Problem of the elderly people

Osemeka Anthony


ID UAD7638HBY14286





























Problem of the elderly people

(Course Work)



























PhD in Psychology

Atlantic International University

School of Social and Human Studies









Table of contents

Table of content-----------------------------------------------------------------------2

Introduction----------------------------------------------------------------------------3

Problem of the elderly people-------------------------------------------------------4-17

HealthCare demand-----------------------------------------------------------------18-32

Legal and Ethical guidelines-------------------------------------------------------32-45

Coping and well-being--------------------------------------------------------------45-81

Important of religion in the elderly people well-being--------------------------81-85

















































1.0.Introduction



1.1.Elders face too many types of problems. Too many to choose from. Declining health, money/retirement funds, cost of living, and discrimination in the work place, in life in general. The younger society views them as useless and frail. Even in movies and cartoons they are seen negatively. Nursing home residents particularly have stereotypes facing them daily and are often compared with children and babies. They have a mutual withdrawal from society and their world gets smaller and smaller. They don't tend to venture out in the neighborhoods; they stay homebound. So much for the 'golden years'. They are alone a lot more, families are too busy to visit them, they have less motivation for self-care and end up losing weight, dehydrated, feeling like burdens to their loved ones. It's very sad. World population has increased rapidly during this century, especially in the last 30 years. Population density has increased more than twofold over 65 years. However, these increases are not uniform: the European population increased by only 26% while in Africa the increase was 155% during the last 40 years. By 2000, two-thirds of the world population aged more than 60 years in developing countries, especially in Asia.

The Thai elderly population (age 60 and over) accounted for only 5.4% of the total population in 1985. This population is projected to increase to 7.5% in 2000, 11.0% by the year 2015 and 14.1% by 2025. The numbers aged over 60 years were only 2.3 million by 1980 but are predicted to be 4.5 and 12.2 million in 2000 and 2025, respectively. These changes will lead to an increase in the elderly dependency ratio which will increase the total dependency ratio by the year 2025.

Routine data sources are not sufficient to quantify the burden of illness associated with an ageing population. However, when all available data (including ad hoc surveys and research studies) are used it is possible to give some indication of the scale of the problems.



















2.0. Problems of the Elderly



2.1.Gerontologists study how older people are treated within a society and how the elderly deal with the inevitable problems of ageing, particularly those involving health and income. Health problems include normal losses in hearing, eyesight, and memory, and the increased likelihood of chronic diseases. These losses are gradual and proceed at different rates for each individual. Many people do not experience declines until very old age, and the great majority of the elderly learn to adapt to the limitations imposed by health problems. In general, the health of older people today is superior to that of previous generations a condition that is likely to improve still further as more people receive better medical care throughout their lives. In most industrial societies, the high cost of treating chronic illness has been assumed, at least partially, by national health plans such as Medicare and Medicaid in the United States. See Health Insurance.

The second major problem of the elderly involves income and economic welfare. Because most old people are no longer in the labor force, some form of income maintenance is necessary. Industrial societies are characterized by systems of pensions and benefits such as Social Security in the United States, which currently is increased automatically as the cost of living rises, thus reducing somewhat the impact of inflation. Although the income of retired people is about half that of working people, most manage to maintain themselves independently. In the United States, however, some elderly live below or slightly above the poverty level; these are predominantly women and members of minority groups for whom economic security has always been a problem. In numerous other industrialized nations, more extensive systems of social welfare have reduced the proportion of the elderly who lack adequate housing, transportation, and social services. People age 65 and over make up a small percent of the United States civilian labor force, and the trend has been toward increasingly earlier voluntary retirement. Income needs and health are the primary considerations in the decision to retire.

Social relationships might be difficult to maintain in old age because of health limitations, death of family members and friends, loss of workmates, and lack of transportation. Still, the majority of old people are deeply involved in friendships and family, and many find companionship at special senior centers.







2.2. Sleep problems in elderly people



Sleep problems are common among older people 12-25% of healthy elderly people report chronic insomnia, with higher rates among those with coexisting medical or psychiatric illness. Despite these high rates little has been published that specifically concerns sleep in people over 60 years. This article provides a brief summary of some of the main evidence available on treatments for what is one of the main sleep related problems in otherwise healthy elderly people, based on a recent series of Cochrane systematic reviews.

There are three main sleep problems: too much (excessive sleepiness); too little (sleeplessness); and "things that go bump in the night" (parasomnias). Nearly 90 sleep disorders are, however, listed in the International Classification of Sleep Disorders. When considering a patient's sleep it can be helpful to think about the quality (was it refreshing?), duration (in hours and minutes, taking account of onset, offset, and wakes), and timing (did the sleep occur at socially acceptable times?). A careful sleep history is fundamental to the diagnosis, and yet a recent study indicates that this is taken in less than 10% of patients attending general medical services. According to one report the median amount of time spent on sleep related issues in medical training in the United Kingdom is five minutes, and that in clinical psychology it is no better.

2.3.Treatments(Cognitive behavioural therapy)

Sleep requirements and patterns change throughout life, although whether older people need less sleep or cannot get the sleep they need has not yet been answered. Despite the high prevalence of sleep disorders, fewer than 15% of adults with chronic insomnia receive treatment. Those who receive treatment typically receive benzodiazepines, which have known side effects including tolerance, addiction, daytime sedation, associated falls, hip fractures, and car accidents especially

from preparations with a long half life and impaired sleep due to long term use. As an alternative, non-pharmacological interventions may be considered. These include cognitive behavioural interventions typically used for psychophysiological insomnia, bright light treatments for problems related to timing of sleep, and physiological interventions such as exercise for insomnia. Currently the evidence is that cognitive behavioural therapy seems worthy of consideration, but its benefit seems to be short lived. Perhaps top up sessions or booklets

providing further information and reminders might help, as booklets have been found to be effective in other populations.

No good quality randomised controlled trials exist of bright light treatment in elderly people. Limited evidence indicates that it has some use in treating sleep phase problems. A small but encouraging study (n=16, mean age 70 years) reported that exposure to bright light in the early evening successfully delayed the time of sleep onset.

As for physical interventions such as exercise, again, evidence is limited, and generalisability of the results is also limited because they have tended to focus on good sleepers or young sleepers, leaving little scope for the measurement of improvement (a ceiling effect). The results of the one small trial of exercise in elderly people are, however, encouraging, particularly for women, for whom outcomes were analysed separately. While sleep latency (time between bedtime and sleep onset) improved only slightly for both sexes, duration of sleep, and scores on a sleep quality questionnaire improved significantly for all participants, and duration of sleep for women increased by an hour. Exercise such as brisk walking and moderate weight training may, however, be unsuitable for many older people.

Some research implies that passive body heating may increase slow wave sleep (a deeper form of sleep, which older people often complain they lack). Such heating could achieve similar results with chronically ill, disabled, or unfit people and that this would be of benefit, particularly for people for whom exercise is difficult or impossible. Exercise programmes designed for older people may help prevent and treat sleep disorders (D F Kripke, personal communication, 2001).

In the future it would be helpful to have good, pragmatic, randomised controlled trials of cognitive behavioural therapy versus (and in combination with) pharmacological interventions, taking into account comorbidities, such as dementia, that occur in this population. A similar need exists for well designed studies of bright light and physiological treatments. A systematic review of the efficacy of acupuncture and acupressure is currently under way, and another on the efficacy of melatonin will begin soon.

2.4.0.Alcohol use disorders in elderly people

Alcohol use disorders in elderly people are common and associated with considerable morbidity. The ageing of populations worldwide means that the absolute number of older people with alcohol use disorders is on the increase, and health services need to improve their provision of age appropriate screening and treatment methods and services.

2.4.1.How common is the problem?

The prevalence of alcohol use disorders in elderly people is generally accepted to be lower than in younger people, but rates may be underestimated because of underdetection and misdiagnosis, the reasons for which are many and varied.7 The cross sectional nature of prevalence studies also means that a cohort effect cannot be ruled out. For example, the drinking habits of Americans from the 1920s may differ substantially from those from the era after the second world war because of the effects of prohibition.

Most prevalence studies have been carried out in North America, and results may not be generalisable to other cultures. Rates of alcohol use disorders also vary depending on the restrictiveness of diagnostic criteria used, with higher rates for "excessive alcohol consumption" and "alcohol abuse" than "alcohol dependence syndrome." For example, community based studies have estimated the prevalence of alcohol misuse or dependence as 2-4%, with much higher rates of 17% (men) and 7% (women) when looser criteria such as excessive alcohol consumption are used. For hospital based studies, the same difficulties abound as the definitions for alcohol use disorders are not clearly specified in many studies. In general, however, the prevalence for elderly inpatients is higher than for elderly people in the community, with estimates of 14% for patients in emergency departments, 18% for medical inpatients, and 23-44% for psychiatric inpatients. Among elderly people, socio-demographic factors associated with alcohol use disorders include being male, socially isolated, single, and separated or divorced.

2.4.2.Reasons for underdetection and misdiagnosis

The reasons for underdetection and misdiagnosis of alcohol use disorders in elderly people are many and varied. One primary care study identified 10% of older patients as having current evidence of alcoholism, yet fewer than half of these patients had documentation of alcohol misuse in their medical records. Elderly people may be less likely to disclose a history of excessive alcohol intake, and the problem is compounded by the fact that healthcare workers have a lower degree of suspicion when assessing older people. Furthermore, healthcare workers are less likely to refer elderly people for specialist treatment. Healthcare workers may perceive alcohol use disorders in older people as being understandable in the context of poor health and changing life circumstances, which leads to therapeutic nihilism when they are confronted with such problems.

The presentation of elderly people with alcohol use disorders may be atypical (such as falls, confusion, depression) or masked by comorbid physical or psychiatric illness,2 which makes detection all the more difficult.

Sensible limits for weekly alcohol intake (for example, 21 units for men and 14 units for women) may not apply to older people because of age related changes in metabolism, advancing ill health, and increased sensitivity to the effects of alcohol.2 Although the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the United States recommends that people older than 65 consume no more than one drink per day,6 limits appropriate to age have not been established for older people elsewhere but are likely to be lower than those for younger people.

Likewise, the features of alcohol use disorders identified by screening questionnaires (for example, CAGE, MAST-G, AUDIT), biophysical screening measures (for example, mean corpuscular volume and -glutamyltransferase), and diagnostic classification systems (international classification of diseases, 10th revision and Diagnostic and Statistical Manual of Mental Disorders, fourth edition) may not apply to elderly people because of changing roles, life circumstances, and differing health characteristics. For example, elderly people may be less likely than younger people to encounter the social, legal, and occupational complications associated with alcohol use disorders and more likely to encounter adverse physical health consequences. Furthermore, diagnostic criteria and screening instruments tend to focus on current levels of alcohol intake. An accurate assessment of lifetime alcohol consumption is essential when assessing alcohol use disorders in elderly people. All of these factors are likely to result in underdetection of alcohol use disorders in elderly people and give false impressions of the true extent of the problem.

2.4.3.Effects of alcohol use disorders in elderly people

Alcohol use disorders in elderly people are associated with widespread impairments in physical, psychological, social, and cognitive health. Age related changes in body composition means that, while absorption, metabolism, and excretion of alcohol are largely unchanged, equivalent amounts of alcohol produce higher blood alcohol concentrations in older people.2

Serious medical disorders among elderly people who misuse alcohol are much more common than among the overall population of a similar age. The associations with having ever been a heavy drinker have been shown to be long lasting: areas shown to be affected include having more major illnesses, poorer self perceived health status, more visits from the doctor, more depressive symptoms, less satisfaction with life, and smaller social networks than non-heavy drinkers and people who have never drunk A risk of over interpreting these results exists, however, since reverse causality cannot be excluded and subjects with poorer health characteristics may be more likely to drink in the first place.

2.4.4.Potential health benefits

Prominence has been given in recent years to the potential health benefits of alcohol. Light to moderate consumption of alcohol has been shown to be associated with a reduction in the risk of coronary heart disease, stroke, and dementia even after extensive adjustment for personal physical and demographic factors. However the personality profiles and social characteristics of those who drink moderately may differ substantially from those of non-drinkers or heavy drinkers and have been less extensively studied. It is possible that these modify this apparent protective effect.

2.4.5.Treatment of alcohol use disorders in elderly people

Historically, few studies of treatment for alcohol use disorders have included older people. However, research into treatment is increasing, because of growing recognition of the prevalence of alcohol use disorders in elderly people. Elderly people have been shown to be at least as likely to benefit from treatment as younger people, and knowledge of this fact may help to combat the therapeutic nihilism associated with alcohol use disorders in elderly people. Treatment for alcohol use disorders can be divided into the physical or medical and the psychological. Physical treatments can be further divided into treatments used in the acute setting and those used in prophylaxis. In view of the high degree of medical comorbidity and increased severity and duration of alcohol withdrawals in elderly people, the authors recommend admission for acute detoxification. Initially, fluid and electrolyte imbalances should be corrected, along with thiamine administration to prevent Wernicke's and Korsakoff's syndromes. Benzodiazepine assisted alcohol withdrawal in elderly people should be undertaken with care because of increased sensitivity to adverse effects and altered pharmacokinetics, especially among older hospital inpatients with serious illness. The use of medications to promote abstinence have not been studied extensively in elderly people. Disulfiram should be used cautiously and only in the short term because of the risk of precipitating a confusional state. Naltrexone has been shown to help prevent relapse in subjects age 50-74. Psychological treatments include psychoeducation, counselling, and motivational interviewing. It has been implied that older people may derive more benefit from such treatments in same age settings.

2.4.6.Alcohol use disorders in elderly people-New approach

Improvements in the approach to alcohol use disorders in elderly people can be addressed at the levels of primary, secondary, and tertiary prevention strategies. Tertiary prevention strategies include the treatment strategies addressed earlier.

The knowledge that a sizeable proportion of elderly people (11-33%) develop alcohol use disorders with late onset should be addressed at a primary prevention level. Alcohol use disorders may arise de novo in elderly people in the context of bereavement, changing role, or illness. The utility of existing screening instruments and diagnostic classification systems need not be addressed when used in older people. Modified screening instruments and diagnostic criteria for older people should focus on the more subtle yet damaging effects of alcohol use disorders on different aspects of health, with due account taken of increased comorbidity among older people, while de-emphasising some of the social, legal and occupational aspects that may be of more relevance to younger people. This can be seen as analogous to the redefining of diagnostic criteria for depressive illness as it affects older people. Secondary prevention strategies should focus on those elderly people whose drinking pattern, while not fulfilling criteria for alcohol misuse or dependence, may be putting their physical or psychological health at risk. For example, an older person on anticoagulant treatment with a moderate intake of alcohol may be unknowingly putting their health at risk.

Healthcare workers in all settings should be vigilant for the role of alcohol in the presentation of older people with physical and psychiatric illness, cognitive impairment, and social problems. A history of current and lifetime alcohol consumption should be ascertained, with a collateral history from a relative or spouse if possible. The CAGE questionnaire has relatively good sensitivity and specificity in older people, is short and easy to use, but should be supplemented by further questions (for example, "Why do you think you should cut down?"). A physical examination and blood screen (liver function tests and mean corpuscular volume) complete the assessment.

3.0.Cognitive effects

Steady decline in many cognitive processes is seen across the lifespan, starting in one's thirties. Research has focused in particular on memory and ageing, and has found decline in many types of memory with ageing, but not in semantic memory or general knowledge such as vocabulary definitions, which typically increases or remains steady. Early studies on changes in cognition with age generally found declines in intelligence in the elderly, but studies were cross-sectional rather than longitudinal and thus results may be an artifact of cohort rather than a true example of decline. Intelligence may decline with age, though the rate may vary depending on the type, and may in fact remain steady throughout most of the lifespan, dropping suddenly only as people near the end of their lives. Individual variations in rate of cognitive decline may therefore be explained in terms of people having different lengths of life. There are changes to the brain: though neuron loss is minor after 20 years of age there is a 10% reduction each decade in the total length of the brain's myelinated axons.

3.1.Memory and aging

One of the key concerns of older adults is the experience of memory loss, especially as it is one of the hallmark symptoms of Alzheimer's disease. However, memory loss is qualitatively different in normal aging from the kind of memory loss associated with a diagnosis of Alzheimer's (Budson & Price, 2005).

3.2.Mild Cognitive Impairment

Memory loss has long been recognized as a common accompaniment of aging. The inability to recall the name of a recent acquaintance or the contents of a short shopping list are familiar experiences for everyone, and this experience seems to become more common as we age.

Over the last few decades, the medical community has changed its view of memory loss in the elderly. These problems were viewed in the past as inevitable accompaniments of aging, often referred to as “senility” or “senior moments.”

More recently, physicians have shifted their view of memory loss, such that memory impairment of a certain degree is now is considered pathological, and thus indicative of some kind of disease process affecting the brain. The threshold most physicians use to make this judgment is that memory loss has progressed to such an extent that normal independent function is impossible; for instance, if one can no longer successfully manage one’s own finances or provide for one’s own basic needs. This degree of cognitive impairment has come to be referred to as dementia. Dementia has many potential causes, the most common of which is probably Alzheimer ’s disease.

However, many older individuals may complain of memory problems, but still manage to independently accomplish all their customary tasks. Usually, their ability to function well is based on compensation for these difficulties, such as increased reliance on a calendar or on reminder notes, lists, etc. In some cases, these memory difficulties are a sign that worsening memory loss is on the horizon.

Until recently, physicians were not able to provide any specific information concerning the significance of these complaints, or what they mean for the future. However, in the last few years, there has been a substantial increase in the number of clinical research studies focusing on patients with these complaints. Although much more work needs to be done, the characterization of this problem and its outcome is much better now than in the past. The syndrome of subjective memory problems has come to be commonly known as "Mild Cognitive Impairment" (MCI), although other terms have been used, including "Cognitive Impairment, Not Dementia" (CIND).

3.3.Symptoms

The patient with MCI complains of difficulty with memory. Typically, the complaints include trouble remembering the names of people they met recently, trouble remembering the flow of a conversation, and an increased tendency to misplace things, or similar problems. In many cases, the individual will be quite aware of these difficulties and will compensate with increased reliance on notes and calendars.

Most importantly, the diagnosis of MCI relies on the fact that the individual is able to perform all their usual activities successfully, without more assistance from others than they previously needed.

3.4.Mild Cognitive Impairment vs.NormalAging

How do the memory difficulties in MCI differ from those of normal aging? This is a very difficult question to which there is, as yet, no definitive answer.

Several studies have examined the cognitive performance of patients with MCI. These have demonstrated that, in general, these patients perform relatively poorly on formal tests of memory, even when compared with other individuals in their age group. They also show mild difficulties in other areas of thinking, such as naming objects or people (coming up with the names of things) and complex planning tasks. These problems are similar, but less severe, than the neuropsychologicalG findings associated with Alzheimer’s disease.

Careful questioning has also revealed that, in some cases, mild difficulties with daily activities, such as performing hobbies, are evident.

3.5.Relationship between MCI and Dementia

What is the significance of memory complaints in MCI? Recent studies have suggested that these types of complaints are more meaningful than previously thought.

Several studies have demonstrated that memory complaints in the elderly are associated with a higher-than-normal risk of developing dementia in the future. Most commonly, the type of dementia that patients with MCI are at risk to develop is Alzheimer’s disease, though other dementias, such as Vascular Dementia or Frontotemporal Dementia may occur as well. However, it is also clear that some patients with these complaints never develop dementia.

Certain features are associated with a higher likelihood of progression. These include confirmation of memory difficulties by a knowledgeable informant (such as a spouse, child, or close friend), poor performance on objective memory testing, and any changes in the ability to perform daily tasks, such as hobbies or finances, handling emergencies, or attending to one’s personal hygiene.

One factor that had to be controlled for in many of these studies was depression, as many patients with depression also complain about their memory. Several studies have suggested that certain measurements of atrophy (shrinkage) or decreased metabolism on images of the brain (PET or MRI scans) increase the chances of developing dementia in the future.

Although these above factors increase the chances of going on to develop dementia, it is not possible currently to predict with certainty which patients with MCI will or will not go on to develop dementia. Thus, many of these measures, particularly the measurements from brain images, are still considered to be useful only for research.

3.6.Evaluation

There is no established approach to evaluating individuals with MCI. At the UCSF Memory and Aging Center, these individuals undergo a thorough evaluation of their complaints, including a medical history, neurological exam and at least a brief neuropsychological evaluation. The medical history usually requires the participation of a knowledgeable informant.

Depending on the results of this evaluation, further testing may necessary, including blood-work and brain imaging. This evaluation is similar to that given to individuals with more severe memory problems, and is directed towards better defining the problem and looking for medical conditions that might have an effect on the brain (infections, nutritional deficiencies, autoimmune disorders, medication side effects, etc.). An important part of this process is screening for depression, particularly in individuals with mild memory complaints.

Although normal performance on neuropsychological testing does not guarantee that the individual will not develop dementia, the current data indicate that normal results are relatively reassuring, at least for the near future (next few years).

3.7.Treatment

There is currently no specific treatment for MCI. Studies are in progress to investigate the usefulness of treatments for Alzheimer’s disease, such as cholinesterase inhibitors G and vitamin E, in preventing cognitive deterioration in patients with MCI, and the results of these studies should be available within the next couple of years.

In the future, new treatments being developed for Alzheimer’s disease will likely be tried for patients with MCI as well. If any unusual causes of memory impairment are uncovered in the process of an evaluation, such as vitamin deficiency or thyroid disease, specific treatments should be instituted.

3.8.People with Memory Concerns — Recommendations

A general recommendation for individuals concerned about their memory would be to discuss these concerns with their significant other (friend, spouse, child, etc.), as well as their physician. Bringing the outside informant to the physician appointment is often very helpful in the evaluation process.

The medical evaluation of the problem should include a thorough exploration of the memory complaints, including what type of information is being forgotten and when, the duration of the problem, and whether other cognitive complaints are occurring (problems with organization, planning, visuospatial abilities, etc). The physician should be aware of the patient’s medical history, the medications taken, etc. As subjective memory complaints can be associated with depression, screening for depressive symptoms is always warranted.

Additional assessment could include neuropsychological testing to document objectively any memory deficit and to assess its severity. Because the interpretation of neuropsychological testing in this setting is in part dependent on age and education, such testing should be performed by an individual familiar with the use and interpretation of these tests.

In addition, though no specific recommendations have been made regarding other testing, it would seem prudent to treat the diagnostic workup for patients with MCI as one would the workup for dementia, including screening for reversible causes of cognitive impairment.

3.9.Implications of a Diagnosis of MCI

Many patients with MCI are actually already convinced that they have dementia. Being told that this is part of normal aging, as might have occurred in the past, is not necessarily reassuring. The availability of a specific diagnosis for an individual’s complaints endorses the validity of their observations, rather than denying them. Furthermore, it can be useful for patients to know that many people with MCI do not progress to dementia even after several years. However, the recognition that this complaint is associated with an increased risk of dementia should prompt an individual to evaluate their support systems (family, living situation) in preparation for the possibility that they may deteriorate in the future.

Lastly, as new medical interventions for Alzheimer’s disease are developed in the future, these are likely to be tried on patients with MCI as well. If data from such trials indicates a beneficial effect in slowing cognitive decline, the importance of recognizing MCI and identifying it early will increase.

4.0.Sunshine vitamin' link to cognitive problems in older people



4.1.Vitamin D linked to cognitive impairment

Researchers from the Peninsula Medical School, the University of Cambridge and the University of Michigan, have for the first time identified a relationship between Vitamin D, the "sunshine vitamin", and cognitive impairment in a large-scale study of older people. The importance of these findings lies in the connection between cognitive function and dementia: people who have impaired cognitive function are more likely to develop dementia. The paper will appear in a forthcoming issue of the Journal of Geriatric Psychology and Neurology.

The study was based on data on almost 2000 adults aged 65 and over who participated in the Health Survey for England in 2000 and whose levels of cognitive function were assessed. The study found that as levels of Vitamin D went down, levels of cognitive impairment went up. Compared to those with optimum levels of Vitamin D, those with the lowest levels were more than twice as likely to be cognitively impaired.

Vitamin D is important in maintaining bone health, in the absorption of calcium and phosphorus, and in helping our immune system. In humans, Vitamin D comes from three main sources – exposure to sunlight, foods such as oily fish, and foods that are fortified with vitamin D (such as milk, cereals, and soya drinks). One problem faced by older people is that the capacity of the skin to absorb Vitamin D from sunlight decreases as the body ages, so they are more reliant on obtaining Vitamin D from other sources.

According to the Alzheimer's Society, dementia affects 700,000 people in the UK and it is predicted that this figure will rise to over 1 million by 2025. Two-thirds of sufferers are women, and 60,000 deaths a year are attributable to the condition. It is believed that the financial cost of dementia to the UK is over £17 billion a year.

Dr. Iain Lang from the Peninsula Medical School, who worked on the study, commented: "This is the first large-scale study to identify a relationship between Vitamin D and cognitive impairment in later life. Dementia is a growing problem for health services everywhere, and people who have cognitive impairment are at higher risk of going on to develop dementia. That means identifying ways in which we can reduce levels of dementia is a key challenge for health services."

Dr Lang added: "For those of us who live in countries where there are dark winters without much sunlight, like the UK, getting enough Vitamin D can be a real problem – particularly for older people, who absorb less Vitamin D from sunlight. One way to address this might be to provide older adults with Vitamin D supplements. This has been proposed in the past as a way of improving bone health in older people, but our results suggest it might also have other benefits. We need to investigate whether vitamin D supplementation is a cost-effective and low-risk way of reducing older people's risks of developing cognitive impairment and dementia."

4.2.Memory decline in normal aging

The ability to encode new memories of events or facts and working memory shows decline in both cross-sectional and longitudinal studies (Hedden & Gabrieli, 2004). Studies comparing the effects of aging on episodic memory, semantic memory, short-term memory and priming find that episodic memory is especially impaired in normal aging (Nilsson, 2003). These deficits may be related to impairments seen in the ability to refresh recently processed information (Johnson et al., 2002). In addition, even when equated in memory for a particular item or fact, older adults tend to be worse at remembering the source of their information (Johnson, Hashtroudi, & Lindsay, 1993), a deficit that may be related to declines in the ability to bind information together in memory during encoding and retrieve those associations at a later time (Naveh-Benjamin, 2000; Mitchell et al., 2000). A postmortem examination of five brains of elderly people with better memory than average called "super aged"found that these individuals had less fiber-like tangles of tau protein than found in typical elderly brains, but a similar amount of amyloid plaque.

4.3.People are poor at assessing their own memory

One thing research seems to show rather consistently is that, for older adults in particular, beliefs about one's own memory performance have little to do with one's actual memory performance¹. People who believe they have a poor memory are usually no worse at remembering than those who believe they have a good memory.

One theory for why this might be, is that people may be influenced by their general beliefs about how memory changes with age. If you believe that your memory will get progressively and noticeably worse as you get older, then you will pay more attention to your memory failures, and each one will reinforce your belief that your memory is indeed (as expected) getting worse.

4.4.Memory decline can be a self-fulfilling prophecy

Research has also shown that common, everyday memory failures tend to be judged more harshly when the failure belongs to an older adult². What is laughed off in a younger adult is treated as an indication of cognitive decline in an older person.

There are ways in which cognitive function (memory, reasoning, problem-solving, etc) declines with age, but it would be fair to say that general belief over-estimates the extent of this. It is, to a large extent, a self-fulfilling prophecy. If you believe deterioration is inevitable, you are not likely to make any effort to halt it.

4.5.Memory decline is associated with physical factors

A large-scale study that tracked seniors over a ten-year period found that cognitive decline is not a normal part of aging for most elderly people: 70% of the nearly 6000 seniors in the study showed no significant decline in cognitive function over the ten-year period. These people had two factors in common: they did not carry any of the apolipoprotein E4 genes (often associated with Alzheimer's disease), and they had little or no signs of diabetes or atherosclerosis³.Other factors that have also been implicated in age-related cognitive decline are obesity, smoking, and high blood pressure. Indeed, researchers have suggested that risk factors for cardiovascular disease are also risk factors for cognitive decline: what's bad for the heart is also bad for the brain.

5.0.Healthcare demand

According to “Schatzlein” No amount of redefinition, however, will change the fact that the boomers are aging, no matter how reluctantly. As their bodies mature, their medical needs shift, as well. "Part of our business planning process is to anticipate the needs of the growing 55 to 64 age group," Schatzlein explains. "At Network hospitals, we expect to see a rise in the need for orthopedic, cardiac and urological care."Boomers desire to continue living an active life and keep from being confined to a bed or wheelchair. The most critical need for the boomer population that we anticipate will be orthopedic care followed by general health care," Miller reports. "The baby boomer population wants to remain healthy and active. And we plan to be an integral part of keeping maturing adults on the move."





5.1.Prevention activities recommended for people aged 65 and above



Disease prevention is even more important in older people than in younger people. Several important preventive activities can help people stay healthy and independent for as long as possible. With good, preventive health care on a routine basis, we can remain functioning longer and extend our lifespan. In other words, older Americans have considerable control over the quality of their health.



Preventive Services Recommended for People Aged 65 and Older



Screening For: How Often

Depression (questionnaire) First visit and periodically

Alcoholism (questionnaire) First visit and periodically

Mental processes Every year

Height and weight At least every year

Blood pressure At least every year

Vision testing Every year

Hearing testing Every year

Bone density measurement (a type of scan for bone health) Women, at least once after age 65

Thyroid function blood test Women, every year

Cholesterol, triglyceride levels (blood test) Every year in people with previous heart attack, stroke, peripheral vascular disease, or chest pain

Glucose level (test for blood sugar) for diabetes Every year (if risk factors, eg, high blood pressure)

Mammogram (breast x-rays) Yearly up to age 70, and continue for those who have reasonable life expectancy

Pap smear (gynecologic/pelvic examination) At least every 3 years

Not needed in women 65 and older if they have had normal Pap smears up to that age; if never tested before, may stop after 2 normal annual Pap smears

Test for blood in stool

Sigmoidoscopy, or

Colonoscopy Every year

Every 3 to 5 years

Every 10 years

Prostate specific antigen (PSA blood test and rectal examination for prostate cancer Men, yearly

Counseling about:

Stop smoking

Low-fat, well-balanced diet

Adequate calcium intake

Physical activity

Injury prevention

Regular dental visits

Every visit

Every year

Every year

Every year

Every year

Every year

Immunization (vaccination) for:

Flu shot

Pneumonia shot

Tetanus booster shot Every year

Once at age 65 (if healthy); repeat every 6-7 years

Every 10 years

Medication for:

Omega-3 fatty acids (fatty fish) to prevent heart attack and stroke

People with previous heart attack At least twice every week

One aspirin every day







On average, a person who is 65 years old can expect to live another 16 years. A person who is 75 can expect to live another 10 years, and a person who is 85 can expect to live another 6 years. People 75-85 years old can also expect to be able to function independently for at least half of that period. In these age groups, our health care goal shifts from extending lifespan to postponing dependency. While preventing disease is still important, maintaining good health for older adults focuses on preventing a loss of function and supporting the abilities we need to remain independent. In other words, the focus changes to vitality, function, and quality of life (rather than just to preventing disease and surviving).

5.2.First-Level Prevention

• Smoking

• Exercise

• Diet

• Alcohol use

• Cholesterol

• Car accidents

• Accidental injury

• Dental checkups

• Low-dose aspirin therapy

• Vaccination



5.3.Second-Level Prevention

• Cervical cancer

• Breast cancer

• Colon cancer

• Prostate cancer

• Alcoholism

• Diabetes

• Heart disease

• Depression

• Obesity or Weight loss

• High blood pressure

• Osteoporosis

• Vision or Hearing problems

• Cholesterol

• Thyroid disease

• Skin cancer

• Dementia



Third-Level Prevention and Comprehensive Geriatric Assessment

5.4.0.First-Level Prevention

First-level prevention is designed to stop disease before it starts (ie, to reduce the risk of getting a disease). In can include changes in behavior and habits, and it is also important to keep up to date on vaccinations.

5.4.1.Smoking

Cigarette smoking remains the single most preventable cause of death in the United States for both men and women. Quitting can increase life expectancy, lower the risk of heart disease, and improve lung function and blood circulation.

People who have stopped smoking found it helpful to do the following:

• set a quit date

• have scheduled reinforcement visits

• use self-help packages

• make visits to community-based programs for people trying to quit

5.4.2.Exercise

Exercise is an important way to prevent many types of health problems, including cardiovascular disease, falls, and depression. The health benefits from regular physical activity are probably greater in older adults than in younger adults. Exercise should be a regular, day-to-day activity. It does not need to be overly strenuous.

5.4.3.Walking is recommended for everyone who is physically able. Walking can be done almost anywhere and at no or very low cost. People who walk for about 30 minutes a day can improve their health. Even small amounts of exercise by those who are typically not very active can have health benefits.

5.4.4.Diet

Eating a well-balanced diet and maintaining a healthy weight is very important as we age. A regular review with your health care provider of the calories, fluid, cholesterol, fiber, sodium, and minerals in your diet is useful. The number of calories you eat should be balanced against the amount of energy you use. Saturated fats should make up less than 10% of total calories. Saturated fat intake can by limited by eating fish, chicken without skin, low-fat dairy products, and lean meats. However, certain fatty fish such as mackerel, lake trout, herring, sardines, albacore tuna, and salmon are high in fatty acids that contain omega-3, a compound that can help prevent heart attack and stroke. Older adults without heart disease are encouraged to eat a variety of fish (preferably fatty) at least twice a week. Other sources of omega-3 include oils and foods like flaxseed, canola and soybean oils, and walnuts. Whole grains, fruits, and vegetables are also highly recommended. Easy ways to reduce salt intake include cutting down on salt use at the table and limiting the use of prepared (eg, canned or packaged) foods. Women generally need to increase their calcium intake as they age. In addition to these general guidelines, you should consider individual counseling from a nutritionist, dietitian, or physician if you have specific health problems and dietary needs. (See also Nutrition.)

5.4.5.Alcohol Use

Alcohol is a problem for about 5% of people over 65 years of age. Drinking too much increases injuries, gastrointestinal illness, and liver disease. It can also cause potentially reversible mental illness. However, having one drink per day (eg, one beer, one mixed drink, or one glass of wine) can reduce risk of heart attack and stroke. Regardless, people who have memory problems should not drink any alcohol.

5.4.6.Cholesterol

Cholesterol continues to be a risk factor for heart disease as we age, along with smoking, high blood pressure, and lack of exercise. Eating a balanced, low-fat diet is beneficial for preventing heart disease as well as for preventing cancer and other forms of illness. People at higher risk, such as those who already have some heart disease, may benefit from further steps to lower cholesterol.

5.4.7.Car Accidents

Car accidents are the leading cause of fatal injuries in adults up to age 75. The crash rate for older drivers (adjusted for the actual miles that they drive) is higher than for any other age group except for drivers under 25. All drivers, of course, should wear seat belts and should not drink before driving. Older drivers may need to change their driving techniques and habits to adjust to certain changes associated with aging (eg, decreased vision). It’s sensible to take a refresher course to improve your knowledge and skills. Both driver education and retraining are offered through the American Association of Retired Persons (AARP) and the American Automobile Association (AAA). People with severe visual or hearing loss, dementia, or certain neurologic diseases should seriously consider not driving.

5.4.8.Accidental Injury

Accidental injury is the sixth leading cause of death among people 65 years old and older. Many of these injuries are related to falls and car accidents. A fall at home that causes serious injury might require hospitalization and possibly care in a nursing home or a rehabilitation facility. Your healthcare provider can offer advice about the following:



• ways to reduce the risk of falling

• safety-related skills and behaviors

• ways to remove hazards in your home

Everyday safety behaviors include:

• regularly wearing seat belts

• having regular driving tests

• not drinking alcohol before driving or operating machinery

Examples of ways to decrease hazards in the environment include:

• lowering the water temperature in your hot-water heater to prevent serious burns

• installing smoke detectors

• Installing alarms and automatic shut-off features on appliances

• getting rid of or safely storing firearms

In addition to general home safety, additional precautions are necessary in special circumstances. For example, if someone in the household uses oxygen, do the patient and all caregivers know how to use and clean the equipment correctly? Are any other types of medical support equipment in use? If so, is the equipment in working order? Does everyone in the household know how to use it properly and safely? Does everyone know what to do if the equipment stops working?

A more formal evaluation of your home to help prevent injuries can also be done by a physical or occupational therapist.

6.0.Dental Checkups

Regular dental visits are important as we age. Many common problems can be found during regular dental visits, including infection in the gums, dry mouth, and cancer. Both daily brushing with toothpaste that contains fluoride and flossing are also necessary for good dental health.

6.1.Low-dose Aspirin Therapy

One regular-strength aspirin tablet every other day is recommended to prevent coronary heart disease, but only if you have two or more of the following risk factors:

• diabetes mellitus

• low HDL cholesterol (the "good" cholesterol)

• male gender

• severe obesity

• strong family history

• smoking

Aspirin therapy can also lower your risk of a second heart attack. However, you should not take aspirin if you have uncontrolled high blood pressure, severe liver disease, ulcers, or any other condition that increases the risk of bleeding. Your health care provider can advise if aspirin therapy is recommended for you.

6.2.0.Vaccination

Although vaccination is most often thought of as being important for children, it continues to be important as we age. Medicare covers the costs of flu, pneumonia, and tetanus immunizations.

6.2.1.Flu shots: During influenza (flu) epidemics, the hospitalization rate for older people increases two to five times. Vaccination for the flu is necessary every year because the flu virus constantly changes. This means that the antibodies in our blood from previous infection or vaccination last year might not protect us this year or next.

Everyone 65 years old or older, or those under 65 who have other illnesses, should receive a flu shot every year between September and mid November. Medical personnel and caregivers for high-risk patients should also be vaccinated. Side effects are usually rare, but include fever, chills, aches and pains, and general feelings of ill health. People who are allergic to eggs or any part of the vaccine should not get a flu shot. If you should not get a flu shot, your healthcare provider can tell you about other options to prevent the flu. If you do get the flu, some oral medications are available that can reduce flu symptoms.

6.2.2.Pneumonia vaccine: Pneumococcal infections continue to be the leading cause of pneumonia and can contribute to disability and death. Of the more than 40,000 deaths caused by these infections each year, 80% are in people over 65 years old. Everybody 65 or older (and people younger than 65 who have other illnesses) should be vaccinated against pneumococcal diseases, such as pneumonia. Side effects after revaccination are rare and mild. If it has been 5 or more years since you were vaccinated and if you received that vaccination when you were younger than 65, you should be vaccinated again. If you are unsure if you have ever been vaccinated against pneumonia, it is best to be vaccinated again. This vaccine cannot totally prevent pneumonia and related diseases, but it is still recommended for older adults.

6.2.3.Diphtheria/Tetanus vaccine: Diphtheria and tetanus are rare but are associated with a high death rate. Over half (60%) of tetanus infections are in people 60 years old and older. So, older adults who have never been vaccinated should receive two tetanus shots, 1-2 months apart, followed by a third shot 6-12 months later. After that, tetanus booster shots should be given about every 10 years. After vaccination, there may be pain or swelling where the shot was given. Rarely, someone may have an allergic reaction. People who have had an allergic or other bad reaction to a previous tetanus shot should not be vaccinated again.

7.0.Second-Level Prevention

Second-level prevention refers to efforts to improve the health of people who already have a disease. It focuses on screening to detect disease early and to begin treatment as soon as possible. In addition to the general preventive activities, second-level prevention includes screening for specific diseases of aging.

7.1.Cervical Cancer

Almost half of new cases of serious cervical cancer, including deaths from cervical cancer, are in women 65 years old and older. All women who are or have been sexually active and who have not had a hysterectomy should have a Pap smear every 1-3 years. Women over 65 years old who have regularly had normal Pap smears in the past usually no longer need to have Pap smears. For older women who have never had a Pap smear, screening can be stopped after two normal annual Pap smears. Medicare covers Pap smears performed every 3 years.

7.2.Breast Cancer

Screening by having an annual examination and a mammogram every 1-2 years is recommended. In general, active older women with a life expectancy of 5 years or longer should have a mammogram at least every 2-3 years. Women at high risk, such as those with a history of breast cancer or abnormal mammograms, should have a mammogram every year. Medicare covers annual screening mammograms.

7.3.Colon Cancer

Older adults should be screened for colon cancer by having a diagnostic procedure called a colonoscopy done. In addition, your healthcare provider may recommend testing for blood in the stool that cannot be seen without a microscope (fecal occult blood testing) and possibly a sigmoidoscopy. (A sigmoidoscopy is a procedure that is similar to a colonoscopy, done to examine the colon).

Screening for colon cancer is especially important for people who have any of the following risk factors:

a close relative (eg, parent, sibling) who has a history of colon cancer

a history of cancer of the breast, ovaries, or uterus

a history of an inflammatory bowel condition, polyps, or previous colon or rectal cancer

Medicare will cover a screening colonoscopy every 10 years, fecal occult blood testing every year, and a sigmoidoscopy every 2 years.

7.4.Prostate Cancer

Screening for prostate cancer is controversial because the disease usually progresses very slowly. In addition, evidence to support the benefit of treatment for early disease is lacking. Only 1 in 380 men with prostate cancer die of the disease. Your doctor can advise you on whether or not you should be screened for prostate cancer.

7.5.Alcoholism

The CAGE questionnaire is often used to indicate signs of alcohol dependence or abuse in older people. Answering "yes" to any of the questions below suggests a drinking problem.

C Have you ever felt you should Cut down?

A Does others’ criticism of your drinking Annoy you?

G Have you ever felt Guilty about drinking?

E Have you ever had an "Eye opener" to steady your nerves or get rid of a hangover?

7.6.Diabetes

Routine screening for diabetes mellitus is recommended if you have risk factors such as obesity, a family history of diabetes, or diabetes mellitus that developed during pregnancy. Symptoms that indicate the need for testing include the following:

• being thirsty a lot of the time

• passing a lot of urine

• unintended weight loss

Sugar levels are routinely measured as part of many blood and urine tests. (See also Diabetes.)

7.7.Heart Disease

An electrocardiogram (ECG) is not an effective screening test for heart disease. However, cardiac stress testing may be useful before beginning an exercise program. If you have had a heart attack, controlling risk factors such as cigarette smoking, high cholesterol, and high blood pressure is very important to prevent another. In addition, drug treatment in the first 3 years after a heart attack seems to reduce risk of death. (See also Disorders of the Heart and Circulatory System.)

7.8.Depression

Depression is common in older adults, but treatment can be highly effective. To help determine if you are depressed, your health care provider might use the Geriatric Depression Scale. You will be asked to respond to a number of questions by answering "yes" or "no" based on how you felt over the past week. (See also Depression.)

7.9.Geriatric Depression Scale

Are you basically satisfied with your life?

Have you dropped many of your activities and interests?

Do you feel that your life is empty?

Do you often get bored?

Are you in good spirits most of the time?

Are you afraid that something bad is going to happen to you?

Do you feel happy most of the time?

Do you often feel helpless?

Do you prefer to stay at home, rather than going out and doing new things?

Do you feel you have more problems with memory than most?

Do you think it is wonderful to be alive now?

Do you feel pretty worthless the way you are now?

Do you feel full of energy?

Do you feel that your situation is hopeless?

Do you think that most people are better off than you are?

7.10.Obesity or Weight Loss

A calculation of body mass index (BMI), can be used to estimate your ideal weight. Your BMI is calculated by dividing your weight in kilograms by the square of your height in meters (ie, kg/m2). Definitions for obesity in men and women follow:

Men: BMI greater than or equal to 27.8 kg/m2

Women: BMI greater than or equal to 27.3 kg/m2

On the other hand, sudden weight loss can also be a problem. An unintentional weight loss of 10 pounds in 6 months can indicate malnutrition or a serious illness and should be discussed with your healthcare provider. (See also Nutrition.)

7.11.High Blood Pressure

The chances of developing high blood pressure increase with age. Treating high blood pressure in older adults can reduce the chance of stroke and heart attack. A normal systolic blood pressure (the first or top number) should be 140 or less. The diastolic blood pressure (the bottom or second number) should be 90 or less. High systolic blood pressure is more common than high diastolic blood pressure after age 65. It is often associated with a drop in blood pressure when the person stands up. To determine if this is the case for you:

Check your blood pressure after sitting quietly for 10 minutes

Stand up and check your blood pressure in the same arm after you have been standing for 2-3 minutes

In general, your standing blood pressure is the one to use in deciding if your blood pressure is normal.

Because blood pressure varies more as we grow older, it needs to be measured more often. In addition, older adults are more likely to have side effects from treatment, so they should be watched carefully if treatment for high blood pressure is started. If you are taking blood pressure medication and feel dizzy or lightheaded, you should contact your healthcare provider. (See also High Blood Pressure.)

7.12.Osteoporosis

Most women 65 years old and older should be screened for osteoporosis (thin or brittle bones) by having a bone density test. People who are at high risk of broken bones should have a bone density test at age 60. Your healthcare provider can explain the importance of getting enough calcium in your diet, stopping smoking, exercising, and avoiding falls. (See also Osteoporosis.)

7.13.Vision and Hearing Problems

Common eye diseases in older adults include glaucoma, cataracts, and macular degeneration. In glaucoma, the pressure within the eyeball increases, leading to gradual loss of vision. Cataracts develop when the lens of the eye becomes cloudy and blocks light from passing into the eye. In macular degeneration, vision loss begins in the center of the visual field and progresses slowly, ultimately leading to blindness. These three diseases and outdated prescription glasses account for most visual problems among older adults. (See also Vision Problems.)

Hearing loss can lead to a feeling of being isolated from others. You should tell your healthcare provider if you’re having any problems with hearing and ask whether a hearing aid would be helpful. (See also Hearing Difficulty.)

7.14.Cholesterol and Triglycerides Correcting

cholesterol and triglyceride levels lowers the risk of future problems in older adults who have evidence of blockage in their arteries (eg, a history of heart attack or chest pains). Keeping your levels of cholesterol and triglycerides within the normal range is important to reduce your risk of cardiovascular problems including heart attack and stroke. Guidelines are as follows:

Your LDL cholesterol (the "bad" cholesterol) should be less than 100 mg/dL.

Your HDL cholesterol (the "good" cholesterol) should be greater than 40 mg/dL.

Your triglycerides should be less than 200 mg/dL.

Treating healthy older adults who have mildly increased levels is not currently recommended.







7.15.Thyroid Disease

Hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid) both become more common as we age. Your healthcare provider might perform a blood test to screen for these conditions, especially in older women.

7.16.Skin Cancer

If any of the moles on your skin change in appearance, or if the appearance of your skin changes in general, you should be checked by your healthcare provider. People who are light-skinned or who have had skin cancer in the past have a high risk of developing skin cancer. They should limit the amount of time they spend outside in the sun and should wear protective clothing when outdoors. Do not hesitate to tell your healthcare provider if you notice a new skin spot or sone that has changed shape, color, or size.

7.17.Dementia

Dementia should be detected as soon as possible because a combination of medications, education, and counseling can benefit both patients and their families. It is important to control risk factors such as high blood pressure and high levels of cholesterol and triglycerides. This may be helpful for patients with dementia caused by cardiovascular problems or Alzheimer’s disease. Staying mentally active by reading, learning new things, or working crossword puzzles may also help prevent dementia. It’s not a bad idea to play Jeopardy! (See also Problems with Remembering, Thinking, and Understanding.)

8.0.Third-Level Prevention

Third-level prevention refers to efforts to prevent disability from becoming worse. This is done by regular and thorough monitoring and treatment of disease, including rehabilitation. Third-level prevention is needed most for older adults who often do not seek care for common sources of disability. Your healthcare provider may recommend a comprehensive geriatric assessment

8.1.Comprehensive Geriatric Assessment

The comprehensive geriatric assessment is one way to identify current medical problems, sources of disability, and needed future care. Usually, a team of healthcare providers is involved so that all areas of a person’s life are considered. Having a thorough assessment is especially important when our health status changes quickly, or when a change in living arrangements appears necessary. Using checklists of ways to support health in older adults helps us stick with any recommendations.

Although preventive health care is important for everyone, doctors at the Mayo Clinic report that the benefits and effects of preventive care may not be as easy to recognize in elderly people. Age-related illness, natural deterioration and reduced activity levels make it difficult to clearly see the effects of preventive care. Because the life span of seniors is shorter, it also becomes more difficult to convince seniors to practice preventive health care.

8.2.Smoking

Elderly people is defined by the Mayo Clinic as those adults over age 65, can benefit from quitting smoking. Although smoking is recognized as unhealthy in people of all ages, it can cause or exacerbate existing conditions such as chronic obstructive pulmonary disease, cancer and heart disease. Smoking cessation can increase longevity and improve functioning and quality of life.

8,3,Exercise

Mayo Clinic doctors report that exercise is the largest contributing factor that seniors can employ to ensure their independence and mobility. Older patients should consider increasing aerobic and anaerobic activity as they age to improve functioning. Exercise that incorporates 30 minutes to an hour of aerobic and strengthen activities at least three times a week can help to curb diabetes and obesity, maintain cardiovascular functions and increase circulation.

8.4.Nutrition

Malnutrition and obesity are two health problems common in elderly people. Eliminating obesity is considered one of the most effective preventive health care tools to control complications due to chronic diseases. Factors that often influence proper nutrition include effects of other illnesses, senility, dental health and depression. In addition to calcium supplements, seniors are advised to eat a balanced diet, high in fresh fruits and vegetables and whole grains.\

8.5.Vision

Screening for age-related vision problems such as glaucoma, cataracts and macular degeneration are important preventive measures for elderly people. Mayo Clinic researchers report that states that require in-depth vision screening for driver's license renewal have a lower rate of senior accidents and fatalities. Early detection of age-related vision loss can help to prevent more rapid deterioration.

8.6.Hearing

Another aspect of health care prevention for elderly people includes screening for hearing loss. As many as one-third of seniors older than 65 report some level of hearing loss, which can greatly affect quality of life. Older adults often become isolated and neglect social and physical activities when they begin to lose their hearing. Learning to adjust and cope early can help seniors maintain communication skills as their hearing loss worsens.

8.7.Mental

Mental health is important for seniors to maintain in order to comply with preventive health care options and to enjoy a high quality of life. The National Institutes of Health reports that seniors older than 65 are more likely to commit suicide than any other population. Depression, the main cause of suicide, should be watched for in annual exams by family members, caregivers and others who are regularly in contact with seniors.



9.0.Legal and Ethical guidelines



physician and other health care providers use medical and scientific knowledge along with clinical judgment and expertise to provide quality healthcare to keep you functioning and independent for as long as possible. However, in some situations, providing the best care requires choosing among conflicting responsibilities, values, and principles. For example, it may not be possible to provide both safety and independence for a person who has serious mental problems. Moving into an institution would increase safety but reduce independence, while staying at home would maintain independence but at an increased risk of injury. There are legal and ethical guidelines that help address such dilemmas, but reaching decisions in individual circumstances is still often difficult. Regardless, your personal wishes are the most important part of the decision.

Respecting Your Choices

• Informed consent

• Decision-making capability

Having Someone Make Decisions for You

• Advance directives

• Living wills

• Durable power of attorney for health care

• Problems with advance directives

• The importance of communication

• Choosing a surrogate decision maker

Acting in Your Best Interests

Preventing Harm

• Placement issues

• Abuse of older adults

• Guardianship

• Decisions for people in nursing homes

Life-Sustaining Treatments

Do-Not-Resuscitate Orders

Withdrawing Treatment

Tube Feeding

Active Euthanasia

Assisted Suicide

9.1.Respecting Your Choices



Except under extraordinary circumstances, you have the legal right to make decisions about your body and your medical care. Ideally, these decisions should be made by capable, informed patients after discussion with their physicians and other health care providers. This underlying principle of "informed consent" is a legal and ethical practice that underlies medical care and research in the United States. It is based on our society’s respect for independence and self-determination.

9.2.Informed consent



Informed consent is a legal doctrine stating that you have the power to choose among medically reasonable plans for your care. Informed consent requires effective communication between you and your doctor, and to be able to make informed choices, you need to discuss many things (as often as needed), including the following:

• your diagnosis

• the overall outlook (ie, prognosis)

• the nature of the recommended test or treatments

• the various alternatives

• the risks and benefits of each alternative

• likely outcomes of each alternative

Informed consent does not mean that you can or should dictate your care. If a person requests tests or treatments that the medical profession considers useless or harmful, physicians have no obligation to comply. Your health care providers have a duty to use their skills for your benefit and not to harm you. If you and your health care provider disagree about the type of care that you should receive, you should discuss the situation further so that your concerns are made clear and you can reach a decision that is mutually acceptable.







9.3.Informed consent for research

Research into the diseases of aging is needed to improve treatment and increase functional independence, especially in areas like dementia and other mental health problems. However, informed consent becomes especially important when people are asked to try experimental or unproven treatments for research purposes. Unfortunately, truly informed consent can be difficult for older people, because they may have a hard time understanding the risks and benefits of the research. This is especially true for those who have some mental impairment. People living in nursing homes and other institutions are also a vulnerable population, because they may feel pressured and hesitate to speak up with an objection. Older adults should ask as many questions as necessary so that they understand the potential risks and benefits of experimental treatments. You always have the right to refuse without any repercussions.

9.4.Decision-making capability

The process of informed consent makes sense only for people who have the ability to make informed decisions. Adults are presumed to have this capacity when they reach the "age of majority" (usually 18 years of age). This does not change unless the individual is determined to be "incompetent or incapacitated" by a court of law. The terms "incompetent or incapacitated" are legal terms and apply specifically to legal cases in court.

In practical terms, physicians are sometimes asked to evaluate a person’s capacity to make decisions. If a physician believes that a person lacks the ability to make informed decisions about medical care, that person is deemed "incapable." This is significant because it means that decisions will then be made by someone other than the patient.

The term "diminished capacity" generally refers to specific types of decisions, rather than to overall inability to make any decision (Table). For example, you may be capable of making decisions about medical care, but not about finances, or vice versa. This selective definition of capacity (often referred to as a "sliding scale") affords people more protection and self determination. Of course, people who are unconscious or severely mentally impaired may lack capacity to make any decisions.









9.5.Judging the Capacity to Make Decisions



Medical decisions

• ability to understand relevant information

• ability to understand the consequences of the decision

• ability to communicate a decision

Decisions of self-care

• ability to care for oneself or

• ability to accept the needed help to keep oneself safe

Finances

• ability to manage bill payment

• ability to appropriately calculate and monitor funds

Last will and testament

• ability to remember estate plans

• ability to express logic behind choices





Your capacity to make decisions about medical care requires that you realize that there are choices regarding the nature of the recommended care, the alternatives, the risks and benefits, and the likely consequences. This ability to understand the situation may change over time. For example, a person with delirium may be mentally clear in the morning but confused in the evening. Imagine having a high fever that clouds your thinking and makes you feel disoriented. When you are capable of making informed decisions, your choices should be respected. If there are times when you are not capable of making informed decisions, these decisions should be postponed if possible until you have regained your decision-making capacity.

People may be given a formal test to gauge their mental status when their capacity is questionable. However, even if someone performs poorly on a mental-status test or has impaired memory, they may still have the capacity to make informed decisions. In these situations, extra care may be needed to make sure the person understands the risks, benefits, and consequences of the alternative plans of care.

It is important not to confuse decision-making capacity with so-called "rational" decisions. Decisions are often based on cultural, ethnic, or religious values and beliefs that vary from person to person. What is rational to one person might not seem rational to another. For example, a Jehovah’s Witness may view a blood transfusion as unacceptable, even if the alternative is death. Requiring rationality would disqualify people who make highly personal or unconventional decisions. As one court declared in a case that involved the refusal of treatment, beliefs that are "unwise, foolish, or ridiculous" do not render a person incompetent.

9.6.Having Someone Make Decisions for You

If you lose the capacity to make decisions, someone will have to make decisions on your behalf. In this case, the person you designate as a stand-in (ie, surrogate decision maker) should try to comply with any wishes you expressed while you were still capable of making decisions. Your expressed wishes are legally and ethically more important than what others want for you, even if they feel that they are acting in your best interests. Two common types of advance directives (ie, advance care plans) that express your wishes are living wills and durable power of attorney for health care. (States have varying terms to designate durable power of attorney for health care, including health care proxy, health care declaration, etc.) It is also important to remember that advance directives have some limitations.

9.7.Advance directives

Whenever possible, health care providers should respect the informed choices that you have expressed while you were still capable of making decisions. Following these advance directives demonstrates respect for your individuality and self-determination, and is a legal and ethical obligation. Following your advance directives is preferable to following the choices of others, such as family members or other caregivers, unless that is your wish.

Most commonly, advance directives come out of the conversations that you had with relatives, friends, and health care workers while you were still capable. However, these should be documented carefully so that your wishes are specific, clear, and available later if needed. You should provide advance directives in writing whenever possible, because written directives clearly reflect your intention to direct future health care and cannot be readily challenged in court.

9.8.Living wills



Laws or legal opinions that authorize living wills have been enacted throughout the United States. These are often called natural death, death with dignity, or right-to-die laws. Generally, these laws allow you to direct health care providers to withhold or withdraw treatment that is keeping you alive if you become terminally ill and are no longer capable of making decisions. In a few states, an individual may also appoint surrogate decision makers. Legal immunity is given to caregivers who comply with an appropriately drafted living will.

9.9.Durable power of attorney for health care

The durable power of attorney for health care is more flexible and comprehensive than a living will. It allows you to designate a surrogate decision maker, presumably a friend or relative, to make the medical decisions if you lose the ability to make them yourself. You give the surrogate your informed consent (or refusal) while you are still capable. You should discuss with your surrogate ahead of time the types of treatment(s) you would or would not want in specific situations so that your surrogate has some guidelines if the need arises.







9.10.Problems with advance directives

Advance directives have limitations. For example, an older adult may not fully understand treatment options or appreciate the consequences of certain choices. Sometimes, people change their minds after expressing advance directives and forget to inform others. Many times, advance directives are too vague to guide clinical decisions. For example, general statements rejecting "heroic treatments" are vague and do not indicate whether you want a particular treatment for a specific situation (such as antibiotics for pneumonia after a severe stroke). On the other hand, very specific directives for future care may not be useful when situations change in unexpected ways. Similarly, new medical therapies may have become available since an advance directive was given. You and your health care provider can do a great deal to avoid these problems by discussing advance directives with each other.

9.11.The importance of communication

Good communication can resolve many problems posed by advance directives. You and your health care provider should routinely share information on advance directives. A straightforward question you can ask to open the topic is: "Can we talk about how decisions will be made for my medical care in case I become too sick to talk to you directly?"

Ask your health care provider about situations that commonly develop with your particular illness or condition. Ask questions about the various treatments and treatment options. Let your health care provider know your wishes, including your designation of a surrogate decision maker. Also tell your doctor the amount of discretion that you want the surrogate to have and how you will let your surrogate know if you change your mind about something. It is also important for you to have periodic discussions about these issues with family members and friends.



9.12.Choosing a surrogate decision maker



Traditionally, family members act as surrogate decision makers (or stand-ins) for incapacitated individuals, because most probably they best know the person’s preferences and will act in their best interests. Family members are also normally consulted by the health care provider. However, the health care provider may sometimes decide that decisions by family members are questionable because of conflicting personalities, values, or interests. In addition, some family members may be estranged or unwilling to make decisions, or they may disagree among themselves. In other cases, older adults have no surviving relatives.

When there are no relatives or friends to represent you, it may be that your physician (or other health care provider) is the next best choice as your surrogate decision maker. Your physician understands the medical procedures and your condition. Your lawyer is another possibility, but bear in mind that the courts can be cumbersome, expensive, and slow. Furthermore the adversarial legal system and media publicity associated with a case may inappropriately influence both family members and health care providers, or lead to medically unrealistic decisions.



9.13.Acting in Your Best Interests



If you have not given advance directives or appointed a surrogate decision maker, health care providers may have to base decisions on what is in your "best interest," by weighing the benefits and possible problems of treatment. This is a complicated and often controversial process that requires dealing with such personal factors as pain and suffering, safety, and loss of independence, privacy, and dignity. Well-meaning third parties may disagree on how much weight to give to each of these factors, which are often summarized by the phrase "quality of life." In addition, quality-of-life judgments based on assessments of third parties may be unfair or discriminatory, particularly if social worth or economic productivity is considered. For example, life situations that would be intolerable to young, healthy people may be acceptable to older, debilitated people, and vice versa.



9.14.Preventing Harm



Health care providers have a duty to use their expertise for the benefit of the people in their care. However, you retain the right to refuse treatments that your health care provider considers to be in your best interest. Again, good communication with your health care providers can improve your mutual understanding of risks, benefits, and underlying beliefs. (See also Communication.)



9.15.Placement issues



Preventing harm to an individual is often raised in decisions to place someone in a nursing home. An older adult may wish to remain at home, but family member or caregivers may override this decision if they believe that living independently is not safe. However, the crucial ethical question is whether the older adult is capable of making an informed decision about where to live. If so, his or her decision should be respected, even if others believe that it is unwise or foolish, and even if it puts that person at greater risk. Caregivers can try to arrange for in-home supportive services that may greatly improve the situation and decrease risk.



9.16.Abuse of older adults



Family members or other caregivers can sometimes become abusive for a variety of reasons. These may include feeling overwhelmed and burnt out by caregiving responsibilities, lacking appropriate caregiving skills, or having no break from caregiving. The duty to protect older people often justifies intervening in these situations. Older adults may not be able to protect themselves or know how to get help. They may also fear retaliation or be ashamed to admit the abuse. Any concerned person who suspects abuse has an ethical duty to try to determine if the victim has the capacity to make decisions, is informed, and is not being coerced. Some states require physicians and caregivers to report suspected abuse to a protective service agency.

If the older person cannot function without extensive care and must remain at risk, support services may be appropriate. These may include obtaining home care services, counseling the abusive caregiver, or moving the older person to another residence. Supporting services should be offered, although capable individuals may refuse the assistance. If a person is not capable and the abuse seems clear, the physician or caregiver must consider a report to adult protective service agencies or a petition to the court for a new guardian. (See also Elder Mistreatment.)

9.17.Guardianship



Some older people cannot manage their finances or provide themselves with food and shelter. Sometimes, relatives or friends make informal arrangements to help these individuals. In other cases, a capable person has executed a durable power of attorney that appointed another person to handle his or her affairs. In still other cases, it is necessary to ask the courts to appoint a guardian, as when property must be managed or sold to pay for long-term care.

In guardianship hearings, relatives or other petitioners (eg, social service agencies or health care providers) must demonstrate that the person is no longer able to safely manage his or her affairs and needs. If the person is found incompetent or incapacitated, the court appoints a guardian.

All states allow the courts to establish limited guardianships (sometimes called conservatorships) and unlimited guardianships (sometimes called committeeships). A limited guardianship gives the guardian the power to take charge of a specific area that the older person is no longer able to manage (eg, finances). An unlimited guardianship strips the older person of all legal authority and gives the guardian the power to make all the decisions about the older person’s life in matters that affect property, residence, medical care, and personal relationships. Most states prefer limited guardianships, because an unlimited guardianship requires that the court find that the person is legally incompetent or incapacitated in all areas of decision making.

9.18.Decisions for people in nursing homes



Nursing-home residents may need additional safeguards when decisions about life-sustaining treatments are made. These people may not have close relatives to act on their behalf, and their relationships with health care providers may be superficial. There are also fewer caregivers involved in decisions at nursing homes compared with hospitals. In addition, substandard care is sometimes a problem in nursing homes.

The decision to transfer a nursing-home resident to a hospital when their condition worsens is a common dilemma. This is because the goal of treatment for many residents is to relieve discomfort rather than to prolong life. If individuals or their surrogates turn down the transfer to a hospital, their wishes should be respected. It should be a routine part of nursing-home care to discuss these decisions well in advance.

Federal legislation now requires inquiry into advance directives for all patients in institutions (eg, nursing homes) that receive federal funds. This leads to a more systematic approach to discussions about treatment status. Since this law was passed, nursing homes have transferred fewer patients to acute-care hospitals, while maintaining patient and family satisfaction with care.

9.19.Life-Sustaining Treatments



Advances in medical technology have often created medical dilemmas. For example, health care providers may be able to successfully treat a sudden complication in a seriously ill person, but restoring function and improving the underlying disease may be impossible. In such a situation, treatment that only prolongs life may be appropriately withheld. In fact, the doctor may refuse treatment under a variety of situations:

• there is no specific medical rationale for the treatment

• the treatment has proved ineffective for the person

• the person is unconscious and will likely die in a matter of hours or days even if the treatment is given

• the expected survival is virtually zero

The doctor’s discretion in these matters may vary widely across the United States.

An informed person who is capable of making medical decisions may refuse life-sustaining treatment, such as cardiopulmonary resuscitation (CPR), intensive care, transfusions, antibiotics, and artificial feedings. An informed refusal should be respected, even if the person’s life may be shortened as a result and even if the person is not terminally ill or in a coma. When people are not capable of making decisions, two questions need to be considered:

• What standard should be used?

• Who should make the decisions?

9.20.Do-Not-Resuscitate Orders



Cardiopulmonary resuscitation (CPR) may be an effective treatment for unexpected sudden death, but it is not effective for people whose death is expected. Older adults generally do poorly after CPR because of serious illnesses and decreased functional status. In fact, less than 10% of people over 70 survive to be discharged from the hospital after CPR.

When CPR is medically pointless and thus ethically inappropriate, a patient should not be offered the choice between CPR and no CPR. Instead, the physician should generally write a do-not-resuscitate order and explain why CPR is not indicated. In some settings, however, the law may require that physicians offer the option of CPR even when it would be pointless. When CPR might be of benefit, the physician must make sure that all concerned are aware that the likelihood of survival is low even if CPR is administered.

Many people with chronic illnesses do not want CPR, and their informed refusal should be respected. The attending physician should indicate the reasons for the order and plans for further care in the medical record. Note that a do-not-resuscitate order means that only CPR will not be performed–other treatments may still be given. Discussions with your health care providers about do-not-resuscitate orders are excellent opportunities to review your total plan of care, including supportive care and appropriate treatments that would be continued after the do-not-resuscitate order takes effect.

9.21.Withdrawing Treatment



Strange emotional feelings are a natural part of decisions to stop, withdraw, or withhold care. We are torn between the impending sense of loss of our loved ones and our desire that their suffering be relieved and their dignity maintained. Regardless, there is little point in continuing a treatment that is not effective.

Often, people make a distinction between stopping treatment and not starting it in the first place. For example, some people are willing to withhold mechanical support of breathing (ie, use of a ventilator), but are reluctant to discontinue it once it has been started. However, logically, ethically, and legally there is no difference between not starting treatment and stopping it. If you feel that there is an important emotional difference for you between stopping a treatment and not starting one, you should explicitly discuss this with your physician.

9.22.Tube Feeding



Tube feedings clearly benefit people who want or agree to this treatment. In addition, feeding provides more time to diagnose and treat underlying conditions. However, providing artificial nutrition and hydration (ie, fluids) is ethically and legally controversial in severely demented or debilitated individuals who cannot or will not eat. The feeding of helpless people is overloaded with symbolic and emotional significance. Also, it is unknown if these individuals suffer hunger or thirst if tube feedings are withheld.

Artificial feeding can become an even greater problem in severely mentally disturbed individuals who consistently refuse food offered by hand or who are unlikely to suffer hunger or thirst. Tube feedings can also cause medical complications, such as pneumonia if the artificial nutrition is breathed into the lungs.

9.23.Restraints



Because individuals often pull out feeding tubes, demented individuals on tube feedings are often physically restrained (ie, strapped down). This removes what little dignity and independence these people have left. The situation is worsened because demented people usually cannot understand how the treatment benefits them. Restraints are also difficult to consider as humane care. Sedation or "chemical restraint" might seem more acceptable on the surface, but these medications also rob people of dignity and often have unacceptable side effects.

When a person pulls out a feeding tube, everyone involved should reconsider whether the feeding tube is appropriate. If so, a more permanent measure should be considered, such as a tube placed directly in the stomach or intestine. If the goal is to provide comfort, then giving the person more direct attention and affection may be better than trying to increase the intake of nutrients through tube feeding.

The use of restraints in the long-term-care setting has become closely regulated and monitored. Physical restraints have little, if any, value in preventing injuries from falls, and less restrictive alternatives are usually available. Physicians and surrogate decision makers should extensively discuss the legal and ethical implications of using physical or chemical restraint.



9.24.Active Euthanasia



Active euthanasia (also called mercy killing) is illegal in the United States. Requests for it generally arise because individuals suffer uncontrolled pain, demand more control over their care, or fear abandonment. However, many terminally ill people who have requested euthanasia change their minds after pain has been relieved. Self-administered pain medication (eg, by a hand-held morphine pump) can help to both relieve pain and provide a feeling of control, which is central to a person’s comfort.

There is great potential for abuse with active euthanasia. Because of this, opponents say that allowing voluntary euthanasia might all too easily lead to involuntary euthanasia of helpless people. Also, some feel that physician involvement in euthanasia may undermine trust in doctors, because doctors should be viewed as healers, not life takers. However, others believe that there are circumstances when it may be more compassionate to carry out a request for active euthanasia than to have the person continue an existence that is degrading. Such exceptional circumstances include cases in which severe symptoms can be relieved only by causing unconsciousness.

Active euthanasia should be distinguished from the withholding or withdrawal of treatment, which is sometimes termed "allowing to die" or "passive euthanasia." Concern that active euthanasia is unethical should not lead health care providers to continue useless treatments or to reject requests by informed individuals to withhold treatment.

9.25.Assisted Suicide



Statistically, older white men are at a greatly increased risk for suicide. Most suicides are impulsive acts that are not well thought out. Also, people who seriously consider suicide usually suffer from depression. Because individuals who are incapacitated by depression cannot make informed decisions, family and friends are quite likely to get involved and seek medical advice. Physicians have traditionally felt it their duty to intercede to prevent suicide. In addition, many physicians believe that assisted rational suicide is unethical for the same reasons that they oppose active euthanasia. That is to say, they feel that there is a great danger of abuse, that assisted suicide does not fit the role of the physician, and that it undermines a person’s trust in doctors.

For some people, however, suicide might be considered a rational choice. For example, a rational person might consider suicide if he or she has widespread cancer and unbearable symptoms that cannot be improved with medication. A person in this situation may feel that continuing to live with a progressive illness of this type is degrading, and may want to have control over his or her death. He or she might ask the physician how to end their life, or request the medications with which to do so. These are matters of individual conscience.

In most states, the law prohibits assisted suicide. However, the US Supreme Court has decided that physician-assisted suicide is not necessarily unconstitutional, leaving each state to settle the issue for its residents. For example, physician-assisted suicide has been legal in Oregon since 1997, although experience has shown that it is a rarely used alternative. During the 3 years after this legalization, only 91 people opted for assisted suicide out of 90,000 who died in Oregon during that time.



10.0.Coping and Well-Being in elderly people –Memory Complaints



10.1.A Systemic Approach



Older adults frequently complain about memory failures and they often perceive a decline in their memory performance (e.g., Blazer, Hays, Fillenbaum, and Gold 1997 ; Cutler and Grams 1988 ). These complaints, of course, do not occur in a vacuum. It is important to investigate where those complaints come from, how older adults deal with this perceived memory decline, and how these are tied in with the individual's well-being. In the present study, we explore the links between memory complaints, coping, and affective variables, adopting a systemic approach; that is, we examined the flow of influences among complaints, coping, and affect through path analytic procedures.

Although at first sight it seems reasonable to assume that memory complaints are tied to memory abilities, many researchers have found that memory complaints are more closely related to affective and personality variables than to objective performance on memory tests (Barker, Carter, and Jones 1994; Bolla, Lindgren, Bonaccorsy, and Bleeker 1991; Flicker, Ferris, and Reisberg 1993 ; Hanninen et al. 1994 ; Kahn, Zarit, Hilbert, and Niederehe 1975 ; Ponds and Jolles 1996 ). Indeed, the external validity of memory complaints is quite low, that is, complaints and objective performance do not covary much (Christensen 1991 ). Perhaps the strongest evidence for the nonvalidity claim comes from a 4-year longitudinal study, in which changes in memory performance were found not to correlate with self-reports of decline (Taylor, Miller, and Tinklenberg 1992 ).

There are, however, other variables that consistently correlate with frequency of memory complaints. One such variable is the presence of depressive symptoms (Blazer et al. 1997 ; Collins and Abeles 1996 ; Schmand, Jonker, Geerlings, and Lindeboom 1997). Most researchers imply that depression has an impact on memory complaints, rather than the other way around (e.g., Barker, Prior, and Jones 1995 ; Bazzargan and Barbe 1994 ). One possible reason for this is that depression is often related to concentration difficulties and to slower information processing, and these deficits may in turn lead to objective memory problems (La Rue 1992 ). Insofar as the individual picks up these signs of diminished functioning, memory complaints may result.

On the other hand, one could argue equally well for the inverse relation, namely the situation in which memory complaints lead to enhanced feelings of depression. Maybe memory complaints (whatever their origin) are then seen by the subject as a foreboding of worse memory trouble to come, or even as a sign of impending dementia. In a 2-year longitudinal study, Tobiansky, Blizard, Livingston, and Mann 1995 indeed found that memory complaints at the first time of measurement were associated with a higher risk for depression at the second point in time. About 1 out of 4 persons with memory complaints in this study eventually ended up with a diagnosis of either depression or dementia.

Another affective variable that has been found to correlate with memory complaints is anxiety, and more specifically anxiety about possible dementia (e.g.Commissaris et al. 1993 ; Hultsch, Hertzog, Dixon, and Davidson 1988 ). In this case, it is more likely to assume that the complaints cause anxiety, rather than the other way around.

When a person experiences memory problems, be they real or imagined, and especially if these perceived problems are distressing, coping mechanisms, problem-focused or emotion-focused, might be triggered (Folkman 1984 ; Lazarus 1966 , Lazarus 1991 ). Instrumental or problem-focused coping (Lazarus 1966 , Lazarus 1991 ) is action oriented. It aims at actively eliminating or alleviating the underlying problem, in this case the supposed underlying memory deficit. An obvious type of instrumental coping would be to try to improve memory performance by applying efficient external and internal memory strategies. There is some evidence that older adults indeed spontaneously engage in such activities. For instance, Ponds, Bruning, and Jolles 1992 found that older people who chose to participate in memory training not only complained more about memory failures but also were more likely to use internal strategies than were noncomplainers, even prior to the training program.

Emotion-focused or cognitive coping (Lazarus 1966 , Lazarus 1991 ) involves internal restructuring rather than acting. It is aimed at reducing the emotional distress associated with the problem, without actually changing the distressing situation. According to coping theories, such emotion-focused coping will be particularly important when the individual perceives the situation as being uncontrollable (Folkman 1984 ). One mechanism for cognitive coping might be social comparison, that is, one tries to find out whether selected age peers experience the same problems. Such social comparison is a coping technique older adults often use with regard to health issues or for coping with the aging process in general (Dittmann-Kohli 1990 ; Heidrich and Ryff 1993 ). In an exploratory interview study about memory complaints, Swaegers 1996 indeed found that almost all of her interviewees (28 out of 30) engaged in such explicit social comparison by sharing instances of personal memory failures with friends and acquaintances of similar age. Very often, episodes of memory failure were told as funny anecdotes, presumably to defuse them of possibly negative meaning for the self.

Clearly, then, memory complaints do not occur in a psychological vacuum. They are embedded in an affective and cognitive context, and people might act on them by using a diversity of coping mechanisms. It seems that for a good understanding of the function and significance of memory complaints in later adulthood, one needs to take this embeddedness into account.

Of course, the concept of memory complaint in and of itself is slightly more complex than we have suggested here. For instance, the two scales for memory complaints in adulthood most often used in research, the Memory Functioning Questionnaire (MFQ; Gilewski, Zelinski, Schaie, and Thompson 1983 ) and the Metamemory In Adulthood Scale (MIA; Dixon and Hultsch 1984 ), both consist of different subscales that can be separated by factor analysis (Hultsch, Hertzog, Dixon, and Davidson 1988 ). For instance, the MIA has different subscales for Capacity (the perception of memory capacities as relevant to certain tasks; this scale can also be interpreted as the inverse of frequency of memory complaints), Change (the perception of one's own memory as being stable or as subject to decline), and Locus of Control (the perceived control one has over one's own memory abilities). The original authors consider these three scales as indicative of a single, higher order construct labeled Memory Self-Efficacy (MSE). Apart from the MSE scales, the MIA also probes for knowledge about basic memory processes (Task), Strategy use, memory-related Anxiety, and perceived importance of a good memory in particular situations (Achievement).

Thus, there is complexity, both at the level of memory complaints themselves and at the level of its correlates. The present study was designed to investigate the mechanisms of multidimensionality and the relation between complaints and their context of coping and affect. In conducting this analysis, we adopted a systemic approach, that is, we investigated the flow of influence between variables by conducting a path analysis on correlational data. The variables included were those mentioned in the literature review above, namely (a) memory complaints, (b) anxiety and depression/dysphoria as affective correlates (a broader index of psychological well-being was included as well), and (c) strategy and social comparison as coping mechanisms. Memory complaints were measured by the MSE subscales of the MIA. Because both Commissaris and colleagues 1993 and Swaegers 1996 suggested that fear of dementia might be distinct from anxiety about memory in general, a self-constructed Dementia Anxiety scale was included. Because the primary determinant of coping is the distress experienced by a stressor (Lazarus 1966 ), we also included a self-constructed Seriousness of Complaint scale, which probed for distress caused by memory problems in both private and social contexts.

To our knowledge, the present study is the first to use such a broad variety of measures. Hence, we considered this study as mainly exploratory and treated the data as such. No preconceived structure was imposed on our path analysis. Rather, we used exploratory fitting procedures to examine the relationships between the variables.



10.2.Coping with the elderly people



The problem of coping with the elderly people is not just found in their poor health, bad mental attitude, and a philosophy of life that runs against the grain. The people who deal with the elderly people must also have some knowledge of the problems of older people and some ability to deal with these problems. Elderly people are not perfect either; and the people who deals with them sometimes lack understanding, patience, and tolerance.

The ten years we took care of my elderly mother were some of the best years of our lives, because my mother was a jewel. Every night I could hear her say her prayers: "Dear Heavenly Father, help me to be a good person and not to be a burden on my son and his wife. Let me carry myself so that I will not make life hard for my loved ones." Mother made it easy for us even when she was desperately ill and unable to take care of the simple functions of life.

Here are some suggestions for dealing with elderly people that I have gleaned from working with my mother, my Christian brothers(elders) and innumerable ladies and gentlemen from the church and life who are older than I am:

10.3.Do not expect old people to be much different from any other age. Some old people can become very childish; but, some young people are very childish also. I do not believe that people change much by getting old. A stubborn young person becomes a cantankerous old one. A life-time of evil character does not suddenly become sweet and innocent with age. People can change at any age, if they want to; but they don't automatically change for the better just because they grow old.

One day I pondered this problem: "Why is it that people who have been driving for 50 years are often worse than someone who has been driving for a few months. Doesn't practice make perfect?" No! Practice does not make perfect, because we often practice our errors, and without proper feedback we cannot correct them. A person who has been driving for 50 years can be a lousy driver if he or she continues to perpetuate bad driving skills.

Just because a person has lived long, don't expect to find a saint or a perfect person. Accept people, even old ones, like they are.

10.4.Give honor and respect to those who are old. Of course I feel that everyone in existence deserves honor and respect. I make it a practice to not despise any of God's creatures, no matter how small or deformed or worn out.

One day I watched a nurse delighting in the experience of changing the diapers of a baby. The baby giggled as the nurse cooed, and extolled the virtues of the potty. Then she kissed the infant on her stomach and the bottoms of her feet as she carefully washed, wiped, oiled, and powdered her. She wrapped the baby in a blanket and with a little squeeze exclaimed, "There, you little precious one, that will make you feel better."

As it happened, I stood outside the room as the same nurse changed the bed of an old lady who had messed in it. The nurse called her every name in the book, jerked her around, and said such things as: "You make me puke, you dirty old bag. If I had my way, I'd let you lay in it." The nurse had no compassion or understanding in her care of an injured older person.

Frankly, an old person who is incontinent does not deserve any less respect than a baby who is not yet potty trained. We need to show respect for those who have lived long on the face of this earth. If we do, when we get in that condition, people will be more likely to show respect for us.

10.5.Learn to love older people. Anyone can love the young and beautiful, particularly when the hormones flow. Young love does exist but it is often confused with passion. To love an older person comes closer to true love. Of course, it is a pleasure to deal with an old person who is sweet, lovely, intelligent, and self-sufficient. Anyone can do that. It takes real character to love those who don't love us, and especially to love those who aren't lovable. So, if the person you are dealing with is an impossible old man or old woman, rise to the occasion and be challenged to treat them especially well.

10.6.Be careful about correcting an old person's opinion. The old person may be wrong; but again, you may be wrong. He or she has lived a long time and his or her opinion is worth the consideration of age. Many times, when my mother was in her eighties, she would give me advice. Usually, sorry to say, I would argue with her and tell her why I couldn't do this or that. As I look back on it, she was right. Every single time she was right. I just did not have the good sense or the flexibility to accept her counsel. Here is one of the times I would like to live life over and listen carefully to an old person who loves me.

10.7.Treat old people just like you want to be treated when you get old. When I was growing up we had a special friend in the family who had little consideration for her parents. She abandoned her parents and dumped them into a poor house (we no longer use that terminology). As a grown man, I watched her children do the same thing to her. They put her away in an indecent, poorly cared-for institution. Now that I am old, I am watching the third generation do to the second generation what the second generation did to the first. If you want to perpetuate cruelty to the second and third generation, then treat your old folks cruelly. Your children will treat you like you treated your parents, and on and on it goes.

10.8.Old folks love to laugh. I learned that older people have a priceless sense of humor when I taught in adult class during Sunday school in my church Holiness power bible ministries in Nigeria some months ago. The teachers who came before me interpreted the older look as the serious look it is not true. More than any other age, older people have a sense of humor. As I write these lines brother Emmanuel Onuaha is an old man of 70, people love to laugh with him, and he loves to laugh. Perhaps that is why he has lived so long.

10.9.Visit the old people. One day I was walking down the corridors of a hospital and I heard an old man crying out, "Nurse, nurse, I'm lonely. Oh nurse, I am so lonely." His cry haunts me to this day. So, whenever I have a chance, I visit my old friends and try to alleviate their loneliness.

At another time I was visiting old friends in a nursing home when I heard the quiet sobs of a little old lady in a corner bed. She had outlived all her relatives. She was blind and very emaciated. Her bony fingers clawed feebly at the air as she moaned for a husband who wasn't there. I walked over to her bed, sat down, took her hand, and held it for two hours. She knew I wasn't her husband and since she couldn't see or hear she didn't know who I was. But, she did know that someone cared as she walked alone down the scary path to death.

The Bible very clearly tell us, "Honor your father and mother" (older people), which is the first commandment with promise "that it may be well with you and you may live long on the earth." This principle of honor is the major way of dealing with our senior citizens--not just because I am one, but because it is the best way of dealing with older people.

11.0.Coping with Loneliness

Loneliness generally occurs at certain times in one’s life especially in old age, retirement, bereaved. Get busy with other things this helps to provide an effective means of dealing with loneliness.

11.1.0.Things to do when Lonely

11.1.1.Keep busy

If you are lonely, do things that one does regularly. live each day with enthusiasm and optimism, go for walks, write letters, visit people, fix something, take up a hobby, become a collector. Learn to be internet savvy, you will find a heap of information here. Be involved in everything that attracts your attention–even the smallest little thing–this can soon grow into a significant projects. Happy people are usually busy people. Busy with any small thing. Cure loneliness by keeping busy.

11.1.2. Involve yourself

If you are lonely, involve yourself in your community. A temple or for that matter any place of worship maybe a good place. There is always something to do. Retired people they find themselves in a precarious condition. Some just sit in a chair staring into space or watch TV. This kind of mental attitude can make a person very lonely. And, if he/she continues like this there will come a time when loneliness will become a full time occupation.

11.1.3.Help others

In your loneliness, look for and strive to cure the loneliness of others–it will cure your own. Give support to some of those people who made no provisions for old age. There are so many people who need help–find them and help them.

11.1.4.Don’t be an escapeist

If you are lonely, don’t day dreaming, don’t sleep too much or watch too much TV. Too much sleep is an escape mechanism. We can find ourselves fleeing from guilt, responsibility, failure, and hopelessness. Don’t turn to alcohol–it only makes matters worse.

11.1.5.Choose to be happy

Loneliness causes depression and unhappiness. Fight unhappiness with a direct attack of the will–try to be happy in spite of the circumstances. You should tell yourself that unhappiness will not make things better. It just makes things worse. So choose to be happy. Fight depression by talking out your problems. If alcoholics can join a group and get control of their drinking, you can join a group and get control of your depression. Talk to people, a counselor, and get into an attitude of optimism.

11.1.6.Collect good thoughts

If you are lonely, listen to good music read inspirational thoughts, jokes, poems, and literary works. Join a library, read good books, if you can, if you have sight problems get someone read to you. You can even go to bookshops and browse around for sometime.

11.1.7.Join a social group

There are so many groups today, join one of the many social groups in your community. Visit the Senior Citizen meetings regularly and meet new people. You will find many individuals there that are involved in social gatherings of various types. Commit yourself to one or more groups that you find of interest. Go to a garden close by your home, this is where a lot of elders ‘Hang out’. There are also laughing groups in many cities now.

11.1.8.Go to place of worship

If you are lonely, this is one place that attracts seniors, as now is the time to devote to God. All your duties and obligations in life are over. Now is the time to do things for yourself for peace and serenity.

Think up, think out, toward people, think around, toward all the exciting things of life, and avoid thinking too much about yourself, and the problem of loneliness will disappear.

12.0.Old age health problems

Old age health problems may start as early as 40 years age, but one is much concerned about them later at the age of 60. The reason here could be related to retirement, the general body weakness, and of course the fear of death.

Chronic diseasses,such as; hypertension, heart problems, prostate, irritable bowl syndrome and gout, are among other common problems that the elderly people do suffer. It is vital that one learns something about these diseases; asking questions at a family practice is the best, but you can also search about it in the internet where information for the patient and for the doctor is available. When you have had enough information then you will know what to do for each of the diseases detailed here below:

12.1.High Blood Pressure:

The most important routine here is to see the doctor every month. Normally the doctor prescribes the drug for you and monitors your blood pressure over one week. When he is convinced that your blood pressure is controlled then he asks you to see him every month. But sometmes a drug that was controlling your blood pressure effectively becomes not suitable for you. Why? I do not know but this happened to me. Initially I was on 'Tenormin' which controlled my blood pressure satisfactorily. However, on one of my routine visits to the doctor he told me that my blood pressure was high. He asked me if I was taking the medicine regularly. In fact I was so he arranged for a daily check of blood pressure with the nurse. Surprisingly my blood pressure was high. Then the doctor changed the medicine and monitored the readings for another week before I continued on my routine again. What I would like to emphasise here is the importance of the routine check with the doctor. Having an electronic blood pressure machine at home is not enough.Besides this precaution one needs to support the medicine with a reasonable exercise. Mine is walking; I walk for 30 minutes every morning. It is also essential that one should have a special diet: much of vegetables and fruits and small amounts of meat. And remember that hypertension is called 'the silent killer'. In order to find out what it is doing silently see your doctor regularly.





12.2.Heart problems:

This is another serious problem that requires regular visits to the doctor. Heart problems are many, but your doctor is the only person who should tell you how serious is yours and what to do. Here you also need to get some information either from the doctor or from the internet. Again exercise and diet are necessary but suggest what you want to do to the doctor and he should tell you what whether it is good or not.

12.3.Prostate Problem:

This is an irritating one intially as you start to find difficulty in urinating and that symptom is the one that takes you to the doctor. The doctor puts you on pills that improve urinating from the second day. normally people continue taking pills for one or two weeks and they stop though the doctor advised a duration of six months. Then one gets problems of frequency and urgency. Then you visit the doctor again and this time you take your pills regularly for the duration advised by the doctor. I know of a close friend with this problem and he was adviced by the doctor that he should see him routinely every three months, and do a blood test every six month. This test, as the doctor told him, to detect any malignancy in your prostate. There isn't much one can do about it but to follow the doctors instructions carefully. I envy the females for not having this problem.

12.4.Irritable Bowl Syndrome:

This is really a pain in the neck as the list of things you should not eat is very long. For example, I know watermelon is not good for you if you have this disease, but when I find it in front of me I cannot do without taking one or two pieces. Unfortunately you will regret doing that after one or two hours. It is normally aggravated by anxiety, and eating certain things mainly the fruits: orange, mango, watermelon. There are some drugs which you can take and enjoy eating. But sometimes the colon might be irritated to an extent that you cannot eat anything. In such cases I stop eating normally and eat bread and bee honey for two days. I always go back to my normal routine after three days. The advice of my doctor is not to stop eating something because it was not good for somebody; rather eat and make your own list of things you should not eat.

12.5.Gout:

Some people in our culture call this disease the 'King's disease'. In explanation to this they say that kings eat a lot of meat and other food products that increase the uric acid. I also have an explanation. When you get a gout attack you will not be able to sleep because of the severe pain that cannot be relieved until you take certain medicine for one or two days. In fact when you get the gout attack on your feet you are bed-ridden and cannot even go to the toilet. My explanation for 'King's disease' is that because kings are not fair and cause a lot of pain to many people God gives them this pain to appreciate the suffering of others. For gout the advice of the doctor is that you stop eating meat with exception of chicken and fish. There is also a tablet of 'Zairolic acid' which one should take regularly.

13.0.Coping with forgetfulness in Old age

Age associated forgetfulness is a common disease entity which we have encountered with our own family members or in elderly individuals whom we have associated. The initial episodes will be nothing more than forgetting the place where they kept their glasses, but with time, the loss of memory will take its toll.

13.1.Forgetfulness in the elderly-Causes

Brain cells, as with all natural occurrences, becomes dysfunctional and atrophied with age. Certain individuals are more susceptible in experiencing this brain cell atrophy than others. They may have,

1. Genetic susceptibility

2. Repeated ischemic events

3. Under nourished

4. Brian related injuries

When the forgetfulness becomes extreme, it can make the patient as well as the care givers frustrated and emotionally subdued in their daily activities. This situation will adversely affect these patients and promote the memory deterioration to accelerate.

13.2.Characteristics of age related forgetfulness?

In order to take adequate measures to minimize the episodes of forgetfulness and its adverse effects on daily functioning, the caregivers need to understand several principles in age related forgetfulness. These are,

• Short term memory is affected more than the long term memory

• Memory will be able to cope with routines and schedules

• Memory will fail in comprehending complex images and situations

Accordingly, following steps can be taken to cope with the age related forgetfulness.





13.3.0.Strategies used to cope with the age related forgetfulness?

13.3.1.Arranging their surroundings to be as simple as possible

This will eliminate the need to comprehend complex tasks and rather focus on simple and mapped out layouts. This will enable the loved one to navigate the surrounding much more easily and keep track of what is available in which places.

13.3.2.Labeling the items they use and places of importance

You can label the drawers and doors as well as equipment and containers to stimulate their memory more quickly and efficiently. The labeling should be done clearly and in large text. It would be a good idea to make use of pictures and symbols as well.

13.3.3.Give a nourishing diet with fruits and vegetable

The progressive cell death that is happening in the brain does have a relationship with the long term nutritional status of an individual. Therefore, a balanced healthy diet with adequate amounts of fruits and vegetables is vital in building resistance to the ongoing process.

13.3.4. Promote breathing exercises that will increase circulation and perfusion

Oxygenating the circulating blood through breathing exercises will enable the brain to receive adequate amounts of oxygen for the proper functioning of the brain cells and it will eliminate the free radicals that could harm the cells in the brain tissue.

13.3.5.Use schedules and time tables.

These will help in carrying out daily rituals as well as attending important events. Even though these might be of use in the early stages of forgetfulness, it might not be as useful later on.

13.3.6. Indulge in memory stimulating activities

Trying to learn new things and playing mind stimulating games would be helpful in keeping the memory in an active mode and enabling cross links to be made within the neuronal system.

13.3.7.Alter the social habits in communication and interaction

When a person suffering from forgetfulness interacts with society, they can benefit a lot by giving the full attention when someone talks, listening while others are talking and talking when others are silent. Therefore, susceptible individuals need to be educated about their condition and practice these methods when they interact with the society.

13.3.8.Writing down things

This will enable a person to keep track of things rather than trying to remember everything. Following these steps and using modern day medications to delay the occurrence of the inevitable, the elderly individuals with forgetfulness can live a life without frustration and with improved quality.

14.0.Forgetfulness attribute to the aging process

It is often disheartening to watch our loved ones cope with the problems of aging. Many of them seem to slow down right before our very eyes and we feel powerless to help them. Many people attribute forgetfulness to the aging process. While it's true that aging can present additional reasons for disruptions in neurological functions, the tips for dealing with the myriad bits of information we must all juggle on a daily basis are very similar for all age groups. Perhaps the following suggestions can help an older person hold onto vital information in day to day living.

14.1.Make a progressive list

Write down everything you need to do, preferably in one central location, as soon as you realize you need to do it. Check off items as you accomplish them or move them forward to the next day's list if they are incomplete. Make this list as thorough as it needs to be. If the only way the laundry gets done is by putting it on the list to complete and scratch off, by all means, write it down.

14.2.Keep accurate records

Use an address book for names, addresses and phone numbers for everyone you need to contact for any reason whatsoever. Don't trust your memory, even if it's good, to recall miniscule details. Use one centralized location for storing these record keeping books.

14.3. Develop an organized system for your stuff

Put you keys in the basket where they belong; keep your purse on the counter; put your glasses on the nightstand. Be consistent. Don't drop things haphazardly as you go along or you'll never remember where they are. This issue applies to young and old alike.

14.4.Adhere to a regular exercise program

Physical activity sends oxygen to your brain and lowers your risk for physical disorders that can affect memory and concentration, such as diabetes or heart disease. As an added bonus, exercise releases the feel good neurotransmitter serotonin that will lift your mood and improve your memory.









14.5.Find outlets for your stress

The stress hormone, cortisol, can lead to malfunctions of the neurotransmitters in the brain. If you can find a way to manage the things that bring stress to your life, you'll go a long way eliminating its negative effects on your memory.

14.6.Cultivate a healthy sleep schedule

Insomnia and sleep apnea disrupt memory and concentration. Allow yourself adequate time to devote to rest and sleep each night. If you can't control the conditions that disrupt your normal sleep cycle, see your doctor for more help. Nothing produces confusion and forgetfulness faster than chronic exhaustion.

14.7.Eliminate the bad habits

Smoking, alcohol use or other drugs constrict blood vessels and arteries, making it more difficult for oxygen to be delivered to the brain. A lifetime of these habits will surely be reflected in your ability to remember details. There's no time like the present to put a stop to these habits.

14.8.Keep your friends

Social relationships keep your brain engaged with challenging conversations and wards off depression and the negative effects of isolation. Keep people in your life everyday. Join a club, go to church, visit friends and invite family to visit you. The stimulation of interacting with others will keep your mind sharp.

14.9.Make your brain work for you

Work crossword puzzles; learn a new skill; read challenging novels or newspapers. Challenge your brain to think about more than just the mundane parts of life. In other words, "use it or lose it!" Forgetfulness is a common concern at all stages of life. While it may increase as we age, it does not have to be grudgingly accepted. Taking steps now to improve your memory and concentration will pay off long into the future.

15.0.Battle plan to fight aging

Keep everything in the same place, write yourself reminders and accept the fact your memory wanes as you grow older. Mapping out ways to overcome this obstacle is part of the battle plan to fight aging. When old you are likely to misplace your glasses and will be astonished to later find them on your head. When this happens reach up and see if your crown is wearing your glasses. If not try to remember where you were when you last wore them. Another thing we go into a room and forget why we went. The solution? We go back where we started from and then it dawns. We go again and find the book, the car keys, the note pad, or whatever, and then we pick up where we left off before we were so rudely interrupted by the aging process.

Knowing acquaintances and not remembering their name is common to all ages but is more so when old. If you really want to remember them the next time you meet, associate their name in your mind with some familiar object. As an example, if the person is named Amy McCall then think of her as the paper doll friend. You remember when in elementary school at her birthday party you gave her paper dolls as a gift. Associate your past friends with some idea of the past that helps you easily recall their name. Another example: Bob Groom reminds you of a horse not that he resembles one but that his last name suggests grooming. Bob himself was always well groomed.

The sillier the association is, the easier it is to remember. Your friends will be amazed that you can still remember their name when they have forgotten yours. You do not have to divulge your secret pet names for your friends. However, if they are having the same problem, and if they are old as you, they probably are, you can tell how to remember people, places and things.

Remembering begins at first meetings. Take the spelling of words. It is annoying at any age to have to repeatedly look up frequently used words. Therefore, as a past time and an antidote against this annoyance, attempt to make the first look up the last one you will need. This will make writing and the recall of correct spelling easier. With the spell checker on your writing software, regaining your spelling acumen is easy. Don't just correct it, but give it a good going over so the next time you meet that peculiar word, you will not have to waste time with it.

Thanks to this practice I can now glide past entrepreneur, Mediterranean and Massachusetts, easily. Just now in my showing off I was stumped when I attempted to do the same with Connecticut. It is not pronounced exactly as it is spelled. I will have to relearn syllable by syllable. Con-nec-ti-cut. What threw me off was forgetting exactly where the ti went. To remember this word you have to grab it by the throat and cut off its neck tie! Con is the hand you grab with, and you yank at the nec and ti cut. A word of caution, don't try this with people and their names! Ty Necchi Hardy would most likely not appreciate it. Remembering is making the effort to do so. You will not always be successful, but it is more rewarding and more fun than giving in and fretting about the problem. There are solutions to all problems of old age and forgetfulness is only one of them. This is an easier problem than most. I am offering suggestions, but I know you can come up with your own style of remembering. It is not only useful; it is a fun way to pass time when you've nothing better to do.

Learning numbers takes another approach. You must place firmly in your mind where 0 to 9 numbers are in your telephone numbers, as an example. Are they before or after. Do they run down the hill or up the hill? The number 432, as an example, is an easy tro to remember. You go downhill. 432-6810. Here you do first a one step, then a two-step dance to remember your phone number. You step back one from 4 to 2 and then again to 3. You pause and at the count of 6 you take two steps to 8 then two more steps to ten.

16.0.Recommendations for preventing forgetfulness in Old age

The following are some recommendations for preventing forgetfulness in old age:

16.1.Write everything down.

Buy an appointment or date book for your home as well as to keep with you. Write all appointments down. If you doctor's appointments; write them on both calendars so you do not forget.

16.2.Make a "To-Do" list.

If you need items from the pharmacist, etc., or someone will be picking them up for you, write them down as you think of them.

16.3.Keep a Refrigerator List

There are small magnetics that you can place on the refrigerator. When you see that you are low on something, add it to this list. When you go to the market (or someone goes for you); you will have a list of the necessities

Many people are forgetful even before old age, so these tips can work for almost everyone. The following are some recommendations for preventing forgetfulness:

16.4.Write everything down.

Buy an appointment or date book for your home as well as to keep in your briefcase or purse. Write all appointments down. If you doctor's appointments; write them on both calendars so you do not forget.

16.5. Make a "To-Do" list.

If you need items from the grocers or someone will be purchasing them for you; write them down as you think of them; even if you are not completely out, but will need them in the next few weeks.

16.6.Keep a Refrigerator List

There are small magnetics that you can place on the refrigerator. When you see that you are low on something, add it to this list. When you go to the market (or someone goes for you); you will have a list of the necessities even if you are not out yet.

16.7.Changes in the Body

If you start feeling strangely in any part of your body, or you have pain or discomfort; write this down so you can share it with your doctor. Do not wait until the appointment if the pain is unbearable. Contact the advice nurse. Your physician will ask you whether there is anything that you want to discuss, so do keep notes of any changes.

16.8.Informational List

If you are to share something with a family member or friend; make a note. For example, if a friend or family member has died; write this down and also the date and time. You do not have to make a separate list; you can also add this to your "To-Do" list or just make a note and place it by your telephone.

16.9.Birthday List

If you normally send cards or gifts to family and friends; write down their birthdays or put it on your calendars. It is very helpful when you can look a month ahead to know whose birthday you should remember. It also helps in budgeting if you are on a fixed income to plan ahead.

16.10. Christmas List

Similar to the Birthday list. Planning ahead as to who and what you will buy during the holidays is very important. Even if you just send cards; getting the addresses and stamps ahead of time will prevent last-minute lines in the post office.

16.11.Telephone and Address Book

Make sure you have a phone and address book. In case of emergency, place a listing of family members and close friend's telephone numbers, as well as doctors, police and fire department, etc., near your telephone. If possible, also include a neighbor's telephone number.

Make sure your eye glasses have an eye glass holder or neck straps so you can always know where they are. It is also wise to purchase two pair when you buy them; if one breaks; you do not have to be inconvenienced.

Place all important items in a convenient place. For example, door and car keys should always be in the same area. Things that you wear or use often, for example, your walking shoes should always be in the same place.

Try to keep the mind mentally sharp by doing crossword puzzles or reading as much as possible. If you enjoy playing cards, find others who also enjoy them. There are also card games that you can play alone, for example, solitaire.

The most important thing to remember is to write, write, and write. If you don't feel up to writing it down; tell your family member or caretaker each time you think of something. Do not try to leave everything to memory; it's impossible.

Forgetfulness will happen on occasion to all of us regardless of age. But, when forgetfulness applies to our old-age, our short term memory lapses and reboots itself within moments or perhaps a short time later and we can recall what it was that we forgot. Usually, it becomes quite consistent. This is called age-related memory loss.

We forget where we put our keys once in a while, we wonder if we locked the door when we left the house or perhaps question whether we shut the stove off after we had been cooking. Did we blow out the candles? Where did I set my purse down? You get the point...right? Age-related memory loss is when a person forgets but is able to later recall what they forgot. This differs from Dementia and the effects of Alzheimer's Disease when an individual can no longer recall certain aspects of life or normal everyday living memory requirements both short and long term.

From the age of twenty brain cells diminish but are reproduced. As we age the brain cells cease reproduction thus causing the lapse in short term memory recall. Simply forgetting where you put your keys, left your mail, or misplaced your cell phone is something we all experience. But, as we grow older according to our chronological age we are changing biologically, physiologically and psychologically; we tend to start forgetting more little things. Sometimes others around you will notice before you do and this is quite helpful as well; so don't resent the ones that love you and bring this to your attention.

It is quite useful to develop some memory techniques such as saying something out loud like; "I just put my keys next to the front door". Another tip is to be more routine by keeping your keys in the same place all of the time. From experience within my own family someone constantly misplaces or leaves their wallet/purse at stores when shopping. I made the suggestion to get a purse that has the long strap to keep around her shoulder so she would not set it down. This is something I already practice. Carrying an organizer or date book to journal what you have done or are planning to do is very helpful for anyone. The most important tip is to try not to be hard on yourself or the individual who is experiencing forgetfulness or age-related memory loss. Find ways that are conducive to the person's lifestyle to cope with the forgetfulness.

Laughter is the best medicine! Try not to belittle or make the person who is experiencing this lapse of memory recall feel as though it is the end of the world or that life can not be fruitful because it can be with small implemented memory techniques. Meet them where they are and walk with them along the way. We have all experienced forgetting something. Think about how frustrating it gets especially when you said you would put that important document in that important place and can't seem to remember where the important place is. It sounds funny; so laugh; perhaps keep that important place in the same place; make that important place a place to remember. Overall, be helpful and encouraging.

17.0.Short-term and Long-term memory

Memory is something that's often taken for granted. It allows us to simply recall information we've been given, experiences we've had and things we've witnessed. Despite it's easy placement in our lives, it's something that's imperative to the highest quality of life. When forgetfulness starts to occur, there are things that can be done to compensate. It's possible to live very well even if you can't remember your keys without applying some tips from this paper. Keep in mind that forgetfulness can effect short-term and long-term memory. The short-term memory refers to anything remembered after a second to a few minutes. The long-term memory can go as far back as your first memory, and it involves the things that are consciously remembered for whatever reason. These tips can help with both memory lapses.

17.1.Lists

Do not underestimate the importance of a list. Use lists for everything once forgetfulness is first noticed. Make a list for groceries. Another list should be kept for all the tasks that need to be done in the day. One can use pretty paper that makes the task of consistent list-making more pleasant, or a simply yellow legal pad works well.

17.2.Helping the Problem

Brain exercises also help in old age. Novelty and sensory stimulation are what consists of the basis for brain exercising. There are books devoted to the subject, and there are even video games if one can convince the older person to play them. It doesn't have to be that complicated. It can start with something so simple as trying to involve all of one's senses in the reading of a book or magazine article. He should try to smell the smells, speak the words aloud, and continue on in this manner.

17.3.Large Print Organizer

Similar to the benefit of lists, an organizer helps keep track of the daily tasks one needs to do. More importantly, it helps keep track of doctor's appointments and other important dates. A to-do list can even be placed as part of the book for the day. Encourage crossing out a day once it's completed for easy visibility of the current date and tasks. Place the owner's name, address and contact information in the front to make sure that it stays with her.

17.4.Supporters

One who is forgetful should surround herself with friends and family members that understand the problem. Explain the situation. Make sure that those around know what might be some trigger words to help guide you back to the memory. Another reason for this is so that the forgetfulness can be overlooked in public if you prefer others not know about the situation.

17.5.Post-it Notes

For the person who is truly forgetful, make good use of the inexpensive post-it notes. They often come in bulk for businesses so use them generously all over the house in the forgetfulness is quite severe. Label food items clearly with perishable dates so the person doesn't forget or overlook it. Label important things with notes not to move them. Label lots of things that can help trigger a memory or that you want to protect in the case of a memory lapse.

17.6.Patience Makes Perfect

Forgetfulness is a frustrating thing. The most important aspect of this situation is setting the tone for how others (or the older person herself) may react. Approach it with a positive attitude. It's simply a temporary situation, and it's a battle to win. Accentuating progress and methods of helping the situation will go a long way to improving the quality of life for someone with frequent forgetfulness.

18.0.Coping with Memory Loss & Forgetfulness as we Age

An ever-increasing problem in industrialized nations is dementia and memory loss as we age. Many might chalk forgetfulness up to getting old or just a bad memory, but studies are beginning to show that many of our societies' new processing techniques for foods, man made additives, synthesized medications, and constant exposure to countless neurotoxins over a lifetime may be the real cause of this sudden influx of mental failure in aged adults. In short, by the time we age our bodies are so polluted that they begin to break down and loose ability to function normally.

So what are we to do if the damage is done and we (or someone we love) are suffering from the beginnings of memory loss?

The first step is accepting that our mental health is directly affected by our environment & nutrition (so we may be ruining ourselves). Understanding the causes of memory loss and forgetfulness can be a powerful tool in aiding prevention of further loss of faculties, as well as increase our ability to maintain and/or improve what abilities we have left. Limiting or eliminating certain exposures that aggravate and/or contribute to weakening of our cognitive abilities, can go a long way toward (not just coping with but)being proactive about forgetfulness as we age.

18.1.Neurotoxins:

Neurotoxins are chemical substances that adversely affect structures or functions of the nervous system, eventually leading to chronic disease and/or encephalopathy (diseases of the brain). The range of affects a neurotoxin has on the nervous depends on the molecular structure of the neurotoxin chemical as well as the specific function and structure of the nervous system tissue. (Patricia M. Rodier, 2004). For example, neurotoxins acting on the Central Nervous System impair neurotransmission in the brain. They are also known to affect the spinal cord causing confusion, irritability, fatigue and other behavioral changes. Neurotoxins that affect the Peripheral Nervous System impair neurotransmission in biological systems. The results are varying levels of weakness, loss of motor control, and prickling/tingling in the limbs.

Neurotoxins seriously impact our mental & physical health and should be avoided as much as possible. Things containing the neurotoxins offspring should be avoided also (although doing so takes research and commitment). Also realize that many neurotoxins are naturally occurring in plants, animals, and even our selves. Our bodies have ways of regulating their levels due to the gifts of evolution. It is the excessive exposure, manipulated forms, & man made neurotoxins that are the culprit.

18.2.For example:

Ammonia is a neurotoxin that our bodies naturally produce. At physiologic pH, it exists mainly as ammonium ion. Excess ammonia is excreted (thanks to the liver) in the form of urea.

It might be surprising that ammonia can be found (under many names & forms) in everything from window cleaner, to food (in the form of ammonium chloride). A study by the Departments of Medicine, Biochemistry, and Surgery, Emory University School of Medicine, and the Clinical Research Facility, Emory University Hospital, Atlanta, Georgia, tested 64 foods for ammonia. Nearly all the foods tested had some level of ammonia in them. Twenty-two of those foods had ammonia concentrations that made up 3-23% of their total nitrogen content. Researchers observed that in eight of the foods studied just one serving contained enough ammonia to contribute toward hyperammonemia (ammonia overdose) in those with weakened liver function.

Note: Strangely aspirin is a reoccurring factor in ammonia overdose via Reye Syndrome (associated with Aspirin) and more commonly Salicylate (associated with aspirin overdose).

Changing our behavior and choices can greatly improve our life styles and environment toward healthier living. For example, avoiding high ammonia containing foods, using vinegar & water in place of window cleaner, and being generally aware can reduce our ammonia exposure.

In general, learning the most common neurotoxins and then avoiding them whenever we can is a great place to start. As our body becomes purified we will feel better and with a little commitment the damage to our neuro-pathways can be minimized. Here is a list of several common neurotoxins and types of products that are neurotoxic:

Home Heating Oils - Artificially scented oils, pest candles, scented candles, burning oils and all other artificially scented aromatherapy products.

Aflatoxins - Corn/corn products, peanuts/peanut products, cottonseed, milk, tree nuts including brazil nuts, pecans, pistachio nuts, and walnuts. Other grains and nuts are susceptible too.



Benzene - Widely used in the United States and ranked in the top 20 chemicals for production volume. Some industries use benzene to make other chemicals which are used to make plastics, resins, and nylon and synthetic fibers. Benzene is also used to make some types of rubbers, lubricants, dyes, detergents, drugs, and pesticides.

It is naturally found only in conditions such as crude oil, volcanoes, and forest fires.

Acetone - Aprox. 75% of the available acetone is used to produce other chemicals. Only about 12% is used as a solvent. It is used in artificial adhesives, cleaning fluids, pharmaceuticals, nail polish removers, cosmetic products, cellulose acetate films and fibers, degreasing & degumming agents, and much more. Aluminum & Aluminum Oxide - Has been linked to Alzheimer's disease since 1965. It is used in the manufacture of glass, rinks, cans, foil wrappings, bottle tops and foil containers, among other things.

Lead - Includes solder used on water pipes (so drinking spring, geyser or mountain water might be a better idea),

Ethanol - Present in alcoholic drinks (beer, wine, spirits). Used in pharmaceutical preparations (e.g. rubbing compounds, lotions, tonics, colognes), cosmetics, perfumes, industrial solvent for fats, oils, waxes, resins, lacquers, plastics/plasticizers, rubber/rubber accelerators, aerosols, mouthwash products, soaps and cleaning preparations, polishes, surface coatings, dyes, inks, adhesives, preservatives, pesticides, explosives, petrol additives/substitutes, elastomers, antifreeze, yeast growth medium, human and veterinary medicines.

Ethylene Glycol - is used a solvent in the paint and plastics industries, the formulations of printers' inks, stamp pad inks, and inks for ballpoint pens, as a softening agent for cellophane, and in the synthesis of plasticizers, synthetic fibers, and synthetic waxes.

18.3.Atrazine (weed killer used on corn)

Not to mention Butane, Deionized Water, Kerosene, Caffeine, Mercury (often used in dental work), Acetylene, Albuterol (widely prescribed breathing medicine), Digxin (heart medication), Captopril (blood pressure medicine), Codeine Phospate (used in prescription cough syrup), Diazepan (the prescription tranquilizer Valium),

We have been exposed to these neurotoxins (and the nearly 1200 known neurotoxins) over time, in small amounts, for at least the past 40 years. It really is no wonder so many of us are more forgetful or are watching those we love slip into dementia. However we are not helpless, and with a little education, willingness to give up a few unhealthy habits, and cooking our own healthy whole foods, coping with memory loss can be a distant memory.

We all know the old saying: a place for everything, and everything in its place. That doesn't always apply to some elderly people, particularly those with Alzheimer's symptoms or other diminishing mental capacities. They're the ones who most likely tend to forget where they've placed things, sometimes with disastrous results.

If there's a forgetful elderly person in the family or a senior friend who needs help, there are ways to cope with the problem:

18.4.Single senior:

If a forgetful senior lives alone, family members, friends or medical services personnel should be there once a day to make sure everything is all right. They can help in organizing clothing, meals and other needs the senior is finding difficult to deal with alone.

18.5.Communications:

Be sure the elderly person has a phone, preferable a cell phone that can be carried from room to room. Set it for loud ringing on incoming calls. If the senior can use a video cell phone or similar device, relatives, friends and medical staffers can call daily, see live video of the face and determine if there's help needed.

18.6. Set up plug-in timers for lighting schedules inside and outside the senior's living quarters. This way there's always light in areas necessary for moving around safely at various times of the day and night.

18.7.Restrict the elderly person's cooking chores to a microwave/toaster oven equipped with a wind-up timer with an automatic turn-off.

This way, when a pot or dish is cooked or heated up, the oven will stay on for only the number of minutes or seconds set on the clock. Frequent fires and burns happen when elderly persons use kitchen gas or electric stoves, and forget to turn off the power.

18.8.Regular wind-up timer:

Give the elderly person a portable wind-up timer/alarm clock for use in cooking, as a reminder to do household chores and when to turn on favorite TV shows.

18.9.Reminder board:

Have the elderly person keep a plastic-coated board on the refrigerator or on a wall. Use an erasable felt-tipped pen to write a list of the day's to-do tasks on it, each with a space to check off as they're done. This helps with such vital reminders as to when to take medications.

If there's space, post another reminder board, printed with a large weekly or monthly grid, with a block for each day to write in required tasks, including doctors' visits and other important scheduled appointments.

18.10.Attend:

Drive or arrange transportation for the elderly person to attend useful programs at church and/or community center. Enroll the senior in activities that can help memory, such as music, storytelling, creative arts and group discussions.

Coping with forgetfulness in old age can be tragic for the senior and frustrating for friends and family members who want to help. However, any effort is worthwhile if it allows the elderly person frequent mental stimulation and the knowledge that someone cares.



19.0.Old age forgetfulness is elusive to evaluate.



At first signs of forgetfulness as young as among 40 year old or fifty year old Americans, social remedies recommend the herb gingko biloba which has American, Koreans or Chinese herbal differences compatible with medications and not compatible with medications.The herb is touted every few months as an elixir of life that will help prevent aging and is even used in energy drinks.Work related exhaustion among fifty and sixty year old people needs rest. Resting will help you realize that you are not normally forgetful and the ginko is still working!

19.1.Establishing A Routine

Begin a journal you keep every day or weekly and summarize what you remember you did every day, day by day. A routine that allows you to manage everything you must do with your life day by day through a weekly journal will help you shift work and other responsibilities as you take a look at it. Include a food section in your journal of what you eat every day. This will help you understand when you might need more food or less food, breakfast, lunch or dinner. Maybe balancing calorie intake every meal will help you keep even energy levels. Even energy levels mean you will not be forgetful because of hunger or fatigue, the two most likely reasons for forgetfulness as you age. Include the amount of time you spend with various tasks. Every month evaluating your previous month's journal will help you decide if you would like different community days or wash days or maybe you can cook four days a week and eat leftovers freezing them to alternate the foods you eat twice a week.

19.2.Keep A Financial Journal Separately

If you receive income only once per month, your financial journal may look different from someone who receives paychecks twice per month. You might choose to pay bills all at once or weekly as a way to keep weekly tabs on what you are spending. Knowing how to bed get your money on a weekly or monthly basis will help you feel you have control over your life and reduce the worry that stress or change brings about. Checking your automatic bill payments before there are problems, right after they come due is the biggest advantage of a weekly budget journal







19.3.Know What Disease Forgetfulness Is

Old age forgetfulness really refers to people who begin to misplace things; do not know who you are; stop paying their bills; and talk to strangers on the phone because they have forgotten who strangers are. Dear Jesus lost and found please help me (or the name of the forgetful person) find (name what is lost) will give you a chance as a family member to evaluate what is going on with the forgetful person. Does he or she have Alzheimers or has her or she had a stroke? Does he or she have dementia? The person may be unable to relate to long term memory, nor can the forgetful person know that anything is wrong. Buspar will help lengthen the time of someone who is developing Alzheimer's disease has... maybe there is a cure right around the corner...

19.4.Keep Track of Your elderly Neighbors

If you are a neighbor of someone of old age knew before who does not see you regularly, remind the aged person who you are and maybe when you last saw him or her. Talk to your family members about whose father and mother wanders around, has dementia, or has had a stroke. talking to people regularly who have had a stroke will help them recover.

19.5.Maintain Your Best Health

This tip can be a challenge as aging brings about physical challenges that may be developing for years such as osteoarthritis caused by the jogging you loved. Be patient with new challenges, look for and listen for new answers.

19.6.Cope with Forgetfulness with Routine

As you age, your ability to remember such things as facts, schedule information, and directions will likely reduce. If memory has never been one of your strong points, aging will increase the problem. But don't despair; I have some helpful tips learned from one of the brightest minds I know, my husband, since he knows he doesn't remember well.

Place important things you want to find in one and only one location. If you wear glasses, take them off and put them on the same table before you sleep. If you lose keys, build, buy and or install a hook for your keys in a convenient location.

19.7.Cope with Forgetfulness with a Calendar

Schedule all of your appointments and put them into your calendar immediately. Include important events, details of where to meet, times and any information you need to bring with you. Husband and wives should share a calendar to help coordinate day to day planning. Often, for travel we add a spreadsheet that documents our entire agenda and budget.

19.8.Cope with Forgetfulness with a To Buy List

My husband and I ensure we have what we need in the kitchen by having a buy two, replace when the first is used policy. To coordinate the need to buy foods we've emptied, we each add them to a joint list located in a central place with a pen or pencil. When you use one, you add it to the list. This lets you buy in bulk, save extra trips to the grocery and prevent arguments.

19.9.Cope with Forgetfulness By Bringing a Map

Map Quest is so easy to use, it is often helpful to type in destinations before you leave and print out a map. This ensures that you will be able to recall where you are going and how to get there.

19.10.Cope with Forgetfulness By Reducing Clutter and Labeling

My hardest task is to find the notebook where I wrote my most beautiful story in a pile of notebooks. If you need more than one of an item, color code them or label to make them easier to find. Weeding out extra paper, old newspapers, magazines and mail will make a surface check for a missing item much easier to perform.

19.11.Cope with Forgetfulness with A Weekly Medicine Container

If you forget whether you've taken your medicine, many find a weekly medicine container helpful. When you take the last pill, refill your container for the entire week. Separating pills helps you remember how many pills you take. Keep a list of your medications you take daily on the refrigerators or by the phone in case emergency treatment is needed.

19.12.Cope with Forgetfulness with Vitamins

Senior vitamin supplements can be helpful for retaining memory function.

19,13,Cope with Forgetfulness with Memory Skill Practices and Mental Challenges

The more you use your brain as you get older, the more likely you are to retain your ability to remember and think. Write your memories down in a journal. Play the picnic game while traveling.

20.0.Forgetfulness arises with age.

The good memory of the past begins to fade and slowly one may even find hard to remember what they were doing just few seconds ago. Even trouble can arise in remembering names of friends and relatives and how you know them. Here are several ways to cope with forgetfulness that arises in the old age:

20.1.Keep a diary:

Using a small diary to note down people's name and important instances can be a great way to recall important things to remember. If you have trouble remembering how to do things, it is best to note down the important steps. Add important dates, appointments on cell phones or other organizers. Even cell phone reminders can be a great timely reminder for any sort of memory lapses.

20.2.Tell it aloud:

Telling it aloud and often can be another way to remember things. It may be difficult to recall the name of a new grand child and one way to remember it is to use them as often as possible in conversations. Instead of saying my grand child, using the name in conversations can be a great way to recall the names when needed.

20.3.Set up timers:

With old age it may be difficult to remember things to do. Attending an important function or to keep up an appointment or to do something at home can be difficult with forgetfulness of old age. Setting up timers to remember things on cell phones and other electronic instruments can provide timely reminders.

20.4.Ask someone to remind you:

Entrust family members and friends to provide timely reminders. Ask them to provide two reminders with one early reminder and another timely reminder of what you are supposed to do. It is always best to depend on electronic reminders, but a not so tech savvy person can depend on others for timely reminders.

20.5.Take on one thing at a time:

Avoid multitasking and stick to the one thing at a time. If it is cooking time, stay focussed only on cooking. Doing too many at the same time can cause confusion. It is also best to stay at the same place to avoid distractions. Forgetting to turn off the gas flame in the kitchen can cause accidents and one way to avoid that is to stay at one place and to take on only one thing at a time.

20.6.Listen carefully:

Again multitasking must be avoided while taking instructions or while listening to someone. Select a quiet place or time to avoid all other distractions. Note down important steps and instructions if required and repeat it during the conversation.

20.7.Put all personal belongings at one place:

Misplacing things and looking for them can be a daily event once forgetfulness sets in. To avoid misplacing things as wallet, glasses or keys, it is best to place them exactly at the same spot each day. If you have to place them in a different location, just jot in down after you place them at a different spot. Follow the simple tips and avoid forgetfulness from interfering with your daily life!

21.0.Often aging people feel they are not as worthy as they used to be.

This is largely due to the fact that in modern society the level of activity seems to be the principal meter in judging people, and of course a person cannot maintain the same levels of energy over the years. However, this is a false concept, and it is very important for an aging person to understand that all the experience acquired in a lifetime is extremely valuable. Sometimes I hear people saying: "I would be proud of my wisdom, if it wasn't for the fact that I'm forgetting everything." If it is true that memory is decreasing with age, it is also true that there are plenty of ways to make it happen so slowly, that the progressive memory loss will be seamless. And it's so easy, that you will be wondering why didn't you start doing it before.



21.1.0.Let's start:

21.1.1.Never lose your self confidence.

This might sound awkward, you'll probably be asking yourself what does your self confidence have to do with your memory at all. Well, it has a lot to do with it, believe me! The first time you happen not to remember something, you start losing your self esteem together with your memory. A lack of self confidence makes you become unsure, makes you hesitate, and think maybe you might not remember things correctly after all. This, in turn, makes you forget more, because you're not as attentive as you were before. It's a vicious circle, so break it now, before even starting it.

21.1.2.Learn - if you didn't already - to valorize your strengths.

Do not think about the memory you're losing, think about what you're good at. Concentrate on what you remember perfectly, for example I'm quite sure you still remember how to cook, how to swim, how to ride a bicycle, and so many other things. Try to realize that forgetting a few things is not the end of the world, actually at times forgetting something might be even positive. It's actually a blessing to be able to forget something unpleasant, isn't it?

21.1.3.Hang one of those white magnetic boards on your wall.

Often sitting down and writing on a piece of paper all the things you have to do can feel so tiring and discouraging. Just buy a few colored marking pens, and you'll see how easier and funnier it can get when you're writing on your hanging board. You can even draw a red heart close to your daughter's birthday reminder, a baseball bat close to your son's, a pipe close to your husband's, a flower for your best friend, and so on. Make if fun, don't make it boring. Remember, nothing is boring in this world, unless we perceive it as such!

Keep a recorder handy at all times.

When you feel uncomfortable even writing on your hanging wall, don't worry. Don't force yourself into doing things you don't feel happy with. Just press your recorder's button and speak away. You will be surprised when you listen to it, because listening to your own voice will not just remind you what you have to do, but it will actually bring back the memory of having said those words, and more often than not, you'll remember also what you were thinking while you recorded them.

If it is possible, get yourself a computer.

A computer is extremely helpful, because it allows you to search for and find in a heartbeat a lot of things you might need. But that's not all! Whatever you do on a computer is training your mind and thus your memory much more than you could ever imagine. Even just playing a game helps keeping your mind active, even reading the news. Engaging in a conversation with someone over the internet will make you write, and writing is a great way to exercise as well.

Plus, if your financial situation allows for it, try to enroll in an online course. Just pick a subject you like and study. How can you study if you don't have enough memory? Just give it a try and you'll see! You'll have problems at first, but as soon as your mind adapts to the new situation, you won't believe how many real life situations you'll be able to remember again!



Do not skip through the points and pick only the points you like.

You have to read all the tips, make them yours, implement them in your life, possibly in the order in which they are written. It is important that you start by working on yourself, on your self confidence, and pass on to the tricks to exercise your memory only afterward, when you feel at peace with yourself.

Remember, if you don't suffer from a specific medical condition that provokes a memory loss, the simple decrease of memory due to aging is slow and even reversible up to a point. Yes, you can help it! Don't forget to read a good book before sleeping - yeah, even if your husband/wife complains about it, never mind! Reading is an invaluable tool to train your mind! If you don't like reading, just know that yes, you can definitely find some books on a subject you like! There are books about anything out there, just look for them!

22.0.Routine exercise



22.1.Recent studies indicate that a simple exercise routine helps put the brakes on memory loss. Keeping up all levels of mental stimulus certainly won't harm - and might just help - your brain as you grow older.

One important thing to remember is that serious memory loss is not an inevitable part of aging. There are many changes in the body during the course of aging, the brain included. A small percentage of 60 year olds will suffer from a mild cognitive impairment such as short-term memory loss, forgetting names, difficulty remembering recent events and conversations or recently acquired information. Long-term memories tend to remain intact. Different Types of Memory

To work on coping with forgetfulness in old age, it might help to understand the different types of memory. Short term memory information remains in the consciousness for about 15 seconds and cannot be recalled unless it is transferred and stored in the long-term memory. Age appears to have no effect on the capacity of long-term memory.

A larger and more important kind of memory is the one that does our thinking for us. Our 'intelligent memory.' Intelligent memory helps people figure things out and ignites creativity. It does this by storing memories and sills learned over time and therefore, intelligent memory grows with age.

The brain will use this knowledge to help it learn automatically by itself. As you age intelligent memory increases because it has added more data to your memory store.

Intelligent memory, alas, does not help you remember where you put your keys. But it will teach you to put your keys in the same place every time!

22.2.How to help Brain Cope with Forgetfulness in Old Age

The memory can be trained to some extent and there are strategies to support forgetfulness.

The better a person is able to visualise new information or associate it with something that has been previously stored, the higher the likelihood that this information will be recalled later.

Most memory problems are related to lack of attention. To improve memory you need to eliminate distractions and recognise when an extra effort to pay attention is needed. Then you can use different memory techniques to help store the information for later recall. These techniques are called mnemonic devices.

22.3.Memory Techniques to Help Forgetfulness in Old Age

One memory technique that is helpful to many people is over-learning. This means repeating and studying something more than you need to. Go over the new material a number of times over the space of a few hours or a few days. Some people keep a notebook of things they want to remember then they can review the material periodically until it is learned.

Memory can be helped by making a simple association between the new thing to be remembered and something you already remember. For example, if you forget to take your pills, try putting them by your toothbrush. Since you brush your teeth everyday you will remember your pills. To recall dates, try to associate them with a date that already means something to you.

The process for transferring information from short to long term memory is called encoding. Encoding is important and some age-linked problems in memory are a result of faulty or shallow encoding. For example, a name or phone number in the short term memory will be lost unless it is transferred to long term memory by visualizing it or repeating it several times.









22.4.Remembering Names

To help remembering name:

1. Repeat the name over to yourself several times.

2. Write down the name for future reference on a calendar or in an address book.

3. Make a simple association such as:

• Same name as someone you already know

• Name of a famous person: Kennedy, Cowell, Moses

• An occupation Singer, Clerk, Gardener, Driver

• A brand or product name Ford, Kellogs, Walkman

22.5.0.Learn to Remember to Remember

22.5.1.How to cope with absent-mindedness:

• Put an item to be remembered in an unusual place. For example put the clothes to be taken to the dry cleaners by the front door.

• Have a memory place. This should be your special place for keys, glasses, pills, notes to yourself etc.

• Organize your environment: a place for everything and everything in its place.

• Set the alarm clock or oven timers to help you remember to do something at a certain time.

• Use object cues. For example turn your ring or watch around, turn an ornament upside down. Noticing something different about the object will remind you that you're supposed to remember something.

• Write notes to yourself and post in conspicuous places

• Keep a calendar and list of things to do. Keep a notepad in your pocket, handbag, by your bed or in your car.

• If a notepad is not available, write on your hand.

• Don't put things off for another time. Do it now while you are thinking about it then there is less chance you will forget.\

• When travelling, count items you take with you so you won't leave any behind.\

• Talk to yourself. I'm turning off the stove now. For things to be done in the future repeat to yourself I'm going to watch that program at 9 pm. Remember there's a program I want to watch." Don't worry, talking to yourself is not a sign of madness!

• If you walk into a room and can't recall why, go back to where you started. This might bring back the memory. Sometimes just imagining yourself in the previously place is enough to remind you.

• Keep your mind active: read, write, crosswords, sudoku, debates, jigsaw puzzles and listening to music are all fun ways to keep your mind working.

Some slight memory loss is a natural part of the aging process and it has been found that mentally active people do seem likely to maintain the faculties much longer.

23.0.Coping with Alzheimer’s or dementia

Every caregiver faces a different challenge, but they also share in a task that routinely takes its toll on their own health and quality of life. A code of silence, of protecting the cared-for at whatever cost, of not identifying themselves as caretakers, is common to all. "So many are uncomfortable with calling themselves anything other than a spouse, a parent or a loving adult child," says Suzanne Mintz, president of the National Family Caregivers Association.

First and foremost, they're husbands and wives, sons and daughters, people taking care of those they love even when they're no longer the people they know.

That's evident at a recent Alzheimer's Association support group meeting _ just an hour, so they can return to their charges _ when the dozen caregiver participants take turns describing their particular situation, outlining the problems they face, and sharing their scattered successes. The tone is matter-of-fact. There's no self-pity. They're coping, as they're prone to say.

There are no solutions to their grinding routines and the relentless demands, both physical and psychological, which require round-the-clock vigilance. The best they can hope for is some relief, a break, a sympathetic ear, others who have an inkling of what they're experiencing.

Each takes a turn to vent, others are given the opportunity to pitch in with advice or empathy or something that has worked for them, and all are guided gently and expertly by facilitator Judy Hutchinson, a senior social worker from the Peninsula Agency on the Aging. The stress of caring for someone with Alzheimer's or dementia has been shown to impact a person's immune system for up to three years after their role ends and it can knock 10 years off their life span. It increases the incidence of depression in spouses six-fold and doubles it in children caring for parents.

Linda and Ed Miller still attend the meetings to help others, even though her aunt whom they cared for died in 2004. "It was an 18-month intensive training in Alzheimer's," confides Linda. It took a toll on Linda's health, aggravating a congenital heart problem that she was previously unaware she had. Even though they placed her 90-year-old aunt in a home, caring for her remained a two-person full-time job, says Ed. While he took care of her financial and legal matters, Linda provided necessary daily supplementary care to the nursing home. To the group, Ed emphasizes the importance of gaining a durable power of attorney and taking advantage of all the help that's available from doctors, pharmacists, lawyers and specialized institutional care. The silver lining for the Millers, who were thrown into a care-taking role without warning, was finding so many people so willing to help.

From each person's story, the underlying message that emerges is the intense pain of caring for a loved one whose personality has changed. Of looking after people, often lifelong companions of more than 50 or even 60 years, who no longer recognize their partners, or who become belligerent and aggressive. Of looking after people, once accomplished and talented, who can no longer manage the simplest tasks. Of letting go of a loved one while bearing the physical burden of round-the-clock care.

The one-hour meeting is an oasis for caregivers taking vital time out to care for themselves.

These are some of the problems participants discussed:

Problem: Resentful of offers of help

Suggestion: Language matters. Ask visitors to use a cooperative approach ("What shall we do?" "Let's go out.") rather than a top-down, "How can I help?"

Problem: Short attention span leading to loss of interest in TV

Suggestion: The TV show "Whose Line is it Anyway?" or any show that uses short skits.

Problem: Paranoia

Suggestion: Silence, don't react to irrational accusations.

Problem: Needing constant attention.

Suggestion: If there's an activity they still enjoy, such as crossword puzzles, bowling on Wii, computer games, see if they'll play with someone else.

Problem: Need for continuity and stability so can't just invite someone over to step in for an hour or two.

Suggestion: Introduce "helper" at church or other visited place and when they come to the house, remind them that they know them from that setting to take away the suspicion of person being a "helper."

Problem: Their desire to continue activities that are no longer safe for them to pursue.

Suggestion: It's important to be proactive and remove potential dangers, such as car keys and power tools. Use distracting techniques as with a child to get them interested in alternative activities.

Problem: Extreme manipulation, such as suicide threats.

Suggestion: Get a full medical evaluation, or if an imminent threat, call 911. Any change in behavior _ or memory and communication skills _ should not be attributed to the aging process; rather it indicates the need for medical assessment. An accurate diagnosis is essential to treatment.

Problem: Knowing how much to tell loved ones who may be lucid at times and not at others.

Suggestion: This is extremely hard for the caregiver, but they must recognize that they can no longer share information as an equal, and it's not necessary for them to be completely candid.

Problem: When caregiver isn't physically strong enough to lift a person who has fallen.

Suggestion: Try to have a plan before there's a crisis, someone you know whom you can call on for help at short notice.



24.0.Important of religion in the elderly people well-being

A study of nearly 4,000 elderly North Carolinians has found that those who attended religious services every week were 46 percent less likely to die over a six-year period than people who attended less often or not at all, according to researchers at Duke University Medical Center.

After controlling for factors that could influence death rates - such as medical illnesses, depression, social connections, health practices and demographics - the frequent religious attenders were still 28 percent less likely to die than others in the study. The size of the effect was so strong that it was equal to that of not smoking cigarettes, Duke psychiatrist Dr. Harold Koenig said

Results of the study, funded by the National Institutes of Mental Health, are published in the July/August issue of Journal of Gerontology, medical sciences edition. Koenig, lead author of the research report, said it is the fourth major study published in the past two years documenting a relationship between religious attendance and longer survival.

"Participating in religious services is associated with significant health benefits in elderly people, even when you take into account the fact that religious people tend to start out with better health practices and more social support," Koenig said.

The current findings build on a series of earlier studies at Duke and elsewhere showing that religious people have lower blood pressure, less depression and anxiety, stronger immune systems and cost the health care system less than people who are less religiously involved.

In the Duke study, researchers arrived at their conclusions by analyzing data from a massive, 10-year research effort funded by the National Institutes of Health. Called the Established Populations for the Epidemiologic Studies of the Elderly (EPESE), the study cataloged information on how older North Carolinians age - everything from social practices to religious behavior to eating and exercise habits.

Of the 1,177 subjects who died during the 6-year study period, 22.9 percent were frequent church attenders compared to 37.4 percent who were infrequent attenders.

While researchers can't explain the association between religious behavior and health, they say there is evidence that religious participation benefits people through a number of psychosocial, biological and behavioral pathways.

First, frequent religious service attenders reported having larger social networks and hence experienced greater social support than infrequent attenders, Koenig said. High levels of social support have been linked to better mental health, and they may also increase the likelihood that illnesses will be detected by friends and family and thus treated more rapidly, he said. Moreover, better mental health may confer protection against a wide range of physical illnesses, from heart disease to stroke, that have been linked to people with depression.

"In dozens of studies, depression has been shown to increase the death rate from all causes," Koenig said. "So it stands to reason that if religious participation fosters better mental health, then death rates would be lower among this population."

Second, the worship and adoration associated with religious rituals may directly contribute to mental well-being by serving as coping mechanisms for stressful events or physical illnesses later in life, Koenig said. "Such positive feelings may counteract stress and convey health effects, like enhanced immune function, that go far beyond the prevention of depression or other negative emotions," he said.

Third, said Koenig, people who cope better with life's ups and downs appear to be less inclined to drink, smoke and engage in other destructive health habits. Even at baseline measurement in the current study, religious elderly people were physically healthier and reported leading healthier lifestyles than less frequent attenders.

But these factors were not sufficient to explain the relationship between religious attendance and longer survival found in the current study or others recently conducted around the nation, Koenig said.

In one of the largest studies to date on the subject, researchers at the University of California at Berkeley, produced similar results in a 28-year study of 5,000 people aged 21 to 65 years old. They found that people who attended religious services at least once a week had a 23 percent lower risk of dying over the study period than less frequent attenders, even after controlling for health, social and demographic factors.



24.1.Benefits of attending church services

Going to church might help you breathe easier. A new study by Temple University's Joanna Maselko, Sc.D., found that religious activity may protect and maintain pulmonary health in the elderly.

"Pulmonary function is an important indicator of respiratory and overall health, yet little is known about the psychosocial factors that might predict pulmonary function. At the same time, religious activity is emerging as a potential health promoting factor, especially among the elderly. We wanted to determine whether there was a connection between the two," Maselko said.

"Religious Service Attendance and Decline in Pulmonary Function in a High-Functioning Elderly Cohort," published in the November 2006 issue of the Annals of Behavioral Medicine, was conducted while Maselko, assistant professor of public health, was at Harvard University.

Using peak expiratory flow rate (PEFR), researchers measured pulmonary function in 1,189 study subjects ranging in age from 70 to 79 years. They found that regular religious service attendance (at least weekly attendance) was associated with a slower pulmonary function decline among men and women, compared to those who never attend services. The findings could not be explained by differences in smoking or physical activity.

Maselko and her colleagues believe that this is the first study to examine the relationship between religious engagement and lung function over time. Religious activity could benefit health in a number of ways. Overall, going to church provides social contact and emotional support, thereby reducing the isolation that afflicts many elderly and boosting psychological well-being.



24.2.Dropping of Religious Activities Linked To Increased Anxiety In Women



For many, religious activity changes between childhood and adulthood, and a new study finds this could affect one’s mental health. According to Temple University’s Joanna Maselko, Sc.D., women who had stopped being religiously active were more than three times more likely to have suffered generalized anxiety and alcohol abuse/dependence than women who reported always having been active.

“One’s lifetime pattern of religious service attendance can be related to psychiatric illness,” said Maselko, an assistant professor of public health and co-author of the study, which appears in the January issue of Social Psychiatry and Psychiatric Epidemiology.

Conversely, men who stopped being religiously active were less likely to suffer major depression when compared to men who had always been religiously active.

Maselko offers one possible explanation for the gender differences in the relationship between religious activity and mental health.

“Women are simply more integrated into the social networks of their religious communities. When they stop attending religious services, they lose access to that network and all its potential benefits. Men may not be as integrated into the religious community in the first place and so may not suffer the negative consequences of leaving,” Maselko said.

The study expands on previous research in the field by analyzing the relationship between mental health — anxiety, depression and alcohol dependence or abuse — and spirituality using current and past levels, said Maselko, who conducted the research when she was at Harvard University.

In the study sample, comprising 718 adults, a majority of men and women changed their level of religious activity between childhood and adulthood, which was critical information for the researchers.

According to Maselko“A person’s current level of spirituality is only part of the story. We can only get a better understanding of the relationship between health and spirituality by knowing a person’s lifetime religious history,”

Out of the 278 women in the group, 39 percent (N=109) had always been religiously active and 51 percent (N=141) had not been active since childhood. About 7 percent of the women who have always been religiously active met the criteria for generalized anxiety disorder compared to 21 percent of women who had stopped being religiously active.

“Everyone has some spirituality, whether it is an active part of their life or not; whether they are agnostic or atheist or just ‘non-practicing.’ These choices potentially have health implications, similar to the way that one’s social networks do,”Maselko said.

























































References



• Almkvist, O., & Arnáiz, E. (2003). Neuropsychological features of mild cognitive impairment and preclinical Alzheimer's disease.

• Adams WL, Cox NS.(1995) Epidemiology of problem drinking among elderly people

• Amrhein P. C.Bond J. K.Hamilton D. A. (1999). Locus of control and the age difference in free recall from episodic memory.

• Barker A.Carter C.Jones R.(1994). Memory performance, self-reported memory loss and depressive symptoms in attenders at a GP-referral and a self-referral memory clinic. International Journal of Geriatric Psychiatry 9:305-311.

• Barker A., Prior J.Jones R., (1995). Memory complaint in attenders at a self-referral memory clinic: The role of cognitive factors, affective symptoms and personality. International Journal of Geriatric Psychiatry 10:777-781.

• Bazzargan M., Barbe A. R.(1994). The effects of depression, health status, and stressful life events on self-reported memory problems among aged Blacks. International Journal of Aging and Human Development 38:351-362.

• Blazer D. G., Hays J. C.Fillenbaum G. G., Gold D. T. (1997). Memory complaint as a predictor of cognitive decline: A comparison of African American and White elders.

• Bolla K. I., Lindgren K. N., Bonaccorsy C., Bleeker M. L. (1991). Memory complaints in older adults.

• Bristow MF, Clare AW.(1992). Prevalence and characteristics of at risk drinkers among elderly acute medical inpatients.

• Budson A.E., & Price B.H. (2005). Memory Dysfunction. The New England Journal of Medicine, 352, 692-699.

• Beresford TP.(1995). Alcoholic elderly: prevalence, screening, diagnosis and prognosis.

• Blow F.( 1991). Michigan alcoholism screening test-geriatric version (MAST-G). Ann Arbor: University of Michigan Alcohol Research Center

• Bernadt MW, Smith B, Murray RM.(1982). Comparison of questionnaire and laboratory tests in the detection of excessive drinking and alcoholism.

• Curtis JR, Geller G, Moore RD. (1989). Characteristics, diagnosis, and treatment of alcoholism in elderly patients.

• Callahan CM, Tierney WM.(1995). Health services use and mortality among older primary care patients with alcoholism

• Cabeza, R. (2002). Hemispheric asymmetry reduction in older adults: The HAROLD model. Psychology and Aging, 17, 85-100.

• Copeland JRM, Dewey ME, Griffiths Jones HM.(1986) A computerised psychiatric diagnosis system and case nomenclature for elderly subjects: GMS and AGEC

• Cicchetti DV, Feinstein AR. (1990). High agreement but low kappa: II. Resolving the paradoxes

• Christensen H., (1991). The validity of memory complaints by elderly persons.

• Collins M. W., Abeles N.(1996). Subjective memory complaints and depression in the able elderly.

• Commissaris C. J. A. M., Jolles J., Verhey F. R. (J.1993). Vergeetachtig of dement? Wie maakt zich zorgen en waarom?

• Crook T. H., Feher E. P.Larrabee G. J. (1992). Assessment of memory complaint in age-associated memory impairment:

• Cutler S. J., Grams A. E., (1988). Correlations of self-reported everyday memory problems. Journal of Gerontology: Social Sciences 43:S82-S90.

• Damasio A. R.(1994). Descartes' error: Emotion, reason, and the human brain Putnam, New York.

• Derouesne C., Alperovitch A., Arvay N., Migeon P., (1989). Memory complaints in the elderly: A study of 367 community-dwelling individuals from 50 to 80 years old.

• Dittmann-Kohli F., (1990). The construction of meaning in old age: Possibilities and constraints. Aging and Society 10:279-294.

• Dixon R. A., Hultsch D. F., (1984). The Metamemory in Adulthood (MIA) instrument. Psychological Documents 14:3

• Ekerdt DJ, Davis R.( 1989). Change in drinking behaviours with retirement: findings from the normative ageing study.

• Ewing JA. (1984).Detecting alcoholism: the CAGE questionnaire.

• Fleischman, D.A., Wilson, R.S.Bennett, D.A. (2004). Abstract A longitudinal study of implicit and explicit memory in old persons. Psychology and Aging, 19, 617-625.

• Folstein MF, McHugh PR.(1975). Mini Mental State: a practical method for grading the cognitive state of patients for the clinician.

• Fleiss JL. ( 1975). Measuring agreement between judges on the presence or absence of a trait.

• Feher E. J.Sudilovsky A. Crook T. H.(1994). Memory self-report in Alzheimer's disease and in age-associated memory impairment. Journal of Geriatric Psychiatry and Neurology 7:58-65.

• Flicker C., Ferris S. H.Reisberg B. (1993). A two-year longitudinal study of cognitive function in normal aging and Alzheimer's disease. Journal of Geriatric Psychiatry and Neurology 6:84-96.

• Floyd M., Scogin F.(1997). Effects of memory training on the subjective memory functioning and mental health of older adults: A meta-analysis. Psychology and Aging 12:150-161.

• Folkman S.(1984). Personal control and stress and coping processes: A theoretical analysis. Journal of Personality and Social Psychology 46:839-852.

• Goldstein MZ, Pataki A, Webb MT. (1996). Alcoholism among elderly persons.

• Ganry O, Joly J, Dubreuil A.(2000). Prevalence of alcohol problems among elderly patients in a university hospital. Addiction.

• Gilewski, M. J. Thompson, L. W. (1983). Abbreviating the metamemory questionnaire: Factor structure and norms for adults. Paper presented at the 91st Annual Convention of the American Psychological Association, Anaheim, CA.

• Grut M.,.Viitanen M., Winblad B.(1993). Memory complaints of elderly people in a population survey: Variation according to dementia stage and depression. Journal of the American Geriatrics Society 41:1295-1300.

• Hänninen T. Koivisto K.Pyörälä K., Riekkinen P. J.(1994). Subjective memory complaints and personality traits in normal elderly subjects.

• Heidrich S. M., Ryff C. D.(1993). The role of social comparison processes in the psychological adaptation of elderly adults.

• Hertzog, C.McGuire, C. L.& Lineweaver, T. T. (1998). Aging, attributions, perceived control and strategy use in a free recall task. Aging, Neuropsychology, and Cognition, 5, 85–106.

• Horton AM Jr.(1986). Alcohol and the elderly.

• Hedden, T., & Gabrieli, J.D.E. (2004). Insights into the ageing mind: A view from cognitive neuroscience. Nature Reviews Neuroscience, 5, 87-97.

• Henry, J.D.& Crawford, J.R. (2004). "A meta-analytic review of prospective memory and aging". Psychology and Aging, 19, 27-39.

• Halabi S, Awaida R, Saab B.( 1992). Reliability and validity of self and proxy reporting of morbidity data: a case study from Beirut, Lebanon.

• Herrmann N.(1985). Retrospective information from questionnaires I. Comparability of primary respondents and their next-of-kin.

• Heymann A, Sigmon AH, Weinberg T. (1984) Alzheimer’s disease: a study of epidemiological aspects.

• Hybels CF, Blazer DG, Pieper CF. (2001). Toward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data from an elderly community sample. Gerontologist

• Isaacowitz D. M., Goren D., et al.(2006). Selective preference in visual fixation away from negative images in old age? An eye tracking study. Psychology and Aging,

• Johnson I.(2000) Alcohol problems in old age: a review of recent epidemiological research.

• Janik SW, Dunham RG. (1983) A nationwide examination of the need for specific alcoholism treatment programs for the elderly.

• Jöreskog K. G., Sørbom D. (1993). Lisrel 8: Structural equation modeling with the SIMPLIS command language Erlbaum, Hillsdale, NJ.

• Johnson, M.K. Hashtroudi, S.& Lindsay, D.S. (1993). Source monitoring. Psychological Bulletin, 114, 3-28.

• Johnson, M.K.& Mitchell, K.J. (2002). Second thoughts versus second looks: An age-related deficit in selectively refreshing just-active information. Psychological Science, 13, 64-67.

• Kahn R. L., Zarit S. H., Hilbert N. M., Niederehe G.(1975). Memory complaint and impairment in the aged: The effect of depression and altered brain function

• Korten AE, McCusker E, Creasey H.( 1992). Control-informant agreement on exposure history in case-control studies of Alzheimer's disease.

• Khan N, Davis P.(2002) Drinking patterns among older people in the community: hidden from medical attention?

• La Rue A., (1992). Aging and neuropsychological assessment Plenum, New York.

• Lazarus R. S., (1966). Psychological stress and the coping process McGraw-Hill, New York.

• Lakhani N. (1997). Alcohol use amongst community-dwelling elderly: a review of the literature.

• Landis JR, Koch GC.(1977). The measurement of observer agreement for categorical data.

• Iliffe S, Haines A, Booroff A, (1991).Alcohol consumption by elderly people: a general practice survey.

• Lazarus R. S.(1991). Emotion and adaptation Oxford University Press, New York.

• Mulinga JD.(1999). Elderly people with alcohol-related problems: where do they go?

• Mather, M., & Carstensen, L. L. (2005). Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences, 9, 496-502.

• Maylor, E. A. (1995). Prospective memory in normal ageing and dementia. Neurocase,

• Mitchell, K.J., Johnson, M.K., & D'Esposito, M. (2000). Aging and reflective processes of working memory: Binding and test load deficits. Psychology and Aging, 15, 527-541.

• Magaziner J&, Hebel JR. (1988).Patient-proxy response comparability on measures of patient health and functional status.

• Magaziner J, Hebel JR, Warren JW.( 1987).The use of proxy responses for aged patients in long-term care settings.

• Neugarten B. L., Havighurst R. J.Tobin S. S. (1961). The measurement of life satisfaction.

• Naveh-Benjamin, M. (2000). Adult age differences in memory performance: Tests of an associative deficit hypothesis. Journal of Experimental Psychology: Learning, Memory, & Cognition.

• Nilsson, L-G. (2003). Memory function in normal aging.

• Pickle LW, &Blot WJ,(1983).Information available from surrogate respondents in case-control interview studies.

• Ponds R. W. H. M., Bruning H. A.,Jolles J.(1992). [Older adults and memory complaints: A study of self-knowledge of memory, depression and memory performance.].

• Ponds R. W. H. M., Jolles J., (1997). Prevalence and covariates of subjective forgetfulness in a normal population in the Netherlands.

• Ponds R. W. H. M., Jolles J.(1996). The abridged Metamemory In Adulthood (MIA) Questionnaire: Structure and effects of age and education. Psychology and Aging 11:324-332.

• Riggs K. M.Lachman M. E.Wingfield A. (1997). Taking charge of remembering: Locus of control and older adults' memory for speech. Experimental Aging Research 23:237-256.

• Rushton J. P., Brainerd C. J.Pressley M.(1983). Behavioral development and construct validity: The principle of aggregation. Psychological Bulletin 94:18-38.

• Rubenstein LZ, Schairer C, Wieland GD, Kane R.(1984).Systematic biases in functional status assessment of elderly adults: effects of different data sources.

• Rocca WA, Pedone D, Groppi C,(1986).The use of surrogate respondents to obtain questionnaire data in case-control studies of neurologic diseases

• Reid MC, Anderson PA.(1997) .Geriatric substance use disorders.

• Saunders PA, Copeland JR, Dewey ME,(1991). Heavy drinking as a risk factor for depression and dementia in elderly men. Findings from the Liverpool longitudinal community study

• Saunders JB.(1993). Development of the alcohol use disorders identification test (AUDIT) Addiction;

• Schmand B., Jonker C., Geerlings M. I., Lindeboom J.(1997). Subjective memory complaints in the elderly: Depressive symptoms and future dementia. British Journal of Psychiatry 171:373-376.

• Taylor J. L., Miller T. P.Tinklenberg J. R. (1992). Correlates of memory decline: A 4-year longitudinal study of older adults with memory complaints. Psychology and Aging 7:185-193.

• Tobiansky R., Blizard R., Livingston G., Mann A. (1995). The Gospel Oak Study stage IV: The clinical relevance of subjective memory impairment in older people.

• Verhaeghen, P. (2003). Aging and vocabulary scores: A meta-analysis. Psychology and Aging..

• Van Duijn CM, Stijnen T, Hofman A.(1993).Risk factors for Alzheimer's disease: overview of the EURODEM collaborative re-analysis of case-control studies.

• van den Heuvel N. Smits C. H. M. Beekman A. T. F.(1997). Personality: A moderator of the relation between cognitive functioning and depression in adults aged 55–85?. Journal of Affective Disorders 41:229-240.

• Verhaeghen P.Van Ranst N. Marcoen A.(1993). Memory training in the community: Evaluations by participants and effects on metamemory. Educational Gerontology 19:525-534.