Tuesday, August 26, 2008
Longevity: Independent, Even in Old Age
The flip side of a longer life expectancy might be a much greater public health burden in caring for the very old and extremely disabled. But that is not the case, according to a new report.
The study, published online in the Proceedings of the National Academy of Sciences, tracked all Danes born in 1905 for seven years beginning in 1998. Most had died by the end of the study, but as the researchers examined them with four assessments at ages 94, 96, 98 and 100, the percentage living independently decreased only slightly in the seven-year span, to 32.7 percent from 38.9 percent.
At the same time, the small number of people who survived to age 100 — 156 of the original 2,234 — showed a significant increase in disability, to 67.3 percent at 100 from 30.1 percent at 92. The explanation for the apparent paradox, the authors write, is the high level of mortality among dependent participants. The few who survived the longest were least likely to be dependent at the start of the study.
“Some worry that extreme old age leads to extreme levels of disability,” said Dr. Kaare Christensen, the lead author of the study and a professor of epidemiology at the University of Southern Denmark. “But our study shows that people are no more dependent at 100 than at 92.”
The New York Times
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Achieving Spectacle Independence With Intraocular Lenses in the 21st Century
The aging of the population means a big increase in the number of people who have developed and will develop cataracts -- and a consequent increase in the demands on the ophthalmic surgeon. Moreover, the success of refractive surgery has created an awareness of and expectation for spectacle independence following cataract surgery. No longer simply satisfied with a return to unobstructed vision, cataract patients are increasingly demanding near 20/20 vision, as well as expecting good distance vision -- all without using spectacles or contact lenses.
In addition to these needs, the evolving technology and work and cultural needs of the 21st century have changed the paradigm of what outcomes are most desired from lens replacement surgery. One change in particular is the new-found importance of "intermediate vision." As computers, personal device assistants (PDAs), and other handheld or arms-length technologies become more prominent for work and social networking, I have increasingly seen patients requesting intermediate vision at the expense of near vision. This preference represents a stark transition from a prioritization of near, low-field vision -- such as that that results from bifocals -- that sufficed when books and printed material dominated our near experience.
Concurrent to changing patient demands is an increased repertoire of tools available to the cataract surgeon. Although a select field of ophthalmologists had been working with the refractive mentality and skill set for 10 years or more, it was the medical industry itself that created new intraocular lens (IOL) designs that created the push toward spectacle-free independent cataract surgery......
However, at the heart of the transition to spectacle independence is the development of a new generation of IOLs. What follows is a discussion of the currently available IOLs, along with some of their benefits and drawbacks, based on the available research and on the author's clinical experience.
MedScape Today from WebMD
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Monday, August 25, 2008
Older Smokers' Quit Rate Rises with Patches and Phones
SANTA MONICA, Calif., Aug. 22 -- Older smokers doubled their quit rate when given nicotine patches and access to telephone counseling, showed a Medicare demonstration program.
The one-year quit rate was almost 20% compared with 10% for smokers who received a brochure about smoking cessation (usual care), Geoffrey Joyce, Ph.D., of the RAND Corp. here, and colleagues, reported online in Health Services Research.
Physician counseling and the combination of counseling and medical therapy also led to higher quit rates compared with usual care.
"The results of this study suggest that a fully integrated [Medicare] benefit structured around low-cost pharmacotherapy in conjunction with available free quitline services would substantially reduce the prevalence of smoking and smoking-related illness among elderly beneficiaries motivated to quit, at a relatively modest cost," the authors concluded.
Smoking-cessation efforts have primarily targeted the young, before they become habitual smokers. However, increasing evidence suggests that quitting smoking after decades of exposure can substantially reduce smoking-related illness, the authors noted.
"A person smoking twenty or more cigarettes per day and who quit at age 65 could expect to increase their life expectancy by two to three years, in addition to any improvements in quality of life," they said.
Most private and public health plans do not fully cover smoking-cessation services, in part because of a lack of evidence that insurance coverage increases long-term abstinence, particularly among older adults who often have smoked for decades.
Medicare beneficiaries in the seven states were recruited into four intervention groups:
A brochure about smoking cessation (usual care).
Reimbursement for four counseling sessions with a physician.
Reimbursement for counseling and smoking-cessation drug therapy (nicotine patches or bupropion [Zyban]).
Nicotine patches plus a telephone hotline.
The six-month quit rates were 9.9% with usual care, 11.9% with provider counseling, 15.8% with counseling plus drug therapy (P=0.05 versus usual care), and 21.2% with nicotine patches plus telephone counseling (P=0.05 versus usual care). At 12 months, the quit rate with usual care (10.2%) was significantly lower compared with each of the other interventions (P=0.05):
14.1% with provider counseling
15.8% with counseling plus drug therapy
19.3% with nicotine patches plus telephone counseling and support
"Rates of confirmed smoking cessation in the Medicare Stop Smoking Program compared favorably with quit rates in the general population and were higher than expected for older adults," the authors said.
The authors noted several limitations of the study: imbalances in patient enrollment, lack of information about the number and quality of counseling sessions that participants in those groups received, and reliance on self-reported information and cessation rates.
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Wednesday, August 20, 2008
Bright Lighting May Alleviate Some Symptoms of Dementia
AMSTERDAM, June 10 -- For older patients who have dementia, bright lighting may help correct circadian rhythms and improve cognitive and physical functioning, researchers found.
Compared with patients in assisted living facilities who were exposed to lower levels of light in the dayroom, those exposed to bright lighting had less cognitive deterioration, fewer depressive symptoms, and a slower decline in functional limitations, Eus Van Someren, Ph.D., of the Netherlands Institute for Neuroscience here, and colleagues reported in the June 11 issue of the Journal of the American Medical Association.
A daily dose of melatonin had mixed effects, they said, improving sleep quality but worsening mood and increasing withdrawn behavior.
Therefore, the researchers said, melatonin's "long-term use by elderly individuals can only be recommended in combination with light to suppress adverse effects on mood."
In older patients with dementia, cognitive decline is frequently accompanied by changes in mood, behavior, sleep, and activities in daily living, which may be influenced by changes in the circadian pacemaker in the brain, the researchers said.
The mean duration of the study was 15 months (maximum 3.5 years).
Bright lighting alone was associated with a relative 5% attenuation of cognitive decline, as measured on the Mini-Mental State Examination (P=0.04).
Bright lights also reduced depressive symptoms by a relative 19% (P=0.02), slowed the increase in functional limitations by a relative 53% (P=0.003), and increased total sleep duration by 2% (P=0.04).
Treatment with melatonin alone shortened sleep onset latency by 19% (P=0.02), increased sleep duration by 6% (P=0.004), and lengthened the average duration of uninterrupted periods of sleep by 25% (P=0.02).
However, the hormone was associated with worse scores on the positive scale of a mood assessment (P=0.02) and higher scores on the negative scale (P=0.01), as well as an increase in withdrawn behavior (P=0.02).
All three of these negative effects were diminished when melatonin was combined with exposure to bright lights, the researchers said.
The combined treatment also reduced agitated behavior by 9%, increased sleep efficiency by 3.5%, improved nocturnal restlessness by 9%, and reduced the average duration of individual awakenings at night by 12% (P=0.01 for all).
None of the treatments increased the occurrence of adverse events and the bright lights reduced dizziness, headache, inability to sleep, irritability, and constipation, which was also reduced by melatonin.
In terms of whether the effects were clinically significant, the researchers concluded, "On the whole, light treatment could have clinically beneficial effects."
For instance, they said, the combined effects of melatonin and bright light on sleep, if sustained over time, "could help maintain sleep efficiency above 85%, which has been regarded as a cutoff for clinically relevant disturbed sleep."
Also, interpretation of the results should be done with caution, they said, because of the multiplicity of analyses and outcomes in the study.
Primary source: Journal of the American Medical Association
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Retooling for an Aging America
The baby boom generation is 78 million adults who begin to turn 65 in 2011. Unless we make changes now, we will not have enough doctors, nurses, and other caregivers prepared to meet the health needs of older Americans.
Too few doctors and nurses are choosing to specialize in geriatrics; less than 1% of all doctors are geriatricians. Informal caregivers -- that is, patients and their family members and friends -- are often ill-prepared to handle the necessary treatments and specialized care that elders require.
To ensure that older Americans receive appropriate and high-quality care, the Institute of Medicine recommends the following steps in its report Retooling for an Aging America: Building the Health Care Workforce:
First, instead of relying predominantly on specialists, we should work to enhance the competence of all individuals involved in the delivery of geriatric care.
Second, at the same time, we need stronger incentives to recruit and retain geriatric specialists and caregivers.
Finally, we need to apply more flexible models of care so that patients and those with lesser amounts of training can do more. For example, new home-based technologies offer an exciting prospect of enabling self-care by patients and other informal caregivers.
By retooling the health workforce, we can help assure that every American can look forward to a healthier future.
That's my opinion. I'm Dr. Harvey Fineberg, President of the Institute of Medicine.
Medscape Today from WebMD
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Tuesday, August 19, 2008
Looking Squarely at Death, and Finding Clarity
Despite her racing pulse and falling blood pressure, the 81-year-old patient was still alert. She was also terrified. Earlier that day, she said in a quavering voice, her leg had started to throb. Then the throb became a bruise. Now, her leg was swollen, cool — and lifeless.
As I gently touched her thigh, I felt the crackle and pop of tiny pockets of air beneath her skin. I looked up and found the woman’s eyes searching mine. Am I dying? they seemed to ask.
I gave her hand a little squeeze. “The antibiotics are already at work,” I told her, as calmly as I could.
Then I returned to the banshees in my brain. “Do this! Do that!” they screeched. The case was an all-out emergency. The moment for intimate conversation with the patient had passed.
Of all the mayhem an infectious-diseases doctor sees in a lifetime, nothing tops spontaneous gas gangrene. One day, out of the blue, a human body part is invaded by large, snub-nosed bacteria from the gut. Once planted in foreign flesh, the organisms — Clostridium perfringens — ferment gas, spew toxins and mutilate muscle. Soon, blisters erupt, and after that point few victims survive. Even with aggressive surgery and industrial-strength antibiotics, their odds are poor.
But this is not so much a story about a rare, violent ambush by a micro-organism as about a doctor and a patient, staring death in the face. That’s what the 81-year-old woman was doing, and from countless wordless clues — her wide-eyed gaze, the periodic flutter of her hand to a cross around her neck — I believe she knew it. These days, when death’s footfalls are often silenced by drugs and machines, not many people have the chance to confront their fate so squarely.
Of course we all expect to go — sometime. As the economist John Maynard Keynes memorably put it, “In the long run, we are all dead.” But Keynes wrote those cool words decades before his own death. Who among his tribe — or the current tribe of medical professionals, for that matter — wants to pull the plug on hope at that moment?
Call me weak, but when I was trying to care for the dying woman, I didn’t.
Were things different in the old days? I’m now well into my 50s. Several of my early mentors began their careers before the era of antibiotics. Back then, although the weapons at their disposal were meager, they took more time to talk. They also understood that some deadly diseases were accompanied by a brief window of crystalline awareness. On that list, curiously enough, was clostridial myonecrosis, or gas gangrene — the same wildfire that consumed my patient’s leg.
Observing her inspired me to note the mental and emotional clarity of other patients under sudden, desperate microbial siege. Sure enough, not much later, I met a recently divorced middle-age man who was uncommonly lucid in the face of disaster. Having just returned from an African safari, he arrived at our emergency room with a fever of 105 and a sleeping-sickness infection so dense that two or three sinuous organisms could be seen in every microscopic field of his blood. Simply put, a biologic tinderbox. The only good thing was that his rapidly multiplying parasites had not yet breached his brain.
Now picture a university emergency room circa 1990, minus cellphones. So certain was my patient that he was about to die — and so aware of the implications of his death — that the critically ill man refused all care until a nurse wheeled him to a desk. Why? He wanted to call his lawyer and change his will.
Fortunately, his story ended well. Although his infection and its toxic cure caused multiple organ failure, he recovered and three weeks later was able to leave the hospital. Today he is happily remarried. From time to time, we still talk about his whisper-close brush with death.
Sadly, there was no next chapter for the lady with gas gangrene. An hour after I met her, she was unresponsive. A few hours later, with her family at her side, she died. She never made it to the operating room, and as far as I know, none of her doctors discussed her imminent death, then simply sat with her.
Of course one could argue that there was no time, there was no need, she already knew, why add to her pain? But looking back, I still wish I had.
The New York Times
Older Trauma Patients Not Sent to Designated Centers
BALTIMORE, Aug. 18 -- Patients 65 and older are less likely to be transported to a trauma center than those who are younger, a retrospective database study showed.
Only half of all older trauma patients were taken to one of eight state-designated trauma centers, compared with more than 80% of younger patients (P<0.001), David Chang, Ph.D., M.P.H., of Johns Hopkins, and colleagues, reported in the August issue of Archives of Surgery.
Emergency medical services and trauma center personnel ranked the top three potential reasons for the undertriage as inadequate training on how to handle older trauma patients, a lack of familiarity with protocol, and possible age bias.
"The problem of age bias raised in this study may negate efforts to improve clinical care for elderly trauma patients within trauma centers if the system as a whole does not function properly and deliver patients appropriately to needed resources," the researchers said.
Although guidelines recommend treating older patients as aggressively as younger patients, some studies have found that age bias remains an issue in trauma care, they said.
To determine whether age bias played a role in determining which patients were taken to a trauma center, the researchers analyzed data from a 10-year period on 26,565 trauma patients from the Maryland Ambulance Information System.
Patients were included in the study if they met criteria for trauma defined by the American College of Surgeons, which included information on presenting physiology, injury pattern, and mechanism of injury, and were classified as priority I status -- critically ill or injured and requiring immediate attention -- by EMS personnel.
The undertriage rates were higher among patients 65 and older in all subgroups, including patients who expressed a preference for a specific hospital (70.8% versus 29.7%) and those who were taken to the closest hospital (68.1% versus 36.8%) (P<0.001>
In a multivariate analysis, patients 65 and older were 52% less likely to be transported to trauma center than younger patients (OR 0.48, 95% CI 0.30 to 0.76).
All patients ages 50 and older had a significantly lower likelihood of being taken to a trauma center than younger patients. Those 50 to 69 were 33% less likely to be taken to a trauma center (OR 0.67, 95% CI 0.57 to 0.77) and those 70 and older were 55% less likely (OR 0.45, 95% CI 0.39 to 0.53).
The researchers presented the findings to EMS and trauma center personnel and then surveyed 166 of them about possible reasons for the differences.
They were asked to provide a percent weight to the various possible reasons that could have contributed to the disparity. The top three were as follows:
"Survey results suggest that lack of training related to elderly trauma patients and unfamiliarity with protocol may be allowing unconscious bias to affect triage decisions and that this problem occurs among both EMS providers and medical personnel at the receiving trauma centers," the researchers said.
They suggested retraining providers with triage protocols and highlighting literature that shows that older trauma patients can return to productive lives after an injury.
In an invited critique, Richard Mullins, M.D., of Oregon Health & Science University in Portland, wrote that "the authors dismissed three pertinent issues."
First, he noted that there is no evidence that older trauma patients would benefit from treatment at a trauma center.
Second, he said, only 20% of Maryland's hospitals are designated trauma centers, and trauma systems improved survival only in states with at least half of their hospitals designated as trauma centers. "Elderly patients are undertriaged in Maryland because rural hospitals are excluded from the state's trauma system," he said.
Finally, Dr. Mullins noted, mandatory admission to a trauma center may go against an older patient's wishes in regard to end-of-life decisions.
"Trauma surgeons must advocate for the inclusion of seriously injured elderly patients in statewide trauma systems but should also recognize that optimal care may be determined by the elderly patient's unique priorities and preferences," he concluded.
Tuesday, August 12, 2008
Runners Live Longer and Have Fewer Disabilities
PALO ALTO, Calif., Aug. 11 -- Regular running in middle age and beyond may lengthen lifespans and retard the disabilities of aging, a longitudinal study showed.
Runners ages 50 to 72 had a 40% reduced risk of being moderately disabled or of dying after a 21-year follow-up than healthy controls, Eliza Chakravarty, M.D., of Stanford, and colleagues reported in the Aug. 11 issue of the Archives of Internal Medicine.
Disability and survival curves continued to diverge between groups after the 21-year follow-up as participants approached their ninth decade of life, they added.
"Our findings of decreased disability in addition to prolonged survival among middle-age and older adults participating in routine physical activities further support recommendations to encourage moderate to vigorous physical activity at all ages," the researchers said.
The study began in 1984, when 538 members of a nationwide running club for those 50 and older and 423 healthy controls -- Stanford faculty and staff members ages 26 to 70 -- were recruited to complete yearly questionnaires.
At baseline, runners were younger (mean age 58 versus 62), leaner, more likely to be male, and less likely to smoke than the controls (P<0.001>
Both groups had little disability -- measured using the Health Assessment Questionnaire Disability Index (HAQ-DI), which asked the participants about their level of difficulty in completing eight tasks -- but runners had a significantly lower mean score compared with controls (P<0.001).>
Two previous reports on this cohort showed that disability was decreased and survival was increased in runners at eight and 13 years of follow-up.
A total of 284 runners and 156 controls completed the study through 21 years of follow-up, and the results extended the previous findings.
Disability scores increased with time for both groups, but at a significantly greater rate for the controls (0.016 points/year versus 0.007, P<0.001).>
Runners took longer to reach various levels of disability compared with controls -- for example, it took 2.6 years for controls to reach a mean HAQ-DI score of 0.075 and 8.7 years for runners, for a difference of 6.2 years (95% CI 3.9 to 8.9).
Among participants who had a baseline disability score of zero, runners had a significantly lower risk of being moderately disabled (HR 0.62, 95% CI 0.46 to 0.84).
Through follow-up, 15% of runners died compared with 34% of controls (P<0.001).>
Rates of death were higher in controls than in runners for cardiovascular disease (P=0.001), cancer (P=0.004), neurological disease (P=0.007), infections (P<0.001),>
The study's findings were similar when the participants were divided into ever-runners -- those who ran regularly for more than one month at some point in their lives -- and never-runners.
The authors suggested several possible reasons for the disability and survival advantages found in runners, including "increased cardiovascular fitness and improved aerobic capacity and organ reserve, increases in skeletal mass and metabolic adaptations of muscle with decreased frailty, lower levels of circulating inflammatory markers, improved response to vaccinations, and improved higher-order cognitive functions."
They acknowledged some limitations, including the self-reported data, possible self-selection bias, and potential confounding by unmeasured lifestyle variables.
In addition, they said, the results of the study may not be generalizable beyond the mostly white and college-educated study population.
Sunday, August 3, 2008
Frankincense Extract Said to Reduce Osteoarthritis Pain
DAVIS, Calif., July 29 -- For patients with knee osteoarthritis, an extract of the Indian frankincense plant gave significant pain relief and reduced levels of a marker of joint pathology, researchers here said.
Patients in a randomized, double-blind, 90-day trial showed significantly greater reductions in pain scores with the agent than with placebo, reported Siba R. Raychaudhuri, M.D., of the University of California Davis, and colleagues online in Arthritis Research and Therapy.
Synovial fluid levels of matrix metalloproteinase-3 also declined significantly in patients receiving the agent, whereas MMP-3 levels rose in the placebo group.
This was the agent's first randomized, placebo-controlled trial in osteoarthritis of the knee, the researchers said.
The agent, tradenamed 5-Loxin, was derived from Boswellia serrata, a plant that has long been prominent in the Ayurvedic system of traditional Indian medicine. It is already widely marketed in the U.S. as a nutritional supplement, with purported benefits including enhanced joint mobility and function.
The extract contains 30% 3-O-acetyl-11-keto-beta-boswellic acid, identified in laboratory and animal studies as the anti-inflammatory component, according to Dr. Raychaudhuri and colleagues.
In particular, the compound appears to inhibit 5-lipoxygenase, a key intermediate in the inflammatory cascade.
The study assigned 70 patients to placebo or to 100 mg or 250 mg of the extract, given orally in divided doses.
Patients at baseline had mean pain scores, on a visual analogue scale, of 56 to 57 points.
At the end of treatment, mean scores in the placebo group were 41.8 (SD 16.0), compared with 21.4 (SD 7.1) in the low-dose treatment group and 14.2 (SD 6.8) for those in the high-dose group. The declines in both treatment groups were significantly greater than in the placebo group (P<0.0001).
Similar results were also seen in the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMUOI).
Improvements in pain scores with the agent were noted in one week in some patients, the researchers aid.
Functional assessments, including the WOMUOI stiffness and functional subscales and Lequesne's Functional Index, also showed significant advantages for the plant extract versus placebo.
For example, mean stiffness scores in the placebo group declined from 33.2 (SD 2.7) at baseline to 24.5 (SD 2.4) after treatment, whereas in the low-dose treatment group, mean scores fell from 31.8 (SD 3.6) at baseline to 14.1 (SD 3.7) following treatment (P<0.0001 versus placebo).
As with the pain scores, greater improvements were seen in the high-dose group: stiffness scores decreased from 27.8 (SD 3.4) at baseline to 9.24 (SD 2.1) after treatment (P<0.0001).
Mean MMP-3 levels in synovial fluid increased slightly in the placebo group, from 902.1 ng/ml (SD 275.1) at baseline to 928.5 (SD 216.0) following treatment.
In the low-dose and high-dose treatment groups, MMP-3 levels fell substantially: from 893.6 (SD 270.1) and 926.9 ng/ml (SD 270.5) at baseline, respectively, to 637.2 (SD 224.5) and 497.5 (SD 167.5) ng/ml after treatment (both P<0.0001 versus placebo).
MMP-3 is a cartilage-degrading enzyme. Its presence in synovial fluid is a marker of joint destruction.
"5-Loxin has potential efficacy in terms of reducing pain and improving the physical ability of osteoarthritis patients," Dr. Raychaudhuri and colleagues wrote.
In combination with animal experiments that found no mutagenic effects or other major toxicity concerns, the adverse event profile in the clinical trial indicates that the compound "is potentially safe in the treatment of osteoarthritis in humans," the researchers said.
Dr. Raychaudhuri and colleagues said the most common adverse effects were diarrhea, nausea, abdominal pain, mild fever, and general weakness, without significant difference between placebo and the active treatment groups.