[Report] Report Will Aid in Detecting, Diagnosing Cognitive Impairment

From the 5 February 2015 post at The Gerontological Society of America

 

For Immediate Release February 6, 2015

Contact: Todd Kluss tkluss@geron.org (202) 587-2839

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

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

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

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

The report is available at www.geron.org/ci. The website also contains a link to a companion webinar held in January, led by workgroup members Katie Maslow, MSW, and Shari M. Ling, MD.

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

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

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

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

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

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

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

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The Gerontological Society of America (GSA), the nation’s oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society, and an educational branch, theAssociation for Gerontology in Higher Education.

 

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[Press release] Are medications’ adverse cognitive effects reversible?

Are medications’ adverse cognitive effects reversible?

View image | gettyimages.com

From the 26 January 2015 University of Indiana press release

INDIANAPOLIS — Whether the adverse cognitive effects of medications can be reversed is of significant importance to an aging population, their caregivers and their families, as well as to an overburdened health care system.

In a commentary in JAMA Internal Medicine, Noll Campbell, Pharm.D., and Malaz Boustani, M.D., MPH, of the Regenstrief Institute and the Indiana University Center for Aging Research, probe the possibility of reversing the adverse cognitive effects of medications frequently prescribed to older adults for chronic conditions including depression, anxiety and incontinence and sold over the counter as allergy and sleep aids.

It is not unusual for older adults to take two, three or more drugs that have a negative impact on their brain function. Over the past decade, Drs. Boustani and Campbell and colleagues have conducted several studies that have found associations between exposure to anticholinergic medications, which block acetylcholine, a nervous system neurotransmitter, and the clinical diagnosis of mild cognitive impairment or dementia. Low levels of acetylcholine have long been implicated in patients with dementia.

In a 2013 study, they reported that drugs with strong anticholinergic effects were associated with a clinical diagnosis of cognitive impairment when taken continuously for as few as 60 days over a one-year period. A similar impact was seen with 90 days of continuous use over a year when taking multiple drugs with weak anticholinergic effect.

In “Adverse Cognitive Effects of Medications: Turning Attention to Reversibility” published in the Jan. 26, 2015, issue of JAMA Internal Medicine, Drs. Campbell and Boustani call for further research to determine whether cognitive impairment caused by the adverse effects of medications can be reversed and to establish the safety risks of discontinuing these medications.

Their commentary accompanies a 10-year observational study by Shelly Gray, Pharm.D., M.S., of the University of Washington and colleagues that reports a higher risk of dementia with increasing dose and duration of exposure to medications with strong anticholinergic activities.

“While the Gray study suggests that adverse cognitive effects of medications were permanent, this may represent the use of dementia as the outcome — a non-reversible condition — rather than a diagnosis of mild cognitive impairment which may be reversible in some older adults. Our previous studies have shown a stronger association of these harmful medications with the diagnosis of mild cognitive impairment than with dementia,” Dr. Campbell said.

“We also differed in populations studied. The Gray study was 91 percent Caucasian, and 66 percent were college educated. Fewer than half had hypertension, and only 8 percent were diabetic. Our study subjects were 60 percent African-American, and nearly all subjects were treated for hypertension, and 3 in 10 had a history of stroke. Higher rates of comorbid disease may explain some of the differences between these studies.”

According to the Alzheimer’s Association, 5 million people with dementia lived in the United States in 2013, accounting for an estimated $214 billion in care costs. With the growth of the aging population, the association estimates that the number of older adults with dementia will be approximately 16 million by 2050, with $1.2 trillion expected in costs of care.

“While the scientific community is actively engaged in the quest, no drugs currently exist to prevent Alzheimer’s disease and other dementing disorders. However, our IU and Regenstrief Institute group has focused on stopping cognitively harmful medications as a safe and cost-effective Alzheimer’s disease prevention,” said Dr. Boustani, who directs the Eskenazi Health Center Healthy Aging Brain Center.

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[Reblog] Clearing the air on a WHO study

From the 17 July 2014 Association of Health Care Journalists post

Last week, I encountered yet another example of why it’s so important to always read the whole study — not just the press release. In this case, it was actually a report, not a study. A press release from Alzheimer’s International with the somewhat misleading headline, “Smoking Increases Risk Of Dementia” arrived in my inbox, citing a new World Health Organization report that put smokers at a 45% higher risk for developing the disease than non-smokers.

…

 

It’s a good reminder that regardless of the reputation of the organization or institution issuing a report, study or press release, read the source information yourself. You never know what you may find.

WHO (Photo credit: Wikipedia)

 

[Reblog of an Alzheimer item] The 36-Hour Day Podcast: Getting Help

 

Write text here…

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Johns Hopkins University Press Blog

Today is the fifth and final in a series of brief podcast excerpts from The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Disease, Related Dementias, and Memory Loss. This bestselling title by Nancy L. Mace, M.A., and Peter V. Rabins, M.D., M.P.H., is in its fifth edition and is now available in an audio edition.

Podcast #5: Excerpt from Chapter 10: Getting Help

In this excerpt from Chapter 10, Dr. Rabins focuses on the need for caregivers to have outside help and have time away from the responsibilities of caregiving. He describes how to find good information on available services, how to seek and accept help from friends and neighbors,  and how to address problems you may encounter.

You can find this podcast and the rest of the series of podcasts here.

These podcasts are excerpted from a Johns Hopkins University Press audio…

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[Repost] Long Term Care — Five Things Physicians and Patients Should Question

I am especially grateful for #4.

From the ABIM fact sheet

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New Yorker Article on New Models of Long-term Elder Care

Your local library might subscribe to this. Call ahead and ask for a reference librarian!

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As Our Parents Age So Do We

If you can locate a copy of The New Yorker May 20, 2013 article The Sense of An Ending by Rebecca Mead, it’s well worth reading because of its focus on new models of providing care to fragile elders with dementia illnesses in nursing homes. The article extensively describes the Beatitudes Campus in Arizona, but it also mentions The Green House Projectand the Pioneer Network. The Beatitudes model and The Green House Project  share many approaches.

So I was excited during dinner with friends last month when one of the people at the table, a neurologist, mentioned The New Yorker article, saying how excited he was to learn about new models that completely change the way we deliver care  to fragile elders, especially those with memory impairments. After he spoke at length about the article — which I had not read yet — I shared information and my…

View original post 147 more words

Nursing homes are seeking to end the stupor

[Editor Flahiff’s note: I remember visiting my great aunt in a nursing home in the early 70’s (I was in my late teens) I found the stupor among the residents very sad…this story was very refreshing to read…

My husband can attest to the importance of personal attention…he is retired and goes to senior centers daily for lunch and the “pool halls”. He makes it a point to visit with those sitting alone at lunch…and has brought a number of folks out their shells during the past few years]

Instead of treating behavioral problems with antipsychotic drugs, the Ecumen chain of 15 homes is using strategies including aromatherapy, massage, music, games, exercise and good talk. The state is helping out.

From the December 4th Star Tribune article by Warren Wolfe (via a NetGold Posting by David P Dillard )

The aged woman had stopped biting aides and hitting other residents. That was the good news.

But in the North Shore nursing home‘s efforts to achieve peace, she and many other residents were drugged into a stupor — sleepy, lethargic, with little interest in food, activities and other people.

“You see that in just about any nursing home,” said Eva Lanigan, a nurse and resident care coordinator at Sunrise Home in Two Harbors, Minn. “But what kind of quality of life is that?”

Working with a psychiatrist and a pharmacist, Lanigan started a project last year to find other ways to ease the yelling, moaning, crying, spitting, biting and other disruptive behavior that sometimes accompany dementia.

They wanted to replace drugs with aromatherapy, massage, games, exercise, personal attention, better pain control and other techniques. The entire staff was trained and encouraged to interact with residents with dementia.

Within six months, they eliminated antipsychotic drugs and cut the use of antidepressants by half. The result, Lanigan said: “The chaos level is down, but the noise is up — the noise of people laughing, talking, much more engaged with life. It’s amazing.”…

….Medicare spends more than $5 billion a year on those [antipsychotic] drugs for its beneficiaries, including about 30 percent of nursing home residents. Several studies have concluded that more than half are prescribed inappropriately. The drugs are especially hazardous to older people, raising the risk of strokes, pneumonia, confusion, falls, diabetes and hospitalization….

….

Instead of looking for causes of disruptive behavior among dementia patients, doctors typically prescribe drugs to mask the symptoms, he said, because “It’s the easy thing to do. … That’s true in hospitals, in clinics and in nursing homes.”

Federal regulators are cracking down on homes that don’t routinely reassess residents on psychotropic drugs. But use remains widespread….

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Working With Pesticides May Affect Memory and More

From a December 2, 2010 Health Day news item by Robert Preidt

WEDNESDAY, Dec. 1 (HealthDay News) — Being exposed to pesticides over a long period of time might be linked to dementia, a new study of agricultural workers suggests.

The research effort included 614 vineyard workers in France who were in their 40s and 50s and had worked for at least 20 years in the agricultural sector. Their intellectual abilities were assessed twice, using nine tests designed to measure memory and recall, language retrieval, verbal skills and reaction time.

The workers’ exposure to pesticides during the six-year span of the study varied. About 20 percent were never exposed to pesticides and more than half had been directly exposed, which included mixing or applying pesticides and cleaning or repairing spraying equipment. The rest had either been indirectly exposed by coming into contact with treated plants or possibly indirectly exposed through their work in buildings, offices, cellars and the like.

On seven of the nine tests, workers who had been exposed to pesticides were most likely to do worse the second time they were tested, the researchers found. The study also reported that pesticide-exposed workers were up to five times more likely than the others to have lower test scores on both occasions and were twice as likely to show a drop of two points in the Mini Mental State Examination (MMSE), which tests cognitive functioning and is frequently used to determine if a person has dementia.

The decline in MMSE score “is particularly striking in view of the short duration of follow-up and the relatively young age of the participants,” Isabelle Baldi, of the Institute de Sante Publique d’Epidemiologie et de Developpement in Bordeaux, France, and colleagues wrote in the report published in the Dec. 2 online edition of Occupational and Environmental Medicine.

“The mild [cognitive] impairment we observed raises the question of the potentially higher risks of injury in this population and also of possible evolution towards neurodegenerative diseases such as Alzheimer’s disease or other dementias,” the study authors added.

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New insight into the cause of common dementia found by researchers at Mayo Clinic

From a November 17, 2010 Eureka news alert

Contact: Kevin Punsky
punsky.kevin@mayo.edu
904-953-2299
Mayo Clinic

New insight into the cause of common dementia found by researchers at Mayo Clinic

JACKSONVILLE, Fla. — Researchers at the Mayo Clinic campus in Florida have found a clue as to how some people develop a form of dementia that affects the brain areas associated with personality, behavior, and language.

In the Nov. 17 online issue of the American Journal of Human Genetics, the scientists write that they discovered a link between two proteins — progranulin and sortilin — they say might open new avenues for the treatment of frontotemporal lobar degeneration (FTLD), which occurs in the frontal lobe and temporal lobe of the brain. This form of dementia, which is currently untreatable, generally occurs in younger people, compared to other common neurodegenerative disorders such as Alzheimer’s disease.

“We now can look for a direct link between these two proteins and the development of FTLD,” says the study’s lead author, neuroscientist Rosa Rademakers, Ph.D. “The hope is that if we do find a strong association, it might be possible to manipulate levels of one or both of these proteins therapeutically.”

Coincidentally, a research group from Yale University led by Stephen Strittmatter, M.D., Ph.D., has also pinpointed sortilin’s association with progranulin — thus confirming Mayo’s results. Their study is being published in Neuron, also on Nov. 17.

FTLD is a family of brain diseases that are believed to share some common molecular features. One is the presence of mutations in the gene that produces tau protein in neurons. The other is mutations in the progranulin gene that Mayo Clinic researchers and their colleagues discovered in 2006. They found that 5 to 10 percent of patients with FTLD have a mutation in this gene, and that these mutations lead to a substantial loss of normal progranulin protein production, and development of FTLD.

The protein made by the progranulin gene is found throughout the body, and performs different functions according to the type of tissue (organ) it is located in. But in the brain, it is believed to support neurons and keep them healthy.

Still, researchers do not really know how normal progranulin protein functions in the brain — what other proteins it interacts with — and so in this study they sought to uncover clues about progranulin biology by conducting a genome-wide association study (GWAS).

Based on their previous findings that a simple blood test is able to measure progranulin levels in plasma and could be used to identify patients with progranulin mutations, they tested blood from 518 healthy individuals in a GWAS to look for genetic variants that could explain some of the normal variability of progranulin levels in plasma. They found very strong association with two genetic variants in the same region of chromosome 1 and confirmed this finding in a second group of 495 healthy individuals.

By reviewing the scientific literature, they further ascertained that the same genetic variant found to be associated with plasma progranulin levels also affects the levels of the protein sortilin. Like progranulin, sortilin is found throughout the body and is involved in different tasks. In the brain, it is known to be important for survival of brain neurons.

“So, using a genetic approach, we identified a previously unknown connection between sortilin and progranulin,” Dr. Rademakers says.

The researchers then studied the two proteins in cell culture and showed that the amount of sortilin in cells determines how much progranulin is taken inside or remains outside of a cell. “Our study shows that changes in the levels of sortilin result in different levels of progranulin available to cells. Given that we found FTLD patients often have less progranulin than they should, we believe that if you can manipulate levels of progranulin and/or sortilin in the brain, you might have a way to treat this disorder,” says Dr. Rademakers.

“Our study and the study led by the Yale researchers describe completely independent and unbiased screens which both identified this protein sortilin as being important in the regulation of progranulin,” Dr. Rademakers says. “This obviously opens new avenues for treatment for patients with progranulin mutations and perhaps dementia patients in general.”

 

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Researchers from the National Institutes of Health, University College London, the University of British Columbia, and Mayo Clinic in Minnesota also participated in this study.

The study was funded by the National Institutes of Health and the Consortium for Frontotemporal Dementia Research. The authors declare no conflicts of interest.

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About Mayo Clinic Mayo Clinic is a non-profit worldwide leader in medical care, research and education for people from all walks of life. For more information, visit www.mayoclinic.org/aboutand www.mayoclinic.org/news.

 

 

Walking 6 to 9 Miles a Week May Help Save Memory

From a Health Day news item

WEDNESDAY, Oct. 13 (HealthDay News) — Walking about six miles a week appears to protect against brain shrinkage in old age, which in turn helps stem the onset of memory problems and cognitive decline, new research reveals.

“We have always been in search of the drug or the magic pill to help treat brain disorders,” noted Kirk I. Erickson, an assistant professor of psychology at the University of Pittsburgh and the study’s lead author. “But really what we are after may be, at least partially, even simpler than that. Just by walking regularly, and so maintaining a little bit of moderate physical activity, you can reduce your likelihood of developing Alzheimer’s disease and [can] spare brain tissue.”

A report on the research, which was supported by the U.S. National Institute on Aging, is published online Oct. 13 in Neurology.

[Not yet available online (as of Oct 13, 2010)…if it is only available by paid subscription, check with your local public, academic, or medical library. Ask for a reference librarian. If it is only available from a library where you do not have borrowing privileges, there may be a charge for a copy. Again, ask a reference librarian for details.]

Could Lifestyle Cut Dementia Rates?

Eliminating depression and diabetes, consuming more fruit and vegetables could reduce new dementiacases by 21 percent, researchers say.

“The exact cause of dementia hasn’t been pinpointed, but several modifiable risk factors have been identified, including a history of depression, type of diet, level of alcohol consumption, education level and vascular risk factors (heart disease, stroke, high blood pressure, obesity, diabetes and high cholesterol).”