Multiple Lifestyle Interventions May Help Those at Risk for Alzheimer’s

afternoon stroll-cRobert wallace

image: Robert Wallce, Flickr Creative Commons

Physical activity, nutritional guidance, cognitive training, social activities and management of heart health risk factors improved cognitive performance, according to Finnish researchers.

Data from a two year clinical trial in Finland of a multi-component lifestyle intervention, known as the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) Study showed both overall and in separate measures of executive function, such as planning abilities, and the relationship between cognitive functions and physical movement. The  two-year randomized controlled trial of 1,260 participants age 60 to 77 with modifiable risk factors for cognitive impairment and Alzheimer’s. Results were presented at the Alzheimer’s Association International Conference in Copenhagen this past week.

Participants were divided into two groups; one received an intervention that included nutritional guidance, physical exercise, cognitive training, social activities, and management of heart health risk factors, while the control group received regular health advice. After two years, the intervention group performed significantly better on a comprehensive cognitive examination. In addition to performing better overall, the intervention group did significantly better on specific tests of memory, executive function (complex aspects of thought such as planning, judgment, and problem-solving), and speed of cognitive processing.

“This is the first randomized control trial showing that it is possible to prevent cognitive decline using a multi-domain intervention among older at-risk individuals. These results highlight the value of addressing multiple risk factors in improving performance in several cognitive domains,” said lead researcher Miia Kivipelto, M.D., Ph.D., Professor at the Karolinska Institutet, Sweden and the National Institute for Health and Welfare, Helsinki, Finland,  “Participants told us their experience was very positive, and dropout rate only 11 percent after two years.”

“This new data is very encouraging, and we look forward to further studies to confirm and extend these findings,” said Keith Fargo, Ph.D., Alzheimer’s Association director of Scientific Programs & Outreach.

The researchers say an extended, seven-year follow up study is planned, and will include measures of dementia/Alzheimer’s incidence and biomarkers including brain imaging with MRI and PET.

Drug Risks Outweigh Benefits for Some Type 2 Diabetes Patients

670px-Cure-Dry-Mouth-Step-1For patients with type 2 diabetes – especially those over age 50 – the negative impact of side effects like weight gain and burdens like frequent insulin shots trumps the benefits of drugs, says a new study by the University of Michigan Health System, the VA Ann Arbor Healthcare System, and University College London.

The findings, which appear in today’s Journal of the American Medical Association Internal Medicine, show that for many, the benefits of taking diabetes medications are so small that they are outweighed by the minor hassles and risks.

These findings suggest that, contrary to current guidelines for type 2 diabetes that recommend intensifying treatment until a person’s blood sugar level reaches a certain goal, the overall benefit of taking a new medicine depends less on blood sugar and more on the hassles, safety and side effects of taking the treatment.

“For people with type 2 diabetes, the goal of managing blood sugar levels is to prevent associated diabetes complications, such as kidney, eye and heart disease, but it is essential to balance complication risks and treatment burdens when deciding how aggressively to treat blood sugars,” says lead author Sandeep Vijan M.D., M.S., professor of Internal Medicine at the U-M Medical School and research scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System.

“If you’re a patient with fairly low complication risks, but are experiencing symptoms from low blood sugar, gaining weight or find frequent insulin shots to be disruptive to your daily life, then the drugs are doing more harm than good. Prescribing medicine isn’t just about reducing risks of complications, but also about helping patients improve their quality of life.”

Vijan notes that for many patients, once moderate levels of glucose control are achieved, there is little additional benefit to intensive blood sugar treatment, but treatment costs, burdens and risks increase substantially. The study finds that the benefits of treatment decline with age and by age 75 the harms of most treatments are likely to outweigh any benefits.

The findings exclude the 15-20 percent of people with type 2 diabetes who have very high blood glucose levels (which are defined by what’s called an A1c test ) and need more aggressive treatment to manage the disease.

Individualized treatment recommendations determined by patients’ estimated risk of diabetes complications – influenced by their age and degree of blood glucose elevation – and considering the side effects and amount of safety data of the medication being considered, is a much better approach than focusing solely on glucose goals, the researchers argue.

“Drugs that lower blood sugar levels are extremely beneficial in some patients but offer almost no benefit for others. These results have major implications for the millions of people who are currently being told that they need to increase medication in order to achieve their ‘glucose goal,’” says senior author Rodney Hayward, M.D., professor of medicine in the U-M Medical School and senior research scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System.

“Current quality measures do not allow doctors and patients to make good decisions for each patient because they emphasize reaching targets instead of thinking of the risks and benefits of starting new medications based on individual circumstances and preferences.”

The study is the latest to challenge “treat-to-target” guidelines in medicine. Research concluding that risks outweighed benefits of drugs intended to achieve specific blood pressure goals in some patients prompted a significant change in hypertension guidelines last year and similar recommendations were implemented for lipid-lowering therapy.

International Federation for Diabetes guidelines for treating older people says the emphasis should be on managing complexity and quality of life issues – especially for frail elderly and those with dementia. “There is a need to individualize the medication
regimen to balance the imperative to control disease states with
the imperative to avoid/minimize medicine related adverse events.
Medicines are associated with significant risks in older people such
as falls, confusion and other cognitive changes, and admission to
hospital or emergency departments could be avoided if medicines are
managed optimally.”

Both Vijan and Hayward are members of the Institute for Healthcare Policy and Innovation.

Most Breast Cancer Patients May Not Be Getting Enough Exercise

Running_womanA new study in the journal CANCER, a peer-reviewed journal of the American Cancer Society, finds that most participants in a large breast cancer study did not meet national physical activity guidelines after diagnosis. African-American women were less likely to meet the guidelines than white women.

Physical activity after breast cancer diagnosis has been linked with prolonged survival and improved quality of life, and the findings indicate that efforts to promote physical activity in breast cancer patients may need to be significantly enhanced.

The US Department of Health and Human Services, as well as the American Cancer Society, recommends that adults engage in at least 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity (or an equivalent combination thereof) each week for general health benefits and for chronic disease prevention and management.

Brionna Hair, a doctoral candidate in epidemiology at the University of North Carolina at Chapel Hill, and her colleagues examined levels of and changes in physical activity following breast cancer diagnosis, overall and by race, in a population-based study of breast cancer patients. The study assessed pre- and post-diagnosis physical activity levels in 1,735 women aged 20 to 74 years who were diagnosed with invasive breast cancer between 2008 and 2011 in 44 counties of North Carolina.

The researchers found that only 35 percent of breast cancer survivors met current physical activity guidelines post-diagnosis. A decrease in activity approximately six months after diagnosis was reported by 59 percent of patients, with the average participant reducing activity by 15 metabolic equivalent hours—equivalent to about five hours per week of brisk walking.

When compared with white women, African-American women were about 40 percent less likely to meet national physical activity guidelines post-diagnosis, although their reported weekly post-diagnosis physical activity was not significantly different from that of White women (12 vs 14 metabolic equivalent hours). Ms. Hair noted that it’s important to realize that African-American women experience higher mortality from breast cancer than other groups in the United States.

“Medical care providers should discuss the role physical activity plays in improving breast cancer outcomes with their patients, and strategies that may be successful in increasing physical activity among breast cancer patients need to be comprehensively evaluated and implemented,” she said.

 

Providers hesitant to discuss end-of-life care with some patients

senior doc checkupWho should discuss end of life care with patients, and when?

Providers are unsure when to approach this issue and whether it’s the role of the primary provider or the heart specialist, according to a study presented at the American Heart Association Healthcare Quality of Care and Outcomes Research 2014 Scientific Sessions. Researchers found reluctance on the part of clinicians to have this conversation with heart failure patients and their families because they feel uncomfortable broaching the topic or lack time.

A survey of 50 physicians and 45 nurse practitioners or physician assistants at three practices at the Mayo Clinic in Rochester, Minnesota and the Mayo Clinic Health System found:

  • Only 12 percent of the healthcare providers reported having routine yearly discussions about end-of-life care as advocated by the American Heart Association.
  • Thirty percent of the group reported having little confidence in discussing or providing end-of-life care.
  • Among the 52 percent who said they felt hesitant mentioning end-of-life-care, 21 percent cited their perceptions that patients weren’t ready to talk about the issue; 11 percent said they felt uncomfortable bringing it up; 9 percent said they worried about destroying a sense of hope; and 8 percent said they lacked time.

Healthcare providers were often unsure about who should bring up end-of-life care: 63 percent of heart failure specialists and 58 percent of community cardiology clinicians thought end-of-life care discussions were the responsibility of heart failure cardiologists, while 66 percent of primary care providers felt it was their responsibility.

Despite these perceptions, heart failure specialists and community cardiology clinicians were far more likely to have referred heart failure patients to palliative care within the past year than primary care physicians (89 percent versus 21 percent).

“Providers did express an interest in receiving additional training to develop the skills and confidence to talk about end-of-life care with their patients with heart failure,” said Shannon Dunlay, M.D., M.S., the study’s lead researcher and a cardiologist at the Mayo Clinic in Rochester, Minnesota.

There is no evidence that bringing up end-of-life care ruins hope, and it may ease anxiety for some patients and families, Dunlay said.

About 5.1 million Americans have heart failure and about half of those die within five years of their diagnosis, according to American Heart Association statistics.

“Communication is key but in many hospitals and health systems this can be difficult as patients often have multiple healthcare providers,” Dunlay said. “Sometimes it’s helpful to pick up the phone and have a provider-to-provider conversation so that everybody is on the same page. Incorporating end-of-life conversations into the ongoing, routine care of the patient is important as goals and preferences can change over time and patients and their families can feel more comfortable and confident in relaying their wishes to multiple providers.”

Our Aging Eyes

excerpted from my post at Covering Health, the blog of Association of Health Care Journalists

EyeExamSitting in the waiting room of my opthalmologist’s office was an an elderly man, who I later learned was 100 years old, perhaps 102, no one was sure.

He could walk with the help of his aide and a sturdy cane and his cognition seemed good. My doctor later told me that this gentleman’s eyesight was as good or better than someone 20 or 25 years younger.

It got me thinking about what happens to our eyes as we age.

Why do some people maintain good vision well into their 90s while others struggle with serious visual decline at a younger age? Loss of vision significantly impacts a senior’s independence, which in turn, may lead to depression.

The American Foundation for the Blind says that the risk of severe eye problems increases with age, especially after 65. Two-thirds of those who are legally blind are seniors suffering from aging-related eye diseases. The National Health Interview Survey (NHIS) found 12.2% of people 65 to 74 years of age and 15.2% of those 75 years of age and over reported having vision loss.

This Scientific American article provides a good overview of the basic structure of the human eye, and what happens as we get older. According to the Cleveland Clinic, retinal disorders from diabetes, age-related degeneration, or retinal detachment are the leading causes of blindness in the US.  Many people also suffer from glaucoma, cataracts, or macular degeneration.

So was mom right when she said “eat your carrots?” Sort of.

Claims about various nutrients, vitamins, and minerals as beneficial to eye health vary from evidence-based to absurd. Experts strongly advise due diligence before reporting on the latest supplement of the month or dietary wonder food.  Various studies show that foods high in Lutein and zeaxanthin (L/Z) such as cantaloupe, carrots, eggs, salmon, and orange/yellow peppers, do have protective properties linked with reduced risk of age-related macular degeneration and cataracts. This article in The Daily Mail contains a good synopsis of caretenoids, which are found in dark green and orange-yellow vegetables.

When it comes to nutritional supplements or “natural” alternatives,  the FDA does not require manufacturers to gain approval before distribution. In addition, companies are permitted to claim that products address a nutrient deficiency, support health or are linked to body functions.

Any manufacturer can make a health claim, as long as there is some kind of study — which are often industry sponsored — to back it up. Look for information from reputable sources, like in this Globe and Mail  article, which describes a well-regarded investigation of specific supplement concentrations — reminding readers that more isn’t necessarily better.