Dementia in extreme elderly population expected to become epidemic according to the 90+ study

Oldest men and women experience 18 percent annual dementia incidence that increases with age

27 feb 2010--University of California researchers found that the incidence rate for all causes of dementia in people age 90 and older is 18.2% annually and significantly increases with age in both men and women. This research, called "The 90+ Study," is one of only a few to examine dementia in this age group, and the first to have sufficient participation of centenarians. Findings of the study appear in the February issue of Annals of Neurology, a journal published by Wiley-Blackwell on behalf of the American Neurological Association.

Dementia (senility) is a progressive, degenerative disorder that affects memory, language, attention, emotions, and problem solving capabilities. A variety of diseases cause dementia including Alzheimer's disease, stroke, and other neurodegenerative disorders. According to a 2000 report from the World Health Organization (WHO), approximately 6%-10% of the population 65 years and older in North America have dementia, with Alzheimer's disease accounting for two-thirds of those cases.

For their population-based, longitudinal study of aging and dementia, Maria Corrada, Sc.D., and colleagues invited members who were originally part of The Leisure World Cohort Study and 90 years of age or older as of January 1, 2003. As of December 31, 2007 there were 950 participants in The 90+ Study and 539 who had completed a full evaluation that included neurological testing, functional ability assessments and a questionnaire covering demographics, past medical history, and medication use. Evaluations were repeated every 6-12 months with a final dementia questionnaire completed shortly after death.

Analysis was completed on 330 participants who were primarily women (69.7%) between the ages of 90 to 102, and who showed no signs of dementia at baseline. Researchers identified 140 new cases of dementia during follow-up with 60% of those cases attributed to Alzheimer's disease (AD), 22% vascular dementia, 9% mixed AD and vascular dementia and 9% with other or unknown cause.

Dr. Corrada explained, "Our findings show dementia incidence rates almost double every five years in those 90 and older." Researchers found the overall incidence rate based on 770 person-years of follow-up was 18.2% per year. Rates increased with age from 12.7% per year in the 90-94 age group, to 21.2% per year in the 95-99 age group, to 40.7% per year in the 100+ age group. Incidence rates were very similar for men and women. Previous results from The 90+ Study found higher estimates of dementia prevalence in women (45%) compared to men (28%), a result also seen in other similar studies.

Prior reports estimate there were 2 million Americans aged 90 and older in 2007 and the number is expected to reach 8.7 million by 2050, making the oldest-old the fastest growing segment of the U.S. population. "In contrast to other studies, we found that the incidence of dementia increases exponentially with age in both men and women past age 90," said Dr. Corrada. "Given the population projections for this age group along with our findings, dementia in the oldest-old threatens to become an epidemic with enormous public health impact."

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Article: "Dementia Incidence Continues to Increase with Age in the Oldest-Old: The 90+ Study." María M. Corrada, Ron Brookmeyer, Annlia Paganini-Hill, Daniel Berlau, Claudia H. Kawas. Annals of Neurology; Published Online: February 23, 2009 (DOI: 10.1002/ana.21915); Print Issue Date: February 2010.

This study is published in Annals of Neurology. Media wishing to receive a PDF of this article may contact medicalnews@wiley.com.

To view the abstract for this article, please click here.

Poor Evidence For Effectiveness Of Influenza Vaccines In Elderly

Evidence for the safety and efficacy of influenza vaccines in the over 65s is poor, despite the fact that vaccination has been recommended for the prevention of influenza in older people for the past 40 years. These are the conclusions of a new Cochrane Systematic Review.

25 feb 2010--Adults aged 65 and over are some of the most vulnerable during influenza season and a priority for vaccination programmes. However, very few systematic reviews of the effectiveness of vaccines in this group have ever been carried out.

The researchers conducted a thorough search of studies based on previous vaccine trials. Randomised controlled trials (RCTs) are often considered the "gold standard", but of the 75 studies included in their review, the researchers were only able to identify one recent RCT with "real" outcomes. In other words, this was the only RCT that used influenza cases as an outcome, as opposed to surrogate outcomes such as measurements of influenza antibodies in the blood. All the other studies included in the review were deemed of low quality and open to bias.

Limited reliable evidence from the studies suggests that the effectiveness of influenza vaccines is modest at best. "Our estimates are consistently below those usually quoted by economists and in decision making," says lead researcher Tom Jefferson of the Cochrane Collaboration in Rome, Italy. "But until we have all available evidence, it is hard to reach any clear conclusions about the effectiveness of influenza vaccines in older people."

"As the evidence is so scarce at the moment, we should be looking at other strategies to complement vaccinations. Some of these are very simple things like personal hygiene, and adequate food and water," says Jefferson. "Meanwhile, we need to undertake a high quality, publicly funded trial that runs over several seasons to try to resolve some of the uncertainties we're currently facing."

Jefferson is also one of the authors of a second review publishing this week, which focuses on the efficacy of influenza vaccinations in healthcare workers who work with the elderly. The results are also inconclusive, with each of the four trials included in the review being of inadequate quality and reaching implausible conclusions. The researchers were unable to draw any conclusions about whether vaccinating healthcare workers helps to prevent influenza symptoms and death in people aged over 60.

Source:
Jennifer Beal
Wiley-Blackwell

WHI data confirm short-term heart disease risks of combination menopausal hormone therapy

New analyses from the Women's Health Initiative (WHI) confirm that combination hormone therapy increases the risk of heart disease in healthy postmenopausal women. Researchers report a trend toward an increased risk of heart disease during the first two years of hormone therapy among women who began therapy within 10 years of menopause, and a more marked elevation of risk among women who began hormone therapy more than 10 years after menopause. Analyses indicate that overall a woman's risk of heart disease more than doubles within the first two years of taking combination HT.

23 feb 2010--The difference in the initial level of risk does not appear related to age, based on findings that the increased risk of heart disease was similar between women in their 50s on combination hormone therapy and women in their 60s.

The study is in the Feb. 16, 2010, Annals of Internal Medicine. The WHI is sponsored by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH).

"Today, most women who take hormone therapy for menopausal symptoms begin therapy shortly after menopause. Based on today's report, even these women appear to be at increased risk of heart disease for several years after starting combination hormone therapy," noted Susan B. Shurin, M.D., NHLBI acting director. "It is clearer than ever that women who are considering postmenopausal hormone therapy for menopausal symptoms should discuss their risk of heart disease and other risks – such as breast cancer, stroke, and dangerous blood clots – with their doctors before starting therapy."

Jacques E. Rossouw, M.D., chief of the NHLBI Women's Health Initiative Branch and a coauthor of the paper, added, "Although the number of recently menopausal women who would be expected to suffer a heart attack during the first years of combination hormone therapy is small, the risk is likely to be real. Our findings continue to support FDA recommendations that postmenopausal hormone therapy should not be used for the prevention of heart disease."

Combination hormone therapy includes progestin in combination with estrogen. Adding progestin is known to prevent endometrial cancer in women with a uterus. Today's findings do not apply to women who have had a hysterectomy and take estrogen-only hormone therapy. Similar analyses on the results of the clinical trial of estrogen only therapy are planned.

Researchers from the Harvard School of Public Health and the NHLBI reanalyzed data from the landmark WHI clinical trial of the effects of combination hormone therapy in 16,608 postmenopausal women with an intact uterus, ages 50 to 79 years (average age of 63) at enrollment.

In the new analyses, the researchers compared the effects of hormone therapy on heart disease risk among women who began hormone therapy within 10 years of menopause and women who began therapy more than 10 years after menopause. The researchers used models that adjusted for adherence, or the actual amount of medication that participants took during the study. They also studied the effects of hormone therapy on heart disease over time (up to eight years). In addition, they compared the findings with similar analyses of 34,575 women in the Nurses Health Study, an observational study with an average follow-up of 9.3 years. The researchers report similar effects of hormone therapy from both studies.

In the WHI clinical trial of estrogen-plus-progestin, 8,506 participants were randomly assigned to receive a combination of estrogen (0.625 milligrams of conjugated equine estrogens per day) plus progestin (2.5 mg of medroxyprogesterone acetate), and 8,102 women were given placebo (inactive pill). The study was stopped in 2002 after an average of 5.6 years of treatment due to an increase in breast cancer in the women on hormone therapy. Compared to women on placebo, women on combination hormone therapy were also at increased risk of stroke, dangerous blood clots, and heart disease, while their risk of colorectal cancer and hip fractures was lower.

Overall, among the 8,506 women assigned to combination hormone therapy during the study, there were 188 cases of coronary heart disease (80 in the first two years), compared to 147 heart disease cases (51 in the first two years) among the 8,102 women on placebo. When adjusted for adherence, the analysis shows that women on combination hormone therapy were about 2.4 times more likely to develop heart disease in the first two years. At eight years, the women on combination hormone therapy were 69 percent more likely to develop heart disease.

The new analyses also showed:

• Women who were within 10 years of menopause had a trend toward an increased risk of heart disease, with a 29 percent higher risk at two years from the start of hormone therapy. Although the increased risk of heart disease was not statistically significant, this finding is consistent with a similar analysis of data from the larger Nurses Health Study.
• Women who started combination hormone therapy less than 10 years after menopause remained at increased risk of heart disease on average for about six years, after which those in the treatment group appeared to have a lower risk of heart disease compared to similar women who were not on combination hormone therapy. In the nurses study, the initially increased risk on combination hormone therapy changed toward lower risk of heart disease after about three years.
• In contrast, women who started hormone therapy 10 years or more after menopause were nearly 3 times more likely to develop heart disease within the first two years of treatment compared to women on placebo. These women continued to be at increased risk of heart disease throughout the 8 years of follow-up.

It is not clear why the heart disease risk appears to be higher in women who start combination hormone therapy a decade after menopause than in women who begin combination hormone therapy within 10 years after menopause. According to Sengwee Toh, Sc.D., lead author of the paper and now an instructor in the Department of Population Medicine, Harvard Medical School, "This study suggests that the risk of heart disease may depend on when women start their combination hormone therapy and how long they are on this treatment. Future investigations should consider both of these aspects."

The WHI is a major 15-year research program designed to address the most frequent causes of death, disability, and poor quality of life in postmenopausal women: cardiovascular disease, cancer, and osteoporosis. The principal findings from the two WHI hormone therapy trials, which studied 27,347 postmenopausal women on estrogen plus progestin, estrogen-alone, or placebo, found that the overall risks of long-term use of hormone therapy outweigh the benefits. Both of these trials were stopped early because of increased health risks and failure to prevent heart disease, a key question of the studies.

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The NHLBI collaborates on the WHI with the National Cancer Institute, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute on Aging, and the Office of Research on Women's Health, all parts of the NIH. Wyeth-Ayerst Research provided the medication and placebo for the hormone study.

To interview Dr. Rossouw, call the NHLBI Communications Office at (301) 496-4236 begin_of_the_skype_highlighting (301) 496-4236 end_of_the_skype_highlighting or email NHLBI_News@nhlbi.nih.gov. To speak with Dr. Toh, please contact David Cameron, Office of Communications and External Relations at Harvard Medical School, at (617) 432-0441 begin_of_the_skype_highlighting (617) 432-0441 end_of_the_skype_highlighting.

For more information:

• NHLBI news release, March 4, 2008: WHI Follow-Up Study Confirms Risk of Long-Term Combination Hormone Therapy Outweigh Benefits for Postmenopausal Women, http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=2554
• NHLBI Media Availability, April 7, 2007: Effect of Hormone Therapy on Risk of Heart Disease May Vary by Age and Years Since Menopause -- Additional Analyses from the Women's Health Initiative, http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=255
• Women's Health Initiative (http://www.nhlbi.nih.gov/whi)
• WHI Estrogen-Plus-Progestin Study (http://www.nhlbi.nih.gov/whi/estro_pro.htm)
• Menopausal Hormone Therapy Information (NIH) (www.nih.gov/PHTindex.htm)
• The Healthy Heart Handbook for Women (http://www.nhlbi.nih.gov/health/public/heart/other/hhw/index.htm)

Remove Diabetes Drug Avandia From Market: FDA Documents

22 feb 2010-- The blockbuster type 2 diabetes drug Avandia raises users' odds for heart attack and heart failure and should be removed from the market, according to confidential U.S. government reports.

The New York Times on Saturday reported on documents from the U.S. Food and Drug Administration that find that if people now taking Avandia (rosiglitazone) switched to a similar medication, Actos, about 500 heart attacks and 300 cases of heart failure would be eliminated each month. And in a report from the Institute for Safe Medication Practice, Avandia was linked to 304 deaths in the third quarter of 2009 alone, the highest for any prescribed drug in that time period, the Times reported.

In one of the FDA documents, dated October 2008, Drs. David Graham and Kate Gelperin -- drug safety officials at the agency -- agreed that "rosiglitazone should be removed from the market."

The reports, obtained early by the Times, are yet another chapter in Avandia's checkered history. The drug was once taken by millions worldwide, but that changed after a study released in early May of 2007 by the Cleveland Clinic suggested that Avandia carried cardiovascular risks. That study, which included more than 28,000 people, found that Avandia increased a user's odds of heart attack by 43 percent compared to those not taking the medicine.

At the time, Dr. Bruce M. Psaty of the University of Washington -- who also co-wrote an accompanying editorial in the New England Journal of Medicine -- urged the FDA to restrict access to Avandia and cited both the agency and the drug's maker, GlaxoSmithKline, for poor oversight.

"The primary problem here is that studies that were needed early on about the health benefits of this drug were never done," Psaty told HealthDay. "As a result of the failure of the sponsor to do long-term clinical trials to show health benefits, as a result of the failure of the FDA to insist on it, we have data that are weak."

Following on the Cleveland Clinic study, the FDA demanded "black box" warnings on labeling for both Avandia and Actos, warning of a potentially heightened risk for heart failure. However, other studies found no raised level of heart risk, and at the time the agency said it had not reached a definitive conclusion on the data.

In November of the same year, the FDA updated Avandia's labeling to include a caution regarding heart attack risk. At the time, Dr. Janet Woodcock, acting director of the FDA's Center for Drug Evaluation and Research, said that, "we are keeping Avandia on the market because we have concluded there isn't enough evidence to indicate that the risk of heart attack is higher for Avandia than other type 2 diabetes treatments."

The story got more complicated in 2008, as a number of studies emerged tying the use of Avandia to increased bone fracture risk.

Throughout 2009, more studies reiterating the drug's heart risks also came to light, including one published in the BMJ suggesting that Avandia's risk for heart failure seemed to outstrip those of its related rival, Actos.

By that point, "most clinicians [had] stopped using Avandia -- some will use Actos instead or go to another class completely," Dr. Carl J. Lavie, medical director of cardiac rehabilitation at the Ochsner Heart and Vascular Institute in New Orleans, told HealthDay at the time.

The emergence of the leaked documents on Saturday comes at a time when officials within the FDA seem to be at loggerheads over whether to ban Avandia or not, the Times reported. The newspaper said that some officials believe that safer alternatives exist, while others say the evidence on Avandia's safety is conflicted and the drug should remain available as a treatment option.

Trying to sort things out, in December of 2009 Woodcock asked officials at the FDA to convene another advisory committee to determine whether Avandia should remain on the market, with a decision expected this summer.

In the meantime, a bipartisan Senate investigation -- overseen by Sen. Max Baucus (D-Mont.) and Sen. Charles E. Grassley(R-Iowa) -- has pored over 250,00 internal documents from GlaxoSmithKline. The investigation has placed much of the blame for the Avandia debacle on the company, contending that it neglected to warn patients for years of the drug's dangers.

"G.S.K. executives attempted to intimidate independent physicians, focused on strategies to minimize or misrepresent findings that Avandia may increase cardiovascular risk, and sought ways to downplay findings that a competing drug might reduce cardiovascular risk," according to the Senate investigation report, which is slated for release Monday but was obtained early by the Times.

Speaking to the newspaper Friday night, agency commissioner Dr. Margaret Hamburg said that, "I await the recommendations of the advisory committee. Meanwhile, I am reviewing the inquiry made by Senators Baucus and Grassley and I am reaching out to ensure that I have a complete understanding and awareness of all of the data and issues involved."

In a statement released Saturday, GlaxoSmithKline said it "rejects the conclusions about the safety of Avandia (rosiglitazone)" as reported in that day's Times story.

"Contrary to the assertions in the story, and consistent with the FDA-approved labeling, the scientific evidence simply does not establish that Avandia increases ischemic cardiovascular risk or causes myocardial ischemic events," the company said. "In 2007, the FDA considered all the available scientific evidence on Avandia, including Dr. Graham's assertions of elevated heart attack risk and demands that the product be withdrawn. Based on the scientific evidence and a recommendation by an independent advisory committee of experts convened by the FDA, the agency has ruled that Avandia remain available to patients for the treatment of Type 2 diabetes."

In the wake of the controversy, GlaxoSmithKline had been directed by the FDA to conduct a trial comparing rates of heart attacks, strokes and heart-linked deaths among users of Avandia, Actos or a placebo. But according to internal documents accessed by the Times, Graham and Gelperin characterized the study, called TIDE, as "unethical and exploitive," with patients being given Avandia despite the fact that it appears to come with greater risks and no added benefit over Actos.

One of the Graham/Gelperin reports -- dated October 2008 -- concludes that, "Although the proposed TIDE trial is motivated by a desire for definitive answers regarding the cardiovascular safety of the drug rosiglitazone, the safety of the study itself cannot be assured and is not acceptable."

However, other FDA officials overruled those concerns and TIDE is still enrolling patients, with preliminary results expected by 2014. Responding to the criticism, GlaxoSmithKline noted Saturday that, "TIDE has been approved by an independent review board and appropriate safety boards that are responsible for assessing the safety of conducting the trial."

The ongoing controversy has dampened patients' and physicians' enthusiasm for Avandia. According to the Times, while sales of the drug topped $3.2 billion in 2006, those numbers plummeted soon after the first studies suggesting risk emerged a year later.

Still, "hundreds of thousands" of people still take Avandia, the Times noted. GlaxoSmithKline's patent on the drug expires in 2012.

Paxil Blocks Tamoxifen, Lowers Survival Odds Against Breast Cancer

21 feb 2010-- Women with breast cancer who take both tamoxifen and the antidepressant Paxil may increase their risk of dying because Paxil reduces tamoxifen's effectiveness, Canadian researchers report.


"Paxil can deprive women of the benefit of tamoxifen, especially when it is used in combination with tamoxifen for a long time," said lead researcher Dr. David Juurlink, division head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Center in Toronto.


"Patients who are on tamoxifen and who require an antidepressant should probably be given something different," he added.


Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that significantly inhibits an enzyme called cytochrome P450 2D6, which is needed to metabolize tamoxifen into its active form. But this dampening effect was not seen with certain other SSRIs evaluated, including citalopram (Celexa) and venlafaxine (Effexor), the researchers said.


Patients taking Paxil and tamoxifen should talk with their doctors about changing their antidepressant, Juurlink said.


But he advised against abruptly discontinuing Paxil.


"There is a very real danger to stopping Paxil suddenly. There is a well-described withdrawal syndrome and the risk of depression becoming more severe," he said.


In addition, any transition to another antidepressant should be done gradually over several weeks, he said.


The report is published in the Feb. 8 online edition of the British Medical Journal.


For the study, Juurlink's group looked at the medical records of 2,430 women with breast cancer who began taking tamoxifen between 1993 and 2005. About 30 percent of the women were also taking an antidepressant, Paxil being the most common. Antidepressants are often prescribed to reduce hot flashes associated with tamoxifen in addition to easing symptoms of depression.


Paxil plus tamoxifen was linked to an increased risk of dying from breast cancer, and the risk increased with the amount of time the drugs were taken together, the researchers found.


Taking Paxil for 41 percent of the time that tamoxifen was also taken resulted in one extra death from breast cancer within five years of stopping tamoxifen among every 20 women taking the drugs simultaneously, Juurlink's team estimated. The more time the drugs were taken together, the greater the risk, they added.


SSRIs inhibit CYP 2D6 to varying degrees, the authors said, noting Paxil is "exceptionally potent" in that respect.


Dr. Frank Andersohn, a senior research associate at the Institute for Social Medicine, Epidemiology, and Health Economics at Charite University Medical Center in Berlin, Germany, and author of an accompanying journal editorial, said that "physicians should be aware that paroxetine and other strong 2D6-inhibiting drugs should be avoided in women treated with tamoxifen."


Fluoxetine (Prozac) is also a strong 2D6 inhibitor, the authors noted.


Another expert, Dr. Harold J. Burstein, said this paper adds to the substantial literature suggesting that drugs that affect the metabolism of tamoxifen might affect breast cancer outcomes for women taking tamoxifen.


"While the results should not alarm patients currently taking SSRIs, they do suggest that, as a practice style, patients on tamoxifen who also need SSRIs should probably seek out agents such as Effexor in preference to Prozac or Paxil," said Burstein, clinical investigator in the breast oncology center at Dana-Farber Cancer Institute, Brigham and Women's Hospital in Boston.


"The findings are also a reminder that each drug that a patient takes should be thought through carefully. If there are drugs that aren't needed, then they aren't needed and can be omitted," he added.

AAN: Chocolate Consumption Linked to Lower Stroke Risk

Higher flavonoid intake from chocolate may lower risk of stroke and stroke-related mortality

12 feb 2010-- Some evidence suggests that higher flavonoid intake from chocolate may be associated with a lower risk of stroke and stroke-related mortality, according to research released Feb. 11 in advance of the annual meeting of the American Academy of Neurology, to be held from April 10 to 17 in Toronto.

Sarah Sahib, of McMaster University in Hamilton, Canada, and colleagues reviewed three relevant prospective cohort studies published between 2001 and 2009.

The researchers found that the studies produced mixed results, with one study showing no association between flavonoid intake consisting of 3 percent catechin intake from chocolate with stroke or death (relative risk, 0.92). A second study, however, found that once-weekly chocolate consumption was associated with a reduced risk of incident stroke (relative risk, 0.78), while a third study suggested that weekly chocolate consumption was associated with a reduced risk of stroke mortality (hazard ratio, 0.54).

"Further prospective studies are needed to assess whether the benefit of chocolate-based flavonoid consumption truly lowers stroke risk, or whether the apparent benefit is biased by a healthy user effect," the authors conclude.

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Magnesium Found Beneficial for Postmenopausal Women

Higher intake linked to decreased levels of markers of inflammation, endothelial dysfunction

12 feb 2010-- In postmenopausal women, increased magnesium intake is associated with lower levels of some markers of systemic inflammation and endothelial dysfunction, according to a study in the February issue of Diabetes Care.

Sara Chacko, of the University of California in Los Angeles, and colleagues studied 3,713 ethnically diverse postmenopausal women aged 50 to 79 years in the Women's Health Initiative Observational Study who were free of cardiovascular disease, cancer, and diabetes at baseline.

The researchers found that magnesium intake was independently and inversely associated with blood concentrations of high-sensitivity C-reactive protein, interleukin 6, tumor necrosis factor-α receptor 2, and soluble vascular cell adhesion molecule-1. They observed no significant ethnic differences.

"These findings are consistent with those of previous studies mostly in whites and support the notion that diets high in magnesium- rich foods including whole grains, nuts, and leafy green vegetables should be encouraged for metabolic disease prevention," the authors conclude.

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Executive Dysfunction With High BP May Help Predict Dementia

More than half of elderly with hypertension and executive dysfunction progress to dementia

11 feb 2010-- In elderly adults, executive dysfunction -- but not memory dysfunction -- accompanied by hypertension may help predict progression to dementia and provide an opportunity to intervene, according to a study in the February issue of the Archives of Neurology.

Shahram Oveisgharan, M.D., of the University of Western Ontario in London, Canada, and a colleague studied 990 subjects (mean age, 83.06 years) with baseline cognitive impairment but no dementia (CIND) who were enrolled in the Canadian Study of Health and Aging.

After a follow-up of five years, the researchers found that the rate of progression to dementia was not affected by the presence of hypertension and memory dysfunction alone or the presence of hypertension, memory dysfunction, and executive dysfunction. However, they found that the rate of progression to dementia was significantly affected by the presence of hypertension and executive dysfunction alone. Among subjects with executive dysfunction alone, 57.7 percent of those with hypertension progressed to dementia compared to 28 percent of those with normal blood pressure.

"It is assumed that cognitive decline progresses to CIND before the development of dementia," the authors conclude. "We show herein that the presence of hypertension predicts progression to dementia in a subgroup of about one-third of subjects with CIND. Control of hypertension in this population could decrease by one-half the projected 50 percent five-year rate of progression to dementia."

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APA announces draft diagnostic criteria for DSM-5

New proposed changes posted for leading manual of mental disorders

ARLINGTON, Va. ,11 feb 2010– The American Psychiatric Association today released the proposed draft diagnostic criteria for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM). The draft criteria represent content changes under consideration for DSM, which is the standard classification of mental disorders used by mental health and other health professionals, and is used for diagnostic and research purposes.

"These draft criteria represent a decade of work by the APA in reviewing and revising DSM," said APA President Alan Schatzberg, M.D. "But it is important to note that DSM-5 is still very much a work in progress – and these proposed revisions are by no means final." The proposed diagnostic criteria will be available for public comment until April 20, and will be reviewed and refined over the next two years. During this time, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real-world clinical settings.

Proposed revisions

Members of 13 work groups, representing different categories of psychiatric diagnoses, have reviewed a wide body of scientific research in the field and consulted with a number of expert advisors to arrive at their proposed revisions to DSM. Among the draft revisions are the following:

• The recommendation of new categories for learning disorders and a single diagnostic category, "autism spectrum disorders" that will incorporate the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term "mental retardation" be changed to "intellectual disability," bringing the DSM criteria into alignment with terminology used by other disciplines.
• Eliminating the current categories substance abuse and dependence, replacing them with the new category "addiction and related disorders." This will include substance use disorders, with each drug identified in its own category.
• Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
• Creating a new category of "behavioral addictions," in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual's appendix instead, with a goal of encouraging additional study.
• New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
• Consideration of a new "risk syndromes" category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
• A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
• New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.

The APA has prepared detailed press releases on each of these topics, which are available on the DSM-5 Web site.

Dimensional Assessments

In addition to proposed changes to specific diagnostic criteria, the APA is proposing that "dimensional assessments" be added to diagnostic evaluations of mental disorders. These would permit clinicians to evaluate the severity of symptoms, as well as take into account "cross-cutting" symptoms that exist across a number of different diagnoses (such as insomnia or anxiety).

"We know that anxiety is often associated with depression, for example, but the current DSM doesn't have a good system for capturing symptoms that don't fit neatly into a single diagnosis, said David Kupfer, M.D., chair of the DSM-5 Task Force. "Dimensional assessments represent an important benefit for clinicians evaluating and treating patients with mental illness. It may help them better evaluate how a patient is improving with treatment, help them address symptoms that affect a patient's quality of life and better assess patients whose symptoms may not yet be severe – leading to earlier effective treatment."

Careful Consideration of Gender, Race and Ethnicity

The process for developing the proposed diagnostic criteria for DSM-5 has included careful consideration of how gender, race and ethnicity may affect the diagnosis of mental illness. The team has sought significant involvement of women, members of diverse racial and ethnic groups, and international researchers and clinicians. The APA also designated a specific study group to review and research these issues, and ensure they were taken into account in the development of diagnostic criteria.

The Gender and Cross-Cultural Study Group reviewed epidemiological data sets from the United States and other countries to determine if there were significant differences in incidence of mental illness among different subgroups (e.g., gender, race and ethnicity) that might indicate a bias in currently-used diagnostic criteria, including conducting meta-analyses (additional analyses combining data from different studies). Group members reviewed the literature from a broad range of international researchers who have explored issues of gender, ethnic and racial differences for specific diagnostic categories of mental illness. The study group also considered whether there was widespread cultural bias in criteria for specific diagnoses.

As a result of this process, the study group has tried to determine whether the diagnostic categories of mental illness in DSM need changes in order to be sensitive to the various ways in which gender, race and culture affect the expression of symptoms.

Public Review of Proposed Revisions

The resulting recommendations for revisions to the current DSM are being posted on the APA's Web site for the manual, www.DSM5.org, for public review and written comment. These comments will be reviewed and considered by the relevant DSM-5 Work Groups.

"The process for developing DSM-5 continues to be deliberative, thoughtful and inclusive," explained Dr. Kupfer. "It is our job to review and consider the significant advances that have been made in neuroscience and behavioral science over the past two decades. The APA is committed to developing a manual that is both based on the best science available and useful to clinicians and researchers."

Overview of DSM-5 Development Process

The last edition of DSM was published in 1994. Beginning in 2000, during the initial phase of revising DSM, the APA engaged almost 400 international research investigators in 13 NIH supported conferences. In order to invite comments from the wider research, clinical and consumer communities, the APA launched a DSM-5 Prelude Web site in 2004 to garner questions, comments, and research findings during the revision process.

Starting in 2007, the DSM-5 Task Force and Work Groups, made up of over 160 world-renowned clinicians and researchers, were tasked with building on the previous seven years of scientific reviews, conducting additional focused reviews, and garnering input from a wide range of advisors as the basis for proposing draft criteria. In addition to the work groups in diagnostic categories, there were study groups assigned to review gender, age and cross-cultural issues.

Based on the upcoming comments to the draft criteria and findings of the field trials, the work groups will propose final revisions to the diagnostic criteria in 2012. The final draft of DSM-5 will be submitted to the APA's Assembly and Board of Trustees for their review and approval. A release of the final, approved DSM-5 is expected in May 2013.

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The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org.

Scientists identify first genetic variant linked to biological aging in humans

Discovery has important implications for the understanding of cancer and age associated diseases

10 feb 2010--Scientists announced today they have identified for the first time definitive variants associated with biological ageing in humans. The team analyzed more than 500,000 genetic variations across the entire human genome to identify the variants which are located near a gene called TERC.

The study in Nature Genetics published today by researchers from the University of Leicester and King's College London, working with University of Groningen in the Netherlands, was funded by The Wellcome Trust and the British Heart Foundation.

British Heart Foundation Professor of Cardiology at the University of Leicester Professor Nilesh Samani, of the Department of Cardiovascular Sciences, who co-led the project explained that there are two forms of ageing – chronological ageing i.e. how old you are in years and biological ageing whereby the cells of some individuals are older (or younger) than suggested by their actual age.

He said: "There is accumulating evidence that the risk of age-associated diseases including heart disease and some types of cancers are more closely related to biological rather than chronological age.

"What we studied are structures called telomeres which are parts of one's chromosomes. Individuals are born with telomeres of certain length and in many cells telomeres shorten as the cells divide and age. Telomere length is therefore considered a marker of biological ageing.

"In this study what we found was that those individuals carrying a particular genetic variant had shorter telomeres i.e. looked biologically older. Given the association of shorter telomeres with age-associated diseases, the finding raises the question whether individuals carrying the variant are at greater risk of developing such diseases"

Professor Tim Spector from King's College London and director of the TwinsUK study, who co-led this project, added:

"The variants identified lies near a gene called TERC which is already known to play an important role in maintaining telomere length. What our study suggests is that some people are genetically programmed to age at a faster rate. The effect was quite considerable in those with the variant, equivalent to between 3-4 years of 'biological aging" as measured by telomere length loss. Alternatively genetically susceptible people may age even faster when exposed to proven 'bad' environments for telomeres like smoking, obesity or lack of exercise – and end up several years biologically older or succumbing to more age-related diseases. "

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Notes to Editors:

The paper, will be published online in Nature Genetics on 07 February 2010. To view the paper, please visit http://www.nature.com/naturegenetics/

Please cite the University of Leicester and King's College London in all reports

Alcohol Use And Cognitive Decline Among The Elderly

Studies of alcohol use and cognition among the elderly are rare and have mixed results. A study of drinking among the elderly in Brazil has found that heavy alcohol use is associated with more memory and cognitive problems than mild-to-moderate alcohol use, especially among women.

10 feb 2010--Results will be published in the April 2010 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"There is a scarcity of information about alcohol use and the elderly," said Marcos Antonio Lopes, corresponding author for the study and currently a visiting lecturer at Newcastle University in the United Kingdom, "which needs to be resolved in order to construct a real diagnosis and promote proper health care for this population."

Jerson Laks, associate professor at the State University of Rio de Janeiro and a researcher with the Brazilian National Committee for Research, agrees. "Alcohol use is frequently an exclusion criterion for any study of cognition and dementia in the elderly, as well as in studies aimed at depression," he said. "Therefore, by simply excluding alcohol use and abuse, most studies cannot reveal the interaction between drinking behaviors and cognition in this age range."

The current study is also important, Laks added, because it did not have any expectations that the elderly would drink less than younger subjects and, furthermore, it asked many difficult questions despite their negative stigmas in order to uncover the facts about drinking among the elderly in Brazil and its association with dementia.

Lopes and his colleagues recruited a sample of 1,145 individuals who were 60 years of age and older (419 men, 726 women), from different socioeconomic levels, and examined them in two phases. The first phase used several instruments, including the CAGE questionnaire, a four-question screening test for alcohol dependence, to identify potential alcohol-related problems, as well as a screening test for dementia to identify cognitive and functional impairment. The second phase used the Cambridge Mental Disorders of the Elderly Examination, as well as the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, to establish a clinical diagnosis of dementia.

"We found that heavy alcohol use among the elderly people we investigated was high at 8.2 percent and affected principally men from low socioeconomic levels," said Lopes. "However, the effects of heavy alcohol use on memory and other cognitive functions were more evident in women." Lopes added that their finding of 8.2 percent was greater than expected, when compared to previous studies, but that the fundamental lack of information in this area of study makes comparisons difficult.

"This study shows that older people keep drinking along the life span," said Laks. "Taking into consideration that drinking may lead to falls and to cognitive impairment when heavy use is the case, this study creates important awareness about this issue."

Source:

Marcos Antonio Lopes, Ph.D.
University of São Paulo

Jerson Laks, M.D., Ph.D.
State University of Rio de Janeiro

Alcoholism: Clinical & Experimental Research

Clinicians Need to Be Aware of Patient Use of Herbal Products

Reviewers warn of serious interactions with many common cardiovascular medications

05 feb 2010-- Health care professionals need to be aware of their patients' use of herbal remedies, which can adversely interact with many common cardiovascular medications, according to a review in the Feb. 9 Journal of the American College of Cardiology.

Ara Tachjian, M.D., of the Mayo Clinic in Rochester, Minn., and colleagues reviewed the medical literature from 1966 to 2008 for studies on the interactions between cardiovascular medications and herbal remedies recommended by complementary and alternative medicine practitioners or the media for a wide range of conditions, including arthritis, heart failure, depression, and back pain. The reviewers identified the products that pose particular risks for interaction with conventional heart and cardiovascular medications.

The researchers found that, among the most common interactions between herbal products and medications occur with the blood thinner warfarin, with some herbal products creating a bleeding risk by increasing warfarin's effect (alfalfa, angelica, bilberry, fenugreek, garlic, ginger, ginkgo), or decreasing its effect (ginseng and green tea). Other herbal remedies interfere with blood pressure medications (capsicum, ginseng, Irish moss, licorice, kelp, ephedra), affect heart rhythm (aloe vera, night blooming cereus, oleander), or variously interfere with beta-blockers, calcium channel-blockers, statins, anticoagulants, or other medications.

"There is a clear need for better public and physician understanding of herbal products through health education, early detection and management of herbal toxicities, scientific scrutiny of their use, and research on their safety and effectiveness. Regulatory policies are also needed to protect people from untoward effects on their health and finances," the authors write.

Abstract
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Not All Terminally Ill Receive Desired End-of-Life Care

Patients are more likely to receive preferred care after discussion with a physician

05 feb 2010-- Most terminally ill patients receive end-of-life care consistent with their stated preferences, and are more likely to receive the care they prefer if they have discussed their preferences with a physician, according to a study published online Feb. 1 in the Journal of Clinical Oncology.

Jennifer W. Mack, M.D., from the Dana-Farber Cancer Institute in Boston, and colleagues surveyed 325 patients with advanced cancer about their preferences for life-extending versus symptom-directed care and the actual end-of-life care they received.

The researchers found that 68 percent of patients received end-of-life care consistent with their preferences. However, 74 percent of patients who recognized that they were terminally ill received such care, and most preferred symptom-directed care. The 39 percent of patients who reported having discussed their end-of-life preferences with a physician were more likely to receive care consistent with their preferences (odds ratio, 2.26), particularly if they recognized that they were terminally ill (odds ratio, 3.94).

"Patients with cancer are more likely to receive end-of-life care that is consistent with their preferences when they have had the opportunity to discuss their wishes for end-of-life care with a physician," Mack and colleagues conclude.

Abstract
Full Text (subscription or payment may be required)

Decreased Muscle Strength Predicts Functional Impairments In Older Adults

03 feb 2010--Decreased muscle strength is associated with difficulty in performing functional activities such as stooping, crouching, or kneeling (SCK) in older adults, according to an observational study published in the January issue of Physical Therapy, (PTJ) the scientific journal of the American Physical Therapy Association (APTA). These researchers found that adults with SCK difficulty had significant decreases in adjusted strength measurements of trunk extensor, knee extensor, and ankle flexion muscles. Concluding that measurements of strength predict SCK difficulty, their study sets the stage for research exploring whether rehabilitation programs that focus on training specific muscle groups are effective in improving functional performance and whether improvements in functional performance reduces falls in older adults.

Bending down and kneeling are fundamental tasks of daily living. Other researchers have suggested that older adults with SCK difficulty are more likely to have limitations in other lower-body functional tasks, such as lifting and prolonged standing. "As with standing up from a chair, stooping, crouching, and kneeling movements require coordination of the whole-body center of mass over a wide range of postures in order to prevent a loss of balance or fall," said physical therapist researcher and APTA member Allon Goldberg, PT, PhD, assistant professor in the Department of Health Care Sciences, Program in Physical Therapy, Mobility Research Laboratory, at Wayne State University in Detroit, Michigan. "More research is needed, but it is reasonable to predict that a physical therapy program to improve strength in older adults who have difficulty performing basic stooping, crouching, or kneeling movements could lead to improvements in performing these activities, and these improvements could be associated with reduced number of falls."

The study was conducted when Goldberg was a post-doctoral fellow at the Institute of Gerontology at the University of Michigan in Ann Arbor. Co-authors of the study are Manuel Hernandez, MS (lead author), and Neil Alexander, MD, both at the University of Michigan.

The study's purpose was to compare trunk and lower-extremity muscle strength differences in older adults who had difficulty with stooping, crouching, or kneeling with older adults who did not have these difficulties. The study analyzed 48 community-dwelling older adults, over age 65, with and without self-reported SCK difficulty. Participants rated their ability to stoop, crouch, or kneel according to a 5-point difficulty scale and were tested on balance, strength, and fall-related measures.

Researchers hypothesized that lower-extremity strength would be significantly decreased in older adults who have trouble stooping, crouching, or kneeling and that measures of distal strength would be the main predictors of these issues in patients. Results suggest that older adults who reported trouble with basic stooping, crouching, or kneeling also had decreased strength in their legs. Researchers also discovered a relationship between SCK difficulty and both the level of strength and the ability to maintain proper balance. Findings suggest that in older adults, a major contributor to SCK difficulty is the strength of the distal leg musculature, which may provide a common link to balance. Future investigation will examine how other trunk and lower-extremity muscle strength may be related to these daily tasks.

"The results of this study may have important implications for clinicians working to reduce falls risk in older adults," Goldberg explained. "Rehabilitation or intervention programs aimed at addressing deficits in self-reported performance in stooping, crouching, or kneeling should focus on improving distal strength. Although addressing strength deficits is very important, those with stooping, crouching, or kneeling difficulty may also benefit from comprehensive programs by physical therapists that address balance confidence, coordination, leg joint limitations such as stiffness and pain, and sensory capacities."

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility - in many cases without expensive surgery or the side effects of prescription medications. APTA represents more than 74,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice, education, and research. In most states, patients can make an appointment directly with a physical therapist, without a physician referral.

Source:
Jennifer Rondon
American Physical Therapy Association

Exercise Linked To Healthier Aging: Four New Studies

03 feb 2010--Four new studies published in a leading journal this week link exercise with healthy aging, either through reduced risk or slower progression of several age-related conditions or through improvements in overall health in older age, and detail associations between physical activity and cognitive function, bone density and overall health.

All four studies, and an accompanying editorial commentary appear in the 25 January issue of the Archives of Internal Medicine.

In the accompanying editorial, Drs Jeff Williamson and Marco Pahor, of the University of Florida, point out that previous studies have linked exercise to beneficial effects on a range of conditions and diseases, including obesity, diabetes, heart disease, cancer, lung disease, arthritis, falls and fractures, that can hamper older people's ability to get on with their day to day tasks and lead indendepent lives.

They write:

"Regular physical activity has also been associated with greater longevity as well as reduced risk of physical disability and dependence, the most important health outcome, even more than death, for most older people."

And now, they suggest, these four new studies advance the field and help us better understand the "full range of important aging-related outcomes for which exercise has a clinically relevant impact".

Exercise in Middle Age Linked to Better Health in Later Life

In the first of the four studies, Dr Qi Sun, of the Harvard School of Public Health, Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues looked at health data from 13,535 participants taking part in the Nurses' Health Study.

They found that among women aged 70 and over, those who engaged in regular physical activity in their middle age were more likely to show signs of better overall health.

The women completed questionnaires about their physical activity in 1986, when their average age was 60.

When the researchers looked at data on health outcomes in those women that survived to age 70 and over from 1995 to 2001, they found that those who had reported higher levels physical activity in their middle age were less likely to have undergone heart surgery, have chronic diseases, or any physical, cognitive or mental impairments.

The researchers wrote that they also found:

"Increasing energy expenditure from walking was associated with a similar elevation in odds of successful survival."

They concluded that as the US population is a rapidly aging one and nearly 25 per cent of Americans do not pursue leisure time activities:

"Our findings appear to support federal guidelines regarding physical activity to promote health among older people and further emphasize the potential of activity to enhance overall health and well-being with aging."

They said people might be more motivated to pursue physical activities if they thought it would increase their chance of being fit and well in old age rather than just extending their lifespan.

Resistance Training Linked to Improved Cognitive Skills in Older Women

In the second of the four studies, Dr Teresa Liu-Ambrose, of Vancouver Coastal Health Research Institute and University of British Columbia, Vancouver, Canada, and colleagues, enrolled 155 women aged 65 to 75 and randomly assigned them to one of three groups that undertook to follow a particular exercise pattern for a year.

One group of 54 participants did resistance training once a week, another group of 52 did it twice a week, and a third group of 49, the control group, didn't do resistance training: they took part in twice-weekly sessions of balance and tone training.

The results showed that after following their exercise program for a year, compared to those in the balance and tone group, the women in both resistance training groups improved their performance on the Stroop test, a cognitive test of selective attention and conflict resolution.

Liu-Ambrose and colleagues also wrote that:

"Task performance improved by 12.6 per cent and 10.9 per cent in the once-weekly and twice-weekly resistance training groups, respectively; it deteriorated by 0.5 per cent in the balance and tone group."

The women in the resistance training groups also improved muscular function.

The authors concluded that:

"This has important clinical implications because cognitive impairment is a major health problem that currently lacks a clearly effective pharmaceutical therapy and because resistance training is not widely adopted by seniors."

"The doses of resistance training we used in this study fall within those recommended by the 2008 Physical Activity Guidelines for seniors," they added.

Exercise May Be Linked to Reduced Cognitive Impairment in Older Adults

In the third of the four studies linking exercise to healthier aging, Dr Thorleif Etgen of the Technische Universität München, Munich, and Klinikum Traunstein, Germany, and colleagues who followed a group of older adults for two years, found that moderate or high physical activity appeared to be linked with a lower risk of developing cognitive impairment.

The participants, who were older than 55 years, enrolled in a community-based prospective cohort study in southern Bavaria, Germany between 2001 and 2003 and were followed for 2 years. They gave data about their physical activity level and underwent tests of cognitive function (the 6-item Cognitive Impairment Test). The main outcome measure was the level of cognitive impairment after the 2 years of follow up.

The results showed that at the start of the study, 418 (10.7 per cent) of the participants had cognitive impairment, leaving 3,485 unimpaired.

After 2 years, 207 (5.9 per cent) of the unimpaired participants developed cognitive impairment.

When they analysed the data on these additional 207, the researchers found that compared with those who did no physical activity, those who reported moderate (exercising less than 3 times a week) or high (3 times a week or more) levels of physical activity at the start of the study (baseline) "showed a significantly reduced risk of incident cognitive impairment after 2 years".

"The incidence of new cognitive impairment among participants with no, moderate and high activity at baseline was 13.9 per cent, 6.7 per cent and 5.1 per cent, respectively," they wrote.

The researchers concluded that further studies should be done to assess how much and what types of exercise might prevent or delay cognitive impairment and to what extent.

Exercise Linked to Denser Bones and Lower Risk of Falls in Older Women

For the fourth study, which ran from May 2005 to July 2008, Dr Wolfgang Kemmler and colleagues at Freidrich-Alexander University of Erlangen- Nuremberg, Erlangen, Germany, recruited and randomly assigned 246 women aged 65 and over either to to follow an exercise program (the exercise group) or a wellness program (the control group) for 18 months.

They found that compared to the control group, the women in the exercise group appeared to have denser bones and a reduced risk of falls, but not a reduced risk of cardiovascular disease.

The exercise group followed a multipurpose 4 days per week exercise program that emphasized exercise intensity, while the controls followed a general wellness program that focused on wellbeing with a low intensity and low frequency program.

The main outcome measures were bone mineral density (BMD), number of falls, risk of coronary heart disease (the Framingham CHD Risk Calculator, which takes into account cholesterol level, blood pressure and presence of diabetes), and health care costs.

The results showed that among the 227 women who completed the study, the 115 in the exercise group had higher bone mineral density in the spine and hip and a 66 per cent reduced rate of falls.

Also, women in the control group were twice as likely to have fractures due to falls compared to those in the exercise group (12 versus 6), but the 10-year risk of cardiovascular disease went down in both groups with no difference between them.

There were no significant differences in direct health care costs per participant between the two groups.

The researchers concluded that:

"Compared with a general wellness program, our 18-month exercise program significantly improved BMD and fall risk, but not predicted CHD risk, in elderly women. This benefit occurred at no increase in direct costs."

"Because this training regimen can be easily adopted by other institutions and health care providers, a broad implementation of this program is feasible," they wrote.

"Physical Activity at Midlife in Relation to Successful Survival in Women at Age 70 Years or Older."
Qi Sun; Mary K. Townsend; Olivia I. Okereke; Oscar H. Franco; Frank B. Hu; Francine Grodstein.
Arch Intern Med. 2010;170[2]:194 -201, published online 25 January 2010.

"Resistance Training and Executive Functions: a 12-Month Randomized Controlled Trial."
Teresa Liu-Ambrose; Lindsay S. Nagamatsu; Peter Graf; B. Lynn Beattie; Maureen C. Ashe; Todd C. Handy.
Arch Intern Med. 2010;170[2]:170 -178, published online 25 January 2010.

"Physical Activity and Incident Cognitive Impairment in Elderly Persons: the INVADE Study."
Thorleif Etgen; Dirk Sander; Ulrich Huntgeburth; Holger Poppert; Hans Forstl; Horst Bickel.
Arch Intern Med. 2010;170[2]:186 -193, published online 25 January 2010.

"Exercise Effects on Bone Mineral Density, Falls, Coronary Risk Factors, and Health Care Costs in Older Women: the Randomized Controlled Senior Fitness and Prevention (SEFIP) Study."
Wolfgang Kemmler; Simon von Stengel; Klaus Engelke; Lothar Haberle; Willi A. Kalender.
Arch Intern Med. 2010;170[2]:179 -185, published online 25 January 2010.

Source: JAMA/Archives.

Premature Aging of the Brain Seen in HIV Patients

02 feb 2010-- Premature aging is striking the brains of people infected with the virus that causes AIDS, new research suggests.

It's not clear if the virus or the drugs that treat it -- or both -- are contributing to the aging. But one thing is clear: The blood flow in HIV patients is about the same as in those of uninfected people who are 15 to 20 years older.

"The graying of the AIDS patient community makes this infection's effects on the brain a significant source of concern," study author Dr. Beau Ances, an assistant professor of neurology at Washington University in St. Louis, said in a university news release.

"Patients are surviving into their senior years, and a number of them are coming forward to express concerns about problems they're having with memory and other cognitive functions," Ances said.

An estimated 14 percent to 18 percent of all AIDS patients in the United States are more than 50 years old, and older people face one of the highest rates of new infections. By 2015, people over the age of 50 may account for more than half of all AIDS patients.

In the study, researchers used MRI scans to study the blood flow in the brains of 26 HIV-infected people and 25 other people who weren't infected. The average age and education level of the participants were similar.

The researchers found reduced blood flow in the brains of younger HIV-infected patients who were infected recently, not just the older ones.

The study was released online in advance of publication in the Feb. 1 print issue of the Journal of Infectious Diseases.

Herbal remedies, heart drugs don't mix: review

WASHINGTON , 02 feb 2010– Taking ginkgo biloba, St. John's wort and other widely used herbal supplements may be risky for people on heart disease medication, especially the elderly, according to a medical review released on Monday.

Some herbal remedies may increase the potency of prescription drugs for heart disease or make them less effective, a team of experts concluded.

Mixing herbs and drugs also could cause serious heart rhythm problems and bleeding, according to the review published in the Journal of the American College of Cardiology.

Use of herbal supplements among elderly patients is especially concerning because they typically have more than one disease, take multiple medications and already are at greater risk of bleeding, the report said.

Previous studies have sounded alarms about use of herbal supplements which are not regulated like traditional medicines. This review examined how supplements and cardiovascular drugs may interact.

"We can see the effect of some of these herb-drug interactions -- some of which can be life-threatening -- on tests for blood clotting, liver enzymes and, with some medications, on electrocardiogram," Dr. Arshad Jahangir of the Mayo Clinic in Arizona said in a telephone interview.

Many patients fail to disclose their use of herbal remedies so healthcare providers should be more probing, Jahangir said in a telephone interview.

"We need to be actively ask about alternative or complementary medicine patients may be seeking on their own to assess these potential interactions or side affects," said Jahangir, a cardiologist.

"They don't even consider that herbs could have a negative effect," he said. "Their impression is that 'natural' is safe,"

Jahangir said doctors and patients need to know about the potential harm herbal products can have, citing reports that more than 15 million Americans use herbal remedies.

The Council for Responsible Nutrition, an industry trade association, said the article represents a biased, poorly written and contrived attack on herbal supplements.

"Many herbal supplements offer healthful benefits and fiber, garlic, and Hawthorne provide heart health benefits, and the potential risk for a drug interaction can be eliminated by speaking openly with your doctor," the group's vice president, Douglas MacKay, said in a statement.

"If consumers are buying from reputable companies, they can feel confident in the quality and safety of these products," MacKay added.

Ginkgo biloba is taken to sharpen cognitive skills and St. John's wort is used to fight depression and sleep disorders.

Early menopause can result in earlier onset dementia

Publication in international scientific journal Journal of Alzheimer Disease

01 feb 2010--Women experiencing an early onset of menopause could develop dementia at a younger age. Research by Tonnie Coppus of Erasmus MC has indicated this. She studied women with Down Syndrome, who are known to have an early onset of menopause. The results of her research can be translated to apply to the general population. Her results will be published in the Journal of Alzheimer Disease today.

Women with Down Syndrome have an earlier onset of menopause compared to women in the general population, 44 years of age and 52 years of age, respectively. Coppus' findings show a strong relationship between the age of menopause onset and the age at which dementia is diagnosed. Coppus: "Women with Down Syndrome with an early onset of menopause also appear to suffer from dementia at an early age. In addition, my study shows that these women also die younger."

Alzheimer's disease is the major cause of illness and death among people with Down Syndrome. The Epidemiology department of Erasmus MC has been studying more than 500 people with Down Syndrome, above the age of 45, since 2000. In particular, the factors affecting the onset of dementia and death are studied. The health development found within this group is in fact an accelerated version of the developments found in the general population. The research results can therefore be translated to similar results for the general population.

A first step in the development of Alzheimer is the build up of so-called amyloid in the brain. The deposition of this amyloid occurs under influence of a certain gene, higher levels of which are found in people with Down Syndrome. Down Syndrome is a chromosomal disorder in which there are three copies of chromosome 21. This chromosome has various genes that play a role in neurological diseases. The most important of these is the gene that is responsible for the production of the protein amyloid. Coppus: "Studying the various factors that influence the development of Alzheimer's disease among people with Down Syndrome also improves our understanding of the role of amyloid in the development of Alzheimer's disease within the general population."

As it appears, not only can a relationship with the age of onset of dementia be determined but also a relationship between early onset of menopause and dying young. Coppus: "As dementia itself also leads to a reduced life expectancy, I made calculations in which I corrected the results of the effect of dementia on death. Despite this, the relationship between early menopause onset and dying young remains. The research results provide substantial information on the relationship between menopause and dementia and the relationship between menopause and death."

UCLA researchers image earliest signs of Alzheimer's, before symptoms appear

Findings could allow for early interventions for the disease

01 feb 2010--Estimates are that some 10 percent of people over the age of 65 will develop Alzheimer's disease, the scourge that robs people of their memories and, ultimately, their lives.

While researchers race to find both the cause and the cure, others are moving just as fast to find the earliest signs that will predict an eventual onset of the disease, well before any outward symptoms. The reason is simple: The earlier the diagnosis, the earlier treatments can be applied.

Now, through the use of sophisticated brain-imaging techniques, researchers at UCLA have been able to predict a brain's progression to Alzheimer's by measuring subtle changes in brain structure over time, changes that occur long before symptoms can be seen. The research appears in two separate papers currently available online and scheduled for future print publication.

In the first study, which appears in the online edition of the journal Human Brain Mapping, UCLA assistant clinical professor of neurology Liana Apostolova and colleagues tracked 169 people over three years who had been diagnosed with mild cognitive impairment (MCI), a condition that causes memory problems greater than those expected for an individual's age — but not the personality or cognitive changes that define Alzheimer's. They found that after three years, those who went on to be diagnosed with Alzheimer's disease showed a 10 to 30 percent greater atrophy in two specific locations within the brain's hippocampus, a part of the brain known to be critical for long-term memory.

In the second study, which appears in the online edition of the journal Neurobiology of Aging, the researchers looked at 10 cognitively normal elderly people and compared their brain scans with those of seven other elderly people who were later diagnosed with MCI and then Alzheimer's. Again, they found that the group that went on to be diagnosed with Alzheimer's showed the same pattern of atrophy in the same regions of the hippocampus.

This shows, Apostolova said, that excess atrophy is present in cognitively normal individuals who are predestined to develop MCI. Further, that atrophy ultimately cascades across the entire hippocampus of the brain, leading to Alzheimer's disease.

"We feel this is an important finding because it is in living humans," said Apostolova, senior author of both papers and a member of the UCLA Laboratory of Neuro Imaging. "Now we have a sensitive technique that shows the 'invisible' — that is, the progression of a disease before symptoms appear."

In the first study, the researchers wanted to track disease progression in the hippocampus. In earlier work, Apostolova's lab had shown that greater atrophy can be documented in the living brain and that it can predict conversion from MCI to Alzheimer's. The researchers looked at two areas within the hippocampus: the CA1 (cornu ammonis) and the subiculum. In this study, they tracked atrophy from the CA1 as it spread to the subiculum, which matched disease progression from the MCI state to a diagnosis of Alzheimer's.

They split the MCI subjects into those who had no noticeable hippocampal atrophy other then what is expected from normal aging alone, and those who had atrophy greater than expected for normal aging. Three years later, the researchers followed up and compared the MCI group with no visual change to the one with premature change. They found 10 to 30 percent greater atrophy in the CA1 and subiculum of those MCI patients with premature atrophy who were later diagnosed with Alzheimer's.

"In looking at the longitudinal changes, we could see there was definitive evidence of a progression from the CA1 to the subiculum region, and on to the other regions of the hippocampus," Apostolova said.

The second, much smaller study of 17 individuals confirmed the findings of the larger study, but this time in people who were cognitively healthy. Here, the researchers looked at 10 cognitively normal elderly subjects who remained normal at three-year and six-year follow-ups, and at seven cognitively normal elderly subjects who were diagnosed with MCI between two and three years after their initial brain scan and with Alzheimer's approximately seven years after the initial scan.

Again, excessive atrophy in the CA1 and subicular regions was present in cognitively normal individuals who went on to be diagnosed with MCI, and a slow progression of atrophy beyond the CA1 and subiculum to other regions was evident in those ultimately diagnosed with Alzheimer's.

Apostolova noted that the degree of atrophy is not easily visible in the brain scans and that very sensitive techniques are required to show its progression.

"We can't see the pathologic changes, but we clearly see the neurodegenerative atrophy associated with MCI and AD, and how it spreads through the hippocampus," she said. "This is exactly what a biomarker, being an indirect measure of disease progression, is supposed to do."

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For the mild cognitive impairment study, other authors included Paul M. Thompson, Amity E. Green, Kristy S. Hwang, Charleen Zoumalan, Arthur W. Toga and Jeffrey L. Cummings, all of UCLA; Clifford R. Jack Jr. and Ronald C. Petersen, of the Mayo Clinic; Danielle Harvey and Charles DeCarli, of UC Davis; and Leon J. Thal and Paul S. Aisen, of UC San Diego.

The study was funded by AFAR, the John A. Hartford Foundation, the Atlantic Philanthropies, the Starr Foundation, an anonymous donor, the Turken Foundation and the National Institutes of Health.

For the cognitively normal study, other authors included Lisa Mosconi, Paul M. Thompson, Amity E. Green, Kristy S. Hwang and Anthony Ramirez, all of UCLA; Rachel Mistur, of New York University School of Medicine; and Wai H. Tsui and Mony J. de Leon, of New York University School of Medicine and the Nathan Kline Institute.

The study was funded by the National Institute on Aging, the National Institute of Mental Health, the National Institutes of Health, the John A. Hartford Foundation, the Atlantic Philanthropies, the Starr Foundation, the Alzheimer's Association and an anonymous donor.