Findings support safety of whooping cough vaccine for older adults

A new study of the safety of the tetanus-diphtheria-acellular pertussis (Tdap) vaccine supports the recommendation that those 65 and older get the vaccine to protect themselves and others, particularly young babies, from pertussis. Published online in Clinical Infectious Diseases, the findings come as reported U.S. cases of the bacterial infection, also known as whopping cough, are at the highest level since the 1950s.

30 nov 2012--An extremely contagious respiratory illness, pertussis puts infants at greatest risk for severe complications, including death. More than half of infants younger than 1 year old who get pertussis are hospitalized, according to the Centers for Disease Control and Prevention (CDC), and 1 or 2 in 100 hospitalized infants die. Immunity is difficult to maintain in the community because infants cannot be vaccinated until they are 2 months old. As a result, they may be at risk, especially from family members and care givers who have the disease.

In their study, Hung Fu Tseng, PhD, MPH, and his team at Kaiser Permanente Southern California found that adverse events following Tdap vaccination in seniors were mostly minor. "Although there is a small increased risk of injection site reaction following Tdap vaccination in the elderly, it is no more common than that following the traditional tetanus and diphtheria (Td) vaccine," Dr. Tseng said.

The researchers' study included 119,573 seniors who received the Tdap vaccine and the same number of people who received the traditional Td vaccine. Safety data were collected from seven health maintenance organizations across the U.S. The risk for adverse events following vaccination was comparable among both groups.

The authors hope the findings will allay any fears among older adults about the safety of the Tdap vaccine and prompt more doctors to urge across-the-board immunization, which is crucial in the wake of recent pertussis outbreaks, such as those in Minnesota, Washington state, Wisconsin, and elsewhere. Current recommendations call for infants older than 2 months, children, teens, adults (including pregnant women, parents, and health care workers), and those over 65 to be vaccinated.

"Pertussis immunization is important, particularly since one of the most common sources of pertussis in infants is their relatives, including their grandparents," Dr. Tseng said. "We suggest that clinicians follow CDC's recommendation and talk to older adult patients about vaccination against pertussis to protect themselves and their family members."

Provided by Infectious Diseases Society of America

Four common antipsychotic drugs found to lack safety and effectiveness in older adults

In older adults, antipsychotic drugs are commonly prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications – schizophrenia and bipolar disorder. The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia, some of which carry FDA warnings on prescription information for these drugs.

29 nov 2012--In a new study – led by researchers at the University of California, San Diego School of Medicine, Stanford University and the University of Iowa, and funded by the National Institute of Mental Health – four of the antipsychotics most commonly prescribed off label for use in patientsover 40 were found to lack both safety and effectiveness. The results will be published November 27 in The Journal of Clinical Psychiatry.

The study looked at four atypical antipsychotics (AAPs) – aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) – in 332 patients over the age of 40 diagnosed with psychosis associated with schizophrenia, mood disorders, PTSD, or dementia.

"Our study suggests that off-label use of these drugs in older people should be short-term, and undertaken with caution," said Dilip V. Jeste, MD, Estelle and Edgar Levi Chair in Aging, Distinguished Professor of Psychiatry and Neurosciences, and director of the Stein Institute for Research on Aging at UC San Diego.

Results of the five-year study led by Jeste, who is also current president of the American Psychiatric Association (which was not involved in this research), showed that within one year of treatment, one-third of the patients enrolled in the study developed metabolic syndrome (medical disorders that can increase the risk of cardiovascular disease or diabetes). Within two years, nearly a quarter of the patients developed serious adverse effects and just over half developed non-serious adverse effects.

Because the patients enrolled in the study were all diagnosed with conditions with psychotic symptoms that required antipsychotic drug treatment according to their treating physicians, no placebo was used in the trial. Instead, the researchers used a technique called "equipoise stratified randomization" which is a hybrid of complete randomization and a clinician's choice method.

"Our goal was to ensure clinical relevance," said Jeste. Patients had to agree to be randomized to 2, 3 or 4 of the study drugs, as they or their physicians were allowed to exclude one or two of the study AAPs, due to past experience or anticipated risk of the particular drug. Treating clinicians could determine the optimal dosage. "We attempted to make the study as 'user-friendly' as possible, to allow the drugs the best chance of success, while seeking to minimize the amount of bias," he explained.

While the researchers' intent was to continue the patients on the randomized medications for two years, the average length turned out to be only six months, after which the medications were halted or switched because they didn't work and/or had side effects.

Because of a notably high incidence of serious adverse events, quetiapine had to be discontinued midway through the trial. The researchers found that there were significant differences among patients willing to be randomized to different AAPs – thus, treating clinicians tended to exclude olanzapine and prefer aripiprazole as one of the possible choices in patients with existing metabolic problems. Yet, the different AAP groups did not appreciably differ in most outcome measures.

Using a common scale called the Brief Psychiatric Rating Scale (BPRS), to measure symptoms such as delusions, hallucinations, unusual behavior, depression, and anxiety, assessments were made at 6 weeks, 12 weeks, and then every 12 weeks. Results using "blind" raters showed no significant improvement in BPRS over a six-month period.

"While there were a few significant differences among the four drugs, the overall risk-benefit ratio for the AAPs in patients over age 40 was not favorable, irrespective of diagnosis and drug," said Jeste.

Jeste points out that clinicians, patients, and caregivers are often left with difficult and unclear choices for treatment for older persons with psychosis, such as that associated with dementia. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there are no FDA-approved alternatives to antipsychotics for this population, and the high cost of newer AAPs also makes their use problematic.

While the researchers say their findings do not suggest that these AAPs should be banned in older patients with psychiatric disorders, they do indicate that considerable caution is warranted in off-label, long-term use of the drugs in older persons.

"When these medications are used off-label, they should be given in low dosages and for short durations, and their side effects monitored closely," said Jeste. "Clearly, there is also a critical need to develop and test new interventions that are safe and effective in older people with psychotic disorders."

Provided by University of California - San Diego

U.S. task force: Baby boomers should be tested for hepatitis C

Generation has highest rate of infection, likely contracted decades ago.

27 nov  2012—A U.S. task force suggests that people at high risk for the hepatitis C virus should be screened, which includes those with a history of intravenous drug use and those who received blood transfusions before 1992.

But, the guidelines also address another, lower-risk group—the baby boomer generation.

The new U.S. Preventive Services Task Force guidelines, released Monday and updated from 2004, take a somewhat softer stance than those of the U.S. Centers for Disease Control and Prevention, which say that all baby boomers should get screened for hepatitis C. By contrast, the task force suggests that clinicians "consider" screening for this age group, which includes those born between 1946 and 1964.

Screening for hepatitis C involves a simple, inexpensive blood test. Unlike other types of hepatitis, there is no vaccine available for hepatitis C. Treatment typically involves a course of antiviral medication.

Hepatitis C is considered a silent killer because it is often symptomless. Undiagnosed and untreated, hepatitis C can result in liver cancer, liver failure and liver transplants.

Risk factors for hepatitis C infection include a history of blood transfusions before widespread adoption of screening and infection control measures, long-term dialysis treatment, exposure to hepatitis C in health care settings, having HIV/AIDS, tattooing in unregulated or unsafe parlors and IV drug use.

"Our recommendations are that people who are known to be at high risk—such as people with a history of IV drug [use] and those who had blood transfusions prior to 1992—should be screened," said task force member Dr. Kirsten Bibbins-Domingo, an associate professor of medicine and of epidemiology and biostatistics at the University of California, San Francisco.

People at highest risk have about a 50 percent chance of being infected with hepatitis C; whereas people born between 1946 and 1964 have a 3 percent to 4 percent chance of being infected, she said.

Bibbins-Domingo said the task force took less a stringent stance on testing for all baby boomers because many people with hepatitis C will live for a long time without progressive disease, and current treatments don't help everyone. "We have effective treatments, but not everybody who has hepatitis C will go on to develop liver failure or liver cancer," she said. "We are in an era where treatments are rapidly evolving, and recommendations may change as treatments get better."

One liver disease expert weighed in on screening for the 47-to-67 age group.

Dr. David Bernstein, chief of hepatology at North Shore-LIJ Healthcare System, in Manhasset, N.Y, said baby boomers should get screened for hepatitis C. "I think the guidelines should have been a little stronger for people born from 1945 to 1965," he said.

"The current therapies have cure rates of 70 to 75 percent," Bernstein said. "In a couple of years, newer therapies may be available which will have much higher cure rates but this is [already] very high."

Get screened, he advised. "Hepatitis C is the most common reason for a liver transplant and development of liver cancer, but if you catch it, you can halt the progression of disease and cure it."

The task force guidelines are now open for a period of public comment.

More information: Get the facts about hepatitis C at the U.S. National Library of Medicine.

Study finds strong ethnic neighborhoods can boost health of seniors

A new study from the Mailman School of Public Health suggests that African-American and Mexican-American seniors are less likely to have cancer or heart disease if they live in an ethnically homogeneous community.

26 nov 2012--Contrary to earlier studies, the researchers found that "living in the barrio or ethnically dense communities isn't always bad for your health," said Kimberly Alvarez, a Ph.D. candidate at Mailman who conducted the study with Becca Levy, associate professor of epidemiology and psychology at the Yale School of Public Health.

The researchers used survey data from 2,367 Mexican-Americans and 2,790 African-Americans over age 65 living in communities with high percentages of residents of the same ethnic background.

Among African-Americans, those living in a county with an ethnic density of 50 percent or more were 46 percent less likely to report doctor-diagnosed heart disease and 77 percent less likely to report cancer than those who lived in a community with an ethnic density of less than 25 percent. Mexican-Americans living in a county with an ethnic density of 50 percent or more were 33 percent and 62 percent less likely to report heart disease and cancer, respectively, than those who lived in a community with an ethnic density of less than 25 percent.

Cultural factors such as respect for elders and close-knit families could help explain the phenomenon. "These networks may facilitate better health behaviors and, in turn, better health outcomes," Alvarez said.

The study was published online last month in the American Journal of Public Health.

Provided by Columbia University

Soy-rich diets may not prevent hot flashes in most menopausal women

Study suggests natural plant estrogens aren't effective for menopause symptoms.

24 nov 2012—Consuming soy products doesn't prevent hot flashes and night sweats in most women, a large study suggests.

Imagine sitting down for a job interview and suddenly feeling very warm and starting to noticeably perspire. Or consider how it feels to frequently lose sleep from drenching night sweats. Of all the symptoms of menopause, women say hot flashes and night sweats often are the most annoying.

The symptoms are caused by fluctuating or decreasing levels of the female hormone estrogen.

Many women are not willing or able to take supplemental estrogen to control hot flashes and night sweats, known as "vasomotor" symptoms, related to widening and narrowing of blood vessels. Some women opt to add dietary soy products like tofu and soy milk to their diet. Also called phytoestrogens, they have a chemical structure similar to estrogen and are thought to mimic the effect of the female hormone in the body.

The study was published online recently and will appear in the March 2013 print issue of the journal Menopause.

"We were interested in finding ways to help women control their own health, and we were hopeful that soy products would prove to be a good alternative to hormone therapy," said lead study author Ellen Gold, professor and chairwoman of the department of public health sciences at the University of California, Davis. Unfortunately, she said, soy "doesn't seem, on average, to prevent these unpleasant symptoms before the onset of menopause."

The study analyzed data from a nationwide study that followed more than 3,000 women who were beginning to experience changes associated with menopause or had not yet begun to have symptoms of menopause. Their ages ranged from 42 to 52 years old at the start of the study.

Participants answered detailed surveys about their dietary habits and fiber intake before they were involved in the study, then at five- and nine-year follow-up points. Fiber was of interest to the researchers because it is thought to increase the impact of estrogen. The women also were asked annually about their menopausal symptoms, including hot flashes and night sweats.

The study found no significant correlation between the intake of dietary phytoestrogens or fiber and the beginning of menopausal symptoms in women who had not yet experienced menopause when they started the study.

Gold said that a randomized, placebo-controlled trial with a diverse range of women would be necessary to prove any ability of dietary phytoestrogens or fiber to prevent hot flashes and night sweats, but she believes the results of this study suggest that it is unlikely a significant effect would be seen.

Although other studies have looked at dietary soy and menopausal symptoms, this study included more women and followed them for a longer period of time than others did, the researchers said. The study also included people representing a broader range of racial and ethnic groups, including black, Hispanic, Chinese and Japanese women.

Although Asian women tend to report fewer vasomotor symptoms than other women, the typical Eastern diet, thought to be high in phytoestrogens, does not seem to be associated with fewer hot flashes and night sweats.

Gold said she believes there may be subsets of women, due to genetic and metabolic factors, who may benefit more from phytoestrogens than others. And she doesn't discourage women from taking soy products. "If women try it and it works for them, fine," she said.

The study has some limitations.

Dr. Wilma Larsen, chief of the division of gynecology at Scott & White Healthcare in Temple, Texas, is concerned that the study used data the women had written down or remembered.

"Any time you're relying on patients to self-report you're not certain what they're actually doing," Larsen said.

Although Larsen said the study contributes new information specifically about whether soy products are helpful in preventing hot flashes and night sweats before they occur, she doesn't think it will change what women do or what physicians recommend.

"I think this isn't going to prevent me from talking about a healthy diet with patients or the value of phytoestrogens," Larsen said. "And I'm certainly not going to be reassuring women that they'll go through menopause without having to take any prescription medicines."

The study was supported in part by the U.S. National Institutes of Health.

More information: Visit the U.S. Centers for Disease Control and Prevention to learn more about menopause.

Inpatient sleeping drug quadrupled fall risk

A drug commonly prescribed to help patients sleep in hospitals has been associated with an increased risk of falls, according to a study published in the Journal of Hospital Medicine.

23 nov 2012--U.S. sleep specialists from the Mayo Clinic found that the fall rate among the 4,962 patients who took zolpidem during their hospital stay was more than four times as high as the 11,358 who did not take the drug.

They also found that the risk posed by the drug was greater than the risks posed by factors such as age, cognitive impairment, delirium or insomnia, regardless of the dosage used.

"Ensuring that people get enough sleep during their hospital stay is very important, but it can also prove very challenging," says the Clinic's Chief Patient Safety Officer Dr. Timothy I. Morgenthaler, who specializes in sleep disorders and pulmonary and critical care.

"Patient falls are also a significant patient safety issue in hospitals and one that has been quite difficult to tackle, despite considerable efforts. That is why it is one of the target aims of the U.S. Department of Health and Human Services Partnership for Patients project."

"Discovering that zolpidem, which is commonly used in hospitals, is a significant risk factor for patient falls provides us with additional knowledge to help tackle this problem."

Key findings of the study include: 

• Just under 39 percent of eligible admissions during 2010 were prescribed zolpidem (16,320 patients) but 88 percent of the prescriptions were issued on an "as needed basis."
• Zolpidem was administered to 30.4 percent of patients who were prescribed it and to 11.8 percent of all Mayo Clinic admissions in 2010.
• Just over three percent of the patients on zolpidem fell during their in-patient hospital stay, compared with 0.7 percent of the patients who did not take zolpidem.
• Zolipdem use continued to be associated with an increased fall risk when other key factors, including health, length of hospital stay and assessed fall risk, were taken into consideration.

"Our hospitals have an overall fall rate of about 2.5 per 1000 patient days, which is lower than many national benchmarks. However, we have not been able to significantly reduce this rate in recent years. Now, we calculate that for every 55 patients who received zolpidem, there was one additional fall that may have been avoided by not administering the drug," says Dr. Morgenthaler.

"As a result of our study, we are now phasing out zolpidem and moving toward sleep enhancement techniques that are not based on drugs and which we believe are safer and probably as effective."

More information: Morgenthaler et al. Zolpidem is Independently Associated with Increased Risk of Inpatient Falls. Journal of Hospital Medicine. DOI: 10.1002/jhm.1985

Provided by Wiley

Routine checkups don't cut cancer, heart deaths, study says

Large evidence review suggests standardized screenings aren't that helpful for the 'worried well.'

22 nov 2012—Routine checkups don't help reduce a patient's risk of dying from either heart disease or cancer, new Danish research suggests.

The finding applies to doctor visits among the general population, in which seemingly healthy patients, without any specific disease risk, come in on a regular basis for an array of standardized screenings and lifestyle counseling.

The goal of such checkups is to catch early signs of disease and thereby reduce the risk for early death.

But the fresh review of 14 previous studies involving nearly 183,000 patients uncovered no evidence that such checkups do anything of the sort. On the contrary, the research team found that routine checkups of healthy people may actually promote the use of potentially harmful invasive testing while at the same time leading to overdiagnosis and unnecessary treatment.

"We could not find evidence of benefit from adding systematic, regular health checks to ordinary preventive health care practice, despite having data from many trials of high quality that included almost 200,000 people," said study lead author Lasse Krogsboll, a doctoral candidate in the Nordic Cochrane Centre, in Copenhagen.

Krogsboll added, however, that part of the lack of notable checkup benefit might be due to prevention interventions having already been carried out by primary care physicians outside the checkup context among at-risk patients who they had already been seeing for other reasons throughout the year.

"[So] our results should not be interpreted as evidence against preventive actions to improve health in general," he said, "or evidence against clinicians trying to identify health problems early and treat risk factors in high-risk groups."

Krogsboll pointed out that "we are not saying that early treatment of manifest disease or treatment of risk factors identified as a part of good doctoring is not a good idea. For example, treatment of moderately or severely elevated blood pressure is well documented to be beneficial."

But, he added, "we cannot take it for granted that more diagnoses and more treatment is always better. Our results do not tell us what the optimal prevention strategy is, but they certainly do not support the idea of regular, systematic health checkups in addition to normal clinical practice."

Krogsboll and colleagues reported their findings in the Nov. 20 edition of the BMJ.

The studies selected for review dated as far back as 1947 and as recently as 2010. All of the participants were at least 18 years old, but no study was included in the review if it focused exclusively on seniors aged 65 and up.

All checkups had taken place in either a primary care or community care setting; none had occurred in a hospital clinic context.

Most studies included in the current review had been conducted in the United Kingdom and continental Europe, while some had taken place in the United States. Follow-up on patient deaths ranged from as low as four years to as much as 22 years after studies began.

The results: Checkups did lead to an uptick in overall diagnoses, as well as a specific increase in treatment for high blood pressure. However, such routine visits were not linked to any reduction in overall mortality or the risk of dying from cardiovascular illness or cancer.

The research team suggested another problem: Patients who decide on their own to go in for a routine physical may not actually be the sort—such as those who haven't seen a doctor in a while—who would most benefit from a checkup.

But just how broadly should the findings be interpreted?

"I do think that the results are applicable to America," Krogsboll said, pointing out that one study, in particular, had been conducted among Kaiser Permanente health plan members. However, he acknowledged that what exactly constitutes "optimal" preventive care is a matter of ongoing debate. He noted that the kind of care provided in some of the older European-based studies may not closely stack up against the current checkup protocols commonly practiced in the United States today.

In an accompanying editorial, Dr. Domhnall MacAuley, the London-based clinical primary care editor for BMJ, alluded to some unintended consequences that can stem from ineffective checkups.

"The potential downsides," MacAuley said, "are that those who come [in for a checkup] tend to be the 'worried well,' who may bear a high risk for being diagnosed with false positives or negatives. Indeed, [the study authors] suggested that there was overdiagnosis—that routine checks tend to pick up conditions that were treated with no obvious benefit in terms of [illness] or mortality."

In his published commentary, MacAuley concluded that "policy should be based on evidence of well-being, rather than on well-meant good intentions" and rejects the notion that checkups for a healthy public are a good idea simply because "they seem a socially responsible approach to caring for patients."

That said, he suggests that "targeted" checkups may be the alternate way to go, by focusing on those patients who have already been identified as having risk factors or conditions that could benefit from routine monitoring.

More information: For more on recommended cancer screenings, visit the American Cancer Society. For more on cardiovascular disease prevention, visit the American Heart Association.

Upbeat view on old age may help seniors bounce back from disability

Study found those with more optimistic outlooks had better recoveries.

21 nov 2012—Seniors who tend to think of other older people as spry instead of decrepit are far more likely to bounce back after a serious disability than people with a more negative outlook, according to a new study.

Older people who had positive age stereotypes were 44 percent more likely to recover completely from a severe disability. They also were 23 percent more likely to progress from a severe disability to a mild disability.

"This research suggests that we might want to think about the role of positive health stereotypes in disability," said the study's lead author, Becca Levy, associate professor of epidemiology and psychology at the Yale School of Public Health in New Haven, Conn.

Results of the study are published as a research letter in the Nov. 21 issue of the Journal of the American Medical Association.

The researchers say they began the study because little research has been done to figure out why some seniors recover from disability and others do not. They recruited more than 700 people aged 70 or older who were not disabled at the start of the study. During the 11-year follow-up period, nearly 600 people were disabled for at least a month.

The disability had to affect a person's ability to perform activities of daily living, such as dressing and feeding themselves.

During the study, the researchers asked the study volunteers, "When you think of old persons, what are the first five words or phrases that come to mind?" Their responses were graded on a scale of one (most negative) to five (most positive). A word such as "decrepit" scored a one, while the word "spry" scored a five.

Those with a more positive attitude toward seniors were far more likely to recover completely from their disability. The positive group had almost an 8 percent higher recovery rate from a severe disability to no disability. A similar improvement occurred in the rates of going from severe disability to mild disability.

There also was a slight improvement in the rates of people going from a mild disability to no disability for those with positive age stereotypes.

A few factors could be at play here, Levy said. One could be that a positive attitude might help buffer against stress and lessen cardiovascular responses to challenges, which could reduce disability from heart issues.

She said it's also possible that people who believe older folks can still be strong may be more likely to go to rehabilitation, and to participate in vigorous exercise programs that may help improve their disability.

Another expert noted how society's view of aging has changed.

"Active life spans have increased for older people, even from just 20 years ago," said Dr. Gary Kennedy, director of the division of geriatric psychiatry at Montefiore Medical Center, in New York City. "That might help make people's perspectives more positive."

And, he added, positive people may "stay physically active, and that can-do attitude lets you attack your problems more aggressively, making you more likely to keep at it until you're better."

If you tend to be more negative naturally, Levy noted, "there are many positive examples out there. Try to think about ways of bolstering positive age stereotypes, and questioning negative stereotypes."

Although the study found an association between having a positive view of aging and better recovery from disability, it did not prove a cause-and-effect relationship.

More information: Learn more about preventing falls, a common cause of disability, from the U.S. National Institutes of Health's Senior Health website.

Gerontologists say research and data should drive policy, budget decisions

America's top authorities on aging spent the last week at The Gerontological Society of America's Annual Scientific Meeting in San Diego detailing workable solutions to the challenges presented by a rapidly aging population, including the demand for affordable health care, high rates of disease, and retirement security.

20 nov 2012--With the backdrop of the recent presidential and congressional elections, the so-called "fiscal cliff," and its real threats to social service and entitlement programs for older adults, the timing of the GSA conference—which brought more than 3,900 researchers, educators, practitioners, and policy experts together—has rarely been so ideal. Attendees brought forward new data and scholarship on how to understand the aging process, treat those with age-related disease, and most effectively and efficiently serve older Americans.

"As Congress and the president face the challenge of reducing the deficit, those of us who work in the field of aging have real concerns that short term savings will have long term negative effects," said GSA Policy Advisor Brian Lindberg, MMHS, who serves as director of the Consumer Coalition for Quality Health Care in Washington, DC. "For example, reducing our commitment to the National Institutes of Health and the National Institute on Aging and its aging-related research, including Alzheimer's disease, could cost our nation billions in care costs in the future."

Lindberg chaired a symposium, "Critical Aging Policy Discussions for the 113th Congress," which explored the significant issues around health care and retirement security that legislators will confront and how aging organizations such as GSA and AARP are presenting their research to mobilize their members and influence senators and representatives.

He was joined by GSA member Cheryl Matheis, AARP's senior vice president for policy, strategy, and international affairs at AARP.

"AARP has spent the last six months engaging our members and the public in a conversation about the future of Social Security and Medicare, and asking them to tell us and their elected officials what they think needs to be done to assure that these programs are there to meet the needs of today's seniors and future generations," Matheis said. "The data we are collecting will provide useful information to Congress on the views of the American people who rely on these programs."

Another session in San Diego focused on new service delivery modes for treating individuals with multiple chronic illnesses. Brad Stuart, MD, chief medical officer of Sutter Care at Home, provided data on the cost savings and high patient ratings for their approach to advanced care, which focuses on understanding what the patient truly wants, care coordination, and reducing unnecessary treatments.

Stuart said that using Sutter's model for providing advanced care will lead to tremendous savings for Medicare both in California and, eventually, on a national level.

GSA's meeting—the country's largest interdisciplinary conference in the field of aging—took place at the San Diego Convention Center from November 14 to 18. The program schedule contained more than 500 scientific sessions featuring research presented for the first time.

Provided by The Gerontological Society of America

Exercise protects against heart failure even at advanced ages 

Among older adults, physical activity may protect against heart failure, as indicated by lower levels of N-terminal pro-B-type natriuretic peptide and cardiac troponin T, according to a study published online Nov. 14 in the Journal of the American College of Cardiology.

18 nov 2012—Among older adults, physical activity may protect against heart failure, as indicated by lower levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT), according to a study published online Nov. 14 in the Journal of the American College of Cardiology.

Christopher R. deFilippi, M.D., of the University of Maryland School of Medicine in Baltimore, and colleagues measured levels of NT-proBNP and cTnT at baseline and after two to three years in 2,933 community-dwelling adults aged 65 and older who were free of heart failure. The authors sought to assess the association between physical activity and changes in levels of these markers and the subsequent risk of heart failure.

The researchers identified an inverse correlation between biomarker concentration at baseline and follow-up visits and physical activity score. After adjustment for comorbidities and baseline levels, participants with the highest score were 50 percent less likely to have an increase in NT-proBNP and 70 percent less likely to have an increase in cTNT levels compared to those with the lowest physical activity scores. Overall, an increase in either biomarker indicated a higher risk of heart failure, and higher physical activity scores were associated with a lower long-term incidence of heart failure.

"Our findings raise the possibility that the trajectory of biomarker change and the subsequent heart failure risk associated with increasing levels may be modifiable by changes in lifestyle even at an advanced age," the authors write.

Several authors disclosed financial ties to Roche Diagnostics and Abbott.

More information: Abstract
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Pilates is beneficial adjunctive therapy in heart failure

Pilates exercises may be a beneficial adjunctive treatment for patients with heart failure, offering functional capacity improvements, according to a study published in the December issue of Cardiovascular Therapeutics.

16 nov 2012—Pilates exercises may be a beneficial adjunctive treatment for patients with heart failure, offering functional capacity improvements, according to a study published in the December issue of Cardiovascular Therapeutics.

To examine the efficacy of Pilates in patients with heart failure, Guilherme Veiga Guimarães, M.D., of the Universidade de São Paulo in Brazil, and colleagues conducted a study involving 16 patients with New York Heart Association class I or II heart failure who were randomly assigned to 30 minutes of aerobic exercise followed by 20 minutes of either mat Pilates training or a conventional cardiac rehabilitation program for 16 weeks.

At 16 weeks, the researchers found that patients in both groups showed a significant increase in exercise time, with a larger increase for the Pilates group (11.9 ± 2.5 to 17.8 ± 4 minutes and 11.7 ± 3.9 to 14.2 ± 4 minutes, respectively). Only the Pilates training exhibited significant increases from baseline in ventilation, peak oxygen consumption (VO₂), and O₂ pulse. Compared with the conventional group, peak VO₂ was significantly improved in the Pilates group.

"The results of this study demonstrate the feasibility of a combined aerobic training and mat Pilates method by its safe and functional capacity improvements in patients with heart failure," the authors write.

More information: Abstract 
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Cancer: Exercise reduces tiredness

Aerobic exercise can help relieve the fatigue often associated with cancer and cancer treatment, according to Cochrane researchers. Their updated systematic review strengthens findings from an earlier version on cancer-related fatigue published in The Cochrane Library.

15 nov 2012--Fatigue is a common and potentially long-lasting side-effect of cancer and cancer treatment. It may last for months or years. Dealing with cancer-related fatigue is crucial because those who suffer its effects may be less inclined to continue with treatment.

Although in the past, people with cancer-related fatigue have been advised to rest, long periods of inactivity may lead to muscle wasting and increased tiredness, whereas balancing rest with physical activity may help to reduce fatigue. A 2008 Cochrane systematic review on the benefits of exercise found some benefits of physical activity for fatigue in cancer based on limited studies.

The new review adds a further 28 studies to those included in the 2008 review. Altogether, 56 studies involving a total of 4,068 people with cancer were included. Half of the studies were carried out in people with breast cancer. Those with solid tumours benefited from aerobic exercise, such as walking or cycling, both during and after cancer treatment. Other forms of exercise, including resistance training, did not significantly reduce fatigue.

"The evidence suggests that exercise may help reduce cancer-related fatigue and should therefore be considered as one component of a strategy for managing fatigue that may include a range of other interventions and education," said lead researcher Fiona Cramp of the Faculty of Health & Life Sciences at the University of the West of England in Bristol, UK. "This updated review provides a more precise conclusion, showing specifically that aerobic exercise, both during and after cancer treatment, can be beneficial."

It remains to be seen how cancer treatment alters the beneficial effects of exercise on cancer-related fatigue. Further research is also needed to understand how the frequency and duration of exercise, and type of cancer, affect the results.

"Twenty eight of the studies we included were carried out in breast cancer patients, so we need to know more about how exercise can help people with a broad range of diagnoses, including patients with advanced disease," said Cramp.

More information: Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD006145. DOI: 10.1002/14651858.CD006145.pub3

Provided by Wiley

Study demonstrates that earlier end of life care discussions are linked to less aggressive care in final days of life

A large population- and health systems-based prospective study reports earlier discussions about end of life (EOL) care preferences are strongly associated with less aggressive care in the last days of life and increased use of hospice care for patients with advanced cancer. The study, published November 13 in the Journal of Clinical Oncology, provides the first-of-its –kind scientific evidence that timing of EOL care discussions affects decisions about EOL care.

14 nov 2012--The findings suggest that initiating EOL care discussions before the last month of life provides the patients opportunity to make decisions regarding their EOL care preferences in a way that late discussions don't seem to do. Patients need time to process the information with their family and make good plans based on that information.

National guidelines recommend that oncologists initiate discussions about EOL care soon after a diagnosis of advanced cancer in order to ensure care aligns with patient goals and wishes. Current guidelines state that conversations should happen "during periods of relative medical stability rather than acute deterioration, and with physicians that know the patient well." In addition, ASCO's own recommendations for patients with advanced cancer include prioritizing discussions related to advanced cancer care preference upon diagnosis. This year ASCO also offered guidance on when oncologists should prioritize palliative and supportive care for patients with advanced cancer who have certain disease characteristics.

"Research has shown that choosing less aggressive care at the end of life offers important benefits for both patients and their caregivers. Patients have a better quality of life in their final days because there is a greater focus on symptom management, and they are more often able to receive care in their homes," said lead author Jennifer W. Mack, MD, MPH, a pediatric hematologist/oncologist at Dana-Farber/Children' Hospital Cancer Center. "This is also important because studies have shown that aggressive care is associated with a higher risk of depression among bereaved caregivers of cancer patients."

In the study, investigators identified discussions about hospice and resuscitation from with 1,231 patients (or surrogates of patients who were deceased or too ill to participate) with end-stage lung or colorectal cancer and via review of their medical records. They found that, on average, EOL discussions were initiated 33 days before death and 39 percent of those discussions occurred within the last 30 days.

Nearly half of all the study participants received at least one form of aggressive care, including chemotherapy in the last 14 days of life, intensive care unit (ICU) care in the last 30 days of life, and acute, hospital-based care in the last 30 days of life. However, compared with cases where EOL discussions took place within the last 30 days of life, cases with earlier EOL discussions were associated with less frequent use of aggressive care (34-45 percent vs. 65 percent) and increased use of hospice care (68-77 percent vs. 49 percent).

"Most patients who recognize that their cancer is terminal want to receive less aggressive care at the end of life," said Dr. Mack. However, aggressive care is still common in this setting, in part because discussions about the end of life are often postponed because they are difficult for both physicians and patients. This study also found that 17 percent of patients or surrogates did not recall EOL care discussions even though they were documented in the medical records, suggesting they may not have fully comprehended the content of the discussion.

The authors emphasize that more research is needed to explore how content of EOL care discussions affects patients' comprehension of the information and subsequent decisions made. In addition, the study underscores a need for a national emphasis from ASCO and many other professional and patient groups on advanced cancer care planning in physician education and training programs.

More information: www.jco.ascopubs.o… ull.pdf+html

Helpful Links from Cancer.Net, ASCO's cancer information website:

Guides to Cancer: http://www.cancer.net/cancer

Advanced Cancer Care Planning: http://www.cancer.net/coping/advanced-cancer-care-planning

Preparation at the End of Life: http://www.cancer.net/coping/end-life-care/preparation-end-life

Hospice Care: http://www.cancer.net/coping/end-life-care/preparation-end-life

When Caregiving Ends: http://www.cancer.net/publications-and-resources/oncologists-perspective/end-life-issues

Cancer.Net Podcast: The Art of Oncology – End-of-Life Care: http://www.cancer.net/coping/end-life-care/preparation-end-life

End-of-Life Issues: http://www.cancer.net/publications-and-resources/oncologists-perspective/end-life-issues

Provided by American Society of Clinical Oncology

Head injury + pesticide exposure = Triple the risk of Parkinson's disease

A new study shows that people who have had a head injury and have lived or worked near areas where the pesticide paraquat was used may be three times more likely to develop Parkinson's disease. The study is published in the November 13, 2012, print issue ofNeurology, the medical journal of the American Academy of Neurology. Paraquat is a herbicide commonly used on crops to control weeds. It can be deadly to humans and animals.

13 nov 2012--"While each of these two factors is associated with an increased risk of Parkinson's on their own, the combination is associated with greater risk than just adding the two factors together," said study author Beate Ritz, MD, PhD, of UCLA's Fielding School of Public Health. "This study suggests that the physiological process that is triggered by a head injury may increase brain cells' vulnerability to attacks from pesticides that can be toxic to the brain or the other way around, for example, chronic low dose exposure to pesticides may increase the risk of Parkinson's after a head injury."

The study involved 357 people with Parkinson's disease and 754 people without the disease, all of whom lived in an agricultural area in central California. The participants reported any head injuries they had ever received with a loss of consciousness for more than five minutes.

The researchers determined participants' exposure to the weed killer based on a 500-meter area around their home and work addresses, using a geographic information system (GIS) that combined data on paraquat use collected by the state of California's Pesticide Use Reporting system with land use maps.

People with Parkinson's disease were twice as likely to have had a head injury with loss of consciousness for more than five minutes as people who did not have the disease. Of the 357 people with Parkinson's disease, 42, or 12 percent, reported ever having had such a head injury, compared to 50 of the 754 people without the disease, or 7 percent.

People with Parkinson's disease were 36 percent more likely to have exposure to paraquat than those who did not have the disease. Of those with Parkinson's, 169 had exposure to the weed killer, or 47 percent, compared to 291 of those without the disease, or 39 percent.

Provided by American Academy of Neurology

Older adults who are frail much more likely to be food insufficient, according to national study

A national study of older Americans shows those who have limited mobility and low physical activity – scientifically categorized as "frail" – are five times more likely to report that they often don't have enough to eat, defined as "food insufficiency," than older adults who were not frail.

12 nov 2012--The nationally representative study of more than 4,700 adults older than age 60 in the United States uses data from the Third National Health and Nutrition Examination Survey. The results are online today in the British Journal of Nutrition.

Lead author Ellen Smit, an epidemiologist at Oregon State University, said food insufficiency occurs when people report that they sometimes or often do not have enough food to eat. Food-insufficient older adults have been shown to have poor dietary intake, nutritional status and health status.

"Although little is known about food insufficiency as it relates to frailty, conceivably we thought if food insufficiency is associated with poorer nutritional status, it may also be associated with physical functioning and frailty," she said.

Frailty is a state of decreased physical functioning and a significant complication of aging that increases the risk for incident falls, fractures, disability, health care expenditures, and premature mortality. People in this study are diagnosed as frail when they meet two of the following criteria: slow walking, muscular weakness, exhaustion and low physical activity.

Smit said as the population ages, with more than 20 percent of Americans expected to be older than 65 by 2030, the need for identifying clinical and population-based strategies to decrease the prevalence and consequences of frailty are needed. In her study, almost 50 percent of people were either frail, or "pre-frail," meaning that they were at risk for decreased physical functioning.

Frail people were older, less educated, at lower income levels, more likely to be female, more likely to be smokers, and less likely to be white than adults who were not frail. Frail people were also more likely to be either underweight or obese, while at the same time eating fewer calories than people who were not frail.

"We need to target interventions on promoting availability and access to nutritious foods among frail older adults," Smit said. "It is also important to improve nutritional status while not necessarily increasing body weight."

Frail adults may have difficulty leaving the house, for instance, and accessing fresh fruits and vegetables. Smit said communities could work on identifying programs or nonprofit organizations that can deliver nutritious meals or fresh produce to older frail adults.

Provided by Oregon State University

Researchers quantify how many years of life are gained by being physically active

This bar graph displays the years of life gained when participants in a study by the National Cancer Institute met various percentages of physical activity guidelines recommended by the US Department of Health and Human Services. Credit: National Cancer Institute

In a new study from Brigham and Women's Hospital, in collaboration with the National Cancer Institute, researchers have quantified how many years of life are gained by being physically active at different levels, among all individuals as well as among various groups with different body mass index.

11 nov 2012--We all know that exercise is good for you, but how good? While previous studies have shown the link between physical activity and a lower risk of premature mortality, the number of years of life expectancy gained among persons with different activity levels has been unclear—until now. In a new study from Brigham and Women's Hospital (BWH), in collaboration with the National Cancer Institute, researchers have quantified how many years of life are gained by being physically active at different levels, among all individuals as well as among various groups with different body mass index (BMI).

The study will be published on November, 2012 in PLOS Medicine.

Researchers from Brigham and Women’s Hospital have quantified how many years of life are gained, by being physically active at different levels, among all individuals as well as among various groups with different body mass index (BMI). Credit: Courtesy of BWH

"We found that adding low amounts of physical activity to one's daily routine, such as 75 minutes of brisk walking per week, was associated with increased longevity: a gain of 1.8 years of life expectancy after age 40, compared with doing no such activity," explained I-Min Lee, MD, associate epidemiologist in the Department of Preventive Medicine at BWH and senior author on this study. "Physical activity above this minimal level was associated with additional gains in longevity. For example, walking briskly for at least 450 minutes a week was associated with a gain of 4.5 years. Further, physical activity was associated with greater longevity among persons in all BMI groups: those normal weight, overweight, and obese."

In pooled data from six prospective cohort studies, the researchers examined associations of leisure-time physical activity of a moderate to vigorous intensity with mortality. They analyzed data from more than 650,000 subjects and followed subjects for an average of ten years- analyzing over 82,000 deaths. The large sample size allowed them to estimate years of life gained after the age of 40 among persons with different levels of physical activity and BMI.

This bar graph displays years of life loss at various body weights and levels of activity. A study by the National Cancer Institute found that physical activity increased life expectancy, regardless of body weight. Credit: National Cancer Institute

The findings show that physical activity was associated with longer life expectancies across a range of activity levels and BMI groups. Participation in a low level of leisure time physical activity of moderate to vigorous intensity, comparable to up to 75 min of brisk walking per week, was associated with a 19 percent reduced risk of mortality compared to no such activity.

Assuming a causal relationship, which is not specifically demonstrated in this research, this level of activity would confer a 1.8 year gain in life expectancy after age 40, compared with no activity. For those who did the equivalent to 150 min of brisk walking per week—the basic amount of physical activity currently recommended by the federal government—the gain in life expectancy was 3.4 years. These benefits were seen in both men and women, and among white and black participants. Importantly, they were also observed among persons who were normal weight, overweight, and obese. Participants faring best were those who were both normal weight and active: among normal weight persons who were active at the level recommended by the federal government, researchers observed a gain in life expectancy of 7.2 years, compared to those with a BMI of 35 or more who did no leisure time physical activity (a 5 ft 5 in tall person with BMI of 35 weighs 210 lb).

"Our findings reinforce prevailing public health messages promoting both a physically active lifestyle and a normal body weight," explained Dr. Steven C. Moore, PhD, research fellow at the National Cancer Institute (NCI) and lead author of this study. This findings may also help convince currently inactive persons that even being modestly active is ''worth it'' for greater longevity, even if it may not result in weight control.

More information: Moore SC, et al. Leisure Time Physical Activity of Moderate to Vigorous Intensity and Mortality: A Large Pooled Cohort Analysis. PLoS Medicine. November 6, 2012. doi: 10.1371/journal.pmed.1001335

Provided by Brigham and Women's Hospital

Physical exercise improves gait speed, muscle strength, fitness in patients with Parkinson's disease

Physical exercise, including treadmill, stretching and resistance exercises, appears to improve gait speed, muscle strength and fitness for patients with Parkinson disease (PD), according to a report of a randomized clinical trial published Online First by Archives of Neurology, a JAMA Network publication.

10 nov 2012--Gait impairment is associated with functional decline in patients with PD and current therapies are inadequate at preserving mobility as PD progresses. There is growing interest in the use of exercise to improve mobility and function, the authors write in the study background.

Lisa M. Shulman, M.D., of the University of Maryland School of Medicine, Baltimore, and colleagues conducted a randomized clinical trial of three types of physical exercise to compare the effectiveness of treadmill, stretching and resistance exercises in improving gait speed, strength and fitness for patients with PD.

The study included 67 patients with PD who had gait impairment and were randomly assigned to one of three groups in the trial: a higher intensity treadmill exercise (30 minutes at 70 percent to 80 percent of heart rate reserve); a lower-intensity treadmill exercise (50 minutes at 40 percent to 50 percent of heart rate reserve); and stretching and resistance exercises (two sets of 10 repetitions on each leg on three resistance machines). Patients performed the exercises three times a week for three months.

"The effects of exercise were seen across all three exercise groups. The lower-intensity treadmill exercise resulted in the greatest improvement in gait speed. Both the higher- and lower-intensity treadmill exercises improved cardiovascular fitness. Only the stretching and resistance exercises improved muscle strength. Therefore, exercise can improve gait speed, muscle strength and fitness for patients with Parkinson disease," the study notes.

According to the study results, all three types of exercise improved distance on the 6-minute walk: lower-intensity treadmill exercise (12 percent increase), stretching and resistance exercises (9 percent increase) , and higher-intensity treadmill exercises (6 percent increase). Both types of treadmill training improved cardiovascular fitness, whereas stretching and resistance had no effect. Only stretching and resistance improved muscle strength (16 percent increase).

"The fact that the lower-intensity treadmill exercise is the most feasible exercise for most patients with PD has important implications for clinical practice. Although treadmill and resistance training are beneficial for gait, fitness and muscle strength, these benefits were not accompanied by improvements in disability and quality of life," the authors conclude. "Future directions for study include trials of combinations of exercise types, longer training periods and investigation of the potential for exercise to modify the trajectory of disease progression over time."

In an editorial, Liana S. Rosenthal, M.D., and E. Ray Dorsey, M.D., M.B.A., of The Johns Hopkins University School of Medicine, Baltimore, Md., write: "In this issue of the journal, Shulman and colleagues offer compelling evidence that exercise can improve gait and fitness among individuals with PD."

"This research adds to the evidence regarding the value of interventions for PD beyond medications and surgery and offers an opportunity for patients to be active participants in their care," they continue.

"Exercise programs among those with neurological disorders increase the patients' sense of self-efficacy, their sense of involvement in their care and overall belief in their abilities to perform certain activities," they conclude. "In essence, exercise puts the patient – not a pill – at the center of care, which is exactly where patients want and ought to be."

More information: 
Arch Neurol. Published online November 5, 2012. doi:10.1001/jamaneurol.2013.646 
Arch Neurol. Published online November 5, 2012. doi:10.1001/jamaneurol.2013.772

Provided by JAMA and Archives Journals