Largest ever multimorbidity trial in primary care challenge current thinking

In the largest ever trial of an intervention to treat people with multiple long-term conditions (multimorbidity) in primary care, researchers at the Universities of Bristol, Manchester, Dundee and Glasgow found that the patient-centred approach taken improved patients' experience of their care but did not improve their health-related quality of life. This is a challenge to current thinking on which UK and international guidelines are based.

30 jun 2018--In a study involving 1,546 patients from England and Scotland, they found that by making health reviews more patient-centred, such as involving patients in the planning and delivery of their care, overall patient satisfaction improved significantly. However, their health-related quality of life, which included measures of mobility, self-care, pain and discomfort, and anxiety and depression, did not.
The findings, published in The Lancet today, provide the best evidence to date of the effectiveness of a person-centred approach for multimorbidity, for which there is international consensus but little evidence.
One in four people in the UK and the US have two or more long-term health conditions, increasing to two-thirds for patients aged over 65, placing a major strain on health services. Conditions include diabetes, heart disease and asthma, and can include mental health conditions such as depression and dementia. Multimorbidity is associated with reduced quality of life, worse physical and mental health, and increased mortality. Treatment for multimorbidity places an additional burden on patients, who may have to take large numbers of drugs, make lifestyle changes and attend numerous appointments for health care.
The study, funded by the National Institute for Health Research (NIHR), tested a new approach to caring for people with three or more long-term conditions, which aimed to improve their health-related quality of life and experience of patient-centred care, and reduce their burden of illness and treatment compared with usual care. The '3-D' approach, which encourages clinicians to think broadly about the different dimensions of health, simplify complex drug treatment and consider mental health (depression) as well as physical health, was designed to treat the whole person and overcome the disadvantages of treating individual conditions in isolation.
Professor Chris Salisbury, from the University of Bristol's Centre for Academic Primary Care and lead author of the study, said: "Existing treatment is based on guidelines for each separate condition meaning that patients often have to attend multiple appointments for each disease which can be repetitive, inconvenient and inefficient. They see different nurses and doctors who may give conflicting advice. Patients with multiple physical health problems frequently get depressed and they also sometimes complain that no-one treats them as a 'whole person' or takes their views into account.
"Internationally, there is broad consensus about the key components of an approach to improve care for people with multimorbidity but we found little evidence about their effectiveness. We incorporated these components in the 3-D approach, including a regular review of patients' problems according to their individual circumstances. We were surprised to find no evidence of improved quality of life for patients as a result of the intervention but this was balanced by significant improvements in patients' experience of care.
"The question now is whether improved patient experience is sufficient justification for this approach. Given that improving patient experience is one of the triple arms of health care, alongside improving health and reducing costs, our view is that providing care that significantly improves patients' experience is justification in itself."
Patients from 33 primary care practices in Bristol, Greater Manchester and Ayrshire in Scotland took part in the study. Roughly half of the practices offered the 3-D intervention (to 797 patients) and other half offered usual care (to 749 patients). Patients were aged 18 and older. The 3-D intervention replaced disease-focused reviews of each health condition with one comprehensive 'patient-centred' review every 6 months with a nurse and doctor. These reviews focused on discussing the problems that bothered the patients most, how to improve their quality of life and how to improve management of their health conditions. A pharmacist reviewed the patient's medication. A health care plan was then devised with each patient and reviewed six months later.
All measures of patient experience showed benefits after 15 months, with patients widely reporting that they felt their care was more joined up and attentive to their needs. However, there was no difference between the two groups in their reported quality of life at the end of the study period.

More information: 'Improving the management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach' by Chris Salisbury et al in The Lancet, www.thelancet.com/journals/lan … (18)31308-4/fulltext


Provided by University of Bristol

USPSTF favors osteoporosis screening to prevent fracture

The U.S. Preventive Services Task Force (USPSTF) recommends screening for osteoporosis to prevent fractures for women aged ≥65 years 

29 jun 2018--Meera Viswanathan, Ph.D., from RTI International-University of North Carolina at Chapel Hill, and colleagues conducted a systematic review of the literature to update the evidence on screening and treatment to prevent osteoporotic fractures.
The researchers found that there was convincing evidence for the accuracy of bone measurement tests for detecting osteoporosis and predicting osteoporotic fractures in women and men. Adequate evidence was found that clinical risk assessment tools are moderately accurate for identifying risk of osteoporosis and osteoporotic fractures. Convincing evidence was found that drug therapies can reduce the rates of subsequent fractures in postmenopausal women. Based on these findings, the USPSTF recommends screening for women aged 65 years and older and in younger women who have been through menopause and are at increased risk (B recommendations). Insufficient evidence was found to recommend screening for osteoporosis to prevent fractures in men (I statement).
"We recommend screening for women over the age of 65 and younger women who have been through menopause and are at increased risk for osteoporosis," one of the task force members said in a statement.

More information: Final Recommendation
Evidence Review
Editorial

Can older, frail patients benefit from 'prehabilitation' before heart surgery?

The "new' approach -- components of "new" prehabilitation in cardiac surgery patients. Credit: Canadian Journal of Cardiology

High risk, frail heart patients might derive benefits from "prehabilitation," a strategy designed to enhance the recovery process after heart surgery by maintaining or improving the patient's overall physical and mental status before surgery, according to a group of eminent cardiac specialists writing in the Canadian Journal of Cardiology. The authors reviewed the current evidence regarding the benefits of prehabilitation and described two ongoing Canadian randomized controlled trials, examining prehabilitation in vulnerable heart disease patients.

28 jun 2018--The demand for surgical services is increasing as a result of an expanding "ageing population." Advances in healthcare practices and delivery have led to an increase in overall life expectancy. Currently, 8.5 percent of the world's population (approximately 620 million people) is older than 65 years of age. This percentage of older adults is projected to increase to 17 percent (1.6 billion) of the world's population by 2050. As a consequence, there has been an increase in the number of frail, older patients with advanced heart disease presenting for complex cardiac surgery procedures.
"The increasing number of older adults with a heart disease and subsequent increase in demand for heart procedures represents a veritable 'silver tsunami'," explained lead investigator Dr. Rakesh C. Arora, MD, Ph.D., from the University of Manitoba/St. Boniface General Hospital, Winnipeg, Manitoba, Canada. "Many of these patients have low physiological reserve. So when they undergo cardiac surgery, they experience a disproportionate decline in their health condition resulting in a long recovery time. In some instances, these vulnerable patients are discharged to a long-term care facility. In such cases, they experience poorer postoperative outcomes and worse quality of life despite a successful heart treatment or procedure. There is, therefore, an urgent need for the heart care team to ensure that the patients are not only liberated of cardiac disease symptoms, but also experience a better postoperative health-related quality of life, so they don't just survive, but thrive after their procedure."
In Canada, patients who require elective cardiac surgery are placed on a "waiting list" for up to two months. Previous investigations have established that patients on surgical waiting lists engage in minimal physical activity as they wait "in fear." There is some evidence to support the effectiveness of "prehabilitation" (prehab), a combination of exercise training, education, and social support, affecting patients' physical and psychological readiness for surgery, but these types of programs are not widespread. Prehab has the overarching goal to reduce postoperative complications and hospital length of stay as well as ideally improving the transition from the hospital back home. However, there is no formal consensus regarding what this should involve. While prehab has been used in patients undergoing bowel or bone surgery, it has not been widely considered for heart patients before surgery.
Dr. Arora and colleagues describe how new treatment protocols, also known as Enhanced Recovery Programs (ERPs), can help the heart team decide on the best treatment plan for vulnerable older adult patients before their procedures. The goals of an ERP are to maintain or improve the overall physical and mental status of the heart patient and reduce the impact of profound stress response following a cardiac procedure. They analyzed evidence from previous trials to support the use of prehab and evaluated how the NEW approach, a three-way approach including nutrition optimization, exercise training, and anxiety (worry) reduction (nutrition, exercise, and worry = NEW) may benefit heart patients.
Part of the barrier to the use of prehab in cardiac patients is the need for well done, multicenter, prospective studies. At present, there are two Canadian randomized controlled trials examining prehab in vulnerable cardiac patients that will hopefully provide new insights into the effectiveness of this intervention in the future:
The Pre-Operative Rehabilitation for Reduction of Hospitalization After Coronary Bypass and Valvular Surgery (PREHAB) is a Canadian multicenter trial that endeavors to provide safety information on the utility of prehab in this vulnerable patient population. The objective is to evaluate the feasibility of exercise intervention before elective cardiac surgeries and its efficacy in improving postoperative outcomes including length of hospitalization, health-related outcomes, and health-related quality of life outcomes.
A new multicenter study that will begin enrolling soon seeks to improve patient-centered outcomes and transitions of care in frail older adults undergoing transcatheter aortic valve replacement (TAVR). The PERFORM-TAVR trial (led by Dr. Jonathan Afilalo, McGill University) will use a combination of a home-based physical activity program that combines walking and strength-building exercises under the supervision of a trained physiotherapist, and nutritional supplementation that seeks to empower patients to adopt self-care behaviors before the procedure that will improve their recovery and diminish their likelihood of progressive deconditioning after a TAVR procedure.
"The fundamental premise behind prehab ERP is that improving patients' functional reserve before their procedure will improve postoperative outcomes that are important to older adults, including preserving mental and functional independence and enhancing postoperative recovery," noted Dr. Arora. "The prehab ERP depends on collaboration and engagement of the patient, their caregivers, and heart team to ensure their success."

More information: "'NEW' Prehabilitation: A 3-way Approach to Improve Postoperative Survival and Health-Related Quality of Life in Cardiac Surgery Patients," Journal of Cardiology(2018). DOI: 10.1016/j.cjca.2018.03.020


Provided by Elsevier

Aging LGBT seniors a major public health issue

Credit: American Heart Association

LGBT people of all ages have experienced health inequalities, but researchers have begun to delve into the consequences of a lifetime of that inequity – and what happens to their health as they grow older.
"They've been relatively invisible, undercounted and underserved," said Dr. Karen Fredriksen Goldsen. "We're talking about a major public health issue."

27 jun 2018--LGBT people face health disparities due to stigma, discrimination and violence, according to the Centers for Disease Control and Prevention study Healthy People 2020. But those problems spike as lesbian, gay, bisexual and transgender people age, said Fredriksen Goldsen, a researcher behind the ongoing Aging with Pride: National Health, Aging, and Sexuality/Gender Study. It's a federally funded project following 2,450 LGBT adults from age 50 to over 100.
"We've found a constellation of high-risk factors, including a history of victimization and not getting access to the services they need," said Fredriksen Goldsen, professor and director of Healthy Generations Hartford Center of Excellence at the University of Washington.
"Not everyone is experiencing poor health – in fact, most are doing very well," she said. "But we wanted to understand the poor health outcomes in this community."
According to the report, about 2.7 million U.S. adults 50 and older identify as LGBT, including 1.1 million age 65 and older. Those numbers are expected to nearly double by 2060.
About 13 percent of LGBT older adults report being denied health care or given poor care because of their sexual or gender identities. Among transgender participants, that number jumped to 40 percent.
"So many people have been denied care or received inferior care that they've become more hesitant now to obtain care," Fredriksen Golden said.
Older LGBT adults are more likely than heterosexuals to smoke, drink excessively and report depression, according to the study.
And disparities exist even among subgroups within the LGBT community, with some struggling with their health more than others:

• Both Hispanic and African-American LGBT older adults in the project are more likely to report having HIV than their white counterparts.
• Hispanic LGBT adults are more likely to report asthma, diabetes and visual impairment.
• African-American LGBT older adults are more likely to be obese and have high blood pressure.
• Native American LGBT older adults are less likely to report cancer than whites but more likely to report poor physical health, disability, obesity, asthma and cardiovascular disease.
• Asian/Pacific Islander LGBT older adults are more likely to have visual impairment, but less likely to be obese or have cancer.

Compounding the problem is a lack of access to high-quality health and senior services. According to a recent AARP survey, about 48 percent of big city residents and 10 percent of rural and small-town residents say they have access to LGBT senior services in their community.
"People in rural areas are more dependent on the luck of the draw," said Lisa Krinsky, director of the LGBT Aging Project at Fenway Health, a Boston-based health care, research and advocacy center.
Some LGBT residents in smaller New England towns regularly band together and make road trips to Boston for medical appointments.
"That's a creative, resilient solution, but I'm concerned about what happens when people age and can no longer do the car ride. What happens when they become less mobile and lose their social connections?" Krinsky said, citing a study that reported social isolation can be as damaging to your health as smoking 15 cigarettes a day. She said Fenway Health recently launched a pilot program to use video-conferencing to reduce social isolation among older LGBT adults.
Another ongoing health issue for older LGBT adults is HIV. Thanks to the success of antiretroviral drugs, people with the disease are living longer, and those 50 and older make up 45 percent of all Americans living with diagnosed HIV, according to the CDC.
"That's a data point that doesn't get much attention," Krinsky said. "We think of it still as a young person's disease."
Yet as HIV patients age, health disparities continue. A recent study reported that those with HIV have about a 50 percent to 100 percent higher risk of heart attack or stroke compared with people who are negative for HIV, partly because doctors were less likely to prescribe them cholesterol-lowering drugs or aspirin.
Statistics like that underscore the unique health roadblocks facing older LGBT adults – including Baby Boomers, a group that's been more open about their identity than older generations, Krinsky said.
"Boomers don't want to have to go back into the closet to receive health care," she said. "But if they perceive themselves as being in an unsafe place, they may have to go back."
Fredriksen Goldsen said the Aging with Pride study has been expanded to explore dementia and other issues. The ongoing study has a high retention rate – 96 percent of the original participants are still in the study five years later – which gives her hope for the future.
"People are very interested in learning how to improve health in the community," she said. "They really want to reduce disparities and create better health opportunities for the next generation."


Provided by American Heart Association

Effect of shock wave treatment for erectile dysfunction wanes

Low-intensity shock wave treatment is effective for short-term treatment of erectile dysfunction, but its efficacy declines after two years, particularly in those with initial severe dysfunction, according to a study published in the July issue of The Journal of Urology.

24 jun 2018--Noam D. Kitrey, M.D., from Sheba Medical Center in Ramat Gan, Israel, and colleagues studied the long-term efficacy of penile low intensity shock wave treatment two years after an initially successful outcome among 156 patients.
The researchers found that at one month, treatment was successful in 99 patients (63.5 percent), but during follow-up a gradual decrease in efficacy was observed. At two years, the beneficial effect was maintained in only 53.5 percent of patients in whom success was initially achieved. Over follow-up the treatment effect was lost in all patients with diabetes who initially had severe erectile dysfunction. However, for patients with milder forms of erectile dysfunction without diabetes there was a 76 percent chance that the beneficial effect of low-intensity shock wave treatment would be preserved after two years.
"Low-intensity shock wave treatment is effective in the short term but treatment efficacy was maintained after two years in only half of the patients," the authors write. "In patients with milder forms of erectile dysfunction the beneficial effect is more likely to be preserved."

More information: Abstract/Full Text

Ketamine acts fast to treat depression and its effects last—but how?

Credit: CC0 Public Domain

In contrast to most antidepressant medications, which can take several weeks to reduce depressive symptoms, ketamine—a commonly used veterinary anesthetic—can lift a person out of a deep depression within minutes of its administration, and its effects can last several weeks. Researchers have long-wondered how ketamine can both act quickly and be so long-lasting.

23 jun 2018--Now, researchers led by Mark Rasenick, distinguished professor of physiology and psychiatry in the University of Illinois at Chicago College of Medicine, describe the molecular mechanisms behind ketamine's ability to squash depression and keep it at bay. They report their findings in the journal Molecular Psychiatry.
Two-thirds of participants in clinical studies who did not respond to traditional antidepressants experienced fast and lasting resolution of their depressive symptoms after being given ketamine intravenously, Rasenick explained. The effects of ketamine typically lasted about a week—much longer than would be expected with ketamine's six-hour half-life in the body.
Rasenick and his colleagues used a cellular model system to investigate how ketamine acted.
In previous research, Rasenick and his colleagues showed that SSRIs—the most commonly prescribed class of antidepressants, which includes Prozac and Zoloft—work in the brain by moving molecules called G proteins off of "lipid rafts" on the cell membrane, where the G proteins are held inactive. G proteins produce cyclic AMP, which nerve cells need to signal properly. People with depression, Rasenick found, tend to have a greater proportion of their G proteins packed into these membrane patches, along with dampened brain cell signaling, which may contribute to symptoms of depression, including a feeling of overall numbness.
In the earlier research, when Rasenick exposed rat brain cells to SSRIs, the drug accumulated in the lipid rafts, and G proteins moved out of the rafts. The movement was gradual, over the span of several days, which Rasenick thinks is the reason why SSRIs and most other antidepressants can take a long time to begin working.
In his current research, Rasenick and his colleagues performed a similar experiment with ketamine and noticed that the G proteins left the rafts much faster. G proteins began migrating out of the lipid rafts within 15 minutes. And the long-lasting effects of ketamine may be due to the fact that the G proteins were very slow to move back into the lipid rafts, Rasenick explained.
The finding contradicts the long-held idea that ketamine works solely by blocking a cellular receptor called the NMDA receptor, which sits on the surface of nerve cells and helps transmit signals.
In fact, when the researchers knocked out the NMDA receptor, ketamine still had the same effect on the cells—quickly moving G proteins out of lipid rafts on the cell membrane.
"When G proteins move out of the lipid rafts, it allows for better communication among brain cells, which is known to help alleviate some of the symptoms of depression," Rasenick said. "Whether they are moved out by traditional antidepressants or ketamine, it doesn't matter, although with ketamine, the G proteins are very slow to move back into the lipid rafts, which would explain the drugs long-term effects on depressive symptoms."
"This further illustrates that the movement of G proteins out of lipid rafts is a true biomarker of the efficacy of antidepressants, regardless of how they work," Rasenick explained. "It confirms that our cell model is a useful tool for showing the effect of potential new antidepressant drug candidates on the movement of G proteins and the possible efficacy of these drugs in treating depression."

More information: Nathan H. Wray et al, NMDAR-independent, cAMP-dependent antidepressant actions of ketamine, Molecular Psychiatry (2018). DOI: 10.1038/s41380-018-0083-8


Provided by University of Illinois at Chicago

Many physicians not prepared for end-of-life talks with patients

While nearly all physicians say end-of-life conversations are important, many report lacking the training to have such conversations, according to a brief report published online May 23 in the Journal of the American Geriatrics Society.

22 jun 2018--Terry Fulmer, Ph.D., from the John A. Hartford Foundation in New York City, and colleagues conducted a 37-item telephone survey to measure attitudes and perceptions of barriers and facilitators to advance care planning among 736 physicians (primary care specialists; pulmonology, cardiology, oncology subspecialists) regularly seeing patients aged ≥65 years.
The researchers found that 99 percent of respondents agreed that it is important to have end-of-life conversations, yet only 29 percent reported that they have received formal training for such conversations. Younger physicians and those caring for a racially and ethnically diverse population were more likely to have had training. The strongest motivating factors in having advance care planning conversations were patient values and preferences. The vast majority of respondents (95 percent) reported supporting a new Medicare fee-for-service benefit reimbursing advance care planning. Time was the biggest barrier reported to advance care planning, as well as not wanting a patient to give up hope and feeling uncomfortable.
"Given the gap between what people want at the end of life and the care they receive, we need to build on available training tools and embed them systematically into practice," the authors write. "Addressing clinician barriers to advance care planning to meet the needs of their older patients and families requires the integration of existing, proven tools into a three-pronged strategy that includes education and training, formal systems, and reimbursement for these critical conversations."

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

New recommendations guide arthritis pain management

The European League Against Rheumatism has released recommendations—published in the June issue of the Annals of the Rheumatic Diseases—for health professionals to use in approaching pain management in inflammatory arthritis (IA) and osteoarthritis (OA).

22 jun 2018--Rinie Geenen, Ph.D., from Utrecht University in the Netherlands, and colleagues on a multidisciplinary task force including professionals and patient representatives conducted a systematic literature review to assess evidence regarding effects on pain of multiple treatment modalities. The authors included 186 reviews in their analysis.
The task force emphasized the importance for the health professional of adopting a patient-centered framework within a biopsychosocial perspective, having sufficient knowledge of IA and OA pathogenesis, and being able to differentiate localized and generalized pain. Pain treatment usually includes education, which can be complemented with physical activity and exercise; orthotics; psychological and social interventions; sleep hygiene education; weight management; pharmacological and joint-specific treatment options; or interdisciplinary pain management. Pain was consistently positively affected by physical activity and exercise interventions as well as psychological interventions.
"Underpinned by available systematic reviews and meta-analyses, these recommendations enable health professionals to provide knowledgeable pain-management support for people with IA and OA," the authors write.

More information: Abstract/Full Text

Pelvic floor problems and incontinence—autoprosthesis significantly improves quality-of-life

Due to their anatomical difference and also the particular stresses associated with pregnancy and childbirth, incontinence and pelvic floor problems are particularly prevalent in women. Apart from incontinence, women can also develop pelvic floor muscle weakness, overstretching of the pelvic connective tissue and displacement of the pelvic organs. Their quality-of-life can be significantly improved by surgical transplantation of endogenous tissue to strengthen the affected area of the pelvic floor.

22 jun  2018--"This is therefore a form of autoprosthesis," summarises Heinz Kölbl, Head of the Division of General Gynecology and Gynecologic Oncology at the Department of Obstetrics and Gynecology, MedUni Vienna/Vienna General Hospital. Kölbl is also head of the local organising committee for the 43rd Annual Meeting of IUGA (International Urogynecological Association), the largest conference in the world in this field, which will take place in the Austria Center Vienna on 27 – 30 June 2018.
In this surgical procedure – which is performed when conservative techniques or medications have failed to achieve the desired result – endogenous tissue is taken from an area adjacent to the affected area, tautened and allowed to scar over, thereby producing the desired strength. Says Kölbl: "On average that improves quality-of-life for affected patients by at least 30 percent." Research is also being conducted into the use of external stem cell tissue. Says Kölbl: "It is our vision that, in future, we will be able to insert external tissue that is even stronger and more functional, using minimally invasive techniques." Currently many patients still suffer a relapse, requiring a second or even third operation to strengthen their pelvic floor.
Researchers in Vienna are currently conducting studies using gene patterns to develop risk profiles for subsequent major pelvic floor damage. "So that we can potentially establish in advance that women from the high-risk group should not be allowed to give birth naturally, for example, in order to prevent subsequent incontinence or other pelvic floor damage," explains Kölbl, who is also a member of MedUni Vienna/Vienna General Hospital's Comprehensive Cancer Center. A similar risk profile already exists for women who are less than 160 cm tall: they should no longer be allowed to give birth naturally, if the embryo weighs more than 4,000 g. Says Kölbl: "That would give them a 100 percent risk of developing pelvic floor problems."
One in three women has bladder problems over the course of her life and one in 25 women experiences pelvic floor problems after childbirth. And around 3 percent of all women are affected by symptomatic forms of pelvic floor prolapse.


Provided by Medical University of Vienna

Financial decision-making capacity need not decline in healthy advanced aging

Credit: CC0 Public Domain

New research from The Center for BrainHealth at The University of Texas at Dallas shows that advancing age alone is not the defining factor in impaired financial decision-making.

22 jun 2018--The study, published in Frontiers in Psychology, assessed how—and whether—age influences cognitive processes that may be involved in financial decision-making. The researchers investigated how factors such as cognition, education and gender affected monetary choices. "All too often, as people age, we tend to develop a bias expecting diminished capacities, which in turn overlooks, short-changes or discounts their competence to remain actively engaged in personal financial matters," said study author Dr. Sandra Bond Chapman, founder and chief director of the Center for BrainHealth, and Dee Wyly Distinguished University Professor.
The study examined the influence of age on financial decision-making in terms of sure options versus gamble options in 200 cognitively healthy adults between 28 and 79 years old.
In the study, participants completed three hours of cognitive testing and several rounds of financial decision-making questions. They were tested on a large battery of cognitive measures in the domains of executive function, memory and complex attention.
At the beginning of each trial, participants received a virtual financial nest egg. They then were asked to choose between taking a guaranteed amount that was less than the initial endowment, or gambling the entire amount for a chance to win—or lose—the larger pot.
"We found that individuals who performed better on certain cognitive tests, regardless of age, were less likely to make risky financial decisions. This research is particularly important because the findings caution against attributing impaired decision-making to age alone," Dr. Chapman continued.
The study also found that older adults were more likely to demonstrate risky financial behavior only when faced with larger amounts of money.
Stronger performance on measures of both strategic learning and delayed memory may predict that a person is better at analytic processing, which is necessary to assess financial risk, Chapman added.
"Future studies are warranted to examine whether these cognitive abilities directly relate to measures of analytic processing and how older adults can be prompted to use analytic processing to avoid potentially fraudulent scams," said Alison Perez MS'13, Ph.D.'16, lead author of the study who conducted the research at the Center for BrainHealth before joining Lockheed Martin Advanced Technology Laboratories as a research scientist.
"When we see declines in decision-making, these problems may signal early changes related to abnormal health or cognitive decline as opposed to age alone. The key is that retained decision-making is possible at any age with a commitment to keeping mentally active and in the absence of neurologic disease or injury," Dr. Perez said.

More information: Alison M. Perez et al, Influential Cognitive Processes on Framing Biases in Aging, Frontiers in Psychology (2018). DOI: 10.3389/fpsyg.2018.00661


Provided by Center for BrainHealth

New study suggests viral connection to Alzheimer's disease

Viral/host networks, including genes and RNA transcripts interact in complex ways. A pair of Herpesviruses--HHV 6A and 7--were found in greater abundance in brain samples from AD patients compared with normal brains. These viruses seem to also be implicated in the AD-related genetic networks responsible for classic Alzheimer's pathology, including cell death, the deposition of amyloid plaque and production of neurofibrillary tangles. Credit: Shireen Dooling for the Biodesign Institute at ASU

Of the major illnesses facing humanity, Alzheimer's disease (AD) remains among the most pitiless and confounding. Over a century after its discovery, no effective prevention or treatment exists for this progressive deterioration of brain tissue, memory and identity. With more people living to older ages, there is a growing need to clarify Alzheimer's disease risk factors and disease mechanisms and use this information to find new ways in which to treat and prevent this terrible disorder.

22 jun 2018--A first-of-its kind study implicates another culprit in the path to Alzheimer's disease: the presence of viruses in the brain.
In research appearing in the advanced online edition of the journal Neuron, scientists at the Arizona State University-Banner Neurodegenerative Disease Research Center (NDRC) and their colleagues at the Icahn School of Medicine at Mount Sinai used large data sets from clinically and neuropathologically characterized brain donors and sophisticated "big data" analysis tools to make sense of both the genes that are inherited and those that are preferentially turned on or off in the brains of persons with Alzheimer's disease. They provide multiple lines of evidence to suggest that certain species of herpesviruses contribute to the development of this disorder.
The new work brings science a step closer to clarifying the mechanisms by which infectious agents may play important roles in the disease. To achieve this, the team capitalized on DNA and RNA sequencing data from 622 brain donors with the clinical and neuropathological features of Alzheimer's disease and 322 brain donors without the disease—data generated from the NIH-sponsored Accelerated Medicines Partnership for Alzheimer's Disease (AMP-AD).
The "whole exome" DNA sequencing was used to provide detailed information about each person's inherited genes. RNA sequencing from several brain regions was used to provide detailed information about the genes that are expressed differently in donors with and without the disease.
Clinical assessments performed before the research participants died provided detailed information about their trajectory of cognitive decline, and neuropathological assessments performed after they died provided relevant neuropathological information, including the severity of amyloid plaques and tangles, the cardinal features of Alzheimer's disease. Sophisticated computational tools were used to develop a kind of grand unified picture of the viral-AD nexus.

Big challenges, big data

Big data-driven analyses offer a particularly powerful approach for exploring diseases like Alzheimer's, which involve many interdependent variables acting in concert in profoundly complex systems. In the current study, researchers explore viral presence in 6 key brain regions known to be highly vulnerable to the ravages of AD. (It is now accepted that damaging effects to these areas often precede clinical diagnosis of the disease by several decades.)
The study identifies high levels of human herpesvirus (HHV) 6A and 7 in brain samples showing signs of AD neuropathology, compared with the lower levels found in normal brains. Further, through the careful comparison of large data sets of viral RNA and DNA with networks of human genes associated with AD and signposts of neuropathology, the study offers the first hints of the viral mechanisms that could trigger or exacerbate the disease.
The findings, originally hinted at from samples provided by Translational Genomics (TGen) in Phoenix, were confirmed in the Mount Sinai Brain Bank, and then replicated in samples from the Mayo Clinic Brain Bank, Rush Alzheimer's Disease Center, and the Banner-Sun Health Research Institute's Brain and Body Donation Program.

Uninvited guests

According to Ben Readhead, lead author of the new study, the researchers' general goal was to discover disease mechanisms, including those that could be targeted by repurposed or investigational drug therapies. "We didn't go looking for viruses, but viruses sort of screamed out at us," Readhead said.
Although the study found a number of common viruses in normal aging brains, viral abundance of two key viruses—HHV 6A and 7—was greater in brains stricken with Alzheimer's.
"We were able to use a range of network biology approaches to tease apart how these viruses may be interacting with human genes we know are relevant to Alzheimer's," Readhead said.

HHV 6A and 7 are common herpesviruses to which most are exposed as children. The two viruses were detected in higher abundance in brains with Alzheimer's disease and their activity appears related to certain hallmarks of the disease. Credit: Shireen Dooling for the Biodesign Institute at ASU

Readhead is an assistant research professor in the NDRC, housed at ASU's Biodesign Institute. Much of the research described in the new study was performed in the laboratory of Joel Dudley, associate professor of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, associate research professor in the NDRC, and senior author of the paper in Neuron.
The nature and significance of viruses and other pathogens in the brain are currently hot topics in neuroscience, though the exploration is still in its early stages. One of the primary questions is whether such pathogens play an active, causative role in the disease or enter the brain simply as opportunistic passengers, taking advantage of the neural deterioration characteristic of AD.
"Previous studies of viruses and Alzheimer's have always been very indirect and correlative. But we were able to perform a more sophisticated computational analysis using multiple levels of genomic information measured directly from affected brain tissue. This analysis allowed us to identify how the viruses are directly interacting with or coregulating known Alzheimer's genes," says Dudley. "I don't think we can answer whether herpesviruses are a primary cause of Alzheimer's disease. But what's clear is that they're perturbing and participating in networks that directly underlie Alzheimer's pathophysiology."

Network news

The new study uses a network biology approach to holistically incorporate molecular, clinical and neuropathological features of AD with viral activity in the brain. Using techniques in bioinformatics, the study integrates high-throughput data into probabilistic networks that are postulated to account for the associations between herpes viruses and the telltale effects of AD.
The networks described suggest that the hallmarks of AD may arise as collateral damage caused by the brain's response to viral insult. According to the so-called pathogen hypothesis of AD, the brain reacts to infection by engulfing viruses with the protein amyloid beta (Aβ), sequestering the invaders and preventing them from binding with cell surfaces and inserting their viral genetic payload into healthy cells.
As Readhead explains, "a number of viruses looked interesting. We saw a key virus, HHV 6A, regulating the expression of quite a few AD risk genes and genes known to regulate the processing of amyloid, a key ingredient in AD neuropathology." (Amyloid concentrations form characteristic plaques in the brain. These plaques, along with neurofibrillary tangles formed by another protein, known as tau, are the microscopic brain abnormalities used to diagnosis Alzheimer's.)
Both HHV 6A, and 7 are common herpesviruses belonging to the genus Roseolovirus. Most people are exposed to them early in life. The likely route of entry for such viruses is through the nasopharyngeal lining. The higher abundance of these viruses in AD-affected brains may initiate an immune cascade leading to deterioration and cell death or act in other ways to promote AD.

Mounting evidence

The results from human brain tissue were further supplemented by mouse studies. Here, researchers examined the effect of depleting miR155, a small snippet of RNA (or micro RNA) that is an important regulator of the innate and adaptive immune systems. Results showed increased deposition of amyloid plaques in miR155-depleted mice, coupled with behavioral changes. As the authors note, HHV 6A is known to deplete miR155, lending further weight to a viral contribution to AD.
The new research is the fruitful result of close working relationships among researchers from Arizona State University, Banner, Mount Sinai, and other research organizations, as well as public-private partnerships in AMP-AD.
"This study illustrates the promise of leveraging human brain samples, emerging big data analysis methods, converging findings from experimental models, and intensely collaborative approaches in the scientific understanding of Alzheimer's disease and the discovery of new treatments," said study co-author Eric Reiman, Executive Director of the Banner Alzheimer's Institute and University Professor of Neuroscience at Arizona State University. "We are excited about the chance to capitalize on this approach to help in the scientific understanding, treatment and prevention of Alzheimer's and other neurodegenerative diseases."

Enemy with a thousand faces

In the meantime, Alzheimer's continues its devastating trajectory. Among the many challenges facing researchers is the fact that the earliest effects of the disease on vulnerable brain regions occur 20 or 30 years before memory loss, confusion, mood changes and other clinical symptoms appear. Without a cure or effective treatment, AD is expected to strike a new victim in the United States every 33 seconds by mid-century and costs are projected to exceed $1 trillion annually.
The research study does not suggest that Alzheimer's disease is contagious. But if viruses or other infections are confirmed to have roles in the pathogenesis of Alzheimer's, it could set the stage for researchers to find novel anti-viral or immune therapies to combat the disease, even before the onset of symptoms.

More information: Readhead et al. Multiscale Analysis of Independent Alzheimer's Cohorts Finds Disruption of Molecular, Genetic, and Clinical Networks by Human Herpesvirus. Neuron. 2018 Jun. 21. DOI: 10.1016/j.neuron.2018.05.023


Provided by Arizona State University

Deep brain stimulation showing promise for patients with mild Alzheimer's disease over 65

Dr. Andres Lozano of Krembil Neuroscience Centre at Toronto Western says 'we are encouraged by these findings.' Credit: The Globe and Mail

An age group analysis of data from the ADvance trial has shown that participants over the age of 65 continue to derive the most benefit from Deep Brain Stimulation of the fornix (DBS-f), as observed in the data from the phase 2 findings (12—24 months) of the Phase II trial.

22 jun 2018--The findings, published today in the Journal of Alzheimer's Disease, by a team of researchers led by Dr. Andres Lozano at Toronto Western Hospital's (TW) Krembil Neuroscience Centre (KNC), are the potential beginnings of a patient profile for DBS-f treatment for Alzheimer's disease. The neurology and psychology aspects of the trial in Toronto were led by TW neurologist Dr. Peter Tang-wai and neuropsychologist Dr. Mary-Pat McAndrews respectively.
To further explore the benefits for this demographic, the research team is soon launching a Phase III, multi-centre international trial that will study the effects of DBS-f in 140 patients over age 65.
"We are encouraged by these findings as they continue to help us identify who will benefit most from DBS to treat Alzheimer's disease and learn more about this illness," says Dr. Andres Lozano, neurosurgeon and the principal investigator of the study. "With so few treatments available and the incidence of Alzheimer's only expected to increase, we really need to fully explore all treatments that seem to be of benefit to patients."
These latest results were captured from the second year of data of the ADvance trial whose first-year data was published in 2016. In that trial, forty-two patients with mild Alzheimer's disease were enrolled in a randomized, double-blind multicentre phase II clinical trial and implanted with DBS electrodes directed at the fornix—a bundle of nerve fibres in the brain that carry signals from the hippocampus—and followed for a total of two years.
In the first 12 months of the trial, to better measure the impact of electrical stimulation in the brain, patients were randomly assigned to either the "on" or "off" stimulation group after their procedure and monitored. Once this phase of follow up was complete, all patients then had their electrodes turned on, and were followed for another 12 months.
In the second 12-month phase, researchers noted similar observations they had seen in the first phase: that, although there were no differences overall in cognitive outcomes between study participants who had their device turned on right after surgery and those who had it turned on after 12 months, those 65 years of age and older appeared to experience a slower progression of Alzheimer's than those under that age, regardless of when their device was turned on.
"The next phase of our research will help determine whether this observed benefit is something we continue to see in this age group," says Lozano who is also University Professor and Chairman, Department of Neurosurgery, University of Toronto. "If it does, this could potentially give us a treatment for mild, late-onset Alzheimer's disease."


Provided by University Health Network

How old is too old for surgery, and why?

Many changes in the body occur in response to the injury and trauma inflicted during surgery. Credit: www.shutterstock.com

Many of us will have been in situations with older loved ones where a doctor says surgery is too risky given the patient's advanced age. Why is it surgery becomes risky in the elderly, and is it based on chronological age or their health?
During surgery and anaesthesia, there are many changes in the body that occur in response to injury and trauma. This is known as the stress response to surgery.

The surgical stress response results in an increased secretion of hormones that promote the break down of carbohydrates, fats and proteins in the body to provide extra energy during and after surgery. The hormonal changes associated with the surgical stress response also activate the sympathetic nervous system.
The sympathetic nervous system is responsible for the "fight or flight" response and causes a rise in heart rate and blood pressure. The changes in the heart rate and blood pressure during surgery and anaesthesia create a state where the heart requires more oxygen, while the surgical stress response and anaesthesia often impedes the oxygen supply to the vital organs such as the heart and the brain. This is a result of less blood flow to the body organs during and after the operation.
Anaesthesia confers risks separate from the risks of surgery. These are mostly minor and easy to treat. But serious problems with the heart, lungs and other major organs are more likely during emergency surgery or in the presence of other health conditions. These factors may increase with chronological age, but frailty is the bigger factor for doctors in deciding whether a patient should undergo surgery and anaesthesia.

Frailty

Frailty is a state where a person is vulnerable due to decline in body function. This in turn reduces their ability to cope with acute and every day stressors.
In a frail person, there is an accumulation of defects in different organ systems of the body, causing them to function close to the threshold of failure. The organ systems near the threshold of failure are then unable to "bounce back" from an external or internal stressor.
An apparently small insult such as a simple fall can result in a significant and disproportionate reduction in reserve and function. The need to have surgery, and the condition that has caused a need for surgery, would often be considered a large insult in a frail person.
Although frailty is more common in older people, it's not exclusive to older people. Most frail people have chronic health problems, and their frailty increases with the number of chronic health conditions. But most people with chronic health conditions are not frail.
There are certain health conditions that are more common in people who are frail, such as heart failure, chronic airways disease and chronic kidney disease.

How do we identify frailty and how does it affect health?

There are many different tools we can use to detect frailty. The Clinical Frailty Scale is one tool based on clinical features present in the patient and the Frailty Index is another tool based on the accumulation of deficits in the patient.
The Clinical Frailty Scale is a single descriptor of a person's level of frailty using clinical judgement graded from one to nine. Level one is a very fit person; level four is "vulnerable" – where the person is not dependent on others for help with daily activities but does have symptoms that limit activities; and level nine is a terminally ill person.
It has been observed that people with a higher Clinical Frailty Scale were more likely to be older, female, have a degree of cognitive impairment and incontinence. The higher proportion of females will most likely reflect the longer life expectancy of women.
Frail people have a higher risk of recurrent falls and fractures and subsequent disability and reduced function. There have been many studies performed to examine how well frailty predicts outcomes after surgery.
In people who have surgery, frailty has been shown to be associated with a higher risk of surgical complications, a greater chance of requiring discharge to a residential care facility and a lower rate of survival. And the more frail the patient, the higher the risk the patient will require readmission after surgery, and the higher the risk of death.
As our population gets older and more frail people have surgery, this will become an important issue, and health care professionals in all areas will need to be more aware of it.

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

Provided by The Conversation

Bad habits that lead to cancer, chronic disease corrected by simple lifestyle intervention

User interfaces in the Make Better Choices 2 app. (a) receiving behavioral feedback in simultaneous and sequential treatments; (b) reporting sedentary leisure screen time in simultaneous and sequential treatments; (c) receiving feedback in contact control treatment. Credit: Northwestern University

Does this sound like someone you know? He or she spends too much time in front of screens, gets little exercise and eats a diet high in fat and low in fruits and vegetables.
It likely sounds familiar because it describes a significant portion of the U.S. population.
A new Northwestern Medicine study found that a lifestyle intervention could fully normalize these four unhealthy behaviors, which put people at risk of developing heart disease and common cancers, including breast, colon and prostate.

19 jun 2018--The study will be published in the Journal of Medical Internet Research Tuesday, June 19.
"Our findings suggest that prevention of chronic disease through behavior change is feasible. They contradict the pessimistic assumption that it's not possible to motivate relatively healthy people to make large, long-lasting healthy lifestyle changes," said lead author Bonnie Spring, director of the Center for Behavior and Health in the Institute for Public Health and Medicine and professor of preventive medicine at Northwestern University Feinberg School of Medicine.
With the help of a smartphone app, a wearable activity tracker, some social support from a coach and a small financial incentive, study participants made large improvements in their eating and activity habits. From a starting point of less than two servings of fruits and vegetables per day, they increased their intake by 6.5 servings per day. They decreased saturated fat intake by 3.6 percent to consume less than 8 percent of their calories from saturated fat. From a baseline of 4.5 hours per day of leisure screen time, they decreased screen time by almost three hours and increased their moderate to vigorous exercise by 25 minutes per day over a nine-month trial.
Even better, participants were able to achieve the same gains whether they implemented all four diet and exercise changes simultaneously or sequentially (changing two or three first and then changing other behaviors later).

A person uses the Make Better Choices 2 smartphone app to track the nutrition in what she wants to eat. Credit: Northwestern University

"When most people start a diet and exercise plan, they're excited to hit the ground running, but they can feel quickly defeated when they can't keep up with everything," Spring said. "The tech tools, support and incentives our intervention offered made the changes simple and motivating enough that our participants were able to start making them all at once without becoming overwhelmed."
Previous research has found that healthy behavior change usually reverts once financial incentives cease. But this study stopped offering the financial incentive after only 12 weeks, and participants still achieved positive results throughout the nine-month trial.
Additionally, the changes observed in this study and in a prior trial by the same group were larger and more sustained than what has been previously observed in studies of technology-supported interventions. Spring said she attributes this to two features of the intervention: modest early financial incentives that motivate participants to make changes larger than what they thought they could achieve; and giving digital feedback not only to participants but also to coaches.

How they conducted the study

Between 2012 and 2014, the study, Make Better Choices 2, enrolled 212 Chicago-area adults, primarily female (76 percent), minority (59 percent), college educated (69 percent) and with a mean age of 41 years old. All participants had low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity and high sedentary leisure screen time.
Participants used smartphones and accelerometers to track their activity and behavior, which they also sent to a coach who monitored whether they were tracking and how they were eating and being active. Perfect behavioral adherence was rewarded with an incentive of $5 per week for 12 weeks.
Based on the incoming data, the coach counseled people by telephone in 10- to 15-minute personalized sessions, weekly for three months, then biweekly for the next three months. Then, until nine months, they retained the intervention app but received no further coaching.
"We suggest that giving accelerometer feedback to both the participant and their coach is the way to improve diet and activity habits, because the coach can support, hold the person accountable and personalize coaching when they know what's going on," Spring said.

More information: Bonnie Spring et al, Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial, Journal of Medical Internet Research (2018). DOI: 10.2196/10528


Provided by Northwestern University

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

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 Science. doi.org/10.1177/1948550618779820


Provided by The Ohio State University

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.

Provided by The Conversation

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.

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.

Provided by The Conversation

Model estimates lifetime risk of Alzheimer's dementia using biomarkers

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