Report will aid in detecting, diagnosing cognitive impairment

A new report from The Gerontological Society of America's Workgroup on Cognitive Impairment Detection and Earlier Diagnosis outlines a course of action for increasing the use of evidence-based cognitive assessment tools as part of the Medicare Annual Wellness Visit (AWV).

07 fev 2015--The AWV was established by 2010's Affordable Care Act to allow Medicare beneficiaries to receive preventive and assessment services during visits with their primary care providers. And although detection of cognitive impairment is among the required AWV services, no specific tools are mandated and no data are available regarding tools used for this purpose.

The new report outlines a plan for addressing this shortcoming and shows how increased detection leads to earlier and optimal diagnostic evaluation, referral to post-diagnosis support and educational services in the community, and ultimately to improved health-related outcomes and well-being for Medicare beneficiaries with diagnosed dementia and their families.

"The Medicare AWV offers a universal opportunity for primary care providers to start a conversation with older adults and their families about cognitive changes that might be worthy of further investigation," said Richard Fortinsky, PhD, chair of the workgroup. "Our workgroup's report provides guidance for providers so they can start this conversation and, as appropriate, employ evidence-based assessment tools to detect cognitive impairment."

"Increased detection of cognitive impairment is essential for earlier diagnosis of Alzheimer's disease and related dementia—and also earlier diagnosis leads to more timely linkage of older adults and their families with community-based services and supports," said Katie Maslow, MSW, workgroup member.

In the report, the workgroup outlines a recommended for four-step process achieving its goals.

Step 1 is to kickstart the cognition conversation. To increase detection of cognitive impairment and promote earlier diagnosis of dementia in the Medicare population, the GSA workgroup endorses that primary care providers use the AWV as an annual opportunity to kickstart—that is, to initiate and continue—a conversation with beneficiaries and their families about memory-related signs and symptoms that might develop in older adulthood.

Step 2 is to assess the patient if he or she is symptomatic. The GSA workgroup endorses use of a cognitive impairment detection tool from a menu of tools having the following properties: it can be administered in five minutes or less; it is widely available free of charge; it is designed to assess age-related cognitive impairment; it assesses at least memory and one other cognitive domain; it is validated in primary care or community-based samples in the U.S.; it is easily administered by medical staff members who are not physicians; and it is relatively free from educational, language, and/or cultural bias. The report provides a list of tools that may be suitable for this purpose.

Step 3 is to evaluate with full diagnostic workup if cognitive impairment is detected. The GSA workgroup recommends that all Medicare beneficiaries who exceed threshold scores for cognitive impairment based on the cognitive assessment tools used in step 2 undergo a full diagnostic evaluation. Numerous published clinical practice guidelines are available to primary care providers and specialists to help them arrive at a differential diagnosis.

Step 4 involves referral to community resources and clinical trials, depending on the diagnosis. The GSA workgroup recommends that all Medicare beneficiaries who are determined to have a diagnosis of Alzheimer's disease or related dementia be referred to all appropriate and available community services to learn more about the disease process and how to prepare for the future with a dementia diagnosis.

"The GSA workgroup views this suggested four-step process as a framework for communicating with a wide variety of stakeholders about the critical importance of incorporating cognitive impairment detection into everyday clinical practice with older adults," Fortinsky said. "We look forward to building on this report by helping to plan additional activities intended to disseminate and implement the report's recommendations in communities throughout the country."

More information: The report is available at www.geron.org/ci

Provided by The Gerontological Society of America

Common drugs adversely impair older adults' physical as well as cognitive functioning

A class of medications previously linked to cognitive impairment in older adults also appears to negatively affect their physical functioning according to investigators from the Regenstrief Institute, the Indiana University Center for Aging Research, the University of East Anglia and several other United Kingdom institutions.

03 aug 2014--In a systemic review of more than a decade of studies on the effects of drugs with anticholinergic properties, they report that these drugs have a significant adverse effect on both cognitive and physical functioning, including the ability to feed and dress oneself. Anticholinergic medications affect the brain by blocking acetylcholine, a nervous system neurotransmitter. They are sold over the counter as sleep aids and bladder leakage preventives and prescribed for many diseases including hypertension and congestive heart failure.

The review found that these 46 studies, which followed 60,944 patients, showed only limited evidence of a connection between anticholinergics and delirium, a short-term decline in cognition. Additionally the review indicated that the studies did not demonstrate a strong tie between medications with anticholinergic properties and death. According to Regenstrief Institute investigator Noll Campbell, Pharm.D., senior author of the review paper, this may be because most studies were insufficient in length to reveal a significant link between the medications and death.

This is the first systematic review to assess the effects of medications with anticholinergic properties on physical function and delirium. The authors say it also provides an important update on cognitive function and mortality.

"Anticholinergics, both over-the-counter and prescription medications, impact the lives of older adults in ways doctors, patients and their families may not realize," said Dr. Campbell, who is also a research assistant professor in the Purdue University College of Pharmacy. "I don't see use of these medications declining. Doctors and patients are familiar with these drugs and unfortunately are far less familiar with equally effective alternatives."

For example, Dr. Campbell advised, rather than taking sleeping pills with anticholinergic properties, one could refrain from napping, limit evening exercise and remove distractions from the bedroom. Institutions like hospitals and nursing homes could work to keep older adults awake and stimulated during the day, naturally encouraging nighttime slumber.

Dr. Campbell and colleagues from the Regenstrief Institute and the IU Center for Aging Research are working to identify diagnosis- and patient-dependent alternatives to exposure to anticholinergic medications as well as methods to inform physicians of their advisability via prompts within electronic medical record systems.

"Significant ongoing concerns remain about these medicines, and this review paper for the first time in one place has highlighted the impact on function as well as memory and death," said Chris Fox, M.D., of the University of East Anglia, the review paper's first author. Dr. Fox is a psychiatrist. In 2011, he and Regenstrief and IU Center for Aging Research collaborators published the results of a study of 13,000 men and women age 65 and older in which they found a link between anticholinergic medications and death.

Provided by Indiana University

Metformin may increase risk of cognitive impairment

Metformin may increase the risk of cognitive impairment in patients with diabetes; however, calcium supplementation may attenuate this risk, according to research published online Sept. 5 in Diabetes Care.

23 sept 2013—Metformin may increase the risk of cognitive impairment in patients with diabetes; however, calcium supplementation may attenuate this risk, according to research published online Sept. 5 in Diabetes Care.

Eileen M. Moore, Ph.D., of the University of Melbourne in Australia, and colleagues conducted a subgroup analysis involving 104 patients with type 2 diabetes and 22 patients with impaired glucose tolerance who participated in the Australian Imaging, Biomarkers and Lifestyle study of aging. The authors sought to determine whether metformin, serum vitamin B₁₂, or calcium supplements are associated with cognitive impairment in patients with diabetes.

The researchers found that, overall, patients with diabetes were 51 percent more likely to exhibit cognitive impairment than those without diabetes, and those taking metformin were more than twice as likely (2.23-fold) to exhibit cognitive impairment. After adjusting for age, sex, level of education, history of depression, serum vitamin B12, and metformin use, cognitive performance was improved for those patients who were also taking calcium supplements.

"Adequately powered, prospective, controlled trials are warranted to investigate further the association between diabetes, cognitive decline, and the effect of metformin therapy, as well as the possible amelioration using vitamin B₁₂ and/or calcium supplementation," the authors write.

Several authors disclosed financial ties the biotechnology industry.

More information: Abstract 

Red Blood Cell Omega-3 Levels Linked to Brain Volume

Levels of DHA in the lowest quartile tied to smaller brain volume, cognitive impairment

28 feb 2012-- In adults without clinical dementia, low red blood cell (RBC) levels of omega-3 fatty acids are associated with smaller brain volumes and lower scores on tests of visual memory and executive function, according to a study published in the Feb. 28 issue of Neurology.

Zaldy S. Tan, M.D., M.P.H., from the David Geffen School of Medicine at the University of California in Los Angeles, and colleagues investigated the association between RBC fatty acid levels in 1,575 dementia-free participants (aged 67 ± 9 years) and performance on cognitive tests and volumetric magnetic resonance imaging. In model A, adjustments were made for age, gender, and education; and in additional models, adjustments were also made for APOE ε4 and plasma homocysteine, for physical activity and body mass index, and for traditional vascular risk factors.

The researchers found that participants with RBC docosahexaenoic acid (DHA) in the lowest quartile had significantly lower total brain volume and greater white matter hyperintensity volumes, compared to those with RBC DHA levels in the second to fourth quartiles. The association with total brain volume persisted after multivariable adjustments. Participants with DHA and ω-3 index (RBC DHA + eicosapentaenoic acid [EPA]) levels in the lowest quartile had lower scores on tests of visual memory, executive function, and abstract thinking in all models, compared to those with levels in the second to fourth quartiles.

"Lower levels of RBC DHA and EPA in late middle-age were associated with markers of accelerated structural and cognitive aging," the authors write.

Several authors disclosed financial ties to the pharmaceutical and biotechnology industries.

Abstract

Healthy older adults with subjective memory loss may be at increased risk for MCI and dementia

09 jan 2009--Forgot where you put your car keys? Having trouble recalling your colleague's name? If so, this may be a symptom of subjective cognitive impairment (SCI), the earliest sign of cognitive decline marked by situations such as when a person recognizes they can't remember a name like they used to or where they recently placed important objects the way they used to. Studies have shown that SCI is experienced by between one-quarter and one-half of the population over the age of 65. A new study, published in the January 11, 2010, issue of the journal Alzheimer's & Dementia, finds that healthy older adults reporting SCI are 4.5 times more likely to progress to the more advanced memory-loss stages of mild cognitive impairment (MCI) or dementia than those free of SCI.

The long-term study completed by researchers at NYU Langone Medical Center tracked 213 adults with and without SCI over an average of seven years, with data collection taking nearly two decades. Further cognitive decline to MCI or dementia was observed in 54 percent of SCI persons, while only in 15 percent of persons free of SCI.

"This is the first study to use mild cognitive impairment as well as dementia as an outcome criterion to demonstrate the outcome of SCI as a possible forerunner of eventual Alzheimer's disease," said Barry Reisberg, MD, professor of psychiatry, director of the Fisher Alzheimer's Disease Program and director, Clinical Core, NYU Alzheimer's Disease Center at NYU Langone Medical Center. "The findings indicate that a significant percentage of people with early subjective symptoms may experience further cognitive decline, whereas few persons without these symptoms decline. If decline does occur in those without SCI symptoms, it takes considerably longer than for those with subjective cognitive symptoms."

According to the authors, scientists and physicians can now target the prevention of eventual Alzheimer's disease in the SCI stage, beginning more than 20 years before dementia becomes evident

"These intriguing results more fully describe the possible relationship between early signs of memory loss and development of more serious impairment. This is critical to know, as we look for ways to define who is at risk and for whom the earliest interventions might be successful," said Neil Buckholtz, PhD, National Institute on Aging (NIA) which supported the research. "These findings also underscore the importance of clinicians' asking about, and listening to, concerns regarding changes in cognition and memory among their aging patients."

###

Co-authors of Dr. Reisberg at the NYU Alzheimer's Disease Center include Melanie B. Shulman, MD, Carol Torossian, PsyD, and Wei Zhu, PhD.

Primary funding for this study was provided by the NIA, which is part of the National Institutes of Health. Additional funding was provided by Mr. Leonard Litwin and the Fisher Center for Alzheimer's Research Foundation.

About NYU Langone Medical Center

NYU Langone Medical Center is one of the nation's premier centers of excellence in healthcare, biomedical research, and medical education. For over 168 years, NYU physicians and researchers have made countless contributions to the practice and science of health care. Today the Medical Center consists of NYU School of Medicine, including the Smilow Research Center, the Skirball Institute of Biomolecular Medicine, and the Sackler Institute of Graduate Biomedical Sciences; the three hospitals of NYU Hospitals Center, Tisch Hospital, a 705-bed acute-care general hospital, Rusk Institute of Rehabilitation Medicine, the first and largest facility of its kind, and NYU Hospital for Joint Diseases, a leader in musculoskeletal care; and such major programs as the NYU Cancer Institute, the NYU Child Study Center, and the Hassenfeld Children's Center for Cancer and Blood Disorders.

Recognizing cognitive impairment key to keeping older adults at home

Training medical professionals to identify red flags

INDIANAPOLIS, 3 april 2009 – Doctors, nurses and others who provide health care to older adults are often so focused on acute medical problems that they may miss symptoms of cognitive impairment. A unique educational summit to be held in April and May in Indianapolis focuses on the problem and will enhance the skills of these health-care providers in recognizing and managing cognitive impairment. The goal is to enable older adults to remain in their homes.

According to Malaz Boustani, M.D., associate professor of medicine at the Indiana University School of Medicine and a Regenstrief Institute research scientist, more than half of Americans with cognitive impairment are not recognized as having the conditions when they go to a hospital and more than three-quarters are not recognized as having cognitive impairment by their primary care physicians. The result is that less than 10 percent receive medications appropriate to their level of cognitive impairment and approximately one-quarter receive medications which are inappropriate.

"Medical professionals who care for older adults are faced with the problems of the real world – providing the best care to patients with multiple acute and chronic diseases under time constraints and reimbursement pressures. We hope with this summit to provide these committed individuals with tools that will help them to identify the red flags of cognitive impairment – to recognize delirium as an urgent medical syndrome, to reduce exposure to inappropriate medications, and to enable them to employ non-pharmacological methods to manage the special needs of both the patient and his family caregiver," said Dr. Boustani.

Dr. Boustani, who is a center scientist with the IU Center for Aging Research, is also the research director for the Indianapolis Discovery Network for Dementia. IDND, fostered by the research of the Regenstrief Institute, is an expanding group of researchers, clinicians, caregivers and community advocates who are working to enhance dementia care in the nation's twelfth largest city. IDND is a national model for how members of the community, caregivers, clinicians and researchers can work together to improve the delivery of dementia care.

Nearly 360 health-care providers from throughout Indiana will participate in the multi-session summit, which is funded by a $75,000 grant from Pfizer Pharmaceuticals to the Medical Education Group of Community Home Health Services. CHHS, which provides home health-care services, has partnered with IDND to sponsor the summit. In late 2007, IDND launched RAPID-PC – Recognizing and Assessing the Progression of Cognitive Impairment and Dementia in Primary Care, a highly successful program.

"We hope that this summit will serve as both a local resource and a national model which will spawn similar educational opportunities to help doctors, nurses and others who take care of older adults in their homes to better deal with their often unrecognized mental health needs," said Jessie Westlund, R.N. of Community Home Health Services, part of Community Health Network.

"Recognizing and properly treating cognitive impairment will only become more important as our population ages. If we can identify and handle it appropriately, we can help keep older adults in their homes and out of long-term care facilities longer, a goal which benefits older adults and saves health-care dollars," said Dr. Boustani.

###

(Note to editors: This event is not open to the public. Interested reporters may attend summit sessions on April 14, 15, 16 or May 5, 6, 7. To request press credentials call 317-274-7722.