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Cognitive and Physical Decline in Older Adults Associated with Severe Sepsis

October 26, 2010 By Leave a Comment

Older adults who survive hospitalization involving severe sepsis, a serious medical condition caused by an overwhelming immune response to severe infection, are at higher risk for cognitive impairment and physical limitations than older adults hospitalized for other reasons, researchers have found.

The research, conducted by the University of Michigan and supported primarily by the National Institute on Aging (NIA), part of the NIH, appears in the Oct. 27, 2010, issue of the Journal of the American Medical Association.

Theodore J. Iwashyna, M.D., Ph.D., and colleagues found that an older person’s risk of cognitive decline increased almost threefold following hospitalization for severe sepsis. They also found that severe sepsis was associated with greater risk for the development of at least one new limitation in performing daily activities following hospitalization.

“Sepsis is common in older people and has a high mortality rate,” said NIA Director Richard J. Hodes, M.D. “This study shows that surviving sepsis may bring substantial and under-recognized problems with major implications for patients, families and the health care system.”

In sepsis, immune system chemicals released into the blood to combat serious infection trigger widespread inflammation. This can lead to low blood pressure, heart weakness, and organ failure. Anyone can get sepsis, but infants, children, older people, and those with weakened immune systems are most vulnerable. People with sepsis often receive treatment in hospital intensive care units to combat the infection, support vital organs and prevent a drop in blood pressure.

“This study should help change the way we think about severe sepsis,” said Iwashyna. “We usually think of severe sepsis as a medical emergency and focus our efforts on making sure the patient survives. This study shows that survivors often have severe problems for years afterwards.”

Using data from the NIA-supported Health and Retirement Study (HRS), the researchers analyzed the cognitive and physical function of older people before and after hospitalization for severe sepsis. The HRS is a long-term study that collects information on the health, economic and social factors influencing the health and well-being of a nationally representative sample of Americans over age 50. Study data on participants 65 and older are linked to Medicare claims data to enable detailed analysis of medical conditions and health status.

The scientists analyzed Medicare claims data from 516 people who survived 623 hospitalizations for severe sepsis between 1998 and 2005. The average age of participants was 77 at the time of hospitalization. The researchers also examined the individuals’ HRS data on cognitive function, measured through standard tests. Physical limitations were measured by the need for assistance in six activities of daily living basic self-care tasks (walking, dressing, bathing, eating, toileting and getting into and out of bed) and five instrumental activities of daily living (preparing a hot meal, shopping for groceries, making telephone calls, taking medicines and managing money), which are associated with the ability to live independently. For comparison, the researchers analyzed Medicare and HRS data on 4,517 survivors of 5,574 non-sepsis general hospitalizations during this time period.

Almost 60 percent of hospitalizations for severe sepsis were associated with worsened cognitive and/or physical function among survivors in the first survey following hospitalization. The risk of progression to moderate or severe cognitive impairment in sepsis survivors was 3.33 times higher than their risk before hospitalization. Severe sepsis was associated with the development of 1.57 new functional limitations among patients with no limitations before sepsis. In contrast, patients who did not develop sepsis and had no functional limitations before hospitalization developed an average of 0.48 new functional limitations. Non-sepsis hospital admissions were not associated with an increased risk for cognitive decline.

“This is one of more than a thousand research papers that have used Health and Retirement Study data,” said Richard Suzman, Ph.D., director of the NIA’s Division of Behavioral and Social Research, which supports the HRS. “The uniquely rich HRS dataset enabled the analysis of both cognitive and physical function in relation to hospitalization for a very specific medical condition. I look forward to the investigators refining their findings in the future.”

Source: NIH, October 26, 2010

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Depression Among Low Income Latinos

March 27, 2010 By Leave a Comment

A new, small study of low-income, depressed Latinos finds that those who stigmatize mental illness are less likely than others are to take medication, keep scheduled appointments and control their condition.

The findings could help physicians develop a series of question to identity patients who might especially be resistant to care and then help them understand how treatment works, said lead study author William Vega.

“Unfortunately, mental-health stigma turns out to be one of the most serious barriers for people receiving care or staying in care,” said Vega, professor of medicine and social work at the University of Southern California.

Many cultures have stereotypes about depression and mental illness, he said, with some viewing it as something that will brand a family for generations. Latinos, in particular, value resilience and think, “it’s a cultural value to be able to handle your own affairs,” he said. “If you can’t, it implies that you’re weak.”

While it might not be surprising that Latinos stigmatize mental illness, “like many things, it’s all anecdotes and innuendo until you do something more solid, like a research study, and start finding out what the issues are,” said Vega, who worked on the study with fellow researchers while at the University of California at Los Angeles.

In the new study, published in the March/April issue of the journal General Hospital Psychiatry, researchers surveyed 200 poor, Spanish-speaking Latinos in Los Angeles. They all had visited local primary care centers; 83 percent were women. All had shown signs of depression in an initial screening.

Another screening found that all but 54 of the 200 individuals were mildly to severely depressed. Researchers deemed 51 percent as those who stigmatize mental illness, based on responses to questions about things like the trustworthiness of a depressed person.

The researchers found that those who stigmatized mental illness were 22 percent less apt to be taking depression medication, 21 percent less likely to be able to control their depression and about 44 percent more likely to have missed scheduled mental-health appointments.

The findings “shows evidence that stigma does exist, and it’s related to things that are important to provide as part of proper treatment,” Vega said.

Jamie Walkup, a Rutgers University associate professor of psychology who studies mental health and stigma, said the key is to find ways to “push back against these negative ideas, hoping that a person with depression will no longer let an aversion to being a person with depression stop them from doing what they may need to do to get help.”

It might be worth asking, he said, “whether it may sometimes make more sense to switch gears with a patient who, for whatever reason, finds it intolerable to think of themselves as having depression.”

In such cases, doctors could find other ways to work with these patients without insisting that they acknowledge their diagnosis.

Source: Vega W, Rodriguez MA, Ang A. Addressing stigma of depression in Latino primary care patients. General Hospital Psychiatry 32(2), 2010.


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Elderly with Untreated Vision Problem More Likely to Develop Alzheimer’s

February 18, 2010 By Leave a Comment

Elderly people with visual disorders that are left untreated are significantly more likely to develop Alzheimer’s disease — the most common form of dementia, according to a University of Michigan Health System study.

The study used Medicare data and shows that those with poor vision who visited an ophthalmologist at least once for an examination were 64 percent less likely to develop dementia.

The study appears online ahead of print in the American Journal of Epidemiology and may draw a new picture of poor vision as predictor of dementia rather than as a symptom after the diagnosis.

“Visual problems can have serious consequences and are very common among the elderly, but many of them are not seeking treatment,” says lead author Mary A.M. Rogers, Ph.D, research assistant professor of internal medicine at the U-M Medical School and research director of the Patient Safety Enhancement Program at the U-M Health System and the Ann Arbor VA Medical Center.

For the study, Rogers and her colleague Kenneth M. Langa, M.D., Ph.D., professor of internal medicine at U-M Medical School, analyzed data from the nationally representative Health and Retirement Study and records from Centers for Medicare and Medicaid Services.

”Our results indicate that it is important for elderly individuals with visual problems to seek medical attention so that the causes of the problems can be identified and treated,” Rogers says.

The types of vision treatment that were helpful in lowering the risk of dementia were surgery to correct cataracts and treatments for glaucoma, retinal disorders and other eye-related problems.

Proper vision is a requirement for many of the activities that previously have been found to lower the risk of Alzheimer’s disease. These include reading, playing board games, other mentally stimulating activities, social networking, as well as physical activity such as walking and routine exercising. A visual disorder may interfere with normal mobility and may also hinder a person’s ability to participate in such activities.

“Many elderly Americans do not have adequate health coverage for vision, and Medicare does not cover preventative vision screenings for most beneficiaries,” Rogers says. “So it’s not unusual that the elderly receive vision treatment only after a problem is severe enough to warrant a visit to the doctor when the problem is more advanced.”

According to a survey conducted by the National Eye Health Education Program, less than 11 percent of respondents understood that there are no early warning signs for eye problems such as glaucoma and diabetic retinopathy.

However, vision problems and blindness are among the top 10 disabilities among adults and can result in a greater tendency to experience other health conditions or even to die prematurely.

“While heart disease and cancer death rates are continuing to decline, mortality rates for Alzheimer’s disease are on the rise,” says Rogers. “So if we can delay the onset of dementia, we can save individuals and their families from the stress, cost and burden that are associated with Alzheimer’s disease.”

The study was based on the surveys and medical information from 625 people compiled from 1992-2005. Only 10 percent of Medicare beneficiaries who developed dementia had excellent vision at the beginning of the study, while 30 percent of those who maintained normal cognition had excellent vision at the onset of the study.

One in five Americans who are over age 50 report experiencing a visual impairment, according to the U.S. Centers for Disease Control and Prevention. Approximately 5 million Americans have Alzheimer’s disease and the number has doubled since 1980. It is expected to be as high as 13 million by 2050.

Source: American Journal of Epidemiology,/em> 2010 Feb. 11; doi:10.1093; University of Michigan

Filed Under: Alzheimer's, Mental Health Tagged With: , ,

Overtime Work Can Lead to Anxiety and Depression

July 2, 2008 By Leave a Comment

Overtime work habits can lead to anxiety and depression, according to a study conducted by Norweigan researchers.

Using a standard screening questionnaire to measure symptoms of anxiety and depression, Elisabeth Kleppa and colleagues at the University of Bergen, Norway, analyzed data on hours worked by a large sample of Norwegian men and women. Scores for anxiety and depression were compared for 1,350 workers putting in 41 to 100 hours of overtime a week, and some 9,000 workers working regular hours (40 or less) without overtime.

Overtime work was linked to higher anxiety and depression scores among both men and women, while “possible” depression rose from about 9% for men working regular hours to 12.5% for those working overtime. “Possible” depression rates in women rose from 7% to 11% and for men and women the “possible” anxiety and depression rates were higher among workers with lower incomes and for less—skilled workers.

The relationship between overtime and anxiety/depression was strongest among men who worked the most overtime—49 to 100 hours per week. Men working such very long hours also had higher rates of heavy manual labor and shift work and lower levels of work skills and education.

Health and safety concerns have been raised in previous studies, but these concentrated on shift work rather than overtime. European Union work rules allow employees to refuse to work more than 48 hours per week. These latest results show increased rates of anxiety and depression among overtime workers, supporting the European Union directive.

Even moderate overtime hours appear to increase the risk of ‘mental distress’, although the study offers no conclusions as to how working long hours results in increased anxiety and depression. It is surmised that working overtime leads to increased “wear and tear,” or that individuals with characteristics predisposing to anxiety and depression (such as low education and job skills) are more likely to take jobs requiring long work hours.

Source: Journal of Occupational and Environmental Medicine, official publication of the American College of Occupational and Environmental Medicine (ACOEM), June, 2008.

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Brain Changes in Elderly Can Affect Mobility and Balance

April 2, 2008 By 1 Comment

Changes in the brain can affect old people’s mobility and balance, according to a recent study. Particularly affecting balance and walking are white matter changes called leukoaraiosis.

The 639 men and women between the ages of 65 and 84 in the study underwent brain scans and walking and balance tests. 284 people in the group had mild age-related white matter changes, 197 moderate changes, and 158 severe changes.

People with severe white matter changes were twice as likely to score poorly on the walking and balance tests as people with mild white matter changes, the study found. The people with severe changes were also twice as likely as those with mild changes to have a history of falls. The moderate group was only one and a half times as likely as the mild group to have a history of falls.

"Walking difficulties and falls are major symptoms of people with white matter changes and a significant cause of illness and death in the elderly," said study author Hansjoerg Baezner, MD, PhD, with the University of Heidelberg in Mannheim, Germany. "Exercise may have the potential to reduce the risk of these problems since exercise is associated with improved walking and balance. We’ll be testing whether exercise has such a protective effect in our long-term study of this group."

"Mobility is one of the key determinants of independent aging," said Baezner. "Limitations in mobility often lead to hospitalization and nursing home placement. This will become a major problem for our social and economic systems in the upcoming decades."

Published in Neurology, the medical journal of the American Academy of Neurology,the 3-year study was coordinated by the Department of Neurological and Psychiatric Sciences of the University of Florence.

Source: Neurology, March 18, 2008

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Despite Successful Antidepressant Treatment, Despair Can Remain

February 23, 2008 By Leave a Comment

While antidepressants can successfully treat depressive symptoms, despair can remain; and this may result in the patient not taking the medication any longer, according to a study that tbe journal, General Hospital Psychiatry.

For many in the study, feelings of hopefulness did not improve until several weeks, or even months, after depressive symptoms lifted, says lead author James E. Aikens, Ph.D., associate professor in the Department of Family Medicine at the University of Michigan Health System.

"The finding suggests that some patients may become unduly pessimistic and stop adhering to an already-helpful therapy," he notes. This finding is troubling, he says, because hopelessness is a strong risk factor for suicide.

573 patients from 37 practices suffering from depression were studied by Aikens and his team, and given either fluxotine (Prozac), paroxetine (Paxil), or sertraline (Zoloft). Patients were then reviewed one, three, six and nine months after treatment began. Patient response to medication was fast: 68% of improvement was achieved by the end of the first month, 88% by three months. Areas of major improvement were positive emotions, work functioning and social functioning.

There was little improvement recorded in head, back and stomach pain after the first month, and Aikens said that if these physical complaints persisted after the first few weeks of treatment, physicians should consider treatments that directly affect pain in depressed patients.

Where hopefulness was concerned improvement noted was more gradual, and Aikens recommended that physicians teach patients to recognize and fight the pessimistic thoughts that often accompany depression, and encourage patients to get involved in mood-lifting activities.

In addition to Aikens, authors were: senior author Amanda Sen, Ph.D., of the Department of Family Medicine, the Department of Statistics and the Center for Statistical Consultation and Research at the University of Michigan; Donald E. Nease Jr., M.D., of the Department of Family Medicine at the U-M Health System; Michael S. Klinkman, M.D., M.S., of the departments of Family Medicine and Psychiatry at the U-M Health System; and Kurt Kroenke, M.D., of Indiana University.

With hopefulness, however, the improvement was much more gradual. Physicians may want to consider cognitive-behavioral strategies, such as teaching patients to identify and challenge the pessimistic thoughts that usually accompany depression, and encouraging them to engage in activities that may improve their mood, Aikens says.

In addition to Aikens, authors were: senior author Amanda Sen, Ph.D., of the Department of Family Medicine, the Department of Statistics and the Center for Statistical Consultation and

Source: General Hospital Psychiatry, (January-February, 2008)

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Cognitive Impairment Among Older Americans Decreasing

February 21, 2008 By Leave a Comment

A recent study shows a downward trend in the rate of cognitive impairment among people aged 70 and older. The study was led by two University of Michigan Medical School physicians and their colleagues, and is based on data from the Health and Retirement Study (HRS), a national survey of older Americans funded by the National Institute on Aging and based at the U-M Institute for Social Research (ISR).

"From these results, we can say that brain health among older Americans seems to have improved in the decade studied, and that education and wealth may be a big piece of the puzzle," says lead author Kenneth Langa, M.D., Ph., an associate professor of internal medicine who also holds appointments in ISR and the VA Ann Arbor Healthcare System.

Between 1993 and 2002 the incidence of cognitive impairment in this age group decreased by 3.5%, or hundreds of thousands of people. The reasons for this decline are not yet known, but the authors of the survey state that older people today have had more formal education, higher economic status and better care for risk factors—high blood pressure, high cholesterol, and smoking – that can endanger their brains. Of the 11,000 people in the study, those with more formal education and personal wealth were less likely to have cognitive problems.

The study was publishe in the the online edition of the journal Alzheimer’s and Dementia.

Source: Alzheimer’s & Dementia, Feb 18, 2008, online edition.

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Study Suggests Folate Deficiency Increases Dementia Risk Three-Fold

February 5, 2008 By Leave a Comment

Recent research suggests that the risk of dementia in elderly people is increased three times by a lack of folate.

518 people were monitored for the development of dementia during the years 2001 through 2003. All subjects were aged 65 and over and lived in either a rural or urban community in the southern part of the country. Tests were carried out at the beginning and end of the 2-year period to check for any dementing illnesses. Blood tests were also conducted to measure levels of folate, vitamin B12, and the protein homocysteine, and how these changed over time. High levels of homocysteine have been associated with cardiovascular disease.

At the beginning of 2001, almost 20% of people monitored hd high levels of homocysteine, 3.5% were folate deficient, and 17% had low vitamin B12 levels.The higher the beginning levels of folate, the higher were vitamin B12 levels, and the lower were those of homocysteine.

By the end of 2003, 45 people had developed dementia, and of these 34 had Alzheimer’s disease, 7 had vascular dementia and 4 had other types of dementia. It was observed that dementia was more probable in the older, poorly educated and inactive subjects, and among those who had deposits of th protein ApoE.

People whose folate levels fell during the 2-year period were significantly more likely to develop dementia, while their homocysteine levels rose. People who were folate deficient to begin with, were almost 3.5 times more likely to develop dementia.

The research was published in the Journal of Neurology Neurosurgery and Psychiatry.

Source: J Neurol Neurosurg Psychiatry 2008; doi 10.1136/jnnp.2007.131482

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Rate of Memory Loss Greater in Dementia Patients With More Education

October 24, 2007 By Leave a Comment

According to a recent study in the journal Neurology, while higher education levels initially delay the onset of dementia, once dementia starts, the rate of memory loss is more rapid than in less educated individuals.

According to study author Charles B. Hall, PhD of the Albert Einstein College of Medicine, "our study showed that a person with 16 years of formal education would experience a rate of memory decline that is 50% faster than someone with just four years of education."

The study started in the 1980s, and monitored 488 people born between 1894 and 1906, with study findings based on the 117 members of the sample who eventually developed Alzheimer’s or some other form of dementia. Study participants ranged from people with postgraduate education to people with less than three years of elementary school education.

Dr. Hall believes that this rapid decline in the more educated people might be explained by their having a greater cognitive reserve, or the brain’s ability to maintain function in spite of damage. This meant that while patients are often diagnosed with dementia at a later date, once the cognitive reserve is no longer able to compensate for the damage that has occurred, then the symptoms emerge.

The study is valuable, says Dr. Hall, because it examines memory loss before a formal diagnosis of Alzheimer’s.

The study was supported by the National Institute on Aging. Other researchers from the Einstein Aging Study involved in the research included Carol Derby, PhD; Aaron LeValley, MA; Mindy J. Katz, MPH; Joe Verghese, MD; and Richard B. Lipton, MD.

Source: Neurology, October 23, 2007

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Researchers Find Major Clues on How Schizophrenia Develops

October 19, 2007 By Leave a Comment

Scientists have found some major clues in learning more about why schizophrenia develops. The new research may lead to better medications to correct gene-related problems that can lead to schizophrenia.

The researchers found that a gene called GAD1, which makes an enzyme essential for production of the chemical messenger called GABA, is turned on at increasingly high rates during normal development of the prefrontal cortex, but that this normal increase may not occur in people with schizophrenia. The prefrontal cortex is involved in higher functions like thinking and decision-making.

While scientists have known that abnormalities in brain development and in GABA synthesis play a role in schizophrenia, this study shows that defects in specific biochemical reactions that regulate gene activity—such as turning genes on and off so that they can make substances like the GAD1 enzyme—are also involved.

"This discovery opens a new area for exploration of schizophrenia," said NIMH Director Thomas R. Insel, MD. "Studies have yielded very strong evidence that schizophrenia involves a decrease in the enzymes, like GAD1, that help make the neurotransmitter GABA. Now we’re starting to identify the mechanisms involved, and our discoveries are pointing to potential new targets for medications."

The researchers also found that people with three different variations of the GAD1 gene that have been associated with schizophrenia also were more likely to have indicators of a malfunction in brain development. Among them were indicators of altered epigenetic actions related to GABA synthesis.

Clozapine and other antipsychotic medications are effective for many patients, but some patients choose to discontinue treatment because of the side effects they experience on these drugs. For this reason, scientists are working to find more precise molecular targets for the development of new medications that can correct the epigenetic flaws.

"We’ve known that schizophrenia is a developmental disease, and that something happens in the maturation of the prefrontal cortex during this vulnerable period of life. Now we’re beginning to find out what it is, and that sets the stage for better ways of preventing and treating it," says the study’s lead author, Schahram Akbarian, MD, PhD.

Results of the research were published in the October 17 issue of the Journal of Neuroscience, by Schahram Akbarian, MD, PhD, Hsien-Sung Huang, PhD student, and colleagues at the University of Massachusetts Medical School and Baylor College of Medicine. The study was funded by the National Institutes of Health’s National Institute of Mental Health (NIMH) and National Institute of Child Health and Human Development.

Sources:

  • National Institutes of Health
  • Journal of Neuroscience, October 17, 2007
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