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Seven Stages of Dementia | Symptoms & Progression

Health professionals sometimes discuss dementia in “stages,” which refers to how far a person’s dementia has progressed. Defining a person’s disease stage helps physicians determine the best treatment approach and aids communication between health providers and caregivers. Sometimes the stage is simply referred to as “early stage”, “middle stage” or “late-stage” dementia, but often a more exact stage is assigned, based on a person’s symptoms.

One of the most commonly used staging scales is the Global Deterioration Scale for Assessment of Primary Degenerative Dementia (GDS), which divides the disease process into seven stages based on the amount of cognitive decline. The GDS is most relevant for people who have Alzheimer’s disease, since some other types of dementia (i.e. frontotemporal dementia) do not always include memory loss.

Global Deterioration Scale for Assessment of Primary Degenerative Dementia (GDS) (also known as the Reisberg Scale)

Diagnosis Stage Signs and Symptoms
No Dementia Stage 1:
No Cognitive Decline

In this stage the person functions normally, has no memory loss, and is mentally healthy. People with NO dementia would be considered to be in Stage 1.
No Dementia Stage 2:
Very Mild Cognitive Decline
This stage is used to describe normal forgetfulness associated with aging; for example, forgetfulness of names and where familiar objects were left. Symptoms are not evident to loved ones or the physician.
No Dementia Stage 3:
Mild Cognitive Decline
This stage includes increased forgetfulness, slight difficulty concentrating, decreased work performance. People may get lost more often or have difficulty finding the right words. At this stage, a person’s loved ones will begin to notice a cognitive decline. Average duration: 7 years before onset of dementia
Early-stage Stage 4:
Moderate Cognitive Decline
This stage includes difficulty concentrating, decreased memory of recent events, and difficulties managing finances or traveling alone to new locations. People have trouble completing complex tasks efficiently or accurately and may be in denial about their symptoms. They may also start withdrawing from family or friends, because socialization becomes difficult. At this stage a physician can detect clear cognitive problems during a patient interview and exam. Average duration: 2 years
Mid-Stage Stage 5:
Moderately Severe Cognitive Decline
People in this stage have major memory deficiencies and need some assistance to complete their daily activities (dressing, bathing, preparing meals). Memory loss is more prominent and may include major relevant aspects of current lives; for example, people may not remember their address or phone number and may not know the time or day or where they are. Average duration: 1.5 years
Mid-Stage Stage 6:
Severe Cognitive Decline (Middle Dementia)
People in Stage 6 require extensive assistance to carry out daily activities. They start to forget names of close family members and have little memory of recent events. Many people can remember only some details of earlier life. They also have difficulty counting down from 10 and finishing tasks. Incontinence (loss of bladder or bowel control) is a problem in this stage. Ability to speak declines. Personality changes, such as delusions (believing something to be true that is not), compulsions (repeating a simple behavior, such as cleaning), or anxiety and agitation may occur. Average duration: 2.5 years
Late-Stage

 

Stage 7:
Very Severe Cognitive Decline (Late Dementia)
People in this stage have essentially no ability to speak or communicate. They require assistance with most activities (e.g., using the toilet, eating). They often lose psychomotor skills, for example, the ability to walk. Average duration: 2.5 years

 

(Reisberg, et al., 1982; DeLeon and Reisberg, 1999)

Two other scales that are sometimes used to describe the progression of dementia are:

  • Functional Assessment Staging (FAST): a seven stage system based on level of functioning and daily activities. View the FAST

    Functional Assessment Staging (FAST)

    Another staging method for dementia, the Functional Assessment Staging (FAST), focuses more on an individual’s level of functioning and activities of daily living versus cognitive decline. Note: A person may be at a different stage cognitively (GDS stage) and functionally (FAST stage).

Functional Assessment Staging (FAST)
Stage 1 — Normal adult
No functional decline
Stage 2 — Normal older adult
Personal awareness of some functional decline.
Stage 3 — Early Alzheimer’s disease
Noticeable deficits in demanding job situations.
Stage 4 — Mild Alzheimer’s
Requires assistance in complicated tasks such as handling finances, planning parties, etc.
Stage 5 — Moderate Alzheimer’s
Requires assistance in choosing proper attire.
Stage 6 — Moderately severe Alzheimer’s
Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.
Stage 7 — Severe Alzheimer’s

Speech ability declines to about a half-dozen intelligible words. Progressive loss of abilities to walk, sit up, smile, and hold head up. (Reisberg, et al., 1988)

The Clinical Dementia Rating (CDR) scale: a five-stage system based on cognitive (thinking) abilities and the individual’s ability to function. Commonly used in dementia research. View the CDR Scale

Clinical Dementia Rating (CDR)

This is the most widely used staging system in dementia research. Here, the person with suspected dementia is evaluated by a health professional in six areas: memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care and one of five possible stages is assigned.

 

Clinical Dementia Rating (CDR) Scale
CDR-0 — No dementia
CDR-0.5 — Mild
Memory problems are slight but consistent; some difficulties with time and problem solving; daily life slightly impaired
CDR-1 Mild
Memory loss moderate, especially for recent events, and interferes with daily activities. Moderate difficulty with solving problems; cannot function independently at community affairs; difficulty with daily activities and hobbies, especially complex ones.
CDR-2 — Moderate
More profound memory loss, only retaining highly learned material; disoriented with respect to time and place; lacking good judgment and difficulty handling problems; little or no independent function at home; can only do simple chores and has few interests.
CDR-3 — Severe
Severe memory loss; not oriented with respect to time or place; no judgment or problem solving abilities; cannot participate in community affairs outside the home; requires help with all tasks of daily living and requires help with most personal care. Often incontinent.

View References

de Leon MJ and Reisberg B. An Atlas of Alzheimer’s Disease. The Encyclopedia of Visual Medicine Series. Parthenon Publishing, Carnforth, 1999. Available at: http://www.alzinfo.org/clinical-stages-of-alzheimers

Reisberg B et al. The Global Deterioration Scale for Assessment of Primary Degenerative Dementia. American Journal of Psychiatry. 1982;139(9):1136-1139.

“Seven Stages of Dementia | Symptoms & Progression.” Dementia Care Central. N.p., n.d. Web. 24 Mar. 2017.

 

Delirium: A Surprising Side Effect of Hospital Stays

(This article originally appeared on KaiserHealthNews.org.)

When B. Paul Turpin was admitted to a Tennessee hospital in January last year, the biggest concern was whether the 69-year-old endocrinologist would survive. But as he battled a life-threatening infection, Turpin developed terrifying hallucinations, including one in which he was performing on a stage soaked with blood. Doctors tried to quell his delusions with increasingly large doses of sedatives, which only made him more disoriented.

Nearly five months later, Turpin’s infection has been routed, but his life is upended. Delirious and too weak to go home after his hospital discharge, he spent months in a rehab center, where he fell twice, once hitting his head. Until recently he did not remember where he lived and believed he had been in a car wreck. “I tell him it’s more like a train wreck,” said his wife, Marylou Turpin.

“They kept telling me in the hospital, ‘Everybody does this,’ and that his confusion would disappear,” she said. Instead, her once astute husband has had great difficulty “getting past the scramble.”

Turpin’s experience illustrates the consequences of delirium, a sudden disruption of consciousness and cognition marked by vivid hallucinations, delusions and an inability to focus that affects 7 million hospitalized Americans annually. The disorder can occur at any age — it has been seen in preschoolers — but disproportionately affects people older than 65 and is often misdiagnosed as dementia.

While delirium and dementia can coexist, they are distinctly different illnesses. Dementia develops gradually and worsens progressively, while delirium occurs suddenly and typically fluctuates during the course of a day. Some patients with delirium are agitated and combative, while others are lethargic and inattentive.

Delirium Triggers

Patients treated in intensive care units who are heavily sedated and on ventilators are particularly likely to become delirious; some studies place the rate as high as 85 percent. But the condition is common among patients recovering from surgery and in those with something as easily treated as a urinary tract infection. Regardless of its cause, delirium can persist for months after discharge.

They kept telling me in the hospital, ‘Everybody does this,’ and that his [my husband’s] confusion would disappear.

— Marylou Turpin

Federal health authorities, who are seeking ways to reduce hospital-acquired complications, are pondering what actions to take to reduce the incidence of delirium, which is not among the complications for which Medicare withholds payment or for which it penalizes hospitals. Delirium is estimated to cost more than $143 billion annually, mostly in longer hospital stays and follow-up care in nursing homes.

“Delirium is very underrecognized and underdiagnosed,” said geriatrician Sharon Inouye, a professor of medicine at Harvard Medical School. As a young doctor in the 1980s, Inouye pioneered efforts to diagnose and prevent the condition, which was then called “ICU psychosis.” Its underlying physiological cause remains a mystery.

“Physicians and nurses often don’t know about it,” added Inouye, who directs the Aging Brain Center at Hebrew SeniorLife, a Harvard affiliate that provides elder care and conducts gerontology research. Preventing delirium is crucial, she said, because “there still aren’t good treatments for it once it occurs.”

Researchers estimate that about 40 percent of delirium cases are preventable. Many cases are triggered by the care patients receive — especially large doses of anti-anxiety drugs and narcotics to which the elderly are sensitive — or the environments of hospitals themselves: busy, noisy, brightly lit places where sleep is constantly disrupted and staff changes frequently.

Recent studies have linked delirium to longer hospital stays: 21 days for delirium patients compared with nine days for patients who don’t develop the condition. Other research has linked delirium to a greater risk of falls, an increased probability of developing dementia and an accelerated death rate.

“The biggest misconceptions are that delirium is inevitable and that it doesn’t matter,” said E. Wesley Ely, a professor of medicine at Vanderbilt University School of Medicine who founded its ICU Delirium and Cognitive Impairment Study Group.

Long-Term Effects

In 2013, Ely and his colleagues published a study documenting delirium’s long-term cognitive toll. A year after discharge, 80 percent of 821 ICU patients ages 18 to 99 scored lower on cognitive tests than their age and education would have predicted, while nearly two-thirds had scores similar to patients with traumatic brain injury or mild Alzheimer’s disease. Only 6 percent were cognitively impaired before their hospitalization.

Cognitive and memory problems are not the only effects. Symptoms of post-traumatic stress disorder are also common in people who develop delirium. A recent meta-analysis by Johns Hopkins researchers found that 1 in 4 discharged ICU patients displayed PTSD symptoms, a rate similar to that of combat veterans or rape victims.

David Jones, a 37-year-old legal analyst in Chicago, Ill., said that he was entirely unprepared for persistent cognitive and psychological problems that followed the delirium that began during his six-week hospitalization for a life-threatening pancreatic disorder in 2012. Terrifying flashbacks, a hallmark of PTSD, were the worst. “They discharged me and didn’t tell me about this at all,” said Jones, whose many hallucinations included being burned alive.

Jones’s ordeal is typical, said psychologist James C. Jackson of Vanderbilt’s ICU Recovery Center, a multidisciplinary program that treats patients after discharge.

Vivid Flashbacks

“They go home and don’t have the language to describe what has happened to them,” said Jackson, adding that such incidents are often mistaken for psychosis or dementia. “Some patients have very striking delusional memories that are very clear distortions of what happened: patients who were catheterized who think they were sexually assaulted and patients undergoing MRIs convinced that they were fed into a giant oven.”

Some hospitals are moving to prevent delirium through a more careful use of medications, particularly tranquilizers used to treat anxiety called benzodiazepines, which are known to trigger or exacerbate the problem. Others are trying to wean ICU patients off breathing machines sooner, to limit the use of restraints and to get patients out of bed and moving more quickly. Still others are trying to soften the environment by shutting off lights in patients’ rooms at night, installing large clocks and minimizing noisy alarms.

A recent meta-analysis led by Harvard researchers found that a variety of non-drug interventions — which included making sure patients’ sleep-wake cycles were preserved, that they had their eyeglasses and hearing aids and that were not dehydrated — reduced delirium by 53 percent. These simple fixes had an added benefit: They cut the rate of falls among hospitalized patients by 62 percent.

Inouye and other experts say that encouraging hospitals to recognize and treat delirium is paramount. They have vehemently argued that federal officials should not classify delirium as a “never” event for which Medicare payment will be denied, fearing that would only drive the problem further underground. (“Never” events include severe bedsores.)

Delirium “is not like pneumonia or a fracture” and lacks an obvious physical indicator, said Malaz Boustani, an associate professor of medicine at Indiana University. He proposes that Medicare create a bundle payment that would pay for treatment up to six months after delirium is detected.

Creating effective incentives is essential, said Ryan Greysen, an assistant professor of medicine at the University of California at San Francisco. Delirium, he said, suffers from a “pernicious know-do gap” — a disparity between knowledge and practice. Many proven interventions, he said, do not seem sufficiently medical. “There’s no gene therapy, no new drug,” Greysen said. “I think we need to put this in the realm of hospital protocol, which conveys the message that preventing and treating delirium is just as important as giving people their meds on time.”

Growing Awareness

Awareness that delirium is a significant problem, not a transitory complication, is recent, an outgrowth of growing expertise in the relatively new field of critical care medicine. The graying of the baby boom generation, whose oldest members are turning 69, is fueling interest in geriatrics. And many boomers are encountering delirium as they help care for their parents who are in their 80s and older.

“In the early 1990s, we thought it was a benevolent thing to protect people from their memories of having a tube down their throat, of being tied down, by using large doses of drugs to paralyze and deeply sedate patients,” Ely noted. “But by the late 1990s, I was just getting creamed by families and patients who told me, ‘I can’t balance my checkbook, I can’t find my car in the parking lot and I just got fired from my job.’ Their brains didn’t work anymore.”

Delirium “is now taught or at least mentioned in every medical and nursing school in the country. That’s a huge change from a decade ago,” said Inouye, adding that research has increased exponentially as well.

In some cases, delirium is the result of carelessness.

One woman said she was repeatedly rebuffed several years ago by nurses at a Washington area hospital after her mother started acting “stoned” after hip surgery. “She said things like ‘I’m having a dinner party tonight and I’ve invited a nice young man to meet you,’ ” recalled the daughter. She asked that her name be omitted to protect the privacy of her mother, now 96, who lives independently in Northern Virginia and “still has all her marbles — and then some.”

“The nurses kept telling me she was off all medication” and that her confusion was to be expected because of her age. “It was only when I insisted on talking to the doctor and going through her chart” that the doctor discovered that a motion sickness patch to prevent nausea had not been removed. “Within an hour, my mother was acting fine. It was very scary because if she hadn’t had an advocate, she might have been sent to a nursing home with dementia.”

Inouye, who developed the Confusion Assessment Method, or CAM scale, now used around the world to assess delirium, said that significant systemic obstacles to preventing delirium remain.

“We need to back up in our care of older patients so that we don’t treat every little symptom with a pill,” she said. Sometimes, she said, a hand rub or a conversation or a glass of herbal tea can be as effective as an anti-anxiety drug.

Two months ago, Inouye, who is in her 50s, was hospitalized overnight, an experience that underscored the ordeal that older, vulnerable patients face. “I was woken out of the deepest sleep every two hours to check my blood pressure,” she said. In addition, alarms in her room began shrieking because a machine was malfunctioning.

“Medical care,” she added, “has evolved to be absolutely inhumane to older people.”

Hospital Elder Life Program (HELP)

In an effort to prevent or reduce delirium, Inouye created a program called HELP, short for Hospital Elder Life Program, currently operating in 200 hospitals around the country. While the core of the program remains the same, each hospital implements the program in different ways. Some enroll ICU patients, while others exclude them. A 2011 study found that HELP saved more than $7 million in one year at UPMC Shadyside Hospital in Pittsburgh, Pa.

At Maine Medical Center in Portland, HELP is a voluntary program open to patients older than 70 who have been in the hospital for 48 hours or less and do not show signs of delirium. ICU and psychiatric patients are excluded. The program relies on a cadre of 50 trained volunteers who visit patients up to three times daily for half-hour shifts, providing help and companionship and helping them stay oriented.

The CAM scale is built into the hospital’s electronic medical record, said geriatrician Heidi Wierman, who oversees the program and heads a medical team that sees patients regularly. HELP prevented delirium in 96 percent of patients seen last year, she said, adding that resistance by doctors and nurses to the 13-year-old program has been minimal because “we tied the incidence of falls to the prevention of delirium.”

Marylou Turpin, whose husband recently returned to their home outside Nashville, is planning to enroll him at Vanderbilt’s ICU Recovery Center as soon as possible. “I’m just hoping we can have some kind of life after this,” she said.

“A Surprising Side Effect of Hospital Stays.” Next Avenue. N.p., 05 Mar. 2017. Web. 09 Mar. 2017.

What to Do About Hearing Losshttps://starlightcaregivers.com/blog/what-to-do-about-hearing-loss/

Know what’s happening as your ears age.

Age-related loss is called presbycusis. It’s caused by deterioration in the functioning of the inner ear. That’s where the cochlea, a snail shell–shaped passageway, turns sound waves into electrical impulses. Those impulses travel up the auditory nerve, also called the cochlear nerve, to the brain, which is where hearing really happens. Sensory hair cells in the cochlea can atrophy with age. A core membrane inside the cochlea called the organ of Corti can also stiffen and become less sensitive.

However, it’s hard to say in most people whether age is the only cause of their hearing loss. The cochlea’s hair cells can also be damaged by exposure to noise. A lifetime of being around anything from lawn mowers to loud music can destroy the cells, which the body does not regenerate. In most middle-aged and older people, hearing loss is probably due to both noise exposure and age.

 

Cut back on noise to keep the hearing you have.

Repeated or prolonged exposure to anything over 85 decibels will harm your inner ear. Even city traffic can generate that level of noise.

Your hair dryer or lawn mower might register at about 90 decibels. A power drill can put out 100 decibels and start to do damage after only 15 minutes. Music turned up and played through earphones can easily reach 105 decibels.

Turn down the volume or move away from loud sounds like sirens when you can. Cover your ears with your hands temporarily or wear ear protection.

Sudden loud noises at close range can cause hearing loss that’s immediate, but most damage caused by noise happens gradually. You won’t notice the effects until they’ve accumulated over time and hearing loss starts to interfere with your conversations and your ability to enjoy the things you want to do.

Choose ear protection that works for you.

The best kind of protection is the kind you’ll use.

Most types of hearing protection are not very expensive. A set of earmuffs might cost you $15 to $20. Earplugs cost $1 to $2 a pair or much less if you buy disposable foam plugs in a bulk package. You can find protection for your ears at home improvement, sporting goods, discount and drug stores or online. Find more about the pros and cons of different types of protection in the list below.

Follow the instructions for whatever protection you choose. When people don’t get good protection from earplugs or earmuffs, it’s often because they don’t insert or wear the devices correctly. There are tips for making even simple foam earplugs work their best.

Hearing protection devices are labeled with a number that represents the level of protection they’ll give. It’s called a noise reduction rating, or NRR, and it can be as high as 33 decibels. NRRs are required by law and they’re determined through laboratory testing by the American National Standards Institute.

But you should know that the usefulness of noise reduction ratings is limited. For one thing, the numbers are a composite of test results, so they can never accurately reflect what will happen with your unique ear anatomy and circumstances. Also, the results are achieved under ideal conditions, where a professional made sure that test subjects were perfectly fitted with the earplugs or other devices being tested and the sounds were consistent from test to test. In actual usage, the variables are much less controlled. As a result, the NRR is only an indicator of potential protection levels, not a measure of actual protection.

In fact, industrial safety professionals use formulas that dramatically discount NRRs to estimate how much real protection their workers are getting. Using one common formula, an NRR of 27 decibels on the package becomes an estimated 10 decibels of real protection in a worker’s ear. That’s still significant protection, but it shows that you can’t take the ratings at face value.

Here are common types of ear protection and advantages and disadvantages for you to consider:

Expandable Foam Earplugs
Made of memory-type foam. You roll them into a narrow cylinder, insert into your ear canal and wait 20 to 30 seconds for the foam to expand and fit itself to your ear.
++ Inexpensive and widely available in bulk for around 10 cents a pair. Corded versions that you keep around your neck run about 20 cents a pair.
–– In an environment where your hands are dirty, it’s hard to remove and reinsert the plugs as needed.

Non-Custom Molded Earplugs
Firmer plugs of silicone or similar material pre-molded to small, medium and large sizes or to a more generic one-size-fits-most.
++ Still inexpensive, around $1 per pair and up. Washable and reusable.
–– You might need a different size for each ear and will need to experiment to find that out. Getting a good, effective fit can be difficult.

Custom-Molded Earplugs
Also made from silicone or similar material, but custom fitted to your ear. The earplugs are made using a plastic mold that is cast from your ear. You can order custom earplugs online or buy them from an audiologist.
++ Good for people with hard-to-fit ears.
–– If you get professionally made custom plugs, you’ll need an audiologist to make a cast of your ears. The cost ranges widely, but can be $50 or more per ear. Custom earplugs themselves generally cost $100 or more for a pair. If you decide to make your own do-it-yourself custom earplugs from a kit, you can get by for under $50 total but your results might not be as good as what a professional can achieve.

Canal Caps
These cover the opening of the ear canal, but aren’t inserted into the canal. They’re on a metal or plastic band that you wear as you would headphones.
++ Easy to use and to put on and take off repeatedly. You can keep the band handy around your neck. Relatively inexpensive at roughly $5 and up.
–– You might find the pressure from the headband uncomfortable.

Earmuffs
Because they enclose the whole ear, earmuffs can be some of the best protection if they fit you well. Prices range widely, starting at $15 to $20. Many good options exist at that low end of the range.
++ Easy to put on and take off. Some have features to help you hear speech, listen to music, etc.
–– People sometimes find them too heavy, too warm or don’t like the feeling of pressure on their head. If you have a beard or wear glasses, it can be hard to get a good snug fit and you’ll lose some protection.

Use medications with caution; some can harm your ears.

Some prescription and over-the-counter drugs are ototoxic, meaning they have the potential to damage the inner ear. They can cause hearing loss, tinnitus (commonly known as ringing in the ears) and balance problems.

For many people, the risk of hearing loss from medications is low, but there are situations where the risk is elevated:
• you have a personal or family history of hearing loss, tinnitus or dizziness
• your kidney function is diminished (most ototoxic drugs are cleared from the body by the kidneys)
• you take more than the recommended or prescribed dosage
• you take more than one ototoxic medication
• you take a medication that is especially ototoxic, such as certain chemotherapy agents and antibiotics

There are about 130 drugs recognized as ototoxic, including some that are obsolete or rarely prescribed anymore. Here are a few of the more commonly used medications that are linked to hearing loss.

Salicylates
Includes aspirin and the ingredient methyl salicylate, which is found in many creams and ointments used for sore muscles and back pain or joint pain

Aminoglycoside Antibiotics
Examples are streptomycin, gentamicin and neomycin

Atineoplastics
A family of drugs used for chemotherapy, including cisplatin and carboplatin

Loop Diuretics
These include furosemide, which goes by the brand name Lasix

One sign that medication is affecting your inner ear is the onset of tinnitus, or ringing sounds. If you suddenly have this problem or you had it earlier but now it’s worse, let your doctor know. Another sign you might experience is a feeling of pressure or fullness in your ears. If you do suffer drug-induced hearing loss, in most cases it will reverse itself when you stop taking the drug.

Don’t stop taking a prescribed medication on your own, however. Even if a treatment carries risks for your ears, it might be vital to your health in other ways. Instead, talk with your doctor about protecting your ears and about any effects that you’ve noticed.

Not everyone winds up with inner ear damage from an ototoxic medication. The effects of a drug will vary from person to person, and with the dosage and length of use.

To be proactive about your hearing, ask about potential side effects when anyone prescribes medication for you, including effects on your ears. Do the same for the over-the-counter remedies you use; a pharmacist can answer your questions about OTC products. Be sure that when you ask questions you also give accurate information about all of the medications you currently use and how much you take, including OTC items.

Using alternative treatments, taking lower doses, or avoiding taking multiple ototoxic medications at once can reduce the chance that your ears will be harmed.

If you need to take a medication that carries a significant risk of hearing loss, ask for a baseline hearing test before you start treatment so you and your doctor can monitor the effects.

Shed extra pounds and stay fit.
This advice might surprise you when it comes to hearing loss, but your overall health does make a difference. Research shows a correlation between diabetes and hearing loss. Studies have also found a link between hearing loss and high blood pressure. Being overweight increases your risk for both of those chronic diseases.

More research is needed to understand exactly how diabetes and high blood pressure are a factor in hearing loss. What is known is that both conditions damage the vascular system. So one possible explanation researchers are looking at is that these diseases damage the tiny blood vessels that nourish and sustain the inner ear.

Another tip: Stop smoking, if you do, and avoid exposure to secondhand smoke. Both have been linked to a higher likelihood of hearing loss as you age.

I think I’m already losing my hearing, how can I tell for sure?

If you’ve noticed that you have trouble hearing or if people close to you say you do, that’s a good indicator that you have a problem. But it doesn’t tell you anything about the cause or the extent of your hearing loss, and it doesn’t move you closer to a solution.

The only way to really know what’s going on with your hearing is to be examined and tested.

Medical doctors are the only ones qualified to do a medical exam. Sometimes they’ll do a preliminary hearing assessment, too, but usually they’ll refer you to an audiologist for a more thorough assessment. Audiologists have extensive training and professional certification but no medical degree.

Hearing loss is caused by more than just age or exposure to noise. A few other causes are infections, medications, head injuries, strokes and tumors. Even a buildup of earwax (the medical term is cerumen) can cause significant loss. To get the right treatment, you need to know the reason for your hearing loss.

If you think you might have hearing loss, it’s a mistake to ignore it or dismiss it as a normal part of aging. Left untreated, it can lead to social isolation and strained relationships. Research is also finding an association between hearing loss and dementia, hearing loss and depression and hearing loss and reduced income.

Many people with age-related loss start to notice it in their 50s. High frequencies are typically the first to drop out. So the high-pitched voices of children might be harder to hear. The same is true for the small differences in sound that help us hear consonants, distinguishing an “f” from a “v” or an “s” from a “th.”

You might also notice that it’s harder to catch someone’s words when you have to do it against a backdrop of other noise, as in a restaurant.

Maybe you fake your way through conversations because you don’t want to keep asking people to repeat themselves. Or you feel stressed from always straining to hear. Or you find that misunderstandings are making you irritable and causing quarrels at home.

Don’t wait for your doctor to bring up the subject, you’ll need to do that.

You might expect your primary care doctor to notice if you have hearing loss and talk with you about it. That’s unlikely. Your contact with your doctor is fairly brief, and under current best practices in health care infants are routinely screened for hearing loss, but adults are not.

So you need to bring up the subject. Your primary care doctor can screen you to identify likely hearing loss. Screening means asking you questions and maybe doing preliminary tests of your hearing. A primary care doctor can also treat some of the health problems that cause hearing loss.

But to know the extent and type of hearing loss that you have and to get treatment for certain causes of hearing loss, you’ll need to see specialists, usually an ear, nose and throat doctor and an audiologist.

Be aware there are serious risks with hearing loss.

Get treatment. If you’ve been putting it off, you’re not alone. Most people with hearing loss wait seven to 10 years before they get help, typically in the form of hearing aids.

But waiting comes with a cost. Age-related hearing loss is progressive, so it will get worse over time. You’ll have an increasing risk of social isolation and other physical, emotional, and financial problems associated with hearing loss.

Risks to Your Health
Hearing loss is associated with other serious health problems: depression, cognitive impairment and risk of falling. Whether and how hearing loss directly causes these problems is still being investigated, but they go hand in hand with hearing loss for many people.

Risks to Your Relationships
There’s a strain on your quality of life and your relationships when poor hearing creates misunderstandings. If you avoid social situations because you can’t hear, it can lead to resentment from others. Opting not to get treatment also sends a hurtful signal to the people close to you, namely that you don’t care enough to want to hear them.

Risks to Your Finances
A 2013 study looked at data on more than 900,000 people who had been diagnosed with hearing loss and found that they were more likely to be unemployed or underemployed and that they earned, on average, 25 percent less than people without hearing loss. So far, research only shows an association between these things, not a causal relationship. But it’s not hard to imagine the ways that unrecognized, untreated hearing loss could affect your relationships and performance at work.

Risks to Your Safety
Think of all the warning sounds you rely on: smoke and carbon monoxide detectors, weather alerts, noises around the house, an oncoming car when you’re on foot or a bike. If you’re driving, you need to hear approaching sirens, horns, and other cues. And you cause confusion for other drivers when you forget to turn off a turn signal that you can’t hear.

Take steps on your own until you can get professional help.

Notice the situations that are the most challenging for you and make adjustments to help yourself succeed in those settings. This will be easier if you let people know about your hearing difficulties. (By the way, these same tips can help if you’re a new user of hearing aids.)

• Ask coworkers, friends and family to get your attention before they start talking. They can do this by stepping into your field of vision and making eye contact or with a gentle tap on the shoulder.

• Position yourself where you can see the person talking to you. Avoid conversing with someone when they’re standing behind you, have their back to you, or have their face in darkness. Ask family members not to start a conversation with you when they’re in another room. In meetings at work, try to sit directly across from the person who’s making a presentation.

• Focus on the conversation at hand. Looking at your phone or working on another task makes it impossible to have a good conversation, even when you can hear perfectly.

• Ask people not to raise their voices and to rephrase instead of repeat. Shouting tends to distort sounds. If a particular combination of words is giving you trouble, different wording might be easier.

• Tell people specifically what you need help with. Summarize back to them what you did hear and ask them to fill in just the piece of information you missed. Ask them to move their hands away from their mouths or to slow down if that’s what would help.

• Mirror back to people what you think you heard. If you’re not sure you understood, repeat what you think you heard and ask for confirmation.

• Remove background noise when you can. Turn the TV or radio down or off when you want to talk with someone. Step over to a less noisy spot at a party. Choose quieter restaurants or go at less busy times.

• Use the induction loop or FM assertive listening systems provided at public events. Some theaters, concert halls, meeting rooms and places of worship have listening systems available for you to use. They transmit the speaker or performer’s voice directly to a small receiver and set of headphones or earbuds that you wear.

Use personal tech devices for now.

You can get hearing help from tech devices without getting hearing aids. Start by looking into the ways you can use your smart phone.

There are phone apps that amplify sound. You can use them alone, relying on your phone’s built-in microphone to pick up sound and using a set of earbuds to deliver it to your ears. Or you can pair an app with a plug-in directional microphone, which might do a better job of pulling in sound from a person seated across the table from you. That kind of set-up could be enough to help you in situations like restaurants or meetings until the day when you’re ready and able to get hearing aids.

The array of apps available is always changing along with the hardware they run on, and this guide doesn’t attempt to list apps or review them. But you can easily start learning about them with a search such as “apps for hearing loss” or “apps that amplify sound” on Google or another search engine, or by searching for “hearing loss” within an app store.

Other apps can help in other ways, for example letting you stream sound from a Bluetooth enabled device, like your smart TV, directly into your earbuds.

Aside from apps for your phone, another worthwhile search is for “assistive devices” or “assistive technology” for hearing loss. That can include devices such as pocket-sized amplifiers that you wear with a set of earbuds or headphones, but also things like smoke detectors, weather radios and doorbells equipped with flashing lights for those who don’t hear well.

Finally, a rapidly growing category of devices in recent years are small amplifiers that look like hearing aids. They’re called PSAPs, for personal sound amplification products. Because they are not required to meet Food and Drug Administration standards like hearing aids are, they can’t be called hearing aids. And because they’re unregulated, their quality and performance is all over the map.

However, PSAPs are gaining credibility and some perform nearly as well as hearing aids for a much lower price—hundreds instead of thousands of dollars. If you decide to shop for PSAPs, try to learn about the companies that make them and what kind of expertise has gone into the product. Soundhawk, for example, is a brand that has received favorable attention from audiologists for its performance, and that’s probably because the products are developed by engineers who formerly designed FDA-approved hearing aids.

As with other hearing questions, your doctor or audiologist can be a good resource when it comes to finding helpful non-hearing aid devices and technology.

Where do I go for help with my hearing loss?

Hearing loss is a health issue. It has a number of possible medical causes and significant health consequences. So at least initially, the kind of help you should get is health care from your family physician or an ear nose and throat doctor.

It’s possible to buy hearing aids — often at substantial savings — by ordering online or shopping at big-box discount retailers. So for cost reasons, you might ultimately choose to take a detour from the traditional path of getting hearing aids from a doctor’s or audiologist’s office and go to these alternative suppliers instead. But to start with, give yourself the best possible opportunity to uncover health issues and deal with them safely by seeing a doctor.

Cost is one of the biggest reasons people put off getting help with their hearing loss. A pair of hearing aids — which is what most people need — can easily cost several thousand dollars. But when you think about cost, be aware that factoring it into your decisions isn’t as simple as comparing the price of one hearing aid to another. Here are a couple of examples to illustrate why that’s true:

• If you buy hearing aids from a discounter, you could be choosing to stick with that provider for the life of the hearing aids, whether you’re satisfied with their service or not. Some sellers program their hearing aids using proprietary software — ask about this when you’re shopping. You could decide later that you want to work with a different audiologist to adjust your hearing aids and find that it isn’t possible. In other words, the discount price might come with an offsetting cost in terms of your satisfaction and your freedom to get the help you want.

• The traditional path to hearing aids — physicians and audiologists — isn’t always cost prohibitive. Many are sympathetic to the cost challenges their patients face and  try to help by offering basic low-cost hearing aids in their mix of options for patients or helping patients choose less-expensive non-hearing aid devices. Some audiologists will negotiate prices if asked and will occasionally work with manufacturers to get price breaks or free hearing aids for patients in need.

Know the difference between a doctor, an audiologist and a hearing aid dispenser.

Even though they overlap in the services they provide, there are big differences in the training they have and what they’re qualified to do.

Physicians
They have medical degrees and years of clinical training and experience. They are the best qualified to diagnose health problems, including problems with hearing. In particular, ENTs (ear, nose and throat doctors) have extensive knowledge of how to medically and surgically treat disorders of the head and neck, including the ears.

ENTs are also called otolaryngologists and some are called otologists. Otologists have the highest level of specialized training related to the ears—the same training as other ENTs, plus an additional two years of residency focused on ear health and disorders.

Audiologists
They do not have a medical degree and are not physicians. Instead, audiologists have a doctoral degree in the science of hearing and balance. They’ve had training in a clinical setting on the prevention, diagnosis and treatment of hearing and balance disorders, and they are licensed by their states. Audiologists can’t prescribe medication or do medical procedures to treat the ear, but they can do a thorough hearing assessment and provide hearing aids or other devices that are an effective match for your specific pattern of hearing loss.

A physician might refer you to an audiologist. Audiologists are sometimes located in the same medical office as a physician, others have a standalone practice or work in a retail setting. You can also skip seeing a doctor and go directly to an audiologist.

Hearing Aid Dispensers or Hearing Instrument Specialists
Under varying titles, dispensers are licensed by their states to do hearing assessments, but only for the purpose of fitting someone with hearing aids. They have no medical training and cannot do a medical or audiological exam.

Requirements vary from state to state, but the training for hearing aid dispensers is always far less rigorous than it is for audiologists. A dispenser might need, for example, a two-year college degree in any field and six months of job-specific training, then a passing score on the licensing exam.

Find out what your health insurance or Medicare will cover.

Conventional wisdom says you’re on your own when it comes to paying for hearing exams and hearing aids, but that’s not entirely true. While some health plans, including Medicare, give no coverage, some private insurance plans give at least limited help.

Medicare
It’s a surprise to many people to learn that Medicare — Part A and Part B, the original parts of the program — does not cover hearing aids. Likewise, the Medicare supplemental coverage known as Medigap insurance doesn’t cover hearing aids. Also not covered are hearing exams, unless they’re for diagnostic purposes beyond getting hearing aids.

However, if you have a Medicare Advantage plan (that’s Medicare Part C, an alternative to buying Part A, Part B and a Medigap supplement) you might be eligible for some coverage of your hearing aids and exam.

Private Insurance
This includes Medicare Advantage plans, plans offered by employers, and plans you buy on your own from insurance companies. The only way to know what a private insurance plan covers is to call your insurer and ask.

Some private insurers provide an allowance — it could be $500 or $1,500 or another amount — toward hearing aids. Often, it’s a dollar amount that you’re eligible to claim at a specified interval—every three years, say, or every five years. Get specific answers from your insurer by asking detailed questions:
• Does my plan cover a hearing exam for purposes of getting a hearing aid?
• Do I have to have a certain kind or degree of hearing loss to get coverage of my hearing aid?
• Do I have to buy a specific brand or type of hearing aid?
• Do I need to choose from a certain set of providers to qualify?
• Can my provider bill the insurance company, or will I need to pay the full cost up front and apply for reimbursement from the insurance company?

State regulations that apply to insurers often mandate coverage of hearing aids for children, but not nearly as often for adults. But a few states do require insurers to give at least partial coverage to adults. New Hampshire requires coverage of at least $1,500 per hearing aid every five years. In Rhode Island, it’s $700 per hearing aid every three years.

To comply with the age discrimination provisions of the Affordable Care Act, Connecticut told insurers they must provide the same coverage to adults as to children for all insurance policies issued or renewed starting January 1, 2016. The minimum coverage required is $1,000 every two years.

Arkansas requires insurers to offer hearing aid coverage to the state’s employers, who can decide to decline it. But if a company includes the coverage in its employee health plan, the minimum the insurer must provide is $1,400 per hearing aid every three years.

FSAs, HSAs and HRAs
Hearing aids and batteries are qualifying expenses, so you can use your FSA (Flexible Spending Account) and HSA (Health Savings Account) dollars to cover them, if you have such accounts.

The rules for HRAs (Health Reimbursement Accounts) are different, and they’re set by individual employers. If an HRA is the type of health fund your company provides, ask your human resources department whether hearing aids are a qualifying expense.

If you’re eligible for veterans’ benefits or medical assistance, those are other ways to get coverage of your costs.

Come ready for your hearing exam.

Come to your appointment ready to tell about any changes you’ve noticed in your hearing and your health. Bring along a list of all the medications you take and the dosages. Include over-the-counter items, vitamins and other supplements.

Be ready to tell about your work history, and especially any jobs or other experiences where you were exposed to prolonged noise or sudden loud noise, even if it was many years ago.

A doctor or audiologist will do a physical examination of your ears. Then you might have several types of tests, particularly if you’re visiting an audiologist. Here are two of the most common.

• Pure-Tone Test: You wear earphones and use verbal or hand signals to indicate when you’re able to hear the tone being played. It shows the lowest volume at which you can hear sounds of varying frequencies.

• Speech Tests: You’re asked to repeat or recognize words, sometimes against a backdrop of other sounds. This shows the lowest volume at which you’re able to decipher speech.

An in-depth hearing assessment takes as much as an hour and results in a chart called an audiogram that maps our your specific hearing ability and hearing loss.

Learn what “mild” or “severe” hearing loss means.

The degree of hearing loss someone has is defined by the decibel range of the loss. If very soft sounds, in the range of 16 to 25 decibels, are the ones you can’t hear, that’s defined as a slight loss. If much louder sounds, in the range of 71 to 90 decibels, are what you can’t hear, that’s called a severe loss.

What really matters for you, though, is not a number or a label but how much the loss impacts your life. Depending on what you do for a living or in your free time, even a slight loss can be a big detriment.

Here’s the full range of hearing loss, defined in decibel terms:
Normal   -10 to 15
Slight   16 to 25
Mild   26 to 40
Moderate   41 to 55
Moderately Severe   56 to 70
Severe   71 to 90
Profound   91 and above

You might have a different degree of hearing loss with high-pitched sounds than with low-pitched sounds. That’s a common attribute of age-related hearing loss.

The specific ability that you have across different frequencies of sound is called the configuration or pattern of your hearing loss. By mapping it on an audiogram and understanding your specific pattern, an audiologist or other professional can program and adjust your hearing aids to work best for your unique needs.

Don’t feel pressured to buy anything.

Being tested does not obligate you to buy hearing aids at the same place or to buy hearing aids at all.

What’s the smartest way to shop for hearing aids?

There is no single best way to go about it, but there are some key ideas to keep in mind:

Your needs are unique.
The hearing aid that someone else thinks is perfect could be a bad pick for you. Because your pattern of hearing loss, the way you spend your work and leisure time, your preferences and what you find comfortable all make up a unique set of needs, you should take published hearing aid reviews and the recommendations of family and friends with a big grain of salt.

For similar reasons, “more expensive” and “more features” don’t necessarily equal “better” for you.

Anyone selling you a hearing aid should be intensely interested in how you spend your days.
If a provider is just talking about products and features and not trying to get a picture of how you live and what you need, walk away. You’ll do better buying from someone who wants to make a good match between you and the technology.

Ask lots of questions.
The Hearing Loss Association of America, a nonprofit made up primarily of people with hearing loss, offers a checklist that you can take with you to audiology appointments and on hearing aid shopping trips.

In particular, be sure you understand and get in writing the purchase terms and return policy for any hearing aids you’re considering. There is generally a trial period of at least 30 days, but you’ll want your provider to put on paper the dates when the trial period starts and ends, and whether the clock stops if you bring the hearing aids in for an adjustment or repair during the trial period.

Know what to expect cost-wise.

The average retail price of a hearing aid is $2,363, according to an October 2015 report from the President’s Council of Advisors on Science and Technology, which has advocated ways to bring costs down. Most people need two hearing aids, so that doubles the expense, to an average of $4,726.

Those are averages, so prices range much lower and much higher. Your actual cost will depend on the specific hearing aids you buy and the features you want.

Reduce your cost.

If you’re starting to shop for hearing aids, you’re coming to the project at an interesting time. There’s already some downward pressure on prices as manufacturers and providers feel competitive pressure from personal electronics.

Adding to that, the Food and Drug Administration is showing new openness to the idea of over-the-counter hearing aids. Over-the-counter devices called personal sound amplification products (PSAPs) are completely unregulated. As a result, some work well while others are junk, not worth buying even at a bargain price. Official recognition and oversight of the category could make PSAPs a more reliable low-cost option for consumers.

Meanwhile, there are things you can do on your own to try to reduce the cost of your hearing aids:

Negotiate
Consumer Reports found an average markup of 117 percent from the wholesale to the retail price of hearing aids, which leaves room to negotiate. Most people aren’t used to bargaining back and forth on the price of medical devices, but in a survey of 1,100 hearing aid owners, Consumer Reports found that 15 percent of them had negotiated and among those, 40 percent had succeeded in getting a lower price.

Compare
If a provider carries only one brand of hearing aid, talk with at least one other provider who carries several brands. You want a chance to compare capabilities and prices.

Unbundle
Ask your provider to show you a list of itemized, or “unbundled,” costs. You want to see separate charges for the hearing aid and each of the support services your provider is proposing to you. Then you can make a clear comparison between hearing aids and providers, and decide which services you do and don’t want. Be aware that unbundling is relatively new and not all providers are willing to share itemized prices, so this could take some extra shopping around.

Buy from a Discounter or Directly from a Manufacturer
You could think of this as a variation on unbundling. You can often get a more attractive price on hearing aids themselves by ordering from a manufacturer online or going to a big-box retailer. It’s another way to separate the cost of the devices from the bundle of support services that come from an audiologist.

One caution, however: Sometimes the hearing aids that you buy this way cannot be adjusted by anyone other than the company you bought them from, so you could be closing off the option of working with the audiologist you’re interested in. Ask about this before you buy.

Typically, an audiologist’s services include things like follow-up visits to adjust your hearing aids based on your experience using them; coaching on how to use your aids effectively, and auditory rehab. Those can be valuable supports, since it often takes time, adjustments to the devices and practice to get the full benefit from hearing aids.

Understand the basics about hearing aids.

Compensation, Not Restoration
No hearing aid, no matter how advanced, can restore your hearing. Hearing aids will help you compensate for what you’ve lost by amplifying the sounds you want to hear; many also have technology to dampen background noises that interfere with hearing. But hearing aids can’t “correct” your hearing the way eyeglasses correct your vision. For most people, it takes a period of adjustment — to the devices and to their own habits — to use hearing aids effectively.

Technology
Almost all hearing aids are digital now, meaning they have digital processors that can enhance the sound picked up by the microphones before delivering it to your ear. Digital hearing aids are customizable and programmable in ways that old analog hearing aids were not. You might want different settings at the gym, in a coffee shop, at home, and at work, for example. Many features are now standard, including feedback management systems that quash the old problem of whistling.

Configuration
When shopping for hearing aids, it’s easy to feel overwhelmed by the huge array of features and different brand-related names for them. But there are still just a few basic types of hearing aids. They’re often referred to by their initials: completely in the canal (CIC), in the canal (ITC), in the ear (ITE), and behind the ear (BTE). Here’s a description of each of those configurations along with a few of the pluses and minuses you might experience:

Completely in the Canal (CIC)
++ Very small and the least visible type of aid. Because it sits deep in the ear, it doesn’t pick up wind noise.
–– Not much space to house features or increased amplification capacity, which you might need over time. Small battery size generally equates to shorter battery life. If you have dexterity problems, tiny CIC hearing aids and batteries can be difficult to handle. CICs, like all types of hearing aids that sit in the ear canal or outer ear, are vulnerable to wax plugging up the speaker.

In the Canal (ITC)
++ Similar to the benefits of a CIC, plus ITCs have a little more room for features and amplification capacity.
–– Again, similar to CIC hearing aids.

In the Ear (ITE)
++ Enough room for many features and strong amplification. Longer battery life and easier handling than with smaller types of hearing aids.
–– Easily visible, if that’s a concern. Like other types of hearing aids that sit in the ear or ear canal, ITEs can give you a “plugged up” feeling, especially if they don’t have good venting. The plugged sensation produces something called the occlusion effect, in which sounds that you produce—your own voice or chewing sounds—seem overly loud and have a strangely booming and interior quality, as if you were under water.

Behind the Ear (BTE) with Receiver in the Aid (RITA)
++ Easy to handle, clean, and change batteries. A housing that sits behind the ear contains all the essential parts of the hearing aid: microphone, processor, and receiver (speaker). Tubing that runs over the top of the ear connects the housing to an earpiece that sits in the ear canal and delivers the sound. BTE RITA aids have enough amplification capacity for anything from mild to severe hearing loss across a full range of frequencies. Earpieces can be non-custom open-fit pieces or custom-molded. The open fit is comfortable for many people and creates a more natural hearing experience if you have high-frequency hearing loss (very common in age-related hearing loss), because the partially open ear canal can keep processing low-frequency sounds on its own.
–– Traditional BTE RITA hearing aids are fairly visible, though some now come with smaller housings, tubing, and earpieces. BTE aids are susceptible to picking up wind noise because the microphone is outside the ear, which might be bothersome if you like outdoor activities.

Behind the Ear (BTE) with Receiver in the Canal (RITC); also called Receiver in the Ear (RITE) and Canal Receiver Technology (CRT)
++ Smaller than traditional BTE hearing aids because the receiver sits in the ear and doesn’t have to fit into the behind-the-ear housing. (As noted, however, even traditional BTE RITA hearing aids now come in smaller sizes.) A thin wire connects to the earpiece and is less visible than standard tubing. As with other BTE aids, the earpiece can be custom-molded or a non-custom open-fit piece.
–– In-the-canal receivers are susceptible to damage from sweat, wax and oil and might need to be replaced

Focus on just the features you’ll use.

Some of the most universally helpful features have become fairly standard and are built into most hearing aids. They include:
• a telecoil (Tcoil) to help you hear better on the phone and take advantage of induction loop, FM, and other hearing systems built into public places
• directional microphones that pick up more of the sound you want to focus on and help minimize background noise
• binaural processing, which means your two hearing aids will work together, more closely mimicking the way your ears work together
• direct audio input, which lets you send sound from your television or an MP3 player directly to your hearing aid, without the interference of ambient noise.

Increasingly, hearing aids have Bluetooth capabilities and connect wirelessly to your smart phone and other devices. Some have data logging and self-learning features so they learn and automatically adjust themselves to your preferences in different situations.

Expect challenges if you’re trying to do an apples to apples comparison of hearing aid features. There are many brand-specific names and variations. Ask providers to help you by giving you more generic names for these capabilities when they describe them to you.

Your own interests and preferences will help you recognize that some features aren’t useful to you. Save money by skipping them. Another savings opportunity is less obvious, and that is not to buy into the highest number of sound-processing channels available. Multiple channels allow for higher-definition sound. It’s akin to having a high-definition image on your TV screen. But beyond 10 or so channels, your ears can’t really perceive the difference in resolution. So paying more for a hearing aid because it boasts two dozen channels doesn’t make sense.

If you have a wish list of features, be aware that not every type of hearing aid can house every kind of feature. The smaller the hearing aid, the less room there is there is to build in extras. Audiologists and manufacturers will work with you to suggest alternatives—either a different feature set or a slightly larger hearing aid—if what you ask for doesn’t fit. Sometimes the issue is your unique ear anatomy, if you’re getting a hearing aid that has custom-molded parts.

What if I can’t afford hearing aids?

You’re not alone. In fact, trouble affording hearing aids is such a common problem that a large network of support resources exists for you to tap into, from the hearing industry itself to nonprofits to local and federal programs.

It takes time to find help you qualify for, but there are a couple of shortcuts open to you. One is to use the links in the next few sections of this guide. Another is to ask your doctor or audiologist to recommend resources to you. Over time, they’ve probably helped other people who had cost questions and might be able to recommend programs that could work for you.

Find out if your state’s Medicaid program will help.

Medicaid is the federally funded and state-run health insurance program for people with low incomes, and it sometimes covers hearing aids. Because each state runs its own Medicaid program, the coverage and requirements differ from place to place.

Check on details of coverage by contacting your state’s Medicaid office. Benefits.gov includes a roster of state programs where you can look up your state and link to contact information.

Ask about help from the hearing industry.

Most manufacturers say they are willing to help people who need hearing aids but can’t afford them. Some do this on a case-by-case basis through referrals from physicians and audiologists.

Others have set up corporate foundations to do this work, such as the Starkey Hearing Foundation, Oticon Hearing Foundation and Miracle Ear Foundation. Some companies instead support nonprofits, such as the Hearing Charities of America.

Start by talking with your doctor or audiologist about help paying for hearing aids. They are probably familiar with resources in the industry and in your community. You can also try the links in the next section of this guide, which lead to nonprofit and community groups that help people get low- or no-cost hearing aids.

Look into nonprofits and state and community programs.

There are nonprofits and state or county agencies that provide help with hearing aids if you qualify for their programs. Here are some leads to get you started on your search:

Audient Alliance
National Hearing Aid Project
Better Hearing Institute
Hearing Loss Association of America
See also the nonprofit foundations formed by hearing industry organizations that are listed in the preceding section of this guide.

State Departments of Health, Human Services, Public Health
These state agencies can connect you with help offered through their offices and direct you to county-level medical assistance or human services contacts.

State Offices of Rehabilitation Services, Vocational Rehabilitation
If you are still working, your state’s rehabilitation office might be able to help you get hearing aids or lead you to other groups that can help.

State Assistive Technology Programs
These vary, but some offer low-interest loans to help with the purchase of hearing aids. They might also lend out recycled hearing aids or provide refurbished aids to those in need.

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Lewy Body Dementia

Lewy body dementia affects an estimated 1.4 million persons and their families in the US. And, it bears close resemblance to other commonly known diseases such as Alzheimer’s and Parkinson’s. Lewy body dementia or dementia with Lewy bodies is the second most common type of progressive dementia after Alzheimer’s disease accounting for up to 20 percent of dementia cases worldwide.

What is LBD?
While researching for Parkinson’s disease, a German doctor, Friederich H Lewy discovered abnormal protein deposits that disrupt the brain’s normal functioning. He found that these proteins that are found in the brain stem deplete the neurotransmitter dopamine causing Parkinsonian symptoms.

In LBD, abnormal proteins are seen to diffuse throughout the areas of the brain including the cerebral cortex. As the brain chemical acetylcholine is depleted, there is disruption of perception, thinking and behavior.

Lewy body dementia exists either in pure form, or in conjunction with other brain changes, including those typically seen in Alzheimer’s disease and Parkinson’s disease.

Symptoms
Though Lewy body dementia (LBD) is an umbrella for Alzheimer’s and Parkinson’s, earliest symptoms for these two differ although the underlying biological changes in the brain remain the same. Over a period of time, patients with both diagnoses develop similar cognitive, physical, sleep as well as behavioral symptoms.

Early diagnosis is vital for early treatment, which may help extend quality of life and independence from LBD.

People with Lewy body dementia may experience visual hallucinations and changes in alertness and attention. Other effects include Parkinson’s disease-like symptoms such as rigid muscles, slow movement and tremors.

Visual hallucinations are one of the first symptoms which often recur. Seeing shapes, animals or people that are not there, sound, smell or touch hallucinations are also possible. Slowed movement, rigid muscles, tremor, or a shuffling walk may occur.

Blood pressure, pulse, sweating and the digestive process are regulated by a part of the nervous system often affected by Lewy body dementia. Dizzy spells and bowel issues such as constipation are also noticed. Confusion, lack of attention, visual-spatial problems and memory loss which are symptoms similar to Alzheimer’s disease are signs of LBD.

Sleep behavior disorder, which can cause a person to act out dreams while asleep and rapid eye movement sleep behavior disorder are often noticed. Drowsiness, long periods of staring into space, prolonged naps during the day and disorganized speech are some other symptoms. Depression and loss of motivations are observed.

Causes
LBD is caused by abnormal buildup of proteins into masses known as Lewy bodies. This protein is associated with Parkinson’s disease and those with Lewy bodies in their brains have plaques and tangles which are signs of Alzheimer’s disease. Risk factors such as medical choices and lifestyle choices are known to increase a person’s chances of LBD. Few families seem to inherit genetic mutations, though rare.

Diagnosis
There is no single test that can diagnose Lewy body dementia. Instead, doctors diagnose LBD by ruling out other conditions that may cause similar signs and symptoms.
A doctor could conduct a short test for 10 minute duration to test memory, thinking skills, which can indicate dementia. Longer tests to identify LBD can take several hours. Blood tests can rule out physical problems that can affect brain function, B-12 deficiency or an underactive thyroid gland. Brain scans such as MRI, PET and CT may be used to identify a stroke or bleeding and to rule out the possibility of tumor. A sleep evaluation check for possible sleep behavior disorder and an automatic function test to look for signs of heart rate and blood pressure instability may be prescribed.

Neurological and physical examination can be used to test reflexes, strength, walking, muscle tone, eye movements, balance and sense of touch.

Lewy body dementia – complications
Lewy body dementia signs and symptoms can worsen over time and can lead to depression, severe dementia, aggressive behavior, worsening of Parkinsonian symptoms, increased risk of falling and injury besides death on an average of eight years after symptoms have begun.

Risks
Being male, older than sixty years of age and having a family member with LBD or Parkinson’s are some of the risk factors that have been identified for developing Lewy body dementia.

Treatment
There are few approved treatments for LBD. With drugs it is often problematic as different people respond differently to it. Often medication given for hallucinations can worsen movement. Drugs also have a negative effect on mental abilities. Hence, managing the symptoms without using drugs is imperative.
Social interaction, cognitive stimulation, structured routine and using practical strategies to live well with memory loss are some non-drug approaches to LBD.

Some drugs which are routinely prescribed for Alzheimer’s can improve a person’s mental abilities as well as the ability to perform day-to-day tasks. However, many other drugs are not currently licensed for use in LBD and hence many doctors are reluctant to prescribe them.
In case of hallucinations and delusions, it is better to try and convince them that they are not seeing anything and what they believe is untrue. Reassurance and support and trying to distract them can help.

Those with LBD should have their glasses and hearing aids checked properly as any problems in these can worsen matters. Misconceptions can be triggered by excess noise and reflective or patterned surfaces. In case hallucinations lead to physical harm, then drug treatments can be offered, though many of them have severe reactions such as moving with difficulty, becoming more confused, and inability to perform tasks or communicate and can cause death.
Music therapy, physical exercise and hand massage can also help. If behavior challenge is acute, then drug treatments may be offered and drugs for Alzheimer’s are also tried in the initial stages. If this fails, anti psychotics are finally offered.

Those suffering LBD often have restless sleep. Increasing physical exercise, regular bedtime and getting up on time and reducing daytime napping can help. If the bedroom is as quiet and comfortable as possible and alcohol, coffee and nicotine are not taken especially at bedtime, it can help. Removing sharp objects and putting a mattress alongside the bed in case the person falls or jumps out are some of the practical steps to be taken.
An occupational therapist or a physiotherapist can help those with movement problems so that these patients can move and stay independent. If the patients falls or is worried about falling, they may be referred to a falls prevention service. Strength balance exercises and medication review can help make the home safer. A language therapist can help if the person develops problems with speaking or swallowing.

Treatment can be challenging, as this is a multi system disease and requires comprehensive treatment. A team of physicians from different specialties collaborate to provide optimum treatment for each symptom without worsening other LBD symptoms.
Non medical treatment for LBD involves:

  • Physical exercises for cardiovascular strengthening and flexibility exercise and gait training
  • Speech therapy to help low voice volume and poor enunciation
  • Occupational therapy to maintain skills and promote function and independence
  • Individual and family psychotherapy to manage emotional and behavioral symptom

Preventing LBD
There are no therapies or behavioral changes identified at present that can prevent LBD. However, some strategies can help stave off memory problems in general. Eating a healthy balanced diet, exercising regularly, and social interaction, stimulating memory and reading and playing an instrument are some ways of keeping LBD at bay. Reducing stress, getting enough sleep can be beneficial.

Some tips for those living with LBD
It is better to adopt a proactive approach right away and reach out to family and friends for support to make lifestyle changes that can help manage the disease. Some tips on LBD management include:

  • Becoming informed, learning as much as possible about LBD and how it can affect a person specifically given the health history, age and lifestyle is important.
  • Reducing stress and anxiety – thereby reducing many symptoms of LBD
  • Relaxing with music therapy, meditations and deep breathing exercises
  • Treating depression and receiving treatment for depression
  • Avoiding isolation and reaching out to family and friends who can offer emotional support
  • Exercising and improving physical function and stress and boosting mood
  • Enjoying games and puzzles and playing cards and word games such as Scrabble or completing a crossword and Sudoku puzzles.

 

“Lewy Body Dementia.” TargetWoman Women Information Portal. N.p., n.d. Web. 24 Feb. 2017.

Coming Up With A Plan To Fight Memory Loss

Memory is such a vital part of our every day lives in every way that it can be catastrophic to suffer any impairment of it. If you feel that you are having a hard time remembering things that once came easily to you, read on for some excellent advice you can put to immediate use to help improve your memory.

If you find yourself having difficulty recalling information, take a deep breath and relax. Sometimes all you need is a bit more time to allow your memory to retrieve the information. Feeling pressed for time can result in stress that inhibits the recall process. Remember that the older you are, the longer it takes to retrieve information from the memory.

If you need to commit a set of facts to memory, try studying that information in many different environments. The reason for this is to dissociate the information with a specific location, and make it a more basic part of you. Think of it this way – when you change up the places where you learn things, it’s easier for the information to move from your short-term memory to your long-term one.

Keep your memory fresh by removing stress. When you are feeling stressed about something it can be harder to pull up memorized data. Find ways to relax yourself before you have to rely on your memory for a task. Meditate for a bit on relaxing thoughts that will allow your brain to process the information you need to access.

To help improve how quickly something is stored in your memory, take the time to bucket the information first. Act like an information architect and organize the information you are try to commit to memory based off of similarities. Once they are bucketed, attack them as a group. You will then find they are easier to memorize!

Use memorization techniques and drills to continually challenge your mind to retain more information. Using these techniques and drills, allows you to improve your memory, while also remembering vital information, like telephone numbers and definitions. The list of data you can use for these techniques is limitless and can also, help you in your daily activities.

When learning new information, try forming a visual image of it in your mind. When your brain is forced to come up with a picture to go along with the information, it has to analyze it more carefully that it otherwise would have. This attention to detail can help cement it in your mind. Not only that, but you can use the mental image that you formed to help you recall the information at a later date.

When you are trying to commit something to memory, it’s important to stay in the current moment as much as you possibly can. Try to avoid the urge to focus on the past or the future as you are learning. Make every effort to focus your attention on the material at hand, and you will retain it better.

Use mnemonic devices to help you remember things. Mnemonic devices are sets of clues that helps by associating things that are usually hard to remember with things that are easier to remember. An example is using an acronym, rhymes, visual images, or even associating a funny story to whatever you want to memorize.

As you have read in this article, there are many things you can do easily, quickly and with little or no money spent to exercise and improve your memory starting right now. Hopefully you have discovered some very valuable information here that will assist you in strengthening and sharpening your memory today!

Hardie, Jeremiah. “Coming Up With A Plan To Fight Memory Loss.” BareFuse. N.p., n.d. Web. 15 Feb. 2017.

The Alzheimer’s Reading Room: A Great Resource for Caregivers

If you have a loved one with dementia, my first suggestion would be to find the very best doctors possible. My second piece of advice would be to go to the Alzheimer’s Reading Room. It’s a free blog that focuses on Alzheimer’s disease and the art of Alzheimer’s caregiving.

The goal of the site is to educate and empower Alzheimer’s caregivers, their families and the entire Alzheimer’s community. This popular site, established in 2008, has more than 29,000 subscribers and reaches over 100,000 new visitors each month. It was ranked #1 by ‘Healthline’ five years in a row (2012 – 2016).

At its core the Alzheimer’s Reading Room is about helping members of the Alzheimer’s Community understand, cope, and communicate with persons living with Alzheimer’s and related dementias. It’s the nation’s largest blog on Alzheimer’s and the number one source of news about Alzheimer’s disease and caregiving.

This site offers advice on issues that are important to Alzheimer’s caregivers. It provides specific insight and solutions to problems they face each day – issues such as wandering, challenging behaviors, showering, toileting, driving, caregiver loneliness, treatments, medications, hospice and so many other problems that arise when caring for someone with Alzheimer’s or other dementias.

The Alzheimer’s Reading Room has 5,000 articles in its searchable database – many written by everyday caregivers. Others are provided by some of the world’s top scientists, clinicians, doctors, nurses and other professionals in the field who share their advice, knowledge and expertise.

The site was established by Bob DeMarco, a former Wall Street professional from Delray Beach, Florida, who was the full-time caregiver to his mother, Dotty, for eight years. He started the site to keep track of the thousands of articles and numerous books he was reading about Alzheimer’s disease to help him understand how to care for his mother. DeMarco himself also contributes a prodigious number of articles to the site, based on both his personal experience caring for Dotty and his own research.

“Soon after I started the blog,” states DeMarco, “I began to receive emails from Alzheimer’s caregivers from all over the world. At first an email here and there. Then thousands began pouring in. I soon realized that these caregivers were often thrust into their roles with little or no experience or training. As a result, they are often overwhelmed and suffer from feelings of helplessness. At its core, the site is about providing advice and insight to help remedy that problem.”

As DeMarco gained experience caring for his mother, he decided to start writing more about the success he was having in fighting the disease. “I learned that the more I let her do, the more she could do,” he says. “I learned that there were solutions to some of the problems posed by the disease.”

The Alzheimer’s Reading Room encourages every reader to comment and share his or her experiences. Readers learn from each other. But most importantly they learn that they are not alone
.
Articles published on the site receive numerous comments, sometimes up to 50 or more each, from the site’s large, loyal readership. In addition, articles from the site have been syndicated on Reuters Fox News, the Wall Street Journal, Time Warner, the Chicago Sun Times, the Houston Chronicle, and Livestrong – just to name a few.

DeMarco says the most rewarding aspect of running the Alzheimer’s Reading Room is when people email him that they’ve had a breakthrough in their caregiving attitudes and skills as a result of reading articles posted there.

The Alzheimer’s Reading Room shows what one person with a mission to help others can accomplish through research, personal experience, drive and dedication. DeMarco is a remarkable man who deserves the highest praise from every person who is loving and caring for a person with Alzheimer’s disease.

Marie Marley is the author of the award-winning, uplifting ‘Come Back Early Today: A Memoir of Love, Alzheimer’s, and Joy‘ and co-author (with Daniel C. Potts, MD, FAAN) of ‘Finding Joy in Alzheimer’s: New Hope for Caregivers.’ Her website (ComeBackEarlyToday.com) contains a wealth of information for Alzheimer’s caregivers.

Marley, Marie. “The Alzheimer’s Reading Room: A Great Resource for Caregivers.” The Huffington Post. TheHuffingtonPost.com, 21 Jan. 2017. Web. 09 Feb. 2017.

The Top Drugs for Older Adults to Avoid

You fill a prescription, a medication you’ve relied on before. A few days later, you experience a troubling side effect. You read online that no one your age should take this medication.

What happened?

Drug Side Effects and Older Adults

Two pharmacists say the aging process is to blame, and they reveal here the names of medications on their “black list” that older adults may want to avoid.

“Prescribing medications for people 65 and older can be more challenging, because some drugs can be more toxic or cause more side effects than when you were younger,” says Kirby Lee, a pharmacist and associate professor of clinical pharmacy at the University of California at San Francisco. “As your body ages, it absorbs medications differently. They can be metabolized differently by your liver and excreted differently by your kidneys, so you may be more sensitive to some medications.”

Nobody should have to live with a problem that is the result of taking a drug.

— Chad Worz, American Society of Consultant Pharmacists

That’s what happened to me.

Antibiotic Causes Painful Achilles

One recent weekend, I experienced a relapse while on doxycycline, an antibiotic prescribed for a bacterial sinus infection. The doctor on call I spoke with prescribed a stronger antibiotic for me, levofloxacin (Levaquin), one I’d taken successfully a decade ago.

After four days on the new drug, a throbbing Achilles tendon awakened me in the wee hours. I hobbled to the computer and learned the drug is not recommended for people 60 and older. I am 68. Later that morning, I called my internist, who advised me to stop taking it and start helping the tendon to heal — no easy task, and one with no quick fix.

Our aging bodies are not the only challenge. Only about 7,500 physicians in the U.S. specialize in the care of older adults, according to the American Geriatrics Society. With 46 million Americans age 65 and older today, that works out to about one geriatrician per 6,100 patients.

That’s obviously not enough geriatricians now — and by 2060, some 98 million Americans will be 65 and over.

“Until you enter a nursing home or assisted living, you might not see a specialist good at treating older adults, because we don’t yet have a health care system designed to take care of older adults,” says Chad Worz. He is a consultant pharmacist with Medication Managers in Cincinnati and president-elect of the American Society of Consultant Pharmacists (ASCP).

More Assistance from Pharmacists

Based in Alexandria, Va., and with more than 9,000 members, ASCP is said to be the only international professional society devoted to “optimal medication management and improved health outcomes” for older people. Consultant pharmacists work in adult day centers, assisted living facilities, community pharmacies, hospice programs, home care programs, mental health facilities, nursing homes, pharmaceutical companies, physicians’ offices and rehab centers.

On the job, ASCP members evaluate individuals’ medication lists to determine which drugs can be dropped. “In that regard, I am an anti-pharmacist,” Worz says, laughing.

“Every day I look at the records for people on 14 or 15 medications and try to get them to eight or nine. Instead of stopping a drug that causes a certain side effect, doctors often prescribe a drug to fix the side effect,” he says. “I don’t blame the doctors. I blame the system, which does not incentivize patients to have sit-down conversations with doctors or pharmacists about medications.”

Medications You May Want to Avoid

Here are six classes of medications considered especially problematic for older adults:

  1. Benzodiazepines  Prescribed — often over-prescribed — for anxiety and sleep disorders, this class of drugs includes diazepam (Valium), lorazepam (Ativan), alpraxolam (Xanax) and chlordiazepoxide (Librium). The medications can cause confusion and greatly increase the risk of falling.
  2. Non-Benzodiazepines  Prescribed for insomnia, Zolpidem (Ambien), zaleplon (Sonata) and eszopiclone (Lunesta) are highly addictive and also can cause bizarre sleep behaviors, including sleepwalking.
  3. Anticholinergics  Diphenhydramine (Benadryl), acetaminophen with diphenhydramine (Tylenol PM) and some muscle relaxants that contain diphenhydramine (an antihistamine) can cause confusion, constipation, dry mouth, blurry vision or urine retention in older adults. Cumulative exposure to these drugs can lead to dementia.
  4. Nonsteroidal anti-inflammatory drugs  Ibuprofen (Motrin), naproxen (Aleve), aspirin and other drugs in this class are “tough on kidneys,” Lee says, and increase the possibility of stomach bleeds. They are not recommended for long-term use. For management of arthritis pain, Lee recommends acetaminophen (Tylenol), physical therapy, acupuncture, aquatic therapy or acupressure.
  5. Antipsychotics  This class of drugs is useful to treat significant psychosis or serious mental health conditions, but is too often prescribed for mild agitation, anxiety or depression. Lee suggests taking the lowest effective dose for the shortest term possible. “People get started on these and then they don’t top,” he says.
  6. Old drugs   Though barbiturates are rarely prescribed any longer, these sedatives are still available and are highly addictive both physically and psychologically.

Worz notes that blood pressure medications also can cause fatigue or lead to falls.

And he suggests being cautious with the dosage for ranitidine (Zantac), often taken for heartburn. “Taking 150mg twice daily is a normal dose, but in an older person, kidney function may no longer be sufficient to eliminate the drug quickly.” That can lead to possible cognitive issues that can look like dementia.

“Nobody should have to live with a problem that is the result of taking a drug,” Worz adds. “Your doctor or pharmacist usually can find better drugs with fewer side effects to help you.”

For information about other medications that may cause problems for older adults, Worz recommends the “Beers List,” named for the physician who first published the list, which is updated periodically by the American Geriatrics Society.

Why That List of Side Effects Is Important

And what about that antibiotic that caused me so much trouble?

Worz notes that other antibiotics in the same class have been pulled from the market after causing changes in the nervous system, hallucinations and other problems. “Still, it’s impossible to predict exactly how a medication may affect someone, and even a lengthy list of potential side effects may not be specific enough,” he adds.

I can’t be angry with the physician who neglected to take my age into consideration, because I share in the blame.

When I picked up the prescription, I waved off a consultation with the pharmacist, saying I’d taken this antibiotic before. Then, after reading just a sentence or two of the lengthy list provided to me of possible side effects, I tossed the paper into a recycling bin.

That is one of two typical responses, Lee says. “I’ve seen people blow it off — or get so scared they won’t take anything. The information on side effects is based on factual data and written for legal purposes, but it will help you sort out common and less-common side effects, learn what side effects are considered severe and be aware of contraindications.”

Once you read the material, Lee adds, you can weigh the side effects against the benefits of taking the medication. “You also can ask the pharmacist or your doctor what taking the medication might mean for you, and what alternatives there are,” he notes.

Don’t Keep Secrets from Your Doctor

Lee stresses the importance of providing your doctor with an updated list of everything you take, including prescribed medications, over-the-counter drugs and dietary supplements. Also, alert your doctor about any drug allergies or bad reactions to medications you’ve had.

As always, talk to your doctor before you stop taking any prescribed medications. And, remember: no one bit of advice fits all.

“Keep in mind that complications from medications are general trends due to body changes by the time you are 65 or 70,” Lee says. “Some people are likely to experience these complications, but others may have a body that functions like that of a 35-year-old. Always look at your metrics and go from there.”

Contributing Writer: Patricia Corrigan

Source:  Next Avenue

 

Delirium: A Surprising Side Effect of Hospital Stays

Often misdiagnosed as dementia, it can cause hallucinations and delusions

Kaiser Health News

(This article originally appeared on KaiserHealthNews.org.)

When B. Paul Turpin was admitted to a Tennessee hospital in January last year, the biggest concern was whether the 69-year-old endocrinologist would survive. But as he battled a life-threatening infection, Turpin developed terrifying hallucinations, including one in which he was performing on a stage soaked with blood. Doctors tried to quell his delusions with increasingly large doses of sedatives, which only made him more disoriented.

Nearly five months later, Turpin’s infection has been routed, but his life is upended. Delirious and too weak to go home after his hospital discharge, he spent months in a rehab center, where he fell twice, once hitting his head. Until recently he did not remember where he lived and believed he had been in a car wreck. “I tell him it’s more like a train wreck,” said his wife, Marylou Turpin.

“They kept telling me in the hospital, ‘Everybody does this,’ and that his confusion would disappear,” she said. Instead, her once astute husband has had great difficulty “getting past the scramble.”

Turpin’s experience illustrates the consequences of delirium, a sudden disruption of consciousness and cognition marked by vivid hallucinations, delusions and an inability to focus that affects 7 million hospitalized Americans annually. The disorder can occur at any age — it has been seen in preschoolers — but disproportionately affects people older than 65 and is often misdiagnosed as dementia.

While delirium and dementia can coexist, they are distinctly different illnesses. Dementia develops gradually and worsens progressively, while delirium occurs suddenly and typically fluctuates during the course of a day. Some patients with delirium are agitated and combative, while others are lethargic and inattentive.

Delirium Triggers

Patients treated in intensive care units who are heavily sedated and on ventilators are particularly likely to become delirious; some studies place the rate as high as 85 percent. But the condition is common among patients recovering from surgery and in those with something as easily treated as a urinary tract infection. Regardless of its cause, delirium can persist for months after discharge.

They kept telling me in the hospital, ‘Everybody does this,’ and that his [my husband’s] confusion would disappear.

— Marylou Turpin

Federal health authorities, who are seeking ways to reduce hospital-acquired complications, are pondering what actions to take to reduce the incidence of delirium, which is not among the complications for which Medicare withholds payment or for which it penalizes hospitals. Delirium is estimated to cost more than $143 billion annually, mostly in longer hospital stays and follow-up care in nursing homes.

“Delirium is very underrecognized and underdiagnosed,” said geriatrician Sharon Inouye, a professor of medicine at Harvard Medical School. As a young doctor in the 1980s, Inouye pioneered efforts to diagnose and prevent the condition, which was then called “ICU psychosis.” Its underlying physiological cause remains a mystery.

“Physicians and nurses often don’t know about it,” added Inouye, who directs the Aging Brain Center at Hebrew SeniorLife, a Harvard affiliate that provides elder care and conducts gerontology research. Preventing delirium is crucial, she said, because “there still aren’t good treatments for it once it occurs.”

Researchers estimate that about 40 percent of delirium cases are preventable. Many cases are triggered by the care patients receive — especially large doses of anti-anxiety drugs and narcotics to which the elderly are sensitive — or the environments of hospitals themselves: busy, noisy, brightly lit places where sleep is constantly disrupted and staff changes frequently.

Recent studies have linked delirium to longer hospital stays: 21 days for delirium patients compared with nine days for patients who don’t develop the condition. Other research has linked delirium to a greater risk of falls, an increased probability of developing dementia and an accelerated death rate.

“The biggest misconceptions are that delirium is inevitable and that it doesn’t matter,” said E. Wesley Ely, a professor of medicine at Vanderbilt University School of Medicine who founded its ICU Delirium and Cognitive Impairment Study Group.

Long-Term Effects

In 2013, Ely and his colleagues published a study documenting delirium’s long-term cognitive toll. A year after discharge, 80 percent of 821 ICU patients ages 18 to 99 scored lower on cognitive tests than their age and education would have predicted, while nearly two-thirds had scores similar to patients with traumatic brain injury or mild Alzheimer’s disease. Only 6 percent were cognitively impaired before their hospitalization.

Cognitive and memory problems are not the only effects. Symptoms of post-traumatic stress disorder are also common in people who develop delirium. A recent meta-analysis by Johns Hopkins researchers found that 1 in 4 discharged ICU patients displayed PTSD symptoms, a rate similar to that of combat veterans or rape victims.

David Jones, a 37-year-old legal analyst in Chicago, Ill., said that he was entirely unprepared for persistent cognitive and psychological problems that followed the delirium that began during his six-week hospitalization for a life-threatening pancreatic disorder in 2012. Terrifying flashbacks, a hallmark of PTSD, were the worst. “They discharged me and didn’t tell me about this at all,” said Jones, whose many hallucinations included being burned alive.

Jones’s ordeal is typical, said psychologist James C. Jackson of Vanderbilt’s ICU Recovery Center, a multidisciplinary program that treats patients after discharge.

Vivid Flashbacks

“They go home and don’t have the language to describe what has happened to them,” said Jackson, adding that such incidents are often mistaken for psychosis or dementia. “Some patients have very striking delusional memories that are very clear distortions of what happened: patients who were catheterized who think they were sexually assaulted and patients undergoing MRIs convinced that they were fed into a giant oven.”

Some hospitals are moving to prevent delirium through a more careful use of medications, particularly tranquilizers used to treat anxiety called benzodiazepines, which are known to trigger or exacerbate the problem. Others are trying to wean ICU patients off breathing machines sooner, to limit the use of restraints and to get patients out of bed and moving more quickly. Still others are trying to soften the environment by shutting off lights in patients’ rooms at night, installing large clocks and minimizing noisy alarms.

A recent meta-analysis led by Harvard researchers found that a variety of non-drug interventions — which included making sure patients’ sleep-wake cycles were preserved, that they had their eyeglasses and hearing aids and that were not dehydrated — reduced delirium by 53 percent. These simple fixes had an added benefit: They cut the rate of falls among hospitalized patients by 62 percent.

Inouye and other experts say that encouraging hospitals to recognize and treat delirium is paramount. They have vehemently argued that federal officials should not classify delirium as a “never” event for which Medicare payment will be denied, fearing that would only drive the problem further underground. (“Never” events include severe bedsores.)

Delirium “is not like pneumonia or a fracture” and lacks an obvious physical indicator, said Malaz Boustani, an associate professor of medicine at Indiana University. He proposes that Medicare create a bundle payment that would pay for treatment up to six months after delirium is detected.

Creating effective incentives is essential, said Ryan Greysen, an assistant professor of medicine at the University of California at San Francisco. Delirium, he said, suffers from a “pernicious know-do gap” — a disparity between knowledge and practice. Many proven interventions, he said, do not seem sufficiently medical. “There’s no gene therapy, no new drug,” Greysen said. “I think we need to put this in the realm of hospital protocol, which conveys the message that preventing and treating delirium is just as important as giving people their meds on time.”

Growing Awareness

Awareness that delirium is a significant problem, not a transitory complication, is recent, an outgrowth of growing expertise in the relatively new field of critical care medicine. The graying of the baby boom generation, whose oldest members are turning 69, is fueling interest in geriatrics. And many boomers are encountering delirium as they help care for their parents who are in their 80s and older.

“In the early 1990s, we thought it was a benevolent thing to protect people from their memories of having a tube down their throat, of being tied down, by using large doses of drugs to paralyze and deeply sedate patients,” Ely noted. “But by the late 1990s, I was just getting creamed by families and patients who told me, ‘I can’t balance my checkbook, I can’t find my car in the parking lot and I just got fired from my job.’ Their brains didn’t work anymore.”

Delirium “is now taught or at least mentioned in every medical and nursing school in the country. That’s a huge change from a decade ago,” said Inouye, adding that research has increased exponentially as well.

In some cases, delirium is the result of carelessness.

One woman said she was repeatedly rebuffed several years ago by nurses at a Washington area hospital after her mother started acting “stoned” after hip surgery. “She said things like ‘I’m having a dinner party tonight and I’ve invited a nice young man to meet you,’ ” recalled the daughter. She asked that her name be omitted to protect the privacy of her mother, now 96, who lives independently in Northern Virginia and “still has all her marbles — and then some.”

“The nurses kept telling me she was off all medication” and that her confusion was to be expected because of her age. “It was only when I insisted on talking to the doctor and going through her chart” that the doctor discovered that a motion sickness patch to prevent nausea had not been removed. “Within an hour, my mother was acting fine. It was very scary because if she hadn’t had an advocate, she might have been sent to a nursing home with dementia.”

Inouye, who developed the Confusion Assessment Method, or CAM scale, now used around the world to assess delirium, said that significant systemic obstacles to preventing delirium remain.

“We need to back up in our care of older patients so that we don’t treat every little symptom with a pill,” she said. Sometimes, she said, a hand rub or a conversation or a glass of herbal tea can be as effective as an anti-anxiety drug.

Two months ago, Inouye, who is in her 50s, was hospitalized overnight, an experience that underscored the ordeal that older, vulnerable patients face. “I was woken out of the deepest sleep every two hours to check my blood pressure,” she said. In addition, alarms in her room began shrieking because a machine was malfunctioning.

“Medical care,” she added, “has evolved to be absolutely inhumane to older people.”

Hospital Elder Life Program (HELP)

In an effort to prevent or reduce delirium, Inouye created a program called HELP, short for Hospital Elder Life Program, currently operating in 200 hospitals around the country. While the core of the program remains the same, each hospital implements the program in different ways. Some enroll ICU patients, while others exclude them. A 2011 study found that HELP saved more than $7 million in one year at UPMC Shadyside Hospital in Pittsburgh, Pa.

At Maine Medical Center in Portland, HELP is a voluntary program open to patients older than 70 who have been in the hospital for 48 hours or less and do not show signs of delirium. ICU and psychiatric patients are excluded. The program relies on a cadre of 50 trained volunteers who visit patients up to three times daily for half-hour shifts, providing help and companionship and helping them stay oriented.

The CAM scale is built into the hospital’s electronic medical record, said geriatrician Heidi Wierman, who oversees the program and heads a medical team that sees patients regularly. HELP prevented delirium in 96 percent of patients seen last year, she said, adding that resistance by doctors and nurses to the 13-year-old program has been minimal because “we tied the incidence of falls to the prevention of delirium.”

Marylou Turpin, whose husband recently returned to their home outside Nashville, is planning to enroll him at Vanderbilt’s ICU Recovery Center as soon as possible. “I’m just hoping we can have some kind of life after this,” she said.

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation. Kaiser Health News (KHN) is a nonprofit national health policy news service.

Cardio in Old Age May Boost Brain Health

Older adults who engage in high levels of cardiovascular exercise — such as jogging, cycling, swimming, or dancing — may be increasing their brain health as well, according to a new study published in the journal Cortex.

The findings show that older adults who scored high on cardiorespiratory fitness (CRF) tests — a measure of the body’s ability to supply oxygen to the muscles during exercise — performed better on memory tests than those who had low CRF. In addition, the more fit the participants were, the more active their brain was during the learning process.

“Importantly, CRF is a modifiable health factor that can be improved through regular engagement in moderate to vigorous sustained physical activity such as walking, jogging, swimming, or dancing,” said corresponding author Scott Hayes, Ph.D., assistant professor of psychiatry at Boston University School of Medicine and associate director of the Neuroimaging Research for Veterans Center at the VA Boston Healthcare System.

“Therefore, starting an exercise program, regardless of one’s age, can not only contribute to the more obvious physical health factors, but may also contribute to memory performance and brain function,”

For the study, researchers recruited healthy young adults (18-31 years) and older adults (55-74 years) with a wide range of fitness levels to walk and jog on a treadmill.

The researchers assessed their cardiorespiratory fitness by measuring the ratio of inhaled and exhaled oxygen and carbon dioxide. These participants also underwent MRI scans which collected images of their brain while they learned and remembered names that were associated with pictures of unfamiliar faces.

As would be expected, older adults had more difficulty than younger adults learning and remembering the correct name associated with each face. Age differences in brain activation were observed during the learning of the face-name pairs, with older adults showing decreased brain activation in some regions and increased brain activation in others.

Importantly, however, the degree to which older adults demonstrated these age-related changes in memory performance and brain activity largely depended on their fitness level. Overall, older adults with high fitness levels showed better memory performance and increased brain activity patterns compared to their low fit peers.

In addition, the increased brain activation found in the high fit older adults was found in brain regions that show typical age-related decline, suggesting that fitness may contribute to brain maintenance. Higher fit older adults also had greater activation than young adults in some brain regions, showing that fitness may also serve a compensatory role in age-related memory and brain decline.

The findings suggest that CRF is not only important for physical health but also for brain function and memory performance.

The researchers caution that maintaining high levels of fitness through physical activity will not entirely eliminate or cure age- or Alzheimer’s disease-related decline, but it may slow down the decline.

Help for seniors living alone is just a call away

The idea came to Fremont community services officer Diana Allen about four years ago when she saw a story out of Arizona about a senior citizen who was found injured inside her home a week after falling.

It reminded Allen of her great aunt, who suffered a stroke and fell in the kitchen of her Southern California apartment. Her aunt had no family down there and when her neighbors hadn’t seen her for a while they called the police, who did a welfare check and found her dead. The medical examiner said “what had killed her was laying in one position for almost a week, not getting medical attention and being dehydrated,” Allen said.

“It made sense that you should have someone check on you,” Allen said, so at her suggestion, the Fremont Police Department launched a pilot program in which regular calls would be made to enrolled seniors who live alone.

A year later in 2013, police started the You Are Not Alone program in partnership with the city’s Human Services Department, which is modeled after similar ones Allen investigated, including one in Piedmont and three other cities in California.

But so far the program has only 16 seniors enrolled who receive phone calls from 10 Fremont police patrol volunteers and the city is hoping to get more elderly, disabled and home-bound residents signed up.

Volunteers call program participants between 8 a.m. and noon Monday through Friday. If a resident does not answer the phone after a few calls, volunteers visit the home.

If the volunteers determine the resident is inside, they ask police officers to go over and check on his or her well-being, Allen said.

“We want our elderly, disabled and home-bound to know they are never alone,” Allen said. She added that the program gives family members who aren’t able to constantly monitor their relatives a “piece of mind to know that someone is checking on their loved one.”

The You Are Not Alone program aims to let seniors and others know help is available if a medical crisis renders them helpless, Allen said.

In the last two years, Allen said there were two incidents in which program participants suffered an injury and required medical attention.

“We had one man who suffered a head injury, and he would not have been able to call and get help,” Allen recalled.

She said participants are relieved and grateful to have people checking up on them. “They invite the volunteers over for tea and send over treats to the department.”

To qualify for the program, participants must be elderly, single and disabled, or elderly shut-in couples otherwise able to take care of their daily needs.

Application forms can be downloaded by visiting fremontpolice.org/yana. For more information, call (510) 790-6691.