Progressive To Acute Social And Psychosocial Introversion Features And Behaviors Toward Alzheimer's Process
L Sanchez de Machado
alzheimer, brain disintegration, coping deficit, de-motivation, perception auto blockade, pyschosocial relationships
L Sanchez de Machado. Progressive To Acute Social And Psychosocial Introversion Features And Behaviors Toward Alzheimer's Process. The Internet Journal of World Health and Societal Politics. 2004 Volume 2 Number 1.
Social relation and communicational behavior, personal losses and the capacity of coping with these were studied in 57 women and 49 men with Alzheimer's disease. As a comparison group, equal number normally aged women and men were studied, matched by age, labor profile, schooling, and other factors (matched pairs). All Alzheimer patients passed through a phase of de-motivation, and subsequent perceptive dysfunction. The social relationship and communication profiles were significantly less versatile and lower than in the matched controls. The capacity of coping with these losses was remarkably impaired in Alzheimer patients. Significant personal losses were similar in both groups. We believe that a progressive psychosocial introversion behavior, together with the coping deficit, is the situation where a de-motivation for life takes place, followed by a perception auto-blockade, that will trigger the gradual cessation of the natural reinforcing mechanisms by which the neuronal networks are maintained and then a progressive disintegration of the brain functions will develop.
Supported by ICUNER's (Entre Rios, Argentine) personal loans and Alzheimer's family groups and associations of Argentine, Brasil and Uruguay.
Several studies give account of diverse factors related to a special profile of the personality at risk for Alzheimer, including limited personal relationships, low physical and intellectual activity, passivity, difficulties in communication, or retirement [1,2,3,4,5,6,7,8]. Similarly, also the inverse has been reported in that the establishment of ample and multiple bonds, an active life, exploration of new experiences, persistent curiosity, physical or intellectual activity, are all protective against this type of dementia [9,10,11]. Among the factors that increase the risk of Alzheimer's disease, several studies have listed a wide range of characteristics of the personality, including painful personal losses (like of close relative: son, daughter, grandson), loss of labor, plan of life, mental capacity (objective or subjective), loss of power on others, physical condition, or important aesthetic aspects [2,3,8,10]. On the other hand, several studies [12,13,14,15,16,17,18,19,20] associate the low level of schooling with this dementia. In addition, type of occupation as well as other social factors, like low socioeconomic status have been emphasized [13,14,15, 17, 20].
Other studies [21,22] suggest remarkable differences in the population or institutional prevalence in different places, countries or different regions of the same country, or even among the same ethnic groups resident in different global regions, clearly speaking against the genetic hypothesis. Furthermore, the different prevalence between certain ethnic groups and races, as well as between inhabitants living in rural regions and those in industrial areas are well established [23, 24]
All this overwhelming evidence contributed to the fact that WHO accepted the influence of the life style attributes as contributory factors of Alzheimer's disease .
Beyond reasonable doubt, social factors are directly or indirectly involved in the process of Alzheimer's disease. A multi-disciplinary project focused on social relations and communication dynamics in the pre-clinical phase of Alzheimer's cases has been ongoing in our research center since 1998. As a part of this study, we here report the results where social relations and communication behavior at seven areas, together with the personal losses and the capacity of coping with these losses, were recorded in a group of 57 women and 49 men with diagnosed Alzheimer's disease and in the same number of carefully matched normally aged controls.
Material and Methods
The material of this study comprises a series of patients affected by Alzheimer's disease as well as carefully matched controls with normal aging process. The patients were enrolled through their family care-takers or their relatives, who agreed to participate after having been well informed in special group meetings, through press, by diffusion of our monthly bulletin, or more recently through the Website (http://www.stopalzheimer.com.ar) of our research center.
The patients were selected according to the following inclusion criteria: a) the clinical diagnosis with at least one year of tracking down and confirmation before the age of 70 years, using the criteria of MMSE and (later) the NINCDS-ADRD, b) 8 to 13 years of schooling, c) total family income of 200 to 350 USD±10%, d) married, separated, or widowers with no more than 10 years without pair, e) resident in the region of the central river basin of Uruguay River (East of Argentina, West of the R.O. of Uruguay, Southwest of Brazil), f) without family history of Alzheimer's disease, senile dementia, arteriosclerosis or depression.
As a comparison group, equal number normally aged women and men were studied, matched by 1) age, 2) labor profile, 3) schooling, 4) familiar group income, and other factors (matched pairs). These volunteers were enrolled from several sources, including “third age” Clubs of Tango, Folkloric Centers, Folkloric Dances, Samba, Friends, Greater Adults, European native and descendant Collectivities, Retired and Pensioners Centers and other third age groups. All the participants (patients and their care-takers, as well as the volunteer controls) were informed about the objectives, purposes and aims of the investigation, and instructed to participate actively.
To record the behavioral and social data, three standardized and previously validated ethnographic-like instruments were used [2, 3]. To evaluate the dynamics of social relations and communication behavior in seven vectors, EDSRC, (Evaluation of the Dynamics of Social Relations and Communication) protocol was used.
EDSRC Protocol for the evaluation of the dynamics of social relations and communication
The second protocol has been designed for objective record of significant personal losses of the patients, known as ESPL (Evaluation of Significant Personal Losses).
ESPL Protocol to register objective and significant personal losses (SPL)
In the ESPL protocol, a numerical score is given to objective and significant personal losses whenever detected. In all cases, the care-taker within the family or another near relative were asked to assign the respective loss in a scale from 0 and 100. The evaluator does not consider his/her personal appreciation upon their affected relative, being focused only on the facts and not to the impact that they have in the affected person. All estimations were done during the period preceding the presumptive diagnosis of Alzheimer.
The third protocol evaluated the capacity of the patients to cope with their personal losses, known as PLCF (Personal losses coping factor).
PLCF protocol evaluating the capacity to find positive alternatives to significant personal losses (coping).
PLCF evaluates the capacity to find positive alternatives to significant personal losses (i.e., coping). The assessment was weighted by the closest care-taker within the family or other relative in the scale from 0 to 10 for each one of the items, and finally converted to the values on the scale from 0 to 1 (0 for absent coping and 1 for total coping). The ratio of the assessment used for daily/existential/transcendental loss was 1/2/7, and the values converted to the scale 0-1 are divided equally with the values obtained from the records of the other items.
For the first two protocols, the scales of assessment were from 0 to 100, and for the third, from 0 to 10, because they are integers in an easily comprehensible scale for those who filled the records, and easily convertible to numerical terms. Importantly, the care-taker in the family or other relative were equally instructed to filling of the respective protocols, similarly as the group of volunteers, who comprised matched persons with normal aging.
All the interviews were made by collaborators in the project, being under-graduate and graduate students in social communication, or in geriatric and mental health nursing, physiatrist, medicine, psychology, psychiatry and social work, who all received a careful previous training. The process was audited by the Committee of Ethics in the Center of Health Sciences Research, on the basis of the International Ethical Guidelines for Biomedical Research in Human Subjects, of the Council of International Organizations of Medical Sciences and the WHO, Geneva, 2002.
All statistical analyses were made using Epi Info 3.0 statistical software package (CDC, USA). The difference in the continuous variables between the patients and their matched controls were analyzed using paired samples T-test, with 95%CI being calculated with the exact method. In all calculations, p values <0.05 were considered statistically significant.
Social and communicational relations at middle age
The average (±SD) scores of the SRCD (SRCDm) protocol in 57 female and 49 male Alzheimer patients and their matched controls are presented in Table 1.
These data clearly indicate that in comparing the dynamics of social and communicational relations in these two groups, the normal ageing controls display a broad (plural) relation-communication profile, significantly different (p=0.05 to p=0.01) from that of the diagnosed Alzheimer patients in most of the aspects evaluated: self-estimation, social relations, labor consideration and relations with the abstract level. These differences between cases and controls are very similar among both women and men, except in the labor dynamic, which is clearly greater in the men than in women. The same seems to be the case with the self-estimation and the sexual issues, being higher in both affected and non-affected males.
Significant personal losses
The records on significant personal losses in Alzheimer patients and their matched controls are summarized in Table 2.
Among women, the only area that showed a significant difference in the objective losses was the self-respect, where losses were greater in the Alzheimer patients than in controls, similarly as among the males, p=0.01 and p=0.025, respectively. In all other areas, no significant differences were observed between Alzheimer women and their controls. In contrast, male patients with Alzheimer's disease showed losses much greater than the women particularly in the labor area and in relation to the abstract thing. These higher losses in the labor thing are probably due to the fact that most of the women had no work outside home. The significant differences between men and women in the last area (abstract thing) might suggest a greater cognitive deterioration among men than in women, but the role of subjectivity in recording cannot be ruled out. In fact, the execution of this protocol generated some difficulties that deserved the continuous attention of the study group, when a tendency to bias this registration of the objective losses appeared, contributed by the subjective appreciation of the items, how the people experienced and expressed those.
The indicator of the modality whereupon the person have faced his/her losses, has been systematized with the protocol of Evaluation of Personal Losses Coping,
The difference is slightly less among the male, but still statistically significant (p<0.01). These data indicate that a coping deficit is a key component in the development of the Alzheimer process.
Social and communicational relations at pre-clinical phase
Analysis of the dynamics of social relation and communication assessed during the pre-clinical phase of Alzheimer's disease and in matched controls with normal aging are summarized in Table 4. The scores were calculated using the formula: SRCDf SRCDm – SPL (1 – CF). In other words, the more recent social relation and communication dynamics (SRCDf), is obtained from the dynamics of the social relation in the middle age (SRCDm), from which are subtracted the personal losses suffered in each area (SPL), corrected by the coping factor (CF). In the extreme cases, with no deficit (CF=1), the present dynamics (SRCDf) is equal to that in the middle age (SRCDm), but if the deficit is total (CF=0), then the final estimated dynamics is reduced directly by the amount of the losses.
The estimation has been made using the formula: SRCDf SRCDm–SPL (1 – CF), as explained in the text.
As evident from the Table, marked difference between the patients and their controls is observed in the issues dealing with relation-communication, being seriously impaired in the subjects, who were eventually affected by Alzheimer's disease. Except the issues concerning relatives and sexual aspects, the differences in women were highly significant (p=0.01) in three areas (with same herself, in the social thing and in relation to the abstract organizations), and significant (p=0.05) in the labor-related items. On the other hand, Alzheimer males and their controls did not significantly differ in their dynamics related to the pair and family, while being otherwise similar to women, showing significant differences in the self-related issues, those of the social thing and the abstract thing, and also significant (p=0.05) in the sexual thing.
Assessment of de-motivation
De-motivation state of all the Alzheimer's cases was proved by the simple test of offer, which they used to like very much while middle aged, but at this stage, did not arouse any response. The phase is establish between 3 to 21 months, with oscillations and differences between subjects.
All the Alzheimer patients entered finally in the phase of a perception blockade, were tested to achieve some positive response only to very strong and unexpected stimulus (of light, noise, or taste), because they did not react to any stimuli of normal situations, like speaking, room light or touching.
The practical phase of these studies was carried out between 1995 and 2003. For the present report, we selected from our data base those participants affected by Alzheimer's disease and normal controls, who were matched (one to one), by diverse demographic and social factors that have been considered relevant in previous studies on Alzheimer's disease. This matching was regarded necessary to control the potential confounding effects of these variables, while assessing the differences between the subjects with Alzheimer's disease (=cases) and those without (=controls).
The methodology used in this study has certain limitations, e.g. in providing the data. It might happen that the information given by the relatives of the person affected by Alzheimer's disease, describing the characteristics of the personality or the personal losses, is not necessarily unbiased by the present situation of these people. Similarly, the matched volunteers enrolled from among the ageing people belonging to the dynamic groups of the elderly, are likely to be skewed towards more positive attitudes and evaluations. However, the results of the present study seem to be in alignment and consistent with a logical sequence of developing the Alzheimer's process, and we anticipate future improvements of the methods reported here.
According to the recorded data, in both males and women, the major differences in the social relation and communication dynamics between the Alzheimer patients and their matched controls seem to occur in their relation with oneself, the social activities and the abstract world or entities (Table 4). It is to be emphasized that in this study, the evaluation of this component has a diffuse (weak) relationship with the level of schooling, which is the indicator more frequently used in studies on “education” and Alzheimer. In fact, this variable was not included in our protocol, simply because a longer period of schooling in this region cannot be deemed as equivalent to the education level. It cannot be directly deducted that the schooling necessarily gives a person the important stimulation related to issues outside the daily life. Thus, e.g. an engineer with a post-graduate university degree, might in our evaluation receive lower scores in comprehension with the abstract world than e.g. a housewife who is actively participating in social events (national and international), who reads novels or who is practicing theater activities.
The results of the present study confirm our previously reported observations. Thus, the profiles of relation and communication in the people who will be soon affected by Alzheimer, are clearly more restricted (narrow) than those of the people who experience normal aging. Similar observations have been reported in previous studies [1 ,4, 6 ,8, 10]. No major differences existed in the profile of significant personal losses between the two sexes (Table 2).
Importantly, in our study, the psycho-social component relative to the capacity to find an alternative solution and to follow it as opposed to one given an important loss (i.e., conceptually equivalent to coping in the European literature), showed differences that are statistically highly significant between healthy aged people and Alzheimer patients (Table 3). It is evident that this component constitutes one of the important key elements in the process of emerging Alzheimer pathology, while comprising the mechanism whereby the personal losses come to worsen the acute social introversion. Indeed, the social relations of the affected persons are extraordinarily impaired as opposed to matched controls. This was not as much due to the amount of the registered losses, that are quite similar, but due to the low values of the coping factor in subjects who ended up with Alzheimer's disease. Our data confirm the observations made using slightly different methods by other researchers [4,7,8].
As a logical result, this sequence of events sets the person in a situation of extreme relational constriction, without capacity of recovery by own means. This in turn gives rise to extreme personal crisis, that appears to external observer like asui generis depression [26, 27]. This consequence can be characterized as a de-motivation to live, constituting the last phase of a long process of social introversion concluding in Alzheimer's disease.
To summarize, it seems that the last phase of acute relational and communicational social introversion followed by the non-coping personal losses, culminate in a state of de-motivation, previously described as depression-associated events. Furthermore, instead of the well-known cognitive dysfunctions, we suggest that these are an epi-phenomenon of a perception blockade, more or less intense at the onset, but progressive and persistent along the time. Progressive blockade of the sensorial activities, despite the integrity of the corresponding functional routes, as detailed for the optic nerve , is a very important alert of this phase, which frequently appears to be accompanying with the recurrent conception of losses with coping deficit. The ability to option to cut the connection with the reality by a perception blockade, called “selective attention”  or “visuo-spatial deficit” [30, 31], is not surprising as such, but something that constitutes a part of the normal modulation and natural regulation of the external stimuli. In the affected subjects, this perception blockade, when it becomes persistent, leads to situation that is also symptomatic: the person watches but does not see, touches but does not feel, listens but does not hear, etc. In other words, covering a multitude of symptoms frequently described in the previous literature, albeit using different nosological categories.
The consequences of this persistent perception blockade will be serious and profound, because of the altered natural process, i.e., the permanent characters of the mechanism of reinforcing the neuronal networks. The cerebral functions start to slow, and an inevitable way of disintegration, possibly by an increased synaptic disintegration, leads to a cascade process. This is the basic concept of our psycho-social/neurobiological theory of the development of established Alzheimer process. We think that it closely conciliates the involvement of the psycho-social factors with the neurobiological ones, and neatly explains the most salient contradictions of the recent studies on Alzheimer pathology
The author expresses warm thanks to the several under-graduate and graduate students of the University for their important contribution, as well as those elderly groups for their valuable participation in the study. Supported by the ICUNER (Argentina), through personal loans, as well as by Alzheimer's disease family associations and groups, which is gratefully acknowledged. I would also like to thank Teresa Lin Lou MD,PhD (CEDIVA, Uruguay) for her support and valuable suggestions, and to Kari Syrjänen MD, PhD (SMW, Finland) for her comments and assistance in manuscript preparation.