Motivation and emotion/Book/2013/Alzheimer's and motivation

Overview
Alzheimer's Disease affects mainly older people, although younger people can also be affected. Roughly half of all adults over 85 years old have or will get Alzheimer's. This makes Alzheimer's a great public health concern and a worry for anyone becoming elderly. So what can be done about Alzheimer's? Is it a fate that must be simply accepted? This is one of the myths about Alzheimer's. Alzheimer's is highly affectable. Multiple research studies have found that many different things can influence the development and progression of AD, such as diet and exercise, education levels and daily use of the brain. Practices such as lifelong learning, early testing and drug treatments, and even social connections and networks, all influence the likelihood of Alzheimer's occurring. If you have the motivation to practice them you may be able to stave off the progression of Alzheimer's whether you have a family history or not.

What is Alzheimer's and how does it differ from dementia?


Alzheimer's is the most common form of dementia, especially for the elderly, with 70% of dementia sufferers having Alzheimer's. Others include Lewy Body and Vascular dementia, which differ from Alzheimer's in how they affect the brain and a person's functioning (Petersen, 2009). The changes that occur in Alzheimer's affect the brain and are irreversible. Treatments may slow damage and early intervention may prevent symptoms but once there it cannot be cured. The damage has multiple causes. Naturally occurring chemicals and proteins within the brain build up over decades. These proteins, most importantly amyloid, slowly build up in the brain. The resulting tangles then causes various dysfunctions, such as memory problems, through the disruption of nerve cell connections (Wolfe, 2007). First affected is hippocampal formation, which is intimately involved with memory. Fluid also accumulates in spaces where neurons have died causing brain shrinkage(Hoffman, Froemke & Golant, 2010), which can be seen in Figure 1. Also important is oxidative damage, which is a byproduct of oxygen being used by the cells. This is highly influenced by diet and will be explained in more detail later (Cotman, 2009). The changes in functioning can be viewed on a PET scan such as that in Figure 2.

All of these changes occur gradually with aging but Alzheimer's causes dramatic and devastating changes which attack the brain and cause normal functioning to decline. It is the severity of damage that is influenced by Alzheimer's (Buckner, 2009). Over time the impairment grows from just memory issues to simple everyday tasks where the person can no longer care for themselves. The process from first symptoms to full-time care requirements usually takes many years and is inevitably fatal.



How can Alzheimer's be prevented or reduced through internal motivation?
After reading about the causes of Alzheimer's it may seem futile to try and prevent any of these naturally occurring changes. The truth however is that multiple lifestyle choices have been identified which can significantly impact the risk of developing the symptoms related to Alzheimer's. The underlying pathology, that is the brain changes, will always occur but whether or not symptoms develop is affected greatly by motivation to carry out a lifestyle that will reduce your risk or even prevent the development of symptoms entirely. Being a highly motivated goal-driven person with a strong purpose and meaning in life can help provide the cognitive drive to stave off the effects of AD as long as possible, which may be until death from something unrelated (Hanlon, 2012). The following two sections split up what can be done before symptom onset and what can be done after symptoms appear.

What can be done in early to middle life
Most people assume that since Alzheimer's is a disease which strikes mainly in old age and the pathology is genetically based that nothing can be done earlier in life to prevent it. This, however, is not the case. Many lifestyle factors in earlier life influence the onset of AD and the symptom severity. A study done by the Mayo Clinic in 2002 found that lifestyle factors such as lifelong learning, mental and physical exercise, continued social engagement, stress reduction, and proper nutrition were protective factors against AD symptoms. They also found harmful lifestyle factors such as smoking, excessive alcohol intake, and medical comorbidities such as diabetes, increased the risk of cognitive decline, the forerunner to AD (Fillit et al., 2002).

Keep the brain active
The brain is a complex organ, and it is experience-hungry. In other words, it constantly craves new and challenging experiences and without them it will naturally decline. Therefore, new, exciting and challenging experiences will help to prevent natural cognitive decline. This is where a "cognitively stimulating lifestyle" comes into play (Wilson in Gray, 2013).

A study done by Wilson (2013) found that those who carried out frequent mental activities in later life experienced some 32% lower mental decline than those who had merely average activity. People with infrequent mental activity suffered the worst, experiencing a 48% faster mental decline (Gray, 2013). Mental activity has been found to build up one's cognitive reserve, which increases the capacity, after the development of AD pathology, to create new pathways and use new areas to overcome declines and therefore rarely or never display symptoms, despite the underlying pathology. Cognitive reserve is built up through early to late life through activities such as higher education and continuation of self-education throughout life (Petersen, 2009).

So what activities should be carried out? On the whole, the type of activity depends on the interests of the person; if you are not interested in a particular activity it will not properly engage and stimulate your brain. Some suggestions include games and puzzles, such as Sudoku and crosswords, taking up a new hobby such as photography, painting, crafts or even a musical instrument, reading exciting or interesting books or even academic studies; anything which gets you cognitively involved in the activity is likely to be beneficial (Gatz, 2005).

Social interaction
Social interaction is important throughout life for psychological well-being; it is in fact a key psychological need. It gets even more important later in life as it can help to protect against AD. Close, supportive relationships are usually built up in early life and it is these that are more beneficial.

The Rush University Religious Orders study lead by Dr David Bennett found that people who have chronic psychological distress and low conscientiousness are almost twice as likely to get AD. Social isolation and feeling alone increases Alzheimer's risk greatly, and reduces the will to live. How you engage with the world, including social networks, can be a protective factor. Having a large social network with whom you regularly converse can protect against symptoms. In the study, the average was seven to eight close friends. One woman who had ten close friends had the underlying pathology but no AD symptoms in her life (Bennett, 2009). The moral of this story is that the more close friends one has, the greater the protection from Alzheimer's.

Social engagement can involve meeting with friends for coffee and a catch-up, playing games such as bingo with others, having a chat while going for a walk, which also fulfills the exercise element discussed later, or chatting with family. Once again the type of activity is up to you as positive social engagement is always beneficial in multiple ways.

Diet and daily habits
What goes into our bodies is important at any age for various health outcomes but the link to Alzheimer's seems less obvious. Oxidative damage, identified earlier, is affected by diet because a diet rich in antioxidants can prevent much of it (Cotman, 2009). A study done by Dr Cotman (2009) on aged beagles found that an antioxidant-rich diet improved learning, ability to remember and rejuvenated the brain to the point that the dogs could perform tasks that other untreated dogs of the same age could not; they had in fact gained function. This is a very important finding as in humans it could return function to those who have lost it and greatly improve quality of life by rejuvenating the aged brain. Earlier in life the diet can prevent damage from occurring at all or at least reduce it.

A diet that is generally healthy and keeps the body fit and healthy is the best for all life outcomes. Plenty of fruits and vegetables is key as well as low salt, fat and sugar foods that can lead to all kinds of health problems, which often become comorbid with AD (Fillit, et al., 2002). Fruits and vegetables are the best source of antioxidants, with the highest being blueberries and prunes. All have different types which work together to minimise damage and increase repair so the wider variety the better. Also, it needs to be the real thing not supplements as they do not have the same beneficial effects (Cotman, 2009; Deweerdt, 2011).

Exercise
Exercise is another factor which is important throughout life for many health outcomes. In relation to Alzheimer's it promotes the production of important chemicals in the brain which are restorative.

Dr Cotman found that exercise increases the brain's levels of Brain Derived Neurotrophic Factor (BDNF), which is a brain protein that affects connections and pathways in the brain. It stimulates them and makes them healthier, therefore acting as a growth stimulant to cells, improving connections. The study used mice with induced AD symptoms to test effects of regular exercise on memory functioning. Those who exercised had better functioning and higher levels of BNDF. BNDF acts like the brain's own self preservation mechanism. Exercise can induce growth factors in the brain, encourage new neuron circuits, improve learning, synapses and vascular functions. Exercise reduces the short-term likelihood of onset, but will not stop it entirely. Also important is the fact that people who exercise generally take better care of themselves, both in terms of diet and medical factors. The person must have the motivation to regularly exercise and eat well and stick with it (Cotman, 2009).

Dr Denise Head et al. (2012) found in a study on the APOE gene, that those with the e4 variant are 15 times more likely to get plaques on the brain, however, those who exercised regularly, walking or jogging for at least 30 minutes five times a week, had plaque development that was in line with those with the normal gene, so exercise could cancel out a genetic propensity to AD. The study also found that those with an inactive lifestyle had more rapid plaque development.

The type of exercise chosen can vary greatly and will be affected by the interests of the person. As always, you are more likely to stick with something when you enjoy it. Social interaction and exercise can even be combined by going for a walk with a friend, family member or partner and having a chat on the way.

Early testing and intervention
New tests that measure levels of amyloid can find biomarkers of AD long before symptoms appear. Treatment to stop the decline can therefore be started long before the real damage has been done (Ainsen, 2009). However, people have to want to get these tests done and stick with treatments or lifestyle changes. In a study by Gooding, et al. (2006) most of the 60 participants at increased risk of AD development, due to familial history, believed that genetic testing for suseptibility was beneficial, providing valuable information despite the fact that no current treatment options can prevent pathology. They wanted to know and this helped with coping strategies, due to increased feelings of control from the knowledge and motivations to make lifestyle changes.

Drug treatments are also improving with further research and one day early testing may lead to early drug interventions. Drugs that target the damaging amyloid peptide could bring a way to stop the decline caused by AD before it has even begun (Ainsen, 2009).

What can be done when the first signs appear?
Firstly one needs to know what the first signs look like. Normal forgetfulness is present throughout life and gets worse as one ages but does not mean that they have Alzheimer's. What is normal forgetfulness? Say you come home put down your handbag, wallet, keys or phone and then forget the place that you put it down, this is normal (most people do something like this on a daily basis). However if you have an important appointment that you have put effort into remembering or you would usually remember when you were younger but are constantly forgetting now, or if you forget your child or spouse's birthday, and you never used to, these are signs that your memory is starting to fail you and the cause may be an underlying cognitive problem, such as Alzheimer's. The important point is that the functioning is different; memory is worse than how it was when the person was younger (Petersen, 2009).

Dr Petersen (2009) identified this period of increasing forgetfulness as mild cognitive impairment (MCI) and it is the first step on the road to Alzheimer's or other types of dementia. The amnestic form of cognitive impairment, only memories not cognitive functioning on the whole, leads to Alzheimer's. Non-amnestic, general cognitive impairment leads to other forms of dementia. It is important to recognise the type of impairment. Other forms such as Lewy-body may be treatable with medications. The different types also have different ways of affecting the brain.

Early detection and treatment of AD is crucial, however this may require the help of family members as the patient often won't see the changes as problematic or will pass it off as normal aging when often it is not. Further information on the family of dementia patients can be found in the related chapter about caregiving and grief in dementia.

Getting onto drug treatments as early as possible can help with the progression. However, current drug treatments try to stimulate new brain connections but cannot repair the damage and function lost due to AD. This means that it only ever plateaus or gets worse, not better (Wolfe, 2007). The other lifestyle factors identified earlier in this chapter offer some of the best hope for Alzheimer's sufferers as many of the interventions, especially exercise, have shown better improvements than those from drugs. Encouraging the person though may be tricky and involve a lot of extrinsic motivation. Specifics on elderly exercise motivation can be found in the motivating the elderly to exercise related chapter.

What causes people to lose motivation in the face of Alzheimer's?
Many aspects of a person's normal functioning are affected by Alzheimer's but one of the potentially most devastating is a loss of motivation. This loss can have many causes including frontal lobe damage, depression and apathy. This can also be particularly devastating for family and friends and upsetting for the person themselves but is often uncontrollable.

Frontal lobe damage caused by Alzheimer's progression can cause loss of motivation as well as other functioning problems. The frontal lobe is responsible for many higher level functions so when it is damaged much is devastated. Motivation, goal-directed behaviour and inhibition are especially affected, which can cause dramatic behavioural changes (Dementia Guide, 2013).

Approximately 60% of Alzheimer's patients suffer from apathy; but what is apathy? Apathy can be defined as a disorder of motivation which involves a lack of goal-directed behaviour, cognition and emotion, and an absence of responsiveness to stimuli and lack of self-initiated action (Robert, Mulin, Mall & David, 2010). Apathy can be present from the time when MCI begins and therefore causes problems before full onset of AD symptoms. Current drug treatments for apathy are not incredibly effective. Other treatments aim to target the person's interests to try to increase involvement and may have more effectiveness, however, more research is needed to prove the theory. The person is unlikely to initiate their own behaviour but may show an increase in responsiveness (Robert, et al., 2010).

| Depression is another motivation killer common in AD. Studies which look at prevalence rates of depression in AD have found incidence rates ranging from 5 to 85%. The types of depression varied from depressive symptoms to major depression, either self-reported or by family members (Tune, 1998). Depressive symptoms are the same as in standard clinical depression and are quite debilitating, adding further troubles on top of the Alzheimer's suffering. The treatment however for AD patients must be varied. Anti-depressants can be used but in smaller doses, for less time and more attention must be paid to the drug's side effects, especially cognitive (Tune, 1998). This is another area that may be helped by exercise as studies have shown that it helps with depressive symptoms.

Negative symptoms, including lack of personal care, lack of interest in social interactions and lack of empathy, are caused by these other factors and can cause many problems for carers and loved ones of the person. Negative symptoms are not a normal part of aging and have an intimate link to level of cognitive decline (Reichman, Coyne, Amirneni, Molino & Egan, 1996). Negative symptoms could be influenced by attempts at extrinsic motivation.

Emotional indifference is also a common problem in AD but is outside the scope of this chapter. The effects of dementia on emotion are examined further in the related chapter Dementia and emotion.

Conclusion
The impact of motivation on Alzheimer's is great. With the right motivation to make lifestyle changes which are beneficial in the progression of AD it can be slowed or even prevented entirely. When brain activity is kept at a high level previously dormant parts of the brain can become more active to compensate for declines. The brain is highly plastic and can cope with many changes. Recent studies have shown the brain's amazing capacity to relearn and retrain despite damage to certain areas (Buckner, 2009). The motivation must be there, though, to overcome problems such as apathy which often co-occur and can cause issues from the earliest stages.

Alzheimer's is not a guaranteed byproduct of aging and many things can help in the prevention or slowing of progression even in early, middle or late old age. Steps taken in early old age may prevent onset or slow symptoms until late old age. Behavioural interventions and changes in behaviour at any stage, although the earlier the better, can combat AD.

Dealing with Alzheimer's involves a lot of motivation and commitment on the part of the carer, family, friends and the person themselves.

Test your Alzheimer's susceptibility
{Without looking back up, which of these is shown in Figure 1?} - Terry Pratchett - Veteran picture - PET scan + Brain shrinkage

{Do you have a family history of Alzheimer's?}

- Parent - Grandparent - Other + No

{Do you eat a variety of fruits and vegetables on a regular basis?} + Yes - No

{How often do you exercise? Moderate exercise for 30 minutes or more?} + Everyday + At least 5 times a week + At least 3 times a week - Less than twice a week - Never

{How many close friends do you have?} + More than 10 + Between 5 and 10 - Less than 5

{If a test was available tomorrow that could predict Alzheimer's suseptibility would you take it?} + Yes - No

{Would you follow a drug and lifestyle change treatment/ prevention plan?} + Yes - No

If you scored highly on this quiz, above 5, then your susceptibility to Alzheimer's may be low and your motivation to keep it at bay is high.