PTSD Linked to Accelerated Aging

Image: Lance Page / t r u t h o u t; Adapted: Andrew Spratley, Conrad Kuiper, Nathan Barry) https://www.flickr.com/photos/truthout/5098046422/in/photolist-8LuPA7-dMS3Ww-dMS4rw-dMS571-dMS3w7-dMS4XU-dMLwcv-dMLwAD-dMS4Bo-dMLvC8-dMLwQH-dMLuHx-dMLxqe-dMLwrD-dMLuAK-dMS42L-dMS4Qd-dMS48s-dMS4f9-dMLwji-mU4Ect-oq1WfG-9ZNTkF-9ZNRb4-i5rf2F-9ZNRVg-99tRWU-bJ52xa-9vMTV6-8SzEPM-7eDa5v-fF2Sfo-bJjYB8-fFxo2K-67vbNh-nsT4Gy-hRrUTD-kYNTBx-rr3U5k-s6hDFS-skyTj3-s6gtcW-snRS7X-rWQsu3-zDP7B-d14oNW-93QFP8-hRXEjY-hR3y3V-8Ja2Y8/
(Image: Lance Page / t r u t h o u t; Adapted: Andrew Spratley, Conrad Kuiper, Nathan Barry) http://bit.ly/1HdTptE

In recent years, public health concerns about post-traumatic stress disorder (PTSD) have risen significantly, driven in part by affected military veterans returning from conflicts in the Middle East and elsewhere. PTSD is associated with number of psychological maladies, among them chronic depression, anger, insomnia, eating disorders and substance abuse.

Researchers at University of California, San Diego School of Medicine and Veterans Affairs San Diego Healthcare System suggest that people with PTSD may also be at risk for accelerated aging or premature senescence. Their results appear in the May 7 online issue of American Journal of Geriatric Psychiatry.

“This is the first study of its type to link PTSD, a psychological disorder with no established genetic basis, which is caused by external, traumatic stress, with long-term, systemic effects on a basic biological process such as aging,” said senior study author Dilip V. Jeste, MD, Distinguished Professor of Psychiatry and Neurosciences and director of the Center on Healthy Aging and Senior Care at UC San Diego.

Existing research has pointed to a potential association between psychiatric conditions, such as schizophrenia and bipolar disorder, and acceleration of the aging process. This investigation attempted to determine whether  PTSD might show a similar association by analyzing previously published studies related to PTSD and aging, going back to 2000.

There is no standardized definition of premature aging, also known as accelerated senescence. For guidance, the researchers looked at early aging phenomena associated with non-psychiatric conditions, such as Hutchinson-Gilford progeria syndrome, HIV infection and Down’s syndrome.

The majority of evidence fell into three categories: biological indicators or biomarkers, such as leukocyte telomere length (LTL), (a complex genetic trait associated with aging), earlier occurrence or higher prevalence of medical conditions associated with advanced age and premature death.

The scientists found consistent evidence of changes in telomeres in people with PTSD as well as increased pro-inflammatory markers associated with PTSD. Their analysis revealed that PTSD  was present alongside several targeted conditions associated with normal aging, including cardiovascular disease, type 2 diabetes, gastrointestinal ulcer disease and dementia. There was also a mild-to-moderate association of PTSD with earlier mortality, consistent with an early onset or acceleration of aging in PTSD.

“These findings do not speak to whether accelerated aging is specific to PTSD, but they do argue the need to re-conceptualize PTSD as something more than a mental illness,” said first author James B. Lohr, MD, professor of psychiatry. “Early senescence, increased medical morbidity and premature mortality in PTSD have implications in health care beyond simply treating PTSD symptoms. Our findings warrant a deeper look at this phenomenon and a more integrated medical-psychiatric approach to their care.”

However, researchers caution that more long-term studies are needed to directly demonstrate accelerated aging in people with PTSD and to determine why.

Most surgeons still encourage annual, earlier mammograms

mammogram_250_310The vast majority of surgeons continue to recommend that women 40 years old or older with an average risk for breast cancer get annual screenings for the disease. This conflicts with a newly released draft statement from the U.S. Preventive Services Task Force (USPSTF)  and its 2009 recommendations that most women be screened every two years beginning at 50 years old and continuing through age 74.

A team of researchers studying the effectiveness of policy recommendations on practicing surgeons found that 88 percent of breast surgeons and 82 percent of general surgeons continue to recommend annual mammography for women with an average risk of developing breast cancer. An even greater percentage–93 percent–reported that they began or would begin annual screenings for themselves at age 40.

This aligns with American Cancer Society recommendations that most women begin annual screening at age 40 and continue past age 75, barring serious health problems.

“We found that the majority of surveyed breast surgeons advocate and personally follow the screening mammography recommendations of the American Cancer Society, the American College of Radiology, and the Society of Breast Imaging, instead of those of the USPSTF,” said coauthor Vilert Loving, director of breast imaging at the Banner MD Anderson Cancer Center.

According to the USPSTF guidelines:

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. 

Study coauthors Jiyon Lee (NYU Cancer Institute) and Elaine Tanaka (VA San Diego Healthcare System and UC San Diego School of Medicine) added, “As we anticipate the USPSTF’s impending guidelines this year, the public should know that the physicians who diagnose and treat women with breast cancer still believe in annual mammography starting at age 40 for average-risk women.”

Results were presented last week at the American Roentgen Ray Society conference in Toronto.

Women with dense breast tissue should consider additional screening such as ultrasound or MRI, according to Nancy Cappello, Ph.D., founder of AreYouDense.org, an advocacy and educational organization working to help women learn about breast density and breast cancer risks. The group has helped to pass breast density inform legislation in 22 states and have introduced or are working on bills in a dozen more.

Emergency doctors and paramedics commonly misinterpret documents for end-of-life care choices

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I wasn’t too surprised to learn that a pair of new studies finds that emergency care providers vary in their understanding of a type of medical order intended to communicate seriously ill patients’ choices for life-sustaining treatments.

Coincidentally, part two of my extensive interview with Nancy Berlinger, Ph.D., a research scholar at The Hastings Center, appears today in Covering Health. Berlinger stressed the need for more conversations and better physician education on end-of-life and palliative care.

The studies show “significant confusion” among emergency physicians and prehospital care providers in interpreting the universal end-of-life care documents, called Physicians Orders for Life Sustaining Treatment (POLST). “Our data suggest that POLST orders can be confusing for Pennsylvania emergency physicians, and likely for physicians nationwide,” concludes lead author Dr. Ferdinando L. Mirarchi of UPMC Hamot, Erie, Pa., and colleagues.

How Well Do Emergency Providers Interpret POLST Documents?

POLST orders are a growing national model for seriously ill patients to document their choices regarding end-of-life-care. The POLST form is a one-page, brightly colored document–varying in color and formatting from state to state–that serves as an active medical order across healthcare settings. The POLST lets patients state their choices regarding resuscitation, either “do not resuscitate” (DNR) or full cardiopulmonary resuscitation (CPR); and other treatments, with options for full treatment, limited treatment, or “comfort measures” only.

Mirarchi and colleagues surveyed Pennsylvania emergency department physicians and prehospital care providers (paramedics and emergency medical technicians) regarding their understanding and interpretation of POLST forms. Both groups were presented with various clinical scenarios of critically ill patients, with POLST forms specifying different options for resuscitation and treatment.

Rates of “consensus”– defined as 95 percent agreement — were assessed in the different situations. Surveys were completed by 223 emergency physicians and 1,069 prehospital care providers.

In the majority of the clinical scenarios, for both emergency physicians and prehospital providers, the results fell well short of consensus benchmarks. “Both studies reveal variable understandings and variable repsonses as far as treating critically ill patients with the available POLST combinations of choices,” Mirarchi commented.

Consensus Reached Only for Patients Choosing CPR and ‘Full Treatment’

Even when the POLST specified “DNR” with “comfort measures” only, ten percent of emergency physicians and 15 percent of prehospital providers indicated they would still perform CPR. The only situation to show 95 percent agreement was when the POLST form specified “CPR” and “full treatment.”

Older and more experienced physicians were less likely to choose “DNR” in certain situations. In both studies, responses were similar for participants with and without previous POLST training.

Intended to address the limitations of “living wills” and advance directives for end-of-life care, “The POLST provides medical orders that are immediately actionable and to be universally honored across various healthcare settings,” according to the study authors.  POLST is currently in use in 20 states; other states are in the process of adopting the standards.  The POLST is generally used by seriously ill patients for whom sudden death within the next year would not be unexpected. However, some states and institutions have adopted its use outside of the specified indications.

According to this Wall Street Journal article, POLST orders may help to ensure that patients receive care consistent with their treatment goals. Additionally, they are very effective at limiting life-saving care and may prevent avoidable readmissions to hospitals.

However, it’s still not clear whether that the POLST combinations truly equate with informed consent by patients. Reports show that the majority of POLST forms are prepared by non-medical personnel, and then become actionable with a physician’s signature.

The new study raises further concern by showing that emergency care providers vary in their interpretation of POLST documents. In some situations, respondents indicate that they would resuscitate when they should be expected to withhold life-saving treatment. Conversely, some respondents would withhold treatment when they would be expected to provide life-saving care.

“Our results reveal clinical and safety issues related to confusion” with POLST documents, the researchers concluded. They call for continued research, standards, and education to help ensure “patient autonomy and appropriate care” regarding life-sustaining treatments for people with serious illnesses and limited life expectancy. They have developed a patient safety checklist to be used at the time of resuscitation to remind providers to confirm and follow expressed treatment choices with an individualized plan of care for the patient.

 

photo credit: Emergency Room via photopin (license)

It’s Heart Health Month

1 and 99.

Two numbers to remember – this month and every month

Heart Disease is the #1 cause of death in the U.S. for both men and women.

99 percent of us need to improve our heart health.

heart-stroke

Take care of your heart. It’s the best Valentine’s present you can give to yourself – and to those who love you.

Check out the American Heart Association’s website for more information on heart disease and stroke – and how you can avoid becoming another statistic.

Many Women with Breast Cancer Have Poor Knowledge About Their Condition

A new analysis finds that many women with breast cancer lack knowledge about their illness, with minority patients less likely than white patients to know and report accurate information about their tumors’ characteristics. This further supports the need to better educate women about their health conditions so they can make more informed treatment decisions.The findings appear in the online version of CANCER, the peer-reviewed journal of the American Cancer Society.

radiotherapy
courtesy Gerry Lauzon CC license

Although previous studies have examined general cancer knowledge, this was the first study that looked at whether women actually know and understand the details about their own cancers. Rachel Freedman, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and her colleagues surveyed 500 women with breast cancer to see how knowledgeable they were about their own cancers, including the tumor stage, grade, and receptor status (breast cancer subtype). While 32 percent to 82 percent reported knowing each of the tumor characteristics that they were asked about, only 20 percent to 58 percent actually reported these characteristics correctly.

Black and Hispanic women were often less likely than white women to know their cancer characteristics, even after adjusting for socioeconomic status and health literacy. 

“Our results illustrate the lack of understanding many patients have about their cancers and have identified a critical need for improved patient education and provider awareness of this issue,” said Freedman in a statement. “Improving patients’ understanding about why a particular treatment is important for her individual situation may lead to more informed decisions and better adherence to treatment.”  Understanding tumor characteristics and the reasons for personalized treatment recommendations could also improve a woman’s trust, confidence, and satisfaction with her cancer treatment providers, Freedman added.

Each year in the United States, more than 200,000 women get breast cancer and more than 40,000 women die from the disease, according to the Centers for Disease Control and Prevention. 

More information about breast cancer can be found through many research and advocacy organizations, including