02/01/11

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Dear Dr. Jeff: Since the recent story in the New York Times about the positive effect of chocolate on patients with Alzheimer's disease, I have been receiving telephone calls from families requesting that their relatives be started on chocolate. I am slightly uncomfortable leaping onto the latest fad, particularly with no scientific support other than a newspaper article. Many of these patients are already overweight, with mobility problems or diabetes, or on medications that put them at risk for diabetes. What do you suggest?

Dr. Jeff responds: The Dec. 31, 2010, front page article was a story to end the year on a happy note. It featured some unconventional care given to dementia patients at an Arizona nursing home.

While the most amazing aspect of the article might have been that any nursing home received favorable coverage in a general circulation newspaper, the aspect that attracted extraordinary attention was triggered in the headline, “Giving Alzheimer's Patients Their Way – Even Chocolate.” Since then, chocolate has been the flavor of the month in dementia care.

One nurse was reported to carry chocolate in her pocket to give residents who were agitated, and there was an account of one resident whose behavior and general well-being seemed to benefit. This single description was enough to stimulate a deluge of comments, water cooler jokes, letters to the editor, and blog references – almost all positive – including endorsement from experts as eminent as John Blass, MD, PhD, professor emeritus of neurology at Weill Cornell Medical College in New York. One might say that chocolate has been on everyone's lips.

Ironically, there does exist a small but not insignificant body of scientific literature on the topic of chocolate and Alzheimer's disease. Chocolate contains caffeine, which in turn is a neurostimulant that has been shown to increase neurotransmitter levels, including those of acetylcholine, and to improve memory and executive function.

Dark chocolate contains much larger quantities of theobromine and other methylxanthines that lower blood pressure and might inhibit beta-secretase. That's the enzyme that produces the beta-amyloid in the brain plaques that characterize Alzheimer's disease. Other related compounds have been patented as possible Alzheimer's treatments.

Chocolate also contains substantial quantities of flavonoids. These antioxidants (and who doesn't love antioxidants?) have been shown in a peer-reviewed article to improve function in Alzheimer's model mice. I assume that the control mice ate cheese instead.

On The Sweet Side

However, I strongly doubt that the nurse featured in the article was mentally reviewing her neuropharmacology when she filled her pocket with chocolate. The stronger justification for her practice was, in fact, the knowledge that agitated behaviors in dementia are generally “about” something rather than simply a behavioral manifestation of the disease.

To the extent that we can identify what a patient wants and needs we can modify his or her behaviors. It might not be clear whether the resident was simply hungry, a lifelong chocoholic needing a fix, or simply feeling neglected or lonely, and so responding to the pleasant flavor and the underlying psychological association that food is love. What is clear is that the chocolate was being used as an element of the nonpharmacologic modalities that often are effective in this setting.

The Beatitudes nursing home in Phoenix, a nonprofit facility on a senior-health campus sponsored by a United Church of Christ congregation, was the facility featured in the New York Times. The article's main topic was actually the wide variety of person-centered interventions the home was using and the potential for improved resident comfort, quality of life, and behaviors.

Beatitudes had recently received an award from the American Association of Homes and Services for the Aged for its work training staff at other facilities in the techniques it was using.

Its approach includes many things already being done at other facilities – perhaps even at yours – to improve the lives of residents, including flexible scheduling of daily routines, individualized activities to replicate pleasant activities from residents pasts, and liberalized diets to make meal times more pleasant and prevent weight loss.

There actually exists a psychometric scale, the Pleasant Events Schedule–AD, intended to quantify the frequency and length of pleasant events in a resident's day.

One resident was pictured holding a doll and another was mentioned who spent his day packing and unpacking his tackle box. The point was the good there is in individualizing care to the person, even if it includes lots of chocolate.

As to the potential health risks of chocolate, they seem overstated for the frail elderly. Although consumption of the confection may be fatal in dogs, which cannot process theobromine, Death by Chocolate is the name of a dessert, not a threat.

John E. Morley, MB, BCh, CMD, the editor of the Journal of the American Medical Directors Association and David R. Thomas, MD, both leaders of the geriatric division at Saint Louis University, recently coedited a well-reviewed textbook on geriatric nutrition. Their own instant summary of 600 pages of text is “weight loss equals death.” So maybe we should worry more about frail patients who don't eat chocolate.

Even voluntary weight loss in a geriatric population seems to trigger a variety of negative metabolic and immunologic outcomes. AMDA's diabetes management clinical guideline supports the use of liberalized diets for diabetic management. The potential benefits of weight loss for patients with advanced degenerative joint disease is certainly more theoretical than real.

Most of our residents are at much greater risk of weight loss than weight gain, even when snacks are added. And certainly for dementia patients, where the use of chocolate was being suggested, there is ample evidence of the ominous prognostic implications of weight loss. The common language reflects this understanding when we speak of elders “wasting away.”

The Nugget Inside

The really interesting question here is why a passing reference in a single article has elicited such a dramatic response. There are at least two answers. The first is the simple fact that dementia is the great fear of aging people. Young women worry about breast cancer. Old women worry about Alzheimer's disease, with good reason.

More than 40% of Americans over the age of 85 years are demented. As our population has aged, nearly everyone has experienced a relative, neighbor, or friend with this devastating condition.

Most of them will exhibit significant behavioral issues, which usually means they also will suffer emotionally as a consequence of their disease. Conventional medicine has had little to offer them except medications with minimal efficacy and major side effects. The prospect of a simple, pleasurable, and inexpensive treatment certainly lifts everyone's hopes.

But the deeper reason for the attention to chocolate, I think, is that long-term care retains many life- and pleasure-denying carryovers from its antecedent institutions – the work house and the hospital. The corollary for medicine being unpleasant is that anything that is pleasurable can't be good for you.

The general assumption, unfortunately reflecting reality, is that our residents have lost the right to pleasure. Think about it. On any given day, and certainly during the recent holiday season, the nurses' station is likely to be overflowing with goodies, often brought in by the families of grateful patients. But does Grandma get a Whitman Sampler for her nightstand? Not likely.

Whatever the merits of the scientific argument here, I think it is important to examine our knee-jerk assumption that if it's a treat, it can't be good for you, especially someone who's on medication. Becoming a resident of a nursing home undeniably means giving up significant pleasures that many Americans rely on to cheer their lives.

In our consumer society, many find shopping a genuine pleasure and stress reliever. A new walker is a poor substitute for a day at the mall. Only people outside our facilities routinely enjoy a walk in the woods or the feeling of a fresh breeze on the face. A shower may be cleansing, but does it replace a leisurely soak in the tub?

There is no reason why small pleasures, exercised in reasonable moderation or perhaps even in excess, should be denied. Our nursing home won a national award for a program in which every resident is offered his or her absolute choice for a birthday dinner. Residents have chosen everything from lobster to a cheeseburger to a whole steamed fish. Interestingly, chocolate cake is a common request.

As wonderful as this program is, it still means that the resident gets exactly what he or she wants for dinner only once a year.

Perhaps the bottom line here is that we need to look at our residents not just as patients, but as people. If the adorable 3-year-old in your life lights up at the sight of a chocolate chip cookie and finishes his dinner with alacrity, why not the adorable (or even not so adorable) 90-year-old dementia patient? The real excitement in the chocolate story was the possibility that even with advanced age and frailty there still can be joy.

Dr. Nichols is the vice president for medical services of the Cabrini Eldercare Consortium in New York City, which includes two skilled nursing facilities, three home care agencies, two adult day care programs, and a senior housing complex. He invites your questions and comments; please post them below.