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'Oldest Old' Still Show Alertness

By Mary Duenwald, New York Times

March 18, 2003

Of all the infirmities people dread in old age, dementia may be the scariest. Many people in their 90's fear declining mental faculties more than they fear death, researchers at the Mayo Clinic in Rochester, Minn., have observed.

If someone lives to be that old, the thinking goes, Alzheimer's disease or some other form of dementia is practically inevitable.

So it may be some comfort that half of the nonagenarians in a recent Mayo study were perfectly alert. About 12 percent had significant memory problems, but were clearheaded enough to live independently and manage daily activities on their own.

"It is quite refreshing to see how many people do so well so late in life," said Dr. Bradley F. Boeve, who directed the study.

"In fact, some of them have amazing memories."

The mental powers of the oldest old have, until recently, drawn little medical interest, Dr. Boeve said, because doctors have considered dementia not only inevitable, but also untreatable in the last years of life. His findings, published last month in the journal Neurology, challenge that assumption by showing that dementia, when it does occur, progresses as gradually in the 90's as it does in younger elderly.

New treatments may slow that progression. People whose memories have begun to falter but are otherwise able to think clearly have come under increasing scrutiny. Their condition, described as mild cognitive impairment, or M.C.I., is thought to be a precursor to dementia, often Alzheimer's disease.

"About 80 percent of people with M.C.I. convert to mild dementia within about six years, based on our studies," Dr. Boeve said.

Researchers are looking into using drugs to delay or prevent that conversion. Aricept, Reminyl and Exelon, which slow the progression of Alzheimer's in the early stages, increase the activity of a brain chemical, acetylcholine. Studies are under way to see whether those medications can benefit people with M.C.I., as well, without serious side effects. If they can, they should be used on everyone with M.C.I., even nonagenarians, Dr. Boeve said.

"If they can have another five or 10 or more good years," he asked, "why not give them the benefit?"

"M.C.I. should not be accepted as a normal part of aging," said Dr. John C. Morris, a neurologist at Washington University in St. Louis. "It should be seen as a warning signal indicating that it's time to go get evaluated."

Such thinking reflects a shift toward greater treatment for the oldest old. In the past, doctors often neglected to treat age-related conditions like cataracts and cancer in people over 90.

"People used to write off the elderly as if it were just too late to care," said Dr. Marcelle Morrison-Bogorad, associate director of the Neuroscience and Neuropsychology of Aging Program at the National Institute on Aging. "But it's not too late. And if they've made it to age 90 or more, they deserve it."

The prevalence of dementia, not surprisingly, increases with age. About 1 percent of people experience some mental decline by 65, about 10 percent of those who live to 75 do, and almost 50 percent of those who make it to 85 are impaired, said Dr. Morrison-Bogorad.

By 100, two of three people have some degree of impairment, studies by Margery Hutter Silver, a neuropsychologist with the New England Centenarian Study at Boston University, have shown.

Dr. Boeve and his colleagues, who examined 111 people ages 90 to 99 in Rochester, found that some could be extremely forgetful. They may frequently fail to remember appointments, details of recent conversations or even what they just said. Yet many of those people function well on their own.

Dr. Boeve plans to keep track of the mental functioning of his study subjects to see how many progress to memory loss or dementia. Many have agreed to autopsies to enable the researchers to determine who, among those with cognitive impairment, actually had Alzheimer's or other dementia.

Still, some of Dr. Boeve's patients show no signs of developing any memory loss. Sister Bibiana Lewis, for example, manages her life and seems to think more clearly than many people several generations younger. A 96-year-old retired math and science teacher, she has just published her family's history, she works the Sunday crossword puzzle in The New York Times each week, she conducts tours of the convent, and she reads excessively, she said.

She attributes her brain power to good genes, healthy living and, especially, daily physical activity. "You can't sit," she said. "You have to keep moving."

"As far as working my brain," Sister Bibiana said, "I've never stopped."