Most doctors ignore one of the most potent ways to improve health, experts say

Escalating rungs of social support. Credit: Penn Medicine

Leveraging existing relationships with friends and family may be a more effective way to improve patients' health and encourage new healthy habits and behaviors than increasing interactions with physicians or other clinicians. In a new perspective published by the New England Journal of Medicine, Penn Medicine behavioral economists suggest a five-step ladder to effectively engineering social engagements that promote health and to test their acceptability and effectiveness.

30 dec 2016--"Spouses and friends are more likely to be around patients when they are making decisions that affect their health - like taking a walk versus watching TV, or what to order at a restaurant. Patients are also more likely to adopt healthy behaviors - like going to the gym - when they can go with a friend," explains co-author David Asch, MD, MBA, a professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania and director of the Penn Medicine Center for Health Care Innovation. "Though people are more heavily influenced by those around them every day than they are by doctors and nurses they interact with only occasionally, these cost-free interactions remain largely untapped when engineering social incentives for health. That's a missed opportunity."
Because of these lost opportunities, and the high costs when doctors and nurses keep tabs on their patients, the authors say it's important to engineer social engagements that enlist the social support patients already have, and allow organizations to test their acceptability. "Concerns about privacy are often the reason doctors and hospitals avoid organizing social support," Asch says. "But while privacy is very important to some patients under some circumstances, more often patients would love if their friends and family helped them manage their diabetes, and those friends and family want to help people get their health under control."
The authors define a ladder with escalating rungs of social support ranging from no social engagement - such as when a patient is expected to take medication as part of a routine, without anyone seeing them do it or holding them accountable - to a design that relies on reputational or economic incentives, and incorporates teams or other designs that hold patients accountable for their health behaviors and habits.
"Although we don't normally think of competition or collaboration among patients are part of managing chronic diseases like high blood pressure, heart failure, or diabetes, research shows that behavior is contagious, and programs that take advantage of these naturally occurring relationships can be very effective," said co-author Roy Rosin, MBA, chief innovation officer at Penn Medicine. "Most health care interventions are designed for the individual patient, but there's a growing body of research that shows how health care organizations can use social engagement strategy to enhance health for patients who want to be involved in group activities or team competitions aimed at improving health."
For example, in the fourth rung, where social incentives are designed with reciprocal support, the authors point to a study in which some patients with diabetes were asked to talk on the phone weekly with peers—a technique known as reciprocal mentorship—and others received more typical nurse-led management. Results showed that those who worked directly with peers saw a more significant decline in glycated hemoglobin levels than those who worked with clinical staff.
"Sure, health care is serious business," Asch says, "but who says it can't be social?"


Provided by Perelman School of Medicine at the University of Pennsylvania

Post-lunch napping tied to better cognition in elderly

Moderate post-lunch napping is tied to better cognition in older adults, according to a study published online Dec. 20 in the Journal of the American Geriatrics Society.

29 dec 2016--Junxin Li, Ph.D., from Johns Hopkins University in Baltimore, and colleagues examined associations between self-reported post-lunch napping and structured cognitive assessments in older Chinese adults (≥65 years).
The researchers found that 57.7 percent of participants reported napping (mean time, 63 minutes). There was a significant association between cognitive function and napping (P < 0.001). Moderate nappers had better overall cognition than non-nappers (P < 0.001) or extended nappers (P = 0.01). Non-nappers also had significantly poorer cognition compared to short nappers (P = 0.03). After controlling for demographic characteristics, body mass index, depression, instrumental activities of daily living, social activities, and nighttime sleep duration, moderate napping was significantly associated with better cognition than non- (P = 0.004), short (P = 0.04), and extended napping (P = 0.002).
"Longitudinal studies with objective napping measures are needed to further test this hypothesis," the authors write.

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

Scientific reasons for keeping your New Year's resolutions

Credit: University of California, San Francisco

More than half of Americans make a New Year's resolution each year, and though most people set out with the best of intentions, just a small percentage are successful in following through on their resolutions.

28 dec 2016--To give you a bit of scientific motivation, UC San Francisco gathered some of the latest research behind the most popular health-related New Year's resolutions that attest to why it really is good for your body to see them through.
Eat Healthier
Tired of counting calories? A more effective way to boost your health through diet may be simply to cut down on added sugars. The average American consumes 66 pounds of added sugar per year, and increasing evidence shows all that excess sugar isn't just making us fat; it's making us sick.
Recent studies by UCSF researchers found that putting obese children on a sugar-restricted diet for just 10 days, while allowing them to consume the same total calories, led to a sharp decline in factors associated with heart disease in adulthood, including triglycerides, the protein ApoC-III, and LDL-cholesterol.
"Everyone thinks sugar are 'empty' calories. But the data show that sugar's detriment is unrelated to its calories. It damages the liver by overwhelming mitochondria, and driving liver fat, which drives chronic disease," explained Robert Lustig, MD, a pediatric endocrinologist and an author on the studies.

Credit: University of California, San Francisco

Sugar overconsumption is a well-documented cause of heart disease and diabetes, yet many people are unaware of the risks – and that's no accident. Earlier this year, UCSF researchers uncovered documents showing that the sugar industry colluded with nutrition scientists in the 1960s to single out fat and cholesterol as contributors to coronary heart disease while downplaying the role of sugar. The media and health policy are beginning to catchup to the truth, and emerging research now suggests too much sugar is also a factor in cancer, Alzheimer's disease and aging.
Sleep More
Getting a good night's sleep affects more than just how you feel the next day. Increasing evidence links poor sleep to serious and chronic health problems like hypertension, diabetes, cancer and obesity.
For the vast majority of the population, the need for eight to eight-and-half hours of sleep is genetically determined. Though people may take pride in sleeping less and getting more work done, those missed hours take their toll, according to Aric Prather, PhD, assistant professor of psychiatry.
Prather's research shows that sleep is essential for the immune system. In one study, people who slept less than six hours a night were four times more likely to succumb when exposed to the cold virus. In another, short sleepers were more than 11 times more likely to fail to develop adequate immunity after receiving a hepatitis B vaccination.

Credit: University of California, San Francisco

Drink Less Alcohol
The common assumption that moderate alcohol use is "heart healthy" is being questioned through new research from the lab of Gregory Marcus, MD, the Endowed Professorship of Atrial Fibrillation Research.
Although some research shows that moderate alcohol use can reduce the risk of heart attacks, the issue is much more complex. The same amount of alcohol can also change the structure of the heart in ways that increase the risk of atrial fibrillation, which in turn increases the risk of stroke.
Alcohol's abilities to protect and harm the heart likely operate through different mechanisms and vary from person to person, said Marcus. A nightly glass of red wine might do you more harm than good, but most people don't think beyond heart attacks when thinking about heart health.
Regardless, one clear pattern has emerged from research: people who believe alcohol is good for the heart tend to drink more.

Credit: University of California, San Francisco

Reduce Stress
Stress has long been linked to cardiovascular disease and weakened immune function, and UCSF researchers are now uncovering how this happens on a cellular level.
They've found that women under chronic stress have lower levels of klotho, a hormone that regulates aging and enhances cognition. In animal studies, when klotho is disrupted, the animals don't live as long and suffer from hardening of arteries, and loss of muscle and bone.
Chronic psychological stress also shortens the length of telomeres, the protective caps on the ends of chromosomes that forestall DNA degradation. Telomeres naturally shorten as we age, but stress can speed up this cellular aging.
A recent study by Elizabeth Blackburn, PhD, Nobel laureate and Morris Herzstein Endowed Chair of Biology and Physiology, and Elissa Epel, PhD, professor of psychiatry, found that healthy older women who experienced stressful life events, such as the death of a loved one or unemployment, had significantly shortened telomeres after just one year.
But relax, there's good news: The same study found that those with a healthier daily lifestyle, including physical activity, healthy diet and good sleep quality, appeared to be protected against the cellular effects of stress. And earlier research found that men who made improvements in diet, exercise, social support and stress management (such as regular meditation) could even increase their telomere length. Blackburn and Epel describe more research-based strategies to reduce stress in their new book.

Credit: University of California, San Francisco

Get in Shape
Besides helping to shed those extra holiday pounds, exercise has profound health benefits that don't show up on the scales. In fact, exercise may be one of the best ways to counter the cellular damage caused by stress and trauma.
In one study of women who were primary caregivers for a family member with dementia, those who had regular physical activity were protected against stress-related telomere shortening. (Shorter telomeres are associated with increased incidence of disease and shorter lifespan.)
Exercise can also help prevent diseases ranging from dementia to cancer. A study last year found that in men ages 40 to 75, those who engaged in regular intense exercise and had other healthy lifestyle factors had a 69 percent lower risk of lethal prostate cancer.
"Exercise has the capacity to help us keep stress at bay and can limit the impact of stress on our minds and bodies," said Eli Puterman, PhD, former assistant professor of psychiatry at UCSF and now at the University of British Columbia. "This is really one more great reason to develop a healthy relationship with exercise and try to incorporate more movement into our daily lives."

Provided by University of California, San Francisco

Head off 'holiday heart syndrome'

Overindulging over the holidays can take a toll on the heart, according to experts at UT Southwestern Medical Center in Dallas.
Heavy drinking and eating too much, especially salty foods, can trigger atrial fibrillation. A-fib is an irregular heartbeat that causes the upper chambers of the heart to contract rapidly, increasing the risk for stroke.

26 dec 2016--People with the condition may feel short of breath, have heart palpitations and feel like their heart is beating much faster than usual.
During December when holiday revelry peaks, emergency rooms see a surge of patients with what's unofficially dubbed "holiday heart syndrome" from too much food and drink, according to UT Southwestern cardiologist Dr. Sharon Reimold.
"It's common for people to go to multiple parties during this time of year. You go to one party and have a drink or two, go to the next party and have a couple more. It's the cumulative effect of alcohol that can put you at risk, sending your heart into atrial fibrillation," Reimhold said in a hospital news release.
Healthy adults should get no more than 1,500 milligrams of sodium a day, according to the American Heart Association. That's less than a teaspoonful. Reimhold said it's important to watch what you're eating and drinking at holiday celebrations and avoid overdoing it.

More information: The American Heart Association provides more information on holiday heart syndrome.

Twenty-second test could identify frailty in hospitalized older adults

Falls and fall-related injuries are a common concern in older adults and can have significant consequences. For older adults who are hospitalized for ground-level falls, their level of frailty can be an important indicator of adverse health outcomes upon discharge. 

19 dec 2016--Experts at Baylor College of Medicine and the University of Arizona recently developed a 20-second upper-extremity function test to help identify frailty in this group of adults and found that the test can be used in the trauma setting to predict adverse outcomes in older adults after discharge. Their report appeared in the journal Gerontology.
The upper-extremity function test uses wearable sensors to identify frailty by testing repetitive elbow flexion (bending) and extension for 20 seconds. The assessment of frailty is based on quantifying weakness, slowness and exhaustion during the 20-seconds of flexion and extension.
"In a previously study, we demonstrated that this simple test could identify frailty status just as well as conventional assessments," said Dr. Bijan Najafi, professor in the Michael E. DeBakey Department of Surgery at Baylor and director of clinical research in the division of vascular surgery and endovascular surgery. Najafi, a biomedical engineer, is the director of the Interdisciplinary Consortium on Advanced Motion Performance (iCAMP) at Baylor.
In this study, Najafi and colleagues examined whether the test could predict adverse health outcomes upon discharge in bedbound older adults admitted to the hospital due to ground-level fall injuries.
Researchers recruited 101 older adults with an average age of 79 who were admitted to a trauma setting. Participants underwent the test at the time of admission and were followed for up to two months with phone calls and chart reviews. Researchers measured health outcomes including discharge disposition (favorable: discharged home or to rehabilitation versus unfavorable), hospital length of stay, 30-day readmission, 60-day readmission and 30-day prospective falls.
They found that the only predictor of 30-day prospective falls postdischarge were patient demographics, which include age, gender and body mass index. The upper-extremity function test was a predictor of discharge disposition, 30-day readmission and 60-day readmission. The indicators of slowness, weakness and exhaustion within the test were highly associated with an unfavorable discharge disposition.
"The study suggests that a 20-second upper-extremity test is practical for a busy hospital setting and could be used as a quick measure for predicting adverse events and outcomes in bedbound patients postdischarge," said Najafi. "It may help in planning discharge disposition and hospital resource allocation among geriatric inpatients as well as in establishing prevention and preoperative strategies to improve both short- and long-term outcomes in these patients."

More information: Bellal Joseph et al. Upper-Extremity Function Predicts Adverse Health Outcomes among Older Adults Hospitalized for Ground-Level Falls, Gerontology (2016). DOI: 10.1159/000453593


Provided by Baylor College of Medicine

A handful of nuts a day cuts the risk of a wide range of diseases

Credit: Lawrencekhoo / Wikipedia.

A large analysis of current research shows that people who eat at least 20g of nuts a day have a lower risk of heart disease, cancer and other diseases.

11 DEC 2016--The analysis of all current studies on nut consumption and disease risk has revealed that 20g a day - equivalent to a handful - can cut people's risk of coronary heart diseaseby nearly 30 percent, their risk of cancer by 15 percent, and their risk of premature death by 22 percent.
An average of at least 20g of nut consumption was also associated with a reduced risk of dying from respiratory disease by about a half, and diabetes by nearly 40 percent, although the researchers note that there is less data about these diseases in relation to nut consumption.
The study, led by researchers from Imperial College London and the Norwegian University of Science and Technology, is published in the journal BMC Medicine.
The research team analysed 29 published studies from around the world that involved up to 819,000 participants, including more than 12,000 cases of coronary heart disease, 9,000 cases of stroke, 18,000 cases of cardiovascular disease and cancer, and more than 85,000 deaths.
While there was some variation between the populations that were studied, such as between men and women, people living in different regions, or people with different risk factors, the researchers found that nut consumption was associated with a reduction in disease risk across most of them.
Study co-author Dagfinn Aune from the School of Public Health at Imperial said: "In nutritional studies, so far much of the research has been on the big killers such as heart diseases, stroke and cancer, but now we're starting to see data for other diseases.
"We found a consistent reduction in risk across many different diseases, which is a strong indication that there is a real underlying relationship between nut consumption and different health outcomes. It's quite a substantial effect for such a small amount of food."
The study included all kinds of tree nuts, such as hazel nuts and walnuts, and also peanuts - which are actually legumes. The results were in general similar whether total nut intake, tree nuts or peanuts were analysed.
What makes nuts so potentially beneficial, said Aune, is their nutritional value: "Nuts and peanuts are high in fibre, magnesium, and polyunsaturated fats - nutrients that are beneficial for cutting cardiovascular disease risk and which can reduce cholesterol levels.
"Some nuts, particularly walnuts and pecan nuts are also high in antioxidants, which can fight oxidative stress and possibly reduce cancer risk. Even though nuts are quite high in fat, they are also high in fibre and protein, and there is some evidence that suggests nuts might actually reduce your risk of obesity over time."
The study also found that if people consumed on average more than 20g of nuts per day, there was little evidence of further improvement in health outcomes.
The team are now analysing large published datasets for the effects of other recommended food groups, including fruits and vegetables, on a wider range of diseases.

More information: Dagfinn Aune et al, Nut consumption and risk of cardiovascular disease, total cancer, all-cause and cause-specific mortality: a systematic review and dose-response meta-analysis of prospective studies, BMC Medicine (2016). DOI: 10.1186/s12916-016-0730-3


Provided by Imperial College London

Association between steps, functional decline in older hospitalized patients

Is walking fewer than 900 steps per day associated with functional decline in older hospitalized patients? A new research letter published online by JAMA Internal Medicine suggests it is.

10 dec 2016--Recent research has suggested 900 steps per day were normative for frail older adults and for older adults hospitalized in internal medicine units. Maayan Agmon, Ph.D., and Anna Zisberg, Ph.D., of the University of Haifa, Israel, and coauthors examined whether that amount of steps differentiated those patients who do, or don't, experience hospitalization-associated functional decline.
The authors used patients within an ongoing study of a newly designed program that promotes in-hospital mobility. The study included 177 older patients hospitalized in internal medicine units at an academic medical center in Israel during the last three months of 2015. Total steps per day were calculated and the evaluation included cognitive, functional and mobility assessments.
Walking fewer than 900 steps per day was associated with hospitalization-associated functional decline, according to the results. Among the 41.8 percent of patients who walked less than 900 steps per day, 55.4 percent (57 patients) reported hospitalization-associated functional decline. Among the 58.2 percent of patients who walked 900 steps per day or more, only 18.4 percent (14 patients) experienced hospitalization-associated functional decline.
Limitations of the study include its sample of a relatively high-functioning group of older adults from a single site.
"Nonetheless, this study adjusts for a broad range of intervening variables and relies on gold-standard, sensor-based data collection. Thus, it fills the gaps uncovered by previous studies and provides preliminary evidence to support the recommendation of 900 steps per day for HAFD [hospitalization-associated functional decline] prevention. These findings should be confirmed by future studies involving diverse groups of older adults," the study concludes.

More information: JAMA Intern Med. Published online December 5, 2016. DOI: 10.1001/jamainternmed.2016.7266


Provided by The JAMA Network Journals

Researchers identify link between brain and bone in Alzheimer's disease

Researchers at NEOMED have just identified a major connection between areas of the brainstem - the ancient area that controls mood, sleep and metabolism - and detrimental changes to bone in a preclinical model of Alzheimer's disease (AD). 

01 dez 2016--The study, titled "Early Evidence of Low Bone Density and Decreased Serotonergic Synthesis in the Dorsal Raphe of a Tauopathy Model of Alzheimer's Disease," is led by Christine Dengler-Crish, Ph.D., assistant professor of pharmaceutical sciences, and anatomy and neurobiology, and will be published in the upcoming issue of the Journal of Alzheimer's Disease, an international multidisciplinary journal that reports progress in understanding the causes, symptoms, and treatment of Alzheimer's.
More than five million Americans are living with Alzheimer's disease. Along with being the sixth leading cause of death in the U.S., Alzheimer's has major social, emotional and financial consequences for patients and their families. Incurable and seemingly unstoppable, less than 5 percent of AD cases are due to a clear genetic reason, so it is hard to predict who will be at risk for acquiring this devastating disease.
Dr. Dengler-Crish and her research team that included graduate students Matthew Smith (NEOMED) and Gina Wilson (Kent State University) report that early reductions in bone mineral density (BMD) that occur in a preclinical model of AD are due to degeneration in an area of the brainstem that produces the majority of the brain's serotonin—a neurochemical that controls mood and sleep, which are two processes that are also affected early in AD.

One's bones may be one of the earliest indicators of brain degeneration in Alzheimer's disease

Reduced BMD, which sometimes leads to osteoporosis, translates to increased bone fracture risk, decreased quality of life, and increased mortality for AD patients. Furthermore, Dr. Dengler-Crish's research suggests that early bone loss and serotonin deficiency in AD may tell us something very important about how we approach diagnosing and treating this disease.
"Measurement of bone density, which is routinely performed in the clinic, could serve as a useful biomarker for assessing AD risk in our aging population," notes Dr. Dengler-Crish. "The findings of this study motivate us to explore the serotonin system as a potential new therapeutic target for this devastating disease."
Dengler-Crish, who received her bachelor's degree from Baldwin Wallace University, her master's in psychology from the University of Illinois at Chicago and her Ph.D. in neuroscience from Vanderbilt University, has now been named an associate editor for the Journal of Alzheimer's Disease. She is excited to facilitate the work of other scientists in this important area. "I am thrilled to be able to assist the publication of researchers' innovative work, here and across the world, that is desperately needed to combat these currently incurable chronic diseases. Now more than ever, there is hope that we soon will be able to slow, stop or reverse the progression of these destructive neurodegenerative conditions."
"This is extremely exciting and has significant translational potential and relevance to early detection of the disease," noted Jason R Richardson, Ph.D., DABT, director for Neurodegenerative Disease and Aging Research at NEOMED.


Provided by Northeast Ohio Medical University

Prostate cancer—what you need to know

Men should discuss health history with their family and physician. Credit: University of Alabama at Birmingham

In 2016, more than 180,890 men will be diagnosed with prostate cancer, the second leading cause of cancer death in men. Next to skin cancers, prostate cancer is the most common cancer diagnosed in American men.

27 nov 2016--"Men's health and prostate cancer are topics that many tend to shy away from, but they need to be discussed more openly," said Soroush Rais-Bahrami, M.D., assistant professor at the University of Alabama at Birmingham in the Department of Urology and co-director for the UAB Program for Personalized Prostate Cancer Care. "One out of eight men will be diagnosed with prostate cancer in his life."
The prostate is a reproductive gland in men located between the bladder and the penis. The fluid from the prostate is discharged into the urethra at the time of ejaculation as part of the semen to nourish and stabilize sperm for reproductive purposes.

Prevention

Men ages 50 and older should be screened during their annual physical exam with a discussion regarding prostate cancer risk. A routine blood test can measure a biomarker called prostate-specific antigen or PSA, which can identify a man's risk of prostate cancer along with a digital rectal exam. Concern based on the PSA blood test level or digital rectal exam can prompt a biopsy of the prostate gland, which can be further evaluated to determine the presence of prostate cancer and, if found, the aggressiveness of the cancer.
"Many men do not know their family history of prostate cancer because men tend not to talk about their health concerns, even with children and other family members," Rais-Bahrami said. "It is important to discuss family history due to the significantly higher risk for men with a first-degree relative who has been diagnosed with prostate cancer."
Certain men may have a higher risk of prostate cancer based on family history or ethnicity, race, and ancestry, and should receive their first screening discussions at the age of 40.

Diagnosis

Symptoms of prostate cancer are rare, and many men show no symptoms before being diagnosed. Once a blood test shows signs of higher PSA levels, a tissue biopsy is required to help determine the grade and stage of the prostate cancer.
In advanced stages, symptoms may affect quality of life, ranging from pain in the bones to bloody urine, blood in the semen, blockage in the urinary tract and renal failure.
Once a man has been diagnosed with cancer, Rais-Bahrami recommends asking these questions to learn more about a path toward a cure:

• How will my personal health be affected?
• What grade or level of aggressiveness is my specific cancer?
• What stage or level of progression does my cancer have?
• Are there any additional staging studies that should be done for me?
• What are my treatment options?
• What are the side effects of each treatment option?

"When a patient has received a positive prostate cancer diagnosis, it is important he communicates with his family and his doctor about the different types of treatment and understands what will be faced through this journey of treatment," Rais-Bahrami said.

Treatment

The patient and physician should look at the options available to treat his prostate cancer and develop a personalized road map to manage symptoms and cure his cancer.
"Treatment is based on the patient's overall health and what works best in treating the patient to ultimately cure the cancer and help the patient preserve an excellent quality of life," Rais-Bahrami said.
In the earliest stages of low-grade prostate cancer, and with the consultation of a physician, men can opt for active surveillance, which is when the doctor does not prescribe immediate treatment, but watches the cancer cells closely to postpone treatment with curative intent, perhaps for years. Other treatment options include:

• Surgery, which includes removing the entire prostate gland and occasionally regional lymph node tissues
• Radiation therapy, or beams of radiation focused on the prostate
• Hormone therapy, which reduces levels of male hormones to stop them from affecting prostate cancer cells
• High-intensity, focused ultrasound therapy, or high-energy sound waves that destroy cancer cells
• Cryosurgery, or the use of extreme cold temperatures to freeze and kill cancer cells

"Prostate cancer is a treatable disease and can be cured if caught in early stages," Rais-Bahrami said. "This is why it is important to receive routine screenings and have early detection when present."
If the cancer is diagnosed in later stages and has spread to other parts of the body, it becomes more aggressive and more difficult to treat in most cases.
To help with personalized care of patients, UAB offers magnetic resonance imaging and ultrasound fusion-guided biopsy. The image fusion allows doctors to target a direct tissue sampling of an individual based on imaging areas of concern that can be tested for prostate cancer.

Current research

New research for prostate cancer is on the horizon, including the ongoing search for better biomarkers that indicate the presence of prostate cancer. Researchers are now searching for prostate cancer biomarkers that have specific implications for improved diagnosis and prediction of cancer aggressiveness and patient prognosis.
"With the serum PSA, a red flag is raised as a potential prostate cancer diagnosis; but it is not specific in diagnosing an individual's prostate cancer," Rais-Bahrami said. "Serum PSA can detect abnormalities with the prostate that are not exclusive to prostate cancer. Biomarker research is important to achieve a more individualized diagnosis."
At UAB, prostate cancer research is focused on advanced imaging and biomarker development, and hopes of defining the best way toward focal therapy of prostate cancer . UAB has become one of two beta sites in the United States to receive the iSR'obotTM Mona Lisa machine. This machine helps surgeons diagnose prostate cancer in earlier stages with imaging guidance and provides precise location mapping to help with targeting cancer cells for treatment.


Provided by University of Alabama at Birmingham

Current evidence does not support vitamin D supplements to prevent disease

Credit: CC0 Public Domain

Current evidence does not support the use of vitamin D supplements to prevent disease, conclude researchers in The BMJ today.

24 nov 2016--Associate Professor Mark Bolland and colleagues at the University of Auckland, New Zealand and the University of Aberdeen, Scotland say those at high risk of vitamin D deficiency should be advised about sunlight exposure and diet and offered low dose supplements, but the rest of us should focus on eating a healthy balanced diet with food containing vitamin D and getting regular short bursts of sunshine.
Vitamin D is made by the skin in response to sunlight. It helps to maintain calcium levels in the body to keep bones, teeth and muscles healthy. A lack of vitamin D can lead to bone deformities such as rickets in children, and bone pain and tenderness due a condition called osteomalacia in adults.
During spring and summer, most people get enough vitamin D from sunlight on their skin and their diet. But in autumn and winter, when exposure to sunshine is minimal, the only source is from a limited range of foods such as oily fish, egg yolk, red meat, liver, fortified breakfast cereals and fat spreads.
As such, Public Health England advises that everyone should consider a 10 microgram daily vitamin D supplement of during these months.
Based on a comprehensive search of published evidence, Associate Professor Bolland and colleagues make the case that existing clinical trials show that vitamin D supplementation does not improve musculoskeletal outcomes, such as falls or fractures.
They also say there is no high quality evidence to suggest that vitamin D supplementation is beneficial for other conditions such as heart disease, stroke, and some cancers—and ongoing trial results are unlikely to alter these conclusions.
If vitamin D supplementation does have benefits, they are most likely to be seen in severely deficient vitamin D populations, they write.
In light of the uncertainty, they suggest people at high risk should be counselled about sunlight exposure and diet, and low dose vitamin D supplements considered on an individual basis. "Otherwise we conclude that current evidence does not support the use of vitamin D supplementation to prevent disease."
In a debate article also published today, two experts discuss whether healthy people should take a vitamin D supplement during the winter months.
Dr Louis Levy, head of nutrition science at Public Health England, says advice to take a vitamin D supplement of 10 micrograms a day is backed by a Scientific Advisory Committee on Nutrition (SACN) review of the evidence on musculoskeletal health outcomes.
He says "Bolland and his colleagues conclude that serum 25-hydroxyvitamin D should not fall below 25 nmol/L, just like the Scientific Advisory Committee on Nutrition did earlier this year. To achieve this, PHE advice includes getting short bursts of summer sun and a balanced diet through summer and spring. But when the days are darker and shorter and sun exposure is minimal, people should consider a daily 10 microgram vitamin D supplement, as it's difficult to get enough through diet alone."
He argues that taking 10 micrograms of vitamin D daily to prevent musculoskeletal ill health "is unlikely to result in harmful levels of vitamin D" and says getting enough vitamin D is particularly important "because poor musculoskeletal health remains in the top 10 causes of disability adjusted life years."
But Tim Spector, Professor of genetic epidemiology at King's College London, questions whether this recommendation is evidence based. He points out that, despite hundreds of studies, "highly convincing evidence of a clear role of vitamin D does not exist for any outcome."
Although vitamin D treatment still has a role in people with proved deficiency or in high risk groups, "the rest of us should avoid being 'treated' for this pseudodisease, save scarce NHS resources, and focus on having a healthy lifestyle, sunshine, and a diversity of real food."

More information: Practice: Should adults take vitamin D supplements to prevent disease? www.bmj.com/cgi/doi/10.1136/bmj.6201
Head to Head: Should healthy people take a vitamin D supplement in winter months? www.bmj.com/cgi/doi/10.1136/bmj.i6183


Provided by British Medical Journal

AGS sets sights on better care, more responsive policies for 'unbefriended' older adults

The "unbefriended" lack the capacity to provide informed consent to medical treatment, often due to declines in physical and/or mental well-being. But these individuals face added challenges because they have no written outline of their care preferences and also have no identified "surrogate," such as a family member or friend, to assist in medical decision-making when needed. Baby boomers are at particular risk for becoming unbefriended, since more than 10 million boomers live alone and as many as 20 percent have no children.

23 nov 2016--Experts at the American Geriatrics Society (AGS) today unveiled new guidance on care and decision-making for a unique and growing group of older adults: the "unbefriended." Proposed clinical practice and public policy changes would support some of society's most vulnerable individuals while also helping protect more of us from becoming unbefriended as we age.
The "unbefriended" lack the capacity to provide informed consent to medical treatment, often due to declines in physical and/or mental well-being. But these individuals face added challenges because they have no written outline of their care preferences and also have no identified "surrogate," such as a family member or friend, to assist in medical decision-making when needed. Baby boomers are at particular risk for becoming unbefriended, since more than 10 million boomers live alone and as many as 20 percent have no children.
"Health professionals have a special responsibility for the unbefriended, but we also face particularly challenging situations when it comes to their medical decisions" notes Timothy W. Farrell, MD, AGSF, a member of the expert panel responsible for the position statement. Added AGS President Ellen Flaherty, PhD, APRN, AGSF: "The AGS has outlined proactive steps we can take to help those at risk of becoming unbefriended. And for older adults who are already facing this reality, our guidance can help create standards and systems of support in more places and for more people. It's not just about improving care; it's about making care more respectful and responsive."

Experts at the American Geriatrics Society (AGS) today unveiled new guidance on care and decision-making for a unique and growing group of older adults: the "unbefriended." Proposed clinical practice and public policy changes would support some of society's most vulnerable individuals while also helping protect more of us from becoming unbefriended as we age. Credit: (c) 2016, American Geriatrics Society

Across clinical practice, AGS experts have called for:

• Avoiding ad hoc approaches to decision-making to ensure fairness and respect;
• Identifying "non-traditional" surrogates—such as close friends, neighbors, or others who know a person well—wherever and whenever possible;
• Putting mechanisms in place to assess decision-making capacity in a systematic fashion;
• Standardizing approaches to caring for the unbefriended in urgent, life-threatening situations;
• Ensuring access to decision-making surrogates who are familiar not only with a person's medical condition but also with his or her needs, preferences, and expectations; and
• Remaining sensitive to all available information—including cultural factors—when considering an unbefriended person's best interests.

Experts at the American Geriatrics Society (AGS) today unveiled new guidance on care and decision-making for a unique and growing group of older adults: the "unbefriended." Proposed clinical practice and public policy changes would support some of society's most vulnerable individuals while also helping protect more of us from becoming unbefriended as we age. Credit: (c) 2016, American Geriatrics Society

At a systemic level, AGS experts also recommend:

• Bringing national stakeholders together to create model legal standards that could be adopted by all states;
• Working with clinicians, healthcare organizations, and other stakeholders to prevent older adults from becoming unbefriended; and
• Developing innovative, efficient, and accessible approaches to protect decision-making for the unbefriended.

As an update to earlier guidance released in 1996, the AGS Ethics Committee developed these new recommendations in collaboration with the AGS Clinical Practice and Models of Care Committee and the AGS Public Policy Committee. The final position statement was published online ahead of print in the Journal of the American Geriatrics Society, and is available for free from GeriatricsCareOnline.org.

More information: Timothy W. Farrell et al, AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults, Journal of the American Geriatrics Society (2016). DOI: 10.1111/jgs.14586


Provided by American Geriatrics Society

How important is the gut microbiome? It may depend on your genetics

Our gut microbiomes—the bacteria that live in our digestive tract—play major roles in our health. Scientists around the world are studying therapies that manipulate the microbiome, including probiotics (such as live bacterial cultures in yogurt), prebiotics (edible fibers meant to promote beneficial bacteria), antibiotics and transplants of microbes from healthy people.

22 nov 2016--Joslin Diabetes Center investigators now are shedding light on how the success of such microbiome treatments may be affected by genetics of the individual or animal being treated.
In work published online today by the Journal of Clinical Investigation, a team of Joslin researchers reported on experiments among three genetically different strains of mice (two closely related and one more distant). They discovered that giving the mice antibiotics produced very different effects on their gut microbiomes, as well as on their insulin sensitivity, tissue inflammation and related metabolic functions such as blood glucose, depending on the genetic background of the mouse.
"The potential implication of our research is that genetic background will make a big difference in response to changing the gut microbiome, not just in mice, but also in humans where such treatments are being used for gastrointestinal and metabolic diseases," says C. Ronald Kahn, Joslin's chief academic officer and professor of medicine at Harvard Medical School.
"Our research suggests that some people are more genetically susceptible to the impact of the microbiome than others, and treatments that change the microbiome will make a big difference in some but not in others," says Kahn, who is senior author on the paper. "So understanding these genetic factors could play an important role in predicting the future usefulness of microbiome therapies for obesity and metabolic disease."
Among the three strains of mice that were studied, one strain is prone to diabetes and obesity, a second is prone to obesity but not diabetes, and a third is not prone to either condition. The mice were placed on high-fat diets, which raise the chances of developing the two conditions. Next, they were given one of two types of antibiotics commonly used in medicine, one that is absorbed into the bloodstream and one that is not, each of which had a different effect on the microbiome.
The researchers discovered that in the mice prone both to obesity and diabetes, treatment with either antibiotic not only changed the gut microbiomes but improved metabolism for the mice—lowering blood glucose, reducing tissue inflammation and increasing insulin signaling. But in the other two types of mice, changes in the microbiome did not bring these positive changes in metabolism.
Many of the metabolic changes in the mice prone both to obesity and diabetes could be duplicated by transferring gut microbes from mice treated with antibiotics to mice lacking normal gut microbes. That finding supports the hypothesis that the antibiotic effects on the microbiome, rather than other biological mechanisms, drive the metabolic changes, Kahn says.
Starting to probe the variations in metabolism between mice, the researchers found that one big factor was how the mice responded to changes in bile acid metabolism. Bile acids are molecules secreted by the liver into the gut, where they aid in the absorption of fats, Kahn explains. Additionally, bacteria in the gut chemically modify bile acids into forms that are reabsorbed into the bloodstream and help to respond to inflammation.
The impact of antibiotics on bile acid metabolism varied across the three strains of mice, which partly explains why the different strains displayed different responses in tissue inflammation, insulin signaling and other metabolic functions. "So we showed, using these animal models, a link between the changing microbiome and changing inflammation, which contributes to insulin resistance," Kahn says.
The Joslin researchers are following up with more detailed study of how bile acids and other metabolites (small molecules) are involved in control of metabolism.
"Bile acids are just the tip of the iceberg," Kahn says. "In on-going research, we've identified hundreds of human metabolites that change a lot in response to both diet and antibiotics. We're trying to track down exactly what these metabolites are, how they might influence insulin sensitivity, and which will be important regulators of blood glucose or weight gain, the two factors we really want to improve in patients at risk for type 2 diabetes."
The team also will look at how these modified metabolites might affect clinical behaviors ranging from eating behaviors to depression and anxiety, he says.
When these mechanisms are better understood, researchers will be better able to predict which patients will respond best to microbiome treatments, Kahn says. "If we can identify those people who are most likely to benefit from changing the microbiome, we might find a big effect among them," he suggests.

More information: Shiho Fujisaka et al. Antibiotic effects on gut microbiota and metabolism are host dependent, Journal of Clinical Investigation (2016). DOI: 10.1172/JCI86674


Provided by Joslin Diabetes Center

Probiotics improve cognition in Alzheimer's patients

For the first time, scientists have shown that probiotics—beneficial live bacteria and yeasts taken as dietary supplements—can improve cognitive function in humans. In a new clinical trial, scientists show that a daily dose of probiotic Lactobacillus and Bifidobacterium bacteria taken over a period of just 12 weeks is enough to yield a moderate but significant improvement in the score of elderly Alzheimer's patients on the Mini-Mental State Examination (MMSE) scale, a standard measure of cognitive impairment.

16 nov 2016--Probiotics are known to give partial protection against certain infectious diarrheas, irritable bowel syndrome, inflammatory bowel disease, eczema, allergies, colds, tooth decay, and periodontal disease. But scientists have long hypothesized that probiotics might also boost cognition, as there is continuous two-way communication between the intestinal microflora, the gastrointestinal tract, and the brain through the nervous system, the immune system, and hormones (along the so-called "microbiota-gut-brain axis"). In mice, probiotics have indeed been shown to improve learning and memory, and reduce anxiety and depression- and OCD-like symptoms. But prior to the present study there was very limited evidence of any cognitive benefits in humans.
Here, the researchers, from Kashan University of Medical Sciences, Kashan, and Islamic Azad University, Tehran, Iran, present results from a randomized, double-blind, controlled clinical trial on a total of 52 women and men with Alzheimer's between 60 and 95 years of age. Half of the patients daily received 200 ml milk enriched with four probiotic bacteria Lactobacillus acidophilus, L. casei, L. fermentum, and Bifidobacterium bifidum (approximately 400 billion bacteria per species), while the other half received untreated milk.
At the beginning and the end of the 12-week experimental period, the scientists took blood samples for biochemical analyses and tested the cognitive function of the subjects with the MMSE questionnaire, which includes tasks like giving the current date, counting backwards from 100 by sevens, naming objects, repeating a phrase, and copying a picture.
Over the course of the study, the average score on the MMSE questionnaire significantly increased (from 8.7 to 10.6, out of a maximum of 30) in the group receiving probiotics, but not in the control group (from 8.5 to 8.0). Even though this increase is moderate, and all patients remained severely cognitively impaired, these results are important because they are the first to show that probiotics can improve human cognition. Future research, on more patients and over longer time-scales, is necessary to test if the beneficial effects of probiotics become stronger after longer treatment.
"In a previous study, we showed that probiotic treatment improves the impaired spatial learning and memory in diabetic rats, but this is the first time that probiotic supplementation has been shown to benefit cognition in cognitively impaired humans," says Professor Mahmoud Salami from Kashan University, the senior author of the study.
Treatment with probiotics also resulted in lower levels of triglycerides, Very Low Density Lipoprotein (VLDL), high-sensitivity C-Reactive Protein (hs-CRP) in the blood of the Alzheimer patients, and likewise a reduction in two common measures (called "Homeostatic Model Assessment", HOMA-IR and HOMA-B) of insulin resistance and the activity of the insulin-producing cells in the pancreas.
"These findings indicate that change in the metabolic adjustments might be a mechanism by which probiotics affect Alzheimer's and possibly other neurological disorders," says Salami. "We plan to look at these mechanisms in greater detail in our next study."
Walter Lukiw, Professor of Neurology, Neuroscience and Ophthalmology and Bollinger Professor of Alzheimer's disease at Louisiana State University, who reviewed the study but was not involved in the research, said: "This early study is interesting and important because it provides evidence for gastrointestinal (GI) tract microbiome components playing a role in neurological function, and indicates that probiotics can in principle improve human cognition. This is in line with some of our recent studies which indicate that the GI tract microbiome in Alzheimer's is significantly altered in composition when compared to age-matched controls, and that both the GI tract and blood-brain barriersbecome significantly more leaky with aging, thus allowing GI tract microbial exudates (e.g. amyloids, lipopolysaccharides, endotoxins and small non-coding RNAs) to access Central Nervous System compartments."
The study is published in the open-access journal Frontiers in Aging Neuroscience.

More information: Effect of probiotic supplementation on cognitive function and metabolic status in Alzheimer's disease: a randomized, double-blind, and controlled trial , Frontiers in Aging Neuroscience, DOI: 10.3389/fnagi.2016.00256


Provided by Frontiers

France expects 13 times as many centenarians by 2070

France, which already has the most centenarians of any European country, could be home to 13 times more people over the age of 100 by 2070, the national statistics agency Insee said Thursday.
In January 2016, there were around 21,000 centenarians living in France, almost 20 times more than in 1970, it said.

14 nov 2016--If current life-expectancy trends continue, this could rise to 270,000 by 2070.
Insee said France currently had the most centenarians of any country in Europe, ahead of Spain and Italy, partly because it has one of the largest populations but also because life expectancy among women is particularly high.
By 2070, almost one centenarian in three was expected to be a man, up from a ratio of one in six currently, the study said.
France was also home to the oldest verified person ever—Jeanne Louise Calment, who died in 1997 aged 122 years and 164 days.

Physical training and social support reduce frailty and malnutrition

Physical training and social support reduce frailty and malnutrition. Credit: Medical University of Vienna

A training program for the reactivation of older and frail people established by MedUni Vienna has achieved remarkable success. It was revealed that physical training and addressing nutrition-relevant aspects with the aid of non-professional volunteers at home has had positive effects on the physical condition. Particularly the "social aspect" is of great significance.


12 NOV 2016--According to studies, 11% of the over 65's in Austria are frail and 41% are pre-frail. Frailty is a geriatric symptom consisting of a combination of sarcopenia (reduced muscle mass and/or muscle power), malnutrition (undernourishment or overeating) and chronic inflammation and is associated with enormous health problems for the affected persons. Preventative programs, consisting of a combination of social support, nutrition and exercise intervention can prevent malnutrition and frailty and reduce isolation and loneliness, particularly in case of people who live alone and hardly ever leave the apartment.
Non-professional volunteers working in an honorary capacity "activate" frail people
MedUni Vienna (Institute for Social Medicine), together with the Vienna Hilfswerk (relief organisation) and Sportunion Austria, initiated the project "Healthy for life". The project was promoted by the Vienna Science and Technology Fund. Volunteers working in an honorary capacity (so-called "buddies") visited frail or malnourished people (average age 83 years) in their homes twice a week for a period of twelve weeks. The skilled buddies trained together with the frail people (strength training with a Thera ribbon) and discussed nutrition-related aspects. An active control group also received visits, but without nutrition and exercise intervention.
After twelve weeks, a significant improvement in the frailty status and malnutrition risk was recorded. The prevalence of impaired nutritional status in the training and nutrition group was reduced by 25%, frailty by 17%. It was remarkable that the control group, who only received social support, also recorded improvements (23% less impaired nutritional status and 16% less frailty).
An active social life is important for physical wellbeing at an advanced age
"The results show that healthy nutrition and physical activity particularly at an advanced age have a special significance for the promotion of health and wellbeing and maintaining autonomy", explains first author Eva Luger of the Institute for Social Medicine of MedUni Vienna; "one essential prerequisite for healthy nutrition and physical activity is social support, particularly in case of older people".
"An active social life and social contacts are important factors to remain autonomous for as long as possible", emphasises study leader Thomas E. Dorner from the Institute for Social Medicine. "It also became evident that trained non-professional volunteers achieve similarly good results with such a program as those conducted by health professionals."
As many frail people live alone and hardly ever leave their apartment, nutrition and exercise programs based on social support are a good solution for the prevention and reduction of frailty.

More information: Eva Luger et al. Effects of a Home-Based and Volunteer-Administered Physical Training, Nutritional, and Social Support Program on Malnutrition and Frailty in Older Persons: A Randomized Controlled Trial, Journal of the American Medical Directors Association (2016). DOI: 10.1016/j.jamda.2016.04.018


Provided by Medical University of Vienna

Sarcopenia, which affects up to 20 percent of European seniors, may increase 63 percent by 2045

Researchers from the University of Liège, Belgium presented a study that reveals the enormous and growing burden of sarcopenia in Europe.

11 nov 2016--Sarcopenia is a disease associated with the ageing process. Hallmark signs of the disorder are loss of muscle mass and strength, which in turn affects balance, gait and overall ability to perform tasks of daily living.
Due to its complexity, there is as yet no global consensus on the definition of the disease for diagnostic purposes. The European Working Group on Sarcopenia in Older People (EWGSOP) has defined sarcopenia as low muscle mass with low muscle strength OR with low gait speed. With two cutoff points available for each of the three components of this definition, eight different methods of diagnosis of sarcopenia can be used.
Using the Eurostat online database, the researchers retrieved age and gender-specific population projections from 2016-2045 for 28 European countries. The age and gender-specific prevalence of sarcopenia was assessed from a study that precisely compared prevalence estimates according to the different diagnostic cutoffs of the EWGSOP proposed definition.
The prevalence estimates were interpolated for adults above 65 years of age. The estimates of sarcopenia prevalence were then applied to population projections until 2045. The results showed that:

• Using the definition providing the lowest prevalence estimates, the number of individuals with sarcopenia in Europe in 2016 is 10,869,527. This will rise to 18,735,173 in 2045 (a 72.4% increase). The overall prevalence of sarcopenia in the elderly will rise from 11.1% in 2016 to 12.9% in 2045. Women currently account for 44.2% of prevalent cases.
• Using the definition providing the highest prevalence estimates, the number of individuals with sarcopenia in Europe is 19,740,527 in 2016, rising to 32,338,990 in 2045 (a 63.8% increase). The overall prevalence of sarcopenia in the elderly will rise from 20.2% in 2016 to 22.3% in 2045. Women currently account for 66.4% of prevalent cases.

Presenting author Dr. Olivier Ethgen stated, "Regardless of which diagnostic cutoff is used to define sarcopenia, the prevalence of this condition is expected to rise substantially in Europe. It is therefore essential that we implement effective prevention and disease management strategies. Health authorities must take action in order to limit the impact on increasingly strained healthcare systems and to help Europeans enjoy healthy, active ageing."

More information: OC24 The Future Prevalence of Sarcopenia in Europe, O. Ethgen, C. Tchokonte, C. Beaudart1, F. Buckinx, J.-Y. Reginster, O. Bruyère
Abstract book: WCO-IOF-ESCEO World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, 14 -17 April 2016, Malaga, Spain Osteoporosis International, Volume 27/ Suppl 1/ 2016


Provided by International Osteoporosis Foundation

Is a marker of preclinical Alzheimer's disease associated with loneliness?

Diagram of the brain of a person with Alzheimer's Disease. 

A new article published online by JAMA Psychiatry used data from a study of 79 cognitively normal adults to examine whether cortical amyloid levels in the brain, a marker of preclinical Alzheimer disease, was associated with self-reported loneliness.

07 nov 2016--Alzheimer disease (AD) is a process that moves through preclinical, mild cognitive impairment and dementia stages before it leads to progressive neuropsychiatric, cognitive and functional declines. Loneliness has been associated with cognitive and functional decline and an increased risk of AD dementia.
Nancy J. Donovan, M.D., of Brigham and Women's Hospital and Harvard Medical School, Boston, and coauthors used imaging as a measure of cortical amyloid levels in the brain and a loneliness scale to indicate levels of loneliness. The study included 43 women and 36 men with an average age of about 76.
Of the participants, 22 (28 percent) were carriers of the genetic risk factor apolipoprotein E ?4 (APOE?4) and 25 (32 percent) were in the amyloid-positive group based on volume in imaging. The participants' average loneliness score was 5.3 on a scale of 3 to 12.
The authors report higher cortical amyloid levels were associated with greater loneliness after controlling for age, sex, APOE?4, socioeconomic status, depression, anxiety and social network. Participants in the amyloid-positive group were 7.5 times more likely to be classified as lonely then nonlonely compared with individuals in the amyloid-negative group. The association between high amyloid levels and loneliness also was stronger in APOE?4 carriers than in noncarriers, according to the results.
Limitations of the study include the demographic profile of the participants who had high intelligence and educational attainment but limited racial and socioeconomic diversity. The participants also had better mental and physical health.
"We report a novel association of loneliness and cortical amyloid burden in cognitively normal adults and present evidence for loneliness as a neuropsychiatric symptom relevant to preclinical AD. This work will inform new research into the neurobiology of loneliness and other socioemotional changes in late life and may enhance early detection and intervention research in AD," the study concludes.

More information: JAMA Psychiatry. Published online November 2, 2016. doi:10.1001/ jamapsychiatry.2016.2657


Provided by The JAMA Network Journals

ASCO updates guidelines on integration of palliative care

The American Society of Clinical Oncology Clinical Practice Guideline on the integration of palliative care into standard oncology care has been updated. The update was published online Oct. 28 in the Journal of Clinical Oncology.

06 nov 2016--Betty R. Ferrell, Ph.D., from City of Hope Medical Center in Duarte, Calif., and colleagues updated the 2012 American Society of Clinical Oncology provisional clinical opinion on the integration of palliative care into standard oncology care. An expert panel was convened to develop an update; members of the panel conducted an updated systematic review of randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of randomized controlled trials in the 2012 provisional clinical opinion.
The authors note that early in the course of disease, inpatients and outpatients with advanced cancer should receive palliative care services concurrent with active treatment. Ideally, patients should be referred to interdisciplinary palliative care teams, and services may complement existing programs. Family and friend caregivers of patients with early or advanced cancer may be referred to palliative care services.
"To enhance and strengthen the evidence base on palliative care, the dissemination of research results, and the quality and equity of palliative care, more research is needed," the authors write.
Several authors disclosed financial ties to the pharmaceutical industry.

More information: Full Text

One in four seniors doesn't discuss end-of-life care

02 nov 2016—More than one-quarter of American seniors have never discussed end-of-life care, a new study finds.
"Despite decades of work to improve advance care planning, over a quarter of older adults have still not engaged in any type of discussion or planning for their end-of-life preferences or plans," said lead author Krista Harrison, a geriatrics research fellow at the University of California, San Francisco.
The researchers looked at more than 2,100 Medicare beneficiaries aged 65 and older. Data from the group included self-reported age, gender, race/ethnicity, education, income, self-rated health, number of chronic conditions, disability in activities of daily living, and dementia.
The researchers found that 60 percent of the beneficiaries said they'd had discussions on end-of-life care, 50 percent on power of attorney, and 52 percent on other advanced directives.
Thirty-eight percent reported discussions on all three elements of advanced care planning, while 27 percent said they hadn't discussed any of the elements.
The rate of discussions on each element varied by as much as 35 percent, depending on patient characteristics. For two or more elements, the rate was lower among those aged 65 to 74, blacks and Hispanics, and those with less education and lower income.
The lowest rate of end-of-life planning was among older Spanish-speaking Hispanics, with 19 percent reporting end-of-life discussion, 20 percent discussing power of attorney and 17 percent discussing advanced directives.
The study also found that older adults with dementia had much lower rates of end-of-life discussions (54 percent) and advance directives (46 percent) than those without dementia (62 percent and 54 percent, respectively).
"Our findings suggest that there are substantial portions of the population of community-dwelling older adults who need to begin discussions about their plans and preferences before they are unable to share those preferences with their loved ones," Harrison said in a university news release.
The study was published Oct. 31 in the journal JAMA Internal Medicine.

More information: The U.S. National Institute on Aging has more about advanced care planning.

High blood pressure can impair cognitive function, pose risk for Alzheimer's

High blood pressure in middle age can lead to impaired cognition and is a potential risk factor for Alzheimer's disease, according to a statement from the American Heart Association co-authored by Loyola Medicine neurologist José Biller, MD.

30 OCT 2016--Dr. Biller is a member of the multidisciplinary panel of experts that wrote the statement, published in the heart association journal Hypertension. Dr. Biller is chair of the department of neurology of Loyola University Chicago Stritch School of Medicine. The panel is chaired by Constantino Iadecola, MD, of Weill Cornell Medicine and co-chaired by Kristine Yaffe, MD, of the University of California San Francisco.

Dementia affects an estimated 30 to 40 million people worldwide, and the number is expected to triple by 2050 due to an aging population and other factors.
An estimated 80 million people in the United States have hypertension, and the brain is among the organs most affected. Except for age, hypertension is the most important risk factor for vascular problems in the brain that lead to stroke and dementia.
There is consistent evidence that chronic high blood pressure during middle age (40 to 64) is associated with altered cognitive function in both middle age and late life (65 to 84). Cognitive abilities that are affected include memory, speed of processing and executive function (ability to organize thoughts, manage time, make decisions, etc.)
The effect of high blood pressure in late life is less clear. Some studies suggest it's harmful, while other research suggests it may improve cognition. This highlights "the complexities of recommending uniform levels of blood pressure across the life course," the expert panel wrote.
Observational studies have demonstrated that high blood pressure causes atherosclerosis (hardening of the arteries) and other damage to the brain's blood vessels, leading to reduced blood flow to brain cells. But evidence from clinical trials that treating blood pressure improves cognition is not conclusive.
After carefully reviewing available studies, the panel concluded there are not enough data to make evidence-based recommendations. However, judicious treatment of high blood pressure, taking into account goals of care and the patient's individual characteristics, "seems justified to safeguard vascular health and, as a consequence, brain health," the panel concluded.
The paper is titled, "Impact of hypertension on cognitive function: a scientific statement from the AmericanHeart Association."

More information: Costantino Iadecola et al, Impact of Hypertension on Cognitive Function: A Scientific Statement From the American Heart Association, Hypertension (2016). DOI: 10.1161/HYP.0000000000000053


Provided by Loyola University Health System

Higher education levels can reduce mortality especially in older people

Highly educated older men have particularly high life expectancy levels in all countries, even surpassing those of long-living nations. Population groups with the highest levels of education—such as the members of the Royal Society in Great Britain, the British Academy of Science, have even higher life expectancy levels. Credit: MPI for Demographic Research

Over the last century, life expectancy rose on average by three months a year. However, this progress has been uneven across educational groups. Highly educated people who systematically display the highest life expectancy levels have been the vanguards leading the way towards a lengthening of life for the remaining population groups. This trend has inspired scholars from the Max Planck Institute for Demographic Research to point out that there is considerable potential for the life expectancy values of entire populations to increase further.

25 oct 2016--The pattern is the same in almost every country: people who are highly educated live longer on average than people who are less educated. Indeed, in some countries the life expectancy levels of the highly educated exceed the world record life expectancy values at the country level that have been reached in countries like Japan or Switzerland. Domantas Jasilionis and Vladimir M. Shkolnikov of the Max Planck Institute for Demographic Research in Rostock have attempted to provide an international overview of this topic in an article that was published in the April issue of the journal Gerontology, and in a shorter version of this article that appears in the current issue of Demografische Forschung aus Erster Hand.

Gaps are especially large in Russia

International evidence suggests that some selective population groups may reach extremely high life expectancy values. For example, studies conducted in the U.S. and Norway have shown that small religious groups like the Mormons and the Seventh-day Adventists have achieved life expectancy levels that are much higher than the average levels in the countries with the highest life expectancy values in the world. Research findings also indicate that life expectancy levels are very high observed among the members of academic organizations like the Royal Society in Great Britain and the national academies of Germany, Austria, and Russia. Importantly, mortality among these scientific elites has been declining faster than the corresponding national averages, even though these groups already had record-low mortality levels at the start of the study period. Similar evidence also comes from mortality studies that looked at mortality among much larger and more conventional population groups, including educational groups.
The European studies on educational differentials show that the life expectancy differences between educational groups have grown in recent decades. Life expectancy has been increasing more rapidly among the highly educated than among the less educated segments of the population in the Scandinavian countries, as well as in Finland, Belgium, France, and Switzerland. In addition, very large and growing gaps between educational groups have been observed in central and eastern European countries, and especially in Lithuania, Estonia, and Russia. An extreme example of this pattern can be seen by looking at the life expectancy projections for Russian men. At the turn of the century, the life expectancy gap between the men with the highest and the lowest educational levels was around 13 years in Russia.
While the overall situation in the U.S. is similar to that of western and northern Europe, it is notable that in the U.S. life expectancy among women varied considerably by social class in the 1980s and the 1990s. Indeed, a number of studies found that the average life expectancy actually declined among the least educated non-Hispanic white women.

Cardiovascular revolution benefits the highly educated

Across all educational groups, gains in life expectancy can be attributed to decreases in mortality at older ages. Mortality among older people has been declining since the 1960s and the 1970s, largely because of improvements in the treatment of heart and circulatory diseases that are collectively referred to as the "cardiovascular revolution." When we look at the contributions of the age groups to these educational group differences, it is clear that the highly educated benefited from this revolution the most. For example, among Finnish men the difference between the highly educated and the other educational groups was 4.4 years in the 1970s; at that time, only one-third of this mortality gap was attributable to lower mortality after age 65. Some 35 years later this gap has expanded to six years, and around 2.5 of these years are attributable to lower mortality among the highly educated at old ages.

Early deaths are preventable

These large advances in life expectancy among the highly educated suggest that there is still considerable potential for life expectancy improvements among the middle and lower social classes. The unfavourable trends in life expectancy among the less educated that have been observed in some countries are avoidable, as they are largely caused by preventable early deaths.
Improvements in the educational attainment levels of populations are also contributing to further increases in life expectancy. For example, around half of the total increase in life expectancy among 30-year-old Swedish men between 1988 and 1999 can be traced back to improvements in the educational attainment levels of the Swedish population as a whole. This trend could also play out in many other countries.
The authors pointed out, however, that average life expectancy is unlikely to converge to the record values observed among the highly educated unless more progress is made in the fight against old -age- related diseases, such as Alzheimer's disease. Furthermore, the life expectancy improvements associated with higher levels of educational attainment may be counteracted by the negative effects of other compositional factors, such as an increase in the share of people who are divorced, or further growth in the proportion of people who are overweight or who smoke.

More information: Domantas Jasilionis et al. Longevity and Education: A Demographic Perspective, Gerontology (2015). DOI: 10.1159/000438901


Provided by Max Planck Society

Frailty in older surgery patients may be under recognized

Key findings in this study show nearly 70% of patients who participated in the frailty screening were determined to be pre-frail or frail. Patients who are frail or pre-frail may be at greater risk of surgical and post-surgical complications. Frailty screening may affect recommendations regarding treatments and surgical options.

23 oct 2016--"Patients with frail health have less ability to overcome stressors such as illness, falls, and injury, and have a higher risk of adverse effects from medications, procedures, and surgery," said Angela K. Beckert, MD, of the Medical College of Wisconsin in Milwaukee. "If a patient is more robust, with better physical performance and vigor—in other words, less frail—then I believe surgical outcomes would be better."
Dr. Beckert, Mark K. Ferguson, MD, and other colleagues from The University of Chicago Medicine, conducted a study to determine the proportion of pre-frail and frail patients who might benefit from frailty reduction intervention. The group examined 125 patients (average age of 70) at The University of Chicago Thoracic Surgery Clinic who were considered candidates for major thoracic surgery, such as lung resection, esophagectomy, or chest wall resection. The majority of patients (68.8%) who participated in the frailty screening were determined to be either pre-frail or frail, suggesting that frailty may be seriously under recognized within the surgery population.
Frailty in surgery patients is consistently associated with a greater risk of surgical complications, increased length of hospital stay, and discharge to a rehabilitation facility rather than home. In addition, frail patients are at a higher risk for readmission, suffer from lower quality of life following surgery, and end up paying higher overall costs for their care.
The researchers conducted frailty screening using five established characteristics: unintentional weight loss, weakness (grip strength), exhaustion, low activity level, and slow gait. The most commonly identified characteristic in this study was exhaustion; the least common was slowness.
"This study indicated that a large number of patients who are candidates for major surgery have important risk factors related to frailty," said Dr. Ferguson. "Knowing what these factors are can help physicians, patients, and the patients' families better understand the risks and may motivate them to participate in activities that reduce their risks."
One of the most important benefits of identifying frailty, explained Dr. Ferguson, is the ability to offer patients activities, such as nutritional and exercise interventions that can modify their frailty status prior to surgery and reduce their surgical risks. This study was just the first step. The research group is currently conducting studies of exercise intervention for frailty and the relationship between frailty and resiliency (the ability to bounce back from complications after surgery).
Frailty screening may also affect the recommendation a doctor makes regarding treatments and surgical options. According to Dr. Beckert, if a patient is determined to be frail, a surgeon may consider a different or less extensive approach to the operation. Also, during the early postoperative period, the health care team may provide more intensive and closely supervised care, including physical, nutritional, and occupational therapy.
"Frailty screening helps doctors better prepare patients for what to expect," said Dr. Beckert. "The screening results provide more accurate information to use in the complex decisions the patient, family, and health care team make about treatment options."
With the rapid growth of the elderly population and improved life expectancy (now 78 years), a rising number of older adults are expected to undergo surgery, with a greater chance of experiencing complications after surgery. The US Census Bureau reports that the elderly population in the United States is projected to almost double, from the most current estimate of 43 million in 2012 to 80 million by the year 2050. In addition, the National Hospital Discharge Survey reported that more than one-third of all surgical procedures are performed on patients over the age of 65, with that number likely to increase over the next few decades.
As a result, experts anticipate that frailty screening—which can be completed within a clinic appointment—will become even more crucial when considering the care of older patients facing surgery.
"There is an increasing awareness of the frailty problem among surgeons," said Dr. Ferguson. "We anticipate that screening efforts will expand substantially in the near future."

More information: Angela K. Beckert et al, Screening for Frailty in Thoracic Surgical Patients, The Annals of Thoracic Surgery (2016). DOI: 10.1016/j.athoracsur.2016.08.078


Provided by Elsevier

Virtual experience gets the elderly to exercise

Credit: Aalborg University

Virtual Reality can get the elderly in nursing homes to be happier about exercising. A new research project from Aalborg University shows that the technology motivates older people in nursing homes to get moving.

21 oct 2016--One of the major problems in nursing homes is that many older people do not move enough. Although nearly all nursing homes in Denmark offer access to fitness facilities and physical therapists, many of the residents rarely get their heart rate up. This needs to be addressed because physical activity keeps the body – and the brain – in shape and makes the elderly more self-reliant. A new PhD project from Aalborg University now shows that new technology in the form of virtual reality may be just the thing to get seniors on exercise bikes.
Jon Ram Bruun-Pedersen of the Multisensory Experience Lab in the Department of Architecture, Design and Media Technology at Aalborg University Copenhagen attempted to turn exercise for the elderly from a chore into a digital experience.
"All too often the elderly end up sitting and looking at a wall or staring passively into a television. As a rule they're usually not particularly motivated to exercise, partly because getting moving again after a long period of inactivity can cause pain, and partly because it's not particularly interesting to sit and look at a wall while you bike," he said.

Long ride in front of a screen

In conjunction with physical therapists at the Copenhagen nursing home Akaciegården, Jon Ram Bruun-Pedersen conducted a study where large TV screens were set up in front of the exercise bikes in the activity room. While they biked, they rode through various virtual landscapes on the TV screen.
The 21 elderly residents who participated in the study could choose among things like riding on a park road between green lawns, lakes, flowers and butterflies; through a snowy pine forest; or on a mountain side. The bikes were linked with the screens so that the speed the subjects biked with reflected their speed through the landscape.
"The study showed that seniors were really happy with the experience," says Jon Ram Bruun-Pedersen. "They really lived it and felt as if they had to pedal extra hard to get up the hill on the screen—even though they really didn't feel higher resistance on the bike."

On with the goggles

In the next part of the study, Jon Ram Bruun-Pedersen made the experience more intense. He equipped the elderly subjects with Virtual Reality goggles – a sort of diving mask with small screens in front of the eyes that makes you feel like you're being led into another world because you can look around the landscape. When you turn your head, it feels like you're looking around in reality – you can see out over the edge of the mountain, see the birds fly in the sky above and move freely around between buildings, plants and trees.
The illusion is very true to life, and the elderly subjects vividly experienced being out in the great outdoors—even though they were still on an exercise bike in the physical therapy room at the nursing home.
"We set the study up so the participants could ride in the same landscapes they knew from the screens. They took to the experience amazingly well. For many people stepping into a virtual world can be an overwhelming experience, but theelderly subjects had a surprisingly high tolerance threshold," explains Jon Ram Bruun-Pedersen.

New possibilities

From the interviews Jon Ram Bruun-Pedersen conducted with study participants you can see that the elderly's desire to use exercise bikes significantly increased.
"This is really positive," he says. "Partly because it is good for them physically to move more, but also because I wanted them to experience getting out of the nursing home and out in the world – even if it's a virtual world."
The beneficial effects of using Virtual Reality with the elderly are not limited to getting them in better physical shape. Jon Ram Bruun-Pedersen mentions the increased quality of life by "getting out" and experiencing something.
"It may well be you can't get out of the nursing home and take a plane to Mallorca or a bus to the Harz mountains, but you can experience what it's like to go for a walk in the mountains or visit some of the world's great attractions. It could also be that you'd like to go for a walk in your childhood neighborhood or something else that has had great significance," he says. "The possibilities are there with Virtual Reality."

Great demand

The study at Akaciegården was completed earlier this year, but it's hardly the last time the elderly had VR goggles on. After the study ended, Jon Ram Bruun-Pedersen was contacted by the physical therapists he worked with who now want to use virtual reality in their training programs for the elderly in the future.
Both the residents at the nursing home and a number of their relatives have also requested that the technology become a fixture in the gym.


Provided by Aalborg University