New study suggests viral connection to Alzheimer's disease

Viral/host networks, including genes and RNA transcripts interact in complex ways. A pair of Herpesviruses--HHV 6A and 7--were found in greater abundance in brain samples from AD patients compared with normal brains. These viruses seem to also be implicated in the AD-related genetic networks responsible for classic Alzheimer's pathology, including cell death, the deposition of amyloid plaque and production of neurofibrillary tangles. Credit: Shireen Dooling for the Biodesign Institute at ASU

Of the major illnesses facing humanity, Alzheimer's disease (AD) remains among the most pitiless and confounding. Over a century after its discovery, no effective prevention or treatment exists for this progressive deterioration of brain tissue, memory and identity. With more people living to older ages, there is a growing need to clarify Alzheimer's disease risk factors and disease mechanisms and use this information to find new ways in which to treat and prevent this terrible disorder.

22 jun 2018--A first-of-its kind study implicates another culprit in the path to Alzheimer's disease: the presence of viruses in the brain.
In research appearing in the advanced online edition of the journal Neuron, scientists at the Arizona State University-Banner Neurodegenerative Disease Research Center (NDRC) and their colleagues at the Icahn School of Medicine at Mount Sinai used large data sets from clinically and neuropathologically characterized brain donors and sophisticated "big data" analysis tools to make sense of both the genes that are inherited and those that are preferentially turned on or off in the brains of persons with Alzheimer's disease. They provide multiple lines of evidence to suggest that certain species of herpesviruses contribute to the development of this disorder.
The new work brings science a step closer to clarifying the mechanisms by which infectious agents may play important roles in the disease. To achieve this, the team capitalized on DNA and RNA sequencing data from 622 brain donors with the clinical and neuropathological features of Alzheimer's disease and 322 brain donors without the disease—data generated from the NIH-sponsored Accelerated Medicines Partnership for Alzheimer's Disease (AMP-AD).
The "whole exome" DNA sequencing was used to provide detailed information about each person's inherited genes. RNA sequencing from several brain regions was used to provide detailed information about the genes that are expressed differently in donors with and without the disease.
Clinical assessments performed before the research participants died provided detailed information about their trajectory of cognitive decline, and neuropathological assessments performed after they died provided relevant neuropathological information, including the severity of amyloid plaques and tangles, the cardinal features of Alzheimer's disease. Sophisticated computational tools were used to develop a kind of grand unified picture of the viral-AD nexus.

Big challenges, big data

Big data-driven analyses offer a particularly powerful approach for exploring diseases like Alzheimer's, which involve many interdependent variables acting in concert in profoundly complex systems. In the current study, researchers explore viral presence in 6 key brain regions known to be highly vulnerable to the ravages of AD. (It is now accepted that damaging effects to these areas often precede clinical diagnosis of the disease by several decades.)
The study identifies high levels of human herpesvirus (HHV) 6A and 7 in brain samples showing signs of AD neuropathology, compared with the lower levels found in normal brains. Further, through the careful comparison of large data sets of viral RNA and DNA with networks of human genes associated with AD and signposts of neuropathology, the study offers the first hints of the viral mechanisms that could trigger or exacerbate the disease.
The findings, originally hinted at from samples provided by Translational Genomics (TGen) in Phoenix, were confirmed in the Mount Sinai Brain Bank, and then replicated in samples from the Mayo Clinic Brain Bank, Rush Alzheimer's Disease Center, and the Banner-Sun Health Research Institute's Brain and Body Donation Program.

Uninvited guests

According to Ben Readhead, lead author of the new study, the researchers' general goal was to discover disease mechanisms, including those that could be targeted by repurposed or investigational drug therapies. "We didn't go looking for viruses, but viruses sort of screamed out at us," Readhead said.
Although the study found a number of common viruses in normal aging brains, viral abundance of two key viruses—HHV 6A and 7—was greater in brains stricken with Alzheimer's.
"We were able to use a range of network biology approaches to tease apart how these viruses may be interacting with human genes we know are relevant to Alzheimer's," Readhead said.

HHV 6A and 7 are common herpesviruses to which most are exposed as children. The two viruses were detected in higher abundance in brains with Alzheimer's disease and their activity appears related to certain hallmarks of the disease. Credit: Shireen Dooling for the Biodesign Institute at ASU

Readhead is an assistant research professor in the NDRC, housed at ASU's Biodesign Institute. Much of the research described in the new study was performed in the laboratory of Joel Dudley, associate professor of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, associate research professor in the NDRC, and senior author of the paper in Neuron.
The nature and significance of viruses and other pathogens in the brain are currently hot topics in neuroscience, though the exploration is still in its early stages. One of the primary questions is whether such pathogens play an active, causative role in the disease or enter the brain simply as opportunistic passengers, taking advantage of the neural deterioration characteristic of AD.
"Previous studies of viruses and Alzheimer's have always been very indirect and correlative. But we were able to perform a more sophisticated computational analysis using multiple levels of genomic information measured directly from affected brain tissue. This analysis allowed us to identify how the viruses are directly interacting with or coregulating known Alzheimer's genes," says Dudley. "I don't think we can answer whether herpesviruses are a primary cause of Alzheimer's disease. But what's clear is that they're perturbing and participating in networks that directly underlie Alzheimer's pathophysiology."

Network news

The new study uses a network biology approach to holistically incorporate molecular, clinical and neuropathological features of AD with viral activity in the brain. Using techniques in bioinformatics, the study integrates high-throughput data into probabilistic networks that are postulated to account for the associations between herpes viruses and the telltale effects of AD.
The networks described suggest that the hallmarks of AD may arise as collateral damage caused by the brain's response to viral insult. According to the so-called pathogen hypothesis of AD, the brain reacts to infection by engulfing viruses with the protein amyloid beta (Aβ), sequestering the invaders and preventing them from binding with cell surfaces and inserting their viral genetic payload into healthy cells.
As Readhead explains, "a number of viruses looked interesting. We saw a key virus, HHV 6A, regulating the expression of quite a few AD risk genes and genes known to regulate the processing of amyloid, a key ingredient in AD neuropathology." (Amyloid concentrations form characteristic plaques in the brain. These plaques, along with neurofibrillary tangles formed by another protein, known as tau, are the microscopic brain abnormalities used to diagnosis Alzheimer's.)
Both HHV 6A, and 7 are common herpesviruses belonging to the genus Roseolovirus. Most people are exposed to them early in life. The likely route of entry for such viruses is through the nasopharyngeal lining. The higher abundance of these viruses in AD-affected brains may initiate an immune cascade leading to deterioration and cell death or act in other ways to promote AD.

Mounting evidence

The results from human brain tissue were further supplemented by mouse studies. Here, researchers examined the effect of depleting miR155, a small snippet of RNA (or micro RNA) that is an important regulator of the innate and adaptive immune systems. Results showed increased deposition of amyloid plaques in miR155-depleted mice, coupled with behavioral changes. As the authors note, HHV 6A is known to deplete miR155, lending further weight to a viral contribution to AD.
The new research is the fruitful result of close working relationships among researchers from Arizona State University, Banner, Mount Sinai, and other research organizations, as well as public-private partnerships in AMP-AD.
"This study illustrates the promise of leveraging human brain samples, emerging big data analysis methods, converging findings from experimental models, and intensely collaborative approaches in the scientific understanding of Alzheimer's disease and the discovery of new treatments," said study co-author Eric Reiman, Executive Director of the Banner Alzheimer's Institute and University Professor of Neuroscience at Arizona State University. "We are excited about the chance to capitalize on this approach to help in the scientific understanding, treatment and prevention of Alzheimer's and other neurodegenerative diseases."

Enemy with a thousand faces

In the meantime, Alzheimer's continues its devastating trajectory. Among the many challenges facing researchers is the fact that the earliest effects of the disease on vulnerable brain regions occur 20 or 30 years before memory loss, confusion, mood changes and other clinical symptoms appear. Without a cure or effective treatment, AD is expected to strike a new victim in the United States every 33 seconds by mid-century and costs are projected to exceed $1 trillion annually.
The research study does not suggest that Alzheimer's disease is contagious. But if viruses or other infections are confirmed to have roles in the pathogenesis of Alzheimer's, it could set the stage for researchers to find novel anti-viral or immune therapies to combat the disease, even before the onset of symptoms.

More information: Readhead et al. Multiscale Analysis of Independent Alzheimer's Cohorts Finds Disruption of Molecular, Genetic, and Clinical Networks by Human Herpesvirus. Neuron. 2018 Jun. 21. DOI: 10.1016/j.neuron.2018.05.023


Provided by Arizona State University

Deep brain stimulation showing promise for patients with mild Alzheimer's disease over 65

Dr. Andres Lozano of Krembil Neuroscience Centre at Toronto Western says 'we are encouraged by these findings.' Credit: The Globe and Mail

An age group analysis of data from the ADvance trial has shown that participants over the age of 65 continue to derive the most benefit from Deep Brain Stimulation of the fornix (DBS-f), as observed in the data from the phase 2 findings (12—24 months) of the Phase II trial.

22 jun 2018--The findings, published today in the Journal of Alzheimer's Disease, by a team of researchers led by Dr. Andres Lozano at Toronto Western Hospital's (TW) Krembil Neuroscience Centre (KNC), are the potential beginnings of a patient profile for DBS-f treatment for Alzheimer's disease. The neurology and psychology aspects of the trial in Toronto were led by TW neurologist Dr. Peter Tang-wai and neuropsychologist Dr. Mary-Pat McAndrews respectively.
To further explore the benefits for this demographic, the research team is soon launching a Phase III, multi-centre international trial that will study the effects of DBS-f in 140 patients over age 65.
"We are encouraged by these findings as they continue to help us identify who will benefit most from DBS to treat Alzheimer's disease and learn more about this illness," says Dr. Andres Lozano, neurosurgeon and the principal investigator of the study. "With so few treatments available and the incidence of Alzheimer's only expected to increase, we really need to fully explore all treatments that seem to be of benefit to patients."
These latest results were captured from the second year of data of the ADvance trial whose first-year data was published in 2016. In that trial, forty-two patients with mild Alzheimer's disease were enrolled in a randomized, double-blind multicentre phase II clinical trial and implanted with DBS electrodes directed at the fornix—a bundle of nerve fibres in the brain that carry signals from the hippocampus—and followed for a total of two years.
In the first 12 months of the trial, to better measure the impact of electrical stimulation in the brain, patients were randomly assigned to either the "on" or "off" stimulation group after their procedure and monitored. Once this phase of follow up was complete, all patients then had their electrodes turned on, and were followed for another 12 months.
In the second 12-month phase, researchers noted similar observations they had seen in the first phase: that, although there were no differences overall in cognitive outcomes between study participants who had their device turned on right after surgery and those who had it turned on after 12 months, those 65 years of age and older appeared to experience a slower progression of Alzheimer's than those under that age, regardless of when their device was turned on.
"The next phase of our research will help determine whether this observed benefit is something we continue to see in this age group," says Lozano who is also University Professor and Chairman, Department of Neurosurgery, University of Toronto. "If it does, this could potentially give us a treatment for mild, late-onset Alzheimer's disease."


Provided by University Health Network

How old is too old for surgery, and why?

Many changes in the body occur in response to the injury and trauma inflicted during surgery. Credit: www.shutterstock.com

Many of us will have been in situations with older loved ones where a doctor says surgery is too risky given the patient's advanced age. Why is it surgery becomes risky in the elderly, and is it based on chronological age or their health?
During surgery and anaesthesia, there are many changes in the body that occur in response to injury and trauma. This is known as the stress response to surgery.

The surgical stress response results in an increased secretion of hormones that promote the break down of carbohydrates, fats and proteins in the body to provide extra energy during and after surgery. The hormonal changes associated with the surgical stress response also activate the sympathetic nervous system.
The sympathetic nervous system is responsible for the "fight or flight" response and causes a rise in heart rate and blood pressure. The changes in the heart rate and blood pressure during surgery and anaesthesia create a state where the heart requires more oxygen, while the surgical stress response and anaesthesia often impedes the oxygen supply to the vital organs such as the heart and the brain. This is a result of less blood flow to the body organs during and after the operation.
Anaesthesia confers risks separate from the risks of surgery. These are mostly minor and easy to treat. But serious problems with the heart, lungs and other major organs are more likely during emergency surgery or in the presence of other health conditions. These factors may increase with chronological age, but frailty is the bigger factor for doctors in deciding whether a patient should undergo surgery and anaesthesia.

Frailty

Frailty is a state where a person is vulnerable due to decline in body function. This in turn reduces their ability to cope with acute and every day stressors.
In a frail person, there is an accumulation of defects in different organ systems of the body, causing them to function close to the threshold of failure. The organ systems near the threshold of failure are then unable to "bounce back" from an external or internal stressor.
An apparently small insult such as a simple fall can result in a significant and disproportionate reduction in reserve and function. The need to have surgery, and the condition that has caused a need for surgery, would often be considered a large insult in a frail person.
Although frailty is more common in older people, it's not exclusive to older people. Most frail people have chronic health problems, and their frailty increases with the number of chronic health conditions. But most people with chronic health conditions are not frail.
There are certain health conditions that are more common in people who are frail, such as heart failure, chronic airways disease and chronic kidney disease.

How do we identify frailty and how does it affect health?

There are many different tools we can use to detect frailty. The Clinical Frailty Scale is one tool based on clinical features present in the patient and the Frailty Index is another tool based on the accumulation of deficits in the patient.
The Clinical Frailty Scale is a single descriptor of a person's level of frailty using clinical judgement graded from one to nine. Level one is a very fit person; level four is "vulnerable" – where the person is not dependent on others for help with daily activities but does have symptoms that limit activities; and level nine is a terminally ill person.
It has been observed that people with a higher Clinical Frailty Scale were more likely to be older, female, have a degree of cognitive impairment and incontinence. The higher proportion of females will most likely reflect the longer life expectancy of women.
Frail people have a higher risk of recurrent falls and fractures and subsequent disability and reduced function. There have been many studies performed to examine how well frailty predicts outcomes after surgery.
In people who have surgery, frailty has been shown to be associated with a higher risk of surgical complications, a greater chance of requiring discharge to a residential care facility and a lower rate of survival. And the more frail the patient, the higher the risk the patient will require readmission after surgery, and the higher the risk of death.
As our population gets older and more frail people have surgery, this will become an important issue, and health care professionals in all areas will need to be more aware of it.

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

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Bad habits that lead to cancer, chronic disease corrected by simple lifestyle intervention

User interfaces in the Make Better Choices 2 app. (a) receiving behavioral feedback in simultaneous and sequential treatments; (b) reporting sedentary leisure screen time in simultaneous and sequential treatments; (c) receiving feedback in contact control treatment. Credit: Northwestern University

Does this sound like someone you know? He or she spends too much time in front of screens, gets little exercise and eats a diet high in fat and low in fruits and vegetables.
It likely sounds familiar because it describes a significant portion of the U.S. population.
A new Northwestern Medicine study found that a lifestyle intervention could fully normalize these four unhealthy behaviors, which put people at risk of developing heart disease and common cancers, including breast, colon and prostate.

19 jun 2018--The study will be published in the Journal of Medical Internet Research Tuesday, June 19.
"Our findings suggest that prevention of chronic disease through behavior change is feasible. They contradict the pessimistic assumption that it's not possible to motivate relatively healthy people to make large, long-lasting healthy lifestyle changes," said lead author Bonnie Spring, director of the Center for Behavior and Health in the Institute for Public Health and Medicine and professor of preventive medicine at Northwestern University Feinberg School of Medicine.
With the help of a smartphone app, a wearable activity tracker, some social support from a coach and a small financial incentive, study participants made large improvements in their eating and activity habits. From a starting point of less than two servings of fruits and vegetables per day, they increased their intake by 6.5 servings per day. They decreased saturated fat intake by 3.6 percent to consume less than 8 percent of their calories from saturated fat. From a baseline of 4.5 hours per day of leisure screen time, they decreased screen time by almost three hours and increased their moderate to vigorous exercise by 25 minutes per day over a nine-month trial.
Even better, participants were able to achieve the same gains whether they implemented all four diet and exercise changes simultaneously or sequentially (changing two or three first and then changing other behaviors later).

A person uses the Make Better Choices 2 smartphone app to track the nutrition in what she wants to eat. Credit: Northwestern University

"When most people start a diet and exercise plan, they're excited to hit the ground running, but they can feel quickly defeated when they can't keep up with everything," Spring said. "The tech tools, support and incentives our intervention offered made the changes simple and motivating enough that our participants were able to start making them all at once without becoming overwhelmed."
Previous research has found that healthy behavior change usually reverts once financial incentives cease. But this study stopped offering the financial incentive after only 12 weeks, and participants still achieved positive results throughout the nine-month trial.
Additionally, the changes observed in this study and in a prior trial by the same group were larger and more sustained than what has been previously observed in studies of technology-supported interventions. Spring said she attributes this to two features of the intervention: modest early financial incentives that motivate participants to make changes larger than what they thought they could achieve; and giving digital feedback not only to participants but also to coaches.

How they conducted the study

Between 2012 and 2014, the study, Make Better Choices 2, enrolled 212 Chicago-area adults, primarily female (76 percent), minority (59 percent), college educated (69 percent) and with a mean age of 41 years old. All participants had low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity and high sedentary leisure screen time.
Participants used smartphones and accelerometers to track their activity and behavior, which they also sent to a coach who monitored whether they were tracking and how they were eating and being active. Perfect behavioral adherence was rewarded with an incentive of $5 per week for 12 weeks.
Based on the incoming data, the coach counseled people by telephone in 10- to 15-minute personalized sessions, weekly for three months, then biweekly for the next three months. Then, until nine months, they retained the intervention app but received no further coaching.
"We suggest that giving accelerometer feedback to both the participant and their coach is the way to improve diet and activity habits, because the coach can support, hold the person accountable and personalize coaching when they know what's going on," Spring said.

More information: Bonnie Spring et al, Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial, Journal of Medical Internet Research (2018). DOI: 10.2196/10528


Provided by Northwestern University

USPSTF: No to ECG screening to prevent CVD in low-risk adults

The U.S. Preventive Services Task Force (USPSTF) recommends against screening with resting or exercise electrocardiography (ECG) to prevent cardiovascular disease (CVD) events in low-risk asymptomatic adults. This final recommendation statement has been published in the June 12 issue of the Journal of the American Medical Association.

18 jun 2018--To inform the USPSTF, Daniel E. Jonas, M.D., M.P.H., from the University of North Carolina at Chapel Hill Evidence-Based Practice Center, and colleagues conducted a systematic review of the evidence from 16 studies with 77,140 participants on screening asymptomatic adults for CVD risk using ECG.
The researchers found that it is very unlikely that the information from resting or exercise ECG would result in a change in a patient's risk category that would lead to a change in treatment or improve health outcomes for asymptomatic adults at low risk for CVD events. Screening with resting or exercise ECG is associated with possible harms, specifically the potential adverse effects of subsequent invasive testing. Based on these findings, the USPSTF recommends against resting or exercise ECG to prevent CVD events in asymptomatic adults (D recommendation). For asymptomatic adults at intermediate or high risk of CVD events, the evidence is insufficient to assess the balance of benefits and harms of screening.
"There is not enough evidence for those who might benefit the most—people at higher risk for CVD—to say if adding ECG screening helps prevent heart attack and stroke," Task Force member Michael J. Barry, M.D., said in a statement. "Clinicians should continue to use traditional risk factors to assess CVD risk and guide treatment for these patients until more evidence is available."

More information: Evidence Review
Final Recommendation Statement
Editorial

Religious affiliation linked to nearly 4-year longevity boost

Credit: The Ohio State University

A new nationwide study of obituaries has found that people with religious affiliations lived nearly four years longer than those with no ties to religion.
That four-year boost – found in an analysis of more than 1,000 obits from around the country – was calculated after taking into account the sex and marital status of those who died, two factors that have strong effects on lifespan.

17 jun 2018--The boost was slightly larger (6.48 years) in a smaller study of obituaries published in a Des Moines, Iowa, newspaper.
"Religious affiliation had nearly as strong an effect on longevity as gender does, which is a matter of years of life," said Laura Wallace, lead author of the study and a doctoral student in psychology at The Ohio State University.
The study was published online today in the journal Social Psychological and Personality Science.
The researchers found that part of the reason for the boost in longevity came from the fact that many religiously affiliated people also volunteered and belonged to social organizations, which previous research has linked to living longer.
"The study provides persuasive evidence that there is a relationship between religious participation and how long a person lives," said Baldwin Way, co-author of the study and associate professor of psychology at Ohio State.
In addition, the study showed how the effects of religion on longevity might depend in part on the personality and average religiosity of the cities where people live, Way said.
The first study involved 505 obituaries published in the Des Moines Register in January and February 2012. In addition to noting the age and any religious affiliation of those who died, the researchers also documented sex, marital status and the number of social and volunteer activities listed.
Results showed that those whose obit listed a religious affiliation lived 9.45 years longer than those who didn't. The gap shrunk to 6.48 years after gender and marital status were taken into account.
The second study included 1,096 obituaries from 42 major cities in the United States published on newspaper websites between August 2010 and August 2011.
In this study, people whose obits mentioned a religious affiliation lived an average of 5.64 years longer than those whose obits did not, which shrunk to 3.82 years after gender and marital status were considered.
Many studies have shown that people who volunteer and participate in social groups tend to live longer than others. So the researchers combined data from both studies to see if the volunteer and social opportunities that religious groups offer might explain the longevity boost.
Results showed that this was only part of the reason why religious people lived longer.
"We found that volunteerism and involvement in social organizations only accounted for a little less than one year of the longevity boost that religious affiliation provided," Wallace said. "There's still a lot of the benefit of religious affiliation that this can't explain."
So what else explains how religion helps people live longer? It may be related to the rules and norms of many religions that restrict unhealthy practices such as alcohol and drug use and having sex with many partners, Way said.
In addition, "many religions promote stress-reducing practices that may improve health, such as gratitude, prayer or meditation," he said.
The fact that the researchers had data from many cities also allowed them to investigate whether the level of religiosity in a city and a city's "personality" could affect how religious affiliation influenced longevity.
The findings showed that a key personality element related to longevity in each city was the importance placed on conformity to community values and norms.
In highly religious cities where conformity was important, religious people tended to live longer than non-religious people.
But in some cities there is a spillover effect.
"The positive health effects of religion spill over to the non-religious in some specific situations," Wallace said. "The spillover effect only occurs in highly religious cities that aren't too concerned about everyone conforming to the same norms. In those areas, non-religious people tend to live as long as do religious people."
Way said there are limitations to the study, including the fact that it could not control for important factors related to longevity such as race and health behaviors. But a potential strength was that, unlike other studies, religious affiliation was not self-reported, but was reported by the obituary writer.
Overall, the study provided additional support to the growing number of studies showing that religion does have a positive effect on health, Wallace said.

More information: Does Religion Stave Off the Grave? Religious Affiliation in One's Obituary and Longevity. Social Psychological and Personality Science. doi.org/10.1177/1948550618779820


Provided by The Ohio State University

Why predicting suicide is a difficult and complex challenge

Anthony Bourdain, left, and Kate Spade, right. Credit: The Conversation with images from PeabodyAwards/flickr, CC BY-SA

Who is going to die by suicide? This terrible mystery of human behavior takes on particular poignance in the wake of suicides by high-profile and much-beloved celebrities Kate Spade and Anthony Bourdain. It is only natural that people want to know why such tragedies occur. Those closest to those who take their lives are often tormented, wondering if there is something they could have – or should have – known to prevent their loved one's suicide.

16 jun 2018--As a scientist who has focused on this question for the past decade, I should have a pretty good idea of who is and isn't going to die by suicide. But the sad truth is, I don't. The sadder truth is, neither do any other suicide experts, psychiatrists or physicians. The sum of the research on suicide shows that it does not matter how long we've known someone or how much we know about them. In my research, my colleagues and I have shown that we can only predict who is going to die by suicide slightly more accurately than random guessing.

The need for answers

The fact that suicide is so hard to predict unfortunately took about 50 years for most scientists to appreciate. About the same time that this recognition became widespread a few years ago, a new hope emerged: a form of artificial intelligence called machine learning. As several research groups have demonstrated in recent years, machine learning may be able to predict who is going to attempt or die by suicide with up to 90 percent accuracy.
To understand why this is, and why we humans won't ever be able to accurately predict suicide on our own, one needs to take a step back and understand a little more about the nature of human cognition, suicide and machine learning.
As humans, we love explanations that have two qualities. First, explanations should be simple, meaning that they involve one or a small number of things. For example, depression is a simple explanation for suicide.
Second, explanations should be determinate, meaning that there is one set explanation that accounts for all or most of something. For example, the idea that depression causes most suicides is a determinate explanation. This simple and determinate explanatory style is highly intuitive and very efficient. It's great for helping us to survive, procreate, and get through our days.
But this style of thinking is terrible for helping us understand nature. This is because nature is not simple and determinate. In recent decades, scientists have come to recognize that nearly everything – from physics to biology to human behavior – is complex and indeterminate. In other words, a very large number of things combined in a complex way are needed to explain most things, and there's no set recipe for most physical, biological or behavioral phenomena.
I know that this latter idea of indeterminacy is especially counterintuitive, so let me provide a straightforward example of it. The math equation X plus Y equals 1 is indeterminate. As humans, we instinctively try to find one solution to this equation (e.g., X equals 1, Y equals 0). But there is no set recipe for solving this equation; there are nearly infinite solutions to this equation. Importantly, however, this does not mean that "anything goes." There are also near infinite values for X and Y that do not solve this equation. This indeterminate middle ground between "one solution" and "anything goes" is difficult for most humans to grasp, but it's how much of nature works.
The sum of our scientific evidence indicates that, just like most other things in nature, the causes and predictors of suicide are complex and indeterminate. Hundreds, and maybe thousands, of things are relevant to suicide, but nothing predicts suicide much more accurately than random guessing. For example, depression is often considered to be an extremely important predictor of suicide. But about 2 percent of severely depressed people eventually die by suicide, which is only slightly higher than the 1.6 percent of people from the general United States population who eventually die by suicide. Such a pattern is consistent with complexity because it suggests that we must put a lot of factors together to account for suicide.

Empathy will always matter

So how should we put all of these factors together? One intuitive solution is to add many of these factors together. But even when summing hundreds of factors, this doesn't work – prediction is still only slightly more accurate than random guessing.
A much better solution would be to somehow find an optimized combination of tens or even hundreds of factors. How can we do this? One promising answer is machine learning. In short, machine learning programs can process a large amount of data and learn an optimal combination of factors for a given task. For example, most existing machine learning studies have used data from electronic health records, spanning hundreds of factors related to mental health diagnoses, physical health problems, medications, demographics and hospital visit patterns. Results from several groups in recent years have shown that this approach can consistently predict future suicide attempts and death with 80-90 percent accuracy. Multiple groups are currently working on applying these algorithms to actual clinical practice.
One important thing to keep in mind is that there isn't, and never will be, a single algorithm or recipe for suicide prediction. This is because suicide is indeterminate, much like the X plus Y equals 1 equation. There are likely near-infinite algorithms that could predict suicide with 80-90 percent accuracy, as a number of studies have shown. Research has already demonstrated that no particular factors are necessary for a good algorithm, and many different types of algorithms can produce accurate prediction. But again, this indeterminacy also means that there are near-infinite bad algorithms, too.
All of this research shows that suicide is unfortunately too complex and indeterminate for humans to predict. Neither I nor anyone else can accurately predict who is going to die by suicide or truly explain why a particular person died by suicide (this includes the suicide decedents themselves). Machine learning can do a much better job of approximating the complexity of suicide, but even it falls far short. Although it can accurately predict who will eventually die by suicide, it cannot yet tell us when someone will die by suicide. This "when" dimension of prediction is critical, and we are likely still many years away from accounting for it.
In the meantime, what can we humans do? While we don't have the ability to know whether someone is going to die by suicide or not, we do have the ability to be supportive and caring. If you believe that someone may be struggling, talk with them and let them know about resources such as the US National Suicide Prevention Lifeline (1-800-273-8255).

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

Provided by The Conversation

Why hip fractures in the elderly are often a death sentence

There are many reasons elderly people who fracture their hip often don’t recover. Credit: shutterstock.com

The news an elderly relative has broken a hip tends to sound alarm bells, perhaps more than breaking another bone would. That's because a hip fracture dramatically increases an older person's risk of death.
One in three adults aged 50 and over dies within 12 months of suffering a hip fracture. Older adults have a five-to-eight times higher risk of dying within the first three months of a hip fracture compared to those without a hip fracture. This increased risk of death remains for almost ten years.

14 jun 2018--Beyond suffering pain, a hip fracture results in a loss of physical function, decreased social engagement, increased dependence, and worse quality of life. Many people who have a hip fracture need to change their living conditions, such as relocating from their home into a residential aged care facility.
Ultimately, the often rapid regression of an older person's health following a hip fracture means outcomes are poor.

Risk factors for hip fractures

Age is a key risk factor, with hip fractures more likely to occur in those aged 65 or older. They're primarily a result of a fall, or when the hip collides with a solid object such as a kitchen bench. However, they can also occur when there has been little or no trauma, such as standing up.
Cognitive impairment such as dementia is a common factor that increases the risk of falling. Frailty, poor vision, the use of a combination of medications, and trip hazards in the home also increase the likelihood of falls. Osteoporosis, a disease characterised by low bone mass and degradation of bone tissue, is another significant risk factor for hip fractures.
Osteoporosis and osteopenia (where bone mass is lower than normal, but not yet osteoporotic) are reported to affect more than one million Australians aged 65 and older. Worldwide, one in three women and one in five men experience a fracture caused by such bone fragility, with a fracture occurring every three seconds. Compared to a fracture of any other bone, a hip fracture results in the most serious of all consequences.
While the reasons remain unclear, hip fractures also disproportionately affect those at the disadvantaged end of the social scale.
Previous research has reported around 30% of people with hip fractures have had a prior fracture; this is known as the "fracture cascade". The increased risk of subsequent fracture may persist for ten years, which highlights the importance of treating the initial fracture promptly and effectively.

Increased risk of death

In Australia, standard clinical care following a hip fracture begins with timely assessment, including X-rays, and pain and cognitive assessments. Australian data indicate more than three-quarters of people who sustain a hip fracture undergo surgery, the most common procedure being a joint replacement. Surgical intervention will generally occur within 48 hours.

Immobility after a hip fracture can lead to poor patient outcomes. Credit: shutterstock.com

But some patients may prefer not to undergo surgery. Or, their medical team may determine the risks are too great to expose the person to surgery.
Combined with the trauma of a fracture and surgery, an existing health condition may significantly increase the risk of death. Death after a hip fracture may also be related to additional complications of the fracture, such as infections, internal bleeding, stroke or heart failure.
One study showed heart disease, stroke and pneumonia resulted in a long-term doubling of risk of death after hip fracture, and this risk remained high for up to ten years in women and 20 in men.
Studies suggest issues related to the hospitalisation, surgery, or immobility (which could put patients at risk of pneumonia) after a fracture lead to other complications that ultimately result in earlier death.

How can patient outcomes be improved?

Together with controlling immediate post-surgery pain and symptoms, patients should receive therapeutic rehabilitation and functional training for the best chance of regaining mobility.
Taking individual capabilities, physical health and function into account, therapeutic rehabilitation may include improving the range of motion, pool therapy, and strengthening and progressive resistance exercises. Functionaltraining will include gait training, and resistance and balance exercises.
Even if the patient has not had surgery, rehabilitation is necessary to begin moving as quickly as possible to avoid the serious complications of being immobilised.
Some data suggest beginning physical activity as soon as possible post-surgery will reduce the likelihood of death. What we don't yet know is the type, intensity and duration of physical activity that will give the best results.
Nutrition can also help recovery. Some data has shown poor nutrition at the time of the fracture reduced people's ability to walk unaided six months after the fracture, compared to those with good nutrition.
There are mixed messages regarding whether nutritional supplements help improve function after a hip fracture. But the combination of protein intake and physical activity is known to increase muscle mass and function. Good muscle mass and function reduce frailty and improve balance, thereby reducing the risk of falls and subsequent fracture.
And there are additional benefits to be gained from being physically active, such as reducing depression – particularly when exercising with other people.

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

Provided by The Conversation

Model estimates lifetime risk of Alzheimer's dementia using biomarkers

PET scan of a human brain with Alzheimer's disease. Credit: public domain

Lifetime risks of developing Alzheimer's disease dementia vary considerably by age, gender and whether any signs or symptoms of dementia are present, according to a new study published online by Alzheimer's & Dementia.

09 jun 2018--According to the authors, these are the first lifetime risk estimates for Alzheimer's that take into account what are believed to be biological changes in the brain that occur 10 to 20 years before the well-known memory and thinking symptoms appear. These early changes, prior to overt clinical symptoms, are referred to as preclinical Alzheimer's disease. This designation is currently only for research use until more scientific evidence is produced to determine if it can accurately predict the progression to symptoms.
The prevalence of this research-only stage of the Alzheimer's continuum, known as preclinical Alzheimer's disease, in the U.S. has been estimated at nearly 47 million people in a previous study. An example from this newly published report is of a 70-year-old male who has just amyloid, but no signs of neurodegeneration and no memory loss, has a lifetime risk of 19.9 percent. But, if he also had neurodegeneration in addition to amyloid, the lifetime risk rises to 31.3 percent. If, in addition, he had mild cognitive impairment (MCI) plus amyloid plus neurodegeneration, the risk rises to 86 percent.
"What we found in this research is that people with preclinical Alzheimer's disease dementia may never experience any clinical symptoms during their lifetimes because of its long and variable preclinical period," said Ron Brookmeyer, Ph.D., from the UCLA School of Public Health, Los Angeles. "The high mortality rates in elderly populations are also an important factor as individuals are likely to die of other causes."
Brookmeyer provides an example of a 90-year-old female with amyloid plaques having a lifetime risk of Alzheimer's disease of only 8.4 percent, compared to a 65-year-old female with amyloid plaques who has a lifetime risk of 29.3 percent. The lower lifetime risk for the 90-year-old versus the 65-year-old is explained by the shorter life expectancy of the older person.
That same 65-year-old female with amyloid plaques has a 10-year risk of Alzheimer's disease dementia of 2.5 percent. Lifetime risks for females are generally higher than males because they live longer. Brookmeyer and his co-author Nada Abdalla, M.S., also of UCLA, state that the lifetime and 10-year risks provide an indication of the potential that someone will develop Alzheimer's disease dementia based on their age and screenings for amyloid deposits, neurodegeneration and presence or absence of MCI or any combination of those three. For men and women, having the combination of all three puts them at the highest risk of developing Alzheimer's disease.
"Just as there are risk predictors for whether you might have a heart attack, it will be important in the future to measure the likelihood that someone will develop Alzheimer's disease," said Maria Carrillo, Ph.D., Alzheimer's Association chief science officer. "In the future, when treatments are available, this would be helpful, especially for people in the stages before the clinical symptoms appear. For example, those people with the highest 10-year risk of getting Alzheimer's dementia would be high priority to volunteer for clinical trials evaluating Alzheimer's medications or other therapies."
After reviewing the existing scientific literature, including some of the largest longitudinal studies available that have measured biomarkers with data from thousands of people, (e.g., The Mayo Clinic Study of Aging) the authors created a computerized mathematical model to ascertain how likely a person would progress in the continuum of the disease. They based their calculations on the transition rates from the published studies and from U.S. death rates data based on age and gender. They acknowledge that future studies looking at transition rates need to be in ethnically diverse populations and also need to consider whether genetic variants such as the Apolipoprotein (APOE) ?4, which puts people at much higher likelihood for developing Alzheimer's disease, would affect the lifetime riskestimates. And future studies will need to be based on research that is more conclusive than the current scientific literature about risk in relation to early biomarkers like presence of amyloid decades before symptoms appear.
"There are still many things to consider when assessing the value of screening people for Alzheimer's disease biomarkers. Lifetime risks will help in formulating screening guidelines to identify those who would be most helped by screening, especially in the preclinical stage," the authors conclude.
The model used in this study differs from the recently announced NIA-AA Research Framework Towards a Biological Definition of Alzheimer's Disease. Under the framework, if a person does not have amyloid plaques, then they do not have Alzheimer's pathology. Amyloid is one of the biomarkers along with tau tangles considered to be hallmark of Alzheimer's disease. In this model, two of the states of progression (state 3 which is neurodegeneration alone and state 6 which is MCI and neurodegeneration alone) do not include amyloid and would not be considered Alzheimer's under the research framework.


Provided by Alzheimer's Association

New hypertension guideline discussed for older adults

Clinicians caring for older adults with hypertension should be mindful of the specific blood pressure (BP) goals proven to reduce cardiovascular disease events, while adopting the new 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline, according to an article published online May 20 in the Journal of the American Geriatrics Society.

04 jun 2018--William C. Cushman, M.D., and Karen C. Johnson, M.D., M.P.H., from the University of Tennessee Health Science Center in Memphis, discuss the 2017 ACC/AHA hypertension guideline in the context of caring for older adults with hypertension.
The authors note that the ACC/AHA hypertension guideline is primarily based on systematic reviews and meta-analyses. Consequently, the classification of BP, thresholds for initiating drug therapy, and treatment goals are not identical with specific levels proven in randomized controlled trials. When caring for older adults, it is important for physicians to be mindful of the specific BP goals proven to reduce cardiovascular disease events in this population. They should also be attentive to proper BP measurement techniques; encourage non-pharmacologic interventions; and monitor patients for concomitant conditions, adverse drug effects, and complications of elevated BP.
"Adjustments to therapy and goals may be necessary as older adults become increasingly frail, cognitively impaired, or institutionalized, or have a limited life expectancy, although many frail older adults will still benefit from appropriate antihypertensive non-pharmacological and drug therapy," the authors write.
One author disclosed financial ties to the pharmaceutical industry.

More information: Abstract/Full Text (subscription or payment may be required)

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