Wednesday, May 12, 2010

Purpose in Life, Alzheimer Disease, and Medical Ethics

This week I came upon a fascinating article in the March issue of the Archives of General Psychiatry: "Effect of a Purpose in Life on Risk of Incident Alzheimer Disease and Mild Cognitive Impairment in Community-Dwelling Older Persons." The researchers found that "greater purpose in life is associated with a reduced risk of Alzheimer Disease and Mild Cognitive Impairment."

The study is part of the Rush University Memory and Aging Project. More than 1200 elderly people in the Chicago area have agreed to detailed annual assessments and to organ donation at the time of death! 951 had baseline evaluations of purpose in life and were followed for up to 7 years. Those in the top 10% for purpose were 2.4 times as likely to remain free of Alzheimer Disease than those in the bottom 10%. This correlation held after correcting for a number of potentially confounding demographic, psychological and medical factors. Purpose in life was also associated with slower cognitive decline for those who developed cognitive impairment during the followup.

This is a major study in terms of the large number of subjects, careful assessment at baseline, and long term followup of cognitive function. The major limitation is that a correlation does not establish causality. It's possible that a common factor causes both stronger purpose and cognitive health.

"Purpose" was assessed with a simple 10 item measure asking subjects to respond to statements like "I feel good when I think of what I have done in the past and what I hope to do in the future," "I have a sense of direction and purpose in life," and "I used to set goals for myself, but now that seems like a waste of time." There was no assessment of the content of the purpose. "High purpose" subjects could be motivated to "get even with my enemies" or to "contribute to the next generation."

Although finding a correlation does not prove a causal connection, and we don't have rigorous evidence for the preventative potential in purpose, those who deal with elderly populations should take an interest in the degree of purpose elderly folks - including home bound frail elderly - experience in their lives. Showing interest can sometimes heighten the sense of purpose itself. If you ask me about what's meaningful in my life, probe to understand the details, and seem interested and enthusiastic about what you hear, that can put more wind in the sails of my purposes! The risks of building in this practice seems quite low, and taking this kind of interest in a population that is often seen as over the hill shows respect.

But we should anticipate ethical dilemmas as well. We have to be on guard against proselytizing for purposes we endorse but which may not be endorsed by the person we're dealing with. You may be very committed to religious belief, but I may believe that God is dead. Or you may be a committed atheist, confused about how to respond to my goal of converting the people in my nursing home to my fundamentalist faith.

Finding purpose, meaning and value in life is a basic challenge for adolescents and young adults. But the Rush study shows that this creative human function is alive and well in old age, and may even have health promoting potential!


eric said...

Purpose helps other functions too. I have begun asking men if they have ever been in love, when they tell me about their erectile dysfunction and Viagra trials. Take the discussion out of the mechanical and into the meaningful. Of course, I preface the question by saying that it is personal and they don't have to answer.

Jim Sabin said...

Hi Eric -

It's always good to hear from you. Thanks for the comment.

I think it's great for physicians to "move from the mechanical into the meaningful"! Asking about being in love is a wonderfully valuable question. Viagra can help with mechanical function. But Pfizer was clear when they put Viagra on the market that it didn't create desire. Sexual desire and love aren't the same thing, but when the planets are properly aligned love, desire, and mechanics, go together. I hope your patients appreciate being invited into an important conversation!



Arnold S. said...

Hello Dr. Jim,

First post here! I am surprised by this study on Alzheimer patients but it does make sense!

That was the conclusion reached by the psychiatrist Viktor Frankl for Nazi concentration camp prisonners: those who could find a meaning to their sufferings would survive and the others would not.

I would think a similar mechanism is at work in cancer patients, too.

But the question then becomes how can someone find meaning in his own suffering? Or, perhaps, "meaning", like "beauty" or "grace", is simply there and we do not have to find it.

I am actually working on a brief for a public consultation on "Death with dignity Act" in the Prov. of Quebec and that's how I came across these thoughts!

Congratulationd for your blog. That's most interesting!

Arnold, from Quebec City

Jim Sabin said...

Hi Arnold -

Thank you for your comment!

Great to make the connection to Viktor Frankl's work on survival in the concentration camp. We don't know if purpose is a cause of increased survival, whether for an inmate of the camps or for a person with Alzheimer's, or whether some other factor that promotes survival also allows for a sense of vigor and purpose. But I see it as an avenue worth pursuing regardless.

A thoughtful neurologist colleague told me that sometimes families push the person with Alzheimer's too hard to be more engaged and "purposeful" than the person is able to do, on the theory that activity is therapeutic, even when the person isn't up to it. He recommends to families that they urge and encourage up to the point of determined resistance, and back off at that point.

In cancer treatment, sometimes patients blame themselves when their cancer recurs, out of the belief that if they had the "right" attitudes the cancer wouldn't do that. To the extent to which this issue has been studied in a rigorous way, that view appears to be false.

But I agree with you that "purpose," like "meaning," "beauty" and "grace" is an intrinsic good, so doing all we can to cultivate it in ourselves and to encourage it in others is a worthy effort, whether or not it prevents the progress of Alzheimer's or some other condition.

I hope you'll visit again as your work on the brief progresses!