Poll: Seniors ready to Skype docs, worry about care quality

In this May 29, 2018, photo, Sidney Kramer, 92, uses a remote medical monitoring system to check his vital signs at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)

Every morning, 92-year-old Sidney Kramer wraps a blood pressure cuff around his arm and steps on a scale, and readings of his heart health beam to a team of nurses—and to his daughter's smartphone—miles from his Maryland home.

31 may 2018--Red flags? A nurse immediately calls, a form of telemedicine that is helping Kramer live independently by keeping his congestive heart failure under tight control.
"It's reassuring both psychologically and physically. The way he's put it to me, it's like having a doctor appointment every morning," said Miriam Dubin, Kramer's daughter.
The vast majority of older Americans and their caregivers are ready to give virtual health care a try: Nearly 9 in 10 adults age 40 and over would be comfortable using at least one type of telemedicine for themselves or an aging loved one, says a new poll from The Associated Press-NORC Center for Public Affairs Research.
But they want to make sure that an e-visit or other remote care is just as good as they'd get in person, and that their health information stays private, according to the survey released Thursday.
Long considered an option mainly for improving access to health care in rural areas with few doctors, telemedicine is gaining ground with tech-savvy younger consumers—they text their physician with questions or Skype with a mild complaint. For seniors with chronic illnesses or mobility problems that make simply reaching a doctor's office an ordeal, telehealth could be more than a convenience. The graying population is raising serious questions about how the nation will provide enough quality long-term care.

In this May 29, 2018, photo, Sidney Kramer, 92, points to his notebook he uses to help him keep track of vital signs after using a remote medical monitoring system at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)

But while private insurance often covers a video visit or other digital health care, seniors have had a harder time because Medicare tightly restricts what it will pay for.
That's starting to change, with a law Congress passed last winter that expands Medicare coverage for such options as video visits to diagnose stroke symptoms or check on home dialysis patients. Also, Medicare Advantage programs used by a third of beneficiaries can start offering additional telehealth options.
"While the interest is huge, one of the big barriers remains reimbursement," said Johns Hopkins University telemedicine chief Dr. Ingrid Zimmer-Galler, who has turned to grants to help fund such services as telepsychiatry for dementia patients. The new law "is really a huge step in the right direction. It certainly doesn't cover everything."
Costs are a major issue for people who need ongoing living assistance. Less than a third of adults age 40 and over have set aside any money for their future long term care needs, the AP-NORC survey shows, and more than half mistakenly think they'll be able to rely on Medicare to help cover nursing care or home health aides.
Telemedicine will have to replace in-person care, not add to it, to help with those costs, cautioned Zimmer-Galler.

In this May 29, 2018, photo, Sidney Kramer, 92, talks with his daughter Miriam Dubin, at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)

As access for seniors promises to grow, the AP-NORC Center poll shows widespread interest in telehealth. More than half of adults of all ages would be comfortable with a video visit via Skype or FaceTime to discuss medications, for ongoing care of a chronic illness or even for an urgent health concern.
In fact, adults 40 and older are just as open to at least some forms of telemedicine as those under 40, with one exception: The older crowd is slightly less comfortable discussing health care by text.
Among caregivers, 87 percent say they'd be interested in using at least one form of telemedicine for that person's medical needs.
"I think the parents would be happier at home instead of being in the doctor's office waiting an hour to see a doctor for 15 minutes," said Don Withey of Courtland, New York, who helps his 92-year-old father and 89-year-old mother get to their appointments. But, "we don't know much more about it other than the fact you can talk to a doctor over the computer or smartphone."
Just 12 percent of adults say they wouldn't use any form of telemedicine.

In this May 29, 2018, photo, Sidney Kramer, 92, checks his weight while using a remote medical monitoring system to check his vital signs at his home in Bethesda, Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)

There are concerns. More than 30 percent of people worry about privacy or the security or health information. About half fear that telemedicine could lead to lower-quality care, the poll found.
"It's not about having a video screen or Skype in the home or even a blood pressure cuff in the home. It's about the team that's behind it and the clinicians who are supporting the care of that patient," said Rachel DeSantis, chief of staff at Johns Hopkins Home Care Group, which provides the 92-year-old Kramer's remote monitoring.
The Hopkins program provides no-cost monitoring for a month or two to select high-risk patients after a hospitalization because research found it reduces their chances of readmission.
When the monitor recorded Kramer's weight creeping up one week, nurses immediately knew it was fluid build-up, a heart failure symptom that needed quick treatment. The machine is programmed for some educational feedback, too.
Dubin says her dad learned quickly when to cut back. "If he enjoys a pastrami sandwich one day, he can see his numbers may be higher the next day."

In this May 29, 2018, photo, nurse Melissa Lantz-Garnish, left, from Johns Hopkins Medicine, talks with her patience 92 year-old Sidney Kramer, right, about using the remote medical monitoring system to check his vital signs in Bethesda Md. A new poll shows older Americans and their caregivers want to give virtual health care a try, even though Medicare has been slow to pay. Nearly 9 in 10 would be comfortable using at least one type of telemedicine for themselves or an aging loved one. (AP Photo/Pablo Martinez Monsivais)

Dubin says the reassurance was worth privately paying, about $250 a month, to keep the monitoring once Kramer's initial time in the program ended.
___
The survey was conducted March 13 to April 5 by The Associated Press-NORC Center for Public Affairs Research, with funding from the SCAN Foundation.
It involved interviews in English and Spanish with 1,945 adults, including 1,522 adults age 40 and over, who are members of NORC's probability-based AmeriSpeak panel, which is designed to be representative of the U.S. population. Results from the full survey have a margin of sampling error of plus or minus 3.3 percentage points.

More information: AP-NORC long term care polls: www.longtermcarepoll.org/

New guidance on treating diabetes in elderly and frail adults

New guidance has been published on managing diabetes in the elderly, including for the first time how to manage treatment for the particularly frail.

30 may 2018--The guidance was produced from a collaboration between experts in diabetes medicine, primary care and geriatric medicine, led by Dr. David Strain at the University of Exeter Medical School.
It will advise clinicians on helping elderly people with type 2 diabetes get the most out of treatment options, and for the first time contains guidance on how and when to stop diabetes treatments in particularly frail adults.
Dr. Strain said: "Older adults have been systematically excluded from clinical trials and have very different ambitions from their diabetes management. This guidance puts the older person with diabetes firmly back at the centre of target setting, ensuring that appropriate goals are agreed to achieve the best quality of life possible, without continuing treatments that would not provide any benefit and potentially cause harm."
The research was carried out in collaboration with NHS England and was published in Diabetic Medicine, the journal of Diabetes UK last month.
The report authors hope it will ultimately be incorporated into national guidance for GPs, to advise GPs on the management of type 2 diabetes in elderly adults, aiming to reduce complications and improve quality of life.
The guidance will be adopted across Devon immediately. The authors hope local health and care commissioners will adopt and implement these principles in their own areas.
Pav Kalsi, Senior Clinical Advisor at Diabetes UK, said: "People with diabetes rightly deserve to have access to the right care and support at every stage of their life, and that means the care they receive needs to be adapted and tailored to suit each individual's changing needs. For example, those who are elderly, and potentially frail, often have different priorities, such as safety and quality of life.
"We're really pleased that these new guidelines will, for the first time, help healthcare professionals give this tailored support and will help them review and decide whether to stop diabetes treatment for particularly frail adults.
"In the future, we hope these guidelines will have a positive impact on the lives of older people with diabetes."
The paper, 'Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative', is available online.

More information: W. D. Strain et al, Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative, Diabetic Medicine (2018). DOI: 10.1111/dme.13644


Provided by University of Exete

What does a good death look like when you're really old and ready to go?

Hawaii recently joined the growing number of states and countries where doctor-assisted dying is legal. In these jurisdictions, help to die is rarely extended to those who don't have a terminal illness. Yet, increasingly, very old people, without a terminal illness, who feel that they have lived too long, are arguing that they also have a right to such assistance.

27 may 2018--Media coverage of David Goodall, the 104-year-old Australian scientist who travelled to Switzerland for assisted dying, demonstrates the level of public interest in ethical dilemmas at the extremities of life. Goodall wanted to die because he no longer enjoyed life. Shortly before his death, he told reporters that he spends most of his day just sitting. "What's the use of that?" he asked.
Research shows that life can be a constant struggle for the very old, with social connections hard to sustain and health increasingly fragile. Studies looking specifically at the motivation for assisted dying among the very old show that many feel a deep sense of loneliness, tiredness, an inability to express their individuality by taking part in activities that are important to them, and a hatred of dependency.
Of the jurisdictions where assisted dying is legal, some make suffering the determinant (Canada, for example). Others require a prognosis of six months (California, for example). Mainly, though, the focus is on people who have a terminal illness because it is seen as less of an ethical problem to hasten the death of someone who is already dying than someone who is simply tired of life.

Why give precedence to physical suffering?

Assisted dying for people with psychological or existential reasons for wanting to end their life is unlikely to be supported by doctors because it is not objectively verifiable and also potentially remediable. In the Netherlands, despite the legal power to offer assistance where there is no life-limiting illness, doctors are seldom convinced of the unbearable nature of non-physical suffering, and so will rarely administer a lethal dose in such cases.
Although doctors may look to a physical diagnosis to give them confidence in their decision to hasten a patient's death, physical symptoms are often not mentioned by the people they are assisting. Instead, the most common reason given by those who have received help to die is loss of autonomy. Other common reasons are to avoid burdening others and not being able to enjoy one's life – the exact same reason given by Goodall. This suggests that requests from people with terminal illness, and from those who are just very old and ready to go, are not as different as both the law – and doctors' interpretation of the law – claim them to be.

Sympathetic coverage

It seems that the general public does not draw a clear distinction either. Most of the media coverage of Goodall's journey to Switzerland was sympathetic, to the dismay of opponents of assisted dying.
Media reports about ageing celebrities endorsing assisted dying in cases of both terminal illness and very old age, blur the distinction still further.
One of the reasons for this categorical confusion is that, at root, this debate is about what a good death looks like, and this doesn't rely on prognosis; it relies on personality. And, it's worth remembering, the personalities of the very old are as diverse as those of the very young.
Discussion of assisted suicide often focuses on concerns that some older people may be exposed to coercion by carers or family members. But older people also play another role in this debate. They make up the rank and file activists of the global right-to-die movement. In this conflict of rights, protectionist impulses conflict with these older activists' demands to die on their own terms and at a time of their own choosing.
In light of the unprecedented ageing of the world's population and increasing longevity, it is important to think about what a good death looks like in deep old age. In an era when more jurisdictions are passing laws to permit doctor-assisted dying, the choreographed death of a 104-year-old, who died listening to Ode to Joy after enjoying a last fish supper, starts to look like a socially approved good death.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

World first use of cognitive training reduces gait freezing in Parkinson's patients

The researchers report significant reduction in the severity and duration of freezing of gait, improved cognitive processing speed and reduced daytime sleepiness.

23 may 2018--Freezing of gait (FoG) is a disabling symptom of Parkinson's Disease, characterized by patients becoming stuck while walking and unable to progress forward, often describing the feeling as being glued to the ground. It is well-known to lead to falls and lower quality of life, making it an important target for treatment.
Research has linked FoG to aspects of attention and cognitive control, a link supported by neuroimaging evidence revealing impairments in the fronto-parietal and fronto-striatal areas of the brain.

The intervention

Patients with Parkinson's Disease who self-reported FoG and who were free from dementia were randomly allocated to receive either a cognitive training intervention or an active control.
Sixty-five patients were randomized into the study. The sample of interest included 20 patients randomly assigned to the cognitive training intervention and 18 randomized to the active control group.
Both groups were clinician-led and conducted twice-weekly for seven weeks. The primary outcome was the percentage of time spent frozen during a 'Timed Up and Go' task, assessed while patients were both on and off dopaminergic medications.
Secondary outcomes included multiple neuropsychological and psychosocial measures, including assessments of mood, well-being and length and quality of sleep.

Results

The researchers report that patients in the cognitive training group showed a large and statistically significant reduction in FoG severity while on dopaminergic medication compared to participants in the active control group on dopaminergic medication.
Patients who received cognitive training also showed improved cognitive processing speed and reduced daytime sleepiness compared to those in the active control while accounting for the effect of dopaminergic medication.
There was no difference between groups when they were tested without their regular dopaminergic medication.
"We believe there is reason to be hopeful for the use of these trials in the future," said study leader, Dr. Simon Lewis, a professor of cognitive neuroscience at the University of Sydney's Brain and Mind Centre and Royal Prince Alfred Hospital in Australia.
"The feedback we've had from participants and family members involved in this study was overwhelmingly positive. The results of this pilot study highlight positive trends, and the importance of nonpharmacological trials involving cognitive training has become increasingly clear."
The research team, comprising scholars from the University of Sydney, Western Sydney University and Cambridge University say the finding that freezing of gait improved only while patients were on dopaminergic medication is noteworthy.
"Taking dopaminergic medications as prescribed is the normal day-day state for patients with Parkinson's Disease," said study lead-author, Dr. Courtney Walton, formerly at the University of Sydney and now at the University of Queensland.
"While more research is needed to better understand and establish these findings, it's likely that participants in the off- dopaminergic state were too impaired to benefit from any of the potential changes initiated through cognitive training."
The researchers say more studies using larger samples are needed to investigate this initial finding that cognitive training can reduce the severity of freezing of gait in Parkinson's diseases patients.


Provided by University of Sydney

Diet soda may be hurting your diet

Coca-Cola is the world’s most popular carbonated soft drink. The original is made with sugar, but the others contain artificial sweeteners that are now linked to a rise in obesity and diabetes. Credit: Chones/shutterstock.com

Artificial sweeteners are everywhere, but the jury is still out on whether these chemicals are harmless. Also called non-nutritive sweeteners, these can be synthetic – such as saccharin and aspartame – or naturally derived, such as steviol, which comes from the Stevia plant. To date, the U.S. Food and Drug Administration has approved six types of artificial and two types of natural non-nutritive sweeteners for use in food.

18 may 2018--That's been great news for those working hard to curb their sugar consumption. Aspartame, for example, is found in more than 6,000 foods worldwide, and about 5,000-5,500 tons are consumed every year in the United States alone.
The American Diabetes Association – the most well-respected professional group focusing on diabetes – officially recommends diet soda as an alternative to sugar-sweetened beverages. To date, seven U.S. municipalities have imposed a sugary beverage tax to discourage consumption.
However, recent medical studies suggest that policymakers eager to implement a soda tax may also want to include diet drinks because these sweeteners may be contributing to chronic diabetes and cardiovascular diseases as well.
Why are these sweeteners calorie-free?
The key to these virtually calorie-free sweeteners is that they are not broken down during digestion into natural sugars like glucose, fructose and galactose, which are then either used for energy or converted into fat.
Non-nutritive sweeteners have different byproducts that are not converted into calories. Aspartame, for example, undergoes a different metabolic process that doesn't yield simple sugars. Others such as saccharin and sucralose are not broken down at all, but instead are absorbed directly into the bloodstream and excreted in the urine.

Theoretically, these sweeteners should be a "better" choice than sugar for diabetics. Glucose stimulates release of insulin, a hormone that regulates blood sugar levels. Type 2 diabetes occurs when the body no longer responds as well to insulin as it should, leading to higher levels of glucose in the blood that damages the nerves, kidneys, blood vessels and heart. Since non-nutritive sweeteners aren't actually sugar, they should sidestep this problem.
Artificial sweeteners, your brain and your microbiome
However, there is growing evidence over the last decade that these sweeteners can alter healthy metabolic processes in other ways, specifically in the gut.
Long-term use of these sweeteners has been associated with a higher risk of Type 2 diabetes. Sweeteners, such as saccharin, have been shown to change the type and function of the gut microbiome, the community of microorganisms that live in the intestine. Aspartame decreases the activity of a gut enzyme that is normally protective against Type 2 diabetes. Furthermore, this response may be exacerbated by the "mismatch" between the body perceiving something as tasting sweet and the expected associated calories. The greater the discrepancy between the sweetness and actual caloric content, the greater the metabolic dysregulation.
Sweeteners have also been shown to change brain activity associated with eating sweet foods. A functional MRI exam, which studies brain activity by measuring blood flow, has shown that sucralose, compared to regular sugar, decreases activity in the amygdala, a part of the brain involved with taste perception and the experience of eating.
Another study revealed that longer-term and higher diet soda consumption are linked to lower activity in the brain's "caudate head," a region that mediates the reward pathway and is necessary for generating a feeling of satisfaction. Researchers have hypothesized that this decreased activity could lead a diet soda drinker to compensate for the lack of pleasure they now derive from the food by increasing their consumption of all foods, not just soda.

Together these cellular and brain studies may explain why people who consume sweeteners still have a higher risk of obesity than individuals who don't consume these products.
As this debate on the pros and cons of these sugar substitutes rages on, we must view these behavioral studies with a grain of salt (or sugar) because many diet soda drinkers – or any health-conscious individual who consumes zero-calorie sweeteners – already has the risk factors for obesity, diabetes, hypertension or heart disease. Those who are already overweight or obese may turn toward low-calorie drinks, making it look as though the diet sodas are causing their weight gain.
This same group may also be less likely to moderate their consumption. For example, those people may think that having a diet soda multiple times a week is much healthier than drinking one case of soda with sugar.
These findings signal that consumers and health practitioners all need to check our assumptions about the health benefits of these products. Sweeteners are everywhere, from beverages to salad dressing, from cookies to yogurt, and we must recognize that there is no guarantee that these chemicals won't increase the burden of metabolic diseases in the future.
As a physician of internal medicine specializing in general prevention and public health, I would like to be able to tell my patients what the true risks and benefits are if they drink diet soda instead of water.
Legislators considering soda taxes to encourage better dietary habits perhaps should think about including foods with non-nutritive sweeteners. Of course, there is an argument to be made for being realistic and pursuing the lesser of two evils. But even if the negative consequences of sugar substitutes doesn't sway our tax policy – for now – at least the medical community should be honest with the public about what they stand to lose or gain, consuming these foods.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Screening for impaired vision in older adults: New Canadian guideline

A new Canadian guideline for impaired vision in older adults recommends against primary care screening of older adults not reporting concerns about their vision. The guideline, published in English and French in CMAJ (Canadian Medical Association Journal) by the Canadian Task Force on Preventive Health Care (CTFPHC), is aimed at primary care practitioners.

17 may 2018--Visual impairment describes less than 20/40 vision, which usually cannot be corrected with glasses, contact lenses or vision-related procedures. This level of difficulty with vision can affect quality of life, as well as participation in work, social and leisure activities, and increases the likelihood of injuries from falls and other accidents.
The task force considered the benefits of screening for visual impairment in primary health care and referring patients to optometrists for formal vision testing.
"We found no evidence of benefit to patients aged 65 years or older from being screened for impaired vision as a way to prevent limitations on daily living or other consequences," said Dr. Brenda Wilson, Task Force Impaired Vision Working Group Chair. "The task force therefore recommends against screening for impaired vision in primary care settings for people living independently in the community."
Currently, people must make their own appointments for regular vision screening or if they suspect visual problems. Most provinces in Canada cover comprehensive eye examinations for adults aged 65 years and older by eye care professionals.
The new guideline updates a previous guideline from 1995, which recommended screening for visual impairment in elderly patients with diabetes of at least 5 years' duration. The 2018 guideline is based on the latest and highest-quality evidence on screening, which includes 15 randomized controlled trials involving participants aged 65 years or older. It is consistent with the recommendation on vision screening for older adults from the United States Preventive Services Task Force.
"Although screening does not appear to be effective, we need to look for ways to effectively support older Canadians who do experience visual impairment so that they get the services they need from optometrists or other eye care professionals" said Dr. Brett Thombs, chair of the CTFPHC .

More information: Screening for impaired vision in community-dwelling adults aged 65 years and older in primary care settings, https://doi.org/10.1503/cmaj.171430


Provided by Canadian Medical Association Journal

Research reveals key factors to support quality of life in dementia

Factors that support quality of life in people with dementia. Credit: University of Exeter

A robust research analysis has identified what factors can be targeted to support people to live as well as possible with dementia.
The study, led by the University of Exeter and published in the journal Psychological Medicine, found that good relationships, social engagement, better everyday functioning, good physical and mental health, and high-quality care were all linked to better quality of life for people with dementia.

17 may 2018--Professor Linda Clare, at the University of Exeter, said: "This research supports the identification of national priorities for supporting people to live as well as possible with dementia. While many investigations focus on prevention and better treatments, it's equally vital that we understand how we can optimise quality of life for the 50 million people worldwide who have dementia. We now need to develop ways to put these findings into action to make a difference to people's lives by supporting relationships, social engagement and everyday functioning, addressing poor physical and mental health, and ensuring high-quality care."
The research was supported jointly by the Economic and Social Research Council (ESRC) and the National for Health Research (NIHR). It involved collaboration with the London School of Economics, the universities of Sussex, Bangor, Cardiff, Brunel and New South Wales in Australia, and Kings College London.
The team carried out a systematic review and meta-analysis to examine all available evidence about the factors that are associated with quality of life for people with dementia. They included 198 studies, which incorporated data from more than 37,000 people.
The study found that demographic factors such as gender, education marital status, income or age were not associated with quality of life in people with dementia. Neither was the type of dementia.
Factors that are linked with poor quality of life include poor mental or physical health, difficulties such as agitation or apathy, and unmet needs.
Factors that are linked with better QoL include having good relationships with family and friends, being included and involved in social activities, being able to manage everyday activities, and having religious beliefs.
Many other factors showed small but statistically significant associations with quality of life. This suggests that the way in which people evaluate their quality of life is related to many aspects of their lives, each of which have a modest influence. It is likely that to some extent the aspects that are most important may be different for each person.
Evidence from longitudinal studies about what predicts whether or not someone will experience a good quality of life at later stages was limited. The best indicator was the person's initial rating of quality of life. This again highlights the importance of optimising quality of life from the earliest stages of living with dementia.
Dr Anthony Martyr, lead author on the study, from the University of Exeter, said: "While in general it is more of a challenge to maintain good quality of life as dementia progresses, we found little evidence to show what predicts whether quality of life will improve or decline over time. The IDEAL programme we are currently leading will follow people living with dementia over several years and will help to answer this question."
Dr Doug Brown, Chief Policy and Research Officer at Alzheimer's Society, said: "Maintaining a healthy social life and doing things you enjoy is important for everyone's quality of life. As this Alzheimer's Society funded study highlights, people living with dementia are no exception.
"Someone develops dementia every three minutes but too many are facing it alone and feel socially isolated- a factor that researchers pinpoint contributing to a lower quality of life.
"People with dementia have a right to continue living a life they love. Alzheimer's Society's Dementia Friendly Communities initiative enables individuals, businesses and communities to involve and empower people affected - but we need all of society to unite to ensure people with dementia feel understood, valued and able to contribute to their community."
The full paper, entitled 'Living well with dementia: a systematic review and correlational meta-analysis of factors associated with quality of life, well-being and life satisfaction in people with dementia', is published in Psychological Medicine. Authors are Anthony Martyr, Sharon M. Nelis, Catherine Quinn, Yu-Tzu Wu, Ruth A. Lamont, Catherine Henderson, Rachel Clarke, John V. Hindle, Jeanette M. Thom, Ian Rees Jones, Robin G. Morris, Jennifer M. Rusted, Christina R. Victor and Linda Clare.
The study stems from the IDEAL programme. IDEAL is a major longitudinal cohort study of 1550 people with dementia and their family members or friends funded by the Economic and Social Research Council and the National Institute for Health Research. The IDEAL study is survey- and interview-based and aims to understand what makes it easier or more difficult for people to live well with dementia. The findings from the study will help to identify what can be done by individuals, communities, health and social care practitioners, care providers and policy-makers to improve the likelihood of living well with dementia. Since 2018 the project has been extended as an Alzheimer's Society Centre of Excellence, making it possible to follow the experiences of participants for several more years.

More information: Anthony Martyr et al, Living well with dementia: a systematic review and correlational meta-analysis of factors associated with quality of life, well-being and life satisfaction in people with dementia, Psychological Medicine (2018). DOI: 10.1017/S0033291718000405


Provided by University of Exeter

The guidelines on low back pain are clear—drugs and surgery should be the last resort

Most people with low back pain aren’t getting the most effective treatment. Credit: shutterstock.com

Low back pain is the leading cause of disability worldwide and is becoming more common as our population ages. Most people who have an episode of low back pain recover within six weeks, but two-thirds still have pain after three months. By 12 months, pain may linger but is usually less intense.

17 may 2018--Still, recurrence is common and in a small number of people it may become persistent and disabling. Chronic back pain affects well-being, daily functioning and social life.
A series on low back pain by the global medical journal The Lancet outlined that most sufferers aren't getting the most effective treatment. The articles state that recommended first-line treatments – such as advice to stay active and to exercise – are often overlooked. Instead, many health professionals seem to favour less effective treatments such as rest, opioids, spinal injections and surgery.
So, here's what evidence shows you need to do to improve your low back pain.
Risk factors for low back pain
The cause of most people's low back pain remains unknown. But we do know of a number of risk factors that could increase the chance of developing low back pain. These include a physically demanding job that involves lifting, bending and being in awkward postures. Lifestyle factors such as smoking, obesity and low levels of physical activity are also associated with developing low back pain.
People with low back pain should see a health professional to rule out the more serious causes of pain such as fracture, malignancy (cancer) or infection.
Once patients are cleared of these, the current guidelines from Denmark, the UK and the US advise self-management and psychological therapies as the initial response for persistent low back pain. These include staying active, doing appropriate exercises and undertaking a psychological program to help manage the pain.
Exercises such as Tai Chi, yoga, motor control (to restore strength, co-ordination and control of the deep core stabilising muscles supporting the spine) and aerobic exercises (such as walking, swimming, cycling and general muscle reconditioning exercises) are recommended.
If any of these therapies fail or stop working, the guidelines point to manual and physical therapies such as spinal manipulation (Denmark, UK, US), massage (UK and US) and yoga and acupuncture (US) – particularly for low back pain lasting more than 12 weeks.
Exercise and psychological therapy
The guidelines are based on many studies that have shown the benefits of exercise and psychological therapies. For instance, a 2006 study compared pain levels across two groups of physically active people with chronic low back pain.
Participants who followed a four-week program using Pilates exercise equipment reported a more significant reduction in pain and disability than those in a control group who received usual care (consultations with a health care professional as needed). The benefit for the exercise group was maintained over a 12-month period.

Credit: The Conversation

Another, 2011 trial explored the benefits of Tai Chi for those with persistent low back pain. Participants who completed a ten-week course of Tai Chi sessions had less bothersome back symptoms, pain intensity and self‐reported disability, compared with a control group who continued with their normal medical care, fitness or health regimen.
Chronic pain is linked with chemical and structural changes at all levels of the nervous system. These include the level of neurotransmitter changes that alter pain modulation, and sensitisation of the nerves involved in transmitting pain signals. Incoming pain signals can be modified by our response to persistent pain.
Psychological treatments – such as mindfulness-based stress reduction – focus on increasing awareness and acceptance of physical discomfort, as well as challenging emotions often associated with chronic pain.
In a trial including 342 participants, around 45% of those who had completed eight sessions of cognitive behaviour therapy or mindfulness-based stress reduction had clinically meaningful improvements in bothersome pain at 26 weeks of follow-up. This was compared to only 26.6% of people who had received usual care.
Manual therapy
In Australia, physiotherapists, chiropractors and osteopaths use manual and physical therapy to treat lower back pain. The treatments often include some form of spinal manipulation and massage, as well as advice to stay active and do exercises. This is consistent with The Lancet's recommendations, also based on evidence from studies.
A 2013 trial of people with acute low back pain compared the effects of spinal manipulation with those of the non-steroidal anti-inflammatory drug diclofenac (Voltaren) and placebo on their pain. Spinal manipulation was found to be significantly better than diclofenac and clinically superior to placebo in reducing disability, pain and the need for rescue medication. It was also found to improve quality of life.
Similar results came from another study of 192 people with low back pain that lasted around two to six weeks. Participants were randomly allocated to one of three groups: chiropractic manipulation with a placebo medication; muscle relaxants with sham manipulation; or placebo medicine with sham manipulation. All subjects improved over time, but the chiropractic group responded significantly better, with a bigger decrease in pain scores, than the control group.
Physiotherapists, chiropractors and osteopaths are required by law to be registered with the Australian Health Practitioner Regulation Agency (AHPRA) to practise in Australia. To be registered, a person must complete a minimum of four years' study at a university in a degree that includes a focus on non-pharmacological (drug-based), non-surgical management of musculoskeletal conditions, including low back pain.
Under the government's Chronic Disease Management Plan patients with persistent low back pain may be referred to physiotherapists, chiropractors or osteopaths for evidence-based therapies such as spinal manipulation and massage. If patients are unfamiliar with these therapies, they can discuss referral with their GP.
Physiotherapists, chiropractors and osteopaths can also be consulted without referral. Their services are usually covered by private health insurance. The AHPRA website lists registered practitioners in your area.
One thing to look out for when you see a practitioner is the number of treatments they recommend. Patients usually start with a short course of two to six treatments to see if the treatment helps. It shouldn't take many treatments for a change in symptom pattern to become obvious.
The message to the public and to health professionals is clear. People with non-specific low back pain need to learn how to independently manage their pain while remaining active, staying at work and maintaining their social life as far as possible.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Review shows lack of evidence supporting use of antidepressants for insomnia

Credit: CC0 Public Domain

A rigorous review of research, led by the University of Southampton, has found there is not enough evidence to support the current clinical practice of prescribing antidepressants for insomnia.
Part-funded by the NIHR School for Primary Care Research, the review, published in the Cochrane Systematic Reviews Library, re-examined 23 previous studies involving a total of 2,806 patients with insomnia.

17 may 2018--The researchers found that, overall, evidence supporting the use of antidepressants for people with sleep problems is of low quality – partly due to the small number of people in individual studies and partly due to how the studies were undertaken and reported.
Some low quality evidence was identified supporting short term (weeks, rather than months) use of some antidepressants, but no evidence was found for amitriptyline, which is commonly used in clinical practice. There was also no evidence to support long-term antidepressant use for insomnia.
Lead researcher, Associate Professor Hazel Everitt, says: "High quality trials of antidepressants for insomnia are needed to provide better evidence in this area to inform clinical practice. Additionally, health professionals and patients should be made aware of the current lack of evidence for antidepressant medications commonly used for insomnia management."
Insomnia causes unsatisfactory sleep – both difficulty getting to sleep and staying asleep. It is a common problem, with one in five people reporting sleep problems each year. It can significantly impair quality of life, leading to physical or mental health problemsand is associated with anxiety, depression and drug and alcohol abuse.
Management of the condition depends on its duration and nature. It may involve treating coexisting medical problems, providing advice on sleep habits and lifestyle, or using medicines and psychological therapies. Medicines called hypnotics are most commonly used to treat insomnia and are known to help, but can have problems, such as tolerance (needing to take more of the medicine to get the same effect) and dependence (physical or mental problems if the medicine is stopped). The use of antidepressant drugs to help with insomnia is widespread, but none are licensed for the condition and, as this study has shown, their effectiveness is unclear.

More information: Antidepressants for insomnia in adults. Cochrane Database of Systematic Reviews, DOI: 10.1002/14651858.CD010753.pub2


Provided by University of Southampton

EULAR recommendations for pain management in inflammatory arthritis and osteoarthritis

The European League Against Rheumatism, EULAR, has published a set of recommendations, designed to help health professionals implement approaches to pain management in inflammatory arthritis and osteoarthritis patients. The aim is to reduce pain and the burden on the individual and society.

17 may 2018--Pain is the predominant symptom for people with inflammatory arthritis (IA) and osteoarthritis (OA), mandating the development of new, evidence-based EULAR Recommendations for the health professional's approach to pain management. The target users of these recommendations are health professionals in the field of rheumatology, including rheumatologists. Prompt and knowledgeable pain management support can reduce pain, increase functioning and well-being, and reduce individual and societal costs. Practitioners in all healthcare settings should therefore have the knowledge and skills required to help people with IA and OA to better manage their pain; rheumatology health professionals are ideally placed to provide comprehensive, evidence-based, and patient-centred care.
Pain management typically includes education. Based on the needs of the patient, education is complemented by physical activity and exercise, aids and assistive devices, psychological and social interventions, sleep hygiene education, weight management, pharmacological and joint-specific treatment options, and interdisciplinary pain management. Underpinned by available systematic reviews and meta-analyses, these recommendations enable health professionals to provide knowledgeable pain managementsupport for people with IA and OA.
A multidisciplinary task force including patient representatives conducted a systematic literature review to evaluate evidence regarding effects on pain of multiple treatment modalities. The task force that included 18 members from 12 countries, consisted of patient representatives, nurses, physiotherapists, psychologists, rheumatologists, a general practitioner, an occupational therapist, a clinical epidemiologist, and a research fellow.
From 2,914 studies initially identified, 186 met inclusion criteria. Based on the reviewed studies and expert opinion, the task force emphasised the importance for the health professional to adopt a patient-centred framework within a biopsychosocial perspective, to have sufficient knowledge of IA and OA pathogenesis, and to be able to differentiate localised and generalised pain. The assessment of patient needs, preferences and priorities; pain characteristics; previous and ongoing pain treatments; inflammation and joint damage; and psychological and other pain-related factors were deemed important.

More information: EULAR Recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis: www.eular.org/sysModules/obxCo … management_ia_oa.pdf


Provided by European League Against Rheumatism (EULAR)

The Yogi masters were right—meditation and breathing exercises can sharpen your mind

Credit: CC0 Public Domain

It has long been claimed by Yogis and Buddhists that meditation and ancient breath-focused practices, such as pranayama, strengthen our ability to focus on tasks. A new study by researchers at Trinity College Dublin explains for the first time the neurophysiological link between breathing and attention.

17 may 2018--Breath-focused meditation and yogic breathing practices have numerous known cognitive benefits, including increased ability to focus, decreased mind wandering, improved arousal levels, more positive emotions, decreased emotional reactivity, along with many others. To date, however, no direct neurophysiological link between respiration and cognition has been suggested.
The research shows for the first time that breathing—a key element of meditation and mindfulness practices—directly affects the levels of a natural chemical messenger in the brain called noradrenaline. This chemical messenger is released when we are challenged, curious, exercised, focused or emotionally aroused, and, if produced at the right levels, helps the brain grow new connections, like a brain fertiliser. The way we breathe, in other words, directly affects the chemistry of our brains in a way that can enhance our attention and improve our brain health.
The study, carried out by researchers at Trinity College Institute of Neuroscience and the Global Brain Health Institute at Trinity, found that participants who focused well while undertaking a task that demanded a lot of attention had greater synchronisation between their breathing patterns and their attention, than those who had poor focus. The authors believe that it may be possible to use breath-control practices to stabilise attention and boost brain health.
Michael Melnychuk, Ph.D. candidate at the Trinity College Institute of Neuroscience, Trinity, and lead author of the study, explained: "Practitioners of yoga have claimed for some 2,500 years, that respiration influences the mind. In our study we looked for a neurophysiological link that could help explain these claims by measuring breathing, reaction time, and brain activity in a small area in the brainstem called the locus coeruleus, where noradrenaline is made. Noradrenaline is an all-purpose action system in the brain. When we are stressed we produce too much noradrenaline and we can't focus. When we feel sluggish, we produce too little and again, we can't focus. There is a sweet spot of noradrenaline in which our emotions, thinking and memory are much clearer."
"This study has shown that as you breathe in locus coeruleus activity is increasing slightly, and as you breathe out it decreases. Put simply this means that our attention is influenced by our breath and that it rises and falls with the cycle of respiration. It is possible that by focusing on and regulating your breathing you can optimise your attention level and likewise, by focusing on your attention level, your breathing becomes more synchronised."
The research provides deeper scientific understanding of the neurophysiological mechanisms which underlie ancient meditation practices. The findings were recently published in a paper entitled 'Coupling of respiration and attention via the locus coeruleus: Effects of meditation and pranayama' in the journal Psychophysiology. Further research could help with the development of non-pharmacological therapies for people with attention compromised conditions such as ADHD and traumatic brain injury and in supporting cognition in older people.
There are traditionally two types of breath-focused practices—those that emphasise focus on breathing (mindfulness), and those that require breathing to be controlled (deep breathing practices such as pranayama). In cases when a person's attention is compromised, practices which emphasise concentration and focus, such as mindfulness, where the individual focuses on feeling the sensations of respiration but make no effort to control them, could possibly be most beneficial. In cases where a person's level of arousal is the cause of poor attention, for example drowsiness while driving, a pounding heart during an exam, or during a panic attack, it should be possible to alter the level of arousal in the body by controlling breathing. Both of these techniques have been shown to be effective in both the short and the long term.
Ian Robertson, Co-Director of the Global Brain Health Institute at Trinity and Principal Investigator of the study added: "Yogis and Buddhist practitioners have long considered the breath an especially suitable object for meditation. It is believed that by observing the breath, and regulating it in precise ways—a practice known as pranayama—changes in arousal, attention, and emotional control that can be of great benefit to the meditator are realised. Our research finds that there is evidence to support the view that there is a strong connection between breath-centred practices and a steadiness of mind."
"Our findings could have particular implications for research into brain ageing. Brains typically lose mass as they age, but less so in the brains of long term meditators. More 'youthful' brains have a reduced risk of dementia and mindfulness meditation techniques actually strengthen brain networks. Our research offers one possible reason for this—using our breath to control one of the brain's natural chemical messengers, noradrenaline, which in the right 'dose' helps the brain grow new connections between cells. This study provides one more reason for everyone to boost the health of their brain using a whole range of activities ranging from aerobic exercise to mindfulness meditation."

More information: Michael Christopher Melnychuk et al. Coupling of respiration and attention via the locus coeruleus: Effects of meditation and pranayama, Psychophysiology (2018). DOI: 10.1111/psyp.13091


Provided by Trinity College Dublin

Why alcohol health warning labels are a good idea: findings from the latest Global Drug Survey

Credit: lOvE lOvE/Shutterstock.com

Drink-driving and drinking while pregnant are socially unacceptable in many countries, yet when it comes to other alcohol-related health risks, public awareness is low.

17 may 2018--Globally around 3.3m people die from causes directly related to alcohol consumption – the top ones being heart disease, cancer, liver disease and accidents. However, a 2016 survey of 2,100 adults in the UK found that just 13% of respondents identified cancer as a potential health risk of alcohol consumption.
It seems that the alcohol industry and governments aren't too bothered about changing this. In fact, mandatory health warnings for alcohol are rare. Across the EU, which boasts the highest per capita alcohol consumption in the world, there is no legislation requiring health warnings.
We know that the most effective strategies to change behaviour and reduce alcohol consumption are legislative. These include raising taxes, minimum unit pricing and lower drink-drive limits. But the alcohol industry lobbies hard against interventions that threaten profits, and most governments seem to defer to the industry's preferred alternative of self-regulation.
The industry and governments don't seem that keen on health warning labels either. One argument is that health messages don't change behaviour or that drinkers don't want to have their pleasure spoiled by uncomfortable truths. And it's true that information in isolation of other public health and health promotion strategies may be of limited value. But when it comes to motivating behaviour change, it can be helpful to raise awareness and challenge people's beliefs about their behaviour.
Health messages, if done well, could raise awareness and for some people might be the switch that gets them thinking about drinking less. Providing accurate information can also help to counter common myths and misunderstandings. For example, ambiguity about the potential health benefits of moderate drinking can be the "excuse" we need to resist changing our behaviour.
On the other hand, it is important to acknowledge evidence that health messages that try to induce fear often backfire – images of diseased lungs on cigarette packaging, being a case in point. Smokers don't want to be confronted by the negative consequences of their behaviour and they may smoke more to deal with the discomfort experienced. The same is likely to be true of alcohol health warnings.

Possible label. Author provided

Some labels that might work
For the latest Global Drug Survey (GDS2018) – a survey of 130,000 people from more than 40 countries – we explored the potential of seven different health messages to change people's drinking habits. We chose a variety of health and social issues to focus on and used a mixture of positive messages, highlighting the benefits of reducing consumption, and negative messages, highlighting risks.
The results show that cancer remains the area that people least associate with alcohol use, and a message such as "drinking less can reduce your risk of seven different types of cancer" could get almost 40% of drinkers to think about drinking less.
The top two other messages that people reported would make them – or maybe make them – think about drinking less were: "Even people with heavy alcohol use can reduce their risk of liver disease by cutting down by even a small amount" (31%), and a label highlighting that a bottle of wine or six small beers has the same number of calories as a hamburger and fries (28%).
Our study also shows that different cultures may be more or less responsive to health warning labels, with Scandinavian countries, which certainly have high rates of alcohol-related harms, seemingly less concerned than those from South America and the Mediterranean.
Of particular interest was the relatively high rate of disbelief of the statement: "Most people get little or no health benefit from alcohol use, even at low levels of drinking". The subtle message that a little alcohol is good for your health is one the alcohol industry is fiercely protective of, and our results show that more work is required to diminish this falsehood.
Conversely, the label stating that alcohol increases the rate of violence and abuse was the one that was believed most by participants.

Globally, this was also rated as the most personally relevant label, closely followed by those about calories and the benefits of having two days off. This perhaps reflects that people are more concerned about the immediate effects of drinking.
Again, there were regional variations; our findings suggest that countries in South America and Eastern Europe may be more affected by the social impact of alcohol than other countries.
Self-regulation doesn't work
Consumers of alcohol, like any other drug, need to be given the facts about the risks they expose themselves to when they drink. They need to know that risk is dependent on how much they drink and that drinking less reduces that risk. They need specific positive messages that allow people to feel OK about making decisions that may improve their health and well-being.
In the same way that plain packaging and health warnings on tobacco products were used as part of a broader public health approach to reducing consumption, appropriate and proportionate health messages on alcohol should be explored as a cheap, easy-to-implement strategy that could raise awareness of alcohol-related harms.
The latest Global Drug Survey supports the call for mandatory health warning labels on alcohol. An industry that makes profits from selling a product will never embrace anything that might lead to people drinking less. A self-regulated industry will always regulate to optimise profits not public health.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Training for 21st century doctors: medicine, business, and leadership development

Given the complex and rapidly evolving health care system in the United States, medical schools must focus their efforts on training more physician leaders to master the diverse skills needed to navigate emerging challenges in the field, urge leaders from the Perelman School of Medicine at the University of Pennsylvania in a new Perspective piece published today in the New England Journal of Medicine.

17 may 2018--"Academic medicine has been somewhat complacent in the face of the disruptive forces in health care, and as a result, the gap between the physician-leader workforce and the needs of our system has only widened," said J. Larry Jameson, MD, Ph.D., executive vice president of the University of Pennsylvania for the Health System and dean of Penn's Perelman School of Medicine. "Health care systems need a new prescription to close this leadership gap. Given the societal impact of health care, we need to accelerate the development of skills that are not typically acquired during traditional medical training."
Historically, physician leaders have been chosen based on their national prominence and excellence as master clinicians, star researchers, and revered educators. While these credentials remain important, they aren't sufficient in the current health care climate, the authors write.
Today's physicians practice in an era of changing payment models, rising costs, IT advances, and emerging technologies and therapies that are reshaping the delivery of patient care. Dynamic changes have also come with ongoing health system mergers and market consolidation. To lead effectively in this environment, doctors need not only sharp clinical expertise, but also opportunities to hone their communication, team building, and decision making skills, and gain knowledge of finance and business.
Jameson and co-author Caryn Lerman, Ph.D., vice dean for Strategic Initiatives and the John H. Glick, MD Professor in Cancer Research in the department of Psychiatry in the Perelman School of Medicine, suggest health systems focus on three strategies to create this new wave of leaders: rigorous mining of diverse talent pools to identify the most promising emerging physician leaders; building pipelines of future leaders with targeted leadership development to enable progressively increasing responsibility; and deliberate onboarding processes to integrate new leaders and assure alignment across missions and with the institutional culture.
Training in finance and business planning and personnel management should be central to professional development, as many physician leaders may manage budgets similar to those of medium-sized businesses, for example, and work in organizations which are among the largest employers in their community.
"Given the high rate of turnover among physician leaders, such as department chairs and deans, we can no longer afford to neglect the skills that are essential for leaders to succeed," they wrote. "We believe there is a need for a new generation of leaders who can promote strategic and cultural alignment in the face of rapid change."
At Penn, the Perelman School of Medicine has joined with the Wharton School to create an executive education program which will launch in 2019 for health care and academic medical leaders from across the nation and world. The program will provide targeted leadership development experiences and practical skills to enable today's and tomorrow's leaders of health systems and academic medical centers to adapt to a rapidly changing environment.
The new endeavor joins the Penn-Wharton MD/Master of Business Administration (MD/MBA) program, which is designed for medical students interested in integrating their medical course work with training in managerial, financial, and technical expertise in the health care field.
Another example is Penn Medicine's Healthcare Leadership for Quality Residency Track. This two-year training pathway for future physician leaders is one of only a few in the country to offer a pathway for residents aspiring to be leaders in health care quality, patient safety, or informatics. So far, more than one hundred residents have participated in the program.
To help meet the challenges of an increasingly complex landscape, the authors say, health systems should make leadership development an organizational priority—an emphasis which will also pay off in improved patient satisfaction and clinical outcomes.
"The 21st century physician leader must be equipped with a new tool kit of skills for the leadership agility necessary for them to respond proactively to rapidly changing environments," Lerman said. "Leadership development should be an organizational priority, preparing today's medical students and physicians to thrive in a continuously evolving era of health care."


Provided by Perelman School of Medicine at the University of Pennsylvania

Brazilians with less education more likely to report being in poor health, study finds

The study found that people in Brazil with less education were more likely to identify themselves as being in poor health. The data pictured are from the Brazil National Health Survey 2013. Credit: Julie McMahon, University of Illinois

Brazilians with less education are more likely to self-report as being in poor health, according to a study using data from nationwide surveys distributed every five years from 1998 to 2013. The study also found that general subjective health did not improve over the study period, even though more people gained education throughout the study, indicating that other factors associated with poor education may need to be addressed to improve self-perceptions of health.

17 may 2018--University of Illinois researchers Flavia Cristina Drumond Andrade, a professor of kinesiology and community health, and Jeenal Deepak Mehta, an undergraduate student, published the study in the journal PLOS ONE.
"Self-reported perceived health is an effective health indicator that has been shown to be a good predictor of mortality," Andrade said. "In social contexts such as developing countries, in which some diseases may go unnoticed or undiagnosed for a while, survey data can give a good sense of individuals' assessment of their overall health."
Andrade and Mehta used data from the 1998, 2003 and 2008 Brazilian National Household Sample Survey and the Brazil National Health Survey 2013. The surveys included many factors, such as education levels, employment, race, location and health. Participants reported themselves as being in "good" or "poor" health.
Overall, the percentage of those who reported themselves as being in poor health was fairly small—the highest being 5.9 percent in 2013. However, when the researchers separated the respondents by education level, they found that the less education a group had, the higher the percentage of self-reported poor health.
The gradient was sharp, and consistent across all years of the survey: Those with no education were seven to nine times more likely to report poor health than those with at least some college.
"Often, those with lower education experience worse employment—with lower wages, worse working conditions and less access to health care—than those with more education," Andrade said. "They may also engage in unhealthy lifestyle behaviors, in part due to lower health knowledge and in part due to economic restrictions. All these conditions put them in relative disadvantage, which could be translated as worse perceived health."
Over the course of the surveyed years, Brazil experienced a period of educational development, Andrade said. The percentage of those who had completed high school rose from 13.9 percent in 1998 to 28.6 percent in 2013, and the percentage of those with some college or more rose from 9 percent to 19.1 percent. Yet the overall percentage of self-reported poor health has not varied largely, and even rose a bit in 2013, although education levels rose.
Again, the researchers noticed a difference in health reporting over time according to education levels.
"There was a worsening of self-reported perceived health among those with primary or secondary education. This is important because most Brazilians are in this group—74.8 percent in 1998 and 68 percent in 2013. On the other hand, we do not see this pattern among those with some college or more. For them, the levels of poor self-reported health did not change."
The researchers posit that these changes may be related to the slowing of economic growth that Brazil experienced over the last two survey cycles.
"Those with less education often suffer with lower incomes and more during these economic decelerations. When relative conditions worsen, perceptions of health and well-being also tend to get worse among those at the bottom of the social scale," Andrade said.
In addition, Andrade urges those seeking to improve general health in Brazil to address not only education but also the aging of the population—the average age of the survey respondents increased from 40 to 44 years over the study period—and the prevalence of chronic conditions, such as diabetes, that were reported on the surveys.
"With increases in age, there are also increases in poor self-perceived health," Andrade said. "Along with the demographic transition, there were also increases in the prevalence of some chronic conditions, which also impacts the perception of health. Therefore, efforts to prevent and control chronic conditions are necessary to improve self-perceptions of health in Brazil."

More information: Flavia Cristina Drumond Andrade et al, Increasing educational inequalities in self-rated health in Brazil, 1998-2013, PLOS ONE (2018). DOI: 10.1371/journal.pone.0196494


Provided by University of Illinois at Urbana-Champaign

Experts have new advice on prostate cancer screening. Here's why they put it back on the table

Micrograph showing prostatic acinar adenocarcinoma (the most common form of prostate cancer) Credit: Wikipedia

In a shift that puts early detection of prostate cancer back on the agenda of middle-aged men and their doctors, a federal panel of experts is recommending that men ages 55 to 69 weigh the potential harms and benefits of prostate cancer screening and judge whether getting tested feels right to them.

15 may 2018--A recommendation issued Tuesday by the U.S. Preventive Services Task Force judged the "net benefits" of screening these men for prostate cancer to be small. But the panel said the prostate-specific antigen, or PSA, test should be offered to them "based on professional judgment and patient preferences."
For men 70 and older, the task force stuck with an earlier recommendation against routine prostate cancer screening.
The new guidance for men in late middle age is an unusual reversal of advice the panel offered in 2012. At that time, the task force suggested that for most men at any age, getting screened for prostate cancer just wasn't worth the risks—including anxiety, infection, erectile dysfunction and incontinence—of the unnecessary treatment that too often came with it.
Since then, the ledger of risks and benefits has changed on both sides.
As large studies have followed men for longer periods of time, researchers have seen that the PSA test can save lives—at least a few more lives than earlier believed—when used to screen men in their late 50s and 60s.
In a European clinical trial, periodic testing was initially found to prevent seven deaths for every 10,000 men screened. But with four years of additional follow-up, researchers have discovered the number of lives saved per 10,000 men screened is closer to 13. And mathematical models suggest that number will likely rise further as the men in the trial get older.
The increase "is not a big number," said Dr. Alex H. Krist, vice chairman of the task force, an independent group that operates under the auspices of the federal Agency for Healthcare Research and Quality. But the new data gave his panel "a little bit more confidence that fewer men would die" when more were screened before age 70.
At the same time, the responses of both doctors and patients to a prostate cancer diagnosis have undergone a significant shift.
In 2012, 90 percent of men who had their diagnosis confirmed with a biopsy were quickly ushered into surgery or treated with radiation, despite growing evidence that many of these cancers would never become dangerous.
Now, no more than 60 percent of such men proceed directly to treatment. The rest begin a process of "active surveillance" in which surgery or radiation is used only if the cancer progresses.
Meanwhile, urologists are using genetic testing, more precisely targeted biopsy procedures and improved imaging techniques to identify the more aggressive prostate tumors that warrant quick action.
Despite efforts to improve prostate cancer treatment, surgery and radiation therapy still exacts a high toll on patients: two out of three men will experience long-term erectile dysfunction, and about 20 percent of those who undergo radical prostatectomy will experience urinary incontinence.
But as more men "watch and wait," fewer men are exposed to the negative effects of treatment that might never have been necessary in the first place.
"That has changed the math of risks and benefits for screening," said Dr. David Penson, who chairs the Department of Urologic Surgery at Vanderbilt University in Nashville and was not involved in the new task force recommendation. "Take that small benefit and then reduce the harms of screening, and suddenly, the equation looks quite different."
In the United States, a man's risk of being diagnosed with prostate cancer at some point in his life is 13 percent, but his risk of dying of the disease is just 2.5 percent. Without screening, many men would never even know they had the disease, which can grow slowly for years. One-third of men who died in their 70s of other causes were found to have had prostate cancer.
For men between 55 and 69, the evolution of both knowledge and medical practice have made the question of whether to get the PSA test a potentially complex judgment call.
"This is what's called a preference-sensitive decision," said Ruth Etzioni, a biostatistician at Seattle's Fred Hutchinson Cancer Research Center who crunched the numbers from two of the largest clinical trials on prostate cancer screening but was not directly involved in setting the new guidelines. "It means the benefits and harms of the decision are going to be different for different people. Screening might be a good decision for you, but your friend may come up with a different decision."
Race would likely be a factor in those deliberations: African American men are nearly twice as likely to die of prostate cancer as white men.
A family history of prostate cancer, and of cancers called adenocarcinomas (which include breast, ovarian, pancreatic and colorectal cancer), also might nudge a man toward regular screening. Smoking, too, is linked to a higher risk of death from prostate cancer.
The task force cautioned, however, that there is insufficient evidence on the role of race and family medical history to draft separate recommendations for subgroups.
"My typical prostate cancer consultation used to be 30 minutes," said Dr. Inderbir S. Gill, chairman of USC's Department of Urology. "Now it's become a one-hour, 15-minute consult, and we're not finished. That's the price of our evolving knowledge."
A man's decision should also take into account such intangibles as his tolerance for uncertainty and his willingness to act in response to an ambiguous threat to his health.
"Don't ask the question if you're not sure what you'll want to do with the result," said Dr. Christopher Saigal, the vice chair of urology at UCLA's Geffen School of Medicine who studies how doctors and patients make decisions about prostate cancer treatment.
Saigal, who was not involved in the task force's deliberations, said he remains convinced that for most men in the designated age group, PSA screening is a sensible choice.
"This is still the most common solid cancer in men, and it's treatable," he said.
But some men are skeptical of screening's value, and others are anxious that any possible threat to their health should be reckoned with head-on. Some have family histories of cancer, and others have so many health issues that a long-term threat like prostate cancer takes a back seat to more immediate concerns.
"The key thing is talking to the man before you draw his blood," Saigal said. Such nuanced discussions take time and time, and in modern medicine, time is in short supply. "We're moving into an era in which personalized medicine and shared decision making is going to come to the forefront. The data is too complex, and people are too complex, for one model to fit everyone."
The new task force recommendations are in line with those of the American Urological Association, which specify that men ages 55 to 69 with a life expectancy of more than 10 to 15 years be informed of screening's benefits and harms. The AUA notes that successive screening tests should be performed at least two years apart.
USC's Gill praised the new recommendations. But he added that the task force was not wrong in issuing its earlier, more skeptical views on prostate screening.
"This group very rightly said in 2008 and 2012, 'You urologists are hurting far more patients than you're helping, and the whole rigamarole starts when you take the PSA,'" Gil said.
"They have certainly stirred soul-searching in the urological community. They have certainly prodded urologists into acknowledging that yes, not every prostate cancer needs to be treated. They have done a great service."

Easy-to-measure grip strength test could help predict major disease risk

Credit: University of Glasgow

Measuring grip strength – a clinical test that is both cheap and easy to perform – could be an important way to identify people who are at high risk for a wide range of diseases.

13 may 2018--New research, led by the University of Glasgow's Institute of Cardiovascular and Medical Sciences and published today in the BMJ, found that lower grip strength was strongly associated with a wide range of poorer health outcomes, including cardiovascular disease and cancer. The study also demonstrated that higher grip strength was associated with a lower risk of all causes of mortality.
The grip strength test only takes a few seconds to do and, the researchers suggest that the addition of this test within clinical practice could improve the prediction ability of an office-based risk score (which currently comprises assessment of age, sex, diabetes status, body mass index, systolic blood pressure, and smoking), by identifying people with low grip strength that might benefit from further health assessments. Researchers believe that this may be of particular use in areas where access to blood biochemical measures, such as cholesterol, is not possible.
Lower muscle strength is already known to be associated with greater mortality and morbidity. However in this study researchers were able to specifically link lower grip strength to a higher incidence of and mortality from, cardiovascular disease, respiratory disease, chronic obstructive pulmonary disease and cancer.
The study looked at 500,293 participants from the UK Biobank and the associations between lower grip strength and adverse health outcomes were consistent between men and women.
Researchers also investigated if the grip strength risk differed by age, and found that the risks associated with low grip strength were slightly stronger in younger age groups. These findings suggest that measuring grip strength could be useful over a broad range of ages.
Lead author Dr. Stuart Gray, Lecturer in Exercise and Metabolic Health, said: "Many studies have already shown that lower muscle strength is associated with greater mortality and morbidity. We wanted to investigate the association of grip strength with the incidence of specific diseases and mortality, and whether grip strength could be used in the clinic to enhance the prediction of an established office-based risk score.
"We found that not only was lower grip strength strongly associated with a broad range of adverse health outcomes, but that it predicted risk of death and cardiovascular disease even more strongly than systolic blood pressure or physical activity."
Dr. Gray said: "Our findings are important because they indicate that the addition of the measurement of grip strength may be useful in screening for risk of cardiovascular disease in community or rural settings, and in developing countries where access to measurements, such as total cholesterol, is not possible.
"Going forward, we need to perform trials which measure grip strength in clinical settings and investigate its effectiveness in risk prediction."
The UK Biobank is made up of 502, 628 participants recruited between April 2007 and December 2010, aged 40-69 years, from the general population across England, Wales, and Scotland.
The paper, "Associations of grip strength with cardiovascular, respiratory, and cancer outcomes and all cause mortality: prospective cohort study of half a million UK Biobank participants," is published in the BMJ.

More information: Yili Wu et al. Association of Grip Strength With Risk of All-Cause Mortality, Cardiovascular Diseases, and Cancer in Community-Dwelling Populations: A Meta-analysis of Prospective Cohort Studies, Journal of the American Medical Directors Association (2017). DOI: 10.1016/j.jamda.2017.03.011


Provided by University of Glasgow

How older patients want to discuss health concerns

Credit: CC0 Public Domain

Nancy Schoenborn, M.D., assistant professor in the Department of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine, and colleagues went straight to the source and conducted three qualitative studies that put older adults at the forefront in order to gain a better understanding of if, and how, they prefer to discuss various health topics.

Let's Talk About Life Expectancy … or Not?

11 may 2018--In a small group study published in November 2017 in the Journal of the American Board of Family Medicine, researchers interviewed 40 older adults on how and when they preferred to discuss life expectancy with their primary care doctor. Schoenborn and team found that 32.5 percent of participants never wanted to discuss their life expectancy, 35 percent were open for discussion if expectancy were longer than one year, and 32.5 percent only wanted to have this discussion toward the end of life. Researchers also found that the majority of the participants, even the ones who never wanted to discuss, were open to be offered the opportunity to discuss life expectancy with their primary care doctor. This research also assessed how the discussion should be phrased when initiating the conversation about life expectancy with older adults.

Frailty Misconceptions

Due to the negative perception of the word "frail," older adults oftentimes overlook frailty as a medical syndrome. Researchers at Johns Hopkins Medicine conducted the first study in the United States that explored older adults' perception of frailty. It was published on Feb. 13, 2018, in BMC Geriatrics.
In a study of 29 participants, Schoenborn and team conducted focus groups with participants in various frailty statuses (frail, prefrail, nonfrail) and at different ages to evaluate existing ideas about frailty. Three major themes were established through this research. First, older adults' ideas about frailty were different from the medical definition of frailty. Many of the participants associated old age with frailty, but not everyone who ages develops the medical syndrome of frailty. Second, participants who were in the nonfrail or prefrail stages were strongly against discussing frailty with their physicians. However, frail participants were more open to having the discussion, but without being labeled "frail." Third, participants in all frailty statuses wanted information regarding prevention of frailty or ways to improve their current condition. This study provides insight on how older adults perceive frailty, but further research needs to be conducted to understand the proper way in which physicians should communicate about frailty.

To Stop or Not to Stop Cancer Screening in Older Adults

Screening for cancer in older adults with limited life expectancy can oftentimes be more harmful than beneficial. However, studies have shown that clinicians may feel uncomfortable stopping cancer screenings on patients with limited life expectancy. In a study published on Aug. 1, 2017, in JAMA Internal Medicine, Schoenborn and other Johns Hopkins researchers conducted interviews with 40 older adults who were 65 years or older to understand what this population thought about stopping cancer screening when life expectancy is limited. Researchers found that the participants were open to considering cessation of cancer screenings. In addition, their willingness to consider stopping screenings was dependent on trusting their physicians. The participantsexpressed that they would commend their physicians for even providing this option. This study showed that older adults do not use life expectancy as a factor when deciding to stop screening; they are more likely to use age and health status to make this decision. Even though life expectancy was not used as a factor when deciding, the group was divided on whether or not physicians should discuss life expectancy in the cancer screening conversation. Researchers also found that the way a physician words the message about life expectancy is very important during the discussion about cancer screening cessation.

More information: Nancy L. Schoenborn et al. Older adults' perceptions and informational needs regarding frailty, BMC Geriatrics (2018). DOI: 10.1186/s12877-018-0741-3

Nancy L. Schoenborn et al. Older Adults' Preferences for When and How to Discuss Life Expectancy in Primary Care, The Journal of the American Board of Family Medicine (2017). DOI: 10.3122/jabfm.2017.06.170067


Provided by Johns Hopkins University