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Study Finds Nursing Care Varies Tremendously by State
April 15, 2014 10:59 AM by Brian Garavaglia

It has been known for some time that nursing home care is not the same in every nursing care facility.  In a recent study published by a nonprofit advocacy group, Families for Better Care, the group's review looked at nursing homes and care found in these facilities found in each state.  The Families for Better Care state that it is the first state-by-state review of nursing home care that has been undertaken.

The data for this undertaking was obtained from three major existing data sources: The Kaiser Health Foundation, Performance measures from the Centers for Medicare and Medicaid Services Nursing Home Care site, and from the Office of State Long-term Care Ombudsman regarding complaint data information. The data obtain compiled information regarding the following areas as they relate to nursing home care:   

  • State's average registered nurse (RN) hours per resident per day
  • State's average certified nurse assistant hours (CNA) hours per resident per day
  • Percentage of facilities with above average registered nurse staffing
  • Percentage of facilities with above average direct care staffing
  • Percentage of facilities with above average health inspections
  • Percentage of facilities with deficiencies for the 2012 calendar year
  • Percentage of facilities with severe deficiencies for the 2012 calendar year
  • Percentage of verified ombudsman complaints for the 2011 federal fiscal year

The abovementioned nursing home data was examined on a state-by-state basis, averaged and then a final letter grade provided to each state based on the quantitative state average. The grades given to the state were letter grades such as A, B, C, D, and F.

The study found that the following states were ranked the highest, or in other words, received an A grade. These states had that highest overall average nursing home care performance:

  • Alaska
  • Rhode Island
  • New Hampshire
  • Hawaii
  • Oregon
  • Maine
  • Utah
  • Idaho
  • South Dakota
  • North Dakota

Conversely, there were a disconcertingly large number of states that had failing marks.  These states had the lowest overall average nursing home care performance ratings. These states were as follows: 

  • Texas
  • Louisiana
  • Indiana
  • Oklahoma
  • Missouri
  • New Mexico
  • New York
  • Michigan
  • Nevada
  • Illinois
  • Iowa

Key Findings From This Study
The study revealed some important findings found among nursing homes and nursing home care throughout the United States. Many of these finding were directly linked to the type of care they provided on a state aggregate level and subsequently the grade that the states received on the basis of the data examined. Here is a brief summary of some of the major findings:

  • States who had greater levels of average nursing home staffing, both professional nursing care staffing and paraprofessional caregivers such as nursing assistants, had higher grades.
  • A very disconcerting finding is that only seven states were found to provide more than one hour of professional nursing care per resident day. Furthermore, it was found that 96 percent of the states offered residents fewer than three hours of direct resident care each day, which entails care not just from nurses, but all staff such as physical therapists, nursing care assistants and activity therapists.
  • Nearly 90 percent of all nursing homes were cited with a deficiency. This statistic has to be viewed cautiously, since it does not say anything about the type or severity of deficiency. However, when looking at the severity of the deficiency as a separate category, Rhode Island nursing care centers scored the lowest with less than four percent of their deficiencies falling into the severe range. Conversely, Michigan performed worst on this statistic, with more than 50 percent of the nursing care facilities receiving a severe deficiency.
  • Resident abuse and neglect in nursing homes was quite common. It was found that one in five nursing homes experienced issues of abuse, neglect or mistreatment in almost one-half of the states.
  • When complaints were submitted and the proper authorities were notified, certain states were found to have higher levels of verified complaint verification. Montana, Connecticut, Wyoming, Washington DC, Missouri, and Massachusetts had extraordinary high complaint verification rates. Conversely, New Hampshire, Nevada, and New Jersey had the fewest. Again, this has to be looked at cautiously as well since those who investigate complaints have a level of subjectivity in their investigative protocol.
  • Health care inspections for nursing homes was found to be low.

The study that has just been discussed is a very large state-by-state study that is the first of its kind in examining nursing home care on a national basis. It provides an important level of information in that it is not just conducting an inter-facility based comparison, but a state-by-state comparison, showing that some states on an aggregate level are doing better than others. However, more needs to be discussed why these states are not doing as well as other states that received superior grades in this area? In particular, why are those states with failing marks not providing enough staffing for the provision of quality care in relation to those states that are given an A grade. This is just but one indicator that needs to be examined in greater depth regarding the disparity found to exist. Nevertheless, the study provides a picture of state-based nursing home care and which states are doing better than others.  However, here again, caution has to exist in interpreting the results. The data was obtained from pre-existing databases, which themselves hold data from surveyors and groups that often obtain data in not exactly the same manner. In other words, although surveys and survey protocol do follow a standard federal basis for surveyors to use, states probably have considerable variability in how they employ and carry out this protocol. This being stated, the study does provide some very interesting, if not attention getting information, that could be used to further nursing home care on a national level.       

References

Renovating seniors' homes may lead to longer independence. Accessed at: http://www.cbsnews.com/news/renovating-seniors-homes-may-lead-to-longer-independence/

Families for Better Care. Accessed at: http://nursinghomereportcards.com/about/

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Nursing Home Treatment is Found to Often be Harmful
March 25, 2014 9:30 AM by Brian Garavaglia

[Editor's note: the following blog post was written by Brian Garavagli] 

A national report on nursing homes, conducted by the Office of the Inspector General of the United States Department of Health and Human Services, has found some very sobering, if not frightening, results. The study found that as many as one-third of all nursing home residents were harmed by their treatment!

The Office of the Inspector General used a large sampling of Medicare patients that were discharged from hospitals to nursing homes within a particular year. It found approximately one-third of the patients that were studied in these nursing homes experienced treatment that harmed them in some way. It was also found that most of these cases of harm were preventable. 

Ruth Ann Dorill of the Department of Health and Human Services stated, "We were surprised at the seriousness of many cases." Many of the problems were not based on case or treatment complexity. Dorrill states that many of the issues were oversights and failures in carrying out proper everyday care. In other words, many of the cases of harm that existed were due to failures in carrying out normal standard protocol correctly. Paying proper attention or failing to monitor an individual correctly were often some of the apparently simple, yet highly important oversights, which lead to many harmful forms of nursing home care, or maybe better stated, lack thereof. Dorrill states that many of these forms of improper treatment intervention leading to harm fall under the classification of "what clinicians would call substandard medical care."

The study found that approximately 60 percent of the nursing home residents that experienced harmful treatment eventually ended up being readmitted back into the hospital. The Office of the Inspector General estimates that the cost to Medicare for such improper and substandard care is approximately 2.8 billion dollars annually. This 2.8 billion dollar estimate is just considering the hospital cost, and it does not entail the cost of physician care and extra time spent being readmitted to a nursing home. Therefore, the cost of improper medical treatment in nursing home care may be adding considerably to the overall health care expenditures that exist in our country. This, during a period in which the government and many third party paying sources are strongly attempting to curtail health care costs, which has become a serious economic problem for our country. However, given the serious economic impact that it has on our health care system, more serious are the concerns related to the potential harm, and in some cases death, that has resulted from improper care.    

Dorill states that today's nursing homes are harboring sicker individuals than in the past, and many have a greater complexity of care found within their nursing home populations. Given this, they need to have staff that pays particular attention to the regimentation of treatment protocol, covering a greater number of patients than had previously needed such types of oversight in past decades. As the population ages, this will become an ever-increasing problem as more individuals may be in need, at least for short-periods of time, of care and rehabilitation provided within a nursing home setting. That being the case, what is quite disconcerting is that many of these forms of inappropriate treatment that lead to harm, or even to the death of the patient, were often simple human factor issues. Paying attention to the administration of certain medications, providing proper attention to prevent falls, or providing proper food administration to prevent aspiration are some of the issues that were found to exist. Many of the problems therefore were not due to a technical inability found to exist in the provider of care. They were acts of omission or commission that could be considered very preventable forms of negligence.   

What can be drawn from this current study? First, there are still considerable care issues that need to be addressed in the nursing home industry. There have been considerable improvements over the past couple of decades, especially since nursing home care improvement was targeted by the federal government and the Institute of Medicine in the 1980's. However, to paraphrase Robert Frost, the nursing home industry still has miles to go until we can sleep. Furthermore, a more effective and efficient form of care has to be focused on, especially toward eliminating unnecessary behaviors and interventions that can actually not only harm individuals, but exacerbate their conditions that lead to greater health care costs in the long run. As was found, many of the clinical aspects that may need to be targeted to avoid harmful treatment interventions are not highly complex issues, in as much as they are human factor issues.  Subsequently, better logistical processes, focusing on human factor engineering issues may be of considerable importance. One last thing to note as well is that iatrogenic forms of illness or treatment are not unique to the nursing home area. Nevertheless, the study's finding of approximately a third of all Medicare nursing home residents experiencing some form of harm has to give one great pause, as well as sensitize the nursing home industry toward addressing this deficiency properly and expediently.  

References

Jaffe, I. (2014, March 5).  One-third of nursing home patients harmed by their treatment.  Accessed at: http://www.npr.org/blogs/health/2014/03/05/286261742/a-third-of-nursing-home-patients-harmed-by-their-treatment

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Nursing Homes May Need to Improve Their Discharge Planning
March 17, 2014 1:55 PM by Brian Garavaglia

In a recent study conducted by the University of North Carolina at Chapel Hill, a high percentage of Medicare residents who are discharged from nursing homes often are re-hospitalized within 30 days. Individuals receiving care within nursing homes in which the care is being paid for by Medicare are often there after they have been discharged from the hospital and are in continued need of receiving rehabilitative care. Nursing homes in the United States have become increasingly used as a continuum of care within the rehabilitative process of many acute care patients. Although nursing home care is still predominately a chronic care enterprise, more nursing homes are being used as an intermediate phase for continued rehabilitation after the hospital is no longer able to maintain the patient and bill insurance for in-patient hospital services.   

Given that more patients, including a younger patient population, are using nursing home facilities as acute care rehabilitative services, the need to address appropriate discharge planning needs are becoming a rising concern with increasingly important ramifications for the health of the patient, as well as the economic costs for society. The current study may indicate that greater administrative organization may need to be untaken in the discharge area.   

The current study followed 50,000 Medicare residents who were treated within a skilled nursing home environment within North and South Carolina. The study found that approximately 22 percent of those Medicare beneficiaries that were being treated within the nursing home environment, with the expectation for discharge after rehabilitation, required emergency care within 30 days of discharge from the nursing home environment and 37.5 percent required some level of acute or hospital type care within 90 days of discharge from the nursing home. As one can see this is a high rate of return to the hospital after a supposedly successful rehabilitation. 

Demographic factors were also examined in the study to find out if there were any differences between certain groups. They found African Americans were more likely to need additional acute care services and subsequently be readmitted to a hospital after discharge from a nursing care facility. Additional factors were also found to be associated with the increased rate of return to the hospital such as being an older adult who suffers from cancer or respiratory disorders. Moreover, having a higher number of previous hospitalizations, having greater levels of comorbidity, and interestingly, receiving care from a for-profit nursing care facility, were associated with higher rates of hospital return.  

The study's authors are not sure how many of these re-hospitalizations or returns to the emergency room are preventable. Under the Affordable Care Act hospitals incur a penalty for readmitting Medicare patients. Therefore, hospitals have a monetary incentive to maintain patients from being re-hospitalized for the same conditions they were treated for previously within the hospital. One can see that this disincentive to readmit patients that hospitals have sent to a nursing home will not aid toward producing productive hospital-nursing home relationships. Furthermore, more has to be examined as to exactly where the problem lies and what has to be done to solve this issue. 

Nursing homes have taken on many new roles within the overall health care spectrum. One of these is the increasing dependence on nursing care facilities to take up the rehabilitative burden for hospitalized patients that no longer qualify for in-patient hospitalization. Since nursing homes are facing a greater rehabilitative burden, and since many are now becoming increasingly post-acute care environments that often have many non-traditional younger, as well as traditional older, long-term care clientele, the need for closer administrative and clinical sensitivity regarding the greater diversity of rehabilitative needs has to be cogently addressed. Along with this, increased sensitivity for out-patient or discharge care planning has taken on an increasingly important and demanding responsibility for nursing home professionals. This is not to say it has not been important previously, but as this study shows, it may have become an even more important skill in today's long-term health care environment. However, we also need to be cautious about extrapolating further on the results of this study. It looked at nursing home discharge and re-hospitalization in two states. Whether this may also be a significant issue in the other 48 states still needs to be answered more definitively. However, it does appear quite plausible that this may be a wide-spread issue that may be found throughout the nursing home industry. 

Since time spent within hospitals has decreased over the years, and since nursing homes have taken on an increasing amount of patient-care slack in the rehabilitation of patients, the need to pay greater attention to the rehabilitative and discharge needs of nursing home residents is becoming very important.   When you add this to the pressing economic issues of reducing health care costs, avoiding expensive hospital care through re-hospitalization has become an increasingly paramount issue. Furthermore, providing a targeted and specific form of rehabilitation for an increasingly diverse rehabilitative population that has not previously been part of the nursing home environment, including many younger individuals who were not normally a part of the long-term care environment, is becoming an increasingly pressing issue as well. A diverse and multifaceted rehabilitation population that is now becoming a natural part of the long-term care environment creates different skill-needs that need to be addressed by the physical, occupational, speech and activity therapists.  Furthermore, the psychosocial placement issues have increased dramatically, creating the need for greater skill in this area as well. Finally, the financial disincentives for re-hospitalizations found in the hospital environment need to bring greater collaboration between hospitals and nursing homes toward solving this potential problem, a collaboration that has often not existed between these two parts of the health care sector. Consequently, although more needs to be found through future studies regarding this issue, the current study may be an important sensitizer toward directing our attention and efforts toward solving an important issue that may be quite endemic within our country's nursing homes and among their post-acute care clientele.                 

References

University of North Carolina at Chapel Hill. (2014, February 20). "After nursing home discharge, many Medicare beneficiaries return to ER." Medical News Today. Retrieved from http://www.medicalnewstoday.com/releases/272891.

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Can Excessive Carbohydrate Intake Lead to Dementia?
February 21, 2014 7:41 AM by Brian Garavaglia

[Editor's note: this is only a portion of the complete article]  

A current book that is on the New York Times best seller list, Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar-Your Brain's Silent Killers, written by Neurologist Dr. David Perlmutter, asserts that a diet high in carbohydrates can actually be instrumental in the development of dementia.  Perlmutter, who is a professor of Medicine at the University of Miami as well as a Fellow with the American College of Nutrition, has raised some important and interesting arguments in favor of this position.  Yet, his arguments are far from airtight.

Perlmutter has pointed to the use of the A1C test that measures glycolated hemoglobin over a period of three to four months previous to the blood test.  It provides an average blood sugar measurement.  He does raise an interesting and important point.  Often the test is used to measure the average metric of blood sugar over the past few months for many diabetics.  However, it is really looking at more than that; it is looking at the glycation going on in the body, which ultimately leads to oxidative stress, free radical formation and inflammation.  These are all harmful to the body and in particular, to the brain.  He also points to recent studies that have shown an association between elevated levels of blood glucose and an increased probability for dementia.  Furthermore, he states that even mild blood glucose increases, which can be in the high normal range, can still be detrimental and lead to glycation, inflammation and an increased likelihood for dementia.  He states that too many physicians look at the blood glucose level and as long as it is within the normal laboratory parameters they feel comfortable with the results.  However, he states that physicians should not be dismissive about these high normal results and should advocate lower blood glucose levels under 100.  He states that regardless of the normal parameters, as they approach the high levels of the normal range, a person increases their probability for acquiring dementia.  However, I am not sure how Dr. Perlmutter has determined this, or how much of a probabistic increase results if it does, and what is the mathematical means that he has used to determine this result? 

Dr. Perlmutter does quote a number of studies that have found associations between higher carbohydrate dietary consumption and a higher risk for acquiring dementia.  However, he further admits the shortcomings of many of these studies, which were observational.  Therefore, although relationships were found between higher carbohydrate diets and the probability for acquiring dementia, this should not be interpreted as carbohydrates necessarily being causative.  Without true experimental-based studies that are able to control for many of the confounding factors, too many possible variables could be influencing the relationships that have been witnessed in the studies cited by Perlmutter.  Furthermore, the correlational studies, since they are not being held constant, all probably had quite different levels of what they viewed as higher carbohydrate levels.  Therefore, how high is what is referred to as being too high as it relates to carbohydrate consumption?  Where is the level of demarcation that quantifies a healthy level from a potentially harmful level?  Finally, is there anything that he can quote and identify as an identifiable quantification that provides an empirical basis of support other than guesswork and an intellectual eyeballing of what he thinks in his clinical judgment are valid quantifiable parameters?  The answers to these are far from clear and need greater empirical support. 

Click here to continue reading the full article.

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Telomeres, Exercise, Lifestyle and their Relationship to Longevity
January 27, 2014 11:42 AM by Brian Garavaglia

Recent research over the last few decades has paid increasing attention to aging at the molecular level. In particular, a genetic component called telomeres, has garnered much attention over the last few decades. Chromosomes are long strands of deoxyribonucleic acid or DNA. DNA is our molecular blueprint of who we are, being the genetic blueprint for forming our genome. Telomeres are found at the end of the chromosome, looking like a cap that helps prevent other chromosomes from fusing together. In essence, a telomere is a part of the DNA found in the nucleus of the cell, made up of six repeating nucleotide bases-- thymine (T), adenine (A), and cytosine (C), or a TTAGGG sequence. Under normal conditions, when cells divide, telomeres and their repeating nucleotide sequence shorten with each cell division. Therefore, similar to determining a tree's age by cutting the tree and examining the number of rings that exist, examining telomere length on the molecular level can provide an indication of the age of the person. 

As cells continue to shorten, the cell and ultimately the human being age, a process referred to as senescence. If the telomere shortens too much, the DNA can be damaged. Furthermore, as the telomere shortens to very short lengths, cell division ultimately stops. Certain cells need to naturally die off for proper health. However as individuals age, all of their body cells' genetic material are ultimately undergoing a telomeric reduction.  Conversely, with cancer, the reverse is often witnessed. Certain cells in the body do not die off naturally and continue an unending life cycle due to enzymatic telomerase production and a tumor-type agglutination of unhealthy cells.   

Given the information that has been presented so far, it appears that aging is an inevitable feature that is determined by the molecular structure of our genetic blueprint. Furthermore, although truth for this proposition appears to be found in what has come to be referred to as the Hayflict Phenomenon, which is the programmed capacity for cells to divide, even under optimal conditions, no more than approximately 50 to 60 times, setting a genetic upper limit to our lifespan, this does not mean human beings have no control in how long they can live. In fact, recent information has provided important knowledge on how we may ultimately slow aging down through the perseveration of telomere integrity.  

A recent study that was led by Dean Ornish, Professor of Medicine as the University of California, San Franciso followed 35 men over five years. All 35 men had been diagnosed with low-risk prostate cancer. Of the 35 men, 10 of the men in the study were assigned to engage in a healthy lifestyle that was composed of a vegetarian diet, regular exercise and regular sessions of stress reduction through use of meditation and yoga. This served as the experimental group. The other individuals who did not experience lifestyle changes served as controls.  

The study demonstrated some interesting results. Until recently most have assumed that the telomeric shortening was ultimately inevitable with aging, give or take some level of individual variation in the speed or progression of the shortening of the telomere, leading to individual differences in how fast one ages. However, in the Ornish study, at the end of five years, the researchers found that those that adopted the healthier lifestyle habits mentioned above demonstrated a younger looking DNA in terms of the degree of its shortening (Raffensperger, 2013). Not only was telomere shortening slowed, but it was actually reversed.  In the 10 men who made lifestyle changes, telomere length grew by an average of 10 percent over the five year study period. Moreover, the quantitatively greater number of healthier lifestyle changes made was associated with more telomere growth. Conversely, the control group experienced a three percent reduction, or shortening in telomere length over the five year length of the study. The study results do have to be interpreted cautiously since the study was far from representative, quite small, with a fairly loose level of control.  Yet, they do present some very interesting results that need further investigation, results that are quite inspiring and salubrious to say the least.      

Telomere shortening is also related with many diseases. However, whether the diseases are caused by the shortening of the telomere or the telomere shortening causes the disease needs to be further studied. Furthermore, centenarians were found to have longer telomeres than those who were 85 years of age. Here again the question is whether the longer telomere led to centenarians reaching their status or was it due to their health being better, leading to greater telomere length, and subsequently greater age (Knox, 2013). Nevertheless, there does appear to be a connection between telomere length, disease and aging.  

Overall however, there is increasing evidence that exercise, better nutrition, and subsequently enhanced health leads to a reduction in the rate of telomere degradation. Both younger and other marathon runners and track athletes demonstrated upregulation of telomere-stabilizing proteins. They also demonstrated decreased expression of apoptosis regulators. Both of these features were not found in more sedentary controls. 

Both younger track-and-field athletes and the older runners had up-regulation of telomere-stabilizing proteins and decreased expression of vascular apoptosis regulators in circulating leukocytes compared with individuals who did not exercise frequently. Furthermore, other research has found that subjects who spent more than three hours each week in vigorous physical activity had longer telomere length as compared to subjects who were 10 years younger than them and who exercised less than 16 minutes each week (Giuliano, 2010). Even with mice that were subjected to increased exercise levels in the laboratory as compared to those that were sedentary controls, telomere length was enhanced among the more active mice (WebMD).

Genetics may also be susceptible to the anti-aging effects of exercise. One would anticipate that identical twins, given that they share the same genetic information, would be an ideal group to see if exercise has a telomeric-enhancing effect that could trump genetic blueprint they are born with and is part of their DNA. What in fact was found is that when one twin was active and one was sedentary and telomere lengths were compared, the identical twin with the greater activity had longer telomeres. This is quite compelling since identical twins share exactly the same genetic material. 

Given what has been reviewed in this article, it appears that we are not just prisoners of our biology. It has been known for some time that exercise, healthy diets and healthy lifestyles can enhance our health and possibly even our longevity. However, now we are seeing increasing evidence for the health-enhancing effects of exercise and nutrition on the molecular level. It appears that exercise, a healthy diet, and a healthy overall lifestyle may have an epigenetic effect on our telomeres that exogenously can have a very beneficial impact on our immanent genetic profile, and potentially on our health and longevity. 

References

Giuliano, V. (2010/Jan).  Exercise, telomerase and telomeres.  http://www.anti-agingfirewalls.com/2010/01/14/exercise-telomerase-and-telomeres/

Knox, R. (2013/Sept).  Healthful Living May Lengthen Telomeres And Lifespans.  http://www.npr.org/blogs/health/2013/09/17/223386084/healthful-living-may-lengthen-telomeres-and-lifespans

Neale, T. (2009/Nov).  Exercise May Slow Telomere Shortening, Aging. http://www.medpagetoday.com/PrimaryCare/ExerciseFitness/17221 

Raffensperger, L. (2013/Sept).  Healthy Diet and Exercise Can Reverse Aging in Our Cells. http://blogs.discovermagazine.com/d-brief/2013/09/17/healthy-diet-and-exercise-can-reverse-aging-in-our-cells/

WebMD.  Molecular Proof: Exercise Keeps You Young
Intense Activity Keeps Telomeres Long. http://www.webmd.com/fitness-exercise/news/20091201/molecular-proof-exercise-keeps-you-young

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Is the Recent Indictment Against Multivitamin Use Really the Final Word?
December 23, 2013 3:31 PM by Brian Garavaglia
A recent editorial in the Annals of Internal Medicine has provided considerable debate about whether multivitamin use has any efficacy. The editorial titled, "Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements," avers, in a very definitive manner, that using multivitamins is useless, providing no help in aiding one's health. The editorial goes on to state, "we believe that the case is closed - supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough." The exclamatory and definitive nature of this editorial statement, however, leaves some room for pause.

Before one closes the case on the issue of multivitamins, a few things need to be addressed. The first contention that needs to be addressed is use of multivitamins for fighting disease. Whether multivitamins do or do not aid in preventing certain diseases is probably not fully closed since some studies have previously found that multivitamin usage does assist in maintaining health, especially among the elderly. Although they probably will not ward off chronic health issues that result from smoking, being overweight, failing to get adequate exercise, drinking heavily, eating poorly, or engaging in a myriad of other counterproductive health behaviors, the intent of multivitamin usage was never meant to override these types of issues. However, yes, it is true that many individuals attempt to delude themselves into thinking that using vitamins, or for that matter any type of pill, will lead to an easy and salubrious form of health-based intervention.

The next issue that needs to be addressed is the benefits derived from taking a multivitamin among those that eat well. Here again, the studies that were reviewed as the basis of the editorial are probably correct in stating that those who eat well and have well-balanced and nutritious dietary habits will receive little, if any, additional benefits from a multivitamin. However, many older adults fail to have proper dietary intake, and subsequently many fail to take in the necessary level of many vitamins and minerals to maintain proper health. This is often found among many older adults who live alone.

 Also quite surprising is how the statement was framed and presented, especially to a professional audience. The Annuls is a respected journal and it therefore is more surprising that even in the editorial section, it would allow such a potentially problematic, misleading and for the most part, unscientific statement to be rendered to the public, and in particular, professional audience that makes up most of its readers. Within the realm of science, claims that often attempt to make broad generalization in a definitive manner are often quite problematic. The editorial in the Annuls provides a broad and definitive statement and their wording is quite misleading by stating that the "case is closed" on the use of multivitamins. It extrapolates from three studies, using the results of these three studies to apply to all individuals. Stating that "enough is enough" and the "case is closed" are words that often are not used in science, and the unscientific word usage that the author of the editorial uses indicates a level of hubris and bias that can mislead the public.

As mentioned, the editorial is based on the results of three studies. Even when a meta-analysis is done on previous studies, the minimum to justify their results often is well beyond three studies. Also, the studies often have to have some level of similarity. In this case one study is based on results of 450,000 individuals (an impressive number to say the least, but the number of individuals by themselves do not lend credence to the soundness of the study), and the effects that multivitamin use had on health, cancer and mortality. Another study tracked 6,000 men, who were all physicians, over a period of 12 years, to see if multivitamins had any effect on cognitive decline. The use of just men and physicians is far from being a representative study. Finally, the third study, also quite different than the previous two mentioned, looked at 1,700 men and women, only this time it looked at the effects of multivitamin usage on those that were recovering from heart attacks, and whether using a multivitamin prevented a second heart attack. These three studies failed to demonstrate any level of efficacy for multivitamin usage. These three studies are the basis by which the editorial extrapolated its results and justifications for the definitive stance that it took toward multivitamin use.        

It must also be stated that this article is not saying that the statements in the Annuals' editorial is incorrect. However, the statements made were definitely cursory and excessively brazen. Furthermore, making such a definitive statement based on three studies, which all are looking at something different on a health and medical level, does not provide adequate justification for such a commentary. Therefore, whether the editorial's statement is correct or not will depend on much more scientific investigation. Science is a continuous enterprise. Typically, nothing is ever closed since our reality is far from invariant. Therefore, saying that one is closing discussion and any further investigation based on the paucity of investigative results used to justify the statements made in the editorial is troublesome.

As has already been mentioned, making a blanket statement as was made in the editorial usually fails to truthfully cover reality. Furthermore, as previously mentioned, many older adults do suffer from nutritional deficiencies that may ultimately benefit from vitamin supplementation. Although holding grand delusional thoughts about vitamin supplementation negating poor lifestyle or health behaviors or reversing chronic forms of illness is also a problem found in our society, this is a different issue that is a separate problem. However, making exclusionary statements regarding multiple vitamins is also quite injudicious. As with most things in life issues of high variability often preclude the use of either/or reasoning, an error that was made by the Annuals' editorial, which can mislead and ultimately result in harmful ramifications.

 

References

Jaslow R. Multivitamin researchers say "case is closed" after studies find no health benefits. http://www.cbsnews.com/news/multivitamin-researchers-say-case-is-closed-supplements-dont-boost-health/

Neergaard L. Two new studies debunk benefits of multivitamins. http://www.nbcnews.com/health/two-new-studies-debunk-benefits-multivitamins-2D11757314

Walton AG. Vitamins lack clear health benefits, may pose risks. http://www.forbes.com/sites/alicegwalton/2013/12/17/study-multivitamins-lack-clear-health-benefits-may-pose-risks/

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New Research Associates the Stomach With Cognitive and Mood Problems
December 19, 2013 8:46 AM by Brian Garavaglia
Cognitive decline as one gets older is often something that is feared by many. There are many reasons for cognitive decline, and although many associate it with age, for the most part age in isolation is usually not the only reason for cognitive decline. Furthermore, cognitive decline is not inevitable as one gets older. However, some new research has found that some pathogenic agents that have often been associated with causing diseases in other parts of the body can also influence cognition as well.

One microorganism that has been implicated is the herpes simplex type 1 virus. Research published in the journal, Neurology, examined 1,625 people who were on average 69 years of age. Memory and blood tests were taken at eight year intervals. The researchers found that those with higher levels of the herpes simplex type 1 virus in their blood were more likely to have more cognitive deficits. The herpes simplex type 1 virus is the virus that is often associated with cold sores. It should not be confused with genital herpes, or herpes simplex type II.

More research needs to be done before one can be more definitive about the relationship between the virus and cognitive decline. As was mentioned, the study found a relationship or association between the herpes virus and cognitive decline, but again the association does not indicate causation. There are too many variables that were not controlled for in this study.

In line with the above study, other studies have found the Helicobacter Pylori (H. pylori), a bacterium linked to many ulcers found in the gastrointestinal tract, may also be instrumental in mood problems and cognitive impairment. It has been known for some time that the gastrointestinal tract is linked to the brain. In fact, we also have what is known as an enteric nervous system, a special nervous system for our gastrointestinal tract, which works in association and complements our autonomic and central nervous system.

In what has been referred to a "leaky gut" disease, pathogenic agents such as H. pylori can leak out of the stomach region and impact the brain. Normally the stomach is a well-contained organ that prevents any type of leakage; however individuals can have their gastrointestinal mucosa compromised leading to the leakage out of pathogenic microorganisms. H. pylori has been found to be associated with increased depressive disorders and cognitive impairment. Again, these studies are far from being definitive.

It must also be mentioned that as individuals age, intestinal mucosa often thins considerably. When this happens, gut leakage can happen. If microorganisms are found to be truly implicated in mood and cognitive disorders, becoming more sensitive toward conducting tests for microorganisms found in the blood that may be instrumental in causing cognitive decline and depression may have to be done more readily during the examination process.

The good news about these finding is that they are highly correctable. Although many people suffer from many forms of intractable depressive disorders as well as cognitive decline that cannot be reversed, depression and cognitive decline that may be associated with these forms of infectious agents could be addressed through highly efficacious pharmacological interventions. Especially with the bacterial infection like H. pylori, a treatment regimen of antibiotics and proton pump inhibitor agents often can eradicate the intestinal microorganism that is not only causing distress within the gastrointestinal tract, but also influencing the neurological system as well.

Given this information, one may want to think how their stomach can not only influence their gastrointestinal health, but also be mindful on how their stomach and gastrointestinal tract can dramatically impact our cognitive health. Understanding that the enteric system with its own enteric nervous system is intricately aligned with our other nervous systems can help us understand how our stomach may influence our brain, our thinking and our mood.

References

Bakalar N. Infections tied to cognitive decline. http://well.blogs.nytimes.com/2013/03/29/infections-tied-to-cognitive-decline/?_r=0

Jaslow R. Herpes virus may lead to memory loss, cognitive declines. http://www.cbsnews.com/news/herpes-viruses-may-lead-to-memory-loss-cognitive-declines/

Rodriguez T. Gut bacteria may exacerbate depression: Microbes that escape the digestive tract may alter mood. Scientific American. http://www.scientificamerican.com/article.cfm?id=gut-bacteria-may-exacerbate-depress

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Living Longer: Facts Vs. Fiction
November 25, 2013 12:00 PM by Brian Garavaglia
The Longevity Project was a longitudinal study started by Stanford University Psychologist Lewis Terman in 1921. Terman's study initially looked at issues of intellect. The 1,500 subjects were tracked over eight decades. From this initial study some important information was revealed about longevity, including what was instrumental in helping some age well, and what also failed to enhance longevity and healthy, functional aging.

A common thought has been that marriage will guarantee greater longevity (Friedman & Martin). This is a partial truth. To say marriage in itself enhances longevity for all, and therefore acts as a constant without any variation among men and women is incorrect. Marriage apparently benefits men more than women. In fact, divorce also appears to have disparate impact on men, severely curtailing men's longevity. However, for women, the benefits that marriage held among those who participated in the Terman study appeared negligible. Married women did show some mild enhancement in longevity, but overall, marriage was not a statistically significant variable for enhancing longevity among women. Furthermore, women who experienced divorce and did not remarry also did not necessarily suffer severe reductions in longevity as was found to exist among men.

Another common thought is that taking it easy and disengaging from active involvement in society can enhance longevity. However, the Terman study participants who experienced the most career success and had the greatest productivity also had greater longevity (Friedman & Martin). Furthermore, those who continued to remain productive and actively engaged were more likely to live longer lives. This is not to say that enhanced stress is good for someone. However, what may be happening is that a continued level of productivity helps the person remain physically and mentally active and provides them with a sense of purpose. Remaining active and productive may also moderate many of the deleterious stressors that may actually lead to reduced longevity.

Conversely, being detail-oriented, obsessive and worrying about small details has been thought to be traits that could shorten one's life expectancy. However, one of the most consistent findings among those in the Terman study was that having higher levels of conscientiousness led to greater longevity (Friedman & Martin). The study found that the best predictor of longevity in children was having higher levels of conscientiousness and this continued to remain a firm predictor into adulthood. Thrifty, detailed-oriented, and meticulously planning individuals lived the longest among the participants in the Terman study. Apparently, as long as individuals do not engage in a pathological level of stressfully conscientious behavior, being meticulous, punctilious and mildly of the so-called Type A personality variation may be quite enhancing for one's longevity.

A higher level of education has been thought in itself to enhance the probability for greater longevity. However, as an isolated variable, it was not found to be a highly important predictor of longevity (Friedman & Martin). This is not to say that education is irrelevant for longevity. Much more relevant than the number of years of formal education was what has already been mentioned: the level of productivity as well as facing appropriate levels of challenges with a level of efficacy and resiliency. Education could well enhance this given that those with greater education also have more productive and challenging types of work in their daily lives.

Another myth often associated with longevity is that those who are more social and extroverted live longer. However, research has not found this to be necessarily true. In fact, those who were more extroverted did not have any significant differences in their longevity as compared to those who were more introverted. Consider that who are more social and extroverted may also engage in unproductive behaviors such as drinking and smoking that may reduce one's longevity.

Optimism is often touted as a sure-fire characteristic that enhances one's longevity. However, cheerful, optimistic children were actually less likely to live to an older age than their counterparts who were less optimistic and cheerful (Friedman & Martin). Moreover, excessively optimistic individuals who fail to worry about much may actually fail to give credence to signs that may portend potentially important indicators of illness or other forms of deleterious issues.

Exercise is one of the most important lifestyle factors for enhancing longevity. However, just because one is athletic when one is younger does not necessarily mean this confers greater longevity. In fact, those who are very active in youth and fail to stay active in middle and later adulthood, thereby increasing their sedentary lifestyles, nullify any benefits incurred through early life activity. It is important to stay active throughout one's life. Furthermore, one does not have to run long distances, lift heavy weights, or be a gym rat to incur benefits from exercise. An individual who engages in even mild activities like walking daily, gardening, cutting grass, and attempting to limit their amount of sedentary lifestyle can increase longevity.

Many myths and misconceptions related to aging and longevity continue to exist. Although this post has attempted to succinctly address some of the more common ones, this list is far from exhaustive. Nevertheless, this author has attempted to address and refute some of the more common myths that continue to be stated in relation to longevity. That being stated, these findings are based on evidence up to this point in time, so one must view the research tentatively. Furthermore, one must also be careful in interpreting some of the results in binary, either-or, fashion. For instance, just because optimism by itself was not found to be an important predictor of longevity, that does not mean one should look at this in a Janus-faced fashion and become the ultimate pessimist. Furthermore, many things have to be examined in context. Although education, in exclusivity, was not found to be a significant predictor of longevity, education as it relates to other contextual features associated with greater levels of education can, and often do, have important implications for longevity.

Subsequently, research on longevity continues to be in its infancy. There are many more myths that need to be dispelled. Furthermore, there is a need to disseminate the inaccuracies to the public, including a continued need for more accurate information among professionals who work with, and service, the older adult population. As we continue to make greater strides in research on aging more myths and misconceptions will be addressed and corrected as they relate to the myriad of anecdotal types of information that are often associated with what has often come to be termed the "anti-aging industry."

Reference

Friedman HS & Martin LR. The myths of living longer. In Aging-Annual Editions 13/14, Harold Cox (Ed). 2011; pp. 30-31. McGraw-Hill, New York, NY.

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Can We Prevent Alzheimer’s?
November 6, 2013 9:18 AM by Brian Garavaglia
During the 2013 meeting of the American Psychiatric Association, the renowned neurologist, Gary Small, MD, addressed whether a change in one's lifestyle can aid in the prevention of Alzheimer's disease. Although research continues to look for a cure, there currently is no form of treatment that can cure the more than 5 million individuals in the U.S. with the disease. At best, we have a few medications that may slow the disease progression, and in some, these medications may not work at all and even lead to serious side effects.

There is compelling evidence that certain genes play a significant role in this disease. Small pointed out that some of these genes actually enhance an inflammatory response that may lead to the progression of Alzheimer's disease. However, he claimed we are not necessarily prisoners of our genes, and that behaviors such as exercise, nutrition and proper sleep habits can act as anti-inflammatory mechanisms that enhance our brain health.

Physical exercise appears to have the greatest scientific support for helping to prevent Alzheimer's disease. It appears to work by reducing the inflammatory index in the brain and reducing the biomarkers indicative of Alzheimer's disease. Small noted that even as little as 15 minutes of walking each day has been found to demonstrate an appreciable preventive effect of Alzheimer's disease. Small also addressed the issue of enhanced mental stimulation, such as through learning or doing challenging mental tasks. This has been a very common area that has been touted as being important for prevention in the area of dementia as one grows older.

Small also addressed stress as an issue that could potentially accentuate the development of Alzheimer's disease. It is imperative that as individuals age, learning how to relax can be critical in fostering enhanced brain health. Getting a proper quantity and quality of sleep is important to augment relaxation as well as enhancing brain health.

Nutritional intake, especially increasing anti-oxidant fruit and vegetable intake, coupled with increased omega-3 fatty acid, has been found to hold strong preventive features toward enhancing health and warding off inflammation.

Click here to read a full-length article to learn more about preventing Alzheimer's disease.

 

 

 

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Ten Ways to Maintain Brain Health as You Age
October 23, 2013 9:53 AM by Brian Garavaglia
The fear of cognitive debilitation as we age is one of the greatest apprehensions that individuals have about aging. It is also an area of misconception as well. Although dementia and other forms of major cognitive decline are not inevitable as we age as so many think, aging is correlated with greater levels of cognitive debilitation, especially through various forms of dementia. Furthermore, as a larger number of our population reaches older age, more concern has continued to exist on how one may be able to ward off feared neurocognitive disturbances such as Alzheimer's disease. The following are some suggestions that have been made by a number of experts in the field of aging and neuroscience.

The first, and possibly the most important source of enhancing brain health, is to remain physically active, especially through regular exercise. Higher rates of physical exercise can have a pronounced effect on reducing dementia. However, even smaller amounts of exercise, as little as 15 minutes three days each week, can have an appreciable effect on enhancing brain health (Howard, 2012).

Another recommendation has been to engage in resistance exercise through the use of weights or even resistance training through exercise bands or calisthenics. In addition to helping to maintain bone and muscle health as we age, it is thought that resistance training helps to promote insulin-like growth factors to nourish and protect brain cells (Howard, 2012).

A third important tip for brain health is to seek out new skills. This is basically tantamount to learning a new and challenging skill. The emphasis on new and challenging is important since it helps to ramp up metabolic activity in the brain and increase brain cell connections. If a person continues to do things that they are already facile at it fails to provide the neurological fodder for building new brain connections. Do not fall prey to the adage of "old dogs cannot learn new tricks." Although learning may not come as easy as when one was younger, attempt to learn new and challenging things to enhance the connectivity of the brain.

The fourth recommendation is to reduce stress. Stress enhances cortisol levels, an important stress hormone, and unremitting cortisol flooding the brain is neurotoxic, which can lead to cell death in the brain. Subsequently, engaging is various forms and techniques of relaxation, such as through meditation, yoga, or other forms of tension reduction strategies can be very important to one's overall brain health.

One's diet is important. Eating a diet that has higher levels of important fatty acids and antioxidants, such as those found in certain fish, nuts, fruits and vegetables can provide a considerable benefit to long-term brain health. Columbia University found that eating a Mediterranean diet reduced the risk of Alzheimer's disease by 34%-48% (Howard, 2012).

Another area that has been given greater attention is possibly using certain spices that may have a potentially therapeutic effect on the brain. Spices like black pepper, cinnamon, oregano, basil, parsley, ginger, and vanilla are high in antioxidants. In addition, the ingredient curcumin found in turmeric, which is a common ingredient in many Indian curries, might hold considerable potential. In looking at the effect of curcumin in animal research, scientists have found that it reduces amyloid plaques, the plaques that play a considerable role in Alzheimer's disease, as well as also helping to reduce tissue inflammation in the brain (Howard, 2012).

Another tip for brain health that researchers provide is developing a unified sense of purpose in one's life. Researchers have found that those that have a greater purpose with a greater clarity in their goals had reduced levels of Alzheimer's disease.

Developing a strong social life may be a protective buffer in helping to prevent dementia. Being socially engaged and interactive has been found to be very instrumental in enhancing one's health at all levels, and as it relates to brain health, it continues to show important health enhancing effects.

Remaining healthy in other areas helps to promote brain health. Reducing levels of obesity and maintaining a healthy weight, maintaining a healthy blood pressure, and keeping one's blood glucose levels under control are all significant in warding off cardiovascular disease, kidney disease as well as many other forms of physical illnesses, all of which can further increase the likelihood for impairing one's brain health.

Finally, make sure you are mindful of maintaining proper vitamin intake. Most of this can be done through a well-balanced diet, but as we age, one may suffer from vitamin deficiencies due to impaired digestive absorption from food intake. Physicians also have to make sure they are more aware of examining deficiencies in this area that could lead to possible cognitive declines.

Although many individuals think that cognitive decline is an inevitable part of aging, this is not true. Many things can be done to reduce and even prevent cognitive decline. However, as with anything in life, a level of effort is needed to achieve the desired goals. However, getting into a regular habit can provide benefits that lead to individuals achieving a much more functional life.

Reference

Howard B. Age-proof your brain: 10 easy ways to stay sharp forever. AARP The Magazine. 2012, Feb/Mar, p. 53-54, 56.

 

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Further Study of Inappropriate Medications Given to Older Adults
August 27, 2013 6:51 AM by Brian Garavaglia
It has been known for some time that the pharmacokinetic features of many medications are quite different based on the age of the person. In particular, many medications that could be given to younger adults with no issues can often lead to adverse affects when given to older adults. Furthermore, the same dosage of a medication that is therapeutically effective for a younger adult may be excessive or build up to dangerous levels in older adults. Also, there are some medications that could be viewed as totally appropriate for the younger adult, yet given to older adults with the same condition, these same medications may be totally inappropriate.

This level of wisdom regarding medications and age has been firmly consolidated among the medical community when it relates to prescribing therapeutic agents for adults and children. However, for some reason, as it relates to younger and middle-age adults versus older adults, the prescriptive and proscriptive logic for pharmacological intervention is at times clouded or even lost. A recent study in the Journal of the American Geriatrics Society continues to find inappropriate medications being prescribed for older adults. Furthermore, the study found that many of these medications are posing an imminent risk for many of our society's older adults.

The current study examined individuals admitted to the ICU unit and followed these individuals after they were discharged. Adverse occurrences due to medications are the most common problem that many older adults face after hospital discharge. This problem may possibly be getting worse as evidenced by the 96 percent increase in medication-related hospital admissions among those who were 65 to 84 years of age between 1997 to 2008 (Morandi et al., 2013). Moreover, almost one-half of these admissions for adverse medication occurrences occurred among those who were 80 years of age or older (Morandi, et al., 2013). Therefore, given this data, it provides fodder for the current study that followed hospitalized older adults and the pharmacological interventions that they encountered as part of their treatment intervention.

The study was a prospective-based study that examined individuals admitted to the intensive care unit. The study had 135 patients that were enrolled and followed in the study. The average age of the participants in the study were 68 years of age. The individuals were followed during their hospitalization and after their discharge.

The study was interested in tracking and investigating those that were discharged on potentially inappropriate medications (PIM) and actually inappropriate medications (AIM). Drugs that are classified as PIMs are those that can have a potentially detrimental effect for the elderly patient. However, PIMs are not necessarily in-and-of-themselves exclusively detrimental and may have benefits that outweigh their costs in certain therapeutic situations. However, drugs classified as AIMs are viewed as having costs that outweigh any potential therapeutic benefits for the older adult. The elderly have been a growing portion of ICU occupancy and many of these types of medications are first prescribed to the elderly within the intensive care unit. Furthermore, it has been found that 85 percent of the elderly who are discharged from the hospital ICU were prescribed at least one PIM and 51 percent were prescribed at least one AIM upon discharge (Morandi, 2013). It was also found that 50 percent of the PIMs and 59 percent of AIMs were first prescribed while the older adult patient was in the intensive care unit (Morandi, 2013).

Results of the Study

The study found that of the 250 PIMs prescribed to the discharged elderly, the most common types where opioids (28 percent), anticholinergics (24 percent), antidepressants (12 percent), and drugs potentially causing orthostatic hypertension (8 percent). As mentioned, although the PIMs have the potential for causing harm, the study found that most of the time the therapeutic intervention with PIMs had benefits that exceeded any potential for harm. Conversely, in examining the patient cases where drugs classified as AIMs were prescribed, anticholinergics were the most commonly prescribed actually inappropriate medications (AIMs) at 37 percent. Other drugs that were viewed as actually inappropriate medications prescribed upon discharge were nonbenzodiazepine hypnotics (14 percent), and opioids (12 percent). The study found that 36 percent of the elderly discharged on medications that were classified as PIMs, also were classified as actually inappropriate medications (AIMs). The medications classes with the highest representation with the AIM category prescribed to the elderly were anticholinergics (55 percent were actually inappropriate medications), atypical antipsychotics (71 percent were actually inappropriate medications), nonbenzodiazapine hypnotics and benzodiazapines (67 percent were actually inappropriate medications) and muscle relaxants (100 percent were actually inappropriate medications).

Summary

In this study, medications labeled as potentially inappropriate medications (PIMs) were frequently prescribed to many elderly within the intensive care unit and remained as part of their treatment regime even after leaving the hospital. However, after clinical review, most of the PIMs were often viewed as clinically appropriate. However, most of the PIMs did not meet the criteria for being actually inappropriate medications. The authors of the study state that greater focus should be placed on avoiding the use of actually inappropriate medications and less emphasis should be given to those with the PIM classification.

Although the study did find that many of those medications listed as potentially inappropriate medications were being prescribed with appropriate clinical justification, the study also did find that there was nevertheless a clinically significant amount of medications that were documented as being actually inappropriate medications, which were being prescribed to many older adults. It appears that many older adults are still being prescribed medications that have a strongly adverse profile, especially given their age group and greater pharmacological sensitivities that often encompass advancing age. As mentioned at the beginning of this paper, hospital admissions among older adults have been increasing due to adverse medication complications. Although not all of these hospitalizations are due to physician-prescribed medications, physicians may need to become more sensitive to their iatrogenic contributions to this problem.

Reference

Morandi, A. et al., (2013). Inappropriate Medication Prescriptions in Elderly Adults Surviving an Intensive Care Unit Hospitalization. Journal of American Geriatric Society, 61(7):L 1128-1134.

 

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Can Retirement be Harmful to Your Health?
August 15, 2013 7:16 AM by Brian Garavaglia
A recent study out of France has examined the impact of retirement and the probability of developing dementia. There have been few studies that have examined the relationship between retirement and dementia, but this study demonstrated an impressive and statistically significant relationship between these two variables. The study's findings demonstrated that retiring later in life significantly reduced the likelihood of a person developing dementia. Dr. Carole Dufouil who led the study stated that the findings demonstrate the "importance of maintaining high levels of cognitive and social stimulation throughout work and retiree life."

The study found that those who retired at 65 years of age had a 14.6% lower risk of developing dementia than those who retired at 60 years of age. This reduced risk, holding all other things constant, what statistically significant at P < 0.0001. This result demonstrates the highly statistically significant results found to exist for those that retired later than earlier in life.

The study is being viewed as further evidence for maintaining intellectually and cognitively engaged. The so-called "use it or lose it" principle appear to be at play here. The assumption found in this study is that those that maintain more years of work also maintain greater cognitive activity that could be beneficial for warding off cognitive decline. Therefore, work in itself is not the key, but work as a method of maintaining a level of cognitive stimulation is what is important. Subsequently, it can also be assumed that many individuals who retire concomitantly fail to maintain adequate levels of cognitive stimulation. If individuals use retirement as a source of complete disengagement, this may hasten cognitive decline. Therefore, if one's work is their only source of cognitive stimulation, a person may want to rethink about retiring early since it may hold formidable consequences for their cognitive health.

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Oliver Sacks Rejoices Over His 80th Birthday
July 8, 2013 5:12 PM by Brian Garavaglia
The Joy of Old Age (No Kidding) is a very inspiring editorial written in the New York Times by the well-known and world renown neurologist Oliver Sacks.  Sacks describes his life, as well as his thoughts, about his approaching 80th birthday.  Far from feeling a sense of despair, he explains that he welcomes his approaching birthday and is looking forward to having achieved such a milestone.  Sacks is still practicing, still teaching, and still writing.  He continues to feel compelled to make contributions and not sit or foster a level of complacency.  In this editorial, I personally was struck by how Sacks has adjusted to his later stage of life.  He does not attempt to sugar-coat his 80 years of life and he does mention that he has some regrets  as stated,

I am sorry I have wasted (and still waste) so much time; I am sorry to be as agonizingly shy at 80 as I was at 20; I am sorry I speak no languages but my mother tongue and that I have not traveled or experienced other cultures as widely as I should have. 

In his own inimitable way, he provides an incisive editorial that begs to be read.  Even as Sacks is approaching his 80th birthday, one cannot help but feel his excitement that he exudes as he approaches the end of his life, yet views each day enthusiastically and energetically as a new beginning.  As he states: "Eighty! I can hardly believe it.  I often feel that life is about to begin, only to realize that it is almost over."  One has to think, that even as Sacks is in the winter season of his life, that season still will be a long and productive one. 

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Yoga Shown to Stimulate Brain Function
June 13, 2013 12:20 PM by Brian Garavaglia
Some recent research has produced some very interesting results regarding yoga and memory. It was found that a 20-minute session of Hatha yoga significantly improved the cognitive abilities of the participants of the study, especially related to working memory and inhibitory cognitive functions. Although most of the participants in the study were younger, similar results have been found using older adults. The study was led by Neha Gothe, professor of kinesiology, health and sports studies at Wayne State University and its findings were reported in the Journal of Physical Activity and Health. 

The Yoga participants engaged in a 20-minute progression of seated, standing and supine yoga postures. While in these different yoga postures, the participants used various isometric muscle contraction and relaxation techniques as well as regulated deep breathing techniques. The participants also completed an aerobic treadmill workout, since in previous studies aerobic exercise has been shown to enhance memory and cognitive performance.  

Gothe and her colleagues were surprised to find that the participants who engaged in yoga showed marked improvement in reaction time and accuracy on cognitive skills tests that were superior to those effects found when compared to the aerobic exercise condition. In fact, the aerobic exercise condition failed to demonstrate any significant improvements in working memory or inhibitory control on their cognitive skills tests.   

The effects found from meditation may actually result from the reduction in anxiety and stress that often is found to exist among those that engage in yoga, especially brought about through systematic muscle relaxation and deep breathing. Yoga also teaches more focus on body movements, leading to a greater level of body-mind awareness while blocking out many of the distractions that often lead to stress and anxiety in our daily lives. 

Yoga often makes use of controlled systematic movements, having the person provide attention to their body movements and sensations, while blocking out many of the other distractions that often impinge on our conscious lives. Moreover, using breathing and muscle relaxation helps to provide a complete body relaxation response. Yoga also provides effective techniques for helping to strengthen muscle tone, enhance flexibility, and exercise one's brain mechanisms that help to enhance balance. 

Although yoga looks deceptively simple, it is a skill that often takes considerable practice to achieve successful results. This could be problematic for many older adults who may not want to enter into a type of health modality that takes some time to learn and be successful at, especially to achieve the desired beneficial health-enhancing results that were found among the participants in the study. 

Nevertheless, yoga does appear to have many salubrious effects. Given its ability to help assist with overall relaxation and reduce stress levels -- both of which if not regulated have been found to lead to a greater probability of illness and accelerated aging -- it would behoove individuals to learn and practice yoga and even various forms of deep breathing and systematic muscle relaxation on a daily basis. In fact, starting off with short 5 to 10-minute sessions a couple of times daily, gradually increasing in the time spent using these techniques throughout the day may be the best way to learn and eventually become proficient at using these important health-enhancing skills. 

Yoga combines breathing and muscle relaxation with body movements and an enhanced attentional focus. Many who practice yoga say that the attention they have given to their body movements leaves them feeling mentally relaxed. This type of enhanced attentional focus could often be beneficial toward helping many older adults deal with issues such as pain (both physical and emotional), anxiety and depression.  However, here again, achieving  the attentional focus that is often needed for efficacious results is often something that takes practice in achieving.  Therefore, again practice is needed.

The overall results from this and other studies have demonstrated favorable results toward health enhancement. However, yoga techniques are skills in themselves that have to be learned. Many people frequently make the incorrect assumption that achieving a state of relaxation or an enhanced level of healthful consciousness can be achieved be sitting around the house or lying down and taking a nap. 

As with anything in life, to achieve optimal benefits, a level of work must be done to correctly learn how to achieve the 1) level of attentional focus one needs to optimize the yoga response; 2) be able to correctly breathe in a manner that facilitates relaxation; 3) learn how to systematically engage is isometric muscle tensing and relaxation to achieve proper muscle relaxation; and 4) be able to become sensitive to the kinesthetic and proprioceptive abilities that we often fail to pay attention to, yet provide important feedback information about our body and its level of tension and relaxation. 

Therefore, instead of thinking of yoga as something that people in other countries do, help older adults open up their minds by toward gradually introducing yoga, or some of the methods that yoga uses, to help enhance their total level of health and fitness. Although it does take practice, the benefits that can be achieved from learning this important technique are worth the time and effort.   

Reference: Science Daily (2013, June 5).  A 20-minute bout of yoga stimulates brain function immediately after.  http://www.sciencedaily.com/releases/2013/06/130605190552

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Older Adults Need to Watch Out For Anticholinergic Agents
May 29, 2013 1:19 PM by Brian Garavaglia

Acetylcholine is an important neurotransmitter found in the brain. In fact, reduced amounts of this neurotransmitter have been found to exist in the brain of those that suffer from Alzheimer's disease. Acetylcholine is an important neurotransmitter that plays a significant role in memory, as well as innervation of muscle activity. Anticholinergic agents counter the effects of acetylcholine and block this important neurotransmitter. As was mentioned this can potentially cause adverse effects on memory since it is an important agent for memory.

Older adults can be especially sensitive to medications that fall into the anticholinergic classification. Furthermore, many medications, both prescription and over-the-counter, have anticholinergic potential, leading to potentially harmful effects on the elderly. It has been found that older adults using medications that have anticholinergic features for just two months are at an increased risk for mild cognitive impairment.

However, it appears that not only is the length of anticholinergic medication use important, but also the strength of the anticholinergic agent. Malaz Boustani, MD, associate director, Indiana University Center for Aging Research, studying the issue of anticholinergic agents found that the risk for cognitive impairment increased by 50 percent in adults receiving at least 3 mild anticholinergic agents for more than 90 days and by 100 percent for those receiving one or more stronger anticholinergic agents for 60 or more days.

Common over-the-counter agents such as Benadryl, Sominex, Advil PM, Dramamine and many cold and cough suppressant agents that have dextromethrophan have anticholinergic properties.  Many of these agents are taken quite regularly by many older adults for colds, sleep, and allergies, often unbeknownst to their physicians. However, physicians as well have been guilty of over-prescribing anticholinergic medications to older adults.  Dr. Boustani states that physicians "absolutely" have been guilty of over-prescribing these forms of medications and often write these prescriptions out with ease and haste instead of sitting down and discussing possible alternatives with their patients.

Many commonly prescribed medications that are frequently used among many older adults have considerable anticholinergic effects. For instance, many drugs used for urinary or bladder issues, such as Oxybutynin, have considerable levels of anticholinergic potential.  Furthermore, many medications for treating various forms of mental illness such as antipsychotic and antidepressant medications can have varying levels of anticholinergic potential.  Even many agents used to treat Parkinson's disease, heart dysrhythmia, and vomiting just to name a few have anticholinergic properties that can adversely affect the cognitive level of many older adults. 

It should be mentioned that the use of anticholinergic medications, although having the potential to lead to mild cognitive impairment, does not subsequently lead the older adult to the more debilitating state of dementia. As Dr. Boustani states, "We found that these medications are a risk factor for the development of MCI, but they are not risk factors for developing dementia."  Furthermore, mild cognitive impairment caused by anticholinergic agents is a reversible condition. 

Other studies have also found considerable issues with anticholinergic medications and the elderly. In fact, it was found that 23 percent of the medications used within a Medicare managed care population were potentially inappropriate.  In fact, antidepressant and anti-anxiety medications were the most commonly cited medications, and it was found that the anticholinergic potential that many of these medications have is often overlooked by many physicians prescribing these medications for the elderly. 

The pervasive anticholinergic impact found among many medications, the potential they can have for cognitive impairment, and the heightened sensitivity that many older adults have for these types of medications makes it very important for physicians to be especially mindful of prescribing these medications if alternative or optional modalities are available.  Furthermore, older adults need to be more careful in the types of medications they use on an over-the-counter basis. In addition, using the expertise of the pharmacist and requesting their advice on medications that older adults may purchase which may have an adverse anticholinergic impact, many also help to forestall future cognitive impairment related to cursory medication usage.  Physicians and older adults have to work together to ward off potentially negative effects of many medications that may ultimately have an ill-effect upon the cognitive health of many of our nation's older adults.      

Resources

Anderson P. Just Two Months Exposure to Anticholinergics Affects Cognition.  Medscape News, May 22, 2013:  http://www.medscape.com/viewarticle/804558?src=wnl_edit_medn_wir&spon=34

Robinson DS. Anticholinergic Effects of Drugs and Cognition in the Elderly. Primary Psychiatry 2009;16(5):19-21.

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    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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