Increased fluctuation in blood pressure linked to impaired cognitive function in older people

Higher variability in visit-to-visit blood pressure readings, independent of average blood pressure, could be related to impaired cognitive function in old age in those already at high risk of cardiovascular disease, suggests a paper published today in BMJ.

31 july 2013--There is increasing evidence that vascular factors contribute in development and progression of dementia. This is of special interest as cardiovascular factors may be amendable and thus potential targets to reduce cognitive decline and the incidence of dementia. Visit-to-visit blood pressure variability has been linked to cerebrovascular damage (relating to the brain and its blood vessels). It has also been shown that this variability can increase the risk of stroke.

It has been suggested that higher blood pressure variability might potentially lead to cognitive impairment through changes in the brain structures.

Researchers from the Leiden University Medical Center (Netherlands), University College Cork (Ireland) and the Glasgow University (UK) therefore investigated the association of visit-to-visit blood pressure variability (independent of average blood pressure) with cognitive function in older subjects at high risk of cardiovascular disease.

All data were obtained from the PROSPER study, which investigated the effect of statins in prevention of vascular events in older men and women. This study took data on 5,461 individuals aged 70-82 years old in Ireland, Scotland and the Netherlands. Average follow-up was three years.

Both systolic (peak pressure) and diastolic (minimum pressure) blood pressures were measured every three months in the same clinical setting. The variability between these measurements were calculated and used in the analyses.

The study used data on cognitive function where the following was tested: selective attention and reaction time; general cognitive speed; immediate and delayed memory performance.

Results showed that visit-to-visit blood pressure variability was associated with worse performance on all cognitive tests. The results were consistent after adjusting for cardiovascular disease and other risk factors.

The main findings of the study were: higher visit-to-visit blood pressure variability is associated with worse performance in different cognitive tests; higher variability is associated with higher risk of stroke and both these associations are independent of various cardiovascular risk factors, in particular, average blood pressure.

Researcher Simon Mooijaart, (Leiden University Medical Centre, Leiden, the Netherlands) says that by using a population of "over five thousand participants and over three years of blood pressure measurements, we showed that high visit-to-visit systolic and diastolic blood pressure variability associates with worse performance in different domains of cognitive function including selection attention, processing speed, immediate verbal memory and delayed verbal memory". The researchers do add though that it is still unclear whether higher blood pressure variability is a cause or consequence of impaired cognitive function.

They suggest several explanations for their findings: firstly that blood pressure variability and cognitive impairment could stem from a common cause, with cardiovascular risk factors being the most likely candidate; secondly that variability might reflect a long term instability in the regulation of blood pressure and blood flow to the key organs in the body; thirdly that exaggerated fluctuations in blood pressure could result in the brain not receiving enough blood, which can cause brain injury, leading to impairment of cognitive function.

The researchers conclude that "higher visit-to-visit blood pressure variability independent of average blood pressure might be a potential risk factor with worse cognitive performance in older subjects at high risk of cardiovascular disease". Given that dementia is a major public health issue, they say that further interventional studies are warranted to establish whether reducing blood pressure variability can decrease the risk of cognitive impairment in old age.

Provided by British Medical Journal

Major changes urged for cancer screening and treatment

To address the growing problem of people being overdiagnosed and overtreated for cancer, a group of scientists convened by the National Cancer Institute and chaired by a UC San Francisco breast cancer expert is proposing a major update of the way the nation approaches diseases now classified as "cancer."

30 july 2013--The "Viewpoint" article will be published online Monday, July 29, in the Journal of the American Medical Association.

When cancer screening programs were widely initiated three decades ago, medical knowledge of the disease was more simplistic. The intent was to detect cancer at its earliest stages to reduce illness and mortality, but in fact early diagnosis has not led to a proportional decline in serious disease and death, the scientists write in the JAMA commentary.

Instead, screening programs are identifying not only malignant cancers, but also slow-growing, low-risk lesions, and sweeping them into the same treatment process. As a result, patients are being diagnosed and treated for forms of cancer that might never actually harm them – a phenomenon that's been termed overdiagnosis, which translates to "too much medicine."

Now, with the advancement of scientific understanding of the biology of cancer, the authors say it is time for significant changes in practice and policy.

"By recognizing that cancer is not one disease, but a number of different diseases, we can individualize our treatment based on biology and avoid overtreatment," said panel chair Laura J. Esserman, MD, MBA, director of the Carol Franc Buck Breast Care Center at the UCSF Helen Diller Family Comprehensive Cancer Center. "The goal going forward is to personalize screening strategies, and focus screening policies on the conditions that are most likely to result in aggressive illness and death."

The authors recommend creation of a new classification for tumors that are indolent (unlikely to cause patients harm). For example, ductal carcinoma of the breast—currently considered the earliest form of breast cancer—would no longer be called cancer. The authors also call for the formation of registries for lesions with low potential for malignancy, and for a multidisciplinary approach across pathology, imaging, surgery and other medical specialties "to revise the taxonomy of lesions now called cancer."

The key, they say, is to improve screening strategies to avoid overtreating tumors that would not be lethal, or that would not even have come to medical attention.

"Although our understanding of the biology of cancer has changed dramatically, perceptions on the part of the public, and among many physicians, have not yet changed," Esserman said. "Cancer is still widely perceived as a diagnosis with lethal consequences if left untreated."

The JAMA article is comprised of recommendations from a working group formed last year during a meeting convened by the National Cancer Institute. The group was charged with developing a strategy to improve current approaches to cancer screening and prevention.

The commentary was co-written by Ian M. Thompson, MD, professor at the University of Texas Health Science Center at San Antonio; and Brian Reid, MD, PhD, director of the Seattle Barrett's Esophagus Program and member of the Human Biology Division at the Fred Hutchison Cancer Research Center in Seattle.

The three authors served as chairs of the NCI working group.

Overdiagnosis is occurring across many medical conditions, but is particularly common in breast cancer, lung cancer, prostate, thyroid cancer and melanoma, said the authors.

They cite DCIS, or ductal carcinoma of the breast, and Barrett's esophagus as illustrations of how the detection and surgical removal of what have been called precancerous lesions have failed to lead to lower rates of invasive cancer.

By contrast, the authors said, colon and cervical cancer serve as examples of "effective screening programs in which early detection and removal of precancerous lesions have reduced incidence as well as late-stage disease."

Cancer screening should have three important missions, the authors write: To detect disease that would ultimately harm the patient; to uncover tumors that benefit from intervention; and to detect disease that is more likely to be cured or better treated when spotted early.

Optimal screening frequency depends on a cancer's growth rate. If a cancer is fast growing, screening is less likely to be effective. "If a cancer is slow growing but progressive, with a long latency and a precancerous lesion, screening is ideal and less frequent screening (eg.10 years for colonoscopy) may be effective," the authors said.

The recommendations include:

• Recognize that screening will identify indolent cancers.
• Change terminology and omit the word "cancer" from premalignant/indolent conditions;
• Convene a multidisciplinary body to revise the current taxonomy of cancer and to create reclassification criteria for indolent conditions;
• Create observational registries for lesions with low potential for malignancy – generate the data to provide patients and their doctors "with confidence to select less invasive interventions;"
• Develop, validate and adopt molecular diagnostic tools that identify indolent or low-risk lesions;
• Mitigate overdiagnosis: appropriately reduce frequency of screening exams while focusing on high-risk populations, and raise the threshold for patients being recalled for re-testing and biopsy.

"Although no physician has the intention to overtreat or overdiagnose cancer, screening and patient awareness have increased the chance of identifying a spectrum of cancers, some of which are not life threatening," the authors wrote. "The ultimate goal is to preferentially detect consequential cancer while avoiding detection of inconsequential disease."

Provided by University of California, San Francisco

A lifespan-extending drug has limited effects on aging

The immunosuppressive drug rapamycin has been shown to increase longevity in mice even when treatment begins at an advanced age. It is unclear if the extension of life also correlates with prolonged health and vigor.

29 july 2013--In the current issue of the Journal of Clinical Investigation, Dan Ehninger and colleagues at the German Center for Neurodegenrative Diseases evaluated age-associated characteristics in mice treated with rapamycin. They found that rapamycin improved memory and spatial learning, reduced thyroid follicle size, and reduced body fat in older mice. However, many of these same attributes were also improved in young mice treated with the drug, indicating an age-independent drug effect.

The prevalence of cancer, a common cause of mouse mortality, was also decreased in older treated mice. The authors did find that rapamycin treatment had no effect on several age related symptoms, including cardiovascular and liver function, loss of muscle mass, strength retention, or balance.

These data suggest that rapamycin treatment may increase lifespan through reduction of cancer rates, and the drug may be useful for relief of some age related conditions.

In the accompanying commentary, Arlan Richards of the University of Texas Health Science Center at San Antonio suggests that clinical trials to study the effect of rapamycin on age related neurodegenerative diseases of the elderly such as Alzheimer's disease should be considered.

More information: J Clin Invest. doi:10.1172/JCI67674

Provided by Journal of Clinical Investigation

Oldest old at risk from social isolation

Using new data from the UK's largest ever social survey, Understanding Society, the Personal Finance Research Centre (PRFC) at the University of Bristol and the International Longevity Centre-UK (ILC-UK) have produced preliminary findings about the 'oldest old' (aged over 85) and their levels of participation, wellbeing and health.

28july 2013--This new analysis, funded by the ESRC's Secondary Data Analysis Initiative, is part of a major project exploring the financial dimensions of wellbeing and wider quality of life measures in older age.

The new research reveals: 

• Around a third of over 85s said they were at least partly dissatisfied with their health, while over three-quarters (78 per cent) of the oldest old felt that their health limited even moderate activities, and about a half felt that pain had interfered with their activities over the past few weeks.
• While over eight in ten of the oldest old (81 per cent) felt they could rely on family 'a lot', more than one in ten (13 per cent) reported not having any friends.
• A worrying 26 per cent of people aged 85 and over reported being at least somewhat dissatisfied with their life overall. On the flip-side, three-quarters of the oldest old were at least somewhat satisfied with their lives.

David Hayes, Research Associate at the PFRC said: "This research is extremely important as we know relatively little about the experiences of those aged over 85 yet this group represents the fastest growing sector of the UK population. With around one in four over 85s at least somewhat dissatisfied with their lives, (much higher than in the general population), policymakers need to devote more time to the issues facing this group."

David Sinclair, Assistant Director, Policy and Communications at ILC-UK added: "This research paints a negative picture of life for far too many people aged over 85. The research backs up ILC-UK's analysis of the English Longitudinal Study of Ageing last year which found that almost four in ten of those aged 85 or older faced some kind of social exclusion. Similarly, our research on centenarians published in December 2011 found that quality of life among the oldest old decreases with age and that the oldest old (aged 85 and over) are, as a group, at greater risk of poverty than younger older people (aged 65-85).

"Bereavement and loneliness is a feature of later life for many. Whilst our new research highlights that over eight in ten of the oldest old could rely on family 'a lot', more than one in ten reported not having any friends. Tackling loneliness and isolation in old age has to become a societal priority."

PRFC and ILC-UK plan to extend analysis of Understanding Society to look at the financial wellbeing of the oldest old.

Provided by University of Bristol

High rate of early delirium after surgery in older adults

Close to half of older adults undergoing surgery with general anesthesia are found to have delirium in the postanesthesia care unit (PACU), according to a study in the August issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

26 july 2013--Delirium occurring early after surgery is linked to decreased cognitive (mental) function and an increased rate of nursing home admission, according to the study by Dr Karin J. Neufeld of Johns Hopkins University and colleagues. They write, "Recognizing delirium in the PACU may be important for identifying patients at higher risk of in-hospital harms…as well as cognitive impairment and institutionalization at hospital discharge."

Many Older Patients Have Delirium after Surgery

The researchers performed testing for delirium in the PACU (recovery room) in 91 older adults undergoing major surgery with general anesthesia. Delirium is defined as "acute change in level of consciousness, inattention, and disturbed cognitive function," and it's a common medical problem—especially in hospitalized patients.

The patients' average age was 79 years, and nearly 80 percent were living independently before their operation. All received widely used forms of general anesthesia for surgery.

On analysis by experts using standard diagnostic criteria, 45 percent of the patients had delirium in the PACU. In many cases, delirium persisted after the patient was moved to the hospital wards. Overall, about three-fourths of all cases of delirium occurring in the hospital after surgery started in the PACU.

Patients with early delirium had decreased mental function, with significant reduction on a standard cognitive test. The decline was significant even after adjustment for other factors, including initial cognitive score and duration of surgery.

Patients with early, persistent delirium were more likely to be discharged to a nursing home or other institution, rather than being sent home: 39 percent, compared to three percent of patients without delirium in the PACU. Of patients who had early delirium but were normal on the day after surgery, 26 percent were discharged to an institution.

A 'Common But Not Universal' Problem

The results show that delirium is a "common but not universal" problem for elderly patients undergoing surgery, according to Dr Neufeld and coauthors. They point out that 55 percent of patients did not have delirium in the PACU. Eighty percent of patients who were free of delirium in the PACU remained normal throughout their hospital stay.

But even brief episodes of postoperative delirium may have lasting effects in older adults, the study suggests. Dr Neufeld and colleagues note that many cases of delirium would have been missed if monitoring had started the day after surgery, rather than in the recovery room. They call for further studies of the rate and impact of early delirium after anesthesia and surgery, including evaluation of longer-term patient outcomes.

More information: www.anesthesia-analgesia.org/content/117/2/471.full

Provided by Wolters Kluwer Health

Many docs don't discuss dietary supplements, study says

Patients need to know more about risks, effectiveness and interactions with conventional drugs.

Patients need to know more about risks, effectiveness and interactions with conventional drugs.

24 july 2013—Doctors do a poor job of providing patients with information about vitamins, minerals, herbs and other dietary supplements, a new study says.

It's an important issue because so many people take these products, which carry risks—including potentially harmful interactions with prescription drugs—and some patients take dietary supplements in place of conventional medicines, the researchers said.

They analyzed transcripts of audio recordings made during office visits by nearly 1,500 patients to 102 primary-care doctors between 1998 and 2010. Of those patients, about 350 had discussions about more than 700 dietary supplements, according to the study, which was published recently in the journal Patient Education and Counseling.

"This is the first study to look at the actual content of conversations about dietary supplements in a primary-care setting," study primary investigator Dr. Derjung Tarn, an assistant professor of family medicine at the David Geffen School of Medicine at the University of California, Los Angeles, said in a university news release.

"The bottom line was that discussions about meaningful topics such as risks, effectiveness and costs that might inform patient decisions about taking dietary supplements were sparse," Tarn said.

The researchers focused on five major topics related to dietary supplements: the reason for taking them, how to take them, potential risks, effectiveness and cost or affordability.

On average, fewer than two of the topics were discussed during the office visits. All five topics were covered during discussions of only six of the more than 700 supplements. None of the topics arose for nearly 300 of the supplements patients told their doctors they were taking.

The researchers did find that discussions about herbal and related supplements were more thorough than those about vitamins and minerals. This is important because herbal and related supplements are more likely to have potentially harmful interactions with conventional medicines.

Both the U.S. Food and Drug Administration and the U.S. National Institutes of Health suggest that patients consult with their doctors before starting to take dietary supplements, the researchers noted.

More information: The U.S. Food and Drug Administration has more about dietary supplements.

No benefit associated with echocardiographic screening in the general population

A study in Norway suggests echocardiographic screening in the general public for structural and valvular heart disease was not associated with benefit for reducing the risk of death, myocardial infarction (heart attack) or stroke, according to a report published by JAMA Internal Medicine, a JAMA Network publication.

23 july 2013--Because of the low prevalence of structural heart disease in the general population, echocardiography has traditionally not been considered justified in low-risk individuals, although echocardiography is recommended for screening asymptomatic individuals with a family history of sudden death or hereditary diseases affecting the heart, according to the study background.

Haakon Lindekleiv, M.D., Ph.D., of the University of Tromsø, Norway, and colleagues examined whether echocardiographic screening in the general population improved long-term survival or reduced the risk of cardiovascular disease in a randomized clinical study.

Researchers studied 6,861 middle-aged participants (3,272 in a screening group and 3,589 in a control group). In the screening group, 290 participants (8.9 percent) underwent follow-up examinations because of abnormal findings and cardiac or valvular pathologic conditions were verified in 249 participants (7.6 percent).

"Among the screening group, the prevalence of structural heart and valvular disease was 7.6 percent, and the most common finding was valvular disease. However, diagnosing asymptomatic disease is useful only if it can lead to clinical action that slows or stops progression of disease. Although sclerosis of the aortic and mitral valves has been associated with a substantial increased risk of cardiovascular disease, we did not find that early diagnosis of valvular disease in the general population translated into reduced risk of death or cardiovascular events," the study notes.

During 15 years of follow-up, 880 people (26.9 percent) in the screening group died and 989 people (27.6 percent) in the control group died. No significant differences were found in the measures for sudden death, mortality from heart disease, or incidence of fatal or nonfatal myocardial infarction and stroke, according to the results.

'This supports existing guidelines that echocardiography is not recommended for cardiovascular risk assessment in asymptomatic adults," the study concludes. "Although our results were negative, we believe that they are of clinical importance because they may contribute to reducing the overuse of echocardiography."

More information: JAMA Intern Med. Published online July 22, 2013. doi:10.1001/jamainternmed.2013.8412

Provided by The JAMA Network Journals

Routine tasks pose problems for older individuals with vitamin D deficiency

Vitamin D-deficient older individuals are more likely to struggle with everyday tasks such as dressing or climbing stairs, according to a recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM).

22 july 2013--Scientists estimate many as 90 percent of older individuals are vitamin D deficient. The vitamin – typically absorbed from sunlight or on a supplementary basis through diet – plays a key role in bone and muscle health. Vitamin D deficiency can lead to a decline in bone density, muscle weakness, osteoporosis or broken bones.

"Seniors who have low levels of vitamin D are more likely to have mobility limitations and to see their physical functioning decline over time," said the study's lead author, Evelien Sohl, MSc, of VU University Medical Center in Amsterdam, the Netherlands. "Older individuals with these limitations are more likely to be admitted to nursing homes and face a higher risk of mortality."

Using data from an ongoing Dutch cohort study (The Longitudinal Aging Study Amsterdam), the researchers examined among two groups – 762 people between the ages of 65 and 88, and 597 people between the ages of 55 and 65 – over the course of six years. Using blood test results, the subjects were split into groups with the highest, moderate and lowest vitamin D levels. To assess mobility limitations, participants were asked about their ability to perform routine tasks, including sitting down and standing up from a chair or walking outside for 5 minutes without resting.

Among the older group of participants, people with the lowest vitamin D levels were 1.7 times more likely to have at least one functional limitation compared to those with the highest vitamin D levels. In the younger cohort, individuals with low vitamin D levels were twice as likely to have at least one physical limitation.

While the majority of the people in the older cohort's top two vitamin D groups did not report any physical limitations, 70 percent of the people with the lowest vitamin D levels had at least one limitation.

In addition, the study found vitamin D-deficient individuals were more likely to develop additional limitations over time. The older cohort reported more mobility issues after three years, while the younger cohort developed additional limitations over the course of six years.

"The findings indicate low vitamin D levels in older individuals may contribute to the declining ability to perform daily activities and live independently," Sohl said. "Vitamin D supplementation could provide a way to prevent physical decline, but the idea needs to be explored further with additional studies."

Provided by The Endocrine Society

Later retirement may help prevent dementia, study says

New research boosts the "use it or lose it" theory about brainpower and staying mentally sharp. People who delay retirement have less risk of developing Alzheimer's disease or other types of dementia, a study of nearly half a million people in France found.

21 july 2013--It's by far the largest study to look at this, and researchers say the conclusion makes sense. Working tends to keep people physically active, socially connected and mentally challenged—all things known to help prevent mental decline.

"For each additional year of work, the risk of getting dementia is reduced by 3.2 percent," said Carole Dufouil, a scientist at INSERM, the French government's health research agency.

She led the study and gave results Monday at the Alzheimer's Association International Conference in Boston.

About 35 million people worldwide have dementia, and Alzheimer's is the most common type. In the U.S., about 5 million have Alzheimer's—1 in 9 people aged 65 and over. What causes the mind-robbing disease isn't known and there is no cure or any treatments that slow its progression.

France has had some of the best Alzheimer's research in the world, partly because its former president, Nicolas Sarkozy, made it a priority. The country also has detailed health records on self-employed people who pay into a Medicare-like health system.

Researchers used these records on more than 429,000 workers, most of whom were shopkeepers or craftsmen such as bakers and woodworkers. They were 74 on average and had been retired for an average of 12 years.

Nearly 3 percent had developed dementia but the risk of this was lower for each year of age at retirement. Someone who retired at 65 had about a 15 percent lower risk of developing dementia compared to someone retiring at 60, after other factors that affect those odds were taken into account, Dufouil said.

To rule out the possibility that mental decline may have led people to retire earlier, researchers did analyses that eliminated people who developed dementia within 5 years of retirement, and within 10 years of it.

"The trend is exactly the same," suggesting that work was having an effect on cognition, not the other way around, Dufouil said.

France mandates retirement in various jobs—civil servants must retire by 65, she said. The new study suggests "people should work as long as they want" because it may have health benefits, she said.

June Springer, who just turned 90, thinks it does. She was hired as a full-time receptionist at Caffi Plumbing & Heating in Alexandria, Virginia, eight years ago.

"I'd like to give credit to the company for hiring me at that age," she said. "It's a joy to work, being with people and keeping up with current events. I love doing what I do. As long as God grants me the brain to use I'll take it every day."

Heather Snyder, director of medical and scientific operations for the Alzheimer's Association, said the study results don't mean everyone needs to delay retirement.

"It's more staying cognitively active, staying socially active, continue to be engaged in whatever it is that's enjoyable to you" that's important, she said.

"My parents are retired but they're busier than ever. They're taking classes at their local university, they're continuing to attend lectures and they're continuing to stay cognitively engaged and socially engaged in their lives."

More information: Alzheimer's info: www.alzheimers.gov
Alzheimer's Association: www.alz.org

Caregivers open to stopping cancer screening as dementia progresses

Research from the Regenstrief Institute and the Indiana University Center for Aging Research has found that many family caregivers of older adults with dementia are willing to consider stopping cancer screening of the elderly individual; they are also relieved when the older adult's physician brings it up.

20 july 2013--"This openness of dementia caregivers to considering cancer screening cessation for older adults provides potential to reduce both patient burden and health care costs as well as family caregiver distress, while improving the overall quality of care for patients with dementia," said Regenstrief Institute investigator Alexia Torke, M.D., an IU Center for Aging Research scientist and an associate professor of medicine at the IU School of Medicine, who led the study. She points to other research showing that patients with serious illness such as dementia often receive cancer screening tests such as colonoscopy and mammography that may be burdensome to the patient but unlikely to be beneficial.

The researchers conducted focus groups with caregivers—from urban and suburban settings in one Midwest metropolitan area and of differing socio-economic status—attending support meetings for family members ofdementia patients. The investigators found that caregivers' concerns about cancer screening for older adults with dementia targeted four areas:

• Quality versus quantity of life.
• Burdens placed on the patient and caregiver by the screening.
• How to end screening.
• Variability of physician expertise on the risks and benefits of screening for this population.

"As dementia progresses, caregivers must take over the process of medical decision-making," Dr. Torke said. "Prior to our study, little had been known about how decisions to continue or stop screening are actually made by caregivers of family members with dementia, or if caregivers' perspectives on cancer screening were as positive as previous studies have found in other populations, including older adults."

For example, the perspective of the caregivers, who mostly favored forgoing cancer screening for older adults with dementia, differs from the perspective of older adults without cognitive impairment. A previous study conducted by the authors of this study found that adults who were not cognitively impaired viewed cancer screening as an automatic, recommended or obligatory action.

The researchers report in this new study that caregivers of people with dementia are not only willing to consider stopping cancer screening, many are relieved when physicians bring it up. Caregivers are most open to discussions of screening cessation when these discussions focus on quality of life and burdens and benefits for the person with dementia.

One caregiver said, "I was concerned about her quality of life and making sure that she was very, very comfortable, and I think that means more than putting people through a lot of unnecessary, uncomfortable … procedures. … It's not going to make the person better. It might make them linger on, but are you really living?"

The caregiver of another older adult said specifically of colon cancer screening, "At the point where my mother is right now, there's no way in the world I could get her to drink all that stuff and not eat. I'm thinking who's going to monitor all 24 hours a day? I can't do it. I can't do it. It's utterly impossible. So I can't send her through that and I can't go through it."

The caregivers, men and women ranging in age from 49 to 85, were primarily spouses or children of older adults with dementia.

Provided by Indiana University

Early detection and treatment of Alzheimer's disease prevents psychological and behavioral symptoms

Persons with Alzheimer's disease are able to manage their everyday activities longer and they suffer from less psychological and behavioural symptoms if the diagnosis is made and treatment begun at a very early phase of the disease, indicates a recent study conducted at the University of Eastern Finland.

19 july 2013--The study followed persons with Alzheimer's disease over a course of three years. The study participants were diagnosed either at the very mild or mild phase of the disease and treated within the standard healthcare system.

According to the study, persons with a very mild Alzheimer's disease at the time of the diagnosis and start of the Alzheimer's disease targeted therapy are better able to manage their everyday activities than persons diagnosed at a more advanced phase of the disease. In addition, in relation to the stage of the disease, they also had less psychological and behavioural symptoms during the follow-up.

According to the researchers, Psychologist Ilona Hallikainen and Adjunct Professor, Psychologist Tuomo Hänninen, the results show that an early detection of the disease is important. Persons with Alzheimer's disease may be able to live at home longer if they are able to manage their daily activities and have less psychological and behavioural symptoms.

In addition, the study enhanced knowledge about the use of common diagnostic tests during a follow-up. The results have been accepted for publication in the journal International Psychogeriatrics. Ms. Hallikainen presented the results at the Alzheimer's Association International Conference (AAIC) in Boston on 17 July.

More information: DOI: 10.1017/S1041610213000653

Provided by University of Eastern Finland

Scientists detail alzheimer's progression, step by step

As researchers learn more, therapy might someday address brain changes much sooner.

As researchers learn more, therapy might someday address brain changes much sooner.

18 july 2013—New research seeks to delineate just how Alzheimer's disease unfolds in the human brain.

Biological changes may happen earlier than scientists had previously thought, according to a new disease model. This suggests that early signs of risk could potentially become treatment targets long before symptoms of Alzheimer's begin to appear, the researchers said.

"We're getting a better idea of what is happening during the asymptomatic [symptomless] phases of the disease," said Dean Hartley, director of science initiatives at the Alzheimer's Association, who was not involved with the new research.

The scientists behind the new research identified distinct but overlapping phases in the course of Alzheimer's disease, each detectable by biological "markers" showing physical changes in the brain. They also have refined their model to distinguish between these "biomarkers" of Alzheimer's disease and those of normal aging.

In the first phase of Alzheimer's, brain markers signaling changes in beta-amyloid protein show up first, the model suggests. Beta-amyloid plaques are protein pieces from the fatty membrane surrounding nerve cells that clump together, contributing to nerve dysfunction.

In the second phase of the disease, signs of degeneration and death of brain cells occur.

Symptoms of dementia are seen in the third phase of Alzheimer's disease, according to the new model.

The refined model should help researchers design better research, guide the selection of study participants, suggest the ideal time to begin treatment and help measure the impact of treatment, said Dr. Clifford Jack Jr.

Jack is lead author of one of three related studies to be presented Tuesday at the Alzheimer's Association International Conference, in Boston. He said his research has been accepted for publication in the journal Neurology.

In addition to beta-amyloid proteins, "tau"—another protein—also plays a role in Alzheimer's, creating what are called "neurofibrillary tangles." Jack said the changes in the brain created by tau seem to occur first, but amyloid aggregation, or clumping, accelerates the changes in tau and causes it to spread.

The central message is that tau and beta-amyloid plaque interact with each other in a synergistic way, said Jack, a professor of radiology and a neuroradiologist at the Mayo Clinic College of Medicine, in Rochester, Minn.

Alzheimer's disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills. Symptoms typically appear after age 60, and about 5 million Americans may have the disease, according to the U.S. National Institute on Aging.

Jack and his team published a hypothetical model of the major Alzheimer's disease biomarkers in Neurology in 2010, describing how the biomarkers changed over time and were related to the beginning and progression of symptoms. For this study, the team reviewed studies that tested and evaluated that model, spurring them to further refine it.

How could the model spark new ideas for treating Alzheimer's disease? "What really makes sense probably is a combined therapeutic approach where you target a point or points in tau and in the amyloid pathways simultaneously," Jack explained.

Just as people often take statins—drugs that lower cholesterol—to reduce their risk of heart disease, it could someday be possible that those at risk for Alzheimer's could take medication to help prevent it, Jack said. He envisions a "cocktail" or combination of drugs that could target different points in the molecular pathways of the disease, administered at an early age, depending on a person's risk for Alzheimer's disease.

The Alzheimer's Association's Hartley said he's excited about the revised model. "It suggests that some of the treatments we're using may be too late in the progression of the disease."

Two related studies were also scheduled for presentation at the meeting. Dr. Victor Villemagne at the University of Melbourne, in Australia, and colleagues followed about 200 people with and without signs of Alzheimer's disease over four years to estimate when beta-amyloid levels tend to become abnormal. The scientists concluded that Alzheimer's disease is a slow process, likely extending for more than 20 years.

The other study, led by Daniela Bertens at VU University Medical Center, in Amsterdam, Holland, provided more evidence that abnormal beta-amyloid is what triggers the development of Alzheimer's disease. The research included about 300 people with abnormal beta-amyloid, and followed them over four years, testing their cerebrospinal fluid for diagnostic signs of the disease.

Because these studies were presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

More information: Learn more about Alzheimer's disease from the U.S. National Institute on Aging.

What are fructooliogosaccharides and how do they provide health benefits?

A new presentation today at the 2013 Institute of Food Technologists (IFT) Annual Meeting & Expo in Chicago focused on the health benefits of short-chain fructooliogosaccharides (scFOS), which are low-calorie, non-digestible carbohydrates that can improve food taste and texture while aiding immunity, bone health and the growth and balance of important bacteria in the digestive track.

17 july 2013--Fructooliogosaccharides are naturally found in chicory, onions, asparagus, wheat, tomatoes and other fruits, vegetables and grains. They also can be derived from cane sugar and seaweed for use as a low-calorie (1.5—2 Kcal/g) food sweetener and supplement. As scFOS provides approximately 30-to-50 percent of the sweetness of regular sugar, it can be used to enhance flavor and lower the amount of sugar in a food product.

In addition, scFOS are considered prebiotics. After they are consumed, fructooliogosaccharides move to the large intestine to stimulate the production of microbiota in the colon and gastrointestinal track.

Microbiotas are "friendly, beneficial" bacteria, said Kelly A. Tappenden, Ph.D., Kraft Foods human nutrition endowed professor at the University of Illinois at Urbana-Champaign and editor-in-chief of the Journal of Parenteral and Enteral Nutrition. Microbiotas produce essential nutrients such as short-chain fatty acids; control epithelial cell growth (the cells that line body cavities); prevent overgrowth of infectious organisms; boost intestinal immunity; and prevent inflammation, diarrhea and other intestinal conditions. This "essential ecosystem" provides an important "balance between health and disease" in the body.

Fructooliogosaccharides also increase calcium absorption in the body, an important consideration for pre- and post-menopausal women, ages 45 and older, who are losing critical bone mass that increases their risk for osteoporosis and bone fractures.

The regular addition of scFOS to the diet is "ideal for maintaining mineral density and (bone) strength," said Phillip Allsopp, Ph.D., research associate at the University of Ulster in Coleraine, Ireland.

Most Americans, including many formula-fed infants and children, do not get enough scFOS, said Cristina Munteanu, senior technical service technologist at Ingredion, Inc.

As an additive, scFOS is a clear, stable powder suitable for pasteurization, baking and beverages, said Munteanu. It can be found in milk, yogurts and other dairy products, as well as snacks, cereal, bars and candy.

Provided by Institute of Food Technologists

An end-of-life 'conversation guide' for physicians to speak with patients

How does a doctor tackle the delicate issue of end-of-life care planning with a patient?

16 july 2013--With an aging population and people living longer with chronic illness, it is increasingly important for patients and family members to decide how they and their loved ones would like to spend their final days. And for physicians in both hospital and primary care settings, it is crucial that they know how to address this issue with sensitivity.

A new "conversation guide" in CMAJ (Canadian Medical Association Journal) aims to guide physicians through these sensitive discussions with patients in hospital and their family members.

Although primary care physicians have an essential role to play in advance care planning, this review focuses on physicians and patients in hospital.

"A stay in hospital presents an important opportunity for engaging in discussions about goals of care, because it signals a change in the trajectory of the patient's illness, giving increased relevance to these conversations, and because potential substitute decision-makers (e.g., the most involved family members) are often present," writes Dr. John You, Department of Medicine and the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, with coauthors.

"By providing structured guidance, specific advice and practical tools, our aim is to increase clinicians' confidence in engaging in meaningful end-of-life communication with patients in hospital and their family members," they write.

The authors provide a framework that will help inform decisions based on:

• identifying patients at high risk of dying
• communicating prognosis
• clarifying patient values around the care plan
• involving substitute-decision makers in care planning
• documenting a patient's wishes.

"Clinicians should exercise judgment and flexibility in engaging patients and family members in these discussions, recognizing that determining goals of care is a process. For patients who have existing advance directives, this process may be straightforward; for others who may be less prepared, the discussion may best unfold in a phased approach, with initial introduction and probing of this issue early during the stay in hospital and more detailed follow up later on," write the authors.

They suggest that efforts should be made to increase public awareness outside hospitals about the importance of advance end-of-life care planning and the limitations of life-sustaining technologies.

More information: www.cmaj.ca/lookup/doi/10.1503/cmaj.121274

Provided by Canadian Medical Association Journal

Undiagnosed pre-diabetes highly prevalent in early Alzheimer's disease study

When Georgetown University neurologist R. Scott Turner, MD, PhD, began enrolling people with mild to moderate Alzheimer's disease into a nationwide study last year, he expected to find only a handful of participants with undiagnosed glucose intolerance, as all the patients were already under a doctor's care and those with known diabetes were excluded. But Turner says he was "shocked" by how many study participants were found to have pre-diabetes—a finding that is triggering important questions.

15 july 2013--Turner's study examines resveratrol, a compound found in red grapes and red wine, to see if it might change glucose levels in patients with mild to moderate Alzheimer's disease (AD). Turner says resveratrol is thought to act on proteins in the brain in a way that mimics effects of a low-calorie diet.

"We know from animal studies that caloric restriction prevents diseases of aging such as diabetes and Alzheimer's," explains Turner, director of the Georgetown University Medical Center's Memory Disorders Program. "On the flip side of the coin, having diabetes increases one's risk of developing AD. So perhaps by improving glucose tolerance, we will prevent or delay both diabetes and Alzheimer's."

To join the resveratrol study, participants were first given a fasting glucose tolerance test to obtain a baseline level, and then retested two hours after eating. During digestion, the blood sugar level increases, but the pancreas produces insulin to lower it. A high sugar level after two hours reveals glucose intolerance (pre-diabetes) or diabetes if the level is very high.

"The number of people with glucose intolerance (pre-diabetes) was much higher than expected," says Turner. "I was surprised by how many people didn't know they were pre-diabetic, and these are individuals who already get the best medical care."

Five (4 percent) of 128 participants had impaired fasting glucose levels while three others (2 percent) had findings consistent with type 2 diabetes mellitus. Of the 125 subjects who completed the two-hour test, 38 (30 percent) demonstrated glucose intolerance while 16 (13 percent) had results consistent with diabetes. Thus, the overall prevalence of impaired glucose tolerance or diabetes at two hours was 43 percent – or almost half of the individuals recruited to the study.

Turner asks, "How does glucose intolerance or diabetes lead to AD? Does the inflammation associated with AD trigger glucose intolerance? Or do both events create a vicious cycle of Alzheimer's and glucose intolerance?"

Turner's study isn't designed to answer these questions, but it might provide important clues. Turner says while a glucose tolerance test is not typically ordered by neurologists, "this result suggests that perhaps we should test all our patients with early Alzheimer's. It's a simple, inexpensive study that reveals critical health information."

Turner will discuss his findings at the Alzheimer's Association International Congress in Boston on July 14.

The resveratrol study is sponsored by the Alzheimer's Disease Cooperative Study through a grant from the National Institute on Aging. Turner reports no personal financial interests related to the study.

Provided by Georgetown University Medical Center

People with Alzheimer's disease may have lower risk of cancer and vice versa

Older people with Alzheimer's disease are less likely to also have cancer, and older people with cancer are less likely to also have Alzheimer's disease, according to the largest study to date on the topic, which appears in the July 10, 2013, online issue of Neurology, the medical journal of the American Academy of Neurology.

14 july 2013--"Since the number of cases of both Alzheimer's disease and cancer increase exponentially as people age, understanding the mechanisms behind this relationship may help us better develop new treatments for both diseases," said study author Massimo Musicco, MD, of the National Research Council of Italy in Milan.

The study involved 204,468 people age 60 and older in northern Italy during a six-year period. During that time, 21,451 people developed cancer and 2,832 people developed Alzheimer's disease.

A total of 161 people had both cancer and Alzheimer's disease, whereas that number would have been expected to be 281 for cancer and 246 for Alzheimer's disease when considering how often the diseases occur in the general population. Therefore the risk of cancer was cut in half for people with Alzheimer's disease, and the risk of Alzheimer's disease was reduced by 35 percent for people with cancer.

"While other studies have noted this relationship before, this is the largest study to date and it has several strengths over previous studies, such as looking for the presence of the second disease both before and after the first disease was diagnosed," Musicco said. "This controls for the possibility that the presence of one disease might obscure the diagnosis of other diseases because any new symptoms might be interpreted as a consequence of the already-diagnosed disease, or in the case of cancer, people might assume that memory problems were a side effect of chemotherapy."

The researchers found the same result in people who died during the course of the study as well as those still living, controlling for the possibility that the reduced life expectancy for the first disease would also reduce the likelihood of living to develop the second disease.

Provided by American Academy of Neurology

China island centenarians claim secret of long life

The elderly residents of one Chinese county have endured invasion, civil war and famine, and many live in unheated concrete shacks on only a few dollars a day. But they are apparently among the longest-lived people on earth.

13 july 2013--Chengmai, a string of villages dotted with orange plantations in the tropical island province of Hainan, claims more than 200 residents aged over 100 out of a population of 560,000—one of the highest ratios in the world.

They are said to include at least three "supercentenarians"—the name given to those aged over 110—out of fewer than 400 thought to exist worldwide.

Li Aizhu, whose government-issued residence permit says she was born in 1900, hobbles daily from her tiny concrete bedroom, where an electric fan beats back the intense heat, to watch quacking ducks waddle past her family farmhouse.

"Who are these people?" Li asked relatives when visitors arrived, a shock of white hair framing her wrinkled face.

She aimed the same question at government officials who arrived with a metal plaque declaring her to be a "longevity celebrity", her family said. It now hangs above a hard wooden bench in her simple living room, entitling her to a 500 yuan ($81) monthly payment, and free medical treatment.

Other clusters of longevity are said to include Cuba, islands off Greece and Japan, and a peninsula in Costa Rica, with researchers finding common characteristics including an emphasis on family, lifestyles requiring physical activity, and a plant-based diet.

As China was swept by dramatic changes—from Japanese invasion, to the Communist victory in the civil war, and a transition from a planned economy to the market—most Chengmai residents carried on doing what they had always done, growing crops.

"I've never done any exercise, except hard farmwork," said 86 year-old Wang Kailu, who lives in a simple concrete shack with his wife Wu Aihe. The couple said they married the day after Japan's World War Two surrender, 68 years ago.

Their one-storey dwelling is barely furnished and Wang draws water from a well to spread on his small vegetable plot.

Experts on ageing who have travelled to the area say several factors could be involved in the phenomenon.

Jennifer Holdaway, who runs the China Environment and Health Initiative of the US-based Social Science Research Council and visited Chengmai for a government-funded conference last year, pointed out that its economy was centred around agriculture.

"There is not a lot of industry, the climate is good, they can get exercise easily, and the diet is healthy; they have plenty of fresh fruit and vegetables, and the soil is also naturally high in selenium", an essential nutrient, she said.

Locals, though, claimed a healthy reliance on alcohol was vital. Xu Yuhe, whose residency permit lists her as 104, told AFP that she takes daily shots of "Three Coconut Spring" a local grain spirit.

"I drink alcohol every evening, just a little bit, it helps you feel warm," added Sheng She, an 80-year-old who says she has 31 children and grandchildren.

Experts say an active social life is also a key to longevity, and each morning dozens of Chengmai's elderly pack out benches in a teahouse, with men at the back playing cards and women at the front, chatting and listening to clattering opera recordings.

"I come here every morning to exercise, watch opera and drink tea," said Sheng, before darting out to test her strength on a yellow-painted metal exercise machine.

A study commissioned by Chengmai's Communist Party committee put its residents' lifespans down to their being "diligent, simple-minded and magnanimous, mainly taking a vegetarian diet, eating sensibly, early to bed early to rise."

The county has coralled its centenarians into singing concerts and paraded them for the media as it seeks to promote itself as a centre of long life.

Property companies—which have developed large swathes of Hainan in recent years—also hope to cash in, with the island a hotspot for retirees from across China.

Soaring clumps of newly-built apartment blocks dot the county, with one named "Longevity City" trumpeting the ageing population in its advertising.

But while Chengmai has stepped up investment in elderly care—AFP visited a newly built set of huts for housing those whose families cannot look after them—facilities for the aged themselves remain basic.

Experts say longevity zones around the world are rarely in rich areas.

"If you're living in a climate like that you don't need very much to be comfortable: simple housing, a mosquito net, some rattan chairs and other people to hang out with," said Holdaway.

"It's a different matter if you live in the North where you have to spend a lot of time indoors and fresh food is expensive in the winter."

Li Aizhu, though, has a simpler explanation. "We asked her once," said the 113-year-old's great-granddaughter, Yi Mei. "She said its because she eats a lot of peanut oil, that's her secret."

Accepting what cannot be changed is key to happiness in old age after loss of independence

When older adults lose control as they move into residential care, they adapt and accept what cannot be changed in order to stay happy. According to a new study, by Jaclyn Broadbent, Shikkiah de Quadros-Wander and Jane McGillivray from Deakin University in Australia, when it comes to satisfaction in later life the ability to accept what cannot be changed is as important as the feeling of being able to exert control. Their work is published online in Springer's Journal of Happiness Studies.

12 july 2013--Ageing with satisfaction has been linked to maintaining a sense of control into the later years. Perceived control consists of two components. Primary control relates to the capacity to make changes to the environment to suit your desire or needs - this applies to older adults living independently in the community. Secondary control describes making cognitive changes within yourself to adapt to the environment - for example when older adults move into residential care. In effect, secondary control buffers losses in primary control by helping us to accept what cannot be changed.

Broadbent, de Quadros-Wander and McGillivray evaluated the differences in levels of life satisfaction and perceived control between 101 older people living in residential care and another 101 living in the community. They also compared how these two types of control might predict well-being in later life. The authors looked at eight key domains of satisfaction: standard of living, health, achieving in life, personal relationships, safety, community connectedness, future security, and spirituality and religion.

Their analyses revealed that the unique relationship between primary control and satisfaction was always larger for the elderly living in the community than those in residential care. Equally, the contribution of secondary control to satisfaction was larger in the residential care group than in the community group. Having a strong sense of control is therefore likely to be more important to older adults living in the community than those living in residential care. In contrast, acceptance is likely to be more important to the well-being of care residents than community dwellers.

The authors conclude: "In order to protect the well-being of older individuals, adaptation involves both a sense of control and the active acceptance of what cannot be changed. Primary and secondary perceived control may predict satisfaction with comparable strength depending on the older person's situation. Acceptance takes more of a prime position in low control situations."

More information: Broadbent J, de Quadros-Wander S, & McGillivray J (2013). Perceived Control's Influence on Well-being in Residential Care vs. Community Dwelling Older Adults. Journal of Happiness Studies; DOI 10.1007/s10902-013-9452-9

Provided by Springer

Negative effects of vitamins on voles cast doubt on health supplement benefits

Vitamin C and vitamin E dramatically reduce the lifespan of voles, biologists have found, raising questions about the benefits of vitamins as a health supplement.

11 july 2013--A new paper published in the journal Biology Letters explains the research. The team fed field voles a diet supplemented with high levels of vitamin E or vitamin C from the age of two months in either warm or cold conditions and compared their longevity to groups of voles fed a regular diet.

High doses of dietary antioxidants such as vitamins are commonly suggested to slow the process of cellular ageing by lessening the damage to proteins, lipids and DNA caused by free radicals.

Previous research conducted by the team had shown that the longevity of mice could be extended by administering particular vitamin supplements, despite the supplements' limited effectiveness in reducing free radical damage.

However, the opposite was found to be true in voles. Voles in cold conditions fed supplements of vitamin E or vitamin C lived much shorter on average than those fed a regular diet. Similarly, in warm conditions, supplemented voles fed vitamin E or vitamin C lived much shorter than those fed a regular diet. Compared to animals on a regular diet, lifespan was reduced by 11% and 26% for vitamin E and C voles in the cold and by 17% and 18% for vitamin E and C voles in the warm. Despite the effect on the voles' lifespans, the researchers found that the vitamin supplements did have some effect in decreasing free radical damage.

Professor Colin Selman of the University of Glasgow's Institute of Biodiversity, Animal Health and Comparative Medicine, who was first author on the work, said: "When we began our research, we expected that voles' lifespans would be boosted by the vitamin supplements in a similar way to the mice we had tested previously, so we were surprised to see that was not the case. Our findings suggest that major differences exist in the effects of high doses of antioxidants on oxidative damage and lifespan across species."

Professor John Speakman, of the University of Aberdeen, who led the work, said: "It's unlikely that randomised controlled trials examining the effects of antioxidant supplementation on human lifespan would be possible, so we are dependent on the results of animal studies. It's impossible at this stage to extrapolate the results from this small amount of data we have on voles and mice but it does suggest that caution is warranted in the use of high doses of antioxidant vitamins."

More information: The paper, titled 'Deleterious consequences of antioxidant supplementation on lifespan in a wild-derived mammal', is published in Biology Letters and is available online atrsbl.royalsocietypublishing.org/content/9/4/20130432.full

Provided by University of Glasgow

Brazil to lure foreigners to fill public health posts

Brazil launched a program Monday to lure thousands of foreign doctors to fill vacancies in its public health system, a move criticized by many domestic health care professionals.

10 july 2013--Improving public health services was one of the key demands made by hundreds of thousands of Brazilians who staged three weeks of nationwide street protests last month.

President Dilma Rousseff said the initiative , which will be implemented by presidential decree, will involve 10,000 posts and an investment of around $1.27 billion.

The government said the three-year posts, with a monthly pay of $4,500, would be filled mainly by Brazilian doctors, but foreign counterparts would also be used to fill the gap.

Those selected will begin working in mid-September, mainly in the country's hinterland and poor suburbs of major cities.

"Every Brazilian must have access to a doctor," Rousseff said. "Brazil is short of doctors. If we don't have enough in Brazil, we will look for good doctors wherever they are."

Foreign applicants must come from countries where there are more than 1.8 doctors per 1,000 inhabitants, such as Spain, Portugal, Argentina or Cuba.

But the daily Folha de Sao Paulo reported Monday that the government dropped plans to import thousands of Cuban doctors and instead decided to turn to those from Spain and Portugal. There was no explanation as to why.

"It is an emergency measure to resolve a serious and urgent problem," Rousseff said. "Nobody should be afraid, I will never take away jobs from our professionals or put the health of the population at risk."

The health ministry said there was a shortage of 54,000 doctors across the country.

But Brazilian doctors' associations last month slammed the plan to lure foreign doctors, insisting that the problem was not a shortage of doctors but rather poor management and a lack of resources in the public health sector.

Doctors, nurses and other health care professionals last month joined the nationwide street protests to express their displeasure over the government program.