A second pandemic shadows our land, trailing after COVID-19: a pandemic of slumbering brains. We isolated the elderly to protect them from the virus, leaving them alone at home or in congregate living with no visitors and minimal staff contact.
Social stimulation livens the brain, slowing the march of dementia. Apart from our clinical experience, mouse models of Alzheimer's prove that stimulation slows the memory loss, even while plaques and tangles still accumulate.
Contrariwise, inactivity and lack of stimulation worsens memory, orientation and other thinking skills, the sad model for our pandemic care of the elderly. An analysis by the Washington Post suggests over 13,000 excess deaths have occurred in dementia patients since the pandemic started, not directly related to COVID.
With COVID, outpatient memory care day programs across the country morphed into online programs or shut down altogether. And brains began shutting down as well. Online programs can provide valuable stimulation, but willing family or caregivers must engage the patient during the program to reap the benefits. A computer screen feels distant, less engaging than a person in front of you, especially for the hearing or vision impaired.
In San Diego, a network of Glenner Alzheimer's Family Centers opened in memory of George Glenner, MD, a pathologist and early Alzheimer's researcher who studied the beta amyloid protein linked to the disease.
The centers provide day programs and other services to Alzheimer's patients and families throughout San Diego County. After 6 weeks of exclusive online services, the centers have now re-opened, moving toward 50% of capacity with social distancing, masking and other precautions. Program Director Marge Galante, RN, BSN, said, "Among Hillcrest clients, at least four or five needed to be placed in [long term care] since March, when they were doing well before the pandemic." Typically, family members were unable to provide enough stimulation and structure, themselves often busy with work or children in online school.
Speaking on a personal level, Galante added that being in a hospital without visitors or family can be "horrifically traumatic" as it was for her own elderly husband, admitted to a hospital for non-COVID medical problems during the pandemic. "The impersonality of the experience destroyed him emotionally," she observed sadly. "He hasn't recovered, and I believe he never will."
At one Glenner center, she finds the social distancing and other measures continue to inhibit interaction and engagement, especially when hearing or vision are limited.
Shannon Patel, MSW, program director at the Chula Vista Glenner site, gave the example of a retired accountant who could do Sudoku, converse freely and complete a 1,000-piece jigsaw puzzle. After the 6-week hiatus from program, he now struggles to find words, can't do puzzles of any size, and has lost urine continence. His wife is looking for long-term care for him.
Families of an elder showing cognitive decline, whether early or late, should pursue careful evaluation for treatable causes with a neurologist, a gerontologist or another physician with an interest in dementia. Removing sedating or anticholinergic medicines helps most, while memantine and the pro-cholinergic medications may slow dementia's progress in Alzheimer's and some other dementias.
Some families notice the patient perking up after starting these medications. As the dementia worsens, suspiciousness or other psychotic symptoms may require antipsychotics like quetiapine or pimavanserin but antipsychotics have been overprescribed and must be used sparingly. Behavioral methods, as simple as changing the subject when a demented patient becomes oppositional, can be learned from books such as The 36 Hour Day or Learning to Speak Alzheimer's for families and caregivers.
In-person programs will strive to provide social distancing during the pandemic. For non-English-speaking patients, an elder care program in their first language gives the best social stimulation and might be offered through local church or other community organizations.
During COVID-19, many families will prefer to create stimulation at home for those with dementia. Many centers like the Glenners offer home programs online, but these are far more effective when family members or caregivers watch with the patient to promote focus and engagement. Social engagement seems to be most stimulating to our brains, but mildly affected individuals may benefit from other cognitive challenges according to their taste, including Sudoku, card games, reading in a new area, or commercial programs such as Lumosity.
Physical activity improves dementia, with "dosing" of exercise according to patient ability and interest. Walking can be combined with conversation. Gym activities can be helpful, either in the home or at a socially distanced program. Treadmills should be avoided due to injury with forgetting how to dismount, but stationary bikes or ellipticals will be safe for many patients.
Nothing hurts like watching a loved one slowly dying. The pandemic forced our elderly into hibernation, accelerating their decline. As a neurologist, I focus on the approximately 6 million Americans with dementia, but the loss of social contact and stimulation potentially affects all of our frail elderly. As we struggle to open up safely, we need to keep their cognitive wellbeing in our hearts, even as they remain the most vulnerable to the effects of COVID-19.
James Santiago GrisolÃa, MD, is a general neurologist in San Diego. He is medical director for stroke at Scripps Mercy Hospital Chula Vista campus. He also is the editor-in-chief of the San Diego County Medical Society's magazine, The San Diego Physician
Disclosures
Grisolia has received compensation from a variety of pharmaceutical companies, totaling under $1,000 per year and mostly for food and beverages. In 2017, he received $129 in food or beverages from Acadia Pharmaceuticals related to pimavanserin.
