Dr. Andrew S. Rosenzweig, a geriatric psychiatrist who specializes in the treatment of the elderly in long-term care facilities, was a guest for a live chat on projo.com, on Monday, June 25, 2007. He was joined by Journal staff writer Tracy Breton, who is specializing in elder care reports. Here is a transcript of that chat:

Q. Dr. Rozensweig, Is there any evidence that nonsteriodal anti-inflammatory drugs or cyclooxygenase-2 inhibitors prevent Alzheimer's Disease in healthy, older people?

A. Rosenzweig: This is an ongoing area of study in the field but the results thus far have been largely underwhelming to recommend their use for dementia purposes. Another interesting area that has shown promise is that of statins such as lipitor.

Q. NURSEWHOCARES: WHY IS IT WHEN A "SIGNIFICANT COMPLAINT IS SUBMITTED TO D.E.A ABUSE UNIT...WHY DOES IT TAKE DAYS..SOMETIMES WEEKS FOR INTERVENTION???? USUALLY THE END RESULT IS UNFORTUNATELY "THE WORST" CASE SCENARIO

A. Rosenzweig: Although I believe the DEA does the best they can with the resources they have, clearly more is needed in the way of resources: case workers, phone hot lines, staff with training in dementia and elder abuse.Sometimes the cases they investigate are not so clear cut though and may take some time to sort things out.

Q. NURSEWHOCARES: BEING IN HOMECARE.....ALL IT TAKES IS A LITTLE ASSISTANCE TO FAMILIES AND PATIENT...TO KEEP THEM IN THEIR FAMILIAR SURROUNDINGS...NOT THROW IN NURSING HOMES THAT ARE ALREADY OVER CROWDED AND UNDERSTAFFED

A. Rosenzweig: I agree but keep in mind sometimes institutionalization really is the best thing. In dementia care it's always a case-by-case basis.

C. NURSEWHOCARES: I AGREE. DEFINITEL..UNFORTUNATELY NO DOUBT WE LIVE IN A SOCIETY NOW THAT THE CHILDREN OF THESE ELDERS "HAVE" TO WORK"..... THIS IS WHERE HOMECARE ASSISTNACE AND DAYCARE ARE A GREAT BURDEN LIFTER

Q. Laura: What is the distinction between Dementia and Alzheimers? And does one progress automatically to the other?

A. Rosenzweig: Common and excellent question. I like to explain that dementia is a "syndrome" of memory and other cognitive deficits that has many, many different causes. While Alzheimers Disease is the most common cause, ie 2/3 of cases, they are dozens of others. Some of the more common ones are strokes, Dementia w/Lewy Bodies, Parkinson's Disease, Fronto-temporal Dementia. Recent research has shown that in fact many people actually have more than one cause, ie strokes and Alzheimers Disease.

Q. This is Tracy and I have a question for you. At what point do you recommend that a person with dementia move out of his or her home into assisted living or a nursing home?

A. Rosenzweig: I think the key issues here are safety (ie wandering, dangerous uses of appliances, driving when it's clearly unsafe) and individual life circumstances (ie family support and proximity, financial resources, etc.) Personality of the person is also key: some people thrive in a social climate while others do better when alone much of the time reading or listening to music. It's not always the best thing to keep the person at home, one reason being the lack of availability of trained, competent caregivers and aides.

C. NURSEWHOCARES: I CERTAINLY AGREE EVERY PERSON AND FAMILY SITUATION IS QUITE DIFFERENT...

Q. Laura: When is institutionalization the best thing? What measure can one apply to make the determination?

A. Rosenzweig: I touched on some of this previously. Unfortunately this decision is often driven by a crisis, ie a fall with a broken hip, being found by the police at 2am after wandering from home, setting a small fire in the house. It's ideal to not wait for a crisis, but start planning early, get the family involved, get educated by going to your local Alzheimers Association or Medical Library.

Q. What do you think about this: "Alzheimer's vaccine shows success in mice" The link is http://www.newscientist.com/article/dn9321 Will we lick this before all the baby boomers go batty?

A. Rosenzweig: This is one of the most exciting areas in all of dementia research; a human vaccine trial was done several years ago with promising results but the study had to be halted due to cases of encephalitis, ie fatal brain infections. A new version of the vaccine is now undergoing trials and from what I know is showing promise. Many experts really believe a human vaccine is possible within the next 5-10 years. But keep in mind it's still a big leap to go from mice to humans in basic science research.

Q. Laura: IF a person has dementia, and has resisted going to assisted living, what suggestions might you have for creating a smooth transition.

A. Rosenzweig: Definitely one of the most difficult aspects of dementia care. I've seen it all, including people "lying" that they are just bringing mom to lunch when in fact the intent is to keep her there at the Assisted Living Facility. Clearly a plan should be coordinated with the family, the facility staff, the patient's doctor if possible, etc. Sometimes the patient gets so agitated and violent they need to be treated first in a psychiatric inpatient unit. Other strategies include bringing important personal belongings to help with the transition, visiting often, and being supportive.

Q. This is Andrea with projo.com. Most of us, as we age, start dealing with some kind of memory loss and scattered thinking. At what point should we be concerned?

A. Rosenzweig: It's unusual that these "senior moments" are truly indicative of an early dementia or serious cognitive problem. Typically, they're reflective of our over-scheduled lives and lack of separation between our work and personal lives. But certainly there is evidence that people in "high risk" groups may one day be screened for dementia with an imaging study (PET scan): for example having a first degree relative with early onset dementia, being a smoker, diabetic, having heart disease. This is all pretty new research findings, ie past few years.

Q. Grandchild: caregivers of older family members i know seem to be struggling with weighing the agency of the elders in their lives vs. their increasing needs: formerly independent people who now may no longer be making decisions in what the rest of us might consider their own best interests, whether to continue driving (despite the risk of harm to self or others), whether to accept a need for medication and diet modification (despite demonstrable of harm to self), etc., and a seeming lack of any sense of the impact these decisions might have on a family caregiver . . . can you talk a little more about how you advise people to navigate that delicate balance?

A. Rosenzweig: As was illustrated so well in Tracy's story about Laurette Eifrig, these "delicate balance" issues can at times go terribly awry. In fact experts even disagree on when the person has crossed over from making competent decisions to making incompetent ones. So I recommend a combination of sound judgment, professional advice, erring on the side of safety and protecting the person from being taken advantage of. I've too many elderly people financially scammed and otherwise victimized.

A. This is Tracy again. If you want to read more about the Eifrig case, you can go to: www.projo.com/extra/2007/elderabuse where my stories are archived.

Q. What kind of special care beyond food, bathing, dressing should a dementia patient receive. What might cause a dementia patient to repeat, I'm confused and I dont know what to do and What did I do wrong? Does there come a point in time in the progression of the disease when the patient ceases to realize they have confusion? And at that progression point, what else do they tend to lose in regard to cognition?

A. Rosenzweig: The care that dementia patients receive should largely be based on the stage of the illness and the individual circumstances.Even prior to the person needing assistance with bathing and dressing, they will likely need help: a calm, supportive environment, activities that are suited to them, reminders of occasions and appointments, etc. Repetitive questions, saying "what did I do wrong" are extremely common and often reflect anxiety in addition to the illness itself. Loss of insight is nearly universal eventually and for some patients occurs very early: they'll never believe there is anything wrong with them.

The medications approved for dementia (aricept, exelon, razadyne snd namenda) show benefits in activities of daily living, behavior and cognition, but the results are different for individuals. These are symptomatic treatments and by no means cures. They don't work for everyone, but they can certainly help delay the progression of the disease and improve lives of both patients and caregivers

Q. This is Tracy again. Many people don't understand the gradations of dementia and the progression of the disease. Does it always advance and is it usually rapid advancement?

A. Rosenzweig: If it's Alzheimers Disease or one of the other "progressive" dementias, it will inevitably get worse in a fairly predictable manner, usually over 10-15 years on average. But there is a lot of variability. Although Alzheimers is now considered the 6th highest cause of death in the US, many patients with it die of other illnessess: ie pneumonia.There is an early-onset form of Alzheimers that occurs much younger than usual (ie in the 40s) and is much more rapidly progressive.

Q. mgonda: Dr. Rosenzweig, thank you for taking questions. I'm curious what sort of mental stimulation you've seen having a possitive effect on elders with dementia.

A. Rosenzweig: Great question. Many things, from exercise to music to dance have all been shown to have positive benefit. The theme in dementia care is structure and appropriate stimulation: not too much, not too little. Reminiscing, life reviews, doing things to foster self-esteem and self-worth are all important. It's important to not argue with the person or try to reason with them.

Q. maryt: This is Mary . I am trying to trying to find information on dealing with severe depression in the elderly. My elderly mother lives out of state and is being treated by her doctor with medication, which has had little effect over the last 2 months. She refuses to move back home. I am flying down within the next week, but am not sure where to begin with helping her recover. Any input would be great..

A. Rosenzweig: Another tough situation. Especially if she's not demented, it's more difficult to intervene against the person's will. Often it takes 2 or 3 medication trials, sometimes with combining drugs or adding talk therapy, to see response. For severe or treatment resistant cases, we sometimes recommend ECT (electroconvulsive therapy). Try to be a little patient, as sometimes in the elderly it can take up to 12 weeks for the meds to start working. It sounds like referral to a geriatric psychiatrist may be appropriate as well.

Q. If you are caring for a parent and they are exhibiting some signs of dementia, how do you work around the resistance to take medication and get help to slow the progression down? My mother is 80 years old and the signs are there, however, she fights me and the doctors every step of the way. She will say to them "you can buy all the pills you want, but you can't make me take them." Help! I am at my wits end. I have my own family I am trying to care for too.

A. Rosenzweig: Keep in mind that the person with the illness is often struggling to maintain some control of their life. Their brains are actually atrophying, or "shrinking", so their world is as well. So the losses of memory, insight, judgement they experience lead to poor decisions. Sometimes "therapeutic fibbing" is called for: saying the medicine is for nerves or stress related to memory loss, that kind of thing.

Q. Doctor, My Mom has dementia and we have been unsucsssfull in moving her to an assisted living/memory care. She refuses to leave her home, we have a caregiver 7 days a week 8 hours a day. She is OK but we believe she would be better with 24 hour care, and the time is running out, we are concerned about her saftey at night. What could you suggest to facilitate a move. There is no way she can be convinced by talking or showing her, we have tried.

A. Rosenzweig: As illustrated with the Eifrig case, sometimes there becomes a need for a legal guardian if appointment of a "durable power of attorney" is not enough to accomplish what needs to be accomplished. This may mean getting an elder care lawyer involved. 24 hour care at home is prohibitively expensive for most people, so doing what it takes to get the person in a safe environment is critical.

Q. This is Tracy again. What are the tell-tale signs that someone is developing dementia? It seems that in some cases, the dementia suddenly crops up but I know some doctors say that it usually progresses steadily and that it's just kept hidden by spouses who try to cover for their declining partner.

A. Rosenzweig: Great question Tracy. Many studies show that apathy, anxiety, depressed mood are often the earliest signs, followed by increasing forgetfulness, word-finding problems, problems using household appliances. Losing interest in previously enjoyed activities is common. Spouses often compensate for these changes in their loved ones, sometimes without even realizing it until it's obvious to others.

Q. Another question from Tracy: How common is it for Alzheimer's pateints to become violent and how much domestic violence do you think exists in elderly families?

A. Rosenzweig: Interestingly enough, Dr. Alois Alzheimer's first patient in 1906, a woman in her 50s named Auguste D., had delusions and violent behavior, screaming that "people were out to murder her." Most studies show that between half to two-thirds of all dementia patients will develop delusions, hallucinations, or agitated, aggressive behaviors at some point in the illness.

This is why there are too few geriatric psychiatrists like myself. Domestic violence is there but not discussed: caregiver stress takes a huge toll on families, there is a lot of neglect, financial and other abuse, undue influence, etc. Clearly we are not doing enough as a society to deal with this problem.

Q. karen: I've read several articles in the Providence Journal within the past few months about elderly people being committed against their will. Often reasons cited are messy housekeeping, or the person did not know what day it was, etc. As a lifelong messy housekeeper, surrounded by the usual absent-minded bookworm clutter and 60-odd years of belongings, and no fan of dusting, and now a retiree who has no reason to know what day it is, since I don't go to work or church, etc., and so I often really do not know until I look at my computer calendar what the heck day is it, this naturally causes me some concern.

It seems that once a person gets to be 80 or so, different standards apply to them, and the some bureaucrat can just swoop down on them and institutionalize them whereas they would never get away with doing that to a younger person. In at least one case written about, the person then lost family heirlooms such as her mother's china, because the state-appointed person let basically thieves into their house to "help" them, and the system did nothing about this. I really think there is a significant abuse of elder rights going on.

A. Rosenzweig: For anyone to be committed to a psychiatric hospital against their will, there needs to be a clear danger to self or others, or clear inability to care for oneself. While some cases are more controversial than others, certainly messy housekeeping or disorientation to time do not qualify as grounds for commitment.

Q. This is Tracy again. I found it interesting in Laurette Eifrig's case that she was someone who was found to be suffering from "moderate dementia" but still has good long-term memory and is able to have a very good conversation with you about a wide range of things. Is your diagnosis based solely on her loss of short-term memory?

A. Rosenzweig: So how can a person be sharp and demented at the same time? It has to do largely with the fact that key aspects of a person, such as personality style, educational attainment, life experience, are still relevant in dementia. But moderate dementia still implies poor judgment, memory deficits and functional deficits that in this case at least necessitated the need for others to step in.

[2007.06.25 13:19:34] Tracy: That's all the time we have today. Thank you for coming and asking questions on these really important subjects. And thank you, Dr. Rosenzweig, for taking so much time out of your busy practice to address our readers' concerns. We will be posting a transcript of this chat on the Web page: www.projo.com/extra/2007/elderabuse

[2007.06.25 13:11:33] Elaine: Thank you, Dr. Rosenzweig. This chat has been helpful.