Vitamin D supplements have little effect on risk of falls in older people

A new meta-analysis, published in The Lancet Diabetes & Endocrinology journal, concludes that there is no evidence to suggest that vitamin D supplements prevent falls, and that ongoing trials to test this theory are unlikely to change this result.

28 april 2014--The study, by Dr Mark Bolland of the University of Auckland, New Zealand, and colleagues, analysed findings from 20 randomised controlled trials which tested the potential of vitamin D supplements to reduce falls, in a total of 29535 people. The findings show that supplements do not reduce falls by 15% or more, meaning that the amount that vitamin D supplementation reduces fall risk at a population level is very low.

Falls can be devastating for older people, and strategies to reduce fall risk are urgently needed as the global population ages. The results of trials that have investigated the ability of vitamin D to prevent falls—and those of previous meta-analyses—have been mixed. It is unclear how vitamin D supplements might prevent falls but, until now, there has been enough positive evidence to support its recommendation by some health organisations.

Bolland and colleagues' findings add to those of previous meta-analyses by also applying trial sequential analysis, which predicts the potential of future trials with a similar design to sway existing evidence. Their results suggest that trials in progress are unlikely to overturn the finding that vitamin D supplements do not appreciably reduce falls, and they conclude that there is insufficient evidence to support prescribing vitamin D to reduce falls.

However, the authors report that existing evidence does not show whether vitamin D might reduce falls in particularly vulnerable older people—ie, those who fall often. This is because most clinical trials report only the total number of falls in the study population, rather than the number of falls per person in the study.

According to Clifford Rosen of Maine Medical Research Institute, Scarborough, USA, and Christine Taylor of the National Institutes of Health, Bethesda, USA, both authors of a Comment linked to the study, "Whether a large trial is feasible in this vulnerable population remains to be established. Until then, we are left with uncertainty about the benefits of vitamin D supplementation for reduction in fall risk, particularly among vulnerable older people."

More information: http://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70068-3/abstract

Provided by Lancet

Brasil vive 'revolução da longevidade', diz médico Alexandre Kalache MARIANA BOMFIM A sociedade brasileira passa pela revolução da longevidade, afirmou o médico e presidente do Centro Internacional de Longevidade, Alexandre Kalache, nesta quinta-feira (27), durante o Fórum a Saúde do Brasil, realizado pela Folha em São Paulo. Kalache citou dados sobre a evolução, nas últimas décadas, e as estimativas para o futuro da taxa de fecundidade e da expectativa de vida ao nascer. Hoje as brasileiras têm uma média de 1,74 filhos ao longo da vida, enquanto na década de 1970 a taxa era de 5,8 filhos. Os brasileiros também estão vivendo mais. Em 1970, a esperança de vida era de 53,5 anos e hoje ultrapassa os 75. "Daqui a três décadas, nós seremos um país tão envelhecido quanto Japão é hoje", comparou Kalache. "Essa longevidade é uma dádiva, mas traz desafios importantes". O médico destaca que, nos países desenvolvidos, onde a revolução já ocorreu, houve enriquecimento antes do envelhecimento. Já no Brasil, a população está envelhecendo em condições de pobreza, o que transforma a velhice em fardo. Para Kalache, é importante executar políticas públicas que garantam a qualidade de vida dos idosos nesses anos de vida que eles ganharam. "Cada vez mais as mortes de pessoas com mais de 60 anos são decorrentes de doenças crônicas, como hipertensão e diabetes, que incapacitam e tiram a qualidade de vida da pessoa", afirma. Segundo dado citado pelo médico, a proporção de mortes de pessoas acima de 60 anos corresponde a 67% do total. O desafio é investir na saúde dos idosos, já que, nessa faixa de idade ela requisita mais recursos. Ele disse que "o grande gasto com saúde geralmente está no último ano de vida". Contudo, os gastos previstos pelo governo federal com a saúde do idoso não estão sendo aplicados, de acordo com números mostrados durante a palestra. O Ministério da Saúde previu um orçamento de R$ 28,5 milhões para a Política de Atenção à Saúde do Idoso, mas só aplicou R$ 14,8 milhões. Para o Programa de Direitos do Idoso, da Secretaria dos Direitos Humanos, estavam previstos R$ 5,8 milhões, dos quais só R$ 623 mil foram gastos. ENVELHECIMENTO ATIVO Ex-chefe do Programa de Envelhecimento e Saúde da OMS (Organização Mundial da Saúde), Kalache acredita que envelhecer com acesso a serviços, renda e autonomia conferem dignidade a essa fase da vida. "Otimizar as oportunidades de saúde, de educação continuada e de participação na vida social, de modo a alimentar a qualidade de vida significa promover envelhecimento ativo", afirma. "Todos devem abraçar o envelhecimento, seja qual for a área de atuação, porque essa revolução está aqui para ficar", concluiu.

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Boston-area researchers develop new delirium severity measure for older adults

A new method for measuring delirium severity in older adults has been developed by researchers from Harvard, Brown, and UMASS. The new scoring system, CAM-S, is based on the Confusion Assessment Method (CAM) and standardizes the measurement of delirium severity for both clinical and research uses. Details of this study are published in Annals of Internal Medicine.

20 april2014-Delirium is defined as the sudden onset of confusion or change in mental status that is often brought about by physical illness, surgery, or hospitalization. Delirium is a common and often costly condition that is a leading complication among older adults who are hospitalized. In fact, studies suggest that delirium in adults ages 65 and older is associated with hospital mortality rates of up to 33%, with estimated annual healthcare costs of more than $182 billion per year.

"Currently, the CAM is the most widely used tool in the world to screen for delirium," says Sharon K. Inouye, M.D., M.P.H., Director of the Aging Brain Center at the Harvard Medical School (HMS)–affiliated Hebrew SeniorLife Institute for Aging Research (IFAR) in Boston and HMS Professor of Medicine. "Our study is the first to develop and test this important new methodology, and to demonstrate the validity and reliability of the CAM-S, a novel approach to measure delirium severity."

The team developed and validated the CAM-S in two groups of patients. The first was a group of 300 patients 70 years of age or older who were scheduled for major surgery as part of the Successful Aging after Elective Surgery (SAGES) study. The second group was part of the Project Recovery study and included 919 older adults (70 or older) who were admitted to the hospital on the medical service. Researchers developed the CAM-S from the 4-item short form and 10-item long form versions of the CAM, and examined the impact of the CAM-S scores on hospital and post-hospital clinical outcomes.

CAM-S scores displayed a strong association with all clinical outcomes including length of hospital stay, nursing home placement, functional and cognitive decline, death, and hospital and post-hospital costs. The study found that length of hospital stay increases with the degree of delirium severity measured by the CAM-S short form from seven days for no delirium symptoms to 13 days for patients with severe delirium; the CAM-S long form showed similar increases in length of stay from six days to 12 days between no and severe symptom groups.

Additionally, mean hospital costs increase with the degree of delirium severity measured by the CAM-S short form from $5,100 for patients without delirium symptoms to $13,200 for those with severe symptoms. Similar results were seen across all levels of the CAM-S long form scores with mean costs increasing from $4,200 to $11,400 across delirium symptom groups ranging from none to severe.

Dr. Inouye concludes, "Our findings demonstrate that the CAM-S provides a new standardized severity measure with high inter-rater reliability, and a strong association with clinical outcomes related to delirium. We believe that this measure holds great promise to improve understanding of the effects of delirium on clinical care, prognosis, pathophysiology, and response to treatment. Ultimately, we hope that this measure will help to prevent the effects of this devastating condition and improve quality of life for older adults."

Provided by Hebrew SeniorLife Institute for Aging Research

Calcium score predicts future heart disease among adults with little or no risk factors

With growing evidence that a measurement of the buildup of calcium in coronary arteries can predict heart disease risk, Los Angeles Biomedical Research Institute (LA BioMed) researchers found that the process of "calcium scoring" was also accurate in predicting the chances of dying of heart disease among adults with little or no known risk of heart disease.

16 april 2014Previous studies had found that calcium scores were effective in predicting heart disease among adults with known heart disease risk factors, such as hypertension, diabetes, dyslipidemia, current smoking or a family history of heart disease. The study conducted by LA BioMed researchers examined 5,593 adults with no known heart disease risk or with minimal risk of heart disease, who had undergone coronary artery calcium screening by non-contrast cardiac computed tomography from 1991-2011.

Normally, the coronary arteries don't contain calcium. A buildup of calcium can narrow the arteries to the heart and lead to a heart attack. The screening process results in a calcium score indicating the amount of calcium in the plaque lining the walls of the coronary arteries.

Among the adults in the study, even those with low coronary artery calcium scores of 1-99 were 50% more likely to die of heart disease than adults with a calcium score of zero. Adults with moderate scores of 100-399 were 80% more likely to die from heart disease than those with a score of zero, and those with scores of 400 or more were three times more likely to die from heart disease, when compared to adults with no calcified plaque buildup, or a score of zero.

"This long-term study builds on previous research conducted at LA BioMed and other institutions that have proven the effectiveness of coronary artery calcium screening in predicting heart disease risks," said Matthew J. Budoff, MD, one of the LA BioMed researchers who conducted the study. "Normally, calcium scoring is only recommended for patients with known heart disease risks. These findings suggest that calcium scoring can be an effective tool for assessing heart disease risks in adults with no known risk factors so that they can make the lifestyle and other changes that can help them avoid heart disease in the future."

Dr. Budoff and Rine Nakanishi, MD, PhD, presented these findings at ACC.14, the annual scientific session of the American College of Cardiology in March, along with other researchers whose studies also found coronary artery calcium screening accurately predicted the risk of future heart disease.

Provided by Los Angeles Biomedical Research Institute at Harbor

For sick, elderly patients, surgical decision making 'takes a village'

Surgical decision making for sick, elderly patients should be orchestrated by a multidisciplinary team, including the patient, his or her family, the surgeon, primary care physician, nurses and non-clinicians, such as social workers, advocates Laurent G. Glance, M.D., in a perspective piece published in the New England Journal of Medicine.

15 april--For this group of patients, surgery can be very risky. Glance, professor and vice-chair for research in the Department of Anesthesiology at the University of Rochester School of Medicine and Dentistry believes a more patient-centered, team-based treatment approach would lead to higher quality care that matches the values and preferences of the sickest patients.

Usually, patients undergo a one-on-one consultation with their surgeon, who is frequently solely responsible for most of the decision making and management surrounding a possible surgical procedure. However, this traditional approach has potential pitfalls. For example, patients may not always be presented the full range of treatment options, such as medical treatment, less invasive surgical options, or watchful waiting.

"Evaluating treatment options, formulating recommendations and articulating the benefits and risks to patients comprehensively require more than a well-informed or experienced surgeon," noted Glance, who is also a professor of Public Health Sciences and a cardiac anesthesiologist at UR Medicine's Strong Memorial Hospital, in addition to holding an adjunct appointment at RAND Health.

Consultation with a team of medical personnel, on the other hand, helps patients better understand the benefits and risks of each option, the likelihood of a good outcome and the risks of complications, enabling them to make informed decisions that are driven by what's most important to them and their family.

According to the article, one-third of elderly Americans have surgery in the last 12 months of their lives, most within the last month. But, three-quarters of seriously ill patients say they would not choosesurgery if they knew they are likely to have severe cognitive or functional complications afterward.

Currently, such teamwork occurs mostly on an ad hoc basis, says Glance. In the future, multidisciplinary teams could meet regularly – in person or virtually – to discuss high-risk cases. By limiting the focus of such efforts to frail, elderly patients or to those with complex conditions who stand to benefit most from this multidisciplinary approach, healthcare organizations could minimize the costs involved. However, Glance acknowledges that gaining acceptance of this shift in the current culture of surgical decision making may not be straightforward.

Provided by University of Rochester Medical Center

Exposure Therapy
for Fears and Phobias

12 april--Exposure Therapy has been shown to be the most effective anxiety treatment for people with many anxiety disorders. You might already know that it involves practicing with what you fear, in order to become less afraid. But how does it work?

Exposure Therapy helps you retrain your brain. It's not just about "getting used to" the fear. It's about retraining your brain to stop sending the fear signal when there isn't any danger.

People struggle against anxiety attacks and phobias because they recognize that their fears are exaggerated and illogical. They try hard to talk themselves out of the fear.

But that doesn't help. So they end up trying to avoid the fear, and that, unfortunately, just strengthens it.

Exposure Therapy will help you retrain your brain to let go of phobias, anxiety attacks, and other forms of anxiety disorders.

Let's see how Exposure Therapy works.

Fight or Flight

When your brain gets a signal of danger, it triggers an immediate response, the familiar Fight or Flight response. That's a good thing, because when we face danger, we need to react quickly and powerfully.

Humans evolved in a different world than the one we inhabit today. It was a world full of predators, without police or deadbolt locks. Our main job was to get enough to eat each day without becoming food for somebody else. We needed a good emergency alert system to keep us out of the jaws of predators.

If we had relied on the thinking, intellectual part of our brain, called the cerebral cortex, to keep us safe, we'd be extinct. It's too slow. It's good for writing a speech, and figuring out your income tax, but not for making snap decisions about danger.

The part of your brain that handles these Fight or Flight responses is very different from the part of the brain you're most familiar with.

The Amygdala

The Amygdala, a little almond shaped part of your brain, is what makes these Fight or Flight decisions. The Amygdala works quickly, without your conscious awareness, because speed is vital in protecting against threats. You only find out what the Amydgala did when you feel its effects in your body (all the familiar panic sensations) and in your behavior (duck, run, escape).

Whenever we make a decision, there are two possible kinds of errors. One is a false positive. If you decide there's a tiger hiding in the tall grass, when there isn't one, that's a false positive. When you make a false positive error, you get afraid in the absence of danger, but you don't get eaten.

The second type is a false negative. If you decide there's no tiger hiding in the tall grass when there really is one, that's a false negative. When you make this false negative error, you feel okay, but you're gonna get eaten.

Your Amygdala doesn't care how many times it scares you unnecessarily. It just aims to keep you alive. It doesn't want to make any false negative mistakes.

If you experience phobias and anxiety attacks, and want to overcome them, you need a form of anxiety treatment which will retrain this part of your brain. The most direct and systematic way to do that is Exposure Therapy.

How Your Amygdala Works

Always Watching

Your Amygdala is always watching, passively, in the background, for some sign of danger. When it sees one, true or false, it presses the "fight or flight" button and fills you with fear. When the danger is real, that's a good thing. But your Amygdala works like it's still 27,000 B.C., and will often make the mistake of seeing danger when there's none.

It Learns by Association, not Reason or Logic

When you run away from whatever the apparent danger is, the Amygdala stands down and goes back to quietly watching. If you ran away from a mugger, that's a good thing. But if you ran away from a grocery store, or a dog on a leash, that's a bad thing. Now your Amygdala will be conditioned to see the grocery store or the dog as dangerous, and will make you afraid next time you see one.

The Amygdala learns by association. It associates the crowded store, or the dog, with danger. It doesn't learn by conscious thought. This is why you can't simply talk yourself out of a phobia or anxiety attack. The fear memory is stored as a conditioned fear, and can only be relieved by more conditioning, not discussion or reason.

It only Learns When You're Afraid

The Amygdala only learns when it's fully activated, when it spots something it considers dangerous. It only forms new memories and associations, new lessons, when you've become afraid. The rest of the time it's on autopilot, passively watching.

Do you see what this means? If you stay away from what you fear, your Amygdala will keep on "believing" the same old mistakes, without a chance to learn anything new.

How Can You "Talk" to Your Amygdala?

Your Amygdala only learns from experience. If you flee the scene every time you have an anxiety attack, your Amygdala learns that you should leave to be safe.

How can you get your Amygdala to learn something new? You have to activate it by exposing yourself to a trigger that gets you afraid. If you have a dog phobia, that would be a dog. If you have anxiety attacks on subways (or highways), you need a subway (or a highway). And you need to stay there with that fear until it gets a lot lower.

That gives your Amygdala the chance to learn that it got all worked up about nothing. That way, it can learn that dogs (or highways) aren't the threat that it had been conditioned to believe. And, with repetition, it will develop a new memory, one that lets you get on with your life without being disrupted by phobias and anxiety attacks.

Retraining Your Amygdala

That's how Exposure Therapy works. Exposure Therapy retrains your Amygdala.

You don't have to do this radically and quickly. What you need to do is to continually arrange to activate your Amygdala by exposing yourself to what you fear, and then stay in place, making sure that the fear leaves before you do. You can use a variety of coping steps to help you do that, or you can just "float", as Claire Weekes called it, and wait for the fear to subside. Either way, Exposure Therapy will enable you to retrain your Amygdala with new learning in ways it can absorb.

Coronary calcium scores may help predict risk of death in patients without family history of heart disease

Current guidelines only recommend coronary artery calcium (CAC) scoring for low-risk patients if they have a family history of early heart disease.

07 april 2014—A new Emory University study shows that coronary artery calcium (CAC) scoring, a type of low-dose CT scan, accurately predicts the risk of dying over the next 15 years in patients with and without a family history of early heart disease. The findings were presented this week at the American College of Cardiology meeting in Washington, D.C.

A coronary artery calcium scan is a simple, non-invasive test that uses low-dose X-rays to measure the amount of calcium in plaque on the walls of the arteries of the heart.

"While we found that CAC scoring is accurate at predicting the risk of death over a 15-year period in all patients, this is the first study to show it is most accurate in those without a family history of early heart disease," says Joseph Knapper, MD, an internal medicine resident at Emory University School of Medicine.

"This suggests there may be a benefit to expanding CAC testing to all low-risk patients, regardless of their family history, allowing patients to learn about their risks sooner and take actions to decrease them."

Current guidelines only recommend CAC scoring for low-risk patients if they have a family history of early heart disease.

Knapper and his colleagues followed 6,300 patients with a family history of early heart disease, and about 2,800 patients without a history. Each study participant underwent a CT scan to receive a CAC score and was interviewed to establish their risk factors for heart disease (i.e. cigarette smoking, high blood pressure, diabetes, etc.). Researchers tracked the patients for 15 years and recorded deaths that occurred in that time period, regardless of the cause.

They found that patients with a higher CAC score were more likely to have died over the 15-year period, even after controlling for other risk factors such as smoking and high blood pressure. Most importantly, the highest risk CAC scores (greater than 1,000) showed a nearly eight times higher risk of death compared to the lowest risk score in patients without a family history, whereas in those with a family history the risk was increased less than four-fold.

Knapper says further research, including cost analysis, is needed before a recommendation could be made to expand CAC screening guidelines.

Provided by Emory University

Calcium supplementation does not increase coronary heart disease concludes new study

Researchers presenting at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases showed the results of a meta-analysis of randomized controlled trials of calcium supplements. The results do not support the hypothesis that calcium supplementation, with or without vitamin D, increases coronary heart disease or all-cause mortality risk in elderly women.

05 april 2014--The results of a study presented today at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases do not support the hypothesis that calcium supplementation, with or without vitamin D, increases coronary heart disease or all-cause mortality risk in elderly women.

The investigators, from centres in Australia, Denmark and the USA, undertook a meta-analysis of randomized controlled trials of calcium supplements with or without vitamin D. They searched for two primary outcomes: coronary heart disease and all-cause mortality verified by clinical review, hospital record or death certificate. The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases were searched from January 1, 1966 – May 24, 2013 for potentially eligible studies, reference lists were checked, and trial investigators were contacted where additional data was required. Eligibility criteria included randomized controlled trials of calcium supplementation with or without vitamin D with events with a mean cohort age >50 years. Trial data were combined using a random-effects meta-analysis to calculate relative risk of heart disease events in participants supplemented with calcium.

Of the 661 potentially eligible reports, 18 met the stringent inclusion criteria, contributing information on 63,564 participants with 3,390 coronary heart disease events and 4,157 deaths from any cause. Five trials contributed coronary heart disease events with pooled relative risk (RR) for calcium of 1.02. And 17 trials contributed to all-cause mortality data with pooled RR for calcium of 0.96. The meta-analysis showed that calcium supplementation with or without vitamin D does not increase coronary heart disease or all-cause mortality risk in elderly women.

More information: OC34 The effects of calcium supplementation on coronary heart disease hospitalisation and death in postmenopausal women: a collaborative meta-analysis of randomised controlled trials. J. R. Lewis, K. L. Ivey, S. Radavelli-Bagatini, L. Rejnmark, J. S. Chen, J. M. Simpson, J. M. Lappe, L. Mosekilde, R. L. Prentice, R. L. Prince. Osteoporos Int. Vol 25, Suppl. 2, 2014

Provided by International Osteoporosis Foundation