trick, you can almost always try something else that will.
Now with this “Why-This, Try-This” framework in mind, let’s go through the seven steps you can use to put this in action.
7 steps to managing difficult dementia behaviors1. REASSURE the person
The hard truth: the person with dementia can’t change the way he or she is. You have to change — your reaction and the environment or situation.
So putting the person first in your thinking as you react is paramount.
Reassuring brings anxiety, upset, or other stress down a notch. It communicates I’m on your side. I take you seriously. Not feeling understood makes anyone more distressed. For someone with dementia, you create a floor to what must feel like bottomless uneasiness.
The catch: To reassure someone else, we first have to collect our own feelings. This can be hard because these are almost always emotionally charged situations!
It’s easy to feel annoyed when your parent is about to drive off yet another caregiver with false accusations. Or scared when your spouse lashes out or hits. Or embarrassed when Mom’s blouse comes off. Or worried Dad will fall or get lost. We want to REACT!
Showing emotional intensity only makes things worse. It puts the other person on the defensive and adds to their instability (more combative, less cooperative). Also, people with dementia tend to be very sensitive to others’ moods, mirroring their demeanor. If you’re upset, they’re apt to continue to be upset or become more upset. If you’re calm and reassuring, you have a much better chance of transmitting that state.
And avoid making the mistake of assuming they’ll forget your angry moment. Research suggests that although people with dementia quickly forget what was said, the emotional impact of an encounter (whether it was negative or positive) lingers for much longer.
How to reassure:
Collect yourself. Do whatever works for you but know that it’s useful to have a “go to” strategy before you dive in. Examples: Take a deep breath. Count silently to three. Have a “silent scream” in the bathroom. I’d consciously remind myself, “It’s not him (or her); it’s the dementia!”— and I needed to enter my relative’s reality.
Approach slowly and from the front. You’re less likely to startle, confuse, or provoke.
Avoid urging, “Calm down!” Seems like the most natural response in the world, right? But when someone is feeling out of control, it’s like grease on fire. It feels dismissive, rather than reassuring. Also avoid asking, “What’s wrong?” The person with dementia likely can’t articulate it and is left feeling more helpless, rather than helped.
Stop yourself from reacting with logic (no matter how tempting). You CANNOT reason with the person, win an argument, or use facts or “proof” to prove your point. It won’t work. So set that impulse aside.
Respond to the emotion being expressed, rather than the behavior. Instead of saying things like, “Don’t do that!” or “What are you doing?!” focus on validating the person’s mood as you assess the situation.
Even before you understand what’s going on, you can play back what you think they’re feeling: “You sound upset.” “You look like you’re in a hurry.” “You look sad; can I help?” “I know this bothers you a lot. Let me see how I can help.”
Some people respond to a special saying or soothing mantra that you can repeat as needed: “I’m here.” “Everything’s all right.” “Not to worry, love.”
Use body language that matches your words. More than half of any message we give (to anyone) is conveyed nonverbally. But this is especially true when someone has dementia. Avoid sighing or rolling your eyes. Relax your posture. Make eye contact. Smile. Nod. Use a friendly tone of voice. All make the listener more open to what you have to say. Touch can also reassure and guide, such as lightly placing your fingers on a forearm, outstretching your hand in invitation, or putting an arm around a shoulder.
2. REVIEW the possible causes
Upsetting behaviors are seldom done “on purpose” or to spite you or annoy you. That requires a sophisticated level of cognition that the person with dementia is struggling to maintain or has more likely lost.
Usually, several factors together influence behavior. My widower father-in-law, lonely and probably bored, and prone to delusions, invented several wives; he’d waken from a nap (where maybe he dreamt about them) and expect one to be in the room. If she wasn’t, she must have “stepped out” or “went in the hospital” and he needed get there PRONTO! Eroded thinking skills make it hard to process reality.
Another common example: Someone who misplaces her sunglasses can’t mentally retrace her steps to figure out where she left them, so she explains away the gap as theft.
How to try to understand the “WHY”:
Consider the timing. Is this a change that’s come on over recent hours or perhaps the last few days? Suspect delirium due to illness, or something about the immediate situation. A recent change in medications could also be the culprit.
Ask yourself if there’s a pattern to when or where the problem seems to happen. Is there something about the light, noise, or activity at that time (or place) that’s different? A common escalation of restless behaviors in late afternoon or early evening is known as sundowning (as in, when the sun goes down). One theory is that there’s a disruption of the body clock in some people with dementia related to light. Vision problems, low lighting, shadows, and fatigue can all increase sundown syndrome.
Make a mental sweep of what’s new or different that might have set the person off. Was there a change in routine? A new aide? A changed or new prescription? Houseguests? Are there other symptoms of illness?
Consider possible unmet needs. At the root of odd behaviors is often:
A basic physical need. Hunger makes anyone hangry—and people with dementia often forget to eat or get distracted easily during meals. Does an incontinence product need to be changed? Is the space particularly hot or cold for how the person is dressed? A poor night’s sleep, or chronic bad sleep, adds confusion and crankiness by day and leads to exaggerated reactions.
Pain. People with dementia are notoriously bad at reporting pain. If you ask, you might hear “no.” Watch for body language, like wincing, moaning, or rubbing/favoring a body part (like an arm, forehead, or side). Less obvious sources to consider include ill-fitting dentures, tooth decay, cuts or sores on the feet from poorly fitting shoes or diabetic ulcers, and pressure sores from sitting or lying in one spot.
Overstimulation. Are there a lot of people around? Fast-paced activity? A need to rush? Too much going on can fuel anxiety and meltdowns. What’s the sound level? Background noise (even things like a dishwasher running) can make it hard to hear, adding frustration for someone who already has trouble following conversations.
Understimulation/boredom. Many repetitive behaviors (pacing, skin picking, rummaging) have roots in not having enough to do. They become default modes that provide both stimulation and comfort, even if they drive others crazy. Wandering is often the expression of an old habit (walking or driving, feeling free and mobile) coupled with a need for stimulation. People who have been busy their whole lives, such as caring for a family or working at a job, have a deep-wired yearning to stay busy.
Frustration. Is the activity at hand frustrating because it’s too challenging or the person can’t remember how? Does he feel misunderstood when no one believes a delusion? The struggle to keep up and hold it together all day can take a toll; the person snaps.
Feeling unsafe or insecure. A new situation (a different aide, a crowded public place) or a deviation from routine (air travel, a doctor appointment during nap time) can fuel anxiety or fear. Hallucinations or physical issues can create unnerving misperceptions; poor vision can turn shadows ominous, for example. Someone who feels unsure, threatened, or taken by surprise might lash out verbally or physically.
Ask the person questions that show you’re on their side—which might also yield clues to what’s going on. Avoid “Why?” because the person can’t articulate feelings and motives. (“Why do you think that?’ “Why are you doing that?”)
Better: Interested questions that use the other W’s (who, what, when, where). “When did you notice?” “Where did she go?”
Riff off what they’re saying or doing: To someone insistent on going home, you might ask, “Who’s at home?” or “What would you like to do when you get home?” With a wanderer, the conversation might go like this: “Where do you need to go?” “To work.” “What will you do at work?” “Meetings!” “Oh, what are the meetings about today?”
Four terrific words to use: “Tell me about it.” It’s a respectful, open-ended way to gather info and insight.
3. REMOVE any triggers
By eliminating what sets off a behavior, you might be able to end it.
My father kept taking a stopped clock off the wall every time he walked past it. I mean every time! He wanted to repair it but had lost the thinking skills to follow-through. Stupidly, I kept putting it back up—until I realized it was directly in his line of vision on his way to the bathroom, a visual reminder all day long of his need to “fix” it. I moved the clock. Out of sight, out of mind, problem solved.
Common triggers for difficult behaviors:
Many triggers for dementia behaviors will fall into one of the following categories:
Visual triggers. They’re common and easiest to address (like my dad and the clock). Some wanderers are triggered by the sight of keys or a coat by a door, for example; relocate them to another spot. Repeated comments and questions often have a visual trigger.
Activity triggers. At dinnertime, my mother-in-law used to ask over and over, “Should I be doing something?” The sounds of meal prep cued her deeply wired habit to be busy and productive. Told no, everything was fine, she’d say okay…and then ask again a few seconds later. Once we found a way to give her a task—even something as simple as stirring a pot or folding a single napkin repeatedly—her anxious questioning improved.
Misperception triggers. A man who’s combative during bathing may misinterpret the help gestures as an invasion of privacy. An aggressive person is often saying, “I’m overwhelmed and out of control.” Withdraw, even if the action seemed (to you) as mild as offering a washcloth. Try again another time.
Sensory misperceptions can also occur. If streetlights and tree shadows look like people, close the curtains after dark. If tree branches are striking the house, have them trimmed or play soothing, favored music in the evening.
It’s also fair to use “therapeutic lying”—a white lie that enters their reality: “The police are checking to make sure everything is safe.” No longer recognizing one’s own reflection in a mirror is common. Thinking you see a stranger in the bathroom is understandably agitating; it it’s upsetting, remove or cover the mirror.
Discomfort triggers. Address the source: food for hunger, a fan if it’s hot. Don’t overlook glare, feeling personally crowded, or pain. Sometimes stripping happens when fabric is itchy or the style uncomfortable. If unbuttoning becomes a nervous tic, switch to pullovers or back buttons that are harder to remove. A “fidget quilt” with buttons and zippers can be an effective substitute for busy hands.
Frustration triggers. Sometimes when you “give” in fantasy what you can’t in reality, it soothes the distress of not feeling understood: “Oh I wish we could go to that old house right this minute. Let’s plan what we’d do there.”
To get my father-in-law to stop hauling his worldly goods to the curb via walker, we finally stopped putting them back at night. We told him we’d store them in the garage because it looked like rain. He was satisfied (we’d listened!) and this, with the visual trigger of the goods gone, stopped his back-and-forthing. If an activity is beyond ability, offer support or casually end it. Retreat and rest is key when just trying to keep it together all day overwhelm.
4. REDIRECT behavior or attention
You may also need to break the loop of upset by redirecting the person’s behavior or attention. To redirect literally means to change the direction of things. Your goal is to move away from the stressful thing and toward calm.
The many different ways to do this are all most effective once you’ve invested a little time reassuring and calmly connecting with the person. Validating my father-in-law’s perceptions always calmed him at least a little bit, putting him in a more receptive frame of mind to then be diverted by some cookies or opera music.
Some ways to redirect:
Introduce a diversion without belaboring the reason for it: “Hey, I have an idea, let’s….” “Oh wow, look at the funny birds at the birdfeeder….” “Dad, I need your help with….”
Offer a choice of two things the person likes to do: “Would you rather eat your ice cream now or rock on the porch with me?” For someone who has difficulty making choices, express it as a yes/no question: “Are you ready for your ice cream?”
Lead the person to a change in scenery. It might be a different chair, another room, or from inside to outdoors. You can’t physically force them along, which only creates more stress. Instead, try using body language. Beckon and offer your hand. “Where are we going?” the person may ask. “It’s a surprise,” you say. That word alone can be diverting—everyone’s intrigued by a surprise. (The “surprise” can be as simple as a snack, a look at clouds, a YouTube baby video, or a baseball game on TV.)
Shift to an entirely different kind of activity. Sensory experiences, like playing music, gardening, rocking in a rocking chair, or helping to prepare food, are known to bring positive emotional associations.
Use bridge phrases to change the topic of conversation. Certain transitional words “build a bridge” to a new direction—away from the thought or image that got the person stuck. “It’s a mystery about your sunglasses. But that reminds me of the time you bought them for that wonderful whale-watching trip and the whale splashed us.”
This approach is handy when someone is stuck on a repetitive question or comment. More examples:
What I’d really like to know is….
Yes, that’s true, and…
You know, I’ve also heard that…
Steer toward a cheerful past. Some people are soothed by comfort objects, like a stuffed animal to pet, a doll to hold, a toolbox to arrange—often things linked with positive memories of their past. You have to use trial and error to see what’s effective but respectful in an individual case. Music, sports games, or talk of weddings (any wedding!) are among popular topics for revisiting.
You know the person best. Even when dementia has altered personality, many core preferences, motivations, and traits remain and you can work with these to find a solution.
5. RESTORE yourself
When a rough episode is over, give yourself a moment. Collect yourself. Give yourself some credit. There’s a tendency to focus only on the person with dementia, but it’s really fortifying to pay attention to yourself, too.
Take a few deep breaths. Scrawl in a journal. Text a friend. Go back in that bathroom for another silent scream. Anything that lets off some of the stress that even a well-handled incident can create.
Have you been worried about an older person’s memory or thinking abilities?
Maybe your parent has seemed more confused recently. Or you may have noticed that your aging spouse is repeating herself, or struggling to do things that didn’t use to pose much of a problem.
These are very common concerns, and they often lead to questions such as:
Is this normal aging or something more significant?
What is wrong?
Could this be Alzheimer’s? Or some other form of dementia?
Can this be treated or reversed?
What should we do about this??
The answer to the last question is this: if you are worried about memory or thinking, then you should seek out some kind of medical evaluation.
That’s because when families worry about an older person’s cognitive abilities, there often are some underlying health issues affecting the mind’s function.
Those need to be detected, and treated if at all possible. So, you’ll need to request help from a health professional, and in this article, I’ll explain what that initial help should consist of. This way you’ll know what to expect, and what the doctor might ask you about.
Technically, these kinds of problems are called “cognitive impairment.” This is a broad term that means some kind of problem or difficulty with one’s memory, thinking, concentration, and other functions of the conscious brain, beyond what might be expected due to normal “cognitive aging.”
(For more on “cognitive aging” and what types of changes are considered normal aging, see here.)
Cognitive impairment can come on suddenly or gradually, and can be temporary or more permanent. It may or may not keep getting slowly worse; it all depends on the underlying cause or causes.
In this article, I’ll share with you the more common causes of cognitive impairment in older adults.
I’ll then share a list of 10 things that should generally be done, during a preliminary medical evaluation for cognitive impairment in an older adult.
Common causes of cognitive impairment in older adults
Cognitive impairment, like many problems in older adults, is often “multifactorial.” This means that the difficulties with memory, thinking, or other brain processes are often due to more than one cause.
Common causes of cognitive impairment in older adults include:
Medication side-effects. Many medications interfere with proper brain function.
The more common neurodegenerative conditions include Alzheimer’s disease, Lewy-Body disease, Parkinson’s disease, and frontotemporal degeneration.
This is not as common in older adults as the other causes above, but certain chronic or acute infections can affect brain cells directly. (If cognitive impairment is caused by an infection outside the brain, such as pneumonia or a urinary tract infection, this would be considered delirium.)
Toxins are another potential cause of cognitive impairment. Research is ongoing as to the cognitive effects of toxins people may be exposed to, such as heavy metals, air pollutants, contaminants in our drinking water, pesticides, and others.
Now that I’ve covered the most common causes of cognitive impairment in older adults, here’s what an initial medical evaluation should generally cover.
10 Things the Doctor Should Do When Evaluating Cognitive Impairment in an Older Adult
Here are ten specific things the clinician should ask about, check on, or do, as part of an initial evaluation for cognitive impairment in an older adult.
The following list reflects my own practice and that of most geriatricians. It is in line with most syntheses of guidelines and best practices, including the UpToDate.com chapter on this subject.
Most experts agree that these steps can be done by primary care clinicians.
1. Ask about and document the patient’s concerns about memory and thinking.
At a minimum, the clinician should ask an older person something like “So, have you noticed any changes in your memory or thinking abilities?”
Now, many older adults will either have noticed nothing or won’t want to talk about it. This in of itself is worth noting, especially if family or others have voiced concerned.
If the older person does have concerns or observations, these should be explored. It’s especially important to ask when the problems started, and whether they seem to be getting worse, and how quickly things seem to be changing.
2. Obtain or request information on memory or thinking difficulties from family members or other “informants.”
Older adults with cognitive impairment are often unaware of — or reluctant to reveal – the difficulties they are experiencing. For this reason, a health provider who has been alerted to the possibility of cognitive impairment should make an effort to get information from a family member or other knowledgeable informant.
It’s sometimes necessary for the health provider to be diplomatic about requesting and getting information from family members, especially if the older person finds it upsetting. People may think that HIPAA doesn’t allow doctors to talk to family over an older person’s objections, but actually, clinicians do have some leeway in these situations. (See my HIPAA article here.)
Family members can facilitate this process by bringing in a written summary of what difficulties they’ve observed. Be sure to include information on when the problems started and whether they seem to be getting worse.
3. Ask about difficulties managing instrumental activities of daily living (IADLs) and activities of daily living (ADLs).
The ideal is to for the health provider to ask both the patient and the family about this. Older adults with cognitive impairment are often not reliable reporters of what difficulties they’re having.
Instrumental activities of daily living (IADLs), in particular, are often affected by cognitive impairment. So it’s important to ask if the older person is having difficulty with problems with tasks such as:
Driving and other forms of transportation
Management of finances
Grocery shopping and meal preparation
Managing the telephone, the mail, and other forms of communication
The provider should also ask about ADLs, which are the more fundamental self-care tasks such as walking around, feeding oneself, getting dressed, managing continence, and so forth.
Difficulties with IADLs and ADLs (which geriatricians refer to as “functional impairment”) are important to document. They offer a practical lens on how “severe” an older person’s cognitive impairment might be, and on what steps could be taken to support an older person while these cognitive issues are getting evaluated.
Functional impairments may correspond with safety issues that need to be addressed; if an older person is having difficulty with finances, it may be a good idea to check for signs of financial exploitation, or otherwise take steps to protect the person financially.
Last but not least, impairment in daily functioning is also a criterion that separates mild cognitive impairment(MCI) from more significant impairment (including dementia). In MCI, a person may be experiencing some cognitive impairment, but it should not be bad enough to significantly interfere with performing daily life tasks.
4. Check for the presence of other behavioral, mood, and thinking symptoms that may be related to certain causes of cognitive impairment.
Apathy (losing motivation)
Confusion about visual-spatial tasks (e.g. having difficulty figuring out how to put on one’s shirt)
5. Ask about any new symptoms or changes in physical health.
It’s especially important to ask about symptoms related to neurological function, such as new difficulties with walking, balance, speech, and coordination. Checking for tremor and stiffness (both of which are associated with Parkinsonism) is also recommended.
The exact questions the clinician asks will depend on the person’s particular medical history, and the other signs and symptoms that have been brought up.
6. Ask about substance use and consider the possibility of substance abuse and/or withdrawal.
Excessive use of alcohol, certain prescription drugs (such as tranquilizers), or of illicit drugs can affect cognitive function. Health providers should inquire about an older person’s use of these substances.
Suddenly stopping or reducing the use of alcohol or other substances can also occasionally cause or worsen cognitive function.
7. Review all medications, with a focus on identifying those known to worsen cognitive function.
Certain types of medications tend to dampen brain function, and may cause a noticeable worsening in cognitive abilities. The health provider should especially ask about use of:
Benzodiazepines, which are often prescribed for either insomnia or anxiety
Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
Prescription sleeping pills, such as zolpidem (brand name Ambien)
Anticholinergics, a broad category of medications which includes most over-the-counter sleeping aids, sedating antihistamines, drugs for overactive bladder, muscle relaxants, and others.
For a list of commonly prescribed medications that are anticholinergic, see here.
At a minimum, the health provider should check vitals (blood pressure and pulse) and should also complete a basic neurological evaluation, including an observation of the person’s gait, balance, and coordination.
The purpose of the physical exam is to look for physical signs that may correspond to causes of cognitive impairment, or that may relate to other symptoms the patient or family brought up.
9. Assess the person’s orientation and perform some type of office-based cognitive test.
Assessing “orientation” means checking to see whether the patient knows things like the day, date, month, year, and where he or she is.
Some office-based testing should also be done, to check and document the older person’s memory and thinking abilities.
Probably the shortest well-validated test is the Mini-Cog, which involves a three-item recall and a clock draw.
A more detailed office-based cognitive test that can be done in primary care is the MOCA test (Montreal Cognitive Assessment Test). This takes 10-20 minutes to administer, so it often requires scheduling a separate visit.
There are some other “intermediate” length tests that can be done in the primary care office, such as the SLUMS (St. Louis University Mental Status Examination). The Mini-Mental State Exam is another option, although most experts (including myself) consider it less useful than the MOCA or SLUMS.
10. Order laboratory testing (unless recently done) and consider brain imaging.
In most cases, it will be appropriate for the health provider to order blood tests, to check for common health problems that can cause or worsen cognitive impairment.
Blood tests to consider include:
A complete metabolic panel, which assesses electrolytes, kidney function, and liver function tests
As for brain imaging, some expert guidelines recommend it for everyone and other guidelines suggest it be used “selectively.”
(In most cases, brain imaging reveals non-specific findings such as signs of cerebral small vessel disease and perhaps some mild atrophy of the brain. These are common findings in many older adults and tend to have a variable correlation with symptoms. Most causes of cognitive impairment cannot be definitely ruled in or ruled out by brain imaging.)
Overall, an initial medical evaluation should result in these four key things happening:
Documentation of the patient’s and family’s cognitive concerns.
This means documenting what the patient and family have noticed, in terms of difficulties and changes in memory, thinking, behavior, or personality.
Documentation of any functional impairment the older person is experiencing.
This means documenting what the patient and family have noticed, in terms of difficulties managing life tasks (IADLs and ADLs).
An objective assessment of the older person’s memory and thinking skills.
This is done through some form of standardized office-based test.
Clinicians can also document their impressions and observations based on talking to the older person. (Did the person seem confused? Paranoid? Repetitive? Tangential? Was the person able to answer detailed questions?)
An evaluation for common medical causes and contributors of cognitive impairment.
This means checking for those common problems that can cause or worsen cognitive impairment.
Generally, it will take at least two primary care visits to complete an evaluation for cognitive impairment.
The second visit is often used to do a cognitive test such as the MOCA, and can enable the clinician to follow up on laboratory tests that were initially ordered.
And then what?
Well, what happens next depends on several things, such as:
Whether the health provider was able to draw conclusions about what is likely causing the cognitive impairment
Whether treatable conditions were identified
How the patient and family feel about the evaluation
Whether the older person is willing and able to cooperate
Whether the clinician feels that referral to a specialist is necessary
Whether the clinician is willing and able to help the older person and the family (or refer them for help) addressing any functional impairment or safety issues
You may be wondering: should you expect a diagnosis or “an answer” after this evaluation?
I’ll be honest here: probably not. Even with an adequate initial evaluation, cognitive impairment may take a few months (or even longer) to completely evaluate and diagnose. For instance, it’s often necessary to try treating one or more potential causes, to see if the cognitive problems improve or not.
Other causes of cognitive impairment — notably neurodegenerative conditions such as Alzheimer’s and some of the other dementias — can take a while to diagnose because clinicians are first supposed to exclude the other potential causes, and that can take a while. (For more on the diagnosis of dementia, see “How We Diagnose Dementia: The Practical Basics to Know.)
What to expect from an initial evaluation
It may not be realistic to expect definite answers. But that doesn’t mean you can’t expect some explanations.
Your health provider should be able to explain
How substantial the cognitive impairment appears to be, based on the office-based testing and the evaluation so far,
What was checked for, and what has been ruled out (or deemed unlikely) as a cause for the problems you’ve been worried about,
Whether any of the medications might be making memory or thinking worse, and what the options are for stopping or reducing those medications,
What the healthcare team proposes to do next, to further evaluate the issues or follow up on the problems.
So if you’ve been worried about memory or thinking problems, ask for that medical evaluation. If your health provider skips any of the steps I listed, don’t be shy and ask about it. (Either it’s an oversight or they should be able to explain why it’s not necessary.)
You probably won’t get all the answers and certainty that you’re hoping for, but you’ll have gotten started and that’s vitally important.
Of course, you may well be facing the problem of not being able to get your older loved one to go to the doctor. That’s an issue I’ll have to write another article about.
In the meantime, especially if it’s a challenge to see the doctor for some reason, then it’s all the more important to the most out of your medical evaluation when you do manage to get there.
Do you have any questions about the initial medical evaluation for cognitive impairment? Please post them below.
Every May, the Administration on Aging leads the national observance of “Older Americans Month.” The theme this year is “Engage at Any Age.”
But I found myself thinking that this would be a nice opportunity to consider: just what does it mean to “succeed” or do well as an older adult?
This is important, because our understanding of what is “success,” and what to strive for, is fundamental to how we judge ourselves and others.
And for us as a society, articulating what’s involved in experiencing “good” or “successful” aging is important because it can help us understand what kinds of things we should focus on, to help more older adults age well, or otherwise “succeed” in late-life.
So, just as philosophers and others have long debated what it means to “live a good life,” we should ask ourselves what it means to “succeed” as an older adult.
This way, we can know whether we are “succeeding” as a society that supports and values its older population.
I can’t summarize the debates on what constitutes successful aging here, but if you’d like to read more, this article from The Gerontologist offers a long and detailed overview of different ways that scholars have conceived of successful aging: Defining Successful Aging: A Tangible or Elusive Concept?
A common (and problematic) definition of successful aging
One prominent model of successful aging, developed in the 1990s (Rowe and Kahn), proposed that it means:
freedom from disease and disability
high cognitive and physical functioning
active engagement with life
Gerontologists have gone way past this model, but this may be pretty close to what many people have in mind, when they think of “successful aging” or “aging well.”
And it’s certainly what many images of older adults convey: people who may “look older” but otherwise appear to do everything they could do earlier in life.
This is what we see in this AARP “Disrupting Aging” video, in which millennials are confronted with some older adults who are much more able than the millennials had expected.
But there’s an obvious problem with this conception of successful aging: many, if not most, older adults will eventually not be able to meet all three criteria.
So have they failed? And: will we tend to judge that it’s their fault if they don’t remain disease- and impairment-free as they age?
A better lens on “successful aging”
This article describes a newer way to frame successful aging that I find intriguing.
The authors describe a model based on the assumption that with increasing age there is an accumulation of health-related and social stressors.”
They note that if it weren’t for common age-related challenges, there would be no need to distinguish successful aging from successful living at any age. (True!)
They propose that those who maintain good physical health, mental health, and engagement in social activities, without any conscious coping efforts, be referred to as “lucky agers”.
But most people will not be lucky, and hence they need to find ways to cope and adapt to age-related stressors, which include:
“lack of person-environment fit”
Coping with age-related stressors in a purposeful way, and finding ways to maintain quality of life, is called making “proactive adaptations.”
The authors go on to describe how this can be done in a “preventive fashion” (e.g. anticipating a future or impending age-related stressor) and then also in a “corrective” way, which means making adaptations once a stressor or problem has occurred.
To adapt, an older person must marshal both internal resources (attitude, optimism, coping with challenges) and external resources (available social support, finances, etc).
The main quality of life outcomes in this model include:
Self-evaluation of success
Meaning in life
Positive affective state (which basically means positive mood or emotions)
In short: in this model, success is not defined as remaining free of disability or disease as one gets older.
Instead, succeeding means finding ways to cope with impending or existing illnesses, losses, and other challenges, by getting help and by marshaling one’s own resilience and internal resources.
In this way, despite experiencing losses and illness and “lack of person-environment fit” (e.g. a house that is a challenge or dangerous to live in), older people often find ways to meet these challenges.
In doing so, they continue to find ways to experience positive outcomes such as life satisfaction, meaning, contentment, and they are still able to participate in valued activities.
Personally, I like this model. (Granted, it’s a little wonky, but that’s true of all substantive academic work.) I especially like the attention to the way that older adults can be proactive and exert their autonomy by anticipating and adapting to common age-related challenges. In the words of the authors, this “reflects human agency directed at stress reduction, resource development, and problem resolution.”
In other words, this model gives credit to those who acknowledge that their lives may or are changing, and purposefully engage in addressing this.
This takes a certain courage. Which, in truth, is what most older adults muster when the time comes. But you’d never know it to see most media images of older adults, which either portray them as free of late-life stressors or instead emphasize their declines without highlighting their successes in adapting, and their ability to find meaning in a new normal.
How can we support older adults in anticipating & coping with age-related challenges?
Most people will encounter losses and impairments as they age.
What if, as a society, we were less afraid of this, and instead embraced it as an opportunity to be proactive, and then to step up to challenges?
What if as a society, we were better at acknowledging and celebrating the remarkable acts of resiliency and problem-solving that many older people are working their way through?
What if older people felt more comfortable getting help when it becomes necessary? What if we were better at providing it?
These are some of the things that I’ll be thinking about during Older Americans Month.
People really can engage at any age.
We need to make sure that message is clear — and actionable — even for those who aren’t among the “lucky agers.”
Now tell me: what comes to mind when you think of “successful aging”? And what could we collectively do to help more older adults feel successful?
It’s an initiative meant to “inspire, educate and empower the public and providers about the importance of advance care planning.”
In other words, National Healthcare Decisions Day is meant to get you to plan for your future…a future time during which you might be ill and others — most likely your family — will have to make decisions about your healthcare.
This is not a particularly unlikely scenario. Between the present-at-all-ages possibility of being in a bad accident and the increased likelihood of illness as one ages, you’d actually have to be quite lucky — or unlucky, depending on how you see it — to reach the end of your life without anyone else ever having to make a medical decision on your behalf.
Still, studies and surveys generally find that many of us have not taken the needed steps to “make our wishes known.”
And even among those who have “made their wishes known,” there’s usually more to it than they realize, and they often have skipped an important piece of the process.
Now in general, older adults do address advance care planning more often than younger people do.
But, a recently published study found that in a 2012 survey of Medicare beneficiaries, only 38% reported having addressed three key parts of advance care planning (having an end-of-life conversation, designating a health power of attorney, and completing a living will).
We can and should do better. Because when we address advance care planning, we not only benefit ourselves, but we also provide an important service and gift to our family and loved ones.
Making medical decisions on behalf of someone else is often extremely stressful. I found this out the hard way many years ago, when my father fell suddenly very ill. (I share this story in a related podcast episode, which you can find here.)
By making an effort to think through “your wishes” — your values and priorities, really — you can make things much easier for your family, should they ever be called to make decisions for you.
And if you think you’ve already taken care of this: you may not have done it as thoroughly as possible the first time around, and you may well be due for a refresher.
So again, for your sake and for that of your loved ones, don’t assume you’re done!
Instead, use April and National Healthcare Decisions Day to ask yourself the following five questions.
5 Questions to Ask Yourself on National Healthcare Decisions Day
1.Have I legally chosen someone to be my surrogate medical decision maker?
Why this matters:
If you ever become sick, you might well lose the ability to make medical decisions for yourself. If this happens, health providers will want to know who is your legally-designated surrogate decision maker.
People sometimes assume that you have to be deathly ill to lose the ability to make medical decisions, but that’s not at all true.
In fact, it’s quite common for older adults to become mentally impaired while hospitalized; one study published in 2014 found that within 48 hours of hospitalization, 47% of older adults required decision help from surrogates.
Of course, it’s also common for older adults to become unable to make medical decisions before dying. A 2010 study found that in about 42% of deaths, decisions about medical treatment had to be made in the last days of life. And in those situations, the older person lacked decision-making capacity 70% of the time.
If you don’t legally designate a particular person, most states will allow your spouse, or your next-of-kin, to make decisions on your behalf. But it’s generally better to have specified someone in particular. This can spare a family confusion about exactly who should be making decisions if the need arises.
What to do:
If you have not legally designated someone to be your healthcare decision maker, now is the time to start thinking about it.
You can get good guidance on how to choose a good person for this role via the PrepareForYourCare.org website.
The ideal surrogate decision-maker is someone who will try to make decisions in accordance with what he/she thinks you would want for yourself (instead of what he/she would want for you). This person should also be willing and able to ask health providers questions on your behalf.
Give yourself time to think about who would be a good surrogate, and be sure to talk to the person — and perhaps other family members — about taking this role.
If you have legally designated someone to be your healthcare decision maker, congrats! But you’re not off the hook, I have more questions for you below.
2. Have I thought about my wishes and preferences for my medical care, if I were too sick or too mentally disabled to make decisions for myself?
Why this matters:
Your healthcare surrogate, your family, and your doctors all want to help you get the medical care that is right for you and your preferences.
But what is “right” for you? They may well have trouble deciding on this, unless you’ve provided them with some useful guidance.
And you might well have a hard time providing this guidance; many people find that this is a hard subject to think about and talk about.
Fortunately, some simple tools can make it much easier for you to think through what your values and priorities would be, in the event of a health crisis or life-threatening emergency.
What to do:
Several tools have been developed to help people think through what they might prefer, if they could not make their own healthcare decisions.
Here are some especially good ones:
PrepareForYourCare.org: PREPARE is an easy-to-use program that uses video and straightforward language to help older adults think through issues related to advance care planning, including “Decide What Matters Most in Life.”
Find the video series here. It is presented in five steps, each of which can be completed in 15 minutes or less. You can save your work as you go along, so it doesn’t all have to be done at once.
The PREPARE website also offers a “talking” feature which reads the content out loud, so it’s accessible to people with very limited vision. The material is also available in Spanish.
The Consumer Toolkit for Health Care Advance Planning. This set of worksheets from the American Bar Association’s Commission on Law and Aging is user-friendly and is designed to help an older person think through values and preferences related to advance care planning.
3. Have I discussed my advance care planning with my healthcare providers?
Why it matters:
It’s important to talk with your healthcare providers for several reasons.
To begin with, since they may well be directing or overseeing your medical care in the event of an emergency, you’ll want them to be aware of whatever your preferences and wishes are, for your future healthcare.
The other reason is that your health providers should be able to tell you what kinds of health decisions your surrogates might have to make on your behalf.
In other words, your health providers can tell you what kinds of health crises or declines to plan for. Understanding this can help you provide your surrogate decision-maker — and your clinicians — with better guidance.
What to do:
Make sure you have discussed your advance care planning with your usual clinicians. It’s best to do this before you finalize your advance directive. (But if you’ve already completed your advance directive, it’s ok! Talk to your clinician anyway. You can always revise your advance directive afterwards, if needed.)
Let your health providers know what you have in mind for your preferences and wishes.
Ask them if there are any particular health declines or crises that they think you might want to plan for.
Remember, it is okay — it’s strongly recommended, actually — to bring up advance planning with your health providers before you complete any legal paperwork.
If you have already completed a durable power of attorney for healthcare, or any other relevant paperwork, you should make sure your health provider has a copy.
4. Have I documented my wishes in a legally-suitable format?
Why it matters:
Once you’ve decided on your wishes, you’ll want to document them. You may want to record your thoughts in a journal, in a letter to your family, or even in a short video. (This can become useful to your family later.) But ultimately, it’s important to also document your wishes in a more legally-binding format, which should be compatible with your state’s laws.
As noted above, if you are designating a surrogate decision-maker, that’s done through a durable power of attorney for healthcare. Such documents are generally mandatory if you want someone who is not your spouse or next-of-kin to make decisions on your behalf.
A healthcare power of attorney is also useful for specifying which of your children or next-of-kin should be the decision-maker. (It can be hard to pick just one person but that’s what experts recommend. Doing so makes family disagreements over “what Mom wanted” — which are surprisingly common — easier to manage.)
If you want to specify your wishes for end-of-life care or other types of preferences for healthcare, that’s done in a living will, which is also sometimes called an advance directive.
(Technically, an advance directive is a legal document specifying your healthcare proxy and/or your wishes in the event of an emergency or life-threatening illness.)
What to do:
First and foremost, don’t stay stuck on this step for too long. Completing an advance directive shouldn’t require an attorney or a lot of expense, and in many states, a notary is not necessary if you have two witnesses.
And remember, as long as a person has the required decision-making capacity, an advance directive can be canceled or revised at any time.
To find an advance directive form valid for your state:
If possible, I recommend using an “easy-to-read” advance directive. These are just as valid as a conventional forms in “legalese,” but are much easier to understand.
The National Hospice and Palliative Care Organization also offers a list of state-specific advance directives here.
For people with advanced illness or who otherwise are likely to experience a life-threatening emergency within the next 1-2 years, you may also want to consider a POLST or MOLST (Physician/Medical Orders for Life-Sustaining Care). Learn more about POLST here.
5. When did I last review my advance directive? Have I reviewed it regularly, or after a significant change in health status?
Why it matters:
It’s essential to regularly review any documents you have completed in the past, to make sure that they still are a good fit for your family situation, your preferences, and your health situation.
For instance, people’s preferences and wishes regarding medical care and end-of-life care often change as their health problems evolve.
People are also sometimes influenced by their experience helping another person with health issues.
Relationships also change over time; the person who seemed right to be your surrogate decision-maker several years ago may no longer be your best choice, for a variety of reasons.
If nothing else, you’ll want to make sure you know what you’ve documented. (People often admit they are unsure when I ask them, because the documents were done years ago as part of an estate planning process, and they haven’t seen them again since!)
What to do:
Generally, you should review your advance care planning every five years or so, OR whenever any of the following occur:
A significant health crisis (e.g. a hospitalization for illness)
Diagnosis of a major new health condition (e.g. cancer)
A significant decline in health or abilities
A significant improvement in health or abilities (this does happen sometimes!)
Diagnosis of a progressive condition expected to cause eventual incapacity (e.g. Alzheimer’s and other dementias)
A significant change in family relationships (e.g. divorce, widowhood, loss of other close family members)
A significant change in living situation (e.g. moving to a new state and/or more supportive living environment)
To review your advance care planning, you can follow these steps:
Review the state of your health and chronic conditions with your usual healthcare providers.
What health declines or health crises should you plan for? What kinds of decisions might your surrogate have to make on your behalf?
Reflect on your values and preferences, and discuss with your family and surrogate decision-maker.
Use PREPARE or a Conversation Project Starter Kit, to guide you through key values to consider.
Try to discuss your preferences for any potential health crises or declines that your surrogate might have to navigate on your behalf. Trust me, your surrogate will be very glad you did this, if they ever have to step in.
Review your existing advance directive and any other documentation.
Does your existing documentation still seem like a good fit for your preferences?
Is your currently designated durable power of attorney still a good fit?
Update your advance directive and documentation if it seems needed.
If you revise your documentation, be sure to let your surrogate decision-maker and all your health providers know, and provide them with copies of the most recent information.
Planning ahead is a gift that benefits you and your loved ones
I know it’s not easy to think ahead to a time when we might be dangerously ill or mentally incapacitated.
But it’s an effort worth making. It will help you get medical care in line with your preferences and values, when the time comes. And you will reduce stress and anxiety in those making decisions for you, by providing much-needed guidance.
So, be sure to ask yourself these five questions for National Healthcare Decisions Day:
Have I legally chosen someone to be my surrogate medical decision maker?
Have I thought about my wishes and preferences for my medical care, if I were too sick or too mentally disabled to make decisions for myself?
Have I discussed my advance care planning with my healthcare providers?
Have I documented my wishes in a legally-suitable format?
When did I last review my advance directive? Have I reviewed it regularly, or after a significant change in health status?
Constipation is not a glamorous topic, but it’s certainly important, especially in older adults.
As anyone who has experienced occasional — or even chronic — constipation can tell you, it can really put a damper on quality of life and well-being.
Constipation can also cause more substantial problems, such as:
Severe abdominal pain, which can lead to emergency room visits
Hemorrhoids, which can bleed or be painful
Increased irritability, agitation, or even aggression, in people with Alzheimer’s disease or other forms of dementia
Stress and/or pain that can contribute to delirium (a state of new or worse confusion that often happens when older adults are hospitalized)
Fecal incontinence, which can be caused or worsened by having a hard lump of stool lodged in the lower bowel
Avoidance of needed pain medication, due to fear of constipation
Fortunately, it’s usually possible to help older adults effectively manage and prevent constipation. This helps maintain well-being and quality of life, and can also improve difficult behaviors related to dementia.
The trouble is that constipation is often either overlooked or sub-optimally managed by busy healthcare providers who aren’t trained in geriatrics. They are often focused on more “serious” health issues. Also, since many laxatives are available over-the-counter, some providers may assume that people will treat themselves if necessary.
Personally, I don’t like this hands-off approach to constipation. Although several useful laxatives are indeed available over-the-counter (OTC), I’ve found that the average person doesn’t know enough to correctly choose among them.
Also, although in geriatrics we often do end up recommending or prescribing laxatives, it’s vital to start by figuring out what is likely to be causing — or worsening — an older person’s constipation.
For instance, many medications can make constipation worse, so we usually make an attempt to identify and perhaps deprescribe those.
In short, if you’re an older adult, or if you’re helping an older loved one with health issues, it’s worthwhile to learn the basics of how constipation should be evaluated and managed. This way, you’ll be better equipped to get help from your health providers, and if it seems advisable, choose among OTC laxative options.
Here’s what I’ll cover in this article:
Common signs and symptoms of constipation
Common causes of constipation in older adults
Medications that can cause or worsen constipation
How constipation should be evaluated, and treated
The laxative myth you shouldn’t believe
3 types of over-the-counter laxative that work (and one type that doesn’t)
My approach to constipation in my older patients
I’ll end with a summary of key take-home points, to summarize what you should know if you’re concerned about constipation for yourself or another older person.
Common signs and symptoms
Constipation can generally be diagnosed when people experience two or more of the following signs, related to at least 25% of their bowel movements:
hard or lumpy stools
a sense of incomplete evacuation
the need for “manual maneuvers” (some people find they need to help their stools come out)
fewer than 3 bowel movements per week
People often want to know what is considered “normal” or “ideal,” when it comes to bowel movements. Although it’s probably ideal to have a bowel movement every day, it’s generally considered acceptable to have them every 2-3 days, provided they aren’t hard, painful, or difficult to pass.
The handy Bristol Stool Scale can be used to describe the consistency of a bowel movement, with Type 4 stool often being considered the “ideal” (formed but soft).
Constipation is pretty common in the general population and becomes even more so as people get older. Experts estimate that over 65% of people over age 65 experience constipation, with straining being an especially common symptom.
Other symptoms that may be caused by constipation in older adults
Constipation may be associated with a feeling of fullness, bloating, or even pain in the belly. In some people, this may interfere with appetite.
Although most older adults will admit to symptoms of constipation when asked, a person with Alzheimer’s or a related dementia may be unable to remember or relay these symptoms. Instead, they might just act out or become more irritable when they are constipated.
Prolonged constipation can also lead to a more urgent problem called “fecal impaction.” This means having a hard mass of stool stuck in the rectum or colon. It happens because the longer stool remains in the colon, the dryer it tends to get (which makes it harder to pass).
Impaction tends to be very uncomfortable, and can even provoke a full-on crisis of belly pain. It can also be associated with diarrhea and fecal incontinence.
Clearing out impacted stool can be hard to do with oral laxatives; these can even make things worse by creating more pressure and movement upstream from the blockage.
Fecal impactions are usually dislodged using treatments “from below” to soften and break up the lump, such as suppositories and/or enemas. (I address what type of enema is safest below.) They sometimes require help from clinicians in urgent care or even the emergency room.
Common causes of constipation in older adults
Like many problems that affect older adults, constipation is often “multifactorial,” or due to multiple causes and risk factors.
To have a normal bowel movement, the body needs to do the following:
Move fecal material through the colon without excess delay (stool gets dryer and harder, the longer it stays in the colon).
Coordinate a defecation response when stool moves down to the rectum, which requires properly working nerves and pelvic muscles.
As people get older, it becomes increasingly common to develop difficulties with one or both of these physical processes. Such problems can be caused or worsened by:
Medication side-effects (more on those below)
Insufficient dietary fiber
Insufficient water intake
Electrolyte imbalances, including abnormal levels of blood calcium, potassium, or magnesium
Endocrine disorders, including hypothyroidism
Slow transit due to chronic nerve dysfunction, which can be due to neurological conditions (including Parkinson’s disease) or can be caused by long-standing conditions that eventually damage nerves, such as diabetes
Psychological factors, such as anxiety, depression, or even fear of pain during the bowel movement
Very low levels of physical activity
“Mechanical obstruction,” which means that the colon or rectum — or their proper function — is impaired by some kind of mass, lump, narrowing, or another physical factor
A tumor can cause this problem, but there are also non-cancerous reasons that a person can develop a mechanical obstruction affecting the bowels.
Medications associated with constipation
Several commonly used medications can cause or worsen constipation in older adults. They include:
Anticholinergics, a broad class which includes sedating antihistamines, medications for overactive bladder, muscle relaxants, anti-nausea medications, and more. (This group of medications is also associated with worse brain function; they block acetylcholine, which is used by brain cells and by the nerves in the gut.)
Opiate painkillers, such as codeine, morphine, oxycodone
Some forms of calcium supplementation
Some forms of iron supplementation
It’s not always possible or desirable to stop every medication associated with constipation. If a medication is otherwise providing an important health benefit and there’s no less constipating alternative, we can continue the medication and look for other ways to improve bowel function.
Still, it’s important to consider whether any current medications can be deprescribed, before deciding to use laxatives and other management approaches.
If opioids are absolutely necessary to manage pain (such as in someone with cancer, for instance), a special type of medication can be used, to counter the constipating effect of opioids in the bowel. This is generally better than depriving a person of much-needed pain medication.
How to evaluate constipation
How to treat constipation basically depends on what appear to be the main causes and contributors to a person’s symptoms.
An evaluation should start with the health provider asking for more information regarding the symptoms, including how long they’ve been going on, as well as the frequency and consistency of stools.
It’s also important for the clinician to ask about “red flags” that might indicate something more serious, such as colon cancer. These include:
Blood in the stool (which can be red, or black and “tarry” in appearance)
New or rapidly worsening symptoms
The next steps of the evaluation will depend on a person’s medical history and symptoms. It’s generally reasonable for a healthcare provider to check for these common causes of constipation:
Low intake of dietary fiber
Low fluid intake
Common causes of painful defecation, such as hemorrhoids or anal fissures
Evaluation for possible mechanical obstruction will depend on what the clinician sees on physical examination, the presence of potential red flags, and other factors. Generally, a rectal exam is a good idea.
In a 2013 review, the American Society for Gastroenterology recommends that clinicians evaluate for possible pelvic floor dysfunction mainly in those people whose constipation doesn’t improve with lifestyle changes and over-the-counter (OTC) laxatives.
They also recommend diagnostic colonoscopy only for people with alarm symptoms, or who are overdue for colorectal cancer screening.
How to treat constipation
In most older adults with constipation, there are no red flags or signs of mechanical obstruction.
To treat these cases of “garden-variety” constipation, geriatricians usually use a step-wise approach:
Identify and reduce constipating medications if possible.
Increase dietary fiber intake and fluid intake, if indicated.
Prunes are often effective because they contain fiber and also sorbitol, a non-absorbable type of sugar that draws water into the bowel. A randomized study published in 2011 found that prunes were more effective than psyllium (brand name Metamucil), for the treatment of constipation.
Other forms of fiber should be slowly increased, to avoid bloating or discomfort. Adequate hydration is essential, because otherwise, fiber can become a hard mass in the colon that is difficult to move out.
Encourage a regular toilet routine, with time on the toilet after meals and/or physical activity.
If necessary — which it often is — use over-the-counter laxatives to establish and maintain regular bowel movements.
The American Society of Gastroenterology recommends more in-depth constipation evaluation for older adults who fail to improve from this type of first-round treatment. Some older adults do have pelvic floor disorders, which can be effectively treated through biofeedback.
The laxative myth you shouldn’t believe
People often have concerns about using laxatives more than occasionally, because they’ve heard this can be dangerous, or risky.
This is a myth that really should be dispelled. Although medical experts used to worry that chronic use of laxatives would result in a “lazy” bowel, there is no scientific evidence to support this concern.
In fact, in their technical review covering constipation, the American Society of Gastroenterology notes that “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system.”
(FYI: the “enteric nervous system” means the system of nerves controlling the digestive tract.)
Lifestyle changes and over-the-counter oral laxatives are the approaches endorsed as the first-line of constipation therapy, by the American Gastroenterology Society and others. There are no evidence-based guidelines that caution clinicians to only use laxatives for a limited time period.
The four types of OTC laxatives that I’ll cover in the next section have been used by clinicians and older adults for decades, and when used correctly, are considered safe and do not seem to cause any long-term problems.
That’s not to say that they should be used willy-nilly, or in any which way. You absolutely should understand the basics of how each type works, so let’s cover that now.
Three types of laxative that work (and one that doesn’t)
There are basically four categories of oral over-the-counter (OTC) laxative available. Three of them are proven to work. A fourth type is commonly used but actually does not appear to be very effective. Each has a different main mechanism of action.
The three types of OTC laxative that work are:
Osmotic agents: These include polyethylene glycol (brand name Miralax), sorbitol, and lactulose. Magnesium-based laxatives also mostly work through this mechanism.
These work by drawing extra water into the stool, which keeps it softer and easier to move through the bowel.
Studies have shown osmotic agents to be effective, even for 6-24 months. Research suggests that polyethylene glycol tends to be better tolerated than the other agents.
Magnesium-based agents should be used with caution in older adults, mainly because it’s possible to build up risky levels of magnesium if one has decreased kidney function, and mild-to-moderately decreased kidney function is quite common in older adults.
Stimulant agents: These include senna (brand name Senakot) and bisacodyl (brand name Dulcolax).
These work by stimulating the colon to squeeze and move things along more quickly.
Studies have shown stimulant laxatives to be effective. They can be used as “rescue agents” (e.g. to prompt a bowel movement if there has been none for two days) or daily, if needed.
Bisacodyl is also available in suppository form, and can be used this way as a “rescue agent.”
Bulking agents: These include soluble fiber supplements such as psyllium (brand name Metamucil) and methylcellulose (brand name Citrucel).
These work by making the stool bigger. Provided the stool doesn’t get too dried out and stiff, a bulkier stool is easier for the colon to move along.
Bulking agents have been shown to improve constipation symptoms, but they must be taken with lots of water. Older adults who take bulking agents without enough hydration — or who otherwise have very slow bowels — can become impacted by the extra fiber.
People with drug-induced constipation or slow transit are not likely to benefit from bulking agents.
And now, let’s address the type of OTC laxative that is least likely to work.
The type of OTC laxative that isn’t really effective is a “stool softener”, such as docusate sodium (brand name Colace).
These create some extra lubrication and slipperiness around the stool. They actually have often been prescribed by doctors; when I was a medical student, almost all of our hospitalized patients were put on some Colace.
But, the scientific evidence just isn’t there! Because this type of laxative is so commonly prescribed, despite a weak evidence base, the Canadian Agency for Drugs and Technologies in Health completed a comprehensive review in 2014. Their conclusion was:
“Docusate appears to be no more effective than placebo for increasing stool frequency or softening stool consistency.”
So, save your money and your time. Don’t bother buying docusate or taking it. And if a clinician suggests it or prescribes it, politely speak up and say you’ve heard that the scientific evidence indicates this type of laxative is less effective than other types.
Laxatives do work and are often appropriate to use, but you need to use one of the ones that has been shown to work.
About prescription laxatives
Newer prescription laxatives are also available, and may be an option for those who remain constipated despite implementing lifestyle changes and correctly used over-the-counter laxatives. These include lubiprostone (brand name Amitiza) and linaclotide (brand name Linzess).
But, it’s not clear, from the scientific research, that they are more effective than older over-the-counter laxatives. In its technical review, the American Society of Gastroenterology noted that “meta-analyses, systematic reviews, and the only head-to-head comparative study suggested that some traditional approaches are as effective as newer agents for treating patients with chronic constipation.”
Since these newer medications have a more limited safety record and are also expensive, they probably should only be used after an older person has undergone careful evaluation, including evaluation for possible pelvic floor disorders.
Enemas are another form of “constipation treatment” available over-the-counter in the U.S.
Enemas certainly can be helpful as “rescue therapy,” to prevent a painful fecal impaction if an older person hasn’t had a bowel movement for a few days. But they should not be used every day.
Frequent use of enemas is really a sign that a person needs a better bowel maintenance regimen. This often means some form of regular laxative use, plus a plan to use a little extra oral laxative as needed, before things reach the point of requiring an enema.
If an enema appears necessary, experts recommend that older adults avoid saline enemas, and instead use a warm tap water enema, or a mineral oil enema.
My approach to constipation in my older patients
Generally, to help my older patients with garden-variety constipation, I start by recommending prunes and encouraging more fiber-rich foods. As noted above, a randomized trial found that 50 grams of prunes twice daily (about 12 prunes) was more effective in treating constipation than psyllium (brand name Metamucil).
Then we usually add a daily osmotic laxative, such as polyethylene glycol (Miralax). If needed, we might then add a stimulant agent, such as senna.
We do sometimes try a bulking agent, but I find that many frailer older adults tend to get stoppered up by the extra bulk. Again, if you use a supplement (such as Metamucil) to put extra fiber in the colon but can’t keep things moving along fast enough, that extra fiber might dry out and become very difficult to pass as a bowel movement.
It usually takes a little trial and error to figure out the right approach for each person, so it’s essential for an older person — or their family — to keep a log of the bowel movements and the laxatives that are taken. If a person has loose stools or too many bowel movements, in response to a given laxative regimen, we dial back the laxatives a bit.
It’s also important to have a plan for “rescue,” which means adding some extra “as-needed” laxative (usually either senna or a suppository), if a person hasn’t had a bowel movement for 2-3 days. The goal of rescue is to avoid the beginnings of fecal impaction.
Last but not least, we also try to make sure an older person is getting enough physical activity, and to establish a routine of having the person sit on the toilet after..
Last year, I wrote an article on cerebral small vessel disease, a very common condition in which the small blood vessels of the brain develop signs of damage.
If you’re an older adult and you’ve had an MRI done of your brain, chances are pretty good that your scan showed signs of at least mild signs of this condition; one study of older adults aged 60-90 found that 95% of them showed signs of these changes.
These are basically like teensy strokes in the brain. Most are un-noticeable to people, but if you have enough of them, you can certainly develop symptoms, such as cognitive impairment, balance problems, or even vascular dementia.
To date, the cerebral small vessel disease article has generated over 100 comments and questions from readers. A common theme was this: “My MRI shows signs of this condition. What can I do?”
As I explain in the article and the comments, the first thing to do is to work closely with your doctors to understand what is the likely cause of the damage to the brain’s small blood vessels.
Now, when you do this, you may well find that your doctor just shrugs, or waves off the question.
That’s because in most people, cerebral small vessel disease is thought to be in large part a result of atherosclerosis (more on this term below) affecting the smaller arteries of the brain. And atherosclerosis affects just about everyone as they age, because it’s related to many basic cardiovascular risk factors that become very common in late-life.
So in many cases, asking the doctor why you have signs of cerebral small vessel disease may be like asking why you might have high blood pressure, or arthritis. These are common conditions and they are usually due to medically mundane causes and risk factors, including sub-optimal “lifestyle” behaviors and the general “wear and tear” on the body that is associated with aging.
(However, in some people, damage to the small vessels in the brain may be related to one or more particular medical conditions. Younger people, in particular, seem more likely to have a particular condition or risk factor that may be causing most of the damage.)
Whether you are younger (i.e under age 60) or older, always start by asking your doctors what they think are the most likely causes for any cerebral small vessel disease, and what they recommend you do to slow the progression.
And for most people, the main advice will be this: evaluate and address your cardiovascular risk factors.
“Vascular,” as you probably already know, means “blood vessels.” And blood vessels are critical to the function of every part of the body, because blood vessels are what brings oxygen and nutrients to every cell in the body. They also carry away waste products and toxins. So, blood vessel health is key to brain health.
This article will help you better understand how to address blood vessel health. Specifically, I’ll cover:
Understanding cardiovascular risk factors
3 key ways blood vessels become damaged
What is atherosclerosis
Why some chronic conditions are considered risk factors
The number one risk factor for future cardiovascular events
12 key cardiovascular risk factors
How to manage cardiovascular risk factors for better brain health
5 key approaches most older adults should implement
Understanding Cardiovascular Risk Factors Known to Affect Brain Health
Lots of factors affect the health and function of your blood vessels. Before we dive into specific factors, let me share some practical ways to think about these risk factors.
3 key ways blood vessels become damaged
Generally, what is bad for blood vessels will fall into one of the following three categories:
A form of inflammation: “Inflammation” basically means that aspects of the body’s immune system are revved up. In the short-term, this helps fight infections, but in the longer-term, this actually creates a fair amount of wear and tear on cells in the body. Inflammation can also cause the blood vessels to build up plaque.
Inflammation is manifested in the body in many different ways. These include having higher levels of certain proteins, such as C-reactive protein, and/or by the increased presence of certain types of white blood cells.
Many health conditions, including obesity, are associated with chronic inflammation in the body. Aging is also associated with chronic inflammation, a phenomenon sometimes called “inflammaging.”
A form of mechanical stress: This means physical forces — such as higher blood pressure — that create wear and tear on blood vessels.
A form of mechanical obstruction: This means build-up on blood vessel walls (sometimes called “plaques”) or blockages of blood vessels. A narrower blood vessel cannot transport oxygen, nutrients, or waste products as effectively as before. Plaques can also break off and then block a downstream part of the blood vessel; this can cause strokes or heart attacks.
Some risk factors will fall into more than one category.
What is atherosclerosis?
Atherosclerosis (and its related term, arteriosclerosis) means the process of artery walls becoming inflamed, thickened (by plaques), and then hardened. Calcium is often deposited into the blood vessel wall, which contributes to stiffening and “calcification.” This process of accumulating damage happens over years and years, and is influenced by lifestyle factors, medical conditions, and other health factors.
In short, atherosclerosis is the most common way that blood vessels become slowly damaged and obstructed over time, and this process happens in large part due to chronic exposure to inflammation and mechanical stress.
Hardened arteries will contribute to higher blood pressure. Having a lot of atherosclerosis is also understandably a strong risk factor for developing problems related to blood vessels, such as heart attacks and strokes.
Damaged blood vessels also tend to become less resilient, and so they are also more prone to break or burst. Such breakages can be the underlying cause of ruptured aneurysms and certain forms of stroke.
Why some chronic health conditions are considered cardiovascular risk factors
Certain health conditions are considered cardiovascular risk factors, because research has shown that they are associated with a higher chance of having or developing cardiovascular disease. They can be categorized into two types:
Health conditions that cause inflammation or other stress on blood vessels:
Lots of diseases fall into this category, including diabetes and most auto-immune diseases.
Mental health conditions such as depression or anxiety may also qualify, as these are associated with increased stress levels in the body.
Health conditions that are often caused by damage to blood vessels.
This includes chronic kidney disease, which often — but not always — is related to blood vessel health, as well as peripheral artery disease.
The Number One Risk Factor for Future Cardiovascular Events
Probably the top risk factor having a cardiovascular event is having had one in the past.
This is called having “established cardiovascular disease,” or “clinical atherosclerotic cardiovascular disease.” It means a person has already experienced a health event or significant condition related to atherosclerosis. These include:
Heart attacks (“myocardial infarctions”), especially those related to a blockage in the coronary arteries, which supply blood to the heart
Strokes, which happen when blood flow to the brain is blocked
Peripheral artery disease, which happens when large arteries bringing blood to limbs (or sometimes organs) develop significant blockages
Since people with established cardiovascular disease have a higher risk of future cardiovascular events, clinicians are usually more proactive about treating their risk factors, to prevent future events. This is called “secondary prevention.” (“Primary prevention” means treating risk factors in people who have not yet had an event.)
The Rotterdam Study, among others, has found that a history of stroke or heart attack is associated with more signs of cerebral small vessel disease on MRI.
12 Key Cardiovascular Risk Factors that Affect Brain Health
Now that we’ve covered the broader categories of what affects blood vessel health, below is a list of the most common and important specific risk factors. If you’ve been worried about cerebral small vessel disease, these are probably the risk factors you’ll want to be discussing with your doctors.
High cholesterol, especially high low-density lipoprotein cholesterol (LDL-C) and high triglycerides
Problems managing blood sugar, including diabetes, insulin resistance, and impaired glucose tolerance
Chronic kidney disease (defined as an estimated glomerular filtration rate (eGFR) < 60 ml/minute)
High levels of inflammation (as measured by C-reactive protein or other tests)
Obstructive sleep apnea
Psychological stressors (including depression, anger, anxiety, and stress)
Dietary factors, including
Diets with a high glycemic index or load
Insufficient fruit and vegetable intake
Insufficient dietary fiber
Higher intake of red meat and high-fat dairy products
Age and gender
Understanding the 12 cardiovascular risk factors in more detail
Now, you may be wondering: how are each of these risk factors defined? What blood pressure is high, or “too high”? What constitutes “insufficient exercise”?
This is where things get tricky. Basically, almost all of these risk factors can be thought of as a risk spectrum, with one side indicating increased cardiovascular risk and the other side associated with less risk. (Although for some factors, extremes on either side are associated with risk).
Where exactly to place a numerical cut-off, for the purpose of defining a disease — e.g. defining “hypertension” — tends to be hotly debated by experts. Similarly, there is often debate as to what constitutes an “optimal range,” or “optimal intake” (for diet and exercise factors), in terms of minimizing cardiovascular risk.
Within this article, it’s not possible to present each factor in depth. Still, here’s a more detailed version of the list with some practical information for each, along with some relevant resources.
Then in the next section, I’ll cover five key approaches, which can address many cardiovascular risk factors simultaneously.
Controlling blood sugar in people with diabetes has been shown to reduce CV risk.
That said, studies find that reducing blood sugar too much via medication is also associated with increased cardiovascular risk (see here and here).
Research suggests that a hemoglobin A1C of 7-7.5% may be safer than using glucose-lowering medications to get the hemoglobin A1C below 7.
People with diabetes should avoid frequent hypoglycemia.
Insulin is a hormone that enables the body’s cell to absorb and use glucose. Higher insulin levels are associated with insulin resistance and pre-diabetes. For more information: Prediabetes & Insulin Resistance.
Chronic kidney disease (usually defined as having an estimated glomerular filtration rate that is chronically less than 60mL/minute) has been associated with increased risk of CV disease.
A glomerular filtration rate of 90-120 mL/minute is normal, and a rate of 60-90 mL/minute is usually considered mild loss of kidney function.
A higher body-mass index (BMI) has generally been correlated with a higher risk CV disease, as in this study.
Obesity increases the likelihood of developing other conditions that increase CV risk, including high blood pressure, high cholesterol, insulin resistance, and diabetes.
Being overweight does seem to become less risky as one ages; learn more about the “obesity paradox” here and here. Some experts also believe that waist circumference is a more useful measurement than BMI in older people.
Tobacco smoking (and other forms of inhaling toxins)
Using C-reactive protein to screen people without symptoms of CV disease is controversial, mainly because it’s unclear that this improves outcomes (compared to using the risk factors included in a “traditional” cardiovascular risk calculator.)
Treatment of OSA has been associated with improvement in high blood pressure and some other cardiovascular factors. However, a recent meta-analysis found that OSA treatment with positive airway pressure did not result in fewer CV events.
Research has linked psychological conditions, including depression, anxiety, and chronic stress, to CV risk.
A randomized study found that stress-management training was associated with improved markers of CV risk, in people with pre-existing heart disease. Another study found that depression treatment reduce the risk of a first CV event.
Exercise and physical activity levels
Generally, greater amounts of exercise and regular physical activity correlate with decreased CV risk, as noted in this study.
Guidelines generally recommend that people aim for 150 min/week of moderate aerobic physical activity, or 75 min/week of vigorous aerobic activity. However, research suggests that lesser amount of exercise also can provide benefit, so some exercise is always better than none. For a review of the effect of exercise on cardiovascular outcomes, see here.
Research generally suggests that higher intakes of dietary fiber, fruits, and vegetables are associated with a lower risk of CV disease. Newer research suggests that the benefits of these foods is at least in part due to their impact on the gut microbiota (the “good bacteria” in every person’s gut).
Research also suggests that a plant-based diet (one with no or minimal animal products, and minimal processed foods) can lead to significant reductions in CV risk.
Red meat consumption has been associated with a higher risk..
Q: My mother is 76 and has Alzheimer’s disease. She had a couple of unavoidable stays last year in the hospital (due to falls). This accelerated her decline due to delirium, which was treated as if she was just being an unruly and difficult patient. Once my sister and I understood what was going on due to this site’s information, we have been able to protect and support her.
Right now things are stable and quiet, so we are trying to plan ahead.
How should we go about planning for the years of decline my mother may experience before her actual last moments near death? It’s hard to imagine this possibility and I need help facing the (to me) not so obvious.
We have a will, power of attorney, and health care proxy in place.
A: Great question, and especially good that you’re taking advantage of a “quiet period” to address these issues.
It’s a little tricky to answer this question without knowing more about your mother’s current ability to participate in decision-making and in planning for her future care.
Since you say she’s declined after hospitalizations for falls and delirium, let me assume that she has moderate Alzheimer’s and can’t manage more than perhaps expressing some of what she likes and doesn’t like. (For more on the stages of Alzheimer’s and related dementias, see here.)
At this point, you’ve been through some health crises already, and you’ve seen her decline. You’ve also probably gotten a sense of just how many decisions have to be made on her behalf. Some are about her medical care and some are about other aspects of her life, like where she lives and how she spends her days.
Planning ahead is an excellent idea. Obviously, it’s simply not possible to anticipate and plan for every decision that will come up.
But let me offer you an approach that you can use both now as well as “in the heat of the moment” when specific issues arise. This is a framework to help you navigate all kinds of care decisions and future crises that you may encounter.
The following five steps will give you a foundation for anticipating, processing, and reacting to the complications and problems of later-stage Alzheimer’s, with less anxiety and more confidence. These steps are:
Be aware of what kinds of declines and crises to expect, as your mother’s Alzheimer’s and other health conditions progress
Think about what she would want, and what your family would want for her
Consider and discuss goals of care with your health care providers
Learn to use a benefits-and-burdens framework to navigate particular decisions
Consider when and how you might dial back on “usual” medical care
Let me now explain each of these in a little more detail. By the end, you should be able to see how they will help you navigate your mother’s continued decline.
1. How to get a sense of what kinds of declines and crises to expect
You’ll be ahead of the curve, and better able to make informed and realistic decisions along the way if you have an understanding of three things:
The basics of how dementia progresses
What kinds of problems and crises might come up due to other chronic conditions your aging parent has
Typical problems and health crises often come up for people with dementia
Learning the basics of how dementia progresses.
If you haven’t already done so, you should become familiar with the broad trajectory of how people decline due to Alzheimer’s and related conditions.
It’s especially important to pay some attention to what happens in the late-stage of dementia, and how people die from dementia. Honestly, most people find it sad and upsetting to learn about this, so many avoid it. You don’t have to think about this every day, but by having peeked ahead and focused on it at least once, you’ll be able to draw on that knowledge when important decisions have to be made.
A research study found that when people viewed videos of people with advanced dementia, they subsequently made different choices on their advance care planning documents.
I also highly recommend discussing this with your mother’s usual doctor. Just ask, “What kind of decline and problems should we expect, as my mother’s Alzheimer’s progresses?” This is a good way to let the doctor know you’re interested in being proactive and in planning.
Learning what to expect from other chronic conditions.
Many people with dementia are also living with other chronic conditions. Some of these may be quite likely to cause health crises, or may even be likely to kill a person before the Alzheimer’s reaches its most advanced stage.
For instance, heart failure and chronic obstructive pulmonary disease are two common chronic conditions that often cause hospitalization. They can even cause breathing problems that might require the use of a ventilator (a breathing machine).
To learn what crises to expect from other chronic conditions, start by asking your mother’s usual doctors to help you understand the state of her other chronic conditions. Then you can ask something like, “Do you think this is likely to cause a hospitalization or health crisis in the coming year? What kinds of problems or declines should we anticipate?”
Other problems and crises that often come up for people with Alzheimer’s.
Most families realize that Alzheimer’s always features a progressive loss of abilities. But beyond that, it’s helpful to think through what types of crises and dilemmas this often sparks.
In short, you’ll want to be aware of situations that are likely to prompt difficult decisions about medical treatment or a care arrangement.
Below is a list of situations that come to my mind for mild and moderate Alzheimer’s.These are common events that tend to spark a significant change in health status or care arrangement.
For each of these, you can ask yourself, “Have we thought about how we’d manage when — or if — this comes up?”
Increased difficulty managing at home (especially for people who live alone or with an older spouse)
Increased need for supervision, assistance, and care
Injury due to falling or a safety problem in the home
Financial mismanagement or abuse
Hospitalization (this is often associated with complications, a difficult rehab stay, and/or a significant step down in health status)
Inability to continue with current care and living arrangement (this can be due to caregiver burnout, financial issues, safety issues, etc.)
Don’t worry too much if you haven’t yet thought through all these potential issues. You actually don’t want to get too deep into considering these, until you’ve gone through the other steps I’m going to describe. For now, the goal is to be aware of some of the issues you’re most likely to run into, and assess where you’re at in planning for them.
2. How to consider what your parent with Alzheimer’s would want
When faced with making decisions on behalf of someone with Alzheimer’s, who has lost the capacity to make the decision, you’ll want to ask yourself: “What would Mom (or Dad, or my partner) want?”
To answer that question, you’ll need to do the following:
Review any existing living wills, advance directives, POLST forms, or other documentation that’s been completed by your parent.
Consider your mother’s values and preferences regarding medical and life care, based on what you know of her. Use a specially designed conversation guide, if possible.
You might be able to invite her to express preferences to you, if she’s able to do so and if it doesn’t cause her too much distress.
Reviewing existing advance directives and other documentation
In an ideal world, every older adult would go through an “advance care planning” process and specify some preferences in writing, before becoming too disabled by Alzheimer’s disease.
By the way, you said you have a will but it wasn’t clear to me if this was a “living will,” which is a type of advance directive that provides some guidance regarding a person’s preferences for care before she dies. (A “last will and testament” type document spells out what a person wants after she dies.)
Considering your mother’s preferences and values
Even if you already have an advance directive or living will available, I recommend going through a questionnaire that will help you think about your mother’s preferences and values.
I especially like the questions on page 11, which are intended for the caregivers of a person no longer able to make decisions (i.e. beyond mild Alzheimer’s). They include questions such as:
Would she worry about not getting enough care? Or that she would get overly aggressive care?
Would she be okay with spending her last days in the hospital? Or would she really want to spend her last days at home?
Would she want us to take care of all her needs ourselves, or would she want us to get some help from professionals?
Would she prefer to be alone most of the time? Or would she prefer to be surrounded by loved ones?
If we had to list the three most important things she wanted us to know about her wishes for end-of-life care, what would they be?
What was she especially concerned about?
What was really, really important to her?
What kinds of treatment would she want (or not want)?
Another question that I think is useful for you to consider: At what point would she want us to back off from life-prolonging care?
Now, you will probably find that it is hard to come up with exact answers to these questions. That’s ok! Just spending time mulling them over and talking with other family members will help you lay that foundation, I promise. You can also return to these kinds of questions when you’re in the midst of a situation involving decision-making.
Now, if your mother had previously completed an advance directive, you may be wondering if you need to bother going through these questions a second time.
I would say yes. In my experience, the information contained in most advance directives isn’t detailed enough to provide the foundation and guidance that dementia caregivers need.
Furthermore, a key part of the advance care planning process is to re-assess preferences and plans regularly, because people’s preferences often evolve as their health and life situation changes.
Given that a person with Alzheimer’s eventually loses the mental capacities needed to do this reassessment on her own, reviewing advance care plans becomes yet another thing that family caregivers and health-care proxies must take on.
As a surrogate, you won’t be able to change past documents. But you will need to provide guidance to your older parent’s doctors. Furthermore, in many states, certain forms specifying preferences for medical care, such as POLST (Physician Orders for Life-Sustaining Care), can be completed and revised by surrogate decision-makers. (Learn more POLST, which is also called MOLST or MOST in some states, here: POLST: Resources & Tips on Avoiding Pitfalls.)
In short, whether or not you have an advance directive available, part of your planning process should involve going through some questions designed to help you remember and crystalize your parent’s preferences and values.
3. How to consider and discuss “goals of care”
Understanding “goals of care”
“Goals of care” is a phrase that’s widely used by health professionals, but hasn’t yet caught on with the public. This is perhaps because many health experts seem to prefer to phrase more like “Talk about what matters most with your doctor.”
Myself, I explain “goals of care” to my patients and their families, because once they understand the idea, I find it becomes easier for us to revise the care plan, and also to navigate tricky situations.
So what are goals of care, and what does it mean to discuss them?
To begin with, it’s helpful to remember that medical care generally serves to help all people with three key goals:
To live longer. We do this by intervening when there is a life-threatening emergency, by operating or using life-support technologies or even by providing antibiotics and specialized medications. We also do this by managing chronic conditions, to prevent them from progressing or causing hospitalizations. And then we do this by using preventive strategies, to reduce a person’s risk of dying or experiencing a life-threatening event such as a heart attack or stroke.
To feel better. This means helping people address pain, shortness of breath, depression, anxiety, or any other issue that might cause distress.
To function better. This means helping people maintain or improve their ability to do things, so that they can keep participating as fully as possible in life. This includes helping people walk and stay mobile, as well as helping a person with dementia have the best brain function possible.
Ideally, medical care helps people with all three of these goals, because all three are usually quite important to people.
But in reality, medical care often involves making trade-offs. For instance, people often accept the side-effects of chemotherapy (which can include pain and disability), in order to have a chance to cure their cancer and live longer.
When people have Alzheimer’s disease, it becomes more and more common for the three goals to come into conflict with each other. For example, hospitalization might be the best way to minimize a person’s chance of dying during an illness, but it also often causes significant distress to a person with dementia. Furthermore, people with dementia have a high risk of developing delirium in the hospital, which can set their brain function back considerably.
In geriatrics, we routinely discuss goals of care with patients and families. We do this because as people get older, whether it’s due to Alzheimer’s or due to other health issues, it becomes impossible to prioritize all three goals equally.
And so, we invite our patients and families to tell us how important each of the three goals is to them, and which they would prioritize, if there were a conflict.
By understanding how important each goal is to a patient, or to a family, we’re then better able to tailor medical care, so that people get what they need the most from it.
How to sort out goals of care
You can certainly do some preliminary thinking on your own, when it comes to goals of care. But don’t try to figure it all out without involving your doctors.
Instead, it’s best to let the doctors know that you want to discuss goals of care for your mother. Even doctors who aren’t trained in geriatrics or palliative care will understand what you are referring to, and if they don’t feel comfortable guiding you through this conversation, they should be able to refer you to a clinician who can.
When you discuss goals of care with your medical team, here are a few more things to keep in mind:
It’s okay if you’re not initially sure which goals to prioritize. Sometimes it’s hard to decide, or it just takes a while for clarity to emerge.
It is normal for goals to change over time. Circumstances change. The health situation evolves. Or you may decide to adjust the goals of care after trying one approach to goals and realizing that it no longer feels like a good fit.
Feel free to bring up goals that don’t seem strictly “medical” or health-related. For instance, your family might realize that a key goal is to keep your mother living at home as long as possible, if you think that’s her preference or that’s what’s best for her quality of life. Your healthcare team should hear about this goal, as this will help them guide you through considering any trade-offs related to the goals of medical care.
4. How to use a benefits-and-burdens framework to navigate particular decisions
Along with understanding preferences and having broad goals of care, there’s an additional way you can hone in on a course of action in specific situations. Basically, it involves asking two key questions:
1.”Do the likely benefits of taking this path (which could be a starting or continuing a medication, proceeding with a hospitalization, or doing a procedure, etc.) outweigh the burdens and risks of doing this?”
2.“Would proceeding this way be in line with the person’s goals of care, and is this likely to help the person achieve their health goals?”
Geriatricians routinely rely on this helpful “benefits-versus-burdens” framework to help families navigate medical dilemmas, difficult decisions, or otherwise explore their options.
The main reason that we do this is that when it comes to many medical interventions, as an older person’s health declines, the likelihood of benefit goes down and the likelihood of harm goes up. So for instance, surgery and hospitalizations become riskier when people are frailer, or have dementia.
You can also use the benefits-and-burdens framework to work through non-medical dilemmas, such as whether to continue with a given caregiving situation versus make a change.
Start by identifying your available options for managing a situation, or even just taking a next step in addressing it.
Then, for each option, make a list of the “benefits” and the “burdens.” (You can also think of them as the “pros” and “cons.”)
Bear in mind that when it comes to figuring out the downsides of a certain course of action, you’ll want to consider two kinds of negatives. “Definite burdens” are the downsides that are pretty certain to happen. Whereas “risks” are bad things that may or may not happen in the future.
So for instance, if you move your mother with dementia into memory care, the usual “definite burdens” are that she’ll be distressed by the transition and that the care arrangement will cost more money. Whereas the “risks,” meaning the bad things that may or may not happen, are often that she might never get used to it, or that the facility might turn out to be lousy.
These are some of the tradeoffs you would be making, in exchange for certain likely benefits. If you’re moving your mother from a home caregiving situation to memory care, the benefit will be relief from many of the hands-on caregiving duties, which can be immensely helpful, especially if you’ve been providing care for a while and are starting to feel burned out. Moving to memory care can also mean more opportunities for social engagement and access to activities designed to engage people with dementia.
Going through the benefits and burdens doesn’t always yield a clear and easy answer. But almost everyone feels better having clarified what trade-offs they are making and why, when they decide to proceed — or not proceed — with a certain intervention, or a certain care plan.
5. Consider when and how you might dial back on “usual” medical care
By “usual” medical care, I mean the healthcare that’s commonly provided to older adults, regardless of whether or not they have dementia or are declining.
As you may have noticed, “usual” medical care tends to be quite oriented towards addressing the goal of helping people live as long as possible. This is done by intervening when people are acutely ill, and by using the emergency room, hospitalization, or even intensive care, in order to minimize the chance of a person dying. It also means providing chronic medical care and preventive care, again with a key goal being to minimize mortality risk.
This kind of care may sound good to you; it’s what most of us expect from our modern medical system. But in fact, it’s worth rethinking when it comes to an older person declining from dementia.
Why? Because when people are declining from dementia – or if they otherwise have limited life-expectancy – usual medical care becomes less likely to help them live longer, or better. It also becomes more likely to cause confusion, distress, and medical complications.
Furthermore, usual medical care can crowd out, or directly conflict, with approaches that help people with dementia maintain the best possible quality of life and function. When given the opportunity, most families of people with moderate and advanced dementia eventually decide to prioritize the goals of well being and function – helping a loved one be comfortable, out of pain, and able to enjoy companionship and the small pleasures of everyday life to the best of their ability – over the goal of extended lifespan whatever the cost.
For these reasons, it’s quite reasonable to consider when and how..
And once again, high blood pressure is making headlines in the news: the American Heart Association and the American College of Cardiology (AHA/ACC) have just released new guidelines about hypertension.
Since this development is likely to cause confusion and concern for many, I’m writing this post to help you understand the debate and what this might mean for you and your family.
By the way, if you’ve read any of my other blood pressure articles on this site, let me reassure you: I am not changing my clinical practice or what I recommend to others, based on the new AHA/ACC guidelines.
The core principles of better blood pressure management for older adults remain the same:
Take care in how you and your doctors measure blood pressure (more on that here),
And then learn more about what are the likely benefits versus risks of aiming for more intensive BP control.
Perhaps the most important thing to understand is this: treatment of high blood pressure in older adults offers “diminishing returns” as we treat BP to get lower and lower.
Scientific evidence indicates that the greatest health benefit, when it comes to reducing the risk of strokes and heart attacks, is in getting systolic blood pressure from high (i.e. 160-180) down to moderate (140-150).
From there, the famous SPRINT study, published in 2015, did show a further reduction in cardiovascular risk, when participants were treated to a lower systolic BP, such as a target of 120.
However, this was in a carefully selected group of participants, it required taking three blood pressure medications on average, and the reduction in risk was small. As I note in my article explaining SPRINT Senior, in participants aged 75 or older, pushing to that lower goal was associated with an estimated 1-in-27 chance of avoiding a cardiovascular event. (The benefit was even smaller in adults aged 50-75.)
SPRINT did not include people who have certain common conditions, including diabetes, heart failure, past stroke, or dementia. Hence it’s not clear that the (small) benefits of intensive blood pressure control would apply to those older adults who would not have qualified for the SPRINT trial.
I will come back to the SPRINT study later in the article, since it undoubtedly influenced the recent AHA/ACC guidelines. But first, a little on why the new guidelines are notable.
Why the new blood pressure guidelines are notable
The most notable thing about these guidelines is that the AHA/ACC has decided to redefine hypertension.
Whereas hypertension has historically been defined as a blood pressure higher than 140/90 mm Hg, this expert group is now declaring that a blood pressure (BP) above 130/80 constitutes high blood pressure.
The AHA/ACC is also taking a notable position regarding the treatment of high blood pressure in older adults: they are not recommending a higher BP treatment goal for most older patients.
Instead, their guidelines say “Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.”
The ACP/AAFP guidelines also recommend that treatment to a lower BP goal be considered for certain older adults, based on their cardiovascular risk and also after discussing the likely benefits and harms with patients.
Why different expert groups are issuing different guidance on blood pressure in older adults
Now, when an expert group issues guidelines, it’s never a quick or casual thing. Guidelines are always the result of a lengthy, careful process of reviewing the scientific evidence before issuing recommendations. And the healthcare professionals who review the science and create guidelines are invariably academics who are highly trained in conducting and assessing scientific evidence.
Still, the experts writing the guidelines do have their favored ways of thinking about healthcare. They also have to exercise some judgment in deciding how the science should be turned into practical recommendations.
In this case, the AHA/ACC group (the cardiologists) and the ACP/AAFP group (the generalists) reviewed the same scientific evidence. But they came to different conclusions about what to recommend to practicing clinicians.
Why did this happen? In practical terms, it looks like the cardiologists heavily relied on SPRINT to guide their recommendations. Whereas the generalists noted that it’s a good trial but only one trial, and they made more nuanced recommendations about when to consider more intensive blood pressure management.
It’s also possible that the generalist expert group was more aware of some practical realities when formulating their guidelines. Namely, they may have been more aware that in real life, working to lower blood pressure down to the minimum can take up time and energy that might be better spent addressing other important health needs a person has.
Think about it: an older person only has so much time with the doctor at each visit. And most people don’t want to — or can’t — go back to the doctor frequently. Furthermore, most older people don’t just have high blood pressure; they also have other chronic conditions, other symptoms, and other questions that need attention.
In that real-world environment, is trying to get blood pressure down to the cardiologist’s idea of “optimal” — assuming the older adult is similar to the SPRINT participants — a good way to expend the time and effort of both the patient and the doctor, as they work to help an older adult achieve better health and wellbeing?
Or might it be better for the clinician and older adult to address fall prevention, or find a way to help the older person build and maintain strength, or perhaps address depression, or any other of the many issues that are often important to better health while aging?
In short, the current divergence in guidelines reflects different groups of experts choosing to frame the scientific evidence in different ways, and also perhaps prioritizing health issues in different ways. Cardiologists are understandably quite focused on minimizing cardiovascular risk. Whereas generalists may have a broader view on an older person’s health, and everything that goes into that.
It is a little unfortunate, in that it’s probably going to cause some confusion for the public, and even within the medical field. But that’s where we are for now.
What you can do: inform yourself
Given the debate and conflicting expert guidelines, what can you do?
Start by learning more about hypertension evaluation and management. Although the cardiology societies and generalist societies have made different recommendations in their guidelines, there are many important points about high blood pressure treatment that are not being contested. These include:
Correctly measuring blood pressure is very important. The ACC/AHA guidelines recommend careful measurement with good technique, using at least two measurements obtained on at least two occasions in order to determine average BP.
They also note that “Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.”
Consider a person’s underlying risk of cardiovascular disease when choosing a treatment goal. People at higher risk of stroke or heart attack are more likely to benefit from hypertension treatment.
I also urge you to learn a little more about the SPRINT trial. It’s especially useful to understand who was — and wasn’t — studied in SPRINT, and just how much benefit and harm the participants experienced.
Regardless of which guidelines you find most persuasive, what is most important is for you to be proactive in making sure that your high blood pressure management is correctly tailored to you. This means:
Making sure your blood pressure is correctly and reliably assessed. Ask questions if you are diagnosed or have your medication adjusted based on quick occasional office-based checks. Home blood pressure readings can be a huge help in getting BP reliably assessed.
Talking to your doctors about what your BP treatment goal should be, and why. Goals are best determined through a conversation between health professionals and patients. Your doctor should be able to discuss with you the pros and cons of aiming for a moderate goal (i.e. less than 150/90) versus a more intensive goal. Obviously, you will be able to ask better questions if you’re informed about the key studies on high blood pressure in older adults; I describe them in my article about SPRINT-Senior.
Getting help implementing lifestyle modifications that help lower blood pressure. Many non-drug approaches have been proven to help lower blood pressure, and they can often benefit your health in other ways.
I also recommend asking extra questions about blood pressure if you’ve had any concern about falls or near-falls. Although SPRINT did not find that intensive (compared to usual) blood pressure treatment resulted in increased falls, both groups did experience some falls and other research has linked blood pressure treatment to falls.
Per guidelines issued by the Center for Disease Control, an older adult who has been falling or seems to be at high risk should have blood pressure checked sitting and standing. You can learn more about medications that may affect falls through lower blood pressure here: 10 Types of Medications to Review if You’re Concerned About Falling.
Do you have any questions or comments about managing high blood pressure in older adults? Post them below, I’d love to know what you think of this latest twist in the high blood pressure guidelines saga.
It’s October, which means it’s that time of the year again: flu vaccination time!
Back when I worked in a primary care clinic, this is when we made a big push to offer the seasonal flu shot to all of our patients. (And we got ourselves immunized, as well.)
Not all of our patients agreed. Many older adults are skeptical of the need to get a yearly vaccination against influenza. They aren’t sure it will help. Or they think that the vaccination will actually give them a mild case of the flu. Or they just don’t like needles.
Or maybe they aren’t sure which type of seasonal flu shot to get: the regular one or one of the newer “stronger” versions, designed for older adults?
I’m never surprised when people bring up these questions. Vaccination for seasonal influenza can indeed be a confusing topic.
But it’s certainly important to consider. Depending on the year, the Centers for Disease Control (CDC) estimates that every year, influenza affects 9-60 million Americans, causes 140,000-710,100 hospitalizations, and results in 12,000-56,000 deaths. (Influenza is more severe in some years than others.) Most people get better without needing hospitalization, but some people get very sick. Older adults are especially likely to get dangerously ill from catching the flu.
So I agree with the CDC’s recommendation: everyone over the age of 6 months should get their seasonal flu shot.
In fact, I’m about to go get mine. As a healthy woman in her 40s, I’m not that concerned about getting dangerously ill from influenza. Instead, I get my annual flu shot because I want to minimize my chance of getting sick and perhaps exposing my older patients to influenza.
This month, you’ll probably be encouraged to get vaccinated too. So in this article, I’ll address some key things to know about influenza and the flu shot, along with some common questions and concerns. Here’s what I’ll cover:
The basics of influenza and vaccination against the flu
What to know about flu shots for older adults
What’s new and resources for the 2017-2018 flu season
Which influenza vaccination is probably best for most older adults
What to do if your older parent or relative is unwilling or unable to get vaccinated
The basics of influenza and vaccination against the flu
Q: What is influenza?
A: Influenza is a contagious respiratory viral illness, caused by influenza A or influenza B virus. It usually causes symptoms such as sore throat, stuffy nose, cough, fever, and body aches. In the Northern hemisphere, influenza is most common in the winter. Peak influenza activity usually occurs between December and February, but it can start as early as October and occur as late as May.
In “uncomplicated” influenza, the flu causes symptoms similar to — but usually worse than — a very bad cold, and then these get better over 5-7 days. Most people who catch the flu experience uncomplicated influenza, with some people experiencing more significant symptoms than others. In fact, some people (14%, in one study) will catch the flu and shed some flu virus, yet not report any symptoms!
However, influenza does sometimes cause more serious health problems, which we call “complications.” These are more likely to happen to people who are older, have other chronic conditions, or have a weakened immune system.
The most common complication of influenza is pneumonia, which means a serious infection of the lungs. Such pneumonias are sometimes purely viral. But it’s more common for them to be caused by bacteria, who are able to infect the lungs due to the body being weakened by influenza infection.
Many older adults also appear to experience worsenings of any chronic heart or lung conditions, when they experience influenza. These complications of influenza often cause hospitalization or even death.
To learn more about the basics of influenza, and for more on diagnosing and treating the flu, see:
Q: How does the flu shot helpprotect one from influenza, and how effective is it?
A: The flu vaccine works by stimulating the body to produce antibodies against whatever strains of influenza were included in that year’s vaccine. After vaccination, it takes about two weeks for the body’s immune system to create its influenza antibodies.
Our bodies are able to fight off viral infections much more quickly, if we already have matching antibodies available when a virus tries to create illness in our bodies. If we don’t have matching antibodies available, then we’ll experience more illness, and it will take longer for our immune systems to control the infection.
The tricky thing about influenza is this: both influenza A and B have a tendency to be constantly changing into slightly different strains. This means that every year, scientists must study what influenza strains are present, and try to predict which ones we’ll be exposed to, during the coming winter. Influenza vaccines are then developed, to match those strains. (This is why the flu shot has to be given every year.)
Sometimes the scientific prediction works out well. In this case, we say that the vaccine was well matched to the influenza viruses circulating that winter, and influenza vaccination will have been more effective in preventing the flu.
But there are years in which the influenza strains that circulate the most in the winter are not the ones that scientists were expecting. These are the years in which the influenza vaccine is not well matched, and there tends to be more illnesses and hospitalizations.
The CDC estimates that when the vaccine is well-matched to the circulating influenza viruses, flu vaccination reduces the risk of flu illness by between 40% and 60%, for the overall population.
Several different flu vaccines are available every year. “Trivalent” flu vaccines have been available for the longest: these protect against two strains of influenza A and one strain of influenza B. “Quadrivalent” flu vaccines, available since 2012, protect against two types of influenza A and two strains of influenza B.
Vaccines also vary in terms of whether they are “standard-dose” versus “high-dose,” and one type includes an “adjuvant,” which is an additive designed to increase the immune system’s response to the vaccine. (More response is better, in that it means more protection from future infection.) I’ll discuss high-dose and adjuvant vaccines later in this article, in the section addressing flu shots for aging adults.
You can find a list of all available influenza vaccines in the Table listed below.
Q: Can you get the flu from the flu shot? What are the risks and side effects of influenza vaccination?
A: No, you can’t get the flu from a flu shot. The currently recommended vaccines are made with either “inactivated” virus (which means the virus has been killed and can’t become alive again) or “recombinant” technology (which means they have cobbled together virus proteins). It is not possible for these vaccines to give you influenza.
There used to a “live attenuated” form of flu shot, available for people ages 2-49, which was given by nasal spray and was especially popular with children. (This did contain a weakened form of influenza virus.) However, the CDC advised against using this vaccine for the 2016-2017 flu season, and also for the 2017-2018 flu season.
The most common side-effect of the flu shot is arm soreness, and sometimes redness. People do sometimes report body aches, fever, or cough after the flu shot. But a randomized trial found that these are equally common in people who just had saline injected, so these symptoms are either due to getting sick from something else after your flu shot, or perhaps to even expecting to feel lousy after your flu shot.
Serious adverse effects related to the flu shot are very rare.
Q: What are best ways to protect oneself from influenza and its complications?
A: To reduce your risk of getting sick from the flu, it’s best to combine two approaches:
Minimize your exposure to people spreading influenza virus in the winter.
Take steps to bolster your immune system, so that if you do get exposed to influenza virus, you’ll be less likely to get very sick.
Older adults should also make sure they are up-to-date on pneumococcal vaccination, which now requires two different vaccinations. (These are one-time, not yearly). Pneumococcal vaccination helps reduce the risk of certain types of bacterial pneumonia and other potential complications of influenza. A 2016 meta-analysis concluded that being vaccinated for both influenza and pneumococcus was associated with a lower risk of pneumonia and death. For more on pneumococcal vaccination, see: 26 Preventive Services for Older Adults (Vaccination section).
Minimizing your exposure to influenza virus
The main way people get exposed to influenza is when they breathe in air droplets containing influenza virus. These droplets are created when people infected with influenza virus talk, sneeze, or cough. The CDC estimates that a person infected with influenza virus may be contagious for one day prior to developing symptoms, and 5-7 days after getting sick.
Based on these facts, the best ways to minimize exposure to influenza are to:
Avoid exposure to people who may be infected with influenza.
Clean household surfaces, especially hard surfaces such as counters, and especially if someone living with you has been sick.
Wash your hands often, especially before touching your eyes, nose, or mouth.
Minimize your time near people who have not been vaccinated for influenza.
Your risk of influenza exposure is reduced if people around you — family members, co-workers, fellow residents of your living facility — are vaccinated for influenza.
Bolstering your immune system
Since we are social creatures and live in communities, we all have a good chance of being exposed to the influenza virus at some point. Whether we get sick from this exposure, and how sick we get, depends on how well our immune system can fight off the influenza virus.
Ways to bolster your immune system are:
Be vaccinated against seasonal influenza. If the vaccine is a good match with circulating viruses and you have a good antibody response, this is probably the best way to prepare your immune system to beat influenza.
Take good care of your health and body. This includes addressing healthy lifestyle basics such as not smoking, getting adequate sleep, avoiding chronic stress, and more. For a good review of what’s known about strengthening the immune system, see: How to boost your immune system (Harvard Health Review)
What to know about flu shots for older adults
Q: Is the flu vaccine effective for older adults?
A: You may have heard people say that the flu shot doesn’t work in older people. This is not entirely correct.
Now, it’s true that flu vaccine is usually less effective in older adults, because aging immune systems tend to not respond as vigorously to the vaccine. In other words, older adults tend to create fewer antibodies in response to vaccination. So if they are later exposed to flu virus, they have a higher chance of falling ill, compared to younger adults.
To provide more effective vaccination to aging immune systems, vaccine makers have developed “stronger” vaccines against the flu, which I explain in the next section.
Q: Are there flu shots specifically designed for older adults?
Yes, over the past several years, vaccine makers have developed vaccines that are designed to work better with an aging immune system. Most research studies to date show that these stimulate aging immune systems to produce more antibodies to influenza. There’s also some evidence that these vaccines reduce the risk of being hospitalized for influenza.
However, so far the CDC’s Advisory Committee on Immunization Practices (ACIP) has not particularly recommended these vaccines for older adults. Instead, the ACIP says that older adults should get any influenza vaccination approved for their age.
There are two influenza vaccines that are specifically approved for people aged 65 and older:
Fluzone High-Dose: This trivalent vaccine contains four times the amount of antigen, compared to Fluzone standard-dose. It is approved for adults age 65+.
Studies have found that the high-dose vaccine does improve antibody response. A study published in 2017 also found that use of the high-dose vaccine in nursing-homes was associated with a lower risk of hospitalization during flu season.
Fluad: This trivalent vaccine contains an “adjuvant,” which is an additive meant to stimulate a better immune response to the vaccine. It is a newer vaccine in the U.S., but had been licensed in Canada and several European countries prior to receiving approval here in 2015.
An Italian study found that this vaccine resulted in higher antibody titers, among older adults.
But no recent clinical trials of efficacy have been published. (Which means we don’t yet know whether people given this vaccine actually have a lower chance of being hospitalized during flu season.)
For more information on flu shots for older adults, see:
Q: Does Medicare cover the cost of influenza vaccination?
Yes, yearly influenza vaccination is 100% covered by Medicare, with no deductible or co-pay. So if you get your flu shot from a health provider that accepts Medicare payment, there should be no cost.
What’s new and resources for the 2017-2018 flu season
The CDC maintains a page dedicated to the current flu season. There is a section for the public and also a section for providers. This is a good place to get up-to-date information on influenza and influenza vaccination. You can find it here:
Also important to know for the 2017-2018: the nasal flu vaccine (technically called “live attenuated” vaccine and branded as FluMist) has never been approved for adults age 50 and older. But in case you are wondering: it’s not recommended for anyone of any age to use, for the 2017-2018 flu season.
Which influenza vaccination is best for older adults?
Looking at the list of available flu shots can be overwhelming. In looking at this year’s CDC table of available influenza vaccines, I counted eleven options that are available for people aged 65 or older:
Only Fluzone High-Dose and Fluad carry an age indication specific to 65 years or older.
However, the CDC does not recommend any influenza vaccine over another, for adults aged 65 or older.
So if you are an older adult, or if you’re trying to arrange a flu shot for an aging relative, which flu vaccine should you try to get?
My take is this: if you have a choice, go for one of the vaccines designed for older adults.
Why? Because we know that as people get older, their immune systems tend to respond less vigorously to immunization. And because research suggests that the high-dose flu shot generates higher antibody titers and has been associated with better influenza outcomes.
We do have more research and experience for Fluzone High-Dose than for Fluad, so unless you are enrolling in a clinical trial of Fluad, I would suggest going with the Fluzone High-Dose.
Now, both flu vaccines designed for older adults are trivalent and not quadrivalent. Quadrivalent vaccines do provide protection against an additional influenza B strain. However, experts say that older adults are less likely to be seriously ill from influenza B than from influenza A. Also, no published study has compared a quadrivalent vaccine against a high-dose trivalent vaccine. So for now, there does not seem to be a particular reason that an older adult should choose a quadrivalent vaccine over a high-dose trivalent vaccine.
You may have also heard that the New England Journal of Medicine published a study this past summer, about a newer influenza vaccine in older adults. That study, funded by the manufacturer of recombinant influenza vaccines, compared the effectiveness of a recombinant quadrivalent vaccine with a standard-dose quadrivalent inactivated vaccine, in adults aged 50 and older. Confirmed influenza cases were 2.2% in the group receiving recombinant vaccine and 3.2% in the group receiving inactivated vaccine. Hence the probability of influenza-like illness was 30% lower with the recombinant vaccine than with the inactivated vaccine. But again, this study did not compare the recombinant vaccine against a high-dose inactivated vaccine.
What is most important is to get any type of flu vaccination that is approved for your age.
Research suggests that older adults are more likely to benefit from a high-dose influenza vaccination, such as Fluzone High-Dose.
If you are under age 65, you might get better protection from an influenza vaccine that is quadrivalent compared to trivalent. You also might get better protection from a vaccine that is recombinant rather than made from inactivated vaccine.
Flumist, the nasally administered vaccine, is not recommended for anyone of any age, for the 2017-2018 season. All influenza vaccinations..
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