Preparing for the ‘silver tsunami'

Some are calling it the "silver tsunami"—the wave of Americans living longer than previous generations. It's great news on the longevity front, but not for a health-care system that is unprepared for the repercussions of an aging population.

Alzheimer's disease is one of the challenges for which the nation is not ready. Today, one in eight older Americans has Alzheimer's, and the risk of developing the brain disorder doubles every five years after age 65. Although most people will not develop Alzheimer's, 6.7 million are expected to have the disease by 2025—30 percent more than today. Without more effective planning and programs in place, the costs and burdens of Alzheimer's care could overwhelm the health-care system and families of people with this disease.

To address a possible crisis, President Obama signed into law the National Alzheimer's Project Act in 2011. To implement the law, the secretary of the U.S. Department of Health and Human Services (DHHS), Kathleen Sebelius, established the National Advisory Council on Alzheimer's Research, Care, and Services. This public-private advisory council makes recommendations to the secretary related to ways that federal programs could improve care and services for people with Alzheimer's and their families. The council also makes recommendations for research and setting funding priorities for prevention, education, diagnosis and treatment strategies. The result—the National Plan to Address Alzheimer's Disease—was unveiled by DHHS in May.

APA committees and divisions reviewed and commented on preliminary drafts of the Alzheimer's plan. Deborah DiGilio, director of APA's Office on Aging, and Patricia Kobor, APA's senior science policy analyst, managed APA's input during the planning. While the first draft included no mention of the word psychology, the final plan is more inclusive. The result, say those involved, will lead to better care for people with Alzheimer's disease and their caregivers, plus more opportunities for psychologists.

The plan has gotten Congress's attention, says Denise C. Park, PhD, who co-directs the Center for Vital Longevity and is the distinguished university chair in behavioral and brain sciences at the University of Texas at Dallas. "It brings enormous recognition that funding has been woefully inadequate for research on the aging mind and brain."

A greater focus on prevention

The National Plan to Address Alzheimer's Disease now provides a framework through 2025 for driving and tracking progress on Alzheimer's initiatives. The Obama administration dedicated additional funds of $130 million for Alzheimer's research in fiscal years 2012 and 2013, plus $26 million for Alzheimer's programs, services, professional training and public education.

The plan's focus on prevention reflects a major shift from 10 years ago, says Glenn E. Smith, PhD, consultant on neurocognitive disorders at the Mayo Clinic and clinical director of Alzheimer's disease resources on MayoClinic.com. "We now conceive of Alzheimer's disease developing over 20 to 30 years or longer," he explains. "We are developing methods that offer windows of opportunity for prevention strategies."

In particular, research has revealed that such chronic disorders as hypertension and diabetes are putting people at risk for Alzheimer's, says neuropsychologist Jennifer Manly, PhD, an associate professor at Columbia University Medical Center who serves on the National Advisory Council and chairs its research subcommittee. "With behavioral interventions to manage diet and exercise, we may see improvements in cognitive health and reduction in Alzheimer's prevalence," she says.

Among the plan's final provisions that APA recommended:

• Interdisciplinary teams. The text was broadened so psychologists and other health-care providers—in addition to physicians—are recognized as part of a skilled Alzheimer's team providing assessment or treatment services. Psychologists are explicitly mentioned as a government resource for evidence-based dementia guidelines to be disseminated. (See APA Guidelines on Dementia and Age-related Cognitive Change)
  
• Risk factor prevention. The final plan includes a stronger statement on the need for clinical trials on non-pharmacologic ways to prevent and manage Alzheimer's disease. A specific objective was added to continue clinical trials on promising lifestyle interventions that address known Alzheimer's risk factors such as obesity, diabetes, hypertension, smoking, depression, and mental and physical inactivity.

A separate research summit convened to address the plan's first goal of establishing research priorities. It called for additional funding for behavioral and cognitive research, as well as more research on neuropsychological markers of Alzheimer's disease.

Opportunities for psychologists

One of the plan's recommendations is to expand funding and incentives for health-care providers to pursue careers in geriatric specialties. As the population ages, psychologists will have to incorporate expertise on aging and caregiving into their general practice, too, says Peter A. Lichtenberg, PhD, professor and director of the Institute of Gerontology and Merrill Palmer Skillman Institute at Wayne State University in Michigan. "They'll need to recognize cognitive decline and know when it's Alzheimer's and not delirium or frailty," Lichtenberg says. (See the APA webinar: New guidelines for the diagnosis of Alzheimer's disease)

Psychologists also are well-positioned to educate people about Alzheimer's and to refer them to resources. According to the most recent "Facts and Figures" from the Alzheimer's Association, only about half of Caucasians and 30 percent of minorities with Alzheimer's are ever formally diagnosed. The national plan proposes more research and activities to aid outreach to high-risk populations and minorities.

Using neuropsychological assessments to diagnose the early stages of Alzheimer's also requires psychological expertise. "Psychology is better than any other discipline at assessing thinking challenges and subtle memory decline," says Smith. These evaluations can also provide useful information about disease progression and the possible impact of intervention.

Manly cites the need for more research to fully understand how biomarkers relate to cognition and behavior, hallmarks of Alzheimer's. "We have technology for amyloid imaging, but we don't know how to use it. We need to do work to standardize this information. What are the best protocols to use?"

Behavioral experts are being tapped as well to develop prevention models for lowering Alzheimer's incidence. Behavioral intervention programs designed to help people lose weight, exercise more, manage diabetes, cope with depression or stop smoking would all be helpful in reducing risk factors. Deborah E. Barnes, PhD, and Kristine Yaffe, MD, of the University of California, San Francisco, suggest that 25 percent improvement in these conditions in Americans would prevent as many as 16.5 percent of Alzheimer's disease cases in the United States (Lancet Neurology, 2011).

Psychologists are also at the forefront of developing behavioral and environmental interventions that can help family caregivers and nursing home staff to manage disruptive behavior that is often associated with dementia. These interventions can help to reduce the use of antipsychotic medications, which can cause serious side effects.

Lichtenberg raises the need for psychologists to understand the necessary balance between an Alzheimer's patient's need for both autonomy and care. "Families make a huge mistake when they rush in and take away the rights and decisions of the person with early signs of memory loss," he says. "This is not ethical or helpful." (Related: APA's Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists (PDF, 1.35MB)) Instead, he proposes that guidelines be drawn that support the older adult's decision-making abilities until he or she truly requires protection. Otherwise, families may encounter strong resistance and risk being cut off from all communication with the older adult.

APA staff will continue to track and contribute to Alzheimer's policy development. Meanwhile, aging experts in psychology are calling on their colleagues to be better advocates in preventing and managing the disease.

"The emphasis in Alzheimer's work has been on biomarkers and the search for a magic cure through pharmacology," says Adam Brickman, PhD, an assistant neuropsychology professor at Columbia University Medical Center. Since scientists have yet to find an effective medication, though, psychologists need to step in, he says. "This is not just about finding a pill."

Eve Glicksman is a writer in the Philadelphia area.