Health, according to the World Health Organization's definition, is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity. Based on that, if doctors and nurses enhance the level of a patient's physical, mental, occupational and even spiritual well-being, can they at the same time raise his level of health? And if they can, it is their job?
These questions are being raised now as it is increasingly being recognized that reducing an elderly person's levels of stress can enhance his well-being, in all its aspects. Although dementia is a very complex process, it is believed that one can improve a patient's neurological health and perhaps arrest the process of degeneration in the brain and nervous system.
This was recently discussed by Dr. Yakir Kaufman, director of neurological services at the psychogeriatric Herzog Hospital in Jerusalem. An Israeli-born behavioral neurologist who was raised in Toronto, received his MD at the Hebrew University-Hadassah Medical School and studied his subspecialty in Canada. He was in fact lecturing from Jerusalem - via videoconference - to psychiatrists and other staffers at the Albert Einstein Hospital in Sao Paulo, Brazil, as well as to Herzog personnel sitting near him.
Hospital director Dr. Yehezkel Caine and Kaufman said they intend to organize an exchange of doctors with the Brazilian hospital founded by the Jewish community and even hold a conference on psychiatric and geriatric issues at the South American institution.
Kaufman, who is not a psychiatrist, is head of Herzog's neuropsychogeriatric department and has studied the science linking body and mind. All the factors of depression, stress, cerebrovascular disease, inflammation and neurodegeneration interact, he said during the videoconferenced lecture.
Emotional stress puts "extraordinary demand on physiological and psychological defenses and adaptation mechanisms and results in a neuroimmnoendocrine response. Stress involves inner turmoil, anxiety, sadness, depression, anger, hostility, pessimism and a feeling of social isolation," Kaufman began. Psycho-neuro-immunology is a new combination of fields that focuses on nervous system control of the connection between the immune and endocrine systems while the brain controls the nervous system.
During the last two decades or so, there has been a new partner in this map, Kaufman said. "It is legitimate or even mandatory to look at role of mind - a 'black box' we still know very little of but are learning more about due to function magnetic resonance instrument (fMRI) and positron emission emission tomography (PET) scans. The brain affects mind, and the mind effects the brain," he declared.
When a person is very stressed, his brain secretes cortisol, while the adrenal glands sitting atop the kidneys secrete adrenaline, which are both important stress hormones. The more stress the body is exposed to and the longer it continues, the more the wear and tear on the body, said Kaufman. Cell life is shortened by chronic stress, he added, and cell death - called apoptosis - can occur from excessuve secretion of cortisol.
It is known that conditions such as stroke can cause dementia, he continued. But it is not well known that depression can be a predictor of stroke and cardiovascular disease. Stress can trigger the secretion of glucocorticosteroids, leading to high blood pressure, insulin resistance and metabolic syndrome, which is the precursor of diabetes. He cited a study of nuns' health carried out in Chicago in which those women whose brains had the physiological signs or pathology of Alzheimer's disease did not develop the clinical symptoms because they had a positive attitude and optimism. Mini-strokes and head trauma can increase the risk of Alzheimer's disease, but so can depression, according to a very large clinical study.
Kaufman noted that severe psychological stress and marital problems can increase the risk of stroke. "So can involuntary loss of your job as by dismissal. "This can be especially severe if they are fired suddenly as they near retirement, for which they are not ready. In a chain of events, this stress can cause harm to the blood vessels, leading to a heart attack or stroke, which in turn can end up as dementia."
Two parts of the brain have a high concentration of receptors for stress - the hippocampus and the substantia nigra.
The first, a vital part of the brains of both humans and other mammals, plays important roles in long-term memory and spatial navigation. It has mirror-image halves in the right and left sides of the brain and curved shapes that to anatomists many centuries ago looked like a seahorse, from which it got its Greek name. This brain structure has a high concentration of receptors for stress and cells for memory storage. If the hippocampus begins to atrophy, said the Herzog neurologist, the ability to memorize data is impaired. In the extreme, this process can lead to Alzheimer's or Parkinson's disease.
Rats that are exposed to stress - such as being put through mazes or on a treadmill or having to find a dry place to land in a pool of water - developed impaired memory. Enhanced baseline levels of stress hormones were recently linked to Alzheimer's in lab animals, and the process is similar to what occurs in the human brain.
The substantia nigra (Latin for "black substance, as parts of it appear darker than surrounding tissue because of high levels of melanin pigments) is located in the midbrain and plays an important role in movement, reward seeking, learning and addiction. When it degenerates, Parkinson's and other neurodegenerative disorders can result.
After explaining all the anatomical and functional background, Kaufman said that knowledge of the interaction between emotions and physical conditions could be implemented in an integrative way. "We should treat as many dimensions of well-being as we can. If people feel their lives and existences are meaningless, it can lead to a feeling of uncontrollability, thus increasing stress and the risk of disease. If we are able to intervene and reduce stress, we can improve health. It is true that we are doctors and not social workers, but we work as a team and, if we adopt this approach, can be even more efficient as clinicians in treating cognitive impairment."
If patients, especially the middle aged and elderly, are given an improved sense of meaning, worth and well-being - even if they lose their job or other things that are important to them - they can be healthier. "I often see in our clinic patients who suddenly lose their jobs who feel meaningless and get stressed. Sometimes they fall into depression. If as a medical team, we can reduce stress by increasing patients' sense of control and the meaning in their lives, if we can provide social, psychological and even spiritual support, wecan improve their health. And by 'spiritual,' I don't mean that you have to give them religion," said the neurologist, who himself, years ago, went through the process of becoming an observant Jew.
Such support can help even those who already have some impairment, he added. Exercise can improve cognitive function, not only for the improved circulation of oxygenated blood in the vessels but also due to endorphins - neurotransmitters - in the brain that produce a sense of pleasure. But exercise, while very beneficial in the elderly, should not be exaggerated and certainly not carried out without supervision, especially in those who have chronic disorders such as arthritis.
The Brazilian hospital doctors were very interested in the way Israelis cope with the stress to which they are exposed on a regular basis due to war and terrorism and whether this leads to more dementia.
Kaufman said Israel is "pretty much like other Western countries in dementia rates, even though Israel's life expectancy is longer than most. "Apparently, there is positive stress in this country. Two people can be put into the same stressful situation, such as being in a tank on the battlefield, and one will get post-traumatic stress disorder, with all its nasty symptoms, while the other one does not. Sweden is a peaceful country that doesn't have what Israel faces every day, but it has a high rate of depression and suicide. Stress is not always objective," he said.
People, he concludes, are flexible and have the ability to change. It depends on how they are raised and how they cope with stresses. Some people are helped by religion, meditation, yoga or special thinking techniques. They are the lucky ones, as they can change their consciousness even when exposed to a lot of stress. They won't break down because of it."
In an effort to reduce stress and a feeling of worthlessness among geriatric patients, Herzog already gives lectures not only to the patients' family members but also to foreign caregivers, including Filipinas and Filipinos, who live in patients' homes. Chaplains are also available to give spiritual support to Jews, Christians and Muslims.