“Did you ever reach a point in your life,” he asks, “where you say to yourself, ‘This is the best I’m ever going to look, the best I’m ever going to feel, the best I’m ever going to do? And it ain’t that great?’”

That’s as good a description as any of what a midlife crisis is all about. Of course, Billy Crystal’s alter ego is far from the only hombre to ride nervously past the buzzards of Midlife Gulch. Ulysses, Dante, and Michelangelo have been there. So have Sigmund Freud and Carl Jung.

In his late thirties, Shakespeare switched from writing comedies to writing tragedies, producing in the process King Lear, Macbeth, Hamlet, and Othello — all tales of men who discover too late that their lives have gone seriously awry.

What is This Vague, Uncomfortable Feeling?

What, exactly, constitutes a midlife crisis? Experts agree there’s no single definition, although a pervasive sense of disappointment and a nagging feeling that time’s running out would be among the major characteristics. Larry Bumpass, Ph.D., a sociologist at the University of Wisconsin in Madison who directs the National Survey of Families and Households, says there’s “an array” of at least 40 events that commonly occur at midlife, from losing a job to the death of a parent, a flagging libido, divorce, or illness.

Midlife for men today is tougher than it’s ever been, says Ronald Levant, Ed.D., a psychologist who teaches at Harvard Medical School. The Ozzie and Harriet model of family life no longer prevails, he says, and new demands on men can exacerbate the confusion of midlife transition.

“It’s more of a crisis now than it might have been for our fathers because of the dynamic changes in the role of women and the structure of the American family,” Dr. Levant says. “Midlife men are now living with role expectations that are vastly different from when they grew up. The traditional masculine code has been broken.”

No Need to Panic

Many experts believe the word “crisis” overstates the degree of angst most middle-age men experience. These same experts also say that many of the stereotypes about men at midlife-such as their burning desire to hold onto youth by latching onto a younger woman-aren’t necessarily true. “Sure, we all know somebody who left his wife for his secretary when he was 45. But men leave their wives when they’re younger, too,” says Dr. Bumpass.

In fact, Dr. Bumpass’s research demonstrates quite clearly that the risk of divorce actually declines the longer people are married. Another study, conducted at the New England Research Institute by psychologist John B. McKinlay, Ph.D. showed that only 2 percent of over 1,700 middle age and older men surveyed reported having more than one current sexual partner, a far lower rate than the stereotypes would have us believe.

The word “crisis” applies more to how midlife transitions are handled than to the fact that transitions are taking place, says Leonard Felder, Ph.D., a psychologist in private practice in Los Angeles and an expert on midlife and career issues.

“Most people between the ages of 30 and 50 go through some major shifts in the way they see themselves and the way they feel about their lives,” he says. “That’s normal. It’s a crisis if men act impulsively during it. If they throw away their wives, kids, friends, then it’s a crisis. If they carefully think this through, it’s a fascinating transition.”

Take Stock of Your Life

That midlife regrets can serve as a potent catalyst for personal growth is a theme sounded repeatedly by experts from many disciplines. “I would go so far as to call it a midlife opportunity,” says Marsha Sinetar, Ph.D., an organizational psychologist and the author of Do What You Love; the Money Will Follow. “It’s time to look at questions like, Who am I? What do I believe? What do I really need? Those are issues worth examining. This means taking yourself seriously, perhaps for the first time.”

The first recommended step for getting the most out of your midlife agonies is to listen to them. Therapists say there’s a strong temptation to deny the questions that come up at midlife because the answers are sometimes threatening.

“Accept what’s happening,” says Dr. Sinetar. “Try to relax into the chaos. Trust that you’re going to find something wonderful in it.”

“Helping the family face their grief and work through the accompanying emotions of sadness, anxiety, anger, guilt, and — finally — acceptance may be the most important single task of the clinician working with a member of the Alzheimer’s family.”  This quote succinctly describes what author Robert B. Santulli, M.D., addresses in The Alzheimer’s Family:  Helping Caregivers Cope. While the physician’s focus is on caring for the person with Alzheimer’s, the focus of a clinician is on caring for the “Alzheimer’s family.”  Reading this book will help to ensure a clinician is well versed in the disease’s impact on the family.

Beginning with identifying the primary caregiver, a process in which family dynamics plays a large role, the author then identifies and elaborates on four areas of providing care for the person with Alzheimer’s (passive, active, cognitive, and behavioral).  A discussion of the basics of memory loss and dementia follows, along with the impairments in activities, behavior, and cognition that typically occur with Alzheimer’s. 

A listing of common medications that can lead to an impairment of short-term memory is also included, running the gamut from antidepressants to muscle relaxants to those for Parkinson’s and cardiovascular disease.  Current medications illustrate one more factor a physician must take into consideration when trying to determine if the memory loss is due to a form of dementia or one of the medications the person may be taking.

One chapter deals specifically with mood and behavioral issues of the person with Alzheimer’s and includes aggressiveness, apathy, agitation, and depression, along with several others.  The last line in each of the subchapters refers to a discussion in the appendix on medications for that particular challenge. 

Santulli states that the purpose of the book is to “prepare clinicians to become skilled counselors for the Alzheimer’s family.”  In that regard, much information is indeed presented that will help a clinician support the family in the many areas of caring for their loved one.  Given the book’s subtitle, Helping Caregivers Cope, I was surprised that the shortest chapter in the book is titled “Caregiver Stress.”  I suppose that one can define the entire family as the caregiver rather than a single person, and caregiving as the family’s handling of the myriad tasks and emotions involved in the journey upon which they embark after diagnosis.  As presented in an earlier chapter, to minimize any resentment and anger that may surface in an individual caring for a loved one with Alzheimer’s disease – which one would assume is responsible for a great deal of stress – the author advises “Blame the disease, not the person.”

One particularly helpful section in a chapter on maintaining a connection with the family member who has Alzheimer’s disease is a list of “do’s” and “don’ts” when communicating with them.  In fact, it seems each item on the list aims to preserve any remaining cognition they may have of themselves by working with their deficits instead of calling attention to them.  As such, these lists may be the most valuable references family members can have regardless of whether a clinician is involved.  Although it is certain clinicians will find The Alzheimer’s Family valuable, it can be a beneficial resource for the family as well.

Throughout this book, it is no stretch of the imagination to feel as though you are the person who has been diagnosed with Alzheimer’s and are reading about your own future and that of your immediate family and close friends.  Rather than being frightening – which the disease is, no doubt – it is more of a play-by-play book from diagnosis to treatment to the end of life.  If you have personal experience with a family member who has Alzheimer’s, or has died from the disease, you may well find yourself grieving for their loss and yours in the last chapter, “The End of the Journey.”

“…it is important to remember that the kindest, fairest way to treat someone with Alzheimer’s disease is usually to do what will cause them the least distress.”  If a clinician gleans nothing else from reading The Alzheimer’s Family but this simple prescription for care, they will provide a great service to a family by using it as a preface to each step along the way in caring for the family as a whole.

The Alzheimer’s Family: Helping Caregivers Cope
W. W. Norton & Company: October 31, 2011
Hardcover, 256 pages
$29.95

You know how it goes: The oldest starts acting bossy. The kid who never helped with the chores still heads for the TV instead of the kitchen or yard where others are helping out. The guy who now runs a substantial business goes back to being the family screw-up.

Meanwhile, the parents oblige by being more parental than they would dream of being with other young adults in their lives: more critical, giving more advice than is appreciated, issuing orders to clean up their language or pick up the coat they dropped on the floor, and treating their adult kids like, well, kids.

Old patterns of behaving die hard. As a high school basketball coach I know frequently tells his players, “Practice doesn’t necessarily make perfect. It makes permanent.”

Think about it. The family is our first experience with the social world. Each kid who comes into the family reacts to those who came before, looking for a way to be unique but also to be part of the group. One kid becomes the “smart one” or the “smart one in math” while the other becomes the “smart one in history.” One becomes the athlete, another gets known to be the funniest, or the best or worst with money or the best or worst at organizing. For each family member, finding a unique identity means strengthening particular attributes and talents.

At the same time, belonging requires some level of conformity to our family’s idea of the family identity, at least some of the time. In the normal shuffle and scuffle of daily life, we learn what wins acceptance from our family and what will get us put in the timeout chair or sent to our room; what ensures our membership in the family and what will risk rejection. For almost 20 years, we spend some part of almost every day as one of the dancers in the elaborate dance of family life. Our roles become as choreographed and familiar as the opening number of a well-known show. Twenty years. That’s a whole lot of practice for making the family style and our role in it permanent.

Our roles may be modified considerably when we move out into the larger world. But get us together with the original group and 20 years of practice bubbles back up to the surface. Never underestimate the seductive draw of what is familiar. It just feels natural to snap back into our well-rehearsed part. The “responsible one” volunteers for more than she really wants to do. The “baby” goes back to playing the cute card in spite of herself. When with her dad, the independent woman can slip once again into the “princess” role she had as a child while her brother starts to swagger a bit like his former teenage jock self.

As we grow to adulthood, we expand our repertoire of skills for interacting with others. Feedback from friends, classmates, and colleagues shape us in new and important ways that may not work as well in the family. It’s normal and okay to regress a bit when in the bosom of family but it’s important to hold onto the adult we’ve become as well. Being mature means catching ourselves when we start to slide into old roles that are self-centered or over-stated or less balanced and actively deciding to relate in the family with the same dignity and maturity we use with others.

As parents age and become the parents of adults, they need to treasure the memories of these big people as the children they once were and at the same time validate and appreciate who they’ve become. It’s normal and okay to regress to a bit to being parental when adult kids come home but it’s important to step out of that well-rehearsed role as well. Being mature means not treating them as children and actively deciding to move to a more adult-adult relationship.

When both generations make the effort, moments of regression to the past can be sweet because they are nested in a larger appreciation of who each person has come to be in the present.

Avoid Getting Stuck in Regression

Most families can and do make the transition into adult-adult relationships. Here are a few ideas to help you avoid getting stuck in regression when pulled by the familiar family dance:

• Regression can be sweet if it’s kept in bounds. You don’t need to hold so tight to your new roles that you can’t enjoy and take comfort from revisiting the old ones. It’s OK for grown kids to enjoy Mom’s cooking or to sit on the couch with Dad to watch favorite sports. Those moments can be treasured – as long as adult kids then pitch in and contribute in some way to rebalance the relationship.
• Resist the impulse to correct, criticize, or give advice unless it is asked for. That goes for both generations. Parents don’t need to revert to being parental. Adult kids don’t need to regress into their teenaged critical selves. No amount of good advice or arguing is going to change things in a holiday weekend. Bite your tongue unless someone takes you aside and asks what you think. That’s a genuine request for help and support you can respond to as long as you do so with tact.
• If your family has always been contentious, promise yourself not to regress to bickering, arguing, or responding in kind to putdowns or critical comments. A fight can happen only if both sides engage. If you use humor instead or simply say, “Let’s not. It’s Christmas,” the other party usually will drop it too. (By the way: It may take a few tries. Sometimes people are so perplexed by a former adversary’s refusal to engage that they try again to start the familiar fight. Stay calm and just continue to decline in as friendly a way as you can. They’ll usually get the message.)
• Pro-gress instead of re-gress. It gets more and more complicated to go “home” when young adults find partners and start having kids of their own. At some point, it may no longer make sense for some or all of the adult kids to travel back to their parents’ home for every family celebration. The older generation can make this transition easier by being flexible about how and when they spend holidays. The younger generation can make it easier by remembering that parents and older relatives who love them are interested in their lives and need to see them – or at least hear from them – during the holiday season. Advance planning is the key. When there are careful and loving conversations about who needs to go where for family holiday events, it’s possible to maintain a sense of family togetherness while accommodating new realities.

Related Article:

The Turkey Trail: Which Home for the Holidays?

Diminishing estrogen levels can actually exacerbate symptoms, and for some women, the decline is sudden and dramatic. Hormonal fluctuations affect our brain’s biochemistry and thereby ADHD symptoms, according to Dr. Patricia Quinn, M.D., a developmental pediatrician and director of the National Center for Girls and Women with AD/HD.

Specifically, estrogen affects the release of the neurotransmitters serotonin and dopamine. “[A deficiency in] dopamine is responsible for increasing ADHD symptoms,” she said, while less serotonin leads to depressed mood. (That’s why women feel so miserable during their menstrual cycles when estrogen levels dip.)

“Because a lack of dopamine is a hallmark sign of ADHD, this additional change in dopamine can lead to even greater difficulties with concentration and focus,” said Stephanie Sarkis, Ph.D, a national certified counselor and licensed mental health counselor and author of 10 Simple Solutions to Adult ADD and Adult ADD: A Guide for the Newly Diagnosed.

Some women also find that their ADHD medications are less effective during perimenopause and menopause. As a result, doctors often increase the dose. But this may be ineffective, Dr. Quinn said, because there’s nothing being done about the low estrogen levels.

What You Can Do About ADHD and Menopause

“A lot of women are blindsided by [worsening ADHD symptoms],” Dr. Quinn said. But she and Sarkis emphasized that women with ADHD do have effective options, and by addressing their symptoms can successfully minimize them and function and feel better. Here are several of their suggestions.

1. Consult your psychiatrist.

If your symptoms are getting worse or your medication isn’t working as effectively, share this information with your psychiatrist. If you aren’t working with a psychiatrist now, find one that specializes in ADHD, Sarkis said.

Stimulants and non-stimulants are highly effective in easing ADHD symptoms (along with behavioral changes). And studies have shown that both improve cognitive functioning and attention in menopausal women without ADHD. (For instance, this study looked at the efficacy of non-stimulant atomoxetine.)

2. Consult your gynecologist, too.

Make sure that your gynecologist knows about your ADHD (or cognitive concerns, if you haven’t been diagnosed) and the medications you’re taking. Sarkis also suggested signing “releases so that your psychiatrist and gynecologist have open communication about your symptoms.”

Hormone therapy may be helpful for some women in improving cognitive functioning. However, it is controversial, so Dr. Quinn suggested patients and their gynecologists extensively weigh the benefits and risks. For instance, hormone therapy may be too risky for women with a family history of breast or endometrial cancer, she said. But for women without such a history and whose functioning is dramatically exacerbated, hormone therapy may provide major relief. Also, she noted that more recent research contradicts some of the findings from the Women’s Health Initiative postmenopausal hormone therapy trials.

Dr. Quinn added that oftentimes women end up educating both their psychiatrist and gynecologist about menopause’s effect on ADHD. She suggested readers bring information to their physicians (such as this handout on hormonal fluctuations).

3. Assess your strengths and weaknesses.

Identify the areas of your life that are being affected and the activities that have become difficult for you, Dr. Quinn said. Women may have extra trouble with everything from staying organized and managing their time to making decisions, being impulsive and forgetting things. As Dr. Quinn said, it can feel like “you’re slogging through mud,” and everyday activities are extra overwhelming.

Also, keep in mind that you can experience cognitive difficulties even when you still have your period. In fact, according to Dr. Quinn, “your estrogen starts going down 10 years before your period stops,” which can occur in your late 30s or early 40s. You also might find yourself unable to manage activities that you were able to before.

4. Create an “ADHD-friendly life.”

Dr. Quinn suggested that readers simplify their lives and set up what she calls an ADHD-friendly life. This simply means taking your symptoms, strengths and challenges into account. You may want to hire a professional organizer, work with an ADHD coach, get active and “take time for yourself,” which you absolutely deserve, she said.

Here’s additional insight on working through various areas of your life:

• Coping with common symptoms
• Studying and completing assignments
• Being more productive and organized
• Succeeding in the workplace
• Improving romantic relationships
• Overcoming common financial pitfalls

And here are links to Amazon.com for the books mentioned in this article:

• 10 Simple Solutions to Adult ADD: How to Overcome Chronic Distraction and Accomplish Your Goals
• Adult ADD: A Guide for the Newly Diagnosed

If you’re still young, you might wonder what could possibly be better about getting older.  Lustbader gives one of the major advantages as self-acceptance.  We move from our youth where we are “trying to figure out what we are good at” to a point where we know what we’re good at and may therefore find it easier to make decisions, to learn new things, and to take risks.  Since time is limited, we may become more courageous and thus become “true to ourselves.”   In her persistently optimistic way, she even discusses the advantages of physical deterioration because as we encounter physical limitations, they “jar…us into prizing that which we can still do.”  Aging can be difficult, but Lustbader reframes the negative aspects of aging, helping the reader to view aging in a more positive way.  To those who fear aging, this is a relief.

Aging involves many losses, not just physical ones.  How does one handle the grief that comes with having lived for many years?  In the essay Loss, Lustbader states that “inside all of us is a great pool of grief that keeps enlarging as each fresh loss is added to the others….Grieving does not get easier, but we acquire the skills to bear it and the wisdom to accede to its rhythms.”  She says that we become more resilient as we age since “we become increasingly confident that we will be able to bear whatever befalls us.”  It becomes easier to go through the grieving process because we have an idea of how long it will take and we know that we will make it through.

Although Lustbader feels that many of our relationships may improve with age, her optimism doesn’t mask reality.  She gives the example of siblings who no longer speak to one another.  As she puts it, “nothing is guaranteed between siblings–neither friendliness nor allegiance.”  The process of aging can, however, heal old wounds.  Lustbader says that relationships between couples can improve because couples who’ve been together a long time learn how to “resolve their conflicts more easily and leave less of a hurt residue.”

In her essay about stories, she stresses the importance of finding the “right kind of listener”–someone who takes the time to listen and who doesn’t interrupt.  This essay might be a useful one to share with the less patient listeners in your life.  The young may not value the telling of stories, but it is so important that our stories be heard that a stranger may become the best audience.  Why is storytelling important?  If our stories are painful, telling them can help us heal.  As Lustbader puts it, “Turning an onerous event into a story changes it into something we can bear.”

One of the greatest fears we have about aging is becoming dependent on others because of lessened physical ability.  Lustbader discusses the value of learning to accept help from others.  She gives the case of a woman who was going blind, so she gave away her books to friends, keeping only a few.  Some of her friends began weekly visits where they read to her.  By sharing the books with her friends in this new way, the accommodation made for her disability brought both her friends and her new joy.

From the first essay, I kept thinking of people I wanted to give a copy of this book to.  An essay about how difficult the twenties are compared to later life would be perfect for my daughter or a young male colleague;  Lustbader’s writing about gratitude and acceptance would be valuable for my mother.  It took me longer to read the book because I found so many quotations that were applicable to my life or that of others. 

The book is not only beautifully written, but because the perspective is so useful, I found myself wanting to lead a group of senior citizens in a discussion group about the book.  Each essay could provide a focus for healthy group discussions. What would a group of seniors feel about this quotation, from the essay on giving and receiving: 

“Life improves when we attend to our interdependence… Those who do not miss a chance to make life easier for someone else wake up each day with eagerness and have less fear about their own future.”

How would a group feel about her statement that “we must move through difficulty rather than try to get around it if we wish to be strengthened by life experience”?  Does life really get better as we age?  After reading Wendy Lustbader’s book, I’m inclined to agree with her that, in many ways, the answer is “Yes.”

Life Gets Better: The Unexpected Pleasures of Growing Older 
by Wendy Lustbader
Hardcover: Tarcher
256 pages, $16.77

It focused on the public perception and awareness of Alzheimer’s disease, and was carried out by Harvard School of Public Health, Boston, Mass., and the nongovernmental organization Alzheimer Europe. Findings were presented on July 20 at the Alzheimer’s Association International Conference 2011, held in Paris, France.

More than 85 percent of respondents would want to see a physician if they were experiencing confusion or memory loss, to find out if the symptoms were due to Alzheimer’s disease. A very high rate (over 94 percent) said they would want the same for a family member.

Other symptoms of the disease include difficulty with language and the ability to communicate, inability to perform previously routine tasks and personality and mood changes.

Alzheimer’s was the second biggest health fear after cancer in four of the five countries, above six other major diseases, with about a quarter of respondents fearing it more than cancer.

The majority of respondents (between 54 and 77 percent) had experience of Alzheimer’s disease in someone they know or have known. Common symptoms were recognized by at least 86 percent.

Heike von Lutzau-Hohlbein of Alzheimer Europe commented, “The results demonstrate the importance of being honest with patients when diagnosing Alzheimer’s disease.

“As a former carer myself, I recognize how valuable it is for people to have firstly a name for all the uncertainties of their condition and then have the time to get their affairs in order. It will always be difficult to receive such a diagnosis but doctors need to empower patients and their loved ones to take the appropriate steps.

“The findings also show there is high awareness of Alzheimer’s disease, which is a testament to the success of the many awareness campaigns co-ordinated by Alzheimer societies.”

Dr. Robert J. Blendon, Professor of Health Policy and Political Analysis at Harvard said, “Across all five countries, if people had symptoms of confusion and memory loss that they thought might be Alzheimer’s, they were quite interested in getting the assessment of whether or not it was. [This is] much larger than many people would have anticipated.

“Many of the public have high expectations about the possibilities of treatment alternatives and medical testing. It is important for doctors to talk to patients about what treatment and testing options are or are not available.

“A very significant number of people — about two-thirds — said they would very likely get a test [for Alzheimer's] in the absence of symptoms. And that raises a whole series of issues if we ever had a test to recommend.”

Studies are currently under way on retinal scans, on blood tests, and on spinal fluids that may eventually be able to detect Alzheimer’s in its earliest stages, before symptoms appear.

Dr. Blendon added that the majority of people are sure there is going to be a breakthrough on this illness through medical science over the next five years. “And so, the worrisome side is, you’re going to have people coming in, expecting something,” he said. “The positive side is, this is going to be a sea change pressure for more medical research. If you believe that the darkness can be pushed away by medical research, you’re going to want your governments to do more of this.”

Florence Lustman, of the French Alzheimer Plan, added, “Alzheimer’s is a fatal condition that affects most people’s lives at some time. One of the key priorities of the French Alzheimer’s Plan is early diagnosis, and the survey results support this focus. The findings demonstrate overwhelming public support for receiving diagnosis.”

Only about 40 percent of the survey respondents realized that Alzheimer’s is a fatal condition. But in high income countries, it is the seventh highest cause of death, and the only one in the top ten for which there is no cure. This was not widely known among the survey respondents. Between 27 and 63 percent thought there was an effective treatment to slow its progression or improve the symptoms.

Alzheimer’s disease is the most common form of dementia, accounting for over 60 percent of all cases. It affects 5.4 million people in the U.S.

References

Blendon, R. J. et al. Key Findings from a Five-Country Survey of Public Attitudes about Alzheimer’s Disease. Poster presented at AAIC, July 2011.

Alzheimer’s Association, 2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, Volume 7, Issue 2.

Olson focuses his narrative on members of his own demographic: mature men who have sex with men (MSM).  Counselors, families and friends of gay men, and anyone interested in the psychology and sociology of both sexual orientation and aging can benefit from reading this book.

MSM is an important distinction, because many of these men don’t think of themselves as gay.  Olson cites a 2006 study in The Annals of Internal Medicine in which ten percent of working-class and immigrant men in New York City who labeled themselves as heterosexual had sex only with other men.  Furthermore, MSM come from all communities, ethnicities, and socioeconomic levels.

Coming-out stories are as varied as the individuals who tell them; those of mature men are particularly underrepresented.  Olson tells his story from the perspective of someone who had come of age during the Cold War, when homosexuals were arrested, fired from their jobs, and classified as mentally ill.  By the time he came out in midlife, he was clueless about what being gay meant.  As a older man living in a youth culture, he felt he was over the hill. “[G]ay men who have been in heterosexual marriages have much more in common with each other than they do with gay men who came out early in their lives,” he writes.

By living publicly as straight for so long, MSM are isolated from the heterosexual communities they rely on and the gay communities they avoid or about which they are completely unaware.  They cannot speak openly and honestly about their true emotional and sexual selves.  By coming out, they risk losing the only support systems they’ve known: the families, friendships, and business associations (and sometimes careers) that they’ve worked for decades to build and maintain.

They also risk losing their lives from engaging in risky behaviors or from depression and suicide engendered by their isolation.  “Traditionally, men have met their partners through family and work associates, but this is impossible in a world where sexual orientation is concealed,” Olson writes. MSM are often faced with unsafe alternatives, coupled with invisibility. They comprise the majority of people living with HIV/AIDS in the United States, but that incidence decreases as acceptance of homosexuality increases.

Finally Out is written in a loose thematic style that combines memoir, psychological research, self-help guidance, and gay history, and draws considerable power from Olson’s own story.  Olson is particularly candid when relating his own experiences, which begin with growing up in a small Midwestern town.  Each chapter is rich with autobiographical material that encompasses his family background, his sexual sensibilities and experimentation as a boy, the double life leading to the end of his first marriage, his search for what it personally meant to be gay within a larger and diverse demographic, and his relationship with and marriage to Doug Mortimer, his partner of twenty-four years.

Olson’s first, heterosexual marriage to his wife Lynn illustrates the complexities, the agonies, and — for Olson — the inevitability of coming out in midlife.  His psychological insights and self-examination add valuable layers to narratives that are unsentimental and highly personal.

Olson also includes stories from other mature men living in diverse cultures.  Underpinning Finally Out is his survey of 132 MSM (median age: 60).  For older men, the coming-out trajectory differs considerably from that for younger populations.  Developmental processes that heterosexual men (who don’t have to come out) experience in late adolescence and early adulthood are delayed in men who discover their true sexual and emotional selves later in life.

Olson examines the mechanism of dissociation and denial that many MSM experience, especially when exposed only to gay stereotypes and demonization.  High-profile personalities like Senator Larry Craig and evangelist Ted Haggard viewed themselves as “men’s men who just wanted a blow job.”  Olson adds, “I know that’s what they were thinking, because that’s what I thought, too.”

Binary thinking creates an internal split between personal and public identity.  When conditioned to equate straight with good and gay with bad, MSM experience self-hatred when the person they know they are differs from the person they think they should be.  This self-hatred then leads to a heightened search for approval, which itself becomes a form of addiction.  One never attains the “ideal self” that one is “supposed” to be.

Instead, Olson asserts, “Letting go of the need for approval allows the coming-out process to begin.”  Changing one’s “ideal self” to be closer in alignment to one’s actual self is the only way to build lasting self-esteem.  For Olson, that included getting to know other gay men whom he admired and respected, rather than basing his self-assessment on values imposed from without.  Joining a gay fathers group changed his preconceived notions about gay men and provided crucial support.

He stresses that his own thoughts and experiences define what has worked specifically for him in his journey toward self-discovery.  One vignette about dressing in drag had caught my eye, not only because it illustrates the variety in gay experience but because of the stereotype itself.  For Olson, “If doing drag was an essential requirement for being gay — as the stereotype implies — it was clear that I might not fit in there either.”  In fact, transvestism is reported to occur more frequently in heterosexual than in homosexual men. In my opinion, this misunderstanding further underscores the complexity that occurs when public and private personas diverge, including among men who are actually straight.

Latter chapters focus specifically on what it means to be an older gay man in a population that has long been underrepresented and underserved.  Olson addresses issues of caregiving and disparities in the quality of care available to homosexual versus heterosexual populations.  Only about 20 percent of LGBT (lesbian, gay, bisexual, and transgender) seniors are as likely as their heterosexual peers to access needed services, and “many elderly gay men and lesbians feel forced to re-closet themselves,” reinforcing isolation.

Olson’s frank discussions about male sexuality throughout life include topics such as masturbation, Viagra, testosterone replacement, and attitudes toward body image and performance as one deals with the natural effects of aging.  But sex is just one expression of the emotional intimacy central to relationships.  “The majority of gay men, particularly those past the age of forty, want to have a loving and committed relationship with another man,” he writes.  Older gay men face the same challenges as the larger LGBT population with respect to marriage inequality and discrepancies in other basic human rights.  To those challenges are added the prejudices against an elderly population whose members are often denied hospital visitation, participation in end-of-life decisions, Social Security survivor benefits, and equal treatment of the assets they leave to a loved one.

LGBT individuals also have less of the social support system usually supplied by family, and elders are often segregated from their younger counterparts.  Olsen advocates more outreach to gay seniors, “the most invisible demographic.”

The book’s reference section includes a broad range of materials for further study.  Olson’s back cover bio states that he blogs at www.MagneticFire.com, but neglects to mention the excellent resources that his website includes and that are nowhere listed in the book itself.  These dozens of resources include general advocacy organizations like the Gay and Lesbian Task Force and the Human Rights Campaign; advocacy organizations specific to elders, such as AARP’s PRiSM Network and SAGE; Prime Timers Worldwide, for mature gay and bisexual men; the Straight Spouse Network; and many others.  Including this resource list within the physical book in any future editions would help fill its several blank pages at the end, and could also benefit members of Olson’s audience who are not Internet-savvy.

Finally Out: Letting Go of Living Straight, a Psychiatrist’s Own Story
By Loren A. Olson, MD
inGroup Press: April 8, 2011
Paperback, 280 pages
$15.95

Another topic he closely explores is his severe anxiety. Since childhood, Tsilimparis has struggled with panic attacks, which peak as he tries to grapple with his family’s grim situation.

In addition to describing the present, Tsilimparis weaves in memories from his childhood along with his parents’ histories and how they met. He focuses on his father’s volatile nature and verbal abuse — a man who named his three sons after Greek gods, spewed insults regularly and left to the Caribbean and Europe by himself whenever he felt unappreciated — and how his behavior affected him and his family. (In short, it terrified them.) Tsilimparis also describes the other tragedies that punctuated their lives, misfortunes that members in the family had control over and those they didn’t.

Mortal Bonds reads like a page-turner. Even though readers know the result, you yearn to know how it all unfolds — and how it does is fascinating, gripping and heart-wrenching.

Tsilimparis also doesn’t hold anything back. In fact, there were many times that I was surprised by his candor and vulnerability. Psychotherapists are discouraged from revealing personal details. So to read a therapist be so open with his feelings, dreams and thoughts was refreshing. For instance, during one particularly dark time, he writes:

I still don’t know how I made it through the divorce. The detachment from Linda, although necessary, was nothing less than a flesh-ripping experience. I paid a huge price for falling in love too quickly. The breakup with my ex-wife inspired some of the worst episodes of panic attacks I had ever experienced. I was severely depressed and at times, suicidal. But even though I got to the point where I wanted to kill myself, the curse I was haunted by — to protect my mother — would not allow it. I had to remain strong for her, so I just kept on suffering.

Readers will find the memoir relatable on many levels. For one, as evident from the previous excerpt, Tsilimparis struggled with the very disorders he helps his clients with, including severe anxiety and depression. This highlights that none of us is immune to life’s battles — even therapists who people commonly assume must have it all figured out. (Note that many complex factors contribute to cause mental illness, including genetics and biology.)

Second, Tsilimparis’s experiences with his dying parents will resonate with readers. Many people fear their parents’ decline or passing, remember the moment or moments they realized their parents weren’t invincible and understand the change that a parent’s death brings.

Mortal Bonds also is well written, though some sections read overly dramatic and detailed. Still, the vivid prose helps readers feel the moments and gain a deeper understanding of the family’s dynamics, including Tsilimparis’s conflicting relationship with his dad and his impenetrable bond with his mom.

As you turn each page, you feel closer and closer to the family. Tsilimparis recalls some heartfelt memories with his father, showing readers that even the hardest of hearts can have a softer side. Still, reading Tsilimparis’s dad’s tirades is tough, especially when you consider how this life shaped each of them. Also hard to read is Tsilimparis’s descriptions of his parents’ decline — of the dignity that disease and old age take away — something again that readers will no doubt relate to. Throughout the book, Tsilimparis also thoughtfully draws insights into his parents’ behaviors and his own.

Ultimately, the memoir provides hope and shows that people can be incredibly resilient, even in the most horrific of times. And that even those times can bring light and transformation.

In his newest book, How We Age: A Doctor’s Journey into the Heart of Growing Old, Marc E. Agronin, M.D., takes a different view than you are accustomed to reading about with regard to caring for the elderly.  His belief that “aging equals vitality, wisdom, creativity, spirit and, ultimately, hope” is a refreshing departure from those who concentrate primarily on what the elderly cannot do.

How We Age provides a look at various aspects of aging in five parts, beginning with how science understands it and how, psychologically, it is imagined and experienced.  After we meet Dr. Agronin’s most memorable patients on “a medical rounds of sorts,” we are then provided an in-depth look at the changing role of memory in old age.  The meaning and development of wisdom and how it is practiced by the elderly and caregivers are then discussed before moving into the final part of the book that explores “aging to the very frontiers of life.”

As the psychiatrist at one of the largest nursing homes in the country, located in Miami, Dr. Agronin tells the stories of his patients in a captivating way.  He looks past the ravages of old age and the results of traumatic experiences to discover the wisdom and meaning in their lives.

Twentieth-century theologian Abraham Heschel’s definition of wisdom is shared with readers as “more than an achievement of aging; it is as integral and essential to the aging process as walking is to the toddler, play is to the young child, and the pursuit of love and partnership is to the young adult.”  Dr. Agronin’s definition of meaning in the later stages of life “refers to both an intellectual and an emotional sense of rightness, harmony, and purpose.”  

These two tenets of his approach to caring for the elderly are evident in the patients we meet in How We Age, whose illnesses include dementia, Alzheimer’s, post-traumatic stress, alcoholism, and mental illness among others.  At the heart of the care plan is that they experience life with dignity rather than death with dignity during their remaining days, however long that may be.

Interestingly, what can sometimes be troublesome for a family is presented as an essential activity in old age.  Reminiscing by a loved one can be seen by the family as an inability to live in the present, choosing instead to dwell in the past.  However, Dr. Agronin believes the ultimate goal of reminiscence is “not to restore what has been lost but to experience gratitude that can come only with the realization that we never truly lose the gifts from the most important figures in our lives.”  While it is possible for this to also bring traumatic events to surface, that risk can be lessened when the listener shows genuine interest and caring for what the person is communicating.

I share Dr. Agronin’s belief that the doctor-patient relationship should be one of truth so that human dignity is preserved.  In the absence of presenting all the bad news at once, he describes “benevolent deception” as a series of partial truths leading toward the eventual disclosure of the whole truth.  This would seem to be a much kinder, gentler way to allow a patient the time necessary to digest what is currently happening to them and what is yet to come.  Even silence is put forth as a suitable expression of the truth in that what is not verbalized can hold deep meaning for a patient.

One in eight Americans, or 36.9 million people, were age 65 and over in the year 2009 according to the latest data available from the Department of Health and Human Services.  That number is expected to rise to almost 72.1 million by the year 2030, almost twice what it was in the year 2000. Dr. Agronin’s wonderfully written book, How We Age, can serve as a primer for families, friends, and healthcare providers.  Indeed, it should be required reading for anyone caring for those of advanced age to ensure an elderly person’s sense of purpose and integrity are not only maintained and encouraged, but also delighted in.

Although age may diminish or even take away completely our capacities for speech, mobility, and lucidity, it does not mean we also lose the life experiences and accomplishments that made us who we are.  Dr. Agronin is to be highly commended for authoring How We Age and bringing to light a new way of looking at the aging process and in caring for our elders with the same diligence and love with which they once cared for us.

How We Age:  A Doctor’s Journey into the Heart of Growing Old
Da Capo Press
320 pages
Hardcover

You know she is able to take care of herself. You know that she isn’t sick. At 60, she manages a demanding full-time job. She is still strong enough to keep her woodstove going in winter and to give the entire house a good cleaning in the spring. So why does every conversation with her leave you feeling guilty or angry?

It would be too easy to call her “controlling” as if that’s an explanation. It’s not. It’s a label that may reflect your angry feelings but may not at all describe what is going on. Before searching the Internet for ways to put her in her place, there’s more to consider than an amateur diagnosis that results in setting rigid boundaries and distancing her from your life.

Possible Explanations for What Looks Like Controlling Behavior

Maybe she is lonesome and can’t admit it to herself. If she is widowed or if your dad is distant and uncommunicative, she may be longing for your company. However close her friends may be, they may not know her as intimately as members of her own family do. If she acknowledges her longing for closeness, it would make her feel too angry at your dad to live with him peacefully or too sad about where her life is ending up. As a member of the family, she feels more able to impose on you than on other people she knows.

She may be grieving. If your father died within the last 5 years, she may be having difficulty with the loss. Yes, some people move on within a year or so. But some people grieve for three to five years following the death of someone significant in their lives. Some people never seem to get through it and need professional help. Being with you may distract her from her grief.

People don’t have to die in order for someone to be grieving.

People don’t necessarily have to die for her to be grieving. If your mom is taking care of her 80-something-year-old parent who is failing or if your dad is sick or if a disabled sibling is suffering early dementia, for example, your mom may be having difficulty managing the new reality. If she is losing her closest friend to cancer or is trying to cook and clean for people she cares about who are ill on top of managing her job and home, she may be overwhelmed by both what’s called “anticipatory grief” and by the added chores. Feeling so out of control of these events, she may be exerting some control where she can — on you.

Perhaps she has an anxiety disorder. People with social phobia are fearful of judgment by others or that they will embarrass themselves in some way if they are among people who don’t know them well. As long as she has a child or two with her (even an adult child), a socially phobic mom can keep the focus off her and on you. If she is agoraphobic as well, not having a companion when she goes places puts her in a panic. Unable to make friends, she leans on you for conversation and company.

Maybe she really is sick but either doesn’t want to face it herself or doesn’t want to burden you. You don’t see her every minute of every day. It may be that it takes her hours to do things that used to take her minutes. You see the woodstove burning or the clean house. You know she gets to work every day. You don’t see what it costs her to do it.

Possibly she is pointing out things that you don’t want to admit might be true. Having been the guardian of your emotional and physical health for a couple of decades, she may not be able to give it up just because you are a grownup. (Even grownups can be unwise.) Maybe the boyfriend really is a loser. Maybe your best friend isn’t looking out for your best interests. Maybe you aren’t seeing in the mirror what she sees when you walk in the door. Perhaps she could be more tactful but just maybe you keep wearing those old jeans because they have stretched out enough that you don’t have to face that you have put on two sizes this year. Proud of how skinny you are? Maybe she is right that you have gotten carried away with your exercise routine. If you’re trying to avoid an issue, it’s not fair to be mad at her for caring enough about you to point it out.

Or maybe she really is the problem. Of course, there is the possibility that she has an untreated personality disorder, that she’s a mean alcoholic, that she is one of those sad people who only feels significant if she’s making other people jump, or that she simply has never been a nice person (so why would she be one now). Maybe she plays favorites, makes threats, and tries to buy alliances in the family in a desperate need to count. In such cases, “controlling” may be an appropriate word.

Analysis of a Situation Is Important

Good analysis is key to knowing how to handle the situation. One size doesn’t fit all. Stop labeling. Start analyzing. Take a huge step back and think about what your mother may be dealing with. There may be more hints than you’ve allowed yourself to see. Reflect on what goes on in her typical day. Are there some legitimate needs being masked by what looks like demanding behavior? If so, compassion and action is more appropriate than annoyance.

Consider whether what you are calling “controlling” is something relatively new or if it has always been a part of your relationship. New behaviors speak to a change in someone’s health or circumstances. Think about what may have changed in her life or yours that could account for the shift. Sometimes dealing directly with such changes settles a person down. Old behaviors, on the other hand, speak to an enduring personality type or dynamics in a relationship that have become habit. In that case, it’s more likely you can only work on acceptance, change how you react, and maybe offer going to therapy together to improve your relationship (if she’s willing).

You know she is able to take care of herself. You know that she isn’t sick. At 60, she manages a demanding full-time job. She is still strong enough to keep her wood stove going in winter and to give the entire house a good cleaning in the spring. So why does every conversation with her leave you feeling guilty or angry?

It would be too easy to call her “controlling” as if that’s an explanation. It’s not. It’s a label that may reflect your angry feelings but may not at all describe what is going on. Before searching the Internet for ways to put her in her place, there’s more to consider than an amateur diagnosis that results in setting rigid boundaries and distancing her from your life.

Possible explanations for what looks like controlling behavior

Maybe she is lonesome and can’t admit it to herself. If she is widowed or if your dad is distant and uncommunicative, she may be longing for your company. However close her friends may be, they may not know her as intimately as members of her own family do. If she acknowledges her longing for closeness, it would make her feel too angry at your dad to live with him peacefully or too sad about where her life is ending up. As a member of the family, she feels more able to impose on you than on other people she knows.

Maybe she is grieving. If your father died within the last five years, she may be having difficulty with the loss. Yes, some people move on within a year or so. But some people grieve for three to five years following the death of someone significant in their lives. Some people never seem to get through it and need professional help. Being with you may distract her from her grief.

People don’t necessarily have to die for her to be grieving. If your mom is taking care of her 80-something-year-old parent who is failing or if your dad is sick or if a disabled sibling is suffering early dementia, for example, your mom may be having difficulty managing the new reality. If she is losing her closest friend to cancer or is trying to cook and clean for people she cares about who are ill on top of managing her job and home, she may be overwhelmed by both what’s called “anticipatory grief” and by the added chores. Feeling so out of control of these events, she may be exerting some control where she can – on you.

Maybe she has an anxiety disorder. People with social phobia are fearful of being judged by others or fearful that they will embarrass themselves in some way if they are among people who don’t know them well. As long as she has a child or two with her (even an adult child), a socially phobic mom can keep the focus off her and on you. If she is agoraphobic as well, not having a companion when she goes places puts her in a panic. Unable to make friends, she leans on you for conversation and company.

Maybe she really is sick but either doesn’t want to face it herself or doesn’t want to burden you. You don’t see her every minute of every day. It may be that it takes her hours to do things that used to take her minutes. You see the wood stove burning or the clean house. You know she gets to work every day. You don’t see what it costs her to do it.

Maybe she is pointing out things that you don’t want to admit might be true. Having been the guardian of your emotional and physical health for a couple of decades, she may not be able to give it up just because you are a grownup. (Even grownups can be unwise.) Maybe the boyfriend really is a loser. Maybe your best friend isn’t looking out for your best interests. Maybe you aren’t seeing in the mirror what she sees when you walk in the door. Perhaps she could be more tactful but just maybe you keep wearing those old jeans because they have stretched out enough that you don’t have to face that you have put on two sizes this year. Proud of how skinny you are? Maybe she is right that you have gotten carried away with your exercise routine. If you’re trying to avoid an issue, it’s not fair to be mad at her for caring enough about you to point it out.

Or maybe she really is the problem. Of course, there is the possibility that she has an untreated personality disorder, that she’s a mean alcoholic, that she is one of those sad people who only feels significant if she’s making other people jump, or that she simply has never been a nice person (so why would she be one now?). Maybe she plays favorites, makes threats, and tries to buy alliances in the family in a desperate need to count. In such cases, “controlling” may be an appropriate word.

The first question to ask yourself is whether your child is actually in a bad relationship.  If your child is mostly happy and stable, and is learning and growing, it is likely that your own preferences and judgments are clouding your viewpoint.  Try to let go of what you want for your child, and support his or her choices.

If you have separated out your own judgments, and still believe that your child is in a relationship that is unhealthy, codependent, or abusive, you may desperately want to do something to change or control your child’s choices. The problem is that you do not have control over another person’s relationship choices.

You do, however, have power in the choices that you make in your own relationships, including your relationship with your child. Doing your part in creating a healthy parent/child relationship is the best and most you can do to help.  This relationship can be an incredible source of strength, stability and perspective for your child.  It also shows, through example, a model of a healthy relationship.

So, help your ‘adult’ child make better romantic relationship choices through building and improving on these basics of a healthy parent/child relationship:

• Compassion.  If it is taking time for your child to learn or make changes in whom he chooses as partners, or how she behaves in her romantic relationships, it is for a good reason.  Relationships are complex, confusing, and powerful.  ‘Bad’ relationship choices are rarely simply an indication that a person has low self-esteem, is stupid, is crazy, or is stubborn.  They reflect a person’s deepest fears and challenges; in order to move forward, those issues will need to be addressed and worked through.
• Respect.  Your child has his or her own path in life, and it is not your job or place to decide what that path looks like, or with whom he or she shares that path.
• Honesty.  Tell it like you see it. Ignoring an issue and pretending it does not exist will take a serious toll on your relationship with your child. The relationship loses its foundation of truth and ‘reality.’  Be clear about how you perceive your child’s partner relationship, while also ‘owning’ the fact that these are your subjective perceptions. Once you express your thoughts and feelings, trust that your child will ask if he or she needs to hear it again.
• Support.  Support can be giving your child a place to stay temporarily, paying for counseling, directing him or her to mental health resources, or talking about all the different and conflicting feelings and thoughts he or she has about the situation.  Support may be welcoming your child and his or her partner into your home for holidays or including them in other family events.  Support can also be a willingness to just spend time with your child, and talk about things other than the ‘relationship problems.’
• Boundaries.  Giving support in a healthy way means that you also must take responsibility for paying attention to when you feel resentful, overwhelmed, depleted, or ‘in over your head.’  For example, if you feel like you can’t cope with talking about the relationship any more, tell your child that you are at your limit.  If it is too much for you emotionally to have your child and his or her partner attend family events at your house, do not invite them. If you don’t feel comfortable allowing your child to sleep on your couch after a fall-out with his or her partner, say no.  If you fear for the safety of your child, your grandchildren, or other children involved, you will have to call the police or Child Protective Services.  Just try to set these boundaries based on your limits, rather than in an attempt to change or control your child’s relationship choices.
• Letting go.  It is incredibly difficult to let go when your child is suffering or even in danger.  Letting go of trying to control his or her choices can feel wrong and irresponsible.  You must remind yourself, however, that the option to control your child’s choices is not available.  So, you’ve got to choose the option that is available — to help by using your power to build the strength of your parent/child relationship.

If you find yourself struggling with these relationship basics, and even needing support to develop your own relationship skills, do not be surprised.  None of this is easy.  Furthermore, as a parent, your stress and worry will probably continue forever.  As you invest your energy into your healthy connection with your child, however, be assured that you are doing everything you can to help.

Photo by Nick Horne, available under a Creative Commons attribution, non-commercial license.

Danielle B. (Klotzkin) Grossman, licensed Marriage and Family Therapist, provides psychotherapy for California clients who are looking for a way to move forward through relationship issues, problems with alcohol, drugs, or managing money, eating and body issues, trauma, grief and loss, depression, bipolar disorder, and anxiety. She consults by phone for mental health professionals nationally.  Contact her at (530) 470-2233 or truckeecounseling.com.

Holidays can be meaningful, enriching times for both the person with Alzheimer’s disease and their family. Maintaining (or adapting) old family rituals and traditions helps all family members feel a sense of belonging and family identity. For a person with AD, this link with a familiar past is reassuring and builds self-esteem, i.e. “Look at the beautiful family I created!”

Learn to set your own limits early, and be clear about them with others. You do not have to live up to the expectations of friends or relatives. Your situation is different now.

It may help to encourage family and friends to visit, even if it’s painful for them. Keep the number of persons visiting at one time to a minimum, or try a few people visiting quietly with the person with AD in a separate room. Most people with AD can pull it together for brief periods, if they have adequate private rest in between.

Try some simple holiday preparation with the person with Alzheimer’s disease  several days ahead. Just observing your preparations will familiarize him/her with the upcoming festivities; if they participate with you, they experience the pleasure of helping and giving as well as the fun of anticipation and reminiscing.

It may help to prepare potential quiet distractions (a family photo album or a simple repetitive chore like cracking nuts) to use if the person with AD becomes upset or over-stimulated. Over-stimulation can be a common concern amongst people with Alzheimer’s disease.

Try to avoid situations that further confuse or frustrate many people with AD:

• crowds of people who expect the person with AD to remember them
• noise, loud conversations or loud music
• strange or different surroundings
• changes in light intensity – too bright or too dark
• over-indulgence in rich or special food or drink (especially alcohol)
• change in regular routine and sleep patterns

Try to avoid scheduling activities — especially outdoor exercise — early in the day to avoid the fatigue from added activity at the end of a long day. Familiar holiday music, story-telling, singing or church services (even on TV) may be especially enjoyable.

If you receive invitations to holiday celebrations which the person with AD cannot attend, consider going yourself. Enjoy the chance to be with friends and family who love you and enjoy your company, with or without your relative.

Preparing Your Guests Visiting the Person with Alzheimer’s

1. Explain as clearly as possible what has happened to the person with AD. Give examples of the unusual behaviors that may take place: incontinence, eating food with fingers, wandering, hallucinations.
2. Explain that it may not be appropriate behavior but the person with AD has a memory loss and does not remember what is expected and acceptable.
3. Remind the visitor through phone calls or letters to be understanding and not to shun the person with AD.
4. If this is the first visit since the person with AD became severely impaired, tell the visitor the visit may be painful. The memory-impaired person may not remember the guest’s name or relationship.
5. Explain that memory loss is the result of the disease and it is not intentional.
6. Stress with the guests that what is important is the meaningfulness of the moment spent together and not what the person remembers.

Preparing the Memory-Impaired Person

1. Begin showing a picture of the guest to the person with Alzheimer’s disease a week before the arrival.
2. Spend more time each day explaining who the visitor is while showing the picture.
3. Arrange a phone call for the person with AD and the visitor. The conversation may help both. The call gives the visitor an idea what to expect and gives the memory-impaired person an opportunity to familiarize him/herself with the visitor.
4. Keep the memory-impaired person’s routine as close to normal as possible.
5. During the hustle and bustle of the holiday season, guard against fatigue and find time for adequate rest.

Drugs for high blood pressure and heart disease have been linked to protection from Alzheimer’s disease and dementia. A team led by Professor Benjamin Wolozin of Boston University looked at the possible effects of angiotensin receptor blockers on the risk of these conditions.

They write in the British Medical Journal that dementia, including Alzheimer’s disease, is one of the major threats to public health. Evidence increasingly points to three main risk factors: age, the buildup of amyloid plaque in the brain, and the deterioration of the cardiovascular system.

Drugs used to treat cardiovascular risk factors may also reduce the risk of dementia, according to the article.

Angiotensin receptor blockers reduce blood pressure and protect against cardiovascular outcomes. The also drugs help to preserve cognitive function through a separate mechanism, say the experts.

They looked at figures on 819,491 individuals in the U.S. Veteran Affairs database. All were age 65 or older and had cardiovascular disease. All but two percent were male.

Over four years, dementia rates for participants taking angiotensin receptor blockers were 19 percent lower than for those taking the blood pressure-lowering drug lisinopril, and 24 percent lower than for those on other cardiovascular drugs.

Among patients already diagnosed with Alzheimer’s disease or dementia, those on angiotensin receptor blockers had a 49 percent lower risk of admission to a nursing home than those on other cardiovascular drugs. Their mortality risk was 17 percent lower, on average.

The drug’s benefits increased on larger doses, and had an additive effect when taken with another type of high blood pressure drug, ACE inhibitors.

The team concluded, “Angiotensin receptor blockers are associated with a significant reduction in the incidence and progression of Alzheimer’s disease and dementia compared with other cardiovascular drugs.”

They added that the lower rate of admission to a nursing home “is a particularly important observation that could have a major impact on public health if validated by future studies.”

Dr. Colleen Maxwell and Dr. David Hogan of the University of Calgary, Canada, write in an accompanying editorial that the drugs may cause “improved cerebral blood flow and an enhanced neuroprotective effect.” But two randomized controlled trials have found “no significant benefit in either the rate of cognitive decline or incident dementia.”

They warn that important factors such as a family history of dementia, education, and severity of disease were not considered, and the “non-random allocation of treatment” is also a serious problem. Racial and ethnic variation in the use of drugs such as these has been shown among American veterans, and the ethnic origin of most participants was not reported. Furthermore, the results may not be generalizable to women, because women comprised only two percent of participants.

“As with all studies of this nature, association does not prove causation. Further work is needed to verify the usefulness of antihypertensives in general and angiotensin receptor blockers in particular,” they conclude.

A previous study by Professor Wolozin’s team reported that simvastatin, a cholesterol-lowering drug, is linked to a reduction in the risk of dementia and Parkinson’s disease. The study also used figures on more than 70,000 people from the database of the U.S. Veteran Affairs.

However, a more recent review, from 2010, states, “There is good evidence from randomized controlled trials that statins given in late life to individuals at risk of vascular disease have no effect in preventing Alzheimer’s disease or dementia.

“Biologically it seems feasible that statins could prevent dementia due to their role in cholesterol reduction and initial evidence from observational studies was very promising. [But] the evidence from subsequent randomized controlled trials has been negative.”

So far, say the authors of this Cochrane review, there is insufficient evidence to recommend statins for the prevention treatment of dementia.

Dr. Mary N. Haan of the University of California, San Francisco points out that there have not been any randomized clinical trials of initially healthy individuals that were expressly designed to test whether statins can prevent dementia.

“It is now recognized that dementia begins to develop decades before it is symptomatic,” she writes in the journal Evidence Based Mental Health. “Thus to design an adequate prevention trial for dementia requires a relatively young study sample, a large sample and substantial follow-up time.”

She believes that, “At this juncture, it is not possible to conclude that statins could or could not prevent dementia.”

References

Li, N-C. et al. Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis. The British Medical Journal, 2010;340:b5465.
www.bmj.com/cgi/doi/10.1136/bmj.b5465

Maxwell, C. J. and Hogan, D. B. Antihypertensive agents and prevention of dementia. The British Medical Journal, 2010;340:b5409.
www.bmj.com/cgi/doi/10.1136/bmj.b5409

Wolozin, B. et al. Simvastatin is associated with a reduced incidence of dementia and Parkinson’s disease. BMC Medicine, published online July 19, 2007.

McGuinness, B. et al. Statins for the treatment of dementia. Cochrane Database of Systematic Reviews, August 4, 2010.

McGuinness, B. et al. Statins for the prevention of dementia. Cochrane Database of Systematic Reviews, April 15, 2009.

Haan, M. N. et al. Review: statins do not protect against development of dementia. Evidence Based Mental Health, Vol. 12, November 2009, p. 114.

Dr. Moore also points out that the brain also needs adequate rest and nutrition, such as a high-fiber diet that releases glucose throughout the day. Rest and nutrition, Moore claims, are as important to brain function as exercise. Although he does not present any scientific or academic studies to support this theory, he does mention the existence of such research.

This book contains puzzles to exercise brain processes to develop or retain functions such as memory and attentiveness. A guide to using the book follows the brief introduction. Here Dr. Moore suggests performing the puzzles in increasing order of difficulty. The three chapters in the book contain puzzles grouped into beginner, intermediate and advanced categories. By performing the exercises in order of increasing difficulty, the reader will be able to note where he or she needs more work.

Puzzles that are perceived to be difficult indicate areas of brain weakness and the need for more training or brain exercise. Each puzzle is labeled with the brain area it is supposed to be exercising. For example, after reading a story the participant is asked to recall details to improve memory.

If the reader has difficulty with memory puzzles in the beginner section, he or she will almost assuredly have trouble with the memory exercises in the intermediate and advanced sections. However, Dr. Moore warns, just because the puzzle is difficult. it is still important to attempt it and work it through. This is how the brain gets exercise, and with increasing work, it will grow strong, just as other muscles do.

The remaining three chapters of puzzles require the reader to have a pen and paper handy. The puzzles are designed to take only a few minutes each. Performing a few puzzles per day is all the exercise necessary for brain improvement.

The material is presented in a fun and conversational way. Train the Brain contains a variety of fun and often challenging puzzles including logic, memory, spatial, speed and arithmetic. The book was small enough to keep in a briefcase and perfect for the work commute. Imagine the pleasure of reaping the benefits of exercising while sitting on the bus to and from work. Train the Brain provides a fun and stimulating brain workout with no muscle pain. It is appropriate for readers of all ages.

Train the Brain: Use It or Lose It
By Dr. Gareth Moore
Tarcher: September 2009
Paperback, 192 pages
$13.95