In a roll call of diseases, few provoke such deep feelings of dread and fear as Alzheimer’s, the fatal brain disorder that mercilessly assaults the mind as well as the body, eventually rendering persons incapable of remembering or connecting with others, and stealing their very identity in the process.

More than a century after the “discovery” of Alzheimer’s, scientists are still searching for a cure. Likewise, while they know the disease involves progressive brain cell failure, researchers have yet to pinpoint the single reason why that occurs. They have, however, identified several risk factors that increase the likelihood of individuals developing Alzheimer’s dementia. After taking a critical look at some of those risk factors — including depression and numerous lifestyle variables related to physical, mental and social activity — Kathryn Douthit believes counselors could potentially play a major role in delaying (if not preventing) the onset of Alzheimer’s dementia for literally millions of people.

“Although the study and treatment of (Alzheimer’s dementia) has largely been the purview of medicine, as information about this disorder has emerged, a clear role for counseling has taken shape,” Douthit wrote in an article for the Spring 2007 issue of ADULTSPAN Journal, published by the Association for Adult Development and Aging, a division of the American Counseling Association. “Interventions across the life span that address stress, depression management, social integration, spirituality and other targets of holistic wellness such as diet and exercise hold much promise for delaying or circumventing the cognitive disabilities associated with (Alzheimer’s dementia).”

Douthit, whose background before becoming a counselor was in the biomedical sciences, began investigating Alzheimer’s disease because of a longstanding interest in gerontology. “I started to look at these lifestyle correlates and environmental conditions — what was related to Alzheimer’s disease and what was related to high cognitive functioning late in life — things you can accumulate over the course of a lifetime that seem to delay or prevent the disease,” she says. “In the process, I found some amazing things that I thought were so relevant to counseling because of our emphasis on holistic health and our wellness orientation.”

Douthit, chair and associate professor of counseling and human development at the University of Rochester, uses a concept from sociology known as cumulative advantage to explain why counselors working across the life span might be able to help avert Alzheimer’s dementia. “As we age, our bodies and our minds are almost like a time capsule, a reflection of our whole lives,” she says. “If you are ‘advantaged’ at the beginning of your life, that advantage just accumulates over time. It’s basically imprinted in our physiology, which affects the way we act and feel. For me, the field of counseling is so germane to late-life psychological health because we address those lifelong accumulations and help prevent the cumulative disadvantages.”

While counseling interventions that address major risk factors such as depression and stress don’t necessarily stave off the disease process itself, Douthit says, evidence suggests those interventions may successfully delay the symptoms of Alzheimer’s dementia. She points out that because the disease most often manifests itself in the years that extend beyond average life expectancy, delayed onset would allow many individuals to reach the end of their lives before the symptoms become apparent. (Early onset Alzheimer’s, which afflicts those younger than age 65, seems to have a much stronger genetic link, and there is little evidence that counseling can play a role in preventing it, says Douthit, a member of ACA, AADA and the Gerontological Society of America.)

Despite the potential importance of the connections Douthit is making between counseling and Alzheimer’s prevention/delay, her work has not yet drawn widespread interest from others seeking to find a cure. “Thus far, I have had some folks in gerontology and sociology who are interested in this work, but I have not had any interaction with people from medicine,” says Douthit, president-elect of the North Atlantic Regional Association for Counselor Education and Supervision. “There are some people within medicine who are saying similar things about prevention, minus the counseling twist. Daniel Amen and William Shankle are two physicians of note who are talking about prevention/delay strategies. But no one I am aware of has made the link between prevention/delay and counseling wellness models in spite of the fact that it has the potential to be a powerful link. This, of course, speaks to the need for more counseling self-advocacy.”

Others in the counseling profession, including Jane Myers, a past president of ACA and one of the leading voices in the field of gerontological counseling, see the importance of the information Douthit and others are compiling. “What we are learning is that we can postpone the onset (of Alzheimer’s) for some people, some of the time, with appropriate preventive activities,” Myers says. “The emerging research is coming out of medicine and physiology, as well as psychology. As an applied profession, we need to build on that knowledge base and design interventions to help people make healthy lifestyle choices. The focus often is on getting the most life from your years rather than the other way around.”

Counseling interventions

Douthit says the identification of specific risk factors for Alzheimer’s dementia opens the door to many potentially helpful interventions that naturally fall under the purview of counseling.

Depression prevention/intervention

Preventing or treating depression looks to be a particularly important element in the struggle against Alzheimer’s, Douthit says. Various studies have shown that prior experience with depression greatly increases the chances of developing Alzheimer’s dementia, she says, and one study has shown that the risk increases even more each time an individual goes through an additional cycle of depression. Depression also negatively impacts other areas of a person’s life and can lead to behaviors that likewise increase the likelihood of developing Alzheimer’s dementia later in life. For instance, Douthit says, persons who are depressed are less likely to engage in physical exercise or to take up activities that exercise their brains. Their relationships are also more likely to be negatively affected. Research suggests that people who experience social isolation or have a sedentary lifestyle are more likely to display symptoms of Alzheimer’s dementia, she says.

“In the area of depression prevention,” Douthit says, “we have to look at those things that are the bedrock of counseling practice: working with grief and loss issues, looking at interpersonal conflicts, adjustment issues, existential issues.”

She says it is critical for counselors to anticipate where clients might encounter these issues instead of waiting for the issues to hit individuals head-on. “For instance, what might women encounter in their 40s or 50s? Have them start talking about those things early,” she says. “When you’re working with a 17-year-old, what does it mean to be that age? Think about what is likely to throw us off balance and cause depression. Developmental counseling that addresses things likely to cause depression and stress are key.”

At the same time, Douthit says, counselors should also have a good handle on empirically supported treatments for depression. “It’s important to keep in mind the prevention techniques, the developmental crossroads, but to also have knowledge of how people can most efficiently quell the symptoms of depression over the short term to get them out of that damaging physiological state,” she says. She adds that counselors also need to know when medication might be helpful in treating a depressed client.

Stress management

Researchers have linked chronic stress to both depression and cardiovascular disease — two of the major factors that increase the likelihood of developing Alzheimer’s dementia. “Stress, particularly early in life, and even prenatally, appears to affect our ability to deal with and rebound from stress later in life,” Douthit says. “It causes our regulation of stress to be compromised. Ultimately, that can set you up for cognitive decline later in life.”

Once again, she says, counselors are naturally positioned to help people deal with stress across the life span. Among the interventions counselors can use:

• Teaching relaxation techniques
• Teaching mindfulness techniques
• Helping individuals to prioritize (values clarification)
• Encouraging individuals to build support networks
• Helping clients improve self-esteem
• Providing guidance to people who are going through career crises
• Anticipating developmental issues
• Attending to psychological problems that can exacerbate stress responses (recognizing underlying problems to help clients improve resiliency)
• Helping clients deal with interpersonal problems

Social integration

Although the specifics remain elusive, researchers have found that social activity has a positive impact on brain health, Douthit says, and counselors can work with clients to overcome many factors that compromise healthy social functioning. “Really, this is lifestyle counseling in many ways,” she says. Among the helpful treatment techniques:

• Helping people with social skills training
• Examining family dynamics to help clients understand relationship patterns and how they interact with other people
• Examining patterns of interpersonal communication
• Working on self-esteem issues
• Helping clients to carve out time for activities that foster social integration
• Helping clients to establish more balanced lifestyles

Developing a comprehensive wellness plan

In examining the risk factors for Alzheimer’s dementia, Douthit has been amazed to see the counseling profession’s emphasis on holistic wellness assert itself again and again as a potentially crucial tool in preventing or delaying the disease. “Counselors haven’t articulated the science behind it (a holistic model of wellness),” she says, “but it’s apparent our good instincts have been right on.”

In particular, Douthit praises the Wheel of Wellness model developed by Myers, Thomas Sweeney and Melvin Witmer. “That’s almost like my bible,” Douthit says. “It’s a great prototype for developing a comprehensive wellness plan.”

Douthit described the Wheel of Wellness in her article for ADULTSPAN Journal: “This model, a centrally important resource in the counseling profession’s focus on prevention and wellness, fosters five so-called ‘life tasks’ as a basis for holistic wellness. These life tasks are (a) spirituality, defined as an awareness of that which exists beyond the realm of the material world; (b) self-direction, which includes sense of worth, sense of control, emotional awareness, coping with emotion, exercise, self-care, and cultural and gender identity; (c) optimization of work and leisure experiences; (d) friendship exclusive of family, marital or romantic ties; and (e) love relationships characterized as long term, mutually committed and intimate. Although these dimensions of wellness were not created specifically with (Alzheimer’s dementia) in mind, the degree to which they correspond to potential features of (Alzheimer’s dementia) prevention are quite remarkable.”

Myers is excited by recent research indicating that wellness lifestyles may hold promise for postponing the symptoms of Alzheimer’s dementia. “Teaching wellness skills can have a lifetime positive effect on everyone,” she says, “and the sooner we help people understand the benefits of a wellness philosophy, the greater the number of years of healthy, happy living we can help people have. … Wellness is at the heart of who we are as a profession.”

Counselor advocacy and identity

Douthit is hopeful her investigation into counseling’s potential role in delaying or preventing Alzheimer’s dementia will become a major tool in advocating for the profession. “So much of what we’re talking about (in trying to head off dementia) really captures counselor identity,” she says. “It’s uncanny the way it aligns. This is fundamentally a part of who we are because we deal with these wellness issues long term. Plus, it pulls in the entire profession.”

Douthit firmly believes that her work concerning Alzheimer’s dementia also has a strong tie-in to counseling’s social justice focus. “Counselors have a firm grasp of social context and how it shapes who we are,” she says, “and so many of the (risk factors for dementia) can be related back to social disadvantage.”

According to Douthit, statistics support the notion that members of Latino and African American communities are at increased risk for developing dementia. Though researchers are not certain of the exact reasons, Douthit believes the higher risk likely has some link to the sociocultural challenges and economic hardships faced by many members of these communities. “If you look at some of the challenges of living in a poor urban or a poor rural area — poor housing, poor infrastructure, increased exposure to violence, exposure to other crime, inadequate schools and so on — there are so many factors present that cause huge stress in people’s lives,” she says. “And over a lifetime, that can be devastating.”

“As part of our social justice mission as counselors, we really need to start sorting through some of these things,” she adds. “We need to figure out how to integrate social justice into our practice.”

Douthit also challenges counselors to raise people’s awareness to the possibility that they can take steps to decrease the risk of developing Alzheimer’s dementia later in life. “If I talk about this with people who are 50, they’re riveted. For people in midlife, this is a selling point (for counseling),” she says. “But if we can get people in their 30s or 40s to start thinking about (holistic wellness), that’s a key time. If you don’t start taking steps before your 50s, it’s less effective.”

“We know that this is in part a ‘use-it-or-lose-it’ phenomenon,” says Myers about efforts to delay or prevent dementia. “Mental exercise is equally important as physical exercise, but we know that our brains are organs that function like all the rest — they need oxygen carried around by healthy blood to function effectively. Exercise, combined with proper nutrition, sets the stage for physical health. We know that health is a neutral state on a continuum that starts on one side with illness or unwellness and ends on the other side with high-level wellness. Our partners in the medical community are working overtime to get people to a state of health. Counselors have a unique role to fill in moving people toward the high end of the worseness-wellness continuum. We are well prepared for doing so, based on our philosophy of wellness, orientation to holism and skills in facilitating the processes of positive human change.”

Kathryn Douthit will present an Education Session on “Working Across the Life Span to Prevent Alzheimer’s Dementia: An Emerging Opportunity for Wellness Counseling” at the ACA Conference & Exposition in Honolulu on Sunday, March 30, from 11:45 a.m.-1:15 p.m.

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.