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November 14, 2011

Caregiving’s Hidden Benefits

Could there be measurable benefits to your health, and to your brain in particular, from being a caregiver?

It’s practically become an article of faith that the reverse is true, that caring for an elderly relative is so stressful, relentless and draining that it takes a toll on your well-being. Some studies have shown that it can increase your risk of depression and heart disease, impair your immune system, even contribute to death.

That caregiving could actually provide some health advantage is so counter intuitive that when Lisa Fredman, a Boston University epidemiologist, first saw such results emerging from her study of elderly women, “I thought, what on earth is going on here?” she recalled. “I blamed myself. I thought something was wrong with my data.”

But over several years of studying the differences between caregivers and non-caregivers in four locations (Baltimore, Pittsburgh, Minneapolis and Portland, Ore.), Dr. Fredman and her colleagues found that while caregivers were indeed more stressed, they still had lower mortality rates than non-caregivers over eight years of follow-up.

In another study of about 900 women drawn from the same four-site sample, even those classified as high-intensity caregivers — because they performed more functions for their dependent relatives — maintained stronger physical performance than non-caregivers. On tests like walking pace, grip strength and the speed with which they could rise from a chair, the high-intensity group declined less than lower-intensity caregivers or non-caregivers over two years.

“That was a shocker,” Dr. Fredman said.

Now Dr. Fredman and her co-author Rosanna Bertrand, a health policy associate at Abt Associates in Cambridge, Mass., have gone back to this pool of women to look at their cognitive functioning. Here, again, caregivers did significantly better on memory tests than did non-caregivers followed over two years. Though the groups were about the same average age, in their early to mid-80s, caregivers scored at the level of people who were 10 years younger.

Along with what’s called “caregiver burden,” gerontologists and psychologists use the phrase “caregiver gain” to reflect the fact that this role, which often exacts such high costs, can bring rewards. But they’ve typically described those rewards in psychological, emotional and even spiritual terms: growing confidence in one’s abilities, feelings of personal satisfaction, increased family closeness. That caregivers can walk faster or recall more words on a memory test — that’s news.

Dr. Fredman has begun referring to this notion that caregivers are not invariably beaten down by their responsibilities as the “healthy caregiver hypothesis.” Taken together, her studies provide some evidence that caregivers, however stressed, may be stronger and stay stronger than women of the same ages who don’t undertake those tasks. The interesting question is why.

You can’t randomize studies like this, assigning some old women to serve as caregivers but not others. So it’s likely that a big part of the differences, Dr. Fredman said, stemmed from self-selection: Women become caregivers because they are healthy enough to shoulder that responsibility. “If you’re not healthy,” she said, “it goes to your daughter or daughter-in-law.” It’s not surprising, therefore, that even high-intensity caregivers have and maintain more physical strength.

It’s also true that Dr. Fredman’s definition of a caregiver sets a fairly low bar, including anyone who performs even one “instrumental activity of daily living,” such as helping someone with bill-paying or phone use. Hands-on help with bathing or toilet use is clearly more stressful, physically and emotionally; caring for someone with dementia can be particularly arduous.

But caregiving itself may provide real benefits. “Most caregiving activities require you to move around a lot,” Dr. Fredman pointed out. “It keeps people on their feet, up and going.” And exercise is known to improve physical health and cognition.

Moreover, Dr. Bertrand added: “Caregiving often requires complex thought. Caregivers monitor medications, they juggle schedules, they may take over financial responsibilities.” That, too, can ward off cognitive decline.

Plus there’s the whole matter of people benefiting from having a purpose. It’s hard to quantify, but it’s real.

So it’s fair to say that the question of how caregiving impacts the caregiver is more complicated and individual than we think. Both could be true, the burdens and the benefits, depending on how demanding the job is and a host of other factors.

That caregiving is a very tough job is beyond debate. “We don’t want to overstate this and say it’s good for caregivers and have governors across the country rush to cut support programs that help families,” said Steven Zarit, a Penn State gerontologist who has studied caregiving. (Of course, governors seem all too eager to do that anyway.)

Still, “it may not be as predictive of their demise as previously thought,” Dr. Bertrand said of elder care and caregivers. “There are potentially some positive aspects.”

By Paula Span

October 31, 2011

New Drugs to Prevent Strokes

By Paula Span

Medical researchers are usually so cautious about characterizing results that when sober cardiologists use phrases like “very excited” and “a home run” and even “a new era,” you pay attention.

What’s causing this ripple is the emergence of new anticoagulant drugs, or blood thinners. Dabigatran (brand name Pradaxa) has already won Food and Drug Administration approval; rivaroxaban (Xarelto) has been endorsed by an F.D.A. advisory panel and awaits a final decision in November. A third drug, apixaban (Eliquis), exceeded investigators’ expectations in global clinical trials, according to findings just reported in The New England Journal of Medicine, and the manufacturer will seek F.D.A. approval by year’s end.

“The results are clear, so we’d expect the review process to be fairly rapid,” said Dr. Christopher Granger, the Duke University cardiologist who led the trials. A fourth new anticoagulant, edoxaban, is in advanced clinical trials.

As these medications hit the market, assuming most will, they’re likely to begin edging out warfarin, for 50 years the standard drug used to prevent strokes in people with atrial fibrillation. That’s what’s causing the cheers, though there are also some less-than-cheerful prospects.

A brief primer: Atrial fibrillation, a heart arrhythmia that can create blood clots, is thought to cause about one in five strokes in the United States. The condition increases steadily with age, so the number of people coping with it will rise along with the sheer numbers of older Americans.

Warfarin (Coumadin) reduces stroke risk from atrial fibrillation by about 60 percent, by thinning the blood so it’s less likely to clot. Along with blood pressure drugs, warfarin is one of the reasons that stroke deaths have declined sharply in recent decades.

But “the saying is that warfarin is the drug people love to hate,” said Dr. Jessica Mega, a cardiologist at Brigham and Women’s Hospital in Boston and author of an editorial in The New England Journal of Medicine hailing “a new era”. “It’s very unpopular.”

That’s because it affects individuals so differently that patients require careful monitoring; they typically have blood drawn each month to be sure the blood remains the proper consistency. “You want it thin enough that the drug is effective — you won’t form clots — but not so thin you’re going to bleed if you bump your head on the kitchen cabinet,” Dr. Mega said. If a doctor finds the monthly results unsatisfactory and adjusts the warfarin dose, the patient has to return for still another test.

“It’s a very labor-intensive medication,” Dr. Mega said. “People get fatigued, and they don’t want to do it anymore.”

Moreover, warfarin doesn’t play well with other drugs, from antibiotics to some blood pressure meds. Users even have to be mindful of what they eat (no bingeing on kale). And while some bleeding caused by warfarin — bruising, say, or nosebleeds –- is simply problematic and unpleasant, doctors particularly worry about bleeding into the brain. An intracranial hemorrhage can be fatal or disabling, as bad as the problems that warfarin was supposed to prevent.

That happens very rarely, it should be said. “It’s a low-frequency event, but it’s devastating,” Dr. Mega said.

So the goal in evaluating the new drugs has been to ascertain “noninferiority.” They didn’t have to be more effective than warfarin, which works quite well; they just have to be easier to take and no more likely to cause bleeding. That is benefit enough to seek F.D.A. approval.

Apixaban did well by those measures, the researchers found. In a randomized study of more than 18,000 people (median age: 70) with atrial fibrillation and at least one other risk factor for stroke, major bleeding occurred in 2.13 percent of patients in the apixaban group per year, significantly less than the 3.09 percent in the warfarin group. Apixaban significantly reduced bleeding in general, and brain bleeds in particular, compared with warfarin. And patients were able to skip the monthly monitoring. (Bristol-Myers Squibb and Pfizer, which hope to market apixaban, financed the study.)

But what caused excitement at the recent meeting of the European Society of Cardiology in Paris was that apixaban, a twice-daily pill, went beyond noninferiority. It prevented 21 percent more strokes than warfarin over the 1.8 years of the study and reduced deaths from any cause by 11 percent, in addition to reducing major bleeding incidents by nearly a third. “That’s a home run,” said Dr. Mega.

The other new drugs had similar benefits, she added: “Across all these trials, they make a whopping reduction in the risk of hemorrhagic stroke.” They have fewer dangerous interactions with other drugs as well. And although some drugs are less effective in the elderly, “one sees very clear findings of lower rates of stroke and bleeding among the elderly” in the apixaban study, Dr. Granger said.

The less-than-cheerful news is how much more the new meds cost than warfarin. Coumadin retails for about $1.50 a day, depending on dose. The generic goes for less than $10 a month at some big chains. By contrast, apixaban is expected to sell for $7 a day, a stiff price for patients on fixed incomes, even if they have Medicare Part D. “They fall into the doughnut hole fairly quickly,” Dr. Granger said.

Perhaps analysts will determine that cost savings of the new anticoagulants — at least a dozen monthly tests people no longer have to undergo, plus fewer strokes — will compensate for the higher costs.

Or maybe the competitive market will work the way it’s supposed to, with several new drugs entering the market in a short time creating downward pressure on costs. “We may be able to persuade pharmaceutical companies that it’s better to have broader use at lower prices than less use at higher prices,” Dr. Granger said.

October 10, 2011

New Drugs to Prevent Strokes

Medical researchers are usually so cautious about characterizing results that when sober cardiologists use phrases like “very excited” and “a home run” and even “a new era,” you pay attention.

What’s causing this ripple is the emergence of new anticoagulant drugs, or blood thinners. Dabigatran (brand name Pradaxa) has already won Food and Drug Administration approval; rivaroxaban (Xarelto) has been endorsed by an F.D.A. advisory panel and awaits a final decision in November. A third drug, apixaban (Eliquis), exceeded investigators’ expectations in global clinical trials, according to findings just reported in The New England Journal of Medicine, and the manufacturer will seek F.D.A. approval by year’s end.

“The results are clear, so we’d expect the review process to be fairly rapid,” said Dr. Christopher Granger, the Duke University cardiologist who led the trials. A fourth new anticoagulant, edoxaban, is in advanced clinical trials.

As these medications hit the market, assuming most will, they’re likely to begin edging out warfarin, for 50 years the standard drug used to prevent strokes in people with atrial fibrillation. That’s what’s causing the cheers, though there are also some less-than-cheerful prospects.

A brief primer: Atrial fibrillation, a heart arrhythmia that can create blood clots, is thought to cause about one in five strokes in the United States. The condition increases steadily with age, so the number of people coping with it will rise along with the sheer numbers of older Americans.

Warfarin (Coumadin) reduces stroke risk from atrial fibrillation by about 60 percent, by thinning the blood so it’s less likely to clot. Along with blood pressure drugs, warfarin is one of the reasons that stroke deaths have declined sharply in recent decades.

But “the saying is that warfarin is the drug people love to hate,” said Dr. Jessica Mega, a cardiologist at Brigham and Women’s Hospital in Boston and author of an editorial in The New England Journal of Medicine hailing “a new era”. “It’s very unpopular.”

That’s because it affects individuals so differently that patients require careful monitoring; they typically have blood drawn each month to be sure the blood remains the proper consistency. “You want it thin enough that the drug is effective — you won’t form clots — but not so thin you’re going to bleed if you bump your head on the kitchen cabinet,” Dr. Mega said. If a doctor finds the monthly results unsatisfactory and adjusts the warfarin dose, the patient has to return for still another test.

“It’s a very labor-intensive medication,” Dr. Mega said. “People get fatigued, and they don’t want to do it anymore.”

Moreover, warfarin doesn’t play well with other drugs, from antibiotics to some blood pressure meds. Users even have to be mindful of what they eat (no bingeing on kale). And while some bleeding caused by warfarin — bruising, say, or nosebleeds –- is simply problematic and unpleasant, doctors particularly worry about bleeding into the brain. An intracranial hemorrhage can be fatal or disabling, as bad as the problems that warfarin was supposed to prevent.

That happens very rarely, it should be said. “It’s a low-frequency event, but it’s devastating,” Dr. Mega said.

So the goal in evaluating the new drugs has been to ascertain “noninferiority.” They didn’t have to be more effective than warfarin, which works quite well; they just have to be easier to take and no more likely to cause bleeding. That is benefit enough to seek F.D.A. approval.

Apixaban did well by those measures, the researchers found. In a randomized study of more than 18,000 people (median age: 70) with atrial fibrillation and at least one other risk factor for stroke, major bleeding occurred in 2.13 percent of patients in the apixaban group per year, significantly less than the 3.09 percent in the warfarin group. Apixaban significantly reduced bleeding in general, and brain bleeds in particular, compared with warfarin. And patients were able to skip the monthly monitoring. (Bristol-Myers Squibb and Pfizer, which hope to market apixaban, financed the study.)

But what caused excitement at the recent meeting of the European Society of Cardiology in Paris was that apixaban, a twice-daily pill, went beyond noninferiority. It prevented 21 percent more strokes than warfarin over the 1.8 years of the study and reduced deaths from any cause by 11 percent, in addition to reducing major bleeding incidents by nearly a third. “That’s a home run,” said Dr. Mega.

The other new drugs had similar benefits, she added: “Across all these trials, they make a whopping reduction in the risk of hemorrhagic stroke.” They have fewer dangerous interactions with other drugs as well. And although some drugs are less effective in the elderly, “one sees very clear findings of lower rates of stroke and bleeding among the elderly” in the apixaban study, Dr. Granger said.

The less-than-cheerful news is how much more the new meds cost than warfarin. Coumadin retails for about $1.50 a day, depending on dose. The generic goes for less than $10 a month at some big chains. By contrast, apixaban is expected to sell for $7 a day, a stiff price for patients on fixed incomes, even if they have Medicare Part D. “They fall into the doughnut hole fairly quickly,” Dr. Granger said.

Perhaps analysts will determine that cost savings of the new anticoagulants — at least a dozen monthly tests people no longer have to undergo, plus fewer strokes — will compensate for the higher costs.

Or maybe the competitive market will work the way it’s supposed to, with several new drugs entering the market in a short time creating downward pressure on costs. “We may be able to persuade pharmaceutical companies that it’s better to have broader use at lower prices than less use at higher prices,” Dr. Granger said.

By PAULA SPAN

September 26, 2011

IT’S FLU VACCINATION SEASON!

CMK Home Care wanted to share with you what the government is saying about flue vaccines this season. Check out this website for all  the details!

September 19, 2011

Seniors Are Saying No to High Tech

The digital revolution may be changing the way we live and work. But large numbers of older Americans are not going online, using smartphones, or even participating in the benefits of electronic healthcare tools specifically designed to help them.

The costs of not participating in electronic communications are growing. Government and the private sector are shifting to online tools as their dominant form of public communication. It saves time and money, and provides more responsive public services. But surveys of Internet and technology use show that many, if not most, older consumers are bypassed with online communication.

Earlier this year, for example, the U.S. Social Security Administration said it would stop sending paper statements to Americans explaining their Social Security benefits. Instead, such statements would be available online. As part of a broader government policy, Social Security will also be ending paper-based benefit checks by May 2013.

The Social Security Administration says growing use of the Internet will allow it to save money on paper-based statements and still meet public needs. However, while the agency has stopped mailing out its annual statement of benefits, it has yet to begin offering this information online. And an agency spokesman says privacy rules prevent the agency from even measuring how many people visit its website. The agency knows that total page views on the site are rising, the spokesman said, but it is not allowed to collect specifics on how many beneficiaries are actually using the site.

The most probable answer, however, is “not many.” According to the Pew Research Center’s Internet & American Life Project, only 42 percent of Americans age 65 and older go online at all. Of these, even smaller percentages use the Internet to research information on specific topics. These numbers are rising, but still are roughly half the level of younger Americans. The Social Security Administration does say it plans to provide paper-based statements to older people, but has not yet spelled out the timing of this effort.

Laurie Orlov is a former Forrester Research analyst who started her own company, Aging in Place Technology Watch, to research and provide consulting advice about seniors and technology. While there have been some gains in technology use by older consumers, price and complexity are barriers to larger gains, as is seniors’ comfort with familiar ways of doing things.

“People are pretty inflexible” about technology use, she says, “so there’s a chance those numbers won’t improve much.” Is it fair to describe seniors as the lost generation in terms of technology? “I think they are,” she says.

Orlov can rattle off an impressive list of the costs to seniors of not being online, from paying extra for airline tickets by using a reservations agent, to missing out on online coupons and other digital bargains, to becoming isolated from grandchildren and other family members who increasingly rely on digital devices to communicate.

Baby boomers, by contrast, are using new technology at rates nearly equal to younger consumers. They are likely to continue such habits as they join the ranks of senior citizens, and it will be this trend that will firmly establish electronic communication and commerce as a senior activity.

For now, Orlov says, she’s extremely optimistic that computers and hand-held tablets and other devices will become easier to use and more friendly to inexperienced and older consumers alike.

Ingenious “apps” and uses for smartphones and other mobile communications devices are driving broad gains in consumer adoption. Orlov thinks the improvements in user interfaces and ease-of-use gains in these mass markets will help all consumers, including seniors. “I think technology is becoming multi-age friendly,” she says.

“We’re at the beginning of a remarkable time,” she says. “It’s going to get better because it can. That’s the nature of technology.”

By Phil Moeller

September 13, 2011

Dieting Beats Exercise for Diabetes Prevention in Older Women, Combo Is Best Strengthening exercise appears to have greater benefits for insulin resistance than aerobic exercise

Lifestyle changes that include dieting to lose weight and exercise can help prevent type 2 diabetes, but researchers were uncertain which element contributes more. A new study suggests that, in postmenopausal women at least, dietary weight loss alone is effective while exercise alone is not effective, and both together are best of all.

“The effects seems to be additive,” said Caitlin Mason, Ph.D., lead study author.

“The women who did both diet and exercise together had the greatest weight loss and greatest improvement in insulin and blood sugar control.”

In light of the additional benefits of exercise, such as preserving muscle mass during weight loss, “a combined program is the way to go,” said Mason, a postdoctoral fellow in public health sciences at the Fred Hutchinson Cancer Research Center.

For the study, which appears online and in the October issue of the American Journal of Preventive Medicine, 439 inactive, overweight postmenopausal women were randomly assigned to participate in a dietary weight loss program, an aerobic exercise program, or a program that included diet and exercise, or were told not to change their eating or exercise patterns.

Participants received diet and exercise counseling in groups of eight to 15 women, rather than individually.

The researchers estimated the women’s insulin resistance – which reflects how well or poorly the body metabolizes sugar – and their fasting blood sugar, when the study began and after 12 months. Increased insulin resistance and elevated blood sugar are signs that the risk of diabetes is high.

Insulin resistance improved significantly with diet and a bit more in the diet-plus-exercise group, but not with exercise alone, compared to women who made no changes. Exercise alone did improve fasting glucose, but only when it was elevated to begin with.

Women in the diet group lost an average of 8.5 percent of their initial body weight, while those who had diet plus exercise lost more than 10 percent. Improvement in insulin resistance was proportional to the amount of weight lost.

Jill Crandall, M.D., director of the Diabetes Clinical Trials Unit at the Albert Einstein College of Medicine, said she was “most impressed” by the magnitude of weight loss achieved in the study, “but the effect this will have on glucose metabolism or diabetes risk in the long run is a little hard to say from this paper.”

One of the most useful things the study did was to show that “a group-based program could be very effective for weight loss,” added Crandall, who has no affiliation with the study. From a public health perspective, she said, “anything done in the group setting is more feasible.”

She noted that strengthening exercise appears to have greater benefits for insulin resistance than aerobic exercise, and suggested that its inclusion in future studies might be “a desirable feature.”

By Carl Sherman, Health Behavior News Service

September 6, 2011

When Lapses Are Not Just Signs of Aging

By JANE E. BRODY

Who hasn’t struggled occasionally to come up with a desired word or the name of someone near and dear? I was still in my 40s when one day the first name of my stepmother of 30-odd years suddenly escaped me. I had to introduce her to a friend as “Mrs. Brody.”

But for millions of Americans with a neurological condition called mild cognitive impairment, lapses in word-finding and name recall are often common, along with other challenges like remembering appointments, difficulty paying bills or losing one’s train of thought in the middle of a conversation.

Though not as severe as full-blown Alzheimer’s disease or other forms of dementia, mild cognitive impairment is often a portent of these mind-robbing disorders. Dr. Barry Reisberg, professor of psychiatry at New York University School of Medicine, who in 1982 described the seven stages of Alzheimer’s disease, calls the milder disorder Stage 3, a condition of subtle deficits in cognitive function that nonetheless allow most people to live independently and participate in normal activities.

One of Dr. Reisberg’s patients is a typical example. In the two and a half years since her diagnosis of mild cognitive impairment at age 78, the woman learned to use the subway, piloted an airplane for the first time (with an instructor) and continued to enjoy vacations and family visits. But she also paid some of the same bills twice and spends hours shuffling papers.

Dr. Ronald C. Petersen, a neurologist at the Mayo Clinic College of Medicine in Rochester, Minn., described mild cognitive impairment as “an intermediate state of cognitive function,” somewhere between the changes seen normally as people age and the severe deficits associated with dementia.

While most people experience a gradual cognitive decline as they get older (only about one in 100 lives long without cognitive loss), others experience more extreme changes in cognitive function, the neurologist wrote in The New England Journal of Medicine in June. In population-based studies, mild cognitive impairment has been found in 10 percent to 20 percent of people older than 65, he noted.

Dr. Petersen described two “subtypes” of the condition, amnestic and nonamnestic, that have different trajectories. The more common amnestic type is associated with significant memory problems, and within 5 to 10 years usually — but not always — progresses to full-blown Alzheimer’s disease, he said in an interview.

“Subtle forgetfulness, such as misplacing objects and having difficulty recalling words, can plague persons as they age and probably represents normal aging,” he wrote. “The memory loss that occurs in persons with amnestic mild cognitive impairment is more prominent. Typically, they start to forget important information that they previously would have remembered easily, such as appointments, telephone conversations or recent events that would normally interest them,” like the outcome of a ballgame would a sports fan.

The forgetfulness is often obvious to those who are affected and to people close to them, but not to casual observers.

The less common nonamnestic type, which is associated with difficulty making decisions, finding the right words, multitasking, visual-spatial tasks and navigating, can be a forerunner of other kinds of dementia, Dr. Petersen said.

In general, Dr. Reisberg said, “mild cognitive impairment lasts about seven years before it begins to interfere with the activities of daily life.”

The Correct Diagnosis

Distinguishing mild cognitive impairment from the effects of normal aging can be challenging. Typically, new patients take a short test of mental status, provide a thorough medical history and are checked for conditions that may be reversible causes of impaired cognition. Problems like depression, medication side effects, vitamin B12 deficiency or an underactive thyroid can mimic the symptoms of mild cognitive impairment.

Other tests, like an M.R.I. or CT scan of the brain, can look for evidence of a stroke, brain tumor or leaky blood vessel that may be impairing brain function.

It is natural, Dr. Petersen said, for patients and their families to want to know whether and how quickly the disorder might progress. While patients decline by about 10 percent each year, on average, certain factors are associated with more rapid progression. Among these are the presence of a gene called APOE e4, more common among patients with Alzheimer’s disease; a reduced hippocampus, a region of the brain important to memory; and a low metabolic rate in the temporal and parietal regions of the brain.

Amyloid plaques in the brain, while a hallmark of Alzheimer’s disease and a predictor of progression, have also been found at autopsy in people with perfectly normal cognitive function.

Preserving Cognitive Function

Despite a number of clinical trials that tested various medications, no drug to treat mild cognitive impairment has been approved by the Food and Drug Administration. But experts like Dr. Reisberg and Dr. Petersen suggest several approaches that may slow the decline in cognitive function.

Although studies did not show that medications like donepezil (brand name Aricept) and memantine (Namenda), both used to treat Alzheimer’s disease, change the ultimate course of mild cognitive impairment, Dr. Reisberg said they can be useful temporary treatments that may stabilize patients for a few years.

Although the drugs are not approved for this condition, licensed physicians can prescribe approved medications “off label.” “Clinicians have to work with what we have,” Dr. Reisberg said.

There are people who think they are having memory problems, but tests do not show anything definitive. Some may be in Stage 1 of Alzheimer’s disease, Dr. Reisberg said, and perhaps could benefit from early treatment with the drugs.

It is also important to reduce cardiovascular risk factors like smoking, elevated cholesterol and high blood pressure; keep blood sugar at normal levels; minimize stress (which in animal studies can cause the hippocampus to shrink); and avoid anticholinergic drugs that can interfere with brain chemicals important to memory. These include Demerol to treat pain, Detrol to treat a leaky bladder, tricyclic antidepressants, Valium, and over-the-counter medications with Benadryl (diphenhydramine), like Tylenol PM, Dr. Petersen said.

Some cognitive rehabilitation exercises, like computer games that enhance focus, may be helpful, Dr. Petersen said, but there have been few good studies to demonstrate a benefit. Compensatory techniques, like taking notes, creating mnemonics and making structured schedules, can be useful aids, he added.

But most promising is regular physical exercise, which in animal studies was found to reduce the accumulation of amyloid in the brain. An Australian study in patients with memory problems showed that brisk walking for 150 minutes a week improved cognitive function.

July 27, 2011

South Carolina: Grasping for Any Way to Prevent Alzheimer’s

Is there a way to prevent Alzheimer’s disease? Last week, a study presented at the Alzheimer’s Association International Conference in Paris suggested there might be, something that would give hope to millions who worry that one day they may be struggling with dementia.

The new study, by researchers at the University of California, San Francisco, estimated how many Alzheimer’s cases might be attributable to certain behaviors or conditions: physical inactivity, smoking, depression, low education, hypertension, obesity and diabetes.

The authors used a mathematical model to surmise that these behaviors and conditions, all of which can be modified, are responsible for about half of the roughly 5.3 million Alzheimer’s cases in the United States and 34 million cases worldwide.

And they calculated that if people addressed these risks — by exercising, quitting smoking, increasing their education or losing weight, for example — a significant number of Alzheimer’s cases could be prevented. Reducing the prevalence of these risk factors by 10 percent, the researchers estimated, could prevent 1.1 million cases worldwide; reducing these risk factors by 25 percent could prevent more than three million cases.

The operative word was “could.” As the researchers pointed out, there is not yet scientific proof that any of these risk factors in fact cause Alzheimer’s. Only if they are shown to do so could the new analysis be considered a practical recipe for preventing the disease.

“These things are not definitive,” said one author, Dr. Kristine Yaffe, a professor of psychiatry, neurology and epidemiology. “We’re assuming that these are sort of causally related to the risk of dementia and Alzheimer’s, but unless you have a great trial, you just don’t know.”

But while experts may have understood that distinction, not everyone else did. Some headlines made things sound more certain: “7 Things You Can Do to Fight Alzheimer’s” or “7 Steps to Prevent Alzheimer’s.”

In an editorial accompanying the study, both published in the journal Lancet Neurology, Dr. Laura Fratiglioni, director of the Aging Research Center at the Karolinska Institute in Sweden, suggested that the report was valuable, but said that the estimates “could be regarded as only theoretical” until more rigorous research is done.

“We have been able to identify some possible preventive factors,” Dr. Fratiglioni said, “but we do not have the final answer because we do not have the experimental studies.”

Indeed, research on prevention of Alzheimer’s is in its infancy. It has only been since the 1980s that dementia has not been considered a symptom of normal aging. And studies on preventing Alzheimer’s can be complicated and costly, especially the randomized controlled trials that provide the strongest evidence. Such trials have to follow people for years, and isolating individual risk factors — separating obesity from hypertension, diabetes, nutrition and physical inactivity, for instance — is challenging.

Last year, a National Institutes of Health panel of experts with no vested interest in Alzheimer’s research concluded that “no evidence of even moderate scientific quality exists to support the association of any modifiable factor (such as nutritional supplements, herbal preparations, dietary factors, prescription or nonprescription drugs, social or economic factors, medical conditions, toxins or environmental exposures) with reduced risk of Alzheimer’s disease.”

Most research, the panel found, involved observational studies, showing that people who did or did not get Alzheimer’s had certain characteristics beforehand, but not whether the characteristics were causal.

The panel found the strongest evidence for only one conclusion: that the herb gingko biloba does not prevent Alzheimer’s. There was moderate evidence that neither vitamin E nor drugs called cholinesterase inhibitors, used to treat dementia symptoms, decrease risk of Alzheimer’s. And there was moderate evidence that the gene ApoE4 significantly increases Alzheimer’s risk, as does menopause therapy with estrogens and progestins.

Evidence for or against any other causal factor was poor, often because studies were small, used vague or changing definitions, or did not rigorously monitor what subjects were doing.

“We debated for hours and hours and hours how to write the report, because certainly we didn’t want it to be the carrier of bad news,” said Dr. Martha Daviglus, the panel’s chairwoman and a preventive medicine expert at Northwestern University. But “we wanted the public to realize that at this point nothing that people can sell to them is proven to work.”

Many members of the Alzheimer’s community were stung, considering the panel’s conclusions a “glass half empty,” said William Thies, the Alzheimer’s Association’s chief medical and scientific officer. “We would agree that we haven’t proven any of these risk factors, but there’s data that are pretty good for some of them. And in a world where we have lots of Alzheimer’s disease and no definitive medical intervention, prevention strategies that are based on lifestyle changes are certainly attractive.”

Dr. Yaffe and her colleague Deborah Barnes excluded risk factors like nutrition or brain exercise because they believed research was not solid enough. They used a more elastic threshold to evaluate research than the N.I.H. panel because, Dr. Yaffe said, the panel “didn’t quite do the field justice.”

Their model weighed the strength of existing research and how widespread the risk factors were. In the United States, they estimated that 1.1 million Alzheimer’s cases, or 21 percent, may be linked to physical inactivity. Fifteen percent may owe to depression, 11 percent to smoking, 8 percent to midlife hypertension, 7 percent to obesity, 7 percent to low education and 3 percent to diabetes.

Their estimates for the risk factors worldwide differed because some behaviors and conditions are more common than in the United States. So low education accounted for 19 percent, or 6.5 million cases, worldwide, while physical inactivity accounted for 13 percent and obesity 2 percent.

Dr. John W. Williams Jr., a professor of medicine at Duke University who led an analysis of Alzheimer’s prevention research for the N.I.H. panel, said studies like Dr. Yaffe’s can be informative “when we don’t have other evidence” and can help shapers of public policy “make decisions about where to invest to reduce risk.”

But he said: “What should individuals do with it? Probably not much.”

Among the limitations, he said, was that some risk factors, like physical inactivity and obesity, “are darn hard to change.”

And does a risk factor like depression cause Alzheimer’s — or is it the other way around?

Still, everyone agrees these risks merit attention for other reasons: preventing cancer or heart disease, improving overall health.

“It’s good if you can do it, but not in the name of Alzheimer’s,” Dr. Daviglus said. “But maybe we will find out that by doing this for other diseases, we are also doing it for Alzheimer’s.”

By PAM BELLUCK

July 12, 2011

New Jersey Senior Health: When ‘Take as Directed’ Poses a Challenge

If the label on one bottle of prescription drugs says, “Take one tablet twice daily,” and the label on another says, “Take one tablet every 12 hours,” would you realize that you could take both medications at the same time?

What if one bottle says, “Take with food and water,” but the second doesn’t?

Given that the average adult over age 55 juggles six to eight medications daily, the ability to consolidate pill-popping is no minor matter. “I’m more likely to be able to sustain a medication regimen if I only have to take it three or four times a day,” said Michael Wolf, an associate professor of medicine at Northwestern University who studies drug safety. “Seven or eight times a day is complicated to fit into your daily schedule.”

His sister, who has lupus, sometimes takes up to 16 different drugs, he noted. “Why can’t we standardize prescriptions?’

Why indeed? The idea has been kicked around for years. Nearly three years ago, the Institute of Medicine proposed that pharmaceutical manufacturers adopt a universal dosing schedule that would make it possible for people to take medications at just four times of day: morning, noon, evening and bedtime.

Virtually all drugs could be formulated to fit into this framework, Dr. Wolf said: “It’s ridiculously simple, an incredibly basic idea.”

As it stands now, however, patients must fight their way through a thicket of often conflicting instructions when taking more than one drug. Many studies suggest that most of them don’t do it very well, even when relatively few medications are involved.

Recently Dr. Wolf and his team interviewed 464 adults ages 55 to 74 who were patients at several Chicago medical practices and clinics. The researchers presented each patient with seven typical amber pill bottles with dosing instructions on the labels and a slotted tray marked with times of day. “Show us how you’d take these medications over 24 hours,” the interviewers instructed the patients.

“There was no reason to take these medications more than four times a day,” Dr. Wolf said. In fact, he pointed out, 90 percent of all prescription medications can be taken no more than four times a day.

Yet the patients struggled to consolidate their doses in the experimental tray. About a third didn’t think to take two of the drugs together, even though the instructions on their labels were identical. When one drug was supposed to be taken with food and water and another carried no such instructions, half the study participants didn’t plan to take them at the same time, though they could have.

Two-thirds of the subjects wouldn’t take pills together if one label specified “twice daily” and the other said “every 12 hours,” though those phrases mean the same thing.

“Less than 15 percent succeeded in dosing in the most efficient way,” Dr. Wolf said. Instead, the participants indicated they’d take pills an average of six times a day, with some setting up as many as 14 doses a day.

The more cumbersome and harder to remember a medication schedule becomes, the greater the likelihood that people will misunderstand instructions, skip doses or abandon their drug regimen altogether. “This could be a major risk factor for adherence,” Dr. Wolf said.

The need for more simplified dosing instructions has been demonstrated in several such studies, but change has been slow to come, partly because pharmacists in each state are regulated by a different board of pharmacy. But a bill requiring a universal medication schedule has been introduced in New York State, and a similar measure has already become law in California.

For now, Dr. Wolf advises patients to regularly review the medications they take with a physician and to ask for help in simplifying the dosing. His suggested script: “Help me reduce the number of times I have to take these medications, so that over months and years, it doesn’t become a drag.”

By Paula Span, New York Times

July 5, 2011

South Carolina Senior health: How to detect and prevent malnutrition

Malnutrition is a serious senior health issue. Know the warning signs and how to help an older loved one avoid poor nutrition.

By Mayo Clinic staff

Good nutrition is critical to senior health — yet many older adults are at risk of inadequate nutrition. Know the causes and signs of nutrition problems in older adults, as well as steps you can take to ensure a nutrient-rich diet for an older loved one.

Problems caused by malnutrition

Malnutrition in older adults can lead to various health problems, including:

  • Fatigue
  • Depression
  • Weak immune system, which increases the risk of infections
  • Low red blood cell count (anemia)
  • Muscle weakness, which can lead to falls and fractures
  • Digestive, lung and heart problems
  • Poor skin integrity

Good nutrition is especially important for older adults who are seriously ill and those who have dementia or have lost weight. These older adults are more likely to be admitted to a hospital or long term care facility and are vulnerable to post-surgical complications and other problems linked to poor nutrition.

How malnutrition begins

The causes of malnutrition may seem straightforward: too little food, a diet lacking in nutrients, digestion problems related to getting older. But malnutrition is often caused by a combination of physical, social and psychological issues. For example:

  • Health problems. Older adults often have health problems that can lead to decreased appetite or trouble eating, such as chronic illness, use of certain medications, trouble chewing due to dental issues, problems swallowing or difficulty absorbing nutrients. A recent hospitalization may be accompanied by loss of appetite or other nutrition problems. In other cases, a diminished sense of taste and smell decreases appetite.
  • Limited income and reduced social contact. Some older adults may have trouble affording groceries, especially if they’re taking expensive medications. Those who eat alone may not enjoy meals, causing them to lose interest in cooking and eating.
  • Depression. Grief, loneliness, failing health, lack of mobility and other factors may contribute to depression — causing loss of appetite among older adults.
  • Alcoholism. Alcoholism is a leading contributor to malnutrition — decreasing appetite and vital nutrients and frequently serving as a substitute for meals.
  • Restricted diets. Older adults often have dietary restrictions, including limits on salt, fat, protein and sugar. Although such diets can help manage many medical conditions, they can also be bland and unappealing.

How to spot malnutrition

The signs of malnutrition in older adults may be hard to spot, especially in people who don’t seem at risk. To uncover problems before they become more serious:

  • Observe your loved one’s eating habits. Spend time with an older loved one during meals at home, not just on special occasions. If your loved one lives alone, find out who buys his or her food. If your loved one is in a hospital or long term care facility, visit during mealtimes.
  • Look for physical problems. Red flags for malnutrition might include poor wound healing, easy bruising, dental difficulties and weight loss. Watch for signs of weight loss, such as changes in how clothing fits.
  • Know your loved one’s medications. Many drugs affect appetite, digestion and nutrient absorption.

What you can do about malnutrition

Even small dietary changes can make a big difference in an older person’s health and well-being. For example:

  • Encourage your loved one to eat foods packed with nutrients. Spread peanut or other nut butters on toast and crackers, fresh fruits and raw vegetables. Sprinkle finely chopped nuts or wheat germ on yogurt, fruit and cereal. Add extra egg whites to scrambled eggs and omelets. Add cheese to sandwiches, vegetables, soups, rice and noodles.
  • Restore life to bland food. Make a restricted diet more appealing by using lemon juice, herbs and spices. If loss of taste and smell is a problem, experiment with seasonings and recipes. A dietitian also can help.
  • Plan between-meal snacks. This can be helpful for older adults who get full quickly. A piece of fruit or cheese, a spoonful of peanut butter and even a milkshake can provide nutrients and calories.
  • Make meals social events. Drop by during mealtime or invite your loved one to your home for occasional meals. Encourage your loved one to join programs where he or she can eat with others.
  • Encourage regular physical activity. Daily exercise — even if it’s light — can stimulate appetite and strengthen bones and muscles.
  • Provide food savings tips. If your loved one shops for groceries, encourage him or her to take a shopping list to the grocery store, check store fliers for sales and choose less expensive generic brands. Suggest splitting the cost of bulk goods or meals with a friend or neighbor, or frequenting restaurants that offer senior discounts.
  • Engage doctors. Talk to your loved one’s doctors about changing medications that affect appetite or the need for a restricted diet. Request screenings for nutrition problems during routine office visits. Ask about nutritional supplements, including drinks and pudding. Inform doctors if you notice weight loss or suspect depression. Consult a dentist about oral pain or chewing problems.
  • Consider outside help. If necessary, hire a home health aide to shop for groceries or prepare meals. Also consider Meals On Wheels and other community services, including home visits from registered dietitians.

Remember, identifying and treating nutrition problems early can promote good health, independence and increased longevity. Take steps now to ensure your loved one’s nutrition.

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