Monday, June 18, 2018

USPSTF: No to ECG screening to prevent CVD in low-risk adults

USPSTF: no to ECG screening to prevent CVD in low-risk adults
The U.S. Preventive Services Task Force (USPSTF) recommends against screening with resting or exercise electrocardiography (ECG) to prevent cardiovascular disease (CVD) events in low-risk asymptomatic adults. This final recommendation statement has been published in the June 12 issue of the Journal of the American Medical Association.

18 jun 2018--To inform the USPSTF, Daniel E. Jonas, M.D., M.P.H., from the University of North Carolina at Chapel Hill Evidence-Based Practice Center, and colleagues conducted a systematic review of the evidence from 16 studies with 77,140 participants on screening asymptomatic adults for CVD risk using ECG.
The researchers found that it is very unlikely that the information from resting or exercise ECG would result in a change in a patient's risk category that would lead to a change in treatment or improve health outcomes for asymptomatic adults at low risk for CVD events. Screening with resting or exercise ECG is associated with possible harms, specifically the potential adverse effects of subsequent invasive testing. Based on these findings, the USPSTF recommends against resting or exercise ECG to prevent CVD events in asymptomatic adults (D recommendation). For asymptomatic adults at intermediate or high risk of CVD events, the evidence is insufficient to assess the balance of benefits and harms of screening.
"There is not enough evidence for those who might benefit the most—people at higher risk for CVD—to say if adding ECG screening helps prevent heart attack and stroke," Task Force member Michael J. Barry, M.D., said in a statement. "Clinicians should continue to use traditional risk factors to assess CVD risk and guide treatment for these patients until more evidence is available."

More information: Evidence Review
Final Recommendation Statement
Editorial

Sunday, June 17, 2018

Religious affiliation linked to nearly 4-year longevity boost

Religious affiliation linked to nearly 4-year longevity boost
Credit: The Ohio State University
A new nationwide study of obituaries has found that people with religious affiliations lived nearly four years longer than those with no ties to religion.
That four-year boost – found in an analysis of more than 1,000 obits from around the country – was calculated after taking into account the sex and marital status of those who died, two factors that have strong effects on lifespan.

17 jun 2018--The boost was slightly larger (6.48 years) in a smaller study of obituaries published in a Des Moines, Iowa, newspaper.
"Religious affiliation had nearly as strong an effect on longevity as gender does, which is a matter of years of life," said Laura Wallace, lead author of the study and a doctoral student in psychology at The Ohio State University.
The study was published online today in the journal Social Psychological and Personality Science.
The researchers found that part of the reason for the boost in longevity came from the fact that many religiously affiliated people also volunteered and belonged to social organizations, which previous research has linked to living longer.
"The study provides persuasive evidence that there is a relationship between religious participation and how long a person lives," said Baldwin Way, co-author of the study and associate professor of psychology at Ohio State.
In addition, the study showed how the effects of religion on longevity might depend in part on the personality and average religiosity of the cities where people live, Way said.
The first study involved 505 obituaries published in the Des Moines Register in January and February 2012. In addition to noting the age and any religious affiliation of those who died, the researchers also documented sex, marital status and the number of social and volunteer activities listed.
Results showed that those whose obit listed a religious affiliation lived 9.45 years longer than those who didn't. The gap shrunk to 6.48 years after gender and marital status were taken into account.
The second study included 1,096 obituaries from 42 major cities in the United States published on newspaper websites between August 2010 and August 2011.
In this study, people whose obits mentioned a religious affiliation lived an average of 5.64 years longer than those whose obits did not, which shrunk to 3.82 years after gender and marital status were considered.
Many studies have shown that people who volunteer and participate in social groups tend to live longer than others. So the researchers combined data from both studies to see if the volunteer and social opportunities that religious groups offer might explain the longevity boost.
Results showed that this was only part of the reason why religious people lived longer.
"We found that volunteerism and involvement in social organizations only accounted for a little less than one year of the longevity boost that religious affiliation provided," Wallace said. "There's still a lot of the benefit of religious affiliation that this can't explain."
So what else explains how religion helps people live longer? It may be related to the rules and norms of many religions that restrict unhealthy practices such as alcohol and drug use and having sex with many partners, Way said.
In addition, "many religions promote stress-reducing practices that may improve health, such as gratitude, prayer or meditation," he said.
The fact that the researchers had data from many cities also allowed them to investigate whether the level of religiosity in a city and a city's "personality" could affect how religious affiliation influenced longevity.
The findings showed that a key personality element related to longevity in each city was the importance placed on conformity to community values and norms.
In highly religious cities where conformity was important, religious people tended to live longer than non-religious people.
But in some cities there is a spillover effect.
"The positive health effects of religion spill over to the non-religious in some specific situations," Wallace said. "The spillover effect only occurs in highly religious cities that aren't too concerned about everyone conforming to the same norms. In those areas, non-religious people tend to live as long as do religious people."
Way said there are limitations to the study, including the fact that it could not control for important factors related to longevity such as race and health behaviors. But a potential strength was that, unlike other studies, religious affiliation was not self-reported, but was reported by the obituary writer.
Overall, the study provided additional support to the growing number of studies showing that religion does have a positive effect on health, Wallace said.

More information: Does Religion Stave Off the Grave? Religious Affiliation in One's Obituary and Longevity. Social Psychological and Personality Sciencedoi.org/10.1177/1948550618779820


Provided by The Ohio State University

Saturday, June 16, 2018

Why predicting suicide is a difficult and complex challenge

Why predicting suicide is a difficult and complex challenge
Anthony Bourdain, left, and Kate Spade, right. Credit: The Conversation with images from PeabodyAwards/flickr, CC BY-SA
Who is going to die by suicide? This terrible mystery of human behavior takes on particular poignance in the wake of suicides by high-profile and much-beloved celebrities Kate Spade and Anthony Bourdain. It is only natural that people want to know why such tragedies occur. Those closest to those who take their lives are often tormented, wondering if there is something they could have – or should have – known to prevent their loved one's suicide.

16 jun 2018--As a scientist who has focused on this question for the past decade, I should have a pretty good idea of who is and isn't going to die by suicide. But the sad truth is, I don't. The sadder truth is, neither do any other suicide experts, psychiatrists or physicians. The sum of the research on suicide shows that it does not matter how long we've known someone or how much we know about them. In my research, my colleagues and I have shown that we can only predict who is going to die by suicide slightly more accurately than random guessing.

The need for answers

The fact that suicide is so hard to predict unfortunately took about 50 years for most scientists to appreciate. About the same time that this recognition became widespread a few years ago, a new hope emerged: a form of artificial intelligence called machine learning. As several research groups have demonstrated in recent years, machine learning may be able to predict who is going to attempt or die by suicide with up to 90 percent accuracy.
To understand why this is, and why we humans won't ever be able to accurately predict suicide on our own, one needs to take a step back and understand a little more about the nature of human cognition, suicide and machine learning.
As humans, we love explanations that have two qualities. First, explanations should be simple, meaning that they involve one or a small number of things. For example, depression is a simple explanation for suicide.
Second, explanations should be determinate, meaning that there is one set explanation that accounts for all or most of something. For example, the idea that depression causes most suicides is a determinate explanation. This simple and determinate explanatory style is highly intuitive and very efficient. It's great for helping us to survive, procreate, and get through our days.
But this style of thinking is terrible for helping us understand nature. This is because nature is not simple and determinate. In recent decades, scientists have come to recognize that nearly everything – from physics to biology to human behavior – is complex and indeterminate. In other words, a very large number of things combined in a complex way are needed to explain most things, and there's no set recipe for most physical, biological or behavioral phenomena.
I know that this latter idea of indeterminacy is especially counterintuitive, so let me provide a straightforward example of it. The math equation X plus Y equals 1 is indeterminate. As humans, we instinctively try to find one solution to this equation (e.g., X equals 1, Y equals 0). But there is no set recipe for solving this equation; there are nearly infinite solutions to this equation. Importantly, however, this does not mean that "anything goes." There are also near infinite values for X and Y that do not solve this equation. This indeterminate middle ground between "one solution" and "anything goes" is difficult for most humans to grasp, but it's how much of nature works.
The sum of our scientific evidence indicates that, just like most other things in nature, the causes and predictors of suicide are complex and indeterminate. Hundreds, and maybe thousands, of things are relevant to suicide, but nothing predicts suicide much more accurately than random guessing. For example, depression is often considered to be an extremely important predictor of suicide. But about 2 percent of severely depressed people eventually die by suicide, which is only slightly higher than the 1.6 percent of people from the general United States population who eventually die by suicide. Such a pattern is consistent with complexity because it suggests that we must put a lot of factors together to account for suicide.

Empathy will always matter

So how should we put all of these factors together? One intuitive solution is to add many of these factors together. But even when summing hundreds of factors, this doesn't work – prediction is still only slightly more accurate than random guessing.
A much better solution would be to somehow find an optimized combination of tens or even hundreds of factors. How can we do this? One promising answer is machine learning. In short, machine learning programs can process a large amount of data and learn an optimal combination of factors for a given task. For example, most existing machine learning studies have used data from electronic health records, spanning hundreds of factors related to mental health diagnoses, physical health problems, medications, demographics and hospital visit patterns. Results from several groups in recent years have shown that this approach can consistently predict future suicide attempts and death with 80-90 percent accuracy. Multiple groups are currently working on applying these algorithms to actual clinical practice.
One important thing to keep in mind is that there isn't, and never will be, a single algorithm or recipe for suicide prediction. This is because suicide is indeterminate, much like the X plus Y equals 1 equation. There are likely near-infinite algorithms that could predict suicide with 80-90 percent accuracy, as a number of studies have shown. Research has already demonstrated that no particular factors are necessary for a good algorithm, and many different types of algorithms can produce accurate prediction. But again, this indeterminacy also means that there are near-infinite bad algorithms, too.
All of this research shows that suicide is unfortunately too complex and indeterminate for humans to predict. Neither I nor anyone else can accurately predict who is going to die by suicide or truly explain why a particular person died by suicide (this includes the suicide decedents themselves). Machine learning can do a much better job of approximating the complexity of suicide, but even it falls far short. Although it can accurately predict who will eventually die by suicide, it cannot yet tell us when someone will die by suicide. This "when" dimension of prediction is critical, and we are likely still many years away from accounting for it.
In the meantime, what can we humans do? While we don't have the ability to know whether someone is going to die by suicide or not, we do have the ability to be supportive and caring. If you believe that someone may be struggling, talk with them and let them know about resources such as the US National Suicide Prevention Lifeline (1-800-273-8255).

This article was originally published on The Conversation. Read the original article.The Conversation

Provided by The Conversation

Thursday, June 14, 2018

Why hip fractures in the elderly are often a death sentence

Why hip fractures in the elderly are often a death sentence
There are many reasons elderly people who fracture their hip often don’t recover. Credit: shutterstock.com
The news an elderly relative has broken a hip tends to sound alarm bells, perhaps more than breaking another bone would. That's because a hip fracture dramatically increases an older person's risk of death.
One in three adults aged 50 and over dies within 12 months of suffering a hip fracture. Older adults have a five-to-eight times higher risk of dying within the first three months of a hip fracture compared to those without a hip fracture. This increased risk of death remains for almost ten years.

14 jun 2018--Beyond suffering pain, a hip fracture results in a loss of physical function, decreased social engagement, increased dependence, and worse quality of life. Many people who have a hip fracture need to change their living conditions, such as relocating from their home into a residential aged care facility.
Ultimately, the often rapid regression of an older person's health following a hip fracture means outcomes are poor.

Risk factors for hip fractures

Age is a key risk factor, with hip fractures more likely to occur in those aged 65 or older. They're primarily a result of a fall, or when the hip collides with a solid object such as a kitchen bench. However, they can also occur when there has been little or no trauma, such as standing up.
Cognitive impairment such as dementia is a common factor that increases the risk of falling. Frailty, poor vision, the use of a combination of medications, and trip hazards in the home also increase the likelihood of falls. Osteoporosis, a disease characterised by low bone mass and degradation of bone tissue, is another significant risk factor for hip fractures.
Osteoporosis and osteopenia (where bone mass is lower than normal, but not yet osteoporotic) are reported to affect more than one million Australians aged 65 and older. Worldwide, one in three women and one in five men experience a fracture caused by such bone fragility, with a fracture occurring every three seconds. Compared to a fracture of any other bone, a hip fracture results in the most serious of all consequences.
While the reasons remain unclear, hip fractures also disproportionately affect those at the disadvantaged end of the social scale.
Previous research has reported around 30% of people with hip fractures have had a prior fracture; this is known as the "fracture cascade". The increased risk of subsequent fracture may persist for ten years, which highlights the importance of treating the initial fracture promptly and effectively.

Increased risk of death

In Australia, standard clinical care following a hip fracture begins with timely assessment, including X-rays, and pain and cognitive assessments. Australian data indicate more than three-quarters of people who sustain a hip fracture undergo surgery, the most common procedure being a joint replacement. Surgical intervention will generally occur within 48 hours.
Why hip fractures in the elderly are often a death sentence
Immobility after a hip fracture can lead to poor patient outcomes. Credit: shutterstock.com
But some patients may prefer not to undergo surgery. Or, their medical team may determine the risks are too great to expose the person to surgery.
Combined with the trauma of a fracture and surgery, an existing health condition may significantly increase the risk of death. Death after a hip fracture may also be related to additional complications of the fracture, such as infections, internal bleeding, stroke or heart failure.
One study showed heart disease, stroke and pneumonia resulted in a long-term doubling of risk of death after hip fracture, and this risk remained high for up to ten years in women and 20 in men.
Studies suggest issues related to the hospitalisation, surgery, or immobility (which could put patients at risk of pneumonia) after a fracture lead to other complications that ultimately result in earlier death.

How can patient outcomes be improved?

Together with controlling immediate post-surgery pain and symptoms, patients should receive therapeutic rehabilitation and functional training for the best chance of regaining mobility.
Taking individual capabilities, physical health and function into account, therapeutic rehabilitation may include improving the range of motion, pool therapy, and strengthening and progressive resistance exercises. Functionaltraining will include gait training, and resistance and balance exercises.
Even if the patient has not had surgery, rehabilitation is necessary to begin moving as quickly as possible to avoid the serious complications of being immobilised.
Some data suggest beginning physical activity as soon as possible post-surgery will reduce the likelihood of death. What we don't yet know is the type, intensity and duration of physical activity that will give the best results.
Nutrition can also help recovery. Some data has shown poor nutrition at the time of the fracture reduced people's ability to walk unaided six months after the fracture, compared to those with good nutrition.
There are mixed messages regarding whether nutritional supplements help improve function after a hip fracture. But the combination of protein intake and physical activity is known to increase muscle mass and function. Good muscle mass and function reduce frailty and improve balance, thereby reducing the risk of falls and subsequent fracture.
And there are additional benefits to be gained from being physically active, such as reducing depression – particularly when exercising with other people.

This article was originally published on The Conversation. Read the original article.The Conversation

Provided by The Conversation

Saturday, June 09, 2018

Model estimates lifetime risk of Alzheimer's dementia using biomarkers

Alzheimer's disease
PET scan of a human brain with Alzheimer's disease. Credit: public domain
Lifetime risks of developing Alzheimer's disease dementia vary considerably by age, gender and whether any signs or symptoms of dementia are present, according to a new study published online by Alzheimer's & Dementia.

09 jun 2018--According to the authors, these are the first lifetime risk estimates for Alzheimer's that take into account what are believed to be biological changes in the brain that occur 10 to 20 years before the well-known memory and thinking symptoms appear. These early changes, prior to overt clinical symptoms, are referred to as preclinical Alzheimer's disease. This designation is currently only for research use until more scientific evidence is produced to determine if it can accurately predict the progression to symptoms.
The prevalence of this research-only stage of the Alzheimer's continuum, known as preclinical Alzheimer's disease, in the U.S. has been estimated at nearly 47 million people in a previous study. An example from this newly published report is of a 70-year-old male who has just amyloid, but no signs of neurodegeneration and no memory loss, has a lifetime risk of 19.9 percent. But, if he also had neurodegeneration in addition to amyloid, the lifetime risk rises to 31.3 percent. If, in addition, he had mild cognitive impairment (MCI) plus amyloid plus neurodegeneration, the risk rises to 86 percent.
"What we found in this research is that people with preclinical Alzheimer's disease dementia may never experience any clinical symptoms during their lifetimes because of its long and variable preclinical period," said Ron Brookmeyer, Ph.D., from the UCLA School of Public Health, Los Angeles. "The high mortality rates in elderly populations are also an important factor as individuals are likely to die of other causes."
Brookmeyer provides an example of a 90-year-old female with amyloid plaques having a lifetime risk of Alzheimer's disease of only 8.4 percent, compared to a 65-year-old female with amyloid plaques who has a lifetime risk of 29.3 percent. The lower lifetime risk for the 90-year-old versus the 65-year-old is explained by the shorter life expectancy of the older person.
That same 65-year-old female with amyloid plaques has a 10-year risk of Alzheimer's disease dementia of 2.5 percent. Lifetime risks for females are generally higher than males because they live longer. Brookmeyer and his co-author Nada Abdalla, M.S., also of UCLA, state that the lifetime and 10-year risks provide an indication of the potential that someone will develop Alzheimer's disease dementia based on their age and screenings for amyloid deposits, neurodegeneration and presence or absence of MCI or any combination of those three. For men and women, having the combination of all three puts them at the highest risk of developing Alzheimer's disease.
"Just as there are risk predictors for whether you might have a heart attack, it will be important in the future to measure the likelihood that someone will develop Alzheimer's disease," said Maria Carrillo, Ph.D., Alzheimer's Association chief science officer. "In the future, when treatments are available, this would be helpful, especially for people in the stages before the clinical symptoms appear. For example, those people with the highest 10-year risk of getting Alzheimer's dementia would be high priority to volunteer for clinical trials evaluating Alzheimer's medications or other therapies."
After reviewing the existing scientific literature, including some of the largest longitudinal studies available that have measured biomarkers with data from thousands of people, (e.g., The Mayo Clinic Study of Aging) the authors created a computerized mathematical model to ascertain how likely a person would progress in the continuum of the disease. They based their calculations on the transition rates from the published studies and from U.S. death rates data based on age and gender. They acknowledge that future studies looking at transition rates need to be in ethnically diverse populations and also need to consider whether genetic variants such as the Apolipoprotein (APOE) ?4, which puts people at much higher likelihood for developing Alzheimer's disease, would affect the lifetime riskestimates. And future studies will need to be based on research that is more conclusive than the current scientific literature about risk in relation to early biomarkers like presence of amyloid decades before symptoms appear.
"There are still many things to consider when assessing the value of screening people for Alzheimer's disease biomarkers. Lifetime risks will help in formulating screening guidelines to identify those who would be most helped by screening, especially in the preclinical stage," the authors conclude.
The model used in this study differs from the recently announced NIA-AA Research Framework Towards a Biological Definition of Alzheimer's Disease. Under the framework, if a person does not have amyloid plaques, then they do not have Alzheimer's pathology. Amyloid is one of the biomarkers along with tau tangles considered to be hallmark of Alzheimer's disease. In this model, two of the states of progression (state 3 which is neurodegeneration alone and state 6 which is MCI and neurodegeneration alone) do not include amyloid and would not be considered Alzheimer's under the research framework.


Provided by Alzheimer's Association

Tuesday, June 05, 2018

New hypertension guideline discussed for older adults

New hypertension guideline discussed for older adults
Clinicians caring for older adults with hypertension should be mindful of the specific blood pressure (BP) goals proven to reduce cardiovascular disease events, while adopting the new 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline, according to an article published online May 20 in the Journal of the American Geriatrics Society.

04 jun 2018--William C. Cushman, M.D., and Karen C. Johnson, M.D., M.P.H., from the University of Tennessee Health Science Center in Memphis, discuss the 2017 ACC/AHA hypertension guideline in the context of caring for older adults with hypertension.
The authors note that the ACC/AHA hypertension guideline is primarily based on systematic reviews and meta-analyses. Consequently, the classification of BP, thresholds for initiating drug therapy, and treatment goals are not identical with specific levels proven in randomized controlled trials. When caring for older adults, it is important for physicians to be mindful of the specific BP goals proven to reduce cardiovascular disease events in this population. They should also be attentive to proper BP measurement techniques; encourage non-pharmacologic interventions; and monitor patients for concomitant conditions, adverse drug effects, and complications of elevated BP.
"Adjustments to therapy and goals may be necessary as older adults become increasingly frail, cognitively impaired, or institutionalized, or have a limited life expectancy, although many frail older adults will still benefit from appropriate antihypertensive non-pharmacological and drug therapy," the authors write.
One author disclosed financial ties to the pharmaceutical industry.

More information: Abstract/Full Text (subscription or payment may be required)

Thursday, May 31, 2018

Poll: Seniors ready to Skype docs, worry about care quality

Poll: Seniors ready to Skype docs, worry about care quality
In this May 29, 2018, photo, Sidney Kramer, 92, uses a remote medical monitoring system to check his vital signs at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)
Every morning, 92-year-old Sidney Kramer wraps a blood pressure cuff around his arm and steps on a scale, and readings of his heart health beam to a team of nurses—and to his daughter's smartphone—miles from his Maryland home.

31 may 2018--Red flags? A nurse immediately calls, a form of telemedicine that is helping Kramer live independently by keeping his congestive heart failure under tight control.
"It's reassuring both psychologically and physically. The way he's put it to me, it's like having a doctor appointment every morning," said Miriam Dubin, Kramer's daughter.
The vast majority of older Americans and their caregivers are ready to give virtual health care a try: Nearly 9 in 10 adults age 40 and over would be comfortable using at least one type of telemedicine for themselves or an aging loved one, says a new poll from The Associated Press-NORC Center for Public Affairs Research.
But they want to make sure that an e-visit or other remote care is just as good as they'd get in person, and that their health information stays private, according to the survey released Thursday.
Long considered an option mainly for improving access to health care in rural areas with few doctors, telemedicine is gaining ground with tech-savvy younger consumers—they text their physician with questions or Skype with a mild complaint. For seniors with chronic illnesses or mobility problems that make simply reaching a doctor's office an ordeal, telehealth could be more than a convenience. The graying population is raising serious questions about how the nation will provide enough quality long-term care.
Poll: Seniors ready to Skype docs, worry about care quality
In this May 29, 2018, photo, Sidney Kramer, 92, points to his notebook he uses to help him keep track of vital signs after using a remote medical monitoring system at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)
But while private insurance often covers a video visit or other digital health care, seniors have had a harder time because Medicare tightly restricts what it will pay for.
That's starting to change, with a law Congress passed last winter that expands Medicare coverage for such options as video visits to diagnose stroke symptoms or check on home dialysis patients. Also, Medicare Advantage programs used by a third of beneficiaries can start offering additional telehealth options.
"While the interest is huge, one of the big barriers remains reimbursement," said Johns Hopkins University telemedicine chief Dr. Ingrid Zimmer-Galler, who has turned to grants to help fund such services as telepsychiatry for dementia patients. The new law "is really a huge step in the right direction. It certainly doesn't cover everything."
Costs are a major issue for people who need ongoing living assistance. Less than a third of adults age 40 and over have set aside any money for their future long term care needs, the AP-NORC survey shows, and more than half mistakenly think they'll be able to rely on Medicare to help cover nursing care or home health aides.
Telemedicine will have to replace in-person care, not add to it, to help with those costs, cautioned Zimmer-Galler.
Poll: Seniors ready to Skype docs, worry about care quality
In this May 29, 2018, photo, Sidney Kramer, 92, talks with his daughter Miriam Dubin, at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)
As access for seniors promises to grow, the AP-NORC Center poll shows widespread interest in telehealth. More than half of adults of all ages would be comfortable with a video visit via Skype or FaceTime to discuss medications, for ongoing care of a chronic illness or even for an urgent health concern.
In fact, adults 40 and older are just as open to at least some forms of telemedicine as those under 40, with one exception: The older crowd is slightly less comfortable discussing health care by text.
Among caregivers, 87 percent say they'd be interested in using at least one form of telemedicine for that person's medical needs.
"I think the parents would be happier at home instead of being in the doctor's office waiting an hour to see a doctor for 15 minutes," said Don Withey of Courtland, New York, who helps his 92-year-old father and 89-year-old mother get to their appointments. But, "we don't know much more about it other than the fact you can talk to a doctor over the computer or smartphone."
Just 12 percent of adults say they wouldn't use any form of telemedicine.
Poll: Seniors ready to Skype docs, worry about care quality
In this May 29, 2018, photo, Sidney Kramer, 92, checks his weight while using a remote medical monitoring system to check his vital signs at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)
There are concerns. More than 30 percent of people worry about privacy or the security or health information. About half fear that telemedicine could lead to lower-quality care, the poll found.
"It's not about having a video screen or Skype in the home or even a blood pressure cuff in the home. It's about the team that's behind it and the clinicians who are supporting the care of that patient," said Rachel DeSantis, chief of staff at Johns Hopkins Home Care Group, which provides the 92-year-old Kramer's remote monitoring.
The Hopkins program provides no-cost monitoring for a month or two to select high-risk patients after a hospitalization because research found it reduces their chances of readmission.
When the monitor recorded Kramer's weight creeping up one week, nurses immediately knew it was fluid build-up, a heart failure symptom that needed quick treatment. The machine is programmed for some educational feedback, too.
Dubin says her dad learned quickly when to cut back. "If he enjoys a pastrami sandwich one day, he can see his numbers may be higher the next day."
Poll: Seniors ready to Skype docs, worry about care quality
In this May 29, 2018, photo, nurse Melissa Lantz-Garnish, left, from Johns Hopkins Medicine, talks with her patience 92 year-old Sidney Kramer, right, about using the remote medical monitoring system to check his vital signs in Bethesda Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)
Dubin says the reassurance was worth privately paying, about $250 a month, to keep the monitoring once Kramer's initial time in the program ended.
___
The survey was conducted March 13 to April 5 by The Associated Press-NORC Center for Public Affairs Research, with funding from the SCAN Foundation.
It involved interviews in English and Spanish with 1,945 adults, including 1,522 adults age 40 and over, who are members of NORC's probability-based AmeriSpeak panel, which is designed to be representative of the U.S. population. Results from the full survey have a margin of sampling error of plus or minus 3.3 percentage points.

More information: AP-NORC long term care polls: www.longtermcarepoll.org/

Wednesday, May 30, 2018

New guidance on treating diabetes in elderly and frail adults

New guidance has been published on managing diabetes in the elderly, including for the first time how to manage treatment for the particularly frail.

30 may 2018--The guidance was produced from a collaboration between experts in diabetes medicine, primary care and geriatric medicine, led by Dr. David Strain at the University of Exeter Medical School.
It will advise clinicians on helping elderly people with type 2 diabetes get the most out of treatment options, and for the first time contains guidance on how and when to stop diabetes treatments in particularly frail adults.
Dr. Strain said: "Older adults have been systematically excluded from clinical trials and have very different ambitions from their diabetes management. This guidance puts the older person with diabetes firmly back at the centre of target setting, ensuring that appropriate goals are agreed to achieve the best quality of life possible, without continuing treatments that would not provide any benefit and potentially cause harm."
The research was carried out in collaboration with NHS England and was published in Diabetic Medicine, the journal of Diabetes UK last month.
The report authors hope it will ultimately be incorporated into national guidance for GPs, to advise GPs on the management of type 2 diabetes in elderly adults, aiming to reduce complications and improve quality of life.
The guidance will be adopted across Devon immediately. The authors hope local health and care commissioners will adopt and implement these principles in their own areas.
Pav Kalsi, Senior Clinical Advisor at Diabetes UK, said: "People with diabetes rightly deserve to have access to the right care and support at every stage of their life, and that means the care they receive needs to be adapted and tailored to suit each individual's changing needs. For example, those who are elderly, and potentially frail, often have different priorities, such as safety and quality of life.
"We're really pleased that these new guidelines will, for the first time, help healthcare professionals give this tailored support and will help them review and decide whether to stop diabetes treatment for particularly frail adults.
"In the future, we hope these guidelines will have a positive impact on the lives of older people with diabetes."
The paper, 'Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative', is available online.

More information: W. D. Strain et al, Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative, Diabetic Medicine (2018). DOI: 10.1111/dme.13644


Provided by University of Exete

Sunday, May 27, 2018

What does a good death look like when you're really old and ready to go?

Hawaii recently joined the growing number of states and countries where doctor-assisted dying is legal. In these jurisdictions, help to die is rarely extended to those who don't have a terminal illness. Yet, increasingly, very old people, without a terminal illness, who feel that they have lived too long, are arguing that they also have a right to such assistance.

27 may 2018--Media coverage of David Goodall, the 104-year-old Australian scientist who travelled to Switzerland for assisted dying, demonstrates the level of public interest in ethical dilemmas at the extremities of life. Goodall wanted to die because he no longer enjoyed life. Shortly before his death, he told reporters that he spends most of his day just sitting. "What's the use of that?" he asked.
Research shows that life can be a constant struggle for the very old, with social connections hard to sustain and health increasingly fragile. Studies looking specifically at the motivation for assisted dying among the very old show that many feel a deep sense of loneliness, tiredness, an inability to express their individuality by taking part in activities that are important to them, and a hatred of dependency.
Of the jurisdictions where assisted dying is legal, some make suffering the determinant (Canada, for example). Others require a prognosis of six months (California, for example). Mainly, though, the focus is on people who have a terminal illness because it is seen as less of an ethical problem to hasten the death of someone who is already dying than someone who is simply tired of life.

Why give precedence to physical suffering?

Assisted dying for people with psychological or existential reasons for wanting to end their life is unlikely to be supported by doctors because it is not objectively verifiable and also potentially remediable. In the Netherlands, despite the legal power to offer assistance where there is no life-limiting illness, doctors are seldom convinced of the unbearable nature of non-physical suffering, and so will rarely administer a lethal dose in such cases.
Although doctors may look to a physical diagnosis to give them confidence in their decision to hasten a patient's death, physical symptoms are often not mentioned by the people they are assisting. Instead, the most common reason given by those who have received help to die is loss of autonomy. Other common reasons are to avoid burdening others and not being able to enjoy one's life – the exact same reason given by Goodall. This suggests that requests from people with terminal illness, and from those who are just very old and ready to go, are not as different as both the law – and doctors' interpretation of the law – claim them to be.

Sympathetic coverage

It seems that the general public does not draw a clear distinction either. Most of the media coverage of Goodall's journey to Switzerland was sympathetic, to the dismay of opponents of assisted dying.
Media reports about ageing celebrities endorsing assisted dying in cases of both terminal illness and very old age, blur the distinction still further.
One of the reasons for this categorical confusion is that, at root, this debate is about what a good death looks like, and this doesn't rely on prognosis; it relies on personality. And, it's worth remembering, the personalities of the very old are as diverse as those of the very young.
Discussion of assisted suicide often focuses on concerns that some older people may be exposed to coercion by carers or family members. But older people also play another role in this debate. They make up the rank and file activists of the global right-to-die movement. In this conflict of rights, protectionist impulses conflict with these older activists' demands to die on their own terms and at a time of their own choosing.
In light of the unprecedented ageing of the world's population and increasing longevity, it is important to think about what a good death looks like in deep old age. In an era when more jurisdictions are passing laws to permit doctor-assisted dying, the choreographed death of a 104-year-old, who died listening to Ode to Joy after enjoying a last fish supper, starts to look like a socially approved good death.

This article was originally published on The Conversation. Read the original article.The Conversation

Provided by The Conversation

Wednesday, May 23, 2018

World first use of cognitive training reduces gait freezing in Parkinson's patients

The researchers report significant reduction in the severity and duration of freezing of gait, improved cognitive processing speed and reduced daytime sleepiness.

23 may 2018--Freezing of gait (FoG) is a disabling symptom of Parkinson's Disease, characterized by patients becoming stuck while walking and unable to progress forward, often describing the feeling as being glued to the ground. It is well-known to lead to falls and lower quality of life, making it an important target for treatment.
Research has linked FoG to aspects of attention and cognitive control, a link supported by neuroimaging evidence revealing impairments in the fronto-parietal and fronto-striatal areas of the brain.

The intervention

Patients with Parkinson's Disease who self-reported FoG and who were free from dementia were randomly allocated to receive either a cognitive training intervention or an active control.
Sixty-five patients were randomized into the study. The sample of interest included 20 patients randomly assigned to the cognitive training intervention and 18 randomized to the active control group.
Both groups were clinician-led and conducted twice-weekly for seven weeks. The primary outcome was the percentage of time spent frozen during a 'Timed Up and Go' task, assessed while patients were both on and off dopaminergic medications.
Secondary outcomes included multiple neuropsychological and psychosocial measures, including assessments of mood, well-being and length and quality of sleep.

Results

The researchers report that patients in the cognitive training group showed a large and statistically significant reduction in FoG severity while on dopaminergic medication compared to participants in the active control group on dopaminergic medication.
Patients who received cognitive training also showed improved cognitive processing speed and reduced daytime sleepiness compared to those in the active control while accounting for the effect of dopaminergic medication.
There was no difference between groups when they were tested without their regular dopaminergic medication.
"We believe there is reason to be hopeful for the use of these trials in the future," said study leader, Dr. Simon Lewis, a professor of cognitive neuroscience at the University of Sydney's Brain and Mind Centre and Royal Prince Alfred Hospital in Australia.
"The feedback we've had from participants and family members involved in this study was overwhelmingly positive. The results of this pilot study highlight positive trends, and the importance of nonpharmacological trials involving cognitive training has become increasingly clear."
The research team, comprising scholars from the University of Sydney, Western Sydney University and Cambridge University say the finding that freezing of gait improved only while patients were on dopaminergic medication is noteworthy.
"Taking dopaminergic medications as prescribed is the normal day-day state for patients with Parkinson's Disease," said study lead-author, Dr. Courtney Walton, formerly at the University of Sydney and now at the University of Queensland.
"While more research is needed to better understand and establish these findings, it's likely that participants in the off- dopaminergic state were too impaired to benefit from any of the potential changes initiated through cognitive training."
The researchers say more studies using larger samples are needed to investigate this initial finding that cognitive training can reduce the severity of freezing of gait in Parkinson's diseases patients.


Provided by University of Sydney