World first study reveals increase in premature deaths in Australian nursing homes

The first comprehensive study of deaths in Australian nursing homes has been published today (29 May), revealing a more than 400 per cent increase in the incidence of premature and potentially preventable deaths of nursing home residents over the past decade.

30 may 2017--These deaths - from falls, choking, suicide and homicide - account for almost 3,300 deaths of nursing home residents over a 13 year period.
The study, led by Professor Joseph Ibrahim, from the Monash University Faculty of Medicine, Nursing and Health Sciences and published in the Medical Journal of Australia, used coronial data to review the deaths by external causes of all of nursing home residents between 2000 and 2013.
The study found that - of the 21,672 deaths of nursing home residents reported to the Coroners Court during the 13 year period, 3,289, or 15.2 per cent, were from external or preventable causes, almost all unintentional.
Unintentional Deaths: Four out of five of those who died from external causes died from falls (81.5 per cent) while one in 12 died of choking (7.9 per cent). Somewhat surprising was the small number who died from complications of clinical care (1.2 per cent).
Intentional Deaths: Almost one in 18 people who died from preventable causes in aged care facilities were killed, either from suicide (4.4 per cent) and resident-to-resident assault (1.0 per cent).
The study found that the 400 per cent increase over the 13 year period in the number of preventable deaths in nursing homes is in part due to better reporting. However, Professor Ibrahim cautions that this figure is probably an under estimate owing to some deaths being misclassified as "natural" due to the tendency for health professionals and society to downplay the significance of the injury-related factors tending to assume old age and any underlying illness are the explanation for deaths.
Professor Ibrahim has called for a national strategy to reduce unnecessary harm including deaths in nursing homes:
"Professionals from governments and the nursing home sector should develop strategies for preventing these deaths and establish a lead authority, responsible for reducing harm by improving practice in nursing homes," Professor Ibrahim said.
"Currently no one entity is responsible for reducing harm by improving practice."
This national study is the first in the world to look at potentially preventable deaths in nursing homes using information from medico-legal investigations.
"Improving the quality of care for nursing home residents requires a better understanding of how, why, where and when they die. The global population is ageing rapidly, and the need for aged care services is consequently increasing," Professor Ibrahim said.
"With this study we have our first real understanding of how many deaths are occurring in nursing homes that shouldn't be happening. However, there is a paucity of information about the cause and manner of premature deaths of nursing home residents from which we can review how these operations are run."
Professor Ibrahim acknowledged that the increased number of preventable deaths identified may be, in part, due to increased scrutiny of aged care facilities by the community and government.

More information: Medical Journal of Australia (2017). DOI: 10.5694/mja16.00873


Provided by Monash University

Some benefit for curcuminoids in knee osteoarthritis

Curcuminoids seem beneficial for knee osteoarthritis (OA), although they are less effective for pain relief than ibuprofen, according to a review and meta-analysis published online May 4 in the International Journal of Rheumatic Diseases.

29 may 2017--Igho J. Onakpoya, M.D., from the University of Oxford in the United Kingdom, and colleagues reviewed data from randomized controlled trials that examined the effectiveness of orally-administered curcuminoids in OA in adults. Data were included from seven studies conducted in Asia, with 797 participants with primarily knee OA.
The overall risk of bias in the studies was moderate. The researchers found that curcuminoids correlated with significantly reduced knee pain (standardized mean difference, − 3.45) and improved quality of life (mean difference, −2.69) compared with placebo. Compared with ibuprofen, curcuminoids had significantly fewer effects on pain relief, knee stiffness, and physical function. Curcuminoids also correlated with significant improvements in Western Ontario and McMaster Universities Arthritis Index total scores and with significant reductions in rescue medication use. There were no serious adverse events.
"Curcuminoids may have some beneficial effects on knee pain and quality of life in patients with knee OA," the authors write. "However, they are less effective at relieving pain compared with ibuprofen."

More information: Abstract

Strategies needed to prevent malnutrition in older people

A pilot study led by Associate Professor Carol Wham, is the first in a series to investigate the prevalence of malnutrition risk in older people across three settings in Auckland.

New research from Massey University shows concerning levels of malnutrition among older people living independently in the community or newly admitted to hospital or a residential care facility.
Associate Professor Carol Wham led the study, investigating the prevalence of malnutrition risk in older people across three accommodation settings. The study was conducted within the Waitemata District Health Board region in Auckland, including North Shore City, Waitakere City and the Rodney District, in 2014.

27 may 2017--Of the 167 participants, 23 per cent were malnourished, and 35 per cent were at high risk of malnutrition. Those recently admitted to residential care had a higher prevalence of malnourishment – 47 per cent, compared to 23 per cent in hospital, and two per cent living in the community.
The pilot study, a first of its kind in New Zealand, is the first in a series to screen for risk of malnutrition in community and early admission to hospital and residential care. The research is currently being followed up, using a larger group of 250 people in each of the three settings. Researchers are now analysing these results.
Dr Wham says older people are known to be at disproportionate risk of malnutrition, with health conditions both contributing to having an inadequate food and nutrition intake and occurring as a consequence of inadequate intake. "Maintaining good nutritional status is important for remaining independent, yet far too often key aspects of food provision for older people are disregarded or taken for granted, especially among those with health disparities."
She says elimination of particular foods or food groups from the diet, due to chewing and swallowing difficulties, aggravates the risk of malnutrition. "Reduced food intake can contribute to dysphagia [difficulty swallowing], and can compromise the integrity of the swallow, which initiates a vicious cycle further decreasing food intake and further exacerbating poor swallowing function."
The risk of malnutrition is a burden on older people and health-care facilities, Dr Wham says. "In community-living older New Zealanders, high malnutrition risk has been shown to impact health-related quality of life. It's associated with higher infection rates, loss of muscle mass, strength and function, longer length of hospital stays, as well as increasing morbidity and mortality."
This study highlights the need for mandatory screening for malnutrition risk in all settings, Dr Wham says.
"We discovered marked differences in nutritional risk and the prevalence of dysphagia between older adults living in the three different social settings. Independently living older adults demonstrated the best nutritional profiles with nutrition risk and prevalence of dysphagia significantly lower than those recently admitted to hospital or residential care facilities. We expected these results. However, this data revealed the stark delineation between well older adults, and those experiencing a slide in their health status and profile.
"Malnutrition and swallowing difficulties significantly affect quality of life and are costly to individuals, families and the community. Simple intervention measures to manage under-nutrition, can make a substantial difference. However, given the differences we have identified between each setting, a more targeted approach should be used to identify the optimum nutrition intervention for each setting," Dr Wham says.
She would like to see awareness around malnutrition in older people, given a higher profile. "This issue should not be considered a 'normal' part of ageing. It needs to be higher up the political agenda," Dr Wham says.

More information: Carol Wham et al. Malnutrition risk of older people across district health board community, hospital and residential care settings in New Zealand, Australasian Journal on Ageing (2017). DOI: 10.1111/ajag.12410


Provided by Massey University

US deaths from Alzheimer's soar 55 percent since 1999

Deaths from Alzheimer's in America have soared 55 percent since 1999, as the burden of this fatal form of dementia grows and the population ages, a federal health report said Thursday.

26 may 2017--The study in the US Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report spanned 1999 to 2014.
Experts say the data shows more caregivers are needed, along with more resources to help people suffering from Alzheimer's disease, the sixth leading cause of death in the United States.
"Millions of Americans and their family members are profoundly affected by Alzheimer's disease," said CDC Acting Director Anne Schuchat.
"As the number of older Americans with Alzheimer's disease rises, more family members are taking on the emotionally and physically challenging role of caregiver than ever before. These families need and deserve our support."
The study also found an increasing number of Alzheimer's deaths occurring at home, rising from 14 percent to 25 percent in the same period.
Most Alzheimer's deaths—54 percent—still occur in a nursing home or long-term care facility.
There is no cure for Alzheimer's disease, the most common form of dementia.
Alzheimer's accounted for 3.6 percent of all US deaths in 2014.
Alzheimer's is a growing problem as people live longer, and medical advances make them less likely to die from other diseases.
"Age is the greatest risk factor for Alzheimer's disease," said the CDC report.
"Most adults with the disease are 65 years or older."
More than five million people in the United States are living with Alzheimer's, and that number could balloon to 16 million by 2050, according to the Alzheimer's Association.

Antibiotic therapy for nearly 1 in 4 adults with pneumonia does not work

Antibiotic treatment ineffective for one in four adults with pneumonia. Credit: ATS

Approximately one in four (22.1 percent) adults prescribed an antibiotic in an outpatient setting (such as a doctor's office) for community-acquired pneumonia does not respond to treatment, according to a new study presented at the 2017 American Thoracic Society International Conference.

24 may 2017--"Pneumonia is the leading cause of death from infectious disease in the United States, so it is concerning that we found nearly one in four patients with community-acquired pneumonia required additional antibiotic therapy, subsequent hospitalization or emergency room evaluation," said lead author James A. McKinnell, MD, an LA BioMed (Los Angeles, CA) lead researcher and infectious disease specialist. "The additional antibiotic therapy noted in the study increases the risk of antibiotic resistance and complications like C. difficile ("C diff") infection, which is difficult to treat and may be life-threatening, especially for older adults."
Dr. McKinnell and colleagues conducted this study because current community-acquired pneumonia guidelines from the American Thoracic Society and the Infectious Disease Society of America, published in 2007, provide some direction, but large-scale, real-world data are needed to better understand and optimize antibiotic choices and to better define clinical risk factors that may be associated with treatment failure.
The researchers examined databases containing records for 251,947 adult patients who were treated between 2011 and 2015 with a single class of antibiotics (beta-lactam, macrolide, tetracycline, or fluoroquinolone) following a visit to their physician for treatment for community-acquired pneumonia. The scientists defined treatment failure as either the need to refill antibiotic prescriptions, antibiotic switch, ER visit or hospitalization within 30 days of receipt of the initial antibiotic prescription. The total antibiotic failure rate was 22.1 percent, while patients with certain characteristics—such as older age, or having certain other diseases in addition to pneumonia—had higher rates of drug failure. After adjusting for patient characteristics, the failure rates by class of antibiotic were: beta-lactams (25.7 percent), macrolides (22.9 percent), tetracyclines (22.5 percent), and fluoroquinolones (20.8 percent).
"Our findings suggest that the community-acquired pneumonia treatment guidelines should be updated with more robust data on risk factors for clinical failure," said Dr. McKinnell. "Our data provide numerous insights into characteristics of patients who are at higher risk of complications and clinical failure. Perhaps the most striking example is the association between age and hospitalization: Patients over the age of 65 were nearly twice as likely to be hospitalized compared to younger patients when our analysis was risk adjusted and nearly three times more likely in unadjusted analysis. Elderly patients are more vulnerable and should be treated more carefully, potentially with more aggressive antibiotic therapy."
Dr. McKinnell also stated that his study found substantial regional variations in treatment outcomes, which are not addressed in a specific way in the community-acquired pneumonia guidelines. In addition, the study showed that thousands of patients who suffer from other conditions - such as chronic obstructive pulmonary disease, cancer or diabetes - were not treated with combination antibiotic therapy or respiratory fluoroquinolone, as the guidelines recommend.
"While certain aspects of the guidelines need to be updated, some prescribers also have room for improvement and should implement the current guidelines," he concluded.

More information: Abstract 8450: Clinical Predictors of Antibiotic Failure in Adult Outpatients with Community-Acquired Pneumonia


Provided by American Thoracic Society

Resilience study examines how people with disabilities live successfully in rural areas

Living in a small town can be challenging for anyone. For people with disabilities, rural areas can create even more serious barriers to accomplishing the things they want to do.
However, with the help of a trait known as resilience, many people with disabilities who live in rural areas have achieved a good quality of life and are able to participate in their communities.

21 may 2017--"Some people do well in life because they face few obstacles to meeting their goals: they are healthy, they have parents who are well-educated and have the resources to provide their children with a good education, and they have the support they need," said Jean Ann Summers, research director at the University of Kansas Research and Training Center on Independent Living, or RTC/IL.
The resilience study – which is still ongoing – didn't focus on this group of people, though.
"Other people do well in life despite the obstacles that they face," Summers said. "They may have grown up poor, they may have a disability, they may live in a community where few jobs or other opportunities are available. And yet they thrive. They are able to achieve their goals and have a satisfying life in the community in spite of the odds that are against them. We say those people are 'resilient.'"
Summers and her collaborators Dot Nary, assistant research professor at the RTC/IL, and Heather Lassmann, graduate research assistant, set out to identify what Summers calls "the secrets of success" that resilient people with disabilities employ to successfully live in rural communities. Their work is part of larger project based at the University of Montana Research and Training Center on the Ecology of Rural Disability.
"The study is important because if we can find out what people who are naturally resilient do, we can design a program to teach others how to be resilient," Nary said.
According to Summers, the thought process behind the study is much different than the approach medical or health care practitioners consider when trying to support people with disabilities or chronic illnesses.
"For example, in the medical model we would approach 'fixing' a broken leg by putting a cast on the leg," Summers said. "But a resilience model would focus on what it takes to make that leg grow strong, with the right nutrition and exercise, to prevent further breakage of those bones in the future."
The study applied this model in two phases. First, researchers conducted two focus groups of people living in rural communities who were nominated by staff at centers for independent living as people who display resilience.
"In the focus groups, we asked the participants to talk about the supports that were helpful to them in enabling them to participate fully in the community," Nary said. "We also asked them to talk about any attitudes or philosophy that helped them succeed in reaching their goals."
The researchers used what they learned in the focus groups to identify a series of supports, both formal and informal, along with coping skills like advocacy and strategies like humor or focusing on others that contribute to a person being resilient. They illustrated these findings in a tree-shaped graphic, which identifies the roots and branches that contribute to resilience.
In the second phase of the study, now ongoing, the researchers partnered with their colleagues at the University of Montana, who had conducted a large-scale national survey of people in rural communities. Using that survey data, they identified a new group of people with disabilities who they defined as resilient for two reasons: they had more than two risk factors, that is obstacles to success, and their survey responses indicated they were successfully participating in their communities.
Summers and Nary are now interviewing these individuals by phone to get a deeper understanding of what contributes to resilience.
"We are hearing things that are similar to what we heard in the focus groups," Summers said, "but we're also looking at other personal or environmental factors that contribute positively. For example, a particular city may offer unique environmental or social features that make participation easy for people with disabilities."
She expects the final report to be completed this fall.


Provided by University of Kansas

Can omega-3 help prevent Alzheimer's disease? Brain SPECT imaging shows possible link

An example of the Omega-3 Index, the method utilized in this study for measuring omega-3 fatty acid levels in red blood cell membranes in the study. Credit: William S. Harris, PHD

The incidence of Alzheimer's disease (AD) is expected to triple in the coming decades and no cure has been found. Recently, interest in dietary approaches for prevention of cognitive decline has increased. In particular, the omega-3 fatty acids have shown anti-amyloid, anti-tau and anti-inflammatory actions in the brains of animals. In a new article published in the Journal of Alzheimer's Disease, researchers have found that for patients with high omega-3 levels, blood flow in specific areas of the brain is increased.

20 may 2017--"This study is a major advance in demonstrating the value of nutritional intervention for brain health by using the latest brain imaging," commented George Perry, PhD, Dean and Professor of Biology, The University of Texas at San Antonio, and Editor-in-Chief of the Journal of Alzheimer's Disease.
Single photon emission computed tomography, or SPECT, can measure blood perfusion in the brain. Images acquired from subjects performing various cognitive tasks will show higher blood flow in specific brain regions. When these images were compared to the Omega-3 Index, a measure of the blood concentration of two omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), investigators found a statistically significant correlation between higher blood flow and higher Omega-3 Index. In addition, they evaluated the neuropsychological functions of the subjects and found that omega-3 levels also correlated with various psychological feelings using a standardized test battery (WebNeuro).
This study drew from a random sample of 166 participants from a psychiatric referral clinic for which Omega-3 Index results were available. The participants were categorized into two groups of higher EPA+DHA concentrations (>50th percentile) and lower concentrations (<50th 128="" and="" brain="" brains="" completed="" computerized="" conducted="" each="" neurocognitive="" of="" on="" p="" participant="" percentile="" quantitative="" regions="" spect="" status.="" testing="" their="" was="">Results indicated statistically significant relationships between the Omega-3 index, regional perfusion on brain SPECT in areas involved with memory, and neurocognitive testing.
Overall, the study showed positive relationships between omega-3 EPA+DHA status, brain perfusion, and cognition. Lead author Daniel G. Amen, MD, of the Amen Clinics Inc., Costa Mesa, CA, adds, "This is very important research because it shows a correlation between lower omega-3 fatty acid levels and reduced brain blood flow to regions important for learning, memory, depression and dementia."
Co-author William S. Harris, PhD, University of South Dakota School of Medicine. Vermillion, SD, lends this perspective, "Although we have considerable evidence that omega-3 levels are associated with better cardiovascular health, the role of the 'fish oil' fatty acids in mental health and brain physiology is just beginning to be explored. This study opens the door to the possibility that relatively simple dietary changes could favorably impact cognitive function."

More information: Journal of Alzheimer's Disease (2017). DOI: 10.3233/JAD-17028

Provided by IOS Press

Studies link healthy brain aging to omega-3 and omega-6 fatty acids in the blood

New studies link specific nutrients to the structure and function of brain regions that are particularly sensitive to aging and neurodegenerative disease. 

19 may 2017--Two new studies link patterns of polyunsaturated fatty acids in the blood to the integrity of brain structures and cognitive abilities that are known to decline early in aging.
The studies add to the evidence that dietary intake of omega-3 and omega-6 fatty acids can promote healthy aging, the researchers said. Further research is needed to test this hypothesis, they said.
The brain is a collection of interconnected parts, each of which ages at its own pace. Some brain structures, and the abilities they promote, start to deteriorate before others, said University of Illinois M.D./Ph.D student Marta Zamroziewicz, who led the new research with psychology professor Aron Barbey.
"We studied a primary network of the brain—the frontoparietal network - that plays an important role in fluid intelligence and also declines early, even in healthy aging," Zamroziewicz said. Fluid intelligence describes the ability to solve problems one has never encountered before.
"In a separate study, we examined the white matter structure of the fornix, a group of nerve fibers at the center of the brain that is important for memory," she said.
Previous research has shown that the fornix is one of the first brain regions to be compromised in Alzheimer's disease.
In both studies, the researchers looked for patterns of polyunsaturated fatty acids in the blood of adults ages 65 to 75. They analyzed the relationship between these nutrient patterns and subjects' brain structure and performance on cognitive tests. This research differs from other such studies, which tend to focus on only one or two polyunsaturated fatty acids, Zamroziewicz said.
"Most of the research that looks at these fats in health and healthy aging focuses on the omega-3 fatty acids DHA and EPA, but those come from fish and fish oil, and most people in the Western Hemisphere don't eat enough of those to really see the benefits," she said. Other fatty acids, like alpha-linolenic acid and stearidonic acid, are precursors of EPA and DHA in the body. Those fats can be derived from land-based foods such as nuts, seeds and oils.
"A central goal of research in nutritional cognitive neuroscience is to understand how these nutrients affect brain health," Zamroziewicz said. "Some of these nutrients are thought to be more beneficial than others."
In a study reported in the journal Nutritional Neuroscience, the researchers looked for relationships between several omega-3 fatty acids in the blood, the relative size of structures in the frontal and parietal cortices of the brain, and performance on tests of fluid intelligence in healthy elderly adults.
The team found correlations between blood levels of three omega-3 fatty acids—ALA, stearidonic acid and ecosatrienoic acid—and fluid intelligence in these adults. Further analyses revealed that the size of the left frontoparietal cortex played a mediating role in this relationship. People with higher blood levels of these three nutrients tended to have larger left frontoparietal cortices, and the size of the frontoparietal cortex predicted the subjects' performance on tests of fluid intelligence.
"A lot of research tells us that people need to be eating fish and fish oil to get neuroprotective effects from these particular fats, but this new finding suggests that even the fats that we get from nuts, seeds and oils can also make a difference in the brain," Zamroziewicz said.
In the second study, the team found that the size of the fornix was associated with a balance of omega-3 and omega-6 fatty acids in the blood, and that a more robust fornix coincided with memory preservation in older adults. Again, the researchers saw that brain structure played a mediating role between the abundance and balance of nutrients in the blood and cognition (in this case, memory). The findings are reported in the journal Aging & Disease.
"These findings have important implications for the Western diet, which tends to be misbalanced with high amounts of omega-6 fatty acids and low amounts of omega-3 fatty acids," Zamroziewicz said.
"These two studies highlight the importance of investigating the effects of groups of nutrients together, rather than focusing on one at a time," Barbey said. "They suggest that different patterns of polyunsaturated fats promote specific aspects of cognition by strengthening the underlying neural circuits that are vulnerable to disease and age-related decline."

More information: Marta K. Zamroziewicz et al, Determinants of fluid intelligence in healthy aging: Omega-3 polyunsaturated fatty acid status and frontoparietal cortex structure, Nutritional Neuroscience (2017). DOI: 10.1080/1028415X.2017.1324357


Provided by University of Illinois at Urbana-Champaign

Volunteering can reduce dementia risk in seniors, study finds

Yannick Griep, assistant professor in the University of Calgary's Department of Psychology, led a five-year study that shows regular volunteering reduces the chance of dementia in seniors.

15 may 2017--Seniors now have a greater incentive than ever for doing volunteer work in their retirement years, in light of a new study that shows volunteering can substantially reduce the development of dementia.
The study, led by University of Calgary psychology professor Yannick Griep and published in the medical journal PLOS One, tracks 1,001 Swedish citizens, all of whom retired in 2010, over a five-year period, monitoring them for the development of cognitive problems.
These retirees are divided into three groups based on their engagement in volunteer work. One group is made up of individuals who consistently volunteered in their respective communities for at least one hour per week. The second group consists of those who sporadically engaged in volunteering. In the third group are retired workers who never engaged in volunteering.
The cognitive health of those individuals is assessed at regular intervals (in 2010, 2012 and 2014) by means of questionnaires as well as the monitoring of physician diagnoses, including the use of anti-dementia medication. The questionnaires touch on such factors as memory and the ability to concentrate and make clear decisions, among other cognitive issues.

Regular volunteer work provides cognitive health benefits

"We found that the people who did volunteer work for at least one hour a week on a regular basis were 2.44 times less likely to develop dementia than the seniors who didn't volunteer," says Griep.
Volunteer work in the study is defined as an activity done out of free will for no monetary compensation. Moreover, Griep clarifies that "the activity has to benefit others who are not your core family; for example, helping out a church, a school, a library a homeless shelter or some sort of charity organization."
Interestingly, Griep and his co-researchers found that the middle group—those retirees who only volunteered sporadically—did not receive any benefits to their cognitive health. "We discovered that for this group there are no differences than with the group that never volunteered," he says.
Griep can only speculate why there are no cognitive health benefits for the sporadic volunteer camp but he believes it's because they don't receive "the latent benefits of work," as do the regular volunteers. "Work has many benefits beyond just a paycheque," he says.
"It brings a structure to the day, like when we need to be up at seven and at the office for 8:30. It offers social contact with people outside of our family. It brings us the social status we get with a job title. It makes us feel like we're making a meaningful contribution to society. And there's a physical aspect as well, even if it's just walking from your house to the spot where you do your volunteer work.

Researchers strongly recommend retirees volunteer at least once a week

"If you volunteer regularly, it starts to feel like a regular job and you get these benefits of work," Griep explains. The underlying assumption, he says, is that those in the regular volunteering camp stay sharper cognitively because they are continuing to engage their minds in these key ways.
Based on the findings, Griep and his team strongly recommend that retired seniors do volunteer work at least once a week.
"This is an important issue," says Griep. "As a senior, your risk of dementia goes up substantially every year. Anything you can do that's low cost and easy to implement that will reduce the likelihood of developing dementia is invaluable. It's not only beneficial for the health-care system but also for those individuals who might develop dementia, as well as the family members who wind up caring for them."

More information: Yannick Griep et al. Can volunteering in later life reduce the risk of dementia? A 5-year longitudinal study among volunteering and non-volunteering retired seniors, PLOS ONE (2017). DOI: 10.1371/journal.pone.0173885


Provided by University of Calgary

Prediction of conversion to Alzheimer's disease with longitudinal measures and time-to-event data

Predicting the timing of Alzheimer's disease (AD) conversion for individuals with mild cognitive impairment (MCI) can be significantly improved by incorporating longitudinal change information of clinical and neuroimaging markers, in addition to baseline characteristics, according to projections made by investigators from The University of Texas Health Science Center at Houston.

 12 may 2017--In an article published in Journal of Alzheimer's Disease, the research team describes how their novel statistical models found that longitudinal measurements of ADAS-Cog was the strongest predictor for AD progression and the predictive utility was consistently significant with progression of disease.
"The growing public health threat posed by Alzheimer's disease has raised urgency to discover and assess prognostic markers for the early detection of the disease," says Sheng Luo, PhD, senior author of the report. "We assessed the comparative predictive utility of thirty-three longitudinal markers in determining the risk of AD conversion at future time points among individuals with MCI. We found that longitudinal measurements of common cognitive and functional tools can provide more accurate prediction regarding AD conversion than volumetric MRI markers for MCI patients, and markers would show different predictive values at different times in disease progression."
The data used for this study was from the Alzheimer's Disease Neuroimaging Initiative (ADNI) study. It was very well suited for the tasks because of its large samples, long follow-up period, breadth of cognitive markers and biomarkers, and prospective nature. "We simultaneously modeled time-to-dementia as well as longitudinal change in the neuropsychological, neuroimaging, and functional/behavioral variables, using joint modelling for longitudinal and survival data. These longitudinal measures may be highly associated with time-to-dementia, and therefore statistical methods that can model both the longitudinal and the time-to-event components jointly are becoming increasingly essential in most observational studies and clinical trials of neurodegenerative disorders such as AD," remarked Dr. Luo.
"The main contribution of the study," according to the lead author Li, "is that it's the first attempt to comprehensively evaluate the comparative predictive ability of longitudinal markers, both clinical and biological, for timing of AD conversion under the joint model framework. We demonstrated that the imaging and other technology-intensive markers are less powerful than cognitive and functional assessments in the prediction of AD conversion. We expect the markers identified as strong predictors in this study along with the joint modeling approach can serve as a useful tool for continuous monitoring of AD progression and treatment effect in the clinical practice."


Provided by IOS Press

Personalized music may help nursing home residents with dementia

A new study suggests that personalized music has important psychiatric benefits for people with dementia living in nursing homes. 

11 may 2017--Across the country, nursing home employees and families are trying personalized music playlists to help seniors cope with the disorienting, anxious experience of living with Alzheimer's disease and related dementias. Now they can look to the results of the first national study to compare key outcomes in homes that implemented an individualized music program called MUSIC & MEMORY with similar homes that did not adopt the program.
The Brown University evaluation found that after homes adopted the program, residents with dementia became significantly more likely to discontinue antipsychotic and antianxiety medications and significantly less likely to engage in disruptive behaviors, compared to those residing in homes used for comparison. But the study of more than 25,000 residents in 196 nursing homes did not identify a significant improvement in mood.
"This is promising," said co-lead author Rosa Baier, an associate professor of practice at the Brown University School of Public Health. "It's a first step to understanding that there may be improvements that can be attributed to this intervention."
Baier noted that many gerontology experts and advocates for patients have called for ways to reduce the use of antipsychotic and antianxiety medications through a national campaign led by Medicare.
"Providers are looking for non-pharmacologic interventions to address dementia behaviors," she said. "This adds to the evidence base that can help improve patient care for these residents."
The study's findings also reinforce personal reports among caregivers and family members, including those presented in the documentary "Alive Inside," suggesting that personalized music helps patients even when their dementia is highly advanced, said co-lead author Kali Thomas, an assistant professor of health services, policy and practice at Brown. Thomas, who directed the study's evaluation, said her family tried a custom playlist with an uncle with dementia and saw him appear more at ease after listening to his favorite music, including from artists Merle Haggard and Johnny Cash.
"When we put the earphones on him, his breathing relaxed and his grimaced face relaxed," Thomas said.

Measures of music

To better understand how widespread such effects may be and how they might become clinically meaningful, Thomas, Baier and their co-authors designed the new evaluation, published in the American Journal of Geriatric Psychiatry, to test the program's effects with greater national breadth and statistical rigor than previous study designs. The work was part of the mission of Brown's Center for Long-Term Care Quality and Innovation, which tests interventions to improve post-acute and long-term care that appear promising, but haven't yet been rigorously evaluated, said Baier, the center's associate director.
To make their comparison, the team identified 98 nursing homes that had received formal training in the MUSIC & MEMORY program during 2013 and then assembled a list of similar nursing homes—accounting for Medicare quality rating, geography, the age mix of residents and other factors—that did not implement the program. The researchers included in the study all residents in each kind of home who had dementia and cognitive impairment, but who were not receiving hospice care and were not comatose. In all, 12,905 such residents lived in program homes, while 12,811 residents lived in non-program homes.
Using federal Medicare and nursing home data, the researchers then compared the before-2013-and-after changes among residents in each group on four metrics: ending antipsychotic medication, ending antianxiety medication, reductions in disruptive behavior and improvement in mood. While there were no significant differences in mood, here's what they found otherwise:
Antipsychotics: The rate of discontinuing these medications rose to 20.1 percent of program home residents after implementation in 2013 compared to 17.6 percent in a similar period before. By comparison, in non-program homes, the rate stayed flat: 15.2 discontinued after 2013 while 15.9 percent discontinued before.
Antianxiety: The discontinuation rate rose to 24.4 percent after MUSIC & MEMORY implementation in program homes, compared to 23.5 percent before, but in non-program homes the rate fell to 20.0 percent after 2013 compared to 24.8 percent before.
Behavior improvement: The rate of reduction in behavior problems increased to 56.5 percent in program homes from 50.9 percent before the program. In non-program homes the rate stayed flat at 55.9 percent after and 55.8 before.
Behavioral improvements not only help the individual patients, Thomas said, but also enhance quality of life for the residents around them and the morale of nursing home staff.
"Research suggests there is a relationship between nursing staff turnover and residents' behaviors," Thomas said.

The next step

Thomas and Baier acknowledged key limitations in their study. Because they did not track everything each nursing home might be doing to achieve these care improvements, they can't be sure that all the improvements resulted from MUSIC & MEMORY specifically.
On the other hand, because the team didn't know which or how many program home residents actually received the intervention, they had to assume that every eligible resident did. Since it might be that only a fraction of residents on average actually received the interventions in program homes, the results of the study might be understated because they are "diluted" by people who were assumed to receive the intervention but did not.
"In other words, the program may have an even greater impact than reported," Baier said.
To improve their evaluation, Baier, Thomas and their colleagues plan to conduct a second study in which they will randomize some homes to implement the program and some comparison homes to continue without it. By randomizing and collecting data about how the program is implemented, they'll be able to account for the current limitations. They have applied for funding to proceed.

More information: Kali S. Thomas et al, Individualized Music Program is Associated with Improved Outcomes for U.S. Nursing Home Residents with Dementia, The American Journal of Geriatric Psychiatry (2017). DOI: 10.1016/j.jagp.2017.04.008


Provided by Brown University

Lower incidence of chronic illness for centenarians

10 may 2017—Among elderly veterans, the incidence of chronic illness is lower for centenarians than octogenarians and nonagenarians, according to a study published online April 19 in the Journal of the American Geriatrics Society.

Raya Elfadel Kheirbek, M.D., M.P.H., from the Washington D.C. Veterans Affairs Medical Center, and colleagues conducted a retrospective study involving community-dwelling veterans born between 1910 and 1915 who survived to at least age 80 (31,121 octogenarians, 52,420 nonagenarians, and 3,351 centenarians). The authors examined the cumulative incidence of chronic conditions according to age group.
The researchers found that octogenarians had higher incidence rates of chronic illnesses than centenarians did (atrial fibrillation, 15 versus 0.6 percent; heart failure, 19.3 versus 0.4 percent; chronic obstructive pulmonary disease, 17.9 versus 0.6. percent; hypertension, 29.6 versus 3 percent; end-stage renal disease, 7.2 versus 0.1 percent; malignancy, 14.1 versus 0.6 percent; diabetes mellitus, 11.1 versus 0.4 percent; and stroke, 4.6 versus 0.4 percent). Nonagenarians also had higher incidence rates of chronic illnesses than did centenarians (atrial fibrillation, 13.2 versus 3.5 percent; heart failure, 15.8 versus 3.3 percent; chronic obstructive pulmonary disease, 11.8 versus 3.5 percent; hypertension, 27.2 versus 12.8 percent; end-stage renal disease, 11.9 versus 4.5 percent; malignancy, 8.6 versus 2.3 percent; diabetes mellitus, 7.5 versus 2.2 percent; and stroke, 3.5 versus 1.3 percent).
"Centenarians had a lower incidence of chronic illness than those in their 80s and 90s, demonstrating similar compression of morbidity and extension of health span observed in other studies," the authors write.

More information: Abstract
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'Silent seizures' discovered in patients with Alzheimer's disease

On the left is Dr. Alica Goldman and on the right is Dr. Jeffrey Noebels. 

Deep in the brains of two patients with Alzheimer's disease, the main memory structure, the hippocampus, displays episodic seizure-like electrical activity. These non-convulsive hippocampal seizures are the first signs of 'silent' brain electrical network dysfunction described in patients with Alzheimer's disease. 

08 may 2017--The discovery, published in the journal Nature Medicine, provides a better understanding of the condition and can potentially lead to new treatments for this devastating disease affecting more than 5 million people in the U.S.
"About 10 years ago, we were surprised to find 'silent seizures' in mouse models of Alzheimer's disease," said co-senior author Dr. Jeffrey L. Noebels, professor of neurology, neuroscience, and molecular & human genetics, and director of the Blue Bird Circle Developmental Neurogenetics Laboratory at Baylor College of Medicine. "When we measured the animal's brain electrical activity, we detected abnormal electrical discharges in the brain with a seizure-like pattern. The mice, however, did not present with convulsions. These 'clinically silent seizures' in the deep regions of the brain, we speculated, could lead to problems of memory."
It's been reported that in a group of patients with Alzheimer's disease, those that have a history of the disease in their families, convulsive seizures are common, especially in advanced cases. However, for most patients with Alzheimer's the condition does not run in the family. In this group of patients, which are said to present with the sporadic form of the disease, convulsive seizures are typically absent. "For this reason, measuring the brain's electrical activity with an electroencephalogram or EEG test is not required for diagnosis and rarely performed," Noebels said.
Even if the test was performed, previous studies in the epilepsy field had shown that seizures deep in the brain, such as the hippocampal region, cannot be detected with routine scalp EEG recordings. Detecting such brain activity requires placing electrodes deep in the brain.

From mouse model to patients

"My colleagues and I have been interested for years in determining whether 'silent seizures' are present in the hippocampus of patients with Alzheimer's disease," Noebels said. "We were able to answer this question when my colleague and senior co-author Dr. Andrew Cole, director of Massachusetts General Hospital Epilepsy Service and professor of neurology at Harvard Medical School, told me that he had two candidates for the procedure."
Cole and Dr. Alice Lam, first-author of the study and a fellow at Massachusetts General Hospital Epilepsy Service, led the team that performed the test in the patients. They used a minimally invasive recording technique involving fine wires inserted through a small natural opening in the skull. This allowed the researchers to monitor this deep region continuously for several days. Simultaneously, the researchers recorded scalp EEG readings.
In the two patients, who had been diagnosed with Alzheimer's disease and had no previous history of epilepsy or behaviorally obvious seizures, the hippocampal recordings showed clear clinically silent seizures. At the same time, the EEG recordings that had been taken simultaneously showed no abnormal brain activity, confirming that EEG tests do not register changes in deep brain activity.
"What was fascinating was that this activity was present at night when the patients were sleeping, a time thought to be critical for the consolidation of recent memories, a trait that is most impaired in early Alzheimer's disease," Noebels said.
"Based on our observations, we are particularly intrigued by the possibility that 'silent seizure' activity per se could contribute to or accelerate the degenerative process underlying Alzheimer's disease," Cole said.
In addition, Noebels and his Baylor colleague, Dr. Alica Goldman, co-author and associate professor of neurology and neurophysiology, performed genetic analysis on the patients' samples.
"We determined that these two patients did not have a gene known to cause epilepsy. So Alica and I, who have been studying epilepsy genes for a long time, sequenced the patients' samples for the three genes known to be linked to Alzheimer's disease," Noebels said. "It turned out that the patients didn't have those either; they present with the sporadic form of the disease."
"It is very exciting that we were able to move from an observation in genetically engineered mouse models of Alzheimer's to a demonstration of the same phenomenon in patients with verified Alzheimer's disease," said Cole. "This is a critical step toward a better understanding of network dysfunction in the disease and opens the window to novel therapeutic approaches for this common condition."
"From a physician's perspective, I think this work opened my eyes toward the need to look deeper into our patients' condition in order to improve the quality of their lives as well as that of their caregivers," Goldman said. "I think this work offers an opportunity for new investigations that could be relevant for moving forward the clinical practice of Alzheimer's disease."

The need for future studies

"This work with two patients proves the concept that 'silent seizures' can occur in patients with Alzheimer's disease," Noebels said.
"Next, we need to determine whether this finding is common in Alzheimer's disease, present in other types of progressive degenerative neurocognitive diseases, and when in the course of the disease it occurs," Cole said.

More information: Silent hippocampal seizures and spikes identified by foramen ovale electrodes in Alzheimer's disease, Nature Medicine (2017). nature.com/articles/doi:10.1038/nm.4330


Provided by Baylor College of Medicine

Stroke prevention may also reduce dementia

Dr. Vladimir Hachinski is a neurologist at Western University and a scientist at Lawson Health Research Institute in Ontario, Canada. 

05 may 2017--Ontario's stroke prevention strategy appears to have had an unexpected, beneficial side effect: a reduction also in the incidence of dementia among older seniors.
A new paper by researchers at Western University, Lawson Health Research Institute and the Institute for Clinical Evaluative Sciences (ICES) shows there's been a decade-long drop in new diagnoses of both stroke and dementia in the most at-risk group—those who are 80 or older.
"Some have said we're on the cusp of an epidemic of dementia as the population ages," said study author Joshua Cerasuolo, a PhD candidate in epidemiology and biostatistics at Western's Schulich School of Medicine and Dentistry. "What this data suggests is that by successfully fighting off the risks of stroke - with a healthy diet, exercise, a tobacco-free life and high blood-pressure medication where needed - we can also curtail the incidence of some dementias.
"The take-home message is that we can prevent some dementias by preventing stroke," Cerasuolo said.
Published in the journal Alzheimer's & Dementia: The Journal of the Alzheimer's Association, this is the first study that has looked at the demographics of both stroke and dementia across Ontario since the province pioneered Canada's first stroke prevention strategy in 2000. That strategy includes more health centres able to manage stroke, more community and physician supports, better use of hypertensive mediation and well-promoted lifestyle changes to reduce risks. Five provinces have stroke strategies and five do not.
"With lifestyle changes, we can reduce our risks of both stroke and some dementias. That's a pretty powerful one-two punch," said Dr. Vladimir Hachinski a clinical neuroscientist at Western's Schulich School of Medicine and Dentistry, a Lawson Health Research Institute scientist and neurologist at London Health Sciences Centre. He is a world pioneer in stroke research and a co-supervisor of the research paper.
Hachinski said more research needs to take place to understand the specific relationships between stroke and dementia but this work suggests there are policy implications where stroke and dementia work can intersect.
"We have systems in place for stroke prevention and our hypothesis is that any studies looking at stroke prevention should also investigate dementia prevention," Hachinski said. "It's a good-news story for Ontario and it could be a good-news story elsewhere."
Most strokes are caused by the restriction or constriction of blood flow to the brain. Vascular dementia also develops as blood supply to the brain is reduced.
Hachinski said someone who has had a stroke is twice as likely to develop dementia. Someone who has had a diagnosis of stroke has also likely had several prior "silent" strokes that may have affected a patient's cognitive abilities.
The data mining took place using information from ICES, based in Toronto.
Specifically, it shows that the incidence of new stroke diagnosis among highest-risk group, people aged 80-plus, dropped by 37.9 per cent in a span of a little more than a decade. During the same timeframe, the incidence of dementia diagnoses in that age group fell by 15.4 per cent.
"As clinicians and researchers, we are still trying to get a handle on how to reduce a person's chances of dementia late in life. Some we can't influence - yet - but here is a pretty clear indication that we can take specific definitive steps to reduce our chances of dementia related to vascular disease," Hachinski said.

More information: Joshua O. Cerasuolo et al, Population-based stroke and dementia incidence trends: Age and sex variations, Alzheimer's & Dementia (2017). DOI: 10.1016/j.jalz.2017.02.010


Provided by University of Western Ontario

Exercise and vitamin D better together for heart health

Johns Hopkins researchers report that an analysis of survey responses and health records of more than 10,000 American adults for nearly 20 years suggests a "synergistic" link between exercise and good vitamin D levels in reducing the risk of heart attacks and strokes.

01 may 2017--Both exercise and adequate vitamin D have long been implicated in reducing heart disease risks, but in a new study—one not designed to show cause and effect—the researchers investigated the relationship between these two health factors and their joint role in heart health. Their findings, which were published in the April 1 issue of the Journal of Clinical Endocrinology & Metabolism, identified a positive and direct relationship between exercise and vitamin D levels in the blood, which may provide evidence that exercise may boost vitamin D stores. They also found that the two factors working together seemed to somehow do more than either factor alone to protect the cardiovascular system. The researchers caution that their study is an observational one and that long-term, carefully controlled clinical trials would be needed to establish evidence for cause and effect. Nevertheless, the study does support the notion that exposure to the "sunshine" vitamin D and exercise are indicators of good health.
"In our study, both failure to meet the recommended physical activity levels and having vitamin D deficiency were very common" says Erin Michos, M.D., M.H.S., associate director of preventive cardiology and associate professor of medicine at the Ciccarone Center for the Prevention of Heart Disease at the Johns Hopkins University School of Medicine. "The bottom line is we need to encourage people to move more in the name of heart health." Michos adds that exposure to a few minutes a day of sunlight in non-winter seasons, eating a well-balanced meal that includes oily fish such as salmon, along with fortified foods like cereal and milk, may be enough to provide adequate levels of vitamin D for most adults.
For their data analysis, the Johns Hopkins researchers used previously gathered information from the federally funded Atherosclerosis Risk in Communities study beginning in 1987 and collected from 10,342 participants initially free of heart or vascular disease. Information about participants was updated and followed until 2013, and included adults from Forsyth County, North Carolina; Jackson, Mississippi; greater Minneapolis, Minnesota; and Washington County, Maryland. The participants were an average age of 54 at the start of the study and 57 percent were women. Twenty-one percent were African-American, with the remaining participants identifying as white.
In the first visit between 1987 and 1989, participants self-reported their exercise levels, which were compared to the American Heart Association recommendations of more than 150 minutes per week of moderate intensity exercise or 75 minutes per week or more of vigorous intensity. The researchers used the information to classify each participant's exercise level as adequate, intermediate or poor. People with adequate exercise levels met the AHA's recommendations, those with intermediate levels exercised vigorously for up to 74 minutes per week or exercised moderately for less than 149 minutes a week, and those classified as poor didn't exercise at all. About 60 percent of the participants had inadequate exercise in the poor or intermediate categories. The researchers converted the exercise to metabolic equivalent tasks (METs), an exercise intensity scale used by cardiologists and other clinicians to assess fitness. They then calculated physical activity levels by multiplying METs by minutes per week of exercise.
Reviewing data from the second study visit by each participant between 1990 and 1992, the researchers measured vitamin D levels in the blood by detecting the amount of 25-hydroxyvitamin D. Anyone with less than 20 nanograms per milliliter of 25-hydroxyvitamin D was considered deficient for vitamin D, and levels above 20 nanograms per milliliter were considered adequate. Thirty percent of participants had inadequate vitamin D levels.
In the first part of their study, the Johns Hopkins team showed that exercise levels positively corresponded to vitamin D levels in a direct relationship, meaning that the more one exercised, the higher their vitamin D levels seemed. For example, people with adequate exercise had an average 25-hydroxyvitamin D level of 26.6 nanograms per milliliter, those with intermediate exercise had 24.4 nanograms per milliliter, and those with poor exercise had 22.7 nanograms per milliliter. Those meeting recommended levels of exercise at visit 1 had a 31 percent lower risk of being vitamin D deficient at visit 2. Yet, the researchers only saw such a positive relationship between exercise and vitamin D in whites and not African-Americans.
In the next part of the study, they found that the most active participants with the highest vitamin D levels had the lowest risk for future cardiovascular disease. Over the 19 years of the study, 1800 adverse cardiac events occurred, including heart attack, stroke or death due to heart disease or stroke. After adjusting the data for age, sex, race, education, smoking, alcohol use, blood pressure, diabetes, high blood pressure medication, cholesterol levels, statin use and body mass index, the researchers found that those people who met both the recommended activity levels and had vitamin D levels above 20 nanograms per milliliter experienced about a 23 percent less chance of having an adverse cardiovascular event than those people with poor physical activity who were deficient for vitamin D. On the other hand, people who had adequate exercise but were vitamin D deficient didn't have a reduced risk of an adverse event. In other words, the combined benefit of having adequate vitamin D and exercise levels was better than either health factor alone.
But Michos says that sun exposure may not be the whole story of the direct relationship found between exercise and vitamin D levels, since vitamin D produced by the skin after exposure to sunlight tends to level off when the body makes enough, and the levels in these participants didn't show signs of doing so. She says this points to evidence that there may be something else going on in the body that causes vitamin D and exercise to positively influence levels of each other. For example, people who exercise may also have other healthy habits that influence vitamin D levels such as lower body fat and a healthier diet. Alternatively, people who exercise may take more vitamin supplements.
As for the racial disparity they saw, this could mean promoting physical activity may not be as effective for raising vitamin D levels in African-Americans as in whites. Michos notes that people with darker skin produce vitamin D less efficiently after sun exposure, possibly due to the greater amount of melanin pigment, which acts as a natural sunscreen. African-Americans also tend to have lower levels of 25-hydroxyvitamin D overall but they don't seem to experience the same consequences, such as bone fractures, that whites have with similarly low levels.
Michos cautions that people who meet the recommended daily amount of 600 to 800 International Units a day and who have adequate levels of vitamin D don't need to take additional vitamin supplements. "More isn't necessarily better once your blood levels are above 20 nanograms per milliliter," says Michos. "People at risk of bone diseases, have seasonal depression, or are obese should have their physicians measure vitamin D levels to ensure they're adequate, but for many, the best way to ensure adequate blood levels of the vitamin is from sun exposure, healthy diet, being active and maintaining a normal body weight." She adds, "Just 15 minutes of sunlight in the summer produces about 3000 international units of vitamin D depending on latitude and skin pigmentation, which is equivalent to 30 glasses of milk. Just be sure to use sunscreen if you plan to be outside longer than 15 minutes."
While the health boost from regular physical activity is undisputed, the benefits of vitamin D supplements haven't yet been proven for heart health. Michos notes that a recent randomized clinical trial published in JAMA Cardiology failed to show any cardiovascular benefit with high-doses of monthly vitamin D supplements among participants living in New Zealand. She says that larger studies including more diverse populations of patients and different dosing regimens are currently on-going and, when published, will provide further insight and guide recommendations for patients.

More information: Kathleen Chin et al, Physical Activity, Vitamin D, and Incident Atherosclerotic Cardiovascular Disease in Whites and Blacks: The ARIC Study, The Journal of Clinical Endocrinology & Metabolism (2017). DOI: 10.1210/jc.2016-3743


Provided by Johns Hopkins University School of Medicine