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We do In Home Alzheimers and Dementia Care. Today there are more options than ever before...
Caring for a person with Alzheimer's disease or Dementia as it worstens at home is a difficult task. Alzheimer's symptoms and Dementia symptoms grow worse over time, and there is no way to predict how quickly the disease will progress or exactly how behavior will change. Managing the basic activities of daily living -- eating, talking, sleeping, finding things to do -- can be hard for both the person with Alzheimer's and the caregiver, especially as the disease becomes more severe. It may be time to call for additional help and planning.
Our experienced in-home care service comes to your home or their home full time or part time to help. We setup a management plan with you so you are comfortable and that that we can be of service in the best possible way.
RESPITE - Family... take a break from the daily routine and stress!
Respite care is the provision of short-term, temporary relief to those who are caring for family members who might otherwise require permanent placement in a facility outside the home.
Our experienced respite in-home care service comes to your home home to help. We setup a management plan with you so you are comfortable and that that we can be of service in the best possible way. For some this may include taking a break for short time, for others it may include a regular scheduled break times or full time help.
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Home Care, (commonly referred to as domiciliary care), is health care or supportive care provided in the patient's home by healthcare professionals (often referred to as home health care or formal care; in the United States, it is also known as skilled care) or by family and friends (also known as caregivers, primary caregiver, or voluntary caregivers who give informal care). Often, the term home care is used to distinguish non-medical care or custodial care, which is care that is provided by persons who are not nurses, doctors, or other licensed medical personnel, whereas the term home health care, refers to care that is provided by licensed personnel.
"Home care", "home health care", "in-home care" are phrases that are used interchangeably in the United States to mean any type of care given to a person in their own home. Both phrases have been used in the past interchangeably regardless of whether the person requires skilled care or not. More recently, there is a growing movement to distinguish between "home health care" meaning skilled nursing care and "home care" meaning non-medical care. In the United Kingdom, "homecare" and "domiciliary care" are the preferred expressions.
Home care aims to make it possible for people to remain at home rather than use residential, long-term, or institutional-based nursing care. Home care providers render services in the client's own home. These services may include some combination of professional health care services and life assistance services.
Professional home health services could include medical or psychological assessment, wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy.
Life assistance services include help with daily tasks such as meal preparation, medication reminders, laundry, light housekeeping, errands, shopping, transportation, and companionship.
While there are differences in terms used in describing aspects of home care or home health care in the United States and other areas of the world, for the most part the descriptions are very similar.
Estimates for the U.S. indicate that most home care is informal with families and friends providing a substantial amount of care. For formal care, the health care professionals most often involved are nurses followed by physical therapists and home care aides. Other health care providers include respiratory and occupational therapists, medical social workers and mental health workers. Home health care is generally paid for by Medicaid, long term insurance, or paid with the patient's own resources.
Aide worker qualifications
It is not a requirement that you have a GED or high school diploma, you will need to check with your local department of health for state requirements. Often aide workers have experience in institutional care facilities prior to a home care agency. Workers can take an examination to become a state tested Certified Nursing Assistant (CNA). Other requirements in the U.S.A. often include a background check, drug testing, and general references.
Licensure and providers by state
California IS a licensure state, mandated by Home Care Services Consumer Protection Act- AB1217
The Home Care Services Consumer Protection Act (HCSCPA) provides for the licensure and regulation of Home Care Organizations (HCOs) and the registration of Home Care Aides (HCAs), effective January 1, 2016.
Organizations: The HCSCPA requires HCOs to be licensed by the California Department of Social Services (CDSS). A HCO is an entity that arranges for home care services by an affiliated HCA to a client. This entity can be an individual who is 18 years of age or older, firm, partnership, corporation, Limited Liability Company, joint venture, association, etc. HCOs are not: home health agencies, licensed hospice agencies, licensed health facilities, In Home Supportive Services, employment agencies, community care facilities, clinics, facilities contracted through a regional center or the State Department of Development Services, alcohol or drug abuse recovery facilities, facilities with only Indian children who are eligible under the Indian Child Welfare Act.
The HCA Registry: The HCSCPA requires CDSS to establish, maintain, and continuously update a public registry of registered HCAs and HCA applicants. The HCA Registry will allow consumers to search for HCAs and view the aides name, registration number, registration status, registration expiration date, and, if applicable, the HCO to which the aide is associated.
Affiliated HCA and Independent HCAs: An affiliated HCA is employed by a HCO to provide home care services to a client and is listed on the HCA Registry. They will be required to have a background check by CDSS, tuberculosis screening and training. An affiliated HCA must be listed on the registry before providing home care services to a client. An independent HCA is not employed by a HCO; however, they have chosen to be listed on the HCA Registry and are providing home care services through a direct agreement with a client. Independent aides will be required to have a background check by CDSS.
Home Care Services: Home care services are nonmedical services and assistance provided by a registered HCA to a client who, because of advanced age or physical or mental disability cannot perform these services. These services enable the client to remain in his or her residence and include, but are not limited to, assistance with the following: · bathing · dressing · feeding · exercising · personal hygiene and grooming · transferring/ ambulating · positioning · toileting and incontinence care · making telephone calls · assisting with medication that the client self-administers · meal planning and preparation · transportation · housekeeping/ laundry · companionship · shopping for personal care items or groceries
Background Check Information: All convictions other than minor traffic violations, including misdemeanors, felonies andconvictions that occurred a long time ago require an exemption. Simply defined, an exemption is a CDSS authorized written document that "exempts" the individual from the requirement of having a criminal record clearance. However, individuals convicted of serious crimes such as robbery, sexual battery, child abuse, elder or dependent adult abuse, rape, arson or kidnapping are not eligible for an exemption. Additionally, CDSS examines arrest records to determine if there is possible danger to clients.
CDSS Responsibilities: CDSS will investigate complaints, conduct inspections of HCOs, and determine if a HCO is in compliance with the law. If so, the Department will impose fines. CDSS has the authority to revoke or suspend HCO licenses and HCA’s registration for violations of the law.
Payments and Fees
Recent AB241 Home Care
On January 1, 2014, passage by the California legislature of AB -241 Caregivers, Companions, and domestic workers, employed by all Agencies, or by individual clients directly, is changing the method of payment by requiring that the live in caregivers are compensated on an hourly basis rather than daily rate. Furthermore the legislation requires that the caregiver be paid overtime for all hours worked over 9 in a day or 45 in a work week. This is a mandatory law and all legally operating agencies have to comply. If you decide to employ a caregiver directly you will be classified as an employer of record and would be required to pay overtime and pay all the matching FICA, unemployment insurance and withholdings, keep appropriate records, file tax returns and submit timely payments to the State of California and IRS. Agencies (not registries) are already complying with state and federal law mandates.
California AB 241
- Effective January 1, 2014, a new law called The Domestic Worker Bill of Rights was enacted which defines domestic work as services related to the care of persons in private households or maintenance of private households or their premises.
- Domestic work occupations include caregivers of elderly persons, people with disabilities, sick or convalescing, and other household occupations, either full time or part time work.
- "Domestic work employer" includes an individual who employs or exercises control over the wages, hours, or working conditions of a domestic work employee.
- This definition confirms the private person organizing the care rather than the individual needing the care as the employer.
- Before AB241 families in need of 24 hour care would typically hire a live in caregiver. Providing room and board has traditionally been part of the caregiver’s compensation in addition to an agreed upon monthly monetary payment.
- After Jan 1, 2014, the room and board portion cannot be considered part of the compensation to the caregiver for their services. Compensation/wages now are entirely an hourly calculation of at least minimum wage (currently $ 9 per hour) for every hour worked, (asleep or awake in the household).
- Now 24 hour care is 24 paid hours at your negotiated hourly rate.
- A shift over 9 hours in a day or 40 hours in a week is earns wages at time and 1/2
- This makes how those hours are structured vital to how much each day of care costs. The least possible cost is 4 caregivers in 8 hour shifts. One alternate caregiver would be needed to cover any sick days of the other 4 caregivers so that everyone stays under 45 hours a week.
- AB241 also requires that the private employer withhold and pay all regular employee / employer taxes. Such as Federal and State withholding, California Disability Insurance, California Unemployment Insurance along with a few other minor taxes.
- Worker’s Compensation Insurance is a separate insurance from regular payroll taxes and is required also. (The CA State Compensation Insurance Fund can be contacted at 888-782-8338.)
- AB241 includes a provision for employees to apply for and receive Unemployment Insurance payments or Disability Insurance payments, regardless of whether or not the employer has purchased the insurance.
- This allows the state to both protect the worker and to verify with the individual-employer that all tax payments and-or penalties have been applied.
- Personal assets of the employer can be attached by the State or Federal government to pay the domestic worker all unpaid wages and related taxes.
2004 Study by NIHS
In February 2004, the National Center for Health Statistics (NCHS) conducted the "National Home and Hospice Study," which was updated in 2005.
The data was collected on about approximately 1.3+ million (1,355,300) persons receiving home care in the USA. Of that total, almost 30% (29.5% or 400,100 persons) were under 65 years of age, while the majority, almost 70%, were over 65 years old (70.5% or 955,200 persons).
The 2005 chart data of estimates based on interviews with non-institutionalized citizens, however, shows a relatively stable number of about 6 to 7 percent of adults age 65 who needed help for personal care (ADLs) - this has remained about the same between 1997 and 2004. (Data has a 95% reliability.) Those aged 85 or older were at least 6 times more likely (20.6%) to need ADL assistance than those of age 65. Between age 65 and 85 years, more women than men needed help.
To review the 2005 Early Release data used, visit the NCHS-NHIS website to see the PDF files. [NOTE: * The 2005 data reflects data, still between 6 to 7%, is only based on interviews conducted between January to June 2005, so it remains to be seen whether the figure remained constant or changed through the end of 2005.] Again, the 1998-2005 data is specific for over 65 or older and does not include any data for adults under 65 years old.
In the 2004 data, just over 30% (30.2% or 385,500) of the total 1.3+million persons lived alone, but the study did not break this down by age groups. A large portion, 1,094,900 or 80.8% had a primary caregiver, and almost 76% (75.9% or 831,100 lived with the primary caregiver, typically the spouse, child or child-in-law, other relative or parent, in that order. (Paid help and the category of neighbor/friend/ or unknown caregiver would be, for the majority, were living with non-family (4.3%) or unknown living arrangement .) Most patients still need external help, even if the primary caregiver is a spouse.
A total of 600,900 persons received personal care.
Payment described in the 2004 study
Page 4 of the study describes the population break-down by type of payment used. Of the 1.3+ million:
710,000 paid by Medicare - Medicare often is the primary billing source, if this is the primary carrier between two types of insurance (like between Medicare and Medicaid). Also, if a patient has Medicare and that patient has a "skilled need" requiring nursing visits, the patient's case is typically billed under Medicare.
277,000 paid by Medicaid - This number seems low for Community Based Services (CBS) or Home Care (HC), especially as a nationwide statistic.
235,000 paid by private insurance, or self/family - Private insurance includes VA (Veterans Administration), some Railroad or Steelworkers health plans or other private insurance. "Self/family" indicates "private pay" status, when the patient or family pays 100% of all home care charges. Home care fees can be quite high; few patients & families can absorb these costs for a long period of time.
133,200 all other payments - including patients unable to pay, or who had no charge for care, or those whose payment "source not yet determined or approved." Sometimes after "opening a case" (the formal paperwork process of admitting a patient to home care services, there can be a short period of time when the office has not yet received approval by one of two or more insurances held by the patient. This is not unusual. There can also be cases where the office must make phone calls to be sure a particular diagnosis is "covered" by the patient's primary insurance. This is not unusual. These delays explain, in part, a couple circumstances where payment source would be listed as "unknown."
Community-Based Long Term Care (CBLTC) is the newer name for Home Health Care Services paid by States' Medicaid programs. Most of these programs have a category called 'Medicaid Waiver' to define level of care being delivered.
The Study "Medicaid
Home and Community-Based Long Term Care – Trends in the U.S.
and Maryland" funded by the National Institute of Disability
and Rehabilitation Research, Department of Education, Information
Brokering for Long Term Care, The Robert Wood Johnson Foundation,
focused on expenditures. In this study, the Medicaid Waiver Expenditures
by Recipient Group in 2001 based on total expenditure of $14,218,236,802
was broken down in this manner of actual spending (presumably this
is based on nationwide figures):
But, the same report included figures on "Participants by Recipient Type" in 2001 based on a total number of 832,915. Participant types were broken down thus (presumably this is based on nationwide figures):
Respite care is the provision of short-term, temporary relief to those who are caring for family members who might otherwise require permanent placement in a facility outside the home.
Respite programs provide planned short-term and time-limited breaks for families and other unpaid care givers of children with a developmental delay and adults with an intellectual disability in order to support and maintain the primary care giving relationship. Respite also provides a positive experience for the person receiving care. The term "short break" is used in some countries to describe respite care.
In the United States today there are approximately 50 million people who are caring at home for family members including elderly parents, and spouses and children with disabilities and/or chronic illnesses. Without this home-care, most of these cared for loved ones would require permanent placement in institutions or health care facilities.
Even though many families take great joy in providing care to their loved ones so that they can remain at home, the physical, emotional and financial consequences for the family caregiver can be overwhelming without some support, such as respite. Respite provides the much needed temporary break from the often exhausting challenges faced by the family caregiver.
Respite is the service most often requested by family caregivers, yet it is in critically short supply, inaccessible, or unaffordable regardless of the age or disability of the individual needing assistance. While the focus has been on making sure families have the option of providing care at home, little attention has been paid to the needs of the family caregivers who make this possible.
Without respite, not only can families suffer economically and emotionally, caregivers themselves may face serious health and social risks as a result of stress associated with continuous caregiving. Three fifths of family caregivers age 19-64 surveyed recently by the Commonwealth Fund reported fair or poor health, one or more chronic conditions, or a disability, compared with only one-third of non caregivers.
Respite has been shown to help sustain family caregiver health and wellbeing, avoid or delay out-of-home placements, and reduce the likelihood of abuse and neglect. An outcome based evaluation pilot study show that respite may also reduce the likelihood of divorce and help sustain marriages.
Models for Respite
There are various models for providing respite care including:
In-home care is popular for obvious reasons. The temporary caregiver comes to the regular caregiver’s home, and gets to know the care receiver in his or her normal environment. The temporary caregiver learns the family routine, where medicines are stored, and the care receiver is not inconvenienced by transportation and strange environments. In this model, friends, relatives and paid professionals may be used. Depending on the state, Medicaid or Medicare may be used to help cover costs. Another in-home model will utilize friends and neighbors as helping hands where the primary caregiver never leaves the premises but may simply be getting a break so that they can cook dinner or pay the bills.
Another model uses a specialized, local facility where the care receiver may stay for a few days or a few weeks. The advantage of this model is that the specialized facility will probably have better access to emergency facilities and professional assistance if needed.
There may be the need for respite care on an emergency basis. When using "planned" emergency care, the caregiver has already identified a provider or facility to call in case there is an emergency. Many homecare agencies, adult day care, health centers, and residential care facilities provide emergency respite care.
Sitter-companion services are sometimes provided by local civic groups, the faith community and other community organizations. A regular sitter-companion can provide friendly respite care for a few hours, once or twice a week. Care must be taken to assure that the sitter-companion is trained in what to do if an emergency occurs while the regular care-giver is out of the home.
Therapeutic adult day care
Therapeutic adult day care may provide respite care during business hours five days a week.
The Lifespan Respite Act
Recognizing this significant contribution and the needs faced by America’s caregivers, the United States Congress passed The Lifespan Respite Care Act of 2006 (HR 3248) which was signed into law in December 2006. The bill was introduced and championed in the US House of Representatives by Rep. Mike Ferguson and James Langevin (D-RI). A companion bill in the Senate was cosponsored by Senator Hillary Clinton (D-NY) and Senator John Warner.
Much of the success for the passage of this legislation is due to the work of The Lifespan Respite Task Force which includes a diverse group of national and state organizations, state respite and crisis care coalitions; health and community social services; disability, mental health, education, faith, family caregiving and support groups; groups from the child advocacy and the aging community; and abuse and neglect prevention groups.
If and when the new law is funded, (check progress at the ARCH website) it will provide funds for states to develop lifespan respite programs to help families access quality, affordable respite care. Lifespan respite programs are defined in the Act “as coordinated systems of accessible, community-based respite care services for family caregivers of children and adults with special needs.” Specifically, the law authorizes funds for:
When the bill passed the House, Rep. Ferguson, whose own father was a caregiver for his ill mother for six years said , “Today's action by the House of Representatives represents not only an important victory for family caregivers nationwide, but it also sends America's caregivers a clear message: Your selfless sacrifice is appreciated, and help is on the way.”
The Lifespan Respite Care Act of 2006 is based on model state lifespan respite programs that have successfully addressed all of these barriers. Three states have enacted legislation to implement lifespan respite programs (Oregon, Nebraska, Wisconsin), which establish state and local infrastructures for developing, providing, coordinating and improving access to respite for all caregivers, regardless of age, disability or family situation. Oklahoma has also implemented a successful lifespan respite program.
Respite in the US
An estimated 50 million family caregivers nationwide provide at least $306 billion in uncompensated services — an amount comparable to Medicare spending in 2004 and more than twice what is spent nationwide on nursing homes and paid home care combined. Family caregivers may suffer from physical, emotional, and financial problems that impede their ability to give care now and support their own care needs in the future. Without attention to their needs, their ability to continue providing care may well be jeopardized.
Respite care is one of the services that Alzheimer’s caregivers say they need most. One study found that if respite care delays institutionalization of a person with Alzheimer’s disease by as little as a month, $1.12 billion is saved annually. A similar study in 1995 found that as respite use increased, the probability of nursing home placement decreased significantly
U.S. businesses also incur high costs in terms of decreased productivity by stressed working caregivers. A study by MetLife estimates the loss to U.S. employers to be between $17.1 and $33.6 billion per year. This includes replacement costs for employees who quit because of overwhelming caregiving responsibilities, absenteeism, and workday interruptions.
Caregiver wellness reduces hospitalizations, doctor visits, work absences
Significant percentages of family caregivers report physical or mental health problems due to caregiving. A recent survey of caregivers of children, adults and the disabled conducted by the National Family Caregivers Association, found that while 70% of the respondents reported finding an inner strength they didn’t know they had, 27% reported having more headaches, 24% reported stomach disorders, 41% more back pain, 51% more sleeplessness and 61% reported more depression.
Three fifths of family caregivers age 19-64 surveyed recently by the Commonwealth Fund reported fair or poor health, one or more chronic conditions, or a disability, compared with only one-third of non caregivers. Caregivers reported chronic conditions at nearly twice the rate of non caregivers (45% to 24%).
A 1999 study in the Journal of the American Medical Association found that participants who were providing care for an elderly individual with a disability and experiencing caregiver strain had mortality risks that were 63% higher than non caregiving controls.
In an Iowa survey of parents of children with disabilities, a significant relationship was demonstrated between the severity of a child’s disability and their parents missing more work hours than other employees. They also found that the lack of available respite care appeared to interfere with parents accepting job opportunities.
Respite for younger family members with disabilities
Respite has been shown to improve family functioning, improve satisfaction with life, enhance the capacity to cope with stress, and improve attitudes toward the family member with a disability.
In a 1989 US national survey of families of a child with a disability, 74% reported that respite had made a significant difference in their ability to provide care at home; 35% of the respite users indicated that without respite services they would have considered out-of-home-placement for their family member.
There was a statistically significant reduction in somatic complaints by in a study of primary caregivers of children with chronic illnesses, and a decrease in the number of hospitalization days required by children, as a direct result of respite care.
Data from an ongoing research project of the Oklahoma State University on the effects of respite care found that the number of hospitalizations, as well as the number of medical care claims decreased as the number of respite care days increased.
A Massachusetts social services program designed to provide cost-effective family-centered respite care for children with complex medical needs found that for families participating for more than one year, the number of hospitalizations decreased by 75%, physician visits decreased by 64%, and antibiotics use decreased by 71%.
An evaluation of the Iowa Respite Child Care Project for families parenting a child with developmental disabilities found that when respite care is used by the families, there is a statistically significant decrease in foster care placement.
A 1999 study of Vermont’s then 10-year-old respite care program for families with children or adolescents with serious emotional disturbance found that participating families experience fewer out-of home placements than nonusers and were more optimistic about their future capabilities to take care of their children.
Results when caregivers of the elderly use respite
Respite for the elderly with chronic disabilities in a study group resulted in fewer hospital admissions for acute medical care than for two other control groups who received no respite care
Sixty-four percent of caregivers of the elderly receiving 4 hours of respite per week, after one year, reported improved physical health. Seventy-eight percent improved their emotional health, and 50% cited improvement in the care recipient as well. Forty percent said they were less likely to institutionalize the care recipient because of respite.
Caregivers of relatives with dementia who use adult day care experience lower levels of caregiving related stress and better psychological well-being than a control group not using this service. These differences were found in both short-term (3 months) and long-term (12 months) users.
Respite provided across the lifespan yields positive outcomes
In a 2004 survey conducted by the Oklahoma Respite Resource Network, 88% of caregivers agreed that respite allowed their loved one to remain at home, 98% of caregivers stated that respite made them a better caregiver, 98% of caregivers said respite increased their ability to provide a less stressful environment, and 79.5% of caregivers said respite contributed to the stability of their marriage.
When newly formed, the Nebraska statewide lifespan respite program conducted a statewide survey of a broad array of caregivers who had been receiving respite services, and found that one in four families with children under 21 reported that they were less likely to place their child in out-of-home care once respite services were available. In addition, 79% of the respondents reported decreased stress and 58% reported decreased isolation.
Data from an outcome based evaluation pilot study show that respite may also reduce the likelihood of divorce and help sustain marriages
Alzheimer's disease (AD), also called Alzheimer disease, senile dementia of the Alzheimer type (SDAT), primary degenerative dementia of the Alzheimer's type (PDDAT), or simply Alzheimer's, is the most common form of dementia. This incurable, degenerative, and terminal disease was first described by German psychiatrist and neuropathologist Alois Alzheimer in 1906 and was named after him. Most often, it is diagnosed in people over 65 years of age, although the less-prevalent early-onset Alzheimer's can occur much earlier. In 2006, there were 26.6 million sufferers worldwide. Alzheimer's is predicted to affect 1 in 85 people globally by 2050.
Although the course of Alzheimer's disease is unique for every individual, there are many common symptoms. The earliest observable symptoms are often mistakenly thought to be 'age-related' concerns, or manifestations of stress. In the early stages, the most commonly recognised symptom is inability to acquire new memories, such as difficulty in recalling recently observed facts. When AD is suspected, the diagnosis is usually confirmed with behavioural assessments and cognitive tests, often followed by a brain scan if available.
As the disease advances, symptoms include confusion, irritability and aggression, mood swings, language breakdown, long-term memory loss, and the general withdrawal of the sufferer as their senses decline. Gradually, bodily functions are lost, ultimately leading to death. Individual prognosis is difficult to assess, as the duration of the disease varies. AD develops for an indeterminate period of time before becoming fully apparent, and it can progress undiagnosed for years. The mean life expectancy following diagnosis is approximately seven years. Fewer than three percent of individuals live more than fourteen years after diagnosis.
The cause and progression of Alzheimer's disease are not well understood. Research indicates that the disease is associated with plaques and tangles in the brain. Currently used treatments offer a small symptomatic benefit; no treatments to delay or halt the progression of the disease are, as of yet, available. As of 2008[update], more than 500 clinical trials have been conducted for identification of a possible treatment for AD, but it is unknown if any of the tested intervention strategies will show promising results. A number of non-invasive, life-style habits have been suggested for the prevention of Alzheimer's disease, but there is a lack of adequate evidence for a link between these recommendations and reduced degeneration. Mental stimulation, exercise, and a balanced diet are suggested, as both a possible prevention and a sensible way of managing the disease.
Because AD cannot be cured and is degenerative, management of patients is essential. The role of the main caregiver is often taken by the spouse or a close relative. Alzheimer's disease is known for placing a great burden on caregivers; the pressures can be wide-ranging, involving social, psychological, physical, and economic elements of the caregiver's life. In developed countries, AD is one of the most costly diseases to society.
The first symptoms are often mistaken as related to aging or stress. Detailed neuropsychological testing can reveal mild cognitive difficulties up to eight years before a person fulfills the clinical criteria for diagnosis of AD. These early symptoms can affect the most complex daily living activities. The most noticeable deficit is memory loss, which shows up as difficulty in remembering recently learned facts and inability to acquire new information.
Subtle problems with the executive functions of attentiveness, planning, flexibility, and abstract thinking, or impairments in semantic memory (memory of meanings, and concept relationships), can also be symptomatic of the early stages of AD. Apathy can be observed at this stage, and remains the most persistent neuropsychiatric symptom throughout the course of the disease. The preclinical stage of the disease has also been termed mild cognitive impairment, but whether this term corresponds to a different diagnostic stage or identifies the first step of AD is a matter of dispute.
In people with AD the increasing impairment of learning and memory eventually leads to a definitive diagnosis. In a small portion of them, difficulties with language, executive functions, perception (agnosia), or execution of movements (apraxia) are more prominent than memory problems. AD does not affect all memory capacities equally. Older memories of the person's life (episodic memory), facts learned (semantic memory), and implicit memory (the memory of the body on how to do things, such as using a fork to eat) are affected to a lesser degree than new facts or memories.
Language problems are mainly characterised by a shrinking vocabulary and decreased word fluency, which lead to a general impoverishment of oral and written language. In this stage, the person with Alzheimer's is usually capable of adequately communicating basic ideas. While performing fine motor tasks such as writing, drawing or dressing, certain movement coordination and planning difficulties (apraxia) may be present but they are commonly unnoticed. As the disease progresses, people with AD can often continue to perform many tasks independently, but may need assistance or supervision with the most cognitively demanding activities.
Progressive deterioration eventually hinders independence; with subjects being unable to perform most common activities of daily living. Speech difficulties become evident due to an inability to recall vocabulary, which leads to frequent incorrect word substitutions (paraphasias). Reading and writing skills are also progressively lost. Complex motor sequences become less coordinated as time passes and AD progresses, so the risk of falling increases. During this phase, memory problems worsen, and the person may fail to recognise close relatives. Long-term memory, which was previously intact, becomes impaired.
Behavioural and neuropsychiatric changes become more prevalent. Common manifestations are wandering, irritability and labile affect, leading to crying, outbursts of unpremeditated aggression, or resistance to caregiving. Sundowning can also appear. Approximately 30% of patients develop illusionary misidentifications and other delusional symptoms. Subjects also lose insight of their disease process and limitations (anosognosia). Urinary incontinence can develop. These symptoms create stress for relatives and caretakers, which can be reduced by moving the person from home care to other long-term care facilities.
During this last stage of AD, the patient is completely dependent upon caregivers. Language is reduced to simple phrases or even single words, eventually leading to complete loss of speech. Despite the loss of verbal language abilities, patients can often understand and return emotional signals. Although aggressiveness can still be present, extreme apathy and exhaustion are much more common results. Patients will ultimately not be able to perform even the most simple tasks without assistance. Muscle mass and mobility deteriorate to the point where they are bedridden, and they lose the ability to feed themselves. AD is a terminal illness with the cause of death typically being an external factor such as infection of pressure ulcers or pneumonia, not the disease itself.
Several competing hypotheses exist trying to explain the cause of the disease. The oldest, on which most currently available drug therapies are based, is the cholinergic hypothesis, which proposes that AD is caused by reduced synthesis of the neurotransmitter acetylcholine. The cholinergic hypothesis has not maintained widespread support, largely because medications intended to treat acetylcholine deficiency have not been very effective. Other cholinergic effects have also been proposed, for example, initiation of large-scale aggregation of amyloid, leading to generalised neuroinflammation.
In 1991, the amyloid hypothesis postulated that amyloid beta (A?) deposits are the fundamental cause of the disease. Support for this postulate comes from the location of the gene for the amyloid beta precursor protein (APP) on chromosome 21, together with the fact that people with trisomy 21 (Down Syndrome) who have an extra gene copy almost universally exhibit AD by 40 years of age. Also APOE4, the major genetic risk factor for AD, leads to excess amyloid buildup in the brain before AD symptoms arise. Thus, A? deposition precedes clinical AD. Further evidence comes from the finding that transgenic mice that express a mutant form of the human APP gene develop fibrillar amyloid plaques and Alzheimer's-like brain pathology with spatial learning deficits.
An experimental vaccine was found to clear the amyloid plaques in early human trials, but it did not have any significant effect on dementia. Researchers have been led to suspect non-plaque A? oligomers (aggregates of many monomers) as the primary pathogenic form of A?. These toxic oligomers, also referred to as amyloid-derived diffusible ligands (ADDLs), bind to a surface receptor on neurons and change the structure of the synapse, thereby disrupting neuronal communication. One receptor for A? oligomers may be the prion protein, the same protein that has been linked to mad cow disease and the related human condition, Creutzfeldt-Jakob disease, thus potentially linking the underlying mechanism of these neurodegenerative disorders with that of Alzheimer's disease.
In 2009, this theory was updated, suggesting that a close relative of the beta-amyloid protein, and not necessarily the beta-amyloid itself, may be a major culprit in the disease. The theory holds that an amyloid-related mechanism that prunes neuronal connections in the brain in the fast-growth phase of early life may be triggered by aging-related processes in later life to cause the neuronal withering of Alzheimer's disease. N-APP, a fragment of APP from the peptide's N-terminus, is adjacent to beta-amyloid and is cleaved from APP by one of the same enzymes. N-APP triggers the self-destruct pathway by binding to a neuronal receptor called death receptor 6 (DR6, also known as TNFRSF21). DR6 is highly expressed in the human brain regions most affected by Alzheimer's, so it is possible that the N-APP/DR6 pathway might be hijacked in the aging brain to cause damage. In this model, beta-amyloid plays a complementary role, by depressing synaptic function.
A 2004 study found that deposition of amyloid plaques does not correlate well with neuron loss. This observation supports the tau hypothesis, the idea that tau protein abnormalities initiate the disease cascade. In this model, hyperphosphorylated tau begins to pair with other threads of tau. Eventually, they form neurofibrillary tangles inside nerve cell bodies. When this occurs, the microtubules disintegrate, collapsing the neuron's transport system. This may result first in malfunctions in biochemical communication between neurons and later in the death of the cells. Herpes simplex virus type 1 has also been proposed to play a causative role in people carrying the susceptible versions of the apoE gene.
Another hypothesis asserts that the disease may be caused by age-related myelin breakdown in the brain. Demyelination leads to axonal transport disruptions, leading to loss of neurons that become stale. Iron released during myelin breakdown is hypothesized to cause further damage. Homeostatic myelin repair processes contribute to the development of proteinaceous deposits such as amyloid-beta and tau.
Oxidative stress is a significant cause in the formation of the pathology.
AD individuals show 70% loss of locus coeruleus cells that provide norepinephrine (in addition to its neurotransmitter role) that locally diffuses from "varicosities" as an endogenous antiinflammatory agent in the microenvironment around the neurons, glial cells, and blood vessels in the neocortex and hippocampus. It has been shown that norepinephrine stimulates mouse microglia to suppress A?-induced production of cytokines and their phagocytosis of A?. This suggests that degeneration of the locus ceruleus might be responsible for increased A? deposition in AD brains.
Alzheimer's disease is characterised by loss of neurons and synapses in the cerebral cortex and certain subcortical regions. This loss results in gross atrophy of the affected regions, including degeneration in the temporal lobe and parietal lobe, and parts of the frontal cortex and cingulate gyrus. Studies using MRI and PET have documented reductions in the size of specific brain regions in patients as they progressed from mild cognitive impairment to Alzheimer's disease, and in comparison with similar Images from healthy older adults.
Both amyloid plaques and neurofibrillary tangles are clearly visible by microscopy in brains of those afflicted by AD. Plaques are dense, mostly insoluble deposits of amyloid-beta peptide and cellular material outside and around neurons. Tangles (neurofibrillary tangles) are aggregates of the microtubule-associated protein tau which has become hyperphosphorylated and accumulate inside the cells themselves. Although many older individuals develop some plaques and tangles as a consequence of aging, the brains of AD patients have a greater number of them in specific brain regions such as the temporal lobe. Lewy bodies are not rare in AD patient's brains.
Alzheimer's disease has been identified as a protein misfolding disease (proteopathy), caused by accumulation of abnormally folded A-beta and tau proteins in the brain. Plaques are made up of small peptides, 39–43 amino acids in length, called beta-amyloid (also written as A-beta or A?). Beta-amyloid is a fragment from a larger protein called amyloid precursor protein (APP), a transmembrane protein that penetrates through the neuron's membrane. APP is critical to neuron growth, survival and post-injury repair. In Alzheimer's disease, an unknown process causes APP to be divided into smaller fragments by enzymes through proteolysis. One of these fragments gives rise to fibrils of beta-amyloid, which form clumps that deposit outside neurons in dense formations known as senile plaques.
AD is also considered a tauopathy due to abnormal aggregation of the tau protein. Every neuron has a cytoskeleton, an internal support structure partly made up of structures called microtubules. These microtubules act like tracks, guiding nutrients and molecules from the body of the cell to the ends of the axon and back. A protein called tau stabilizes the microtubules when phosphorylated, and is therefore called a microtubule-associated protein. In AD, tau undergoes chemical changes, becoming hyperphosphorylated; it then begins to pair with other threads, creating neurofibrillary tangles and disintegrating the neuron's transport system.
Exactly how disturbances of production and aggregation of the beta amyloid peptide gives rise to the pathology of AD is not known. The amyloid hypothesis traditionally points to the accumulation of beta amyloid peptides as the central event triggering neuron degeneration. Accumulation of aggregated amyloid fibrils, which are believed to be the toxic form of the protein responsible for disrupting the cell's calcium ion homeostasis, induces programmed cell death (apoptosis). It is also known that A? selectively builds up in the mitochondria in the cells of Alzheimer's-affected brains, and it also inhibits certain enzyme functions and the utilisation of glucose by neurons.
Various inflammatory processes and cytokines may also have a role in the pathology of Alzheimer's disease. Inflammation is a general marker of tissue damage in any disease, and may be either secondary to tissue damage in AD or a marker of an immunological response.
The vast majority of cases of Alzheimer's disease are sporadic, meaning that they are not genetically inherited although some genes may act as risk factors. On the other hand, around 0.1% of the cases are familial forms of autosomal-dominant inheritance, which usually have an onset before age 65.
Most of autosomal dominant familial AD can be attributed to mutations in one of three genes: amyloid precursor protein (APP) and presenilins 1 and 2. Most mutations in the APP and presenilin genes increase the production of a small protein called A?42, which is the main component of senile plaques. Some of the mutations merely alter the size ratio between A?42 and the other major forms—e.g., A?40—without increasing A?42 levels. This suggests that presenilin mutations can cause disease even if they lower the total amount of A? produced and may point to other roles of presenilin or a role for alterations in the function of APP and/or its fragments other than A?.
Most cases of Alzheimer's disease do not exhibit autosomal-dominant inheritance and are termed sporadic AD. Nevertheless genetic differences may act as risk factors. The best known genetic risk factor is the inheritance of the ?4 allele of the apolipoprotein E (APOE). Between 40 and 80% of patients with AD possess at least one apoE4 allele. The APOE4 allele increases the risk of the disease by three times in heterozygotes and by 15 times in homozygotes. Geneticists agree that numerous other genes also act as risk factors or have protective effects that influence the development of late onset Alzheimer's disease. Over 400 genes have been tested for association with late-onset sporadic AD, most with null results.
Alzheimer's disease is usually diagnosed clinically from the patient history, collateral history from relatives, and clinical observations, based on the presence of characteristic neurological and neuropsychological features and the absence of alternative conditions. Advanced medical imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and with single photon emission computed tomography (SPECT) or positron emission tomography (PET) can be used to help exclude other cerebral pathology or subtypes of dementia. Moreover, it may predict conversion from prodromal stages (mild cognitive impairment) to Alzheimer's disease.
Assessment of intellectual functioning including memory testing can further characterise the state of the disease. Medical organisations have created diagnostic criteria to ease and standardise the diagnostic process for practicing physicians. The diagnosis can be confirmed with very high accuracy post-mortem when brain material is available and can be examined histologically.
The National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) and the Alzheimer's Disease and Related Disorders Association (ADRDA, now known as the Alzheimer's Association) established the most commonly used NINCDS-ADRDA Alzheimer's Criteria for diagnosis in 1984, extensively updated in 2007. These criteria require that the presence of cognitive impairment, and a suspected dementia syndrome, be confirmed by neuropsychological testing for a clinical diagnosis of possible or probable AD. A histopathologic confirmation including a microscopic examination of brain tissue is required for a definitive diagnosis. Good statistical reliability and validity have been shown between the diagnostic criteria and definitive histopathological confirmation. Eight cognitive domains are most commonly impaired in AD—memory, language, perceptual skills, attention, constructive abilities, orientation, problem solving and functional abilities. These domains are equivalent to the NINCDS-ADRDA Alzheimer's Criteria as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) published by the American Psychiatric Association.
Neuropsychological tests such as the mini-mental state examination (MMSE), are widely used to evaluate the cognitive impairments needed for diagnosis. More comprehensive test arrays are necessary for high reliability of results, particularly in the earliest stages of the disease. Neurological examination in early AD will usually provide normal results, except for obvious cognitive impairment, which may not differ from that resulting from other diseases processes, including other causes of dementia.
Further neurological examinations are crucial in the differential diagnosis of AD and other diseases. Interviews with family members are also utilised in the assessment of the disease. Caregivers can supply important information on the daily living abilities, as well as on the decrease, over time, of the person's mental function. A caregiver's viewpoint is particularly important, since a person with AD is commonly unaware of his own deficits. Many times, families also have difficulties in the detection of initial dementia symptoms and may not communicate accurate information to a physician.
Another recent objective marker of the disease is the analysis of cerebrospinal fluid for amyloid beta or tau proteins, both total tau protein and phosphorylated tau181P protein concentrations. Searching for these proteins using a spinal tap can predict the onset of Alzheimer's with a sensitivity of between 94% and 100%. When used in conjunction with existing neuroimaging techniques, doctors can identify patients with significant memory loss who are already developing the disease. Spinal fluid tests are commercially available, unlike the latest neuroimaging technology. Alzheimer's was diagnosed in one-third of the people who did not have any symptoms in a 2010 study, meaning that disease progression occurs well before symptoms occur.
Supplemental testing provides extra information on some features of the disease or is used to rule out other diagnoses. Blood tests can identify other causes for dementia than AD—causes which may, in rare cases, be reversible. It is common to perform thyroid function tests, assess B12, rule out syphillis, rule out metabolic problems (including tests for kidney function, electrolyte levels and for diabetes), assess levels of heavy metals (e.g. lead, mercury) and anemia. (See differential diagnosis for Dementia). (It is also necessary to rule out delirium).
When available as a diagnostic tool, single photon emission computed tomography (SPECT) and positron emission tomography (PET) neuroimaging are used to confirm a diagnosis of Alzheimer's in conjunction with evaluations involving mental status examination. In a person already having dementia, SPECT appears to be superior in differentiating Alzheimer's disease from other possible causes, compared with the usual attempts employing mental testing and medical history analysis. Advances have led to the proposal of new diagnostic criteria.
A new technique known as PiB PET has been developed for directly and clearly imaging beta-amyloid deposits in vivo using a tracer that binds selectively to the A-beta deposits. The PiB-PET compound uses carbon-11 PET scanning. Recent studies suggest that PiB-PET is 86% accurate in predicting which people with mild cognitive impairment will develop Alzheimer's disease within two years, and 92% accurate in ruling out the likelihood of developing Alzheimer's.
A similar PET scanning radiopharmaceutical compound called (E)-4-(2-(6-(2-(2-(2-([18F]-fluoroethoxy)ethoxy)ethoxy)pyridin-3-yl)vinyl)-N-methyl benzenamine, or 18F AV-45, or florbetapir-fluorine-18, or simply florbetapir, contains the longer-lasting radionuclide fluorine-18, has recently been created, and tested as a possible diagnostic tool in Alzheimer's patients. Florbetapir, like PiB, binds to beta-amyloid, but due to its use of fluorine-18 has a half-life of 110 minutes, in contrast to PiB's radioactive half life of 20 minutes. Wong et al. found that the longer life allowed the tracer to accumulate significantly more in the brains of the AD patients, particularly in the regions known to be associated with beta-amyloid deposits.
One review predicted that amyloid imaging is likely to be used in conjunction with other markers rather than as an alternative.
Volumetric MRI can detect changes in the size of brain regions. Measuring those regions that atrophy during the progress of Alzheimer's disease is showing promise as a diagnostic indicator. It may prove less expensive than other imaging methods currently under study.
Recent studies suggest that brain metabolite levels may be utilized as biomarkers for Alzheimer's disease.
Three antibodies have been found that could act as biomarkers for AD.
At present, there is no definitive evidence to support that any particular measure is effective in preventing AD. Global studies of measures to prevent or delay the onset of AD have often produced inconsistent results. However, epidemiological studies have proposed relationships between certain modifiable factors, such as diet, cardiovascular risk, pharmaceutical products, or intellectual activities among others, and a population's likelihood of developing AD. Only further research, including clinical trials, will reveal whether these factors can help to prevent AD.
Although cardiovascular risk factors, such as hypercholesterolemia, hypertension, diabetes, and smoking, are associated with a higher risk of onset and course of AD, statins, which are cholesterol lowering drugs, have not been effective in preventing or improving the course of the disease. The components of a Mediterranean diet, which include fruit and vegetables, bread, wheat and other cereals, olive oil, fish, and red wine, may all individually or together reduce the risk and course of Alzheimer's disease. Its beneficial cardiovascular effect has been proposed as the mechanism of action. There is limited evidence that light to moderate use of alcohol, particularly red wine, is associated with lower risk of AD.
Reviews on the use of vitamins have not found enough evidence of efficacy to recommend vitamin C, E, or folic acid with or without vitamin B12, as preventive or treatment agents in AD. Additionally vitamin E is associated with important health risks. Trials examining folic acid (B9) and other B vitamins failed to show any significant association with cognitive decline. Docosahexaenoic acid, an Omega 3 fatty acid, has not been found to slow decline.
Long-term usage of non-steroidal anti-inflammatory drug (NSAIDs) is associated with a reduced likelihood of developing AD. Human postmortem studies, in animal models, or in vitro investigations also support the notion that NSAIDs can reduce inflammation related to amyloid plaques. However trials investigating their use as palliative treatment have failed to show positive results while no prevention trial has been completed. Curcumin from the curry spice turmeric has shown some effectiveness in preventing brain damage in mouse models due to its anti-inflammatory properties. Hormone replacement therapy, although previously used, is no longer thought to prevent dementia and in some cases may even be related to it. There is inconsistent and unconvincing evidence that ginkgo has any positive effect on cognitive impairment and dementia, and a recent study concludes that it has no effect in reducing the rate of AD incidence. A 21-year study found that coffee drinkers of 3–5 cups per day at midlife had a 65% reduction in risk of dementia in late-life.
People who engage in intellectual activities such as reading, playing board games, completing crossword puzzles, playing musical instruments, or regular social interaction show a reduced risk for Alzheimer's disease. This is compatible with the cognitive reserve theory, which states that some life experiences result in more efficient neural functioning providing the individual a cognitive reserve that delays the onset of dementia manifestations. Education delays the onset of AD syndrome, but is not related to earlier death after diagnosis. Physical activity is also associated with a reduced risk of AD.
Medical marijuana appears to be effective in delaying Alzheimer's Disease. The active ingredient in marijuana, THC, prevents the formation of deposits in the brain associated with Alzheimer's disease. THC was found to inhibit acetylcholinesterase more effectively than commercially marketed drugs. THC was also found to delay amylogenesis.
Some studies have shown an increased risk of developing AD with environmental factors such the intake of metals, particularly aluminium, or exposure to solvents. The quality of some of these studies has been criticised, and other studies have concluded that there is no relationship between these environmental factors and the development of AD.
While some studies suggest that extremely low frequency electromagnetic fields may increase the risk for Alzheimer's disease, reviewers found that further epidemiological and laboratory investigations of this hypothesis are needed. Smoking is a significant AD risk factor. Systemic markers of the innate immune system are risk factors for late-onset AD.
There is no cure for Alzheimer's disease; available treatments offer relatively small symptomatic benefit but remain palliative in nature. Current treatments can be divided into pharmaceutical, psychosocial and caregiving.
Four medications are currently approved by regulatory agencies such as the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) to treat the cognitive manifestations of AD: three are acetylcholinesterase inhibitors and the other is memantine, an NMDA receptor antagonist. No drug has an indication for delaying or halting the progression of the disease.
Reduction in the activity of the cholinergic neurons is a well-known feature of Alzheimer's disease. Acetylcholinesterase inhibitors are employed to reduce the rate at which acetylcholine (ACh) is broken down, thereby increasing the concentration of ACh in the brain and combating the loss of ACh caused by the death of cholinergic neurons. As of 2008[update], the cholinesterase inhibitors approved for the management of AD symptoms are donepezil (brand name Aricept), galantamine (Razadyne), and rivastigmine (branded as Exelon and Exelon Patch). There is evidence for the efficacy of these medications in mild to moderate Alzheimer's disease, and some evidence for their use in the advanced stage. Only donepezil is approved for treatment of advanced AD dementia. The use of these drugs in mild cognitive impairment has not shown any effect in a delay of the onset of AD. The most common side effects are nausea and vomiting, both of which are linked to cholinergic excess. These side effects arise in approximately 10–20% of users and are mild to moderate in severity. Less common secondary effects include muscle cramps, decreased heart rate (bradycardia), decreased appetite and weight, and increased gastric acid production.
Glutamate is a useful excitatory neurotransmitter of the nervous system, although excessive amounts in the brain can lead to cell death through a process called excitotoxicity which consists of the overstimulation of glutamate receptors. Excitotoxicity occurs not only in Alzheimer's disease, but also in other neurological diseases such as Parkinson's disease and multiple sclerosis. Memantine (brand names Akatinol, Axura, Ebixa/Abixa, Memox and Namenda), is a noncompetitive NMDA receptor antagonist first used as an anti-influenza agent. It acts on the glutamatergic system by blocking NMDA receptors and inhibiting their overstimulation by glutamate. Memantine has been shown to be moderately efficacious in the treatment of moderate to severe Alzheimer's disease. Its effects in the initial stages of AD are unknown. Reported adverse events with memantine are infrequent and mild, including hallucinations, confusion, dizziness, headache and fatigue. The combination of memantine and donepezil has been shown to be "of statistically significant but clinically marginal effectiveness".
Antipsychotic drugs are modestly useful in reducing aggression and psychosis in Alzheimer's patients with behavioural problems, but are associated with serious adverse effects, such as cerebrovascular events, movement difficulties or cognitive decline, that do not permit their routine use. When used in the long-term, they have been shown to associate with increased mortality.
Patients with Alzheimer’s disease who have taken Huperzine A have improved general cognitive function, global clinical status, functional performance and reduced behavioural disturbance compared to patients taking placebos, according to a Cochrane Review.
Psychosocial interventions are used as an adjunct to pharmaceutical treatment and can be classified within behaviour-, emotion-, cognition- or stimulation-oriented approaches. Research on efficacy is unavailable and rarely specific to AD, focusing instead on dementia in general.
Behavioural interventions attempt to identify and reduce the antecedents and consequences of problem behaviours. This approach has not shown success in improving overall functioning, but can help to reduce some specific problem behaviours, such as incontinence. There is a lack of high quality data on the effectiveness of these techniques in other behaviour problems such as wandering.
Emotion-oriented interventions include reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration, also called snoezelen, and simulated presence therapy. Supportive psychotherapy has received little or no formal scientific study, but some clinicians find it useful in helping mildly impaired patients adjust to their illness. Reminiscence therapy (RT) involves the discussion of past experiences individually or in group, many times with the aid of photographs, household items, music and sound recordings, or other familiar items from the past. Although there are few quality studies on the effectiveness of RT, it may be beneficial for cognition and mood. Simulated presence therapy (SPT) is based on attachment theories and involves playing a recording with voices of the closest relatives of the person with Alzheimer's disease. There is partial evidence indicating that SPT may reduce challenging behaviours. Finally, validation therapy is based on acceptance of the reality and personal truth of another's experience, while sensory integration is based on exercises aimed to stimulate senses. There is little evidence to support the usefulness of these therapies.
The aim of cognition-oriented treatments, which include reality orientation and cognitive retraining, is the reduction of cognitive deficits. Reality orientation consists in the presentation of information about time, place or person in order to ease the understanding of the person about its surroundings and his or her place in them. On the other hand cognitive retraining tries to improve impaired capacities by exercitation of mental abilities. Both have shown some efficacy improving cognitive capacities, although in some studies these effects were transient and negative effects, such as frustration, have also been reported.
Stimulation-oriented treatments include art, music and pet therapies, exercise, and any other kind of recreational activities. Stimulation has modest support for improving behaviour, mood, and, to a lesser extent, function. Nevertheless, as important as these effects are, the main support for the use of stimulation therapies is the change in the person's routine.
Since Alzheimer's has no cure and it gradually renders people incapable of tending for their own needs, caregiving essentially is the treatment and must be carefully managed over the course of the disease.
During the early and moderate stages, modifications to the living environment and lifestyle can increase patient safety and reduce caretaker burden. Examples of such modifications are the adherence to simplified routines, the placing of safety locks, the labelling of household items to cue the person with the disease or the use of modified daily life objects. The patient may also become incapable of feeding themselves, so they require food in smaller pieces or pureed. When swallowing difficulties arise, the use of feeding tubes may be required. In such cases, the medical efficacy and ethics of continuing feeding is an important consideration of the caregivers and family members. The use of physical restraints is rarely indicated in any stage of the disease, although there are situations when they are necessary to prevent harm to the person with AD or their caregivers.
As the disease progresses, different medical issues can appear, such as oral and dental disease, pressure ulcers, malnutrition, hygiene problems, or respiratory, skin, or eye infections. Careful management can prevent them, while professional treatment is needed when they do arise. During the final stages of the disease, treatment is centred on relieving discomfort until death.
A small recent study in the US concluded that patients whose caregivers had a realistic understanding of the prognosis and clinical complications of late dementia were less likely to receive aggressive treatment near the end of life.
The early stages of Alzheimer's disease are difficult to diagnose. A definitive diagnosis is usually made once cognitive impairment compromises daily living activities, although the person may still be living independently. The symptoms will progress from mild cognitive problems, such as memory loss through increasing stages of cognitive and non-cognitive disturbances, eliminating any possibility of independent living.
Life expectancy of the population with the disease is reduced. The mean life expectancy following diagnosis is approximately seven years. Fewer than 3% of patients live more than fourteen years. Disease features significantly associated with reduced survival are an increased severity of cognitive impairment, decreased functional level, history of falls, and disturbances in the neurological examination. Other coincident diseases such as heart problems, diabetes or history of alcohol abuse are also related with shortened survival. While the earlier the age at onset the higher the total survival years, life expectancy is particularly reduced when compared to the healthy population among those who are younger. Men have a less favourable survival prognosis than women.
The disease is the underlying cause of death in 70% of all cases. Pneumonia and dehydration are the most frequent immediate causes of death, while cancer is a less frequent cause of death than in the general population.
Two main measures are used in epidemiological studies: incidence and prevalence. Incidence is the number of new cases per unit of person–time at risk (usually number of new cases per thousand person–years); while prevalence is the total number of cases of the disease in the population at any given time.
Regarding incidence, cohort longitudinal studies (studies where a disease-free population is followed over the years) provide rates between 10 and 15 per thousand person–years for all dementias and 5–8 for AD, which means that half of new dementia cases each year are AD. Advancing age is a primary risk factor for the disease and incidence rates are not equal for all ages: every five years after the age of 65, the risk of acquiring the disease approximately doubles, increasing from 3 to as much as 69 per thousand person years. There are also sex differences in the incidence rates, women having a higher risk of developing AD particularly in the population older than 85.
Prevalence of AD in populations is dependent upon different factors including incidence and survival. Since the incidence of AD increases with age, it is particularly important to include the mean age of the population of interest. In the United States, Alzheimer prevalence was estimated to be 1.6% in 2000 both overall and in the 65–74 age group, with the rate increasing to 19% in the 75–84 group and to 42% in the greater than 84 group. Prevalence rates in less developed regions are lower.[dead link] The World Health Organization estimated that in 2005, 0.379% of people worldwide had dementia, and that the prevalence would increase to 0.441% in 2015 and to 0.556% in 2030. Other studies have reached similar conclusions. Another study estimated that in 2006, 0.40% of the world population (range 0.17–0.89%; absolute number 26.6 million, range 11.4–59.4 million) were afflicted by AD, and that the prevalence rate would triple and the absolute number would quadruple by 2050.
The ancient Greek and Roman philosophers and physicians associated old age with increasing dementia. It was not until 1901 that German psychiatrist Alois Alzheimer identified the first case of what became known as Alzheimer's disease in a fifty-year-old woman he called Auguste D. Alzheimer followed her until she died in 1906, when he first reported the case publicly. During the next five years, eleven similar cases were reported in the medical literature, some of them already using the term Alzheimer's disease. The disease was first described as a distinctive disease by Emil Kraepelin after suppressing some of the clinical (delusions and hallucinations) and pathological features (arteriosclerotic changes) contained in the original report of Auguste D. He included Alzheimer's disease, also named presenile dementia by Kraepelin, as a subtype of senile dementia in the eighth edition of his Textbook of Psychiatry, published in 1910.
For most of the 20th century, the diagnosis of Alzheimer's disease was reserved for individuals between the ages of 45 and 65 who developed symptoms of dementia. The terminology changed after 1977 when a conference on AD concluded that the clinical and pathological manifestations of presenile and senile dementia were almost identical, although the authors also added that this did not rule out the possibility that they had different causes. This eventually led to the diagnosis of Alzheimer's disease independently of age. The term senile dementia of the Alzheimer type (SDAT) was used for a time to describe the condition in those over 65, with classical Alzheimer's disease being used for those younger. Eventually, the term Alzheimer's disease was formally adopted in medical nomenclature to describe individuals of all ages with a characteristic common symptom pattern, disease course, and neuropathology.
Society and culture
Dementia, and specifically Alzheimer's disease, may be among the most costly diseases for society in Europe and the United States, while their cost in other countries such as Argentina, or South Korea, is also high and rising. These costs will probably increase with the ageing of society, becoming an important social problem. AD-associated costs include direct medical costs such as nursing home care, direct nonmedical costs such as in-home day care, and indirect costs such as lost productivity of both patient and caregiver. Numbers vary between studies but dementia costs worldwide have been calculated around $160 billion, while costs of Alzheimer in the United States may be $100 billion each year.
The greatest origin of costs for society is the long-term care by health care professionals and particularly institutionalisation, which corresponds to 2/3 of the total costs for society. The cost of living at home is also very high, especially when informal costs for the family, such as caregiving time and caregiver's lost earnings, are taken into account.
Costs increase with dementia severity and the presence of behavioural disturbances, and are related to the increased caregiving time required for the provision of physical care. Therefore any treatment that slows cognitive decline, delays institutionalisation or reduces caregivers' hours will have economic benefits. Economic evaluations of current treatments have shown positive results.
The role of the main caregiver is often taken by the spouse or a close relative.[dead link] Alzheimer's disease is known for placing a great burden on caregivers which includes social, psychological, physical or economic aspects. Home care is usually preferred by patients and families. This option also delays or eliminates the need for more professional and costly levels of care. Nevertheless two-thirds of nursing home residents have dementias.
Dementia caregivers are subject to high rates of physical and mental disorders. Factors associated with greater psychosocial problems of the primary caregivers include having an affected person at home, the carer being a spouse, demanding behaviours of the cared person such as depression, behavioural disturbances, hallucinations, sleep problems or walking disruptions and social isolation. Regarding economic problems, family caregivers often give up time from work to spend 47 hours per week on average with the person with AD, while the costs of caring for them are high. Direct and indirect costs of caring for an Alzheimer's patient average between $18,000 and $77,500 per year in the United States, depending on the study.[dead link]
As Alzheimer's disease is highly prevalent, many notable people have developed it. Well-known examples are former United States President Ronald Reagan and Irish writer Iris Murdoch, both of whom were the subjects of scientific articles examining how their cognitive capacities deteriorated with the disease. Other cases include the retired footballer Ferenc Puskas, the former Prime Ministers Harold Wilson (United Kingdom) and Adolfo Suárez (Spain), the actress Rita Hayworth, the actor Charlton Heston, the novelist Terry Pratchett, Indian politician George Fernandes, and the 2009 Nobel Prize in Physics recipient Charles K. Kao.
AD has also been portrayed in films such as: Iris (2001), based on John Bayley's memoir of his wife Iris Murdoch; The Notebook (2004), based on Nicholas Sparks' 1996 novel of the same name; A Moment to Remember (2004);Thanmathra (2005); Memories of Tomorrow (Ashita no Kioku) (2006), based on Hiroshi Ogiwara's novel of the same name; Away from Her (2006), based on Alice Munro's short story "The Bear Came over the Mountain". Documentaries on Alzheimer's disease include Malcolm and Barbara: A Love Story (1999) and Malcolm and Barbara: Love's Farewell (2007), both featuring Malcolm Pointon.
As of 2010[update], the safety and efficacy of more than 400 pharmaceutical treatments had been or were being investigated in 858 clinical trials worldwide, and approximately a quarter of these compounds are in Phase III trials; the last step prior to review by regulatory agencies.
One area of clinical research is focused on treating the underlying disease pathology. Reduction of amyloid beta levels is a common target of compounds (such as apomorphine) under investigation. Immunotherapy or vaccination for the amyloid protein is one treatment modality under study. Unlike preventative vaccination, the putative therapy would be used to treat people already diagnosed. It is based upon the concept of training the immune system to recognise, attack, and reverse deposition of amyloid, thereby altering the course of the disease. An example of such a vaccine under investigation was ACC-001, although the trials were suspended in 2008. Another similar agent is bapineuzumab, an antibody designed as identical to the naturally induced anti-amyloid antibody. Other approaches are neuroprotective agents, such as AL-108, and metal-protein interaction attenuation agents, such as PBT2. A TNF? receptor fusion protein, etanercept has showed encouraging results.
In 2008, two separate clinical trials showed positive results in modifying the course of disease in mild to moderate AD with methylthioninium chloride (trade name rember), a drug that inhibits tau aggregation, and dimebon, an antihistamine. The consecutive Phase-III trial of Dimebon failed to show positive effects in the primary and secondary endpoints.
Preliminary research on the effects of meditation on retrieving memory and cognitive functions have been encouraging. Limitations of this research can be addressed in future studies with more detailed analyses.
January 2011: The FDA panel voted with definite decision 16-0 to recommend approval of Avid's Amyvid, which is currently used in investigational study. It can detect Alzheimer's brain plaques, but it should requires additional research before it's ready for clinical use.
Dementia (taken from Latin, originally meaning "madness", from de- "without" + ment, the root of mens "mind") is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. Although dementia is far more common in the geriatric population, it may occur in any stage of adulthood.
This age cutoff is defining, as similar sets of symptoms due to organic brain syndrome or dysfunction, are given different names in populations younger than adult. Up to the end of the 19th century, dementia was a much broader clinical concept. Well into the second half of the 20th century, dementia of the elderly was called senile dementia or senility and viewed as a normal aspect of growing old rather than as being caused by any specific diseases, while Alzheimer's disease was seen as a rare disease of middle age, until the neurologist Robert Katzmann signaled a link between "senile dementia" and Alzheimer's.
Dementia is a non-specific illness syndrome (set of signs and symptoms) in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed; cognitive dysfunction that has been seen only over shorter times, in particular less than weeks, must be termed delirium. In all types of general cognitive dysfunction, higher mental functions are affected first in the process.
Especially in the later stages of the condition, affected persons may be disoriented in time (not knowing what day of the week, day of the month, or even what year it is), in place (not knowing where they are), and in person (not knowing who they are or others around them). Dementia, though often treatable to some degree, is usually due to causes that are progressive and incurable.
Symptoms of dementia can be classified as either reversible or irreversible, depending upon the etiology of the disease. Less than 10% of cases of dementia are due to causes that may presently be reversed with treatment. Causes include many different specific disease processes, in the same way that symptoms of organ dysfunction such as shortness of breath, jaundice, or pain are attributable to many etiologies.
Without careful assessment of history, the short-term syndrome of delirium (often lasting days to weeks) can easily be confused with dementia, because they have all symptoms in common, save duration. Some mental illnesses, including depression and psychosis, may also produce symptoms that must be differentiated from both delirium and dementia.
Chronic use of substances such as alcohol can also predispose the patient to cognitive changes suggestive of dementia, although moderate intake may have a protective effect.
Signs and symptoms
Dementia is not merely a problem of memory. It reduces the ability to learn, reason, retain or recall past experience and there is also loss of patterns of thoughts, feelings and activities (Gelder et al 2005). Additional mental and behavioral problems often affect people who have dementia, and may influence quality of life, caregivers, and the need for institutionalization. As dementia worsens individuals may neglect themselves and may become disinhibited, the individual may become incontinent as their condition worsens. (Gelder et al 2005).
Depression affects 20–30% of people who have dementia, and about 20% have anxiety. Psychosis (often delusions of persecution) and agitation/aggression also often accompany dementia. Each of these needs to be assessed and treated independent of the underlying dementia.
Risk to self and others
The Canadian Medical Association Journal has reported that driving with dementia could lead to severe injury or even death to self and others. Doctors should advise appropriate testing on when to quit driving.
In the United Kingdom, as with all mental disorders, where a sufferer could potentially be a danger to themselves or others, they can be detained under the Mental Health Act 1983 for the purposes of assessment, care and treatment. This is a last resort, and usually avoided if the patient has family or friends who can ensure care.
The United Kingdom DVLA (Driving & Vehicle Licensing Agency) states that dementia sufferers who specifically suffer with poor short term memory, disorientation, lack of insight or judgment are almost certainly not fit to drive—and in these instances, the DVLA must be informed so said license can be revoked. They do however acknowledge low-severity cases and early sufferers, and those drivers may be permitted to drive pending medical report.
Fixed cognitive impairment
Various types of brain injury, occurring as a single event, may cause irreversible but fixed cognitive impairment. Traumatic brain injury may cause generalized damage to the white matter of the brain (diffuse axonal injury), or more localized damage (as also may neurosurgery). A temporary reduction in the brain's supply of blood or oxygen may lead to hypoxic-ischemic injury. Strokes (ischemic stroke, or intracerebral, subarachnoid, subdural or extradural hemorrhage) or infections (meningitis and/or encephalitis) affecting the brain, prolonged epileptic seizures and acute hydrocephalus may also have long-term effects on cognition. Excessive alcohol use may cause alcohol dementia, Wernicke's encephalopathy and/or Korsakoff's psychosis, and certain other recreational drugs may cause substance-induced persisting dementia; once overuse ceases, the cognitive impairment is persistent but not progressive.
Slowly progressive dementia
Dementia which begins gradually and worsens progressively over several years is usually caused by neurodegenerative disease; that is, by conditions affecting only or primarily the neurons of the brain and causing gradual but irreversible loss of function of these cells. Less commonly, a non-degenerative condition may have secondary effects on brain cells, which may or may not be reversible if the condition is treated.
The causes of dementia depend on the age at which symptoms begin. In the elderly population (usually defined in this context as over 65 years of age), a large majority of cases of dementia are caused by Alzheimer's disease, vascular dementia or both. Dementia with Lewy bodies is another fairly common cause, which again may occur alongside either or both of the other causes. Hypothyroidism sometimes causes slowly progressive cognitive impairment as the main symptom, and this may be fully reversible with treatment. Normal pressure hydrocephalus, though relatively rare, is important to recognize since treatment may prevent progression and improve other symptoms of the condition. However, significant cognitive improvement is unusual.
Dementia is much less common under 65 years of age. Alzheimer's disease is still the most frequent cause, but inherited forms of the disease account for a higher proportion of cases in this age group. Frontotemporal lobar degeneration and Huntington's disease account for most of the remaining cases. Vascular dementia also occurs, but this in turn may be due to underlying conditions (including antiphospholipid syndrome, CADASIL, MELAS, homocystinuria, moyamoya and Binswanger's disease). People who receive frequent head trauma, such as boxers or some martial artists, are at risk of dementia pugilistica.
In young adults (up to 40 years of age) who were previously of normal intelligence, it is very rare to develop dementia without other features of neurological disease, or without features of disease elsewhere in the body. Most cases of progressive cognitive disturbance in this age group are caused by psychiatric illness, alcohol or other drugs, or metabolic disturbance. However, certain genetic disorders can cause true neurodegenerative dementia at this age. These include familial Alzheimer's disease, SCA17 (dominant inheritance); adrenoleukodystrophy (X-linked); Gaucher's disease type 3, metachromatic leukodystrophy, Niemann-Pick disease type C, pantothenate kinase-associated neurodegeneration, Tay-Sachs disease and Wilson's disease (all recessive). Wilson's disease is particularly important since cognition can improve with treatment.
At all ages, a substantial proportion of patients who complain of memory difficulty or other cognitive symptoms are suffering from depression rather than a neurodegenerative disease. Vitamin deficiencies and chronic infections may also occur at any age; they usually cause other symptoms before dementia occurs, but occasionally mimic degenerative dementia. These include deficiencies of vitamin B12, folate or niacin, and infective causes including cryptococcal meningitis, HIV, Lyme disease, progressive multifocal leukoencephalopathy, subacute sclerosing panencephalitis, syphilis and Whipple's disease.
Rapidly progressive dementia
Creutzfeldt-Jakob disease typically causes a dementia which worsens over weeks to months, being caused by prions. The common causes of slowly progressive dementia also sometimes present with rapid progression: Alzheimer's disease, dementia with Lewy bodies, frontotemporal lobar degeneration (including corticobasal degeneration and progressive supranuclear palsy).
On the other hand, encephalopathy or delirium may develop relatively slowly and resemble dementia. Possible causes include brain infection (viral encephalitis, subacute sclerosing panencephalitis, Whipple's disease) or inflammation (limbic encephalitis, Hashimoto's encephalopathy, cerebral vasculitis); tumors such as lymphoma or glioma; drug toxicity (e.g. anticonvulsant drugs); metabolic causes such as liver failure or kidney failure; and chronic subdural hematoma.
Dementia as a feature of other conditions
There are many other medical and neurological conditions in which dementia only occurs late in the illness, or as a minor feature. For example, a proportion of patients with Parkinson's disease develop dementia, though widely varying figures are quoted for this proportion. When dementia occurs in Parkinson's disease, the underlying cause may be dementia with Lewy bodies or Alzheimer's disease, or both. Cognitive impairment also occurs in the Parkinson-plus syndromes of progressive supranuclear palsy and corticobasal degeneration (and the same underlying pathology may cause the clinical syndromes of frontotemporal lobar degeneration). Chronic inflammatory conditions of the brain may affect cognition in the long term, including Behçet's disease, multiple sclerosis, sarcoidosis, Sjögren's syndrome and systemic lupus erythematosus. Although the acute porphyrias may cause episodes of confusion and psychiatric disturbance, dementia is a rare feature of these rare diseases.
Aside from those mentioned above, inherited conditions which may cause dementia alongside other features include:
Proper differential diagnosis between the types of dementia (cortical and subcortical) will require, at the least, referral to a specialist, e.g., a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist. Duration of symptoms must evident for at least six months for a diagnosis of dementia or organic brain syndrome to be made (ICD-10).
There exist some brief tests (5–15 minutes) that have reasonable reliability and can be used in the office or other setting to screen cognitive status. Examples of such tests include the abbreviated mental test score (AMTS), the mini mental state examination (MMSE), Modified Mini-Mental State Examination (3MS), the Cognitive Abilities Screening Instrument (CASI), and the clock drawing test. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances; for example, a person highly depressed or in great pain will not be expected to do well on many tests of mental ability.
While many tests have been studied, and some may emerge as better alternatives to the MMSE, presently the MMSE is the best studied and most commonly used.
Another approach to screening for dementia is to ask an informant (relative or other supporter) to fill out a questionnaire about the person's everyday cognitive functioning. Informant questionnaires provide complementary information to brief cognitive tests. Probably the best known questionnaire of this sort is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). On the other hand the General Practitioner Assessment Of Cognition combines both, a patient assessment and an informant interview. It was specifically designed for the use in the primary care setting and is also available as a web-based test. It can be accessed at www.gpcog.com.au.
Further evaluation includes retesting at another date, and administration of other tests of mental function.
Routine blood tests are also usually performed to rule out treatable causes. These tests include vitamin B12, folic acid, thyroid-stimulating hormone (TSH), C-reactive protein, full blood count, electrolytes, calcium, renal function, and liver enzymes. Abnormalities may suggest vitamin deficiency, infection or other problems that commonly cause confusion or disorientation in the elderly. The problem is complicated by the fact that these cause confusion more often in persons who have early dementia, so that "reversal" of such problems may ultimately only be temporary.
Testing for alcohol and other known dementia-inducing drugs may be indicated.
A CT scan or magnetic resonance imaging (MRI scan) is commonly performed, although these modalities do not have optimal sensitivity for the diffuse metabolic changes associated with dementia in a patient that shows no gross neurological problems (such as paralysis or weakness) on neurological exam. CT or MRI may suggest normal pressure hydrocephalus, a potentially reversible cause of dementia, and can yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia.
The functional neuroimaging modalities of SPECT and PET are more useful in assessing long-standing cognitive dysfunction, since they have shown similar ability to diagnose dementia as a clinical exam. The ability of SPECT to differentiate the vascular cause from the Alzheimer's disease cause of dementias, appears to be superior to differentiation by clinical exam.
Recent research has established the value of PET imaging using carbon-11 Pittsburgh Compound B as a radiotracer (PIB-PET) in predictive diagnosis of various kinds of dementia, in particular Alzheimer's disease. Studies from Australia have found PIB-PET to be 86% accurate in predicting which patients with mild cognitive impairment would develop Alzheimer's disease within two years. In another study, carried out using 66 patients seen at the University of Michigan, PET studies using either PIB or another radiotracer, carbon-11 dihydrotetrabenazine (DTBZ), led to more accurate diagnosis for more than one-fourth of patients with mild cognitive impairment or mild dementia.
It appears that the regular moderate consumption of alcohol (beer, wine, or distilled spirits) and a Mediterranean diet may reduce risk. A study has shown a link between high blood pressure and developing dementia. The study, published in the Lancet Neurology journal July 2008, found that blood pressure lowering medication reduced dementia by 13%.
Brain-derived neurotrophic factor (BDNF) expression is associated with some dementia types.
Except for the treatable types listed above, there is no cure to this illness. Cholinesterase inhibitors are often used early in the disease course. Cognitive and behavioral interventions may also be appropriate. Educating and providing emotional support to the caregiver (or carer) is of importance as well (see also elderly care).
Pain and dementia
As people age, they experience more health problems, and most health problems associated with aging carry a substantial burden of pain; so, between 25% and 50% of older adults experience persistent pain. Seniors with dementia experience the same prevalence of conditions likely to cause pain as seniors without dementia. Pain is often overlooked in older adults and, when screened for, often poorly assessed, especially among those with dementia. Beyond the issue of humane care, unrelieved pain has functional implications. Persistent pain can lead to decreased ambulation, depressed mood, sleep disturbances, impaired appetite and exacerbation of cognitive impairment, and pain-related interference with activity is a factor contributing to falls in the elderly.
Although persistent pain in the person with dementia is difficult to communicate, diagnose and treat, failure to address persistent pain has profound functional, psychosocial and quality of life implications for this vulnerable population. Health professionals often lack the skills and usually lack the time needed to recognize, accurately assess and adequately monitor pain in people with dementia. Family members and friends can make a valuable contribution to the care of a person with dementia by learning to recognize and assess their pain. Educational resources (such as the tutorial) and observational assessment tools are available.
Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Adult daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers.
While some preliminary studies have found that music therapy may be useful in helping patients with dementia, their quality has been low and no reliable conclusions can be drawn from them.
In a study issued by European researchers, it is estimated that about 35 million people have dementia worldwide. They said that figure is likely to double every 20 years, to nearly 66 million in 2030 and 115 million in 2050.
The county is famous for its tourism, as the home of such attractions as Disneyland and Knott's Berry Farm, as well as several beaches along its more than 40 miles (64 km) of coastline. It is also known for its affluence and political conservatism. In fact, a 2005 academic study listed three Orange County cities as being among America's 25 "most conservative," making it the only county in the country containing more than one such city. It also became well-known for being the largest US county ever to have gone bankrupt, when in 1994 citizens rejected tax increases to pay back debts incurred by the county treasurer's misinvestments.
Whereas most population centers in the United States tend to be identified by a major city, there is no defined urban center in Orange County. It is mostly suburban, except for some traditionally urban areas such as those of Anaheim, Santa Ana, Orange, Huntington Beach, and Fullerton. There are also several edge city-style developments such as South Coast Metro and Newport Center.
While Santa Ana serves as the governmental center of the county, Anaheim is its main tourist destination, and Irvine its major business and financial hub. Four Orange County cities have populations exceeding 200,000: Santa Ana, Anaheim, Irvine, and Huntington Beach.
Thirty-four incorporated cities are located in Orange County; the newest is Aliso Viejo, which was incorporated in 2001. Anaheim was the first city incorporated in Orange County, in 1870 when the region was still part of neighboring Los Angeles County.
Members of the Tongva, Juaneño, and Luiseño Native American groups long inhabited the area. After the 1769 expedition of Gaspar de Portolà, a Spanish expedition led by Junipero Serra named the area Valle de Santa Ana (Valley of Saint Anne). On November 1, 1776, Mission San Juan Capistrano became the area's first permanent European settlement. Among those who came with Portolá were José Manuel Nieto and José Antonio Yorba.Both these men were given land grants - Rancho Los Nietos and Rancho Santiago de Santa Ana, respectively. The Nieto heirs were granted land in 1834. The Nieto ranches were known as Rancho Los Alamitos, Rancho Las Bolsas, and Rancho Los Coyotes. Yorba heirs Bernardo Yorba and Teodosio Yorba were also granted Rancho Cañón de Santa Ana (Santa Ana Canyon Ranch) and Rancho Lomas de Santiago, respectively. Other ranchos in Orange County were granted by the Mexican government during the Mexican period in Alta California.
A severe drought in the 1860s devastated the prevailing industry, cattle ranching, and much land came into the possession of Richard O'Neill, Sr., James Irvine and other land barons. In 1887, silver was discovered in the Santa Ana Mountains, attracting settlers via the Santa Fe and Southern Pacific Railroads.
This growth led the California legislature to divide Los Angeles County and create Orange County as a separate political entity on March 11, 1889. The county is generally said to have been named for the citrus fruit (its most famous product). However, in the new county there was already a town by the name of Orange, named for Orange County, Virginia, which itself took its name from William of Orange. The fact the county took the same name as one of its towns may have been coincidence.
Other citrus crops, avocados, and oil extraction were also important to the early economy. Orange County benefited from the July 4, 1904 completion of the Pacific Electric Railway, a trolley connecting Los Angeles with Santa Ana and Newport Beach . The link made Orange County an accessible weekend retreat for celebrities of early Hollywood. It was deemed so significant that the city of Pacific City changed its name to Huntington Beach in honor of Henry Huntington, president of the Pacific Electric and nephew of Collis Huntington. Transportation further improved with the completion of the State Route and U.S. Route 101 (now mostly Interstate 5) in the 1920s.
Agriculture, such as the boysenberry which was made famous by Buena Park native Walter Knott, began to decline after World War II but the county's prosperity soared. The completion of Interstate 5 in 1954 helped make Orange County a bedroom community for many who moved to Southern California to work in aerospace and manufacturing. Orange County received a further boost in 1955 with the opening of Disneyland.
In the 1980s, the population topped two million for the first time; Orange County had become the second-most populous county in California.
An investment fund melt-down in 1994 led to the criminal prosecution of County of Orange treasurer Robert Citron. The county lost at least $1.5 billion through high-risk investments in derivatives. On December 6, 1994, the County of Orange declared Chapter 9 bankruptcy, from which it emerged in June 1995. The Orange County bankruptcy was the largest municipal bankruptcy in U.S. history.
In recent years land-use conflicts have arisen between established areas in the north and less developed areas in the south. These conflicts have regarded things such as construction of new toll roads and the re-purposing of a decommissioned air base. For example, the El Toro Marine Corps Air Station site was designated by a voter measure in 1994 to be developed into an international airport to alleviate the heavily used John Wayne Airport. But subsequent voter initiatives and court actions have caused the airport plan to be permanently shelved. Instead it will become the Orange County Great Park.
According to the U.S. Census Bureau, the county has a total area of 2,455 km2 (948 sq mi), making it the smallest county in Southern California. Surface water accounts for 411 km2 (159 sq mi) of the area, 16.73% of the total; 2,044 km2 (789 sq mi) of it is land. The average annual temperature is about 68 °F (20 °C). Despite its small size as a county, Orange County's total area in square miles is actually just smaller than the State of Rhode Island's land area.
Orange County is bordered on the southwest by the Pacific Ocean, on the north by Los Angeles County, on the northeast by San Bernardino County and Riverside County, and on the southeast by San Diego County.
The northwestern part of the county lies on the coastal plain of the Los Angeles Basin, while the southeastern end rises into the foothills of the Santa Ana Mountains. Most of Orange County's population reside in one of two shallow coastal valleys that lie in the basin, the Santa Ana Valley and the Saddleback Valley. The Santa Ana Mountains lie within the eastern boundaries of the county and of the Cleveland National Forest. The high point is Santiago Peak (5,689 feet (1,734 m)), about 20 mi (32 km) east of Santa Ana. Santiago Peak and nearby Modjeska Peak, just 200 feet (60 m) shorter, form a ridge known as Saddleback, visible from almost everywhere in the county. The Peralta Hills extend westward from the Santa Ana Mountains through the communities of Anaheim Hills, Orange, and ending in Olive. The Loma Ridge is another prominent feature, running parallel to the Santa Ana Mountains through the central part of the county, separated from the taller mountains to the east by Santiago Canyon.
The Santa Ana River is the county's principal watercourse, flowing through the middle of the county from northeast to southwest. Its major tributary to the south and east is Santiago Creek. Other watercourses within the county include Aliso Creek, San Juan Creek, and Horsethief Creek. In the North, the San Gabriel River also briefly crosses into Orange County and exits into the Pacific on the Los Angeles-Orange County line between the cities of Long Beach and Seal Beach. Laguna Beach is home to the county's only natural lakes, Laguna Lakes, which are formed by water rising up against an underground fault.
Residents sometimes figuratively divide the county into "North Orange County" and "South County" (meaning Northwest and Southeast—following the county's natural diagonal orientation along the local coastline). This is more of a cultural and demographic distinction perpetuated by the popular television shows "The OC" and "Laguna Beach", between the older areas closer to Los Angeles, and the more affluent and recently developed areas to the South and East. A transition between older and newer development may be considered to exist roughly parallel to State Route 55 (aka the Costa Mesa Freeway). This transition is accentuated by large flanking tracts of sparsely developed area occupied until recent years by agriculture and military airfields.
While there is a natural topographical Northeast-to-Southwest transition from inland elevations to the lower coastal band, there is no formal geographical division between North and South County. Perpendicular to that gradient, the Santa Ana River roughly divides the county between northwestern and southeastern sectors (about 40% to 60% respectively, by area), but does not represent any apparent economic, political or cultural differences, nor does it significantly affect distribution of travel, housing, commerce, industry or agriculture from one side to the other.
As of August 2006, Orange County has 34 incorporated cities. The oldest is Anaheim (1870) and the newest is Aliso Viejo (2001).
Some of the communities that exist within city limits are listed below:
These communities are outside of city limits in unincorporated county territory:
Orange County has a history of large planned communities. Nearly 30% of the county was created as master planned communities, the most notable being the City of Irvine, Coto de Caza, Anaheim Hills, Tustin Ranch, Tustin Legacy, Ladera Ranch, Talega, Rancho Santa Margarita, and Mission Viejo. Irvine has become the model master planned city, encompassing many villages which were all planned under a master plan by the Irvine Company in the mid-1960s.
National protected areas
Surface transportation in Orange County relies heavily on three major interstate highways: the Santa Ana Freeway (I-5), the San Diego Freeway (I-405 and I-5 south of Irvine), and the San Gabriel River Freeway (I-605), which only briefly enters Orange County territory in the northwest. The other freeways in the county are state highways, and include the perpetually congested Riverside and Artesia Freeway (SR 91) and the Garden Grove Freeway (SR 22) running east-west, and the Orange Freeway (SR 57), the Costa Mesa Freeway (SR/SR 55), the Laguna Freeway (SR 133), the San Joaquin Transportation Corridor (SR 73), the Eastern Transportation Corridor (SR 261, SR 133, SR 241), and the Foothill Transportation Corridor (SR 241) running north-south. Minor stub freeways include the Richard M. Nixon Freeway (SR 90), also known as Imperial Highway, and the southern terminus of Pacific Coast Highway (SR 1). There are no U.S. Highways in Orange County, though two existed in the county until the mid-1960s: 91 and 101. 91 went through what is now the state route of the same number, and 101 was replaced by Interstate 5. SR-1 was once a bypass of US-101 (Route 101A).
Transit in Orange County is offered primarily by the Orange County Transportation Authority. The American Public Transportation Association (APTA) cited OCTA as the best large property transportation system in the United States for 2005. OCTA manages the county's bus network and funds the construction and maintenance of local streets, highways, and freeways; regulates taxicab services; maintains express toll lanes through the median of California State Route 91; and works with Southern California's Metrolink to provide commuter rail service along three lines - the Orange County Line, the 91 Line, and the Inland Empire-Orange County Line.
The bus network comprises 6,542 stops on 77 lines, running along most major streets, and accounts for 210,000 boardings a day. The fleet of 817 buses is gradually being replaced by LNG (liquified natural gas)-powered vehicles, which already represent over 40% of the total.
Starting in 1992, Metrolink has operated three commuter rail lines through Orange County, and has also maintained Rail-to-Rail service with parallel Amtrak service. On a typical weekday, over 40 trains run along the Orange County Line, the 91 Line and the Inland Empire-Orange County Line. Along with Metrolink riders on parallel Amtrak lines, these lines generate approximately 15,000 boardings per weekday. Metrolink also began offering weekend service on the Orange County Line and the Inland Empire-Orange County line in the summer of 2006. As ridership has steadily increased in the region, new stations have opened at Anaheim Canyon, Buena Park, Tustin, and Laguna Niguel/Mission Viejo. Stations at Placentia and Yorba Linda are proposed for future construction.
Orange County's first public Monorail line is undergoing Environmental impact assessment. This line will connect the Disneyland Resort, Convention Center, and Angel Stadium to the proposed ARTIC transportation hub, in the city of Anaheim.
Orange County's only major airport is John Wayne Airport. Although its abbreviation (SNA) refers to Santa Ana, the airport is in fact located in unincorporated territory surrounded by the cities of Newport Beach, Costa Mesa, and Irvine. Unincorporated Orange County (including the John Wayne Airport) has mailing addresses which go through the Santa Ana Post Office. For this reason, SNA was chosen as the IATA Code for the airport. The actual Destination Moniker which appears on most Arrival/Departure Monitors in airports throughout the United States is "Orange County," which is the common nickname used for the OMB Metropolitan Designation: Santa Ana-Anaheim-Irvine, California. Its modern Thomas F. Riley Terminal handles over 9 million passengers annually through 14 different airlines.
According to Census Bureau's 2006 American Community Survey the racial or ethnic makeup of the county was 64.76% White, 16.05% Asian, 0.33% Pacific Islander, 1.72% African American, 0.38% Native American, 14.32% from other races, and 2.44% from two or more races. 32.89% of the population were Hispanic of any race. 30.49% of the population was foreign born.
As of the census of 2000, there were 2,846,289 people, 935,287 households, and 667,794 families residing in the county, making Orange County the second most populous county in California. The population density was 1,392/km² (3,606/sq mi). There were 969,484 housing units at an average density of 474/km² (1,228/sq mi). The racial makeup of the county was 64.81% White, 13.59% Asian, 1.67% African American, 0.70% Native American, 0.31% Pacific Islander, 14.80% from other races, and 4.12% from two or more races. 30.76% are Hispanic or Latino of any race. 8.9% were of German, 6.9% English and 6.0% Irish ancestry according to Census 2000. 58.6% spoke English, 25.3% Spanish, 4.7% Vietnamese, 1.9% Korean, 1.5% Chinese (Cantonese or Mandarin) and 1.2% Tagalog as their first language.
In 1990, still according to the census there were 2,410,556 people residing in the county. The racial makeup of the county was 78.60% White, 10.34% Asian or Pacific Islander, 1.77% African American, 0.50% Native American, and 8.79% from other races. 23.43% were Hispanic or Latino of any race.
There were 935,287 households out of which 37.0% had children under the age of 18 living with them, 55.9% were married couples living together, 10.7% had a female householder with no husband present, and 28.6% were non-families. 21.1% of all households were made up of individuals and 7.2% had someone living alone who was 65 years of age or older. The average household size was 3.00 and the average family size was 3.48.
The population is diverse age-wise, with 27.0% under the age of 18, 9.4% from 18 to 24, 33.2% from 25 to 44, 20.6% from 45 to 64, and 9.9% 65 years of age or older. The median age is 33 years. For every 100 females there were 99.0 males. For every 100 females age 18 and over, there were 96.7 males.
The median income for a household in the county was $61,899, and the median income for a family was $75,700 (these figures had risen to $71,601 and $81,260 respectively as of a 2007 estimate). Males had a median income of $45,059 versus $34,026 for females. The per capita income for the county was $25,826. About 7.0% of families and 10.3% of the population were below the poverty line, including 13.2% of those under age 18 and 6.2% of those age 65 or over.
In 2010 Orange County was voted number 83 on The Daily Caller's list of America's top 100 conservative-friendly counties.
Average household income by community
Unincorporated communities are included if their population is greater than 15,000. These numbers are estimates from the 2005 Census updates for these locales. Numbers are approximate until a new Census occurs.
Orange County is the headquarters of many Fortune 500 companies including Ingram Micro (#69) and First American Corporation (#312) in Santa Ana, Western Digital (#439) in Lake Forest and Pacific Life (#452) in Newport Beach. Irvine is the home of numerous start-up companies and also is the home of Fortune 1000 headquarters for Allergan, Broadcom, Edwards Lifesciences, Epicor, Standard Pacific and Sun Healthcare Group. Other Fortune 1000 companies in Orange County include Beckman Coulter in Fullerton, Quiksilver in Huntington Beach and Apria Healthcare Group in Lake Forest. Irvine is also the home of notable technology companies like PC-manufacturer Gateway Inc., router manufactuer Linksys, and video/computer game creator Blizzard Entertainment. Many regional headquarters for international businesses reside in Orange County like Mazda, Toshiba, Toyota, Samsung, Kia Motors, in the City of Irvine, Mitsubishi in the City of Cypress, and Hyundai in the City of Fountain Valley. Fashion is another important industry to Orange County. Oakley, Inc., the renowned sunglasses company, is headquartered in the City of Lake Forest. Hurley Inc. is headquartered in Costa Mesa. The shoe company Pleaser USA, Inc. is located in Fullerton. St. John is headquartered in Irvine. Wet Seal is headquarted in Lake Forest. Restaurants such as Del Taco, Wahoo's Fish Tacos, Taco Bell, El Pollo Loco, In-N-Out Burger, Claim Jumper, Marie Callender's, Wienerschnitzel, have headquarters in the City of Irvine as well.
Orange County contains several notable shopping malls. Among these are the world-renowned South Coast Plaza in Costa Mesa and Fashion Island in Newport Beach. Other significant malls include the Brea Mall, The Shops at Mission Viejo, The Block at Orange, and the Irvine Spectrum Center. There is also Downtown Disney adjacent to Disneyland.
Tourism remains a vital aspect of Orange County's economy. Anaheim is the main tourist hub, with the Disneyland Resort's Magic Kingdom Park being the second most visited theme park in the country. The Anaheim Convention Center receives many major conventions throughout the year. Resorts within the Beach Cities receive visitors throughout the year due to their close proximity to the beach, biking paths, mountain hiking trails, golf courses, shopping and dining.
Tallest buildings in Orange County
Arts and culture
Points of interest
The area's warm Mediterranean climate and 42 miles (68 km) of year-round beaches attract millions of tourists annually. Huntington Beach is a hot spot for sunbathing and surfing; nicknamed "Surf City, U.S.A.", it is home to many surfing competitions. "The Wedge", at the tip of The Balboa Peninsula in Newport Beach, is one of the most famous body surfing spots in the world. Other tourist destinations include the theme parks Disneyland and Disney's California Adventure in Anaheim and Knott's Berry Farm in Buena Park. Water parks in Orange County include Wild Rivers in Irvine and Soak City in Buena Park. The Anaheim Convention Center is the largest such facility on the West Coast. The old town area in the City of Orange (the traffic circle at the middle of Chapman Ave. at Glassell) still maintains its 1950s image, and appeared in the That Thing You Do! movie. Little Saigon is another notable tourist destination, being home to the largest concentration of Vietnamese people outside of Vietnam. There are also sizable Taiwanese, Chinese, and Korean communities, particularly in western Orange County. This is evident in several Asian-influenced shopping centers in Asian American hubs like the city of Irvine.
Some of the most exclusive (and expensive) neighborhoods in the U.S. are located here, many along the Orange County Coast, and some in north Orange County.
Historical points of interest include Mission San Juan Capistrano, the renowned destination of migrating swallows, and the Richard Nixon Presidential Library and Museum in Yorba Linda. The Richard Nixon Birthplace home, located on the grounds of the Presidential Library, is a National Historic Landmark. Other notable structures include the home of Madame Helena Modjeska, located in Modjeska Canyon on Santiago Creek; Ronald Reagan Federal Building and Courthouse in Santa Ana, the largest building in the county; the historic Balboa Pavilion in Newport Beach; and the Huntington Beach Pier. It is also recognized for its nationally known centers of worship, such as Crystal Cathedral in Garden Grove, the largest house of worship in California; Saddleback Church in Lake Forest, one of the largest churches in the United States; and the Calvary Chapel.
Since the premiere in fall 2003 of the hit Fox series The O.C., and the 2007 Bravo series "The Real Housewives of Orange County" tourism has increased with travelers from across the globe hoping to see the sights seen in the show. However, the former was rarely filmed anywhere in Orange County.
Orange County is also the base for several significant religious organizations:
There are about 1.04 million Catholics in Orange County.
A number of novels by best-selling fiction and horror author Dean Koontz, a resident of Newport Beach, are set in the area.
Orange County is the place in which Kim Stanley Robinson's Three Californias Trilogy is set. These books depict three different futures of Orange County (survivors of a nuclear war in The Wild Shore, a developer's dream gone mad in The Gold Coast, and an ecotopian utopia in Pacific Edge). Philip K. Dick's novel A Scanner Darkly was also set in Orange County.
From his first novel, "Laguna Heat," to more recent books such as "California Girl," mystery-writer T. Jefferson Parker has set many of his novels in Orange County.
The classic novel "Two Years Before the Mast" by Richard Henry Dana, Jr. describes journeys along the California coast in the early 1800s and the trading of goods for cow hides with the local residents. The south Orange County city of Dana Point takes its name from the author, as the cliffs around the harbor were a favorite location of his.
In popular culture
Orange County has been the setting for numerous films and television shows:
Orange County has also been used as a shooting location for several films and television programs. Examples of movies at least partially shot in Orange County are Tom Hanks's That Thing You Do, the Coen Brothers' The Man Who Wasn't There, and the Martin Lawrence movie Big Momma's House. All three of which were filmed in or around the Old Towne Plaza in the City of Orange.
Huntington Beach annually plays host to the U.S. Open of Surfing, AVP Pro Beach Volleyball and Vans World Championship of Skateboarding. It was also the shooting location for Pro Beach Hockey. USA Water Polo, Inc. has moved its headquarter offices to Huntington Beach. Orange County's active outdoor culture is home to many surfers, skateboarders, mountain bikers, cyclists, climbers, hikers, kayaking, sailing and sand volleyball.
The Major League Baseball team in Orange County is the Los Angeles Angels of Anaheim, who won the World Series in 2002. In 2005, new owner Arte Moreno wanted to change the name to "Los Angeles Angels" in order to better tap into the Los Angeles media market, the second largest in the country, which includes Orange County. However, the standing agreement with the city of Anaheim demanded that they have "Anaheim" in the name, so they became the Los Angeles Angels of Anaheim. This name change was hotly disputed by the city of Anaheim and the Los Angeles Dodgers, who wanted sole possession of the title "Los Angeles," but the change stood and still stands today, which prompted a lawsuit by the city of Anaheim against Angels owner Arte Moreno, won by Moreno. It has been widely unpopular in Orange County, although attendance has increased.
The county's National Hockey League team, the Anaheim Ducks, won the 2007 Stanley Cup beating the Ottawa Senators. They also came close to winning the 2003 Stanley Cup finals after winning three games in a seven-game series against the New Jersey Devils.
The Orange County Flyers are a Golden Baseball League team based in Fullerton, California. The league is not affiliated with Major League Baseball. The Flyers were sold on March 21, 2007 to an Orange County investment group, making them the first Golden Baseball League team to ever be sold. Before their sale, the Flyers were called the Fullerton Flyers, but on March 28, 2007 they became the Orange County Flyers; they kept their team colors (blue and orange) and home games are still played at Cal State Fullerton's Goodwin Field.
The Orange County Blue Star is a USL Premier Development League soccer club. They play at Orange Coast College. Among those who have played for OCBS are Jürgen Klinsmann, the former German star and Germany's 2006 World Cup coach, who played under an assumed name.
Orange County Roller Girls - an All Female Flat Track Roller Derby League formed in 2006 and actively plays (bouts) at various locations in Orange County. Many of the league's bouts are played against teams from other cities throughout the United States.
Former and defunct Orange County sports teams
The National Football League football left the county when the Los Angeles Rams relocated to St. Louis in 1995. Anaheim city leaders are in talks with the NFL to bring a Los Angeles-area franchise to Orange County, though they are competing with other cities in and around Los Angeles.
The Los Angeles Salsa played at Cal State Fullerton's Titan Stadium in 1993–94 in the American Professional Soccer League (APSL), at the time the top soccer league in the U.S. The Salsa, whose general manager was former Cosmos star Ricky Davis and its coach former Brazil star Rildo Menezes, also played some games at East Los Angeles College in Monterey Park, California, attempting a season in Mexico's second-tier Primera A Division. That attempt was cancelled after several games when FIFA and CONCACAF ruled a club could not play in two leagues in separate countries. The Salsa lost to the Colorado Foxes in the 1993 APSL final at Cal State Fullerton.
Anaheim was also the home of the prior American Basketball Association franchise known as the Anaheim Amigos in the mid-sixties.
The Southern California Sun was an American football team based out of Anaheim that played in the World Football League in 1974 and 1975. Their records were 13–7 in 1974 and 7–5 in 1975. Their home stadium was Anaheim Stadium.
The Orange County Ramblers were a professional football team that competed in the Continental Football League from 1967-68. The Ramblers played their home games in Anaheim, California. The team was coached both seasons by Homer Beatty, who had won a small college national title at Santa Ana College in 1962.
Orange County is a chartered county of California; its seat is Santa Ana. Its legislative and executive authority is vested in a five-member Board of Supervisors. Each Supervisor is popularly elected from a regional district, and together the board oversees the activities of the county's agencies and departments and sets policy on development, public improvements, and county services. At the beginning of each year the Supervisors select a Chairman and Vice Chairman, but the administration is headed by a professional municipal manager, the County Executive. The current supervisors are Janet Nguyen, John Moorlach, Bill Campbell, and Patricia C. Bates, with a vacancy in the Fourth District, which was previously occupied by Chris Norby until he resigned to become a member of the California State Assembly.
Seven other public officials are elected at-large: the County Assessor, Auditor-Controller, Clerk-Recorder, District Attorney, Sheriff-Coroner, Treasurer-Tax Collector and Public Administrator. Since 2008, the Orange County Sheriff's Department has been led by Sheriff-Coroner Sandra Hutchens. Her predecessor, Mike Carona, resigned earlier in the year to defend himself against corruption charges.
Orange County has long been known as a Republican stronghold and has consistently sent Republican representatives to the state and federal legislatures. Republican majorities in Orange County helped deliver California's electoral votes to Republican presidential candidates Richard Nixon (1960, 1968 and 1972), Gerald Ford (1976), Ronald Reagan (1980, 1984), and George H. W. Bush (1988). Orange County has not voted for a Democratic presidential candidate since Franklin D. Roosevelt's 1936 landslide re-election for a second term. Although Democrats have made inroads in the northern end of the county since the mid-1980s, Orange County politics are still dominated by Republicans. Five of the county's six U.S. Representatives, four of its five State Senators and seven of its nine State Assemblymembers are Republicans, as are all five members of the County Board of Supervisors. Only four Democrats have carried the county in a statewide race in the last 50 years; Jerry Brown in his successful campaign for Governor in 1978, March Fong Eu for Secretary of State and Kenneth Cory for State Controller, both also in 1978 and Kathleen Connell for Controller in 1998.
In Congress, representatives whose districts are completely or partially in the county include Republicans Ed Royce (CA-40), Gary Miller (CA-42), Ken Calvert (CA-44), Dana Rohrabacher (CA-46), and John Campbell (CA-48), and Democrat Loretta Sanchez (CA-47). In the State Senate, Senators whose districts are completely or partially in the county include Republicans Bob Huff (SD-29), Mimi Walters (SD-33), Tom Harman (SD-35), and Mark Wyland (SD-38), and Democrat Lou Correa (SD-34). In the State Assembly, Assemblymembers whose districts are completely or partially in the county include Republicans Curt Hagman (AD-60), Jim Silva (AD-67), Van Tran (AD-68), Chuck DeVore (AD-70), Jeff Miller (AD-71), Chris Norby (AD-72), and Diane Harkey (AD-73), and Democrats Tony Mendoza (AD-56) and Jose Solorio (AD-69).
According to the Orange County Registrar of Voters, as of July 21, 2009, Orange County had 1,599,889 registered voters. Of these, 43.6% (698,140) are registered Republicans, and 32.1% (512,853) are registered Democrats. An additional 20.2% (324,669) declined to state a political party.
Orange County has produced such notable Republicans as President Richard Nixon (born in Yorba Linda and lived in San Clemente), U.S. Senator John F. Seymour (previously mayor of Anaheim), and U.S. Senator Thomas Kuchel (of Anaheim). Former Congressman Chris Cox (of Newport Beach), a White House counsel for President Ronald Reagan, is also a former chairman of the U.S. Securities and Exchange Commission. Orange County was also home to former Republican Congressman John G. Schmitz, a presidential candidate in 1972 from the ultra-conservative American Independent Party and the father of Mary Kay Letourneau. In 1996, Curt Pringle (currently mayor of Anaheim) became the first Republican-elected Speaker of the California State Assembly in decades.
While the growth of the county's Hispanic and Asian populations in recent decades has significantly influenced the culture of Orange County, its conservative reputation has remained largely intact. Partisan voter registration patterns of Hispanics, Asians and other ethnic minorities in the county have tended to reflect the surrounding demographics, with resultant Republican majorities in all but the central portion of the county. When Democrat Loretta Sanchez defeated veteran Republican Bob Dornan in the congressional contest of 1996, she was continuing a trend of Democratic representation of that district that had been interrupted by Dornan's 1984 upset of former Congressman Jerry Patterson. Until 1992, Sanchez herself was a Republican, and she is viewed as having moderate or even conservative positions on many issues.
Republicans have responded to the influx of non-white immigrants by making more explicit efforts to court the Hispanic and Asian vote. In 2004, George W. Bush captured 60% of the county's vote, up from 56% in 2000, despite a higher Democratic popular vote compared with the 2000 election. Although Barbara Boxer won statewide, and fared better in Orange County than she did in 1998, Republican Bill Jones defeated her in the county, 51% to 43%. While the 39% that John Kerry received is higher than the percentage Bill Clinton won in both 1992 and 1996, the percentage of the vote George W. Bush received in 2004 (59.7% of the vote) is the highest any presidential candidate has received since 1988, showing a still-dominant GOP presence in the county. In 2006, Senator Dianne Feinstein won 45% of the vote in the county, the highest margin of a Democrat in a Senate race in over four decades, but Orange was nevertheless the only Coastal California county to vote for her Republican opponent Dick Mountjoy. In terms of voter registration, the Democratic Party has a plurality or majority of registrations only in the cities of Santa Ana, Stanton, and Buena Park.
The county is featured prominently in the book Suburban Warriors: The Origins of the New American Right by Lisa McGirr. She argues that the county's conservative political orientation in the 20th century owed much to its settlement by Midwestern transplants, who reacted strongly to communist sympathies, the civil rights movement, and the turmoil of the 1960s in nearby Los Angeles — across the "Orange Curtain".
In the 1970s and 1980s, Orange County was one of California's leading Republican voting blocs and a sub-culture of residents to hold "Middle American" values that emphasized a capitalist religious morality in contrast to West coast liberalism that well existed there.
Orange County has a high portion of Republican voters from culturally conservative Asian-American, Middle Eastern and Latino immigrants. Some of these came as refugees from wars and dictatorships, and are strongly loyal to Republican anti-communist policies. The large Vietnamese-American communities in Garden Grove and Westminster are predominantly Republican; Vietnamese Americans registered Republicans outnumber those registered as Democrats by 55% to 22%. Republican Assemblyman Van Tran was elected to become the first Vietnamese-American to serve in a state legislature and joined with Texan Hubert Vo as the highest-ranking elected Vietnamese-American in the United States prior to the 2008 election of Joseph Cao in Louisiana's Second Congressional District. In the 2007 special election for the vacant county supervisor seat following Democrat Lou Correa's election to the state senate, two Vietnamese-American Republican candidates topped the list of 10 candidates, separated from each other by only seven votes, making the Board of Supervisors entirely Republican.
Orange County is the home of many colleges and universities, including:
The Orange County Department of Education oversees 28 school districts.
The county is primarily served by The Orange County Register. OC Weekly is an alternative weekly publication and Excélsior is a Spanish-language newspaper. A few communities are served by the Los Angeles Times' publication of the Daily Pilot, the Huntington Beach Independent and the Laguna Beach Coastline Pilot. OC Music Magazine is also based out of Orange County, serving local musicians and artists.
Orange County is served by radio stations from the Los Angeles area. There are a few radio stations that are actually located in Orange County. KJLL-FM 92.7 has an adult contemporary format. KSBR 88.5 FM airs a jazz music format branded as "Jazz-FM" along with news programming. KUCI 88.9FM is a free form college radio station that broadcasts from UC Irvine. KWIZ 96.7 FM, located in Santa Ana, airs a regional Mexican music format branded as "La Rockola 96.7". KWVE-FM 107.9 is owned by the Calvary Chapel of Costa Mesa. KWVE-FM is also the primary Emergency Alert System station for the county. The Los Angeles Angels of Anaheim also own and operate a sports-only radio station from Orange, KLAA.
Notable natives and residents
Due to Orange County's proximity to Los Angeles, the entertainment capital of the United States, many film and media celebrities have moved or bought second homes in the county. Actor John Wayne, who lived in Newport Beach, is the namesake for Orange County's John Wayne Airport. Orange County has also produced many homegrown celebrities, including musician Jeffree Star, golfer Tiger Woods, musician Andrew McMahon, basketball players Dennis Rodman and Kobe Bryant, a number of professional ballplayers, including retired slugger Mark McGwire, WWE Wrestler, Chavo Guerrero Jr. actor, Kevin Costner, comedian/actors Steve Martin and Will Ferrell, actresses Michelle Pfeiffer and Diane Keaton, and singers Chester Bennington, Bonnie Raitt, Gwen Stefani, Jeff Buckley, Marc Cherry, Drake Bell and Major League Ballhawk John Witt. Ms. America Susan Jeske is also a resident. Avenged Sevenfold, Lit, No Doubt, Social Distortion, The Offspring, Atreyu and Leo Fender (the inventor of the first commercially successful solid body electric guitars) also call Orange County home.
The county's most famous resident was perhaps Richard Nixon, the 37th President of the United States, who was born in Yorba Linda and lived in San Clemente for several years following his resignation. His presidential library is in Yorba Linda.
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