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Gerotalk

A Simple Piece of String Can Enhance Your Life
December 8, 2014 10:52 AM by Brian Garavaglia

Living longer. Many individuals are often attempting to find some fountain of youth that can enhance their lives. Commercials and advertisements abound with supposed remedies that will increase one's life. Yet, a very simple technique that dentists have been advocating for years can be an important enhancement for one's longevity. Research has been finding that oral care is very important for not only warding off diseases of the mouth, but also other more systemic ailments. Furthermore, gum health and regular flossing of one's teeth can be an incredibly important lifestyle feature that can be an important preventative form of health care as well as a technique that can be used to enhance one's life.

For years dentists have advanced the importance of using that simple piece of string to mechanically remove debris that settles in between teeth and at the gum line. The gums often become inflamed due to bacterial infections, many of which go unnoticed. Food particles that remain between teeth and in the gum lines can further produce a very good growth environment for bacteria. Bacteria within the gums does not just stay within the oral cavity, but further migrates to other areas of the body. In particular, recent research has paid particular attention to how poor oral care and infections in the oral cavity can contribute to heart disease. In addition, chronic inflammation of the gums due to bacterial infections can lead to further health issues as the bacteria moves to other areas of the body. These continuous levels of infection within the gums and oral cavity can continue to lead an assault on the body that reduces one's life expectancy. 

Many simple solutions often fall far short of their stated results. However, a simple piece of string or dental floss used regularly appears to be one of those important simple, yet profoundly impactful lifestyle habits that can hold significant consequences for a person's longevity. Many individuals often have minimized the importance of oral care in general, and flossing in particular, as part of a healthy lifestyle behavioral intervention that can enhance one's health and longevity. In fact, it has been estimated that sound oral health can add approximately 1.5 to 6 years to one's longevity. 

Most of the older adult population fails to recognize the importance of flossing. Moreover, most of the older adult population also show signs of gum disease. This is problematic since not only is gum disease the leading cause of tooth loss, it is evidence of a constant and unabated infection that exists. A continuous level of bacterial buildup infecting the body can have a pervasive impact on one's health. That can ultimately lead to more health issues and premature death. Yet, a very simple mechanical measure of flossing daily can provide important dividends for one's overall health. 

As problematic as gum infections are in the mainstream population, among the institutional population it is even a greater epidemic issue. Among those older adults within nursing homes, dental hygiene is often overlooked by caregivers. A large portion of the nursing home population not only fails to receive adequate professional dental care, but they are also failing to get the appropriate level of daily care that can lead to not only good dental and periodontal health, but also assist in forestalling greater levels of infection, compromised health, and possibly unnecessary hospitalization. Again, much of the inadequate dental care provided to older adults is frequently due to the lack of knowledge among the staff regarding the importance of oral and dental health to the overall systemic health of the person.

Given the growing level of research on dental health and its connection to the overall health of the person, it is becoming increasingly apparent that aging in a healthy manner, compressing overall morbidity as we age, as well as increasing our longevity is dependent upon paying greater attention to our dental care, and in particular being sensitive to our gum health and our need for proper flossing to assist in this area. It appears that individuals can often be dismissive about the importance of flossing, particularly due to it being a very simplistic modality which intuitively does not seem to fit with the complexity that we often seek for increasing health and longevity. Yet, this very simple dental procedure, if used daily, can aid in gum health, and aid in the general health of the person, which in turn can potentially add years to one's life.     

References

Stibich, M (2014).  Simple steps to increase your life expectancy.  http://longevity.about.com/od/liveto100/ss/life-expectancy_4.htm

Adult dental health: Healthy aging (2014).  https://www.deltadentalins.com/oral_health/adult-dental-health.html

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Finding the Problem: Avoiding the Misguided Search
October 30, 2014 11:11 AM by Brian Garavaglia

One of the buzzwords in long-term care is looking for the "root-cause" for various problems that arise. Many of these "root-cause" searches are often based on resident care. Others are often facility-based, especially related to financial information, staffing, and general supplies and facility maintenance. However, many of these supposed "root-cause" analyses often fall far short of ever finding the supposed cause that they were set to initially determine. In fact, many frequently become side-tracked and move into other areas, compromising their focus on the initial target. What follows is a brief overview of a few major issues that lead to problems in long-term care never being discovered and subsequently addressed. 

Failure to Understand and Find the True Problem

To be able to address a problem, the problem has to be clearly defined. It is common to find and address a problem. However, whether it is truly the problem that is leading to the issue is a totally different story. The successful amelioration of a problem is incumbent upon defining the appropriate problem. All too often attempting to isolate what the true problem is provides considerable difficulty. The reason for this is that often there are a number of potential issues that are closely related. Yet, each of these issues may have considerably different ramifications. However, without being able to isolate the specific issue or problem that leads to the particular health care consequence, the person is left chasing rainbows. 

Finding the specific issue and then defining the problem is much more difficult that it appears. This author has provided simple, single paragraph problems to his classes in which they were instructed to find and isolate the problem that brought about a particular scenario. When the problem was imbedded with other superfluous information most individuals often failed to identify and isolate the specific problem or issue. Many targeted the consequence, and not the problem. Furthermore, many others often would isolate the superfluous issues that were not even close to being related to the true problem. Without any training, isolating a problem that is leading to the consequence of a particular situation is quite difficult. Yet, in health care situations, adjurations are often made for health care professionals to undertake this task as if it is easy or as if long-term care professionals and administrators are well-practiced and proficient at this task. Many of these individuals are often surprised to find out how a seemingly very simple problem in a single paragraph is unable to be clearly isolated and articulated. Therefore, given these results it should be no surprise to find that many individuals often fail to find and express the true problem in real-life situations when these problems are often much more intertwined with a myriad of other closely aligned, yet different problems, all leading to very different consequences.  

The Illusion of Cause 

Cause if often referred to as the goal in examining problems faced within any health care area, including long-term care. However, the image of a person often finding and isolating a single cause, as is often misleadingly made during such techniques commonly referred to as "root-cause" analysis, leads to an impression that there is often a single root cause that can be found for everything. This is a residual aspect of the Platonic vertical process of thinking, which asserts if you dig deep enough you will always find the quiddity for anything. However, this is far from being the reality that exists. A single "root-cause" is often not a reality, since often there is frequently more than one antecedent that can lead to a single cause. Furthermore, a single antecedent can lead to more than one consequence. Moreover, often the best that we can find is not a cause but a number of correlations, often failing to understand the distinction between causative and correlational findings. As one can see, something that is often conveyed as being a facile assignment of finding a problem is quite complex and needs considerable training. Far from what most higher level managers or executives assume when they mandate these problem-solving assignments onto their staff, this assignment, looking for a "root-cause" or any type of cause, is far from manageable for most individuals who fail to have proper training in this area, including most upper level managers.

Moreover, think of a simple cause that you do find. A simple cause (C) will often have many subcomponents involved (C1...........Ca). Take for instance something apparently simple such as turning on a light. What causes the light to be turned on (C)? The person flipping the electrical switch? However, is that the cause? Yes, but not the sole cause. What about the switch making proper contact? What about having a proper electrical conduit? What about the need from proper electrical wiring? What about paying the electrical bill to maintain electricity coming into the home so the switch can activate the process? Also, what if all of this is in place and there is no bulb within the light socket? As one can see, C (turning on the light switch to turn on the light) actually subsumes a number of other features that also are part of the causative process.

What about a person that has a medical issue such as an ischemic cardiac incident? Apparently, since it is an ischemic issue that should be the cause (C = ischemia). Although that may be viewed as the proximal cause, could there be others. Could volumetric changes in the blood and viscosity also be issues that are even more proximal? What about the inadequate nature of certain clotting factors? What about continuous lack of mobility leading to thrombotic features to form?  Could a poor diet of fried food and saturated fats be causative? Could the lack of exercise have led to this issue? Could heavy smoking, along with a generally unhealthy and sedentary lifestyle have been the true ultimate or root cause? Here again, we see a number of causative factors that often are inclusive in what many individuals have assumed is the apparent cause. Is what was thought to be the apparent cause (ischemia) just the most recent and proximal of many other linkages that were more distally causative? Look at the complexity that just in these brief few paragraphs have been brought to the attention of the reader. And yet, when many long-term care personnel are instructed to find root causes, personnel who have often little if any training in this area, the assumption is that they will assuredly find the root cause. What is even more disconcerting is that those that do the investigation, frequently in a cursory manner, often come away with a false self-confidence in their results, thinking that without exception they have found the elusive, quintessential factor that led to the problem.  

So What are the Consequences?

Problems are an endemic part of life. Finding the reason for their existence and attempting to solve these problems are an unending quandary that we face as part of life. Problems in long-term health care situations are no different? Whether it is attempting to find the reason behind unanticipated hospital admissions, or why average staffing ratios are running higher than in other facilities, or even why family members are selecting other facilities over your facility, many mistakes are often made toward attempting to find and solve important problems. 

Thinking that one will always find the so-called "root-cause" is one major misattribution. Many problems quite simply will never manifest a clear "root." Furthermore, assuming that there is only a single cause is also quite problematic in itself. Even though many executives are adjuring their staff to "find the problem," they themselves, referring to the "problem" in its singular form are framing the issue in such a manner that those that will approach the problem will think that there is a single cause. Even the concept of "root-cause analysis" often conveys that a singular cause can be found and is always there to be apprehended. 

Furthermore, another issue that has been mentioned is that individuals will often approach problems in health care without a clear understanding of what the problem is. Failing to clearly isolate and identify the problem will provide a totally misguided approach to solving any particular problem. Regardless of the assiduous nature of your investigatory endeavor, you could painstakingly follow a wonderfully deductive and logical approach that achieves a perfectively sensible result and solution. Yet, if you start off with the wrong problem, the solution will nevertheless be incorrect. For instance, consider the following:

  • All dogs have three legs,
  • Buck is a dog,
  • Therefore, Buck has three legs

Is the syllogism above logically correct? Yes, but is it true since it started out with an incorrect major premise (All dogs have three legs)? No, it is absolutely not true. Even though it is deductively valid, following the steps to achieve a logical conclusion, starting out with an incorrect premise still leaves us with a valid conclusion but one that is not true-all dogs do not have three legs. The same exists for those that start off by defining the problem correctly. A valid conclusion may be deductively found, but it may have nothing to do with the correct problem. 

Thinking that solving problems correctly in long-term care can be achieved by anyone and just by using a little hard work is a very misguided assumption. Problem solving is something that needs considerable practice and training. All too often, problem solving, not just in long-term care but in all health care is approached with an ill-conceived, loosely structured, and even a somewhat cavalier attitude. However, hopefully after reading this paper, individuals will see that problems, finding them and solving them are often far more complicated than many think and that it often entails a considerable level of training and practice to become proficient at such a practice. Understanding the complexity of problem solving and consistently practicing your skills and avoiding some of the common errors that have been discussed will ultimately lead to addressing many concerns that arise within long-term care in a more insight and productive manner.                       

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Can Jellyfish Hold the Secret to the Fountain of Youth?
October 22, 2014 2:06 PM by Brian Garavaglia
The fountain of youth and eternal life has been something that has been sought and spoken about for a number of years. We still often hear the term, "anti-aging" used in reference to various types of supplements that are frequently advertised, as if using these supposed products will reverse aging or prevent any further aging in the person.  However, some recent research has provided a level of authenticity to claims of age-enhancement. 

However, who would have thought that the answer to some of these questions may be found in the jellyfish. One researcher thinks that these marine animals may be able to provide important contributions to our knowledge regarding aging. These gelatinous, strange-looking aquatic forms of life are now being looked at for holding some possible answers to the questions for life-enhancement. 

A professor at Kyoto University in Japan, who has been studying jellyfish for over three decades, feels that these creatures may hold important clues toward potentially enhancing human life expectancy. Shin Kubota has been studying the jellyfish since 1979. According to Kubota, one type of jellyfish has a particular quality to regenerate itself and take on a level of immortality. The type of jellyfish that has this potential is referred to as the scarlet jellyfish. He stated that this species of jellyfish have the ability to "rejuvenate" themselves.  Furthermore, he has also noted that there are two other species of jellyfish that also hold this potential. 

According to Kubota, the adult scarlet jellyfish, referred to as a medusa, when injured, goes to the ocean floor. However, instead of dying, it goes through a process of rejuvenation.  It goes back into an infant state of development referred to as a polyp. The polyp continues to develop back into the adult medusa.  Kubota, in his laboratory work with this species of jellyfish has been able to successfully make the jellyfish rejuvenate 12 times in his laboratory studies.     

Kubota states that genetically the jellyfish and humans are not that different. Therefore, he is hopeful that the studies will result in finding out further information about this regenerative ability found in the scarlet jellyfish that may be able to be applied to human beings, which may ultimately help enhance their longevity. However, the research is still in its early stages. However, it does lend a level of excitement, witnessing one living species that may have some level of immortal ability being able to possibly lend some secrets that may help human beings enhance the overall life expectancy as well.

One note of caution has to be mentioned. Kubota himself recognizes the possibilities that this research may hold for human development. However, at this time there is still much more research and many questions that need to be answered. Yet, there are some products that are currently being advertised as anti-aging or longevity enhancing products that are taking advantage of the scientific findings of the jellyfish research and marketing themselves has having "the chemical compound" that is found in jellyfish and that will enhance human longevity. So watch out for those products that are attempting to use scientific research, such as has been discussed here, and often misrepresenting that research as if it were definitive in an attempt to sell a product that has no proven standards.     

Reference

Said-Moorhouse, L. & Sealy, A. (2014, Aug 29). Does 'immortal' jellyfish have the secret to everlasting life? CNN World.  http://www.cnn.com/2014/08/28/world/asia/can-immortal-jellyfish-unlock-everlasting-life/?c=&page=1

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One Half of Commonly Prescribed Medications Increase Falls Among the Elderly
September 3, 2014 11:26 AM by Brian Garavaglia

The European Journal of Public Health has found some important news: Many medications prescribed to the elderly may potentially lead to more harm due to falls, which subsequently can lead to certain life-threatening injuries. It was found that one-half of the 20 most commonly prescribed medications that are used frequently among the older adult population increase the risk of falls. This is very sobering news since many of these medications may be needed for other health related conditions, yet the cost may be falls that could in fact lead to more serious issues than the initial conditions that the medication was prescribed for.

Among the most serious medications that contributed to the increased fall risk were painkilling medications and antidepressants as well as sedatives and hypnotic agents used for sleep. All of these medications have an impact upon the central nervous system. They can cause grogginess, lethargy, a lack of coordination, and a clouding of one's consciousness, all of which may greatly increase an older adult's likelihood of falls.   

The researchers analyzed data on nearly seven million Swedish elderly and they found 64,399 cases of falls that lead to hospitalizations that were contributed to by the use of medications that had fall-inducing effects. The researchers found that those that were taking opioid and antidepressant medications had more than twice the likelihood of experiencing an injury due to a fall as compared to those that did not take these medications. Opioids are powerful pain killing medications, such as codeine, morphine or Vicodin just to name a few. They are opiate or opiate derivatives that have can not only have a pronounced pain killing effect, but they also can have a powerful effect on a person's consciousness as well as well as leading to an unsteady gait. Antidepressant medications, prescribed for depression or anxiety, often can lead to anxiety or feeling jittery, lightheadedness, and an unsteady gait. These are just a few of the common side-effects that can be found among these medications. Furthermore, the likelihood for these side-effects, all of which can lead to greater likelihoods for falls, increases with age. Although older adult males and females who took opioid medications appeared to be equally likely to experience adverse side-effects leading to falls, older women who took antidepressants had approximately 75 percent greater likelihood of falls.  

There were some surprising medications that appeared to be correlated  with an increased risk for falls. Medications used to treat GERD, calcium, often used for bone health supplementation, Vitamin B12, frequently given at higher doses by way of injection by physicians, and certain non-opioid pain killing medications demonstrated an increased risk of falls that ranged from 15% to 75%. Diuretics, often referred to more colloquially as water pills and frequently prescribed for edema due to congestive heart disease also was found to increase the probability of falls        

It must be stated however that these were correlational findings.  In other words, this was not a cause-effect finding. It is often very difficult to differentiate between the falls being due to the affects of the medications or due to the underlying medical conditions of the elderly. However, as one physician stated, one needs to pay attention to symptoms caused by many drugs that can potentially lead to falls. Individuals, including the older adult's physician, have to be vigilant for such things as vertigo, drowsiness, motor movement impairment, muscular weakness and cognitive impairment.  

The likelihood for experiencing side-effects that may cause falls does not in itself mean that these medications are not justified for use in the elderly. What it does state is that the physician needs to always consider weighing the fall risk that is incurred versus the therapeutic value that the medication may have for helping the quality of life of the older adult.

Older adult's become more sensitive to the side-effects of almost all medications as they age. The medication's dosage levels are often not determined based on different adult age group variations. This in itself is problematic since different ages, based on changes in the biological organism's structure and function as we age also alter the pharmacokinetic effects of medications. Therefore, given this, one needs to make sure that individuals are judiciously followed and evaluated for adverse effects that may potentially lead to falls and offset any therapeutic value of using the drug.         

References

Kennedy, M. (2014/Aug).  Many Meds Taken by Seniors Can Raise Risk of Falls.  Medscapehttp://www.medscape.com/viewarticle/829826?src=wnl_edit_medn_wir&uac=87637DR&spon=34

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New Study Examines Gait Speed as Being Related to Future Dementia
August 19, 2014 10:07 AM by Brian Garavaglia

Dementia is a prominent concern among the older adult population. As the elderly population continues to increase, the number of those with dementia also will increase in number. Recent research on dementia and cognitive impairment in the aging has targeted a new disorder and with it, a new symptom that may be related to the likelihood of acquiring dementia. 

A recently newly defined disorder found among older adults, referred to as motoric cognitive risk syndrome (MCR) is characterized by cognitive decline with motor-based symptoms. The disorder appears to be common in older adults. However, those that have the disorder also appear to be at greater risk of developing further cognitive impairment that leads to various forms of dementia, including Alzheimer's disease. In fact, those that developed MCR were approximately two times more likely to develop dementia. 

The current syndrome, motoric cognitive risk syndrome, is diagnosed by simple questions related to memory as well as measuring gait speed over a fixed distance. MCR is able to be diagnosed independent of cognitive tests. The group under study was composed of 26,802 older adults, with an average age of 71.6 years. Slightly more than half of the sample was women. There were 22 cohorts from 17 different countries that made up the sample. 

Gait speed was measured using a stop watch and measuring the fixed distance that one walks within a given period of time. The average or mean gait speed was 81.8 cm/s, which is slightly less than three feet traveled per second. Those who were one standard deviation below the average walking speed were viewed as slow walkers and therefore comprised motorically. 

The finding showed that those that were diagnosed with MCR had worse performance on all cognitive tests than those who were not diagnosed with MCR.  Those with MCR also had a higher prevalence of disease, especially vascular diseases. The diagnosis of Motoric Cognitive Risk Syndrome has appeared to be able to have important predictive value as well. As Dr. Joe Verghese, lead study author states, "You would expect that the people who actually have dementia but are being classified as MCR would meet dementia criteria pretty soon over the next 2 or 3 years, but if you take them out, that would suggest that MCR can predict beyond the initial few years and capture cases that are going to develop dementia more than 3 years out." 

The study emphasized the importance of gait speed as being an important predictor of future dementia. As Dr. Verghese states, gait speed is highly reliable and has been a very sound predictor of health outcomes. In addition, gait speed measurements are simple, highly accessible, and easily done in most health care settings. However, he also stated that it may not be the only, or even the strongest motor predictor of dementia. However, the research in this area has been limited up to this time.   

Given that predementia testing is often quite expensive and frequently not covered by insurances, simple and expensive forms of testing and diagnostic evaluations are often welcome. Although this study appears to shed some light on a new diagnosis that may be an important predementia diagnostic, as well as the use of simple and less expensive diagnostic assessments for anticipating future progression to dementia, the new syndrome and its concomitant diagnostics will probably not be fully embraced at this early level. Furthermore, more research will be need to be completed before one can provide greater assurance regarding the validity of this new diagnosis and whether it is truly an important predementia diagnostic that can enhance our ability toward slowing down the progression of dementia.

Furthermore, the study did not appear to address the cause and effect nature of the issue of motor decline as it relates to dementia. Is motor decline a sign of, or even cause, of impeding dementia, or is it a related effect of dementia, albeit incipient stage brain changes that may already be occurring due to the dementia process. Moreover, if a person stays active and maintains a better gait speed, will that reduce the likelihood of dementia? Finally, is MCR a diagnosis that is truly separate from the dementia diagnoses and by creating a new diagnostic category will it be useful for treatment intervention or is it just another label being attached to the elderly person?

Many of the above questions I feel still need to be answered before we enthusiastically embrace a new diagnostic category. For the most part, some of the discovery that motor involvement may be related to dementia is not a great surprise since many forms of dementia will demonstrate motor issues as the disease progresses due to further insult upon brain tissue. I feel that the main question that really is of concern here and that needs to have greater clarification is whether:

  1. maintaining enhanced gait speed through exercise will reduce the likelihood of future dementia
  2. whether the diagnosis of MCR will be useful so that successful intervention can be brought about that would ultimately prevent or slow down further neurological disease progression.    

References

Anderson, P. (2014, July).   Slow Gait, Cognitive Complaints Predict Cognitive Decline.  Medscape, http://www.medscape.com/viewarticle/829135?src=wnl_edit_medn_wir&uac=87637DR&spon=34#1

 

 

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Will Nursing Home Care be a Viable Option for the Baby Boomers?
July 21, 2014 11:45 AM by Brian Garavaglia

The baby boom cohort, those who were born between 1946 and 1964, is the largest birth cohort that has ever been produced in the United States.  As soldiers returned home from the war, the birth rate increased and subsequently for a decade and a half, we witnessed a very large number of children being born. Furthermore, we also have witnessed an increasing life expectancy as many acute illnesses that formerly lead to early mortality have now been controlled or conquered. Given the burgeoning birth cohort, coupled with an increased life expectancy, our population will be witnessing a large increase in those who are 65 years of age and older. The impetus for much of this increase will be found in the baby boom cohort as more and more of the group continues to age and move into the later stages of life. Inevitably, as the population ages, there will be a need for many older adults who will need placement in nursing care facilities. However, given the need, will they actually be able to afford such care is a question that is being asked. 

A recent report, released by the National Institute on Aging, states that the problem of affordability for nursing home care may be very serious in the years ahead and may limit those in the baby boom cohort from being able to obtain the needed nursing home care that many will need. One of the changes that occurred among the baby boom generation is that as they aged and married, their birth rates went down. Many of those baby boomers had significantly less children than their parents and grandparents did. As the baby boom cohort ages, many of them will have more chronic illnesses and will be in need of extended care. However, since they have had fewer children, who in past generations often assisted with parental care, nursing home care for many may be the only alternative. Yet, nursing home care is expensive and will continue to be even more expensive in future years. Furthermore, with a greater life expectancy, more chronic illnesses, and less adult children to assist with care, the baby boomers will be facing the potential need for a greater number of years in which care will be provided from an extra-familial source like a nursing care facility. 

Richard Suzman, who is director for the National Institute on Aging's Behavioral and Social Research division states that this demographic change that will be part of the baby boomers entering later adulthood will approach a crisis situation in the years ahead, stating "Baby boomers had far fewer children than their parents. Combined with higher divorce rates and disrupted family structures, this will result in fewer family members to provide long-term care in the future. This will become more serious as people live longer with conditions such as cancer, heart disease and Alzheimer's"1.

The National Institute on Aging examined the average cost of nursing home care. In 2010, the average cost of a private room within a nursing care facility was $229 a day, which equated to $84,000 each year1. Although semi-private rooms, which most older adults are placed in are less expensive, the costs still are typically well over what most can afford, especially on an extended level. Furthermore, the National Institute on Aging also found that given the cost of nursing home care, less than one-fifth of all older adults in the United States can afford to live within a nursing home for more than three years. Even more disconcerting, nearly two-thirds are unable to afford the cost of nursing home care for even a single year1

As one can see, given the current problems of affordability, coupled with the increasing size of the future older adult cohort, a serious problem for servicing the chronic health care needs of the older adult population is quite evident. Since the current older adult population makes up approximately 13 percent of our population and will expand over the next 35 years to approximately 20 percent of the total population, one can start to see the important issue that arises as it relates to older adults and their potential long-term health care needs. How will they as a group be able to get the needed long-term care to assist with their needs if it is a resource that they will not be able to afford?   

Another concern that needs to be mentioned is that Medicare payment covers at most only 100 days of skilled nursing home care after a qualifying hospital stay. However, even this level of small assistance is not a given. As mentioned, not all individuals qualify for 100 days, and even if they do there are also copayments that also are applied as well. Moreover, as the high inflationary costs of the medical industry continue to place a tremendous burden on our social system, one has to ask will there be any cuts in Medicare as it applies to nursing home care in future years. 

Furthermore, Medicare, an insurance for the indigent, pays almost one-half of the long-term care nursing home expenses in the United States1. However, to qualify, most individuals have to severely reduce most of their personal assets to an indigent level. This has to give many a time to pause and consider that after a lifetime of accruing some level of net worth, at the end of their lives when they need care most, they have to become indigent just to be able to obtain the care they need. This is not a dignified level of existence as one moves to their final stage of life. 

Moreover, currently, the Affordable Care Act has mandated greater allocation of assets to increase the state Medicare coffers. However, that is not explicitly for nursing home care. Furthermore, here again, one has to wonder, given the inflationary health care climate, how long additional resources diverted to Medicaid will be able to last to support this endeavor.

As one can hopefully see, we are approaching a crisis mode for individuals of the baby-boom cohort. As this large birth cohort now is moving into the older adult stages of life, the population that is 65 years of age and over will start to increase dramatically and will be approaching approximately 20 percent of the total population over the next 35 years. However, the question remains, how will many of these individuals, with increasing life expectancies and the greater burden of an ever-increasing amount of chronic conditions be cared for? Will they be able to afford the long-term care options to assist them with their health care needs? Furthermore, with less children available to shoulder the burden of care for their older adult parents, the need for long-term placement, which may be a placement even longer for many in future years than it has been in past years, may become an insurmountable financial burden. This situation definitely is legitimately able to be termed a "crisis" situation that will be part of our future health care years and that we cannot ignore.            

References

Preidt, R. (2014, June 30).  Nursing Home Care Out of Reach for Many 'Boomers'?  WebMD.  http://www.m.webmd.com/a-to-z-guides/news/20140630/nursing-home-care-may-be-out-of-reach-for-many-aging-boomers-study

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Oxytocin: New Wonder Hormone That May Reduce Muscle Aging
June 23, 2014 2:10 PM by Brian Garavaglia

Oxytocin, secreted by the posterior pituitary, is not a new hormone.  Nor is its importance for the biological health of the organism something new. Oxytocin has been known about for many years. It was known to be instrumental in helping uterine contraction during childbirth, for enhancing breast contraction during breast feeding, and even more recently, it has been found to be instrumental in helping to establish bonds between parents and infants as well as enhance bonding and trust in social relationships. Furthermore, oxytocin increases dramatically during sexual intercourse, and has often been referred to as the love hormone. However, this hormone that already has been found to be so instrumental in so many areas of our life is now providing us with new findings, and these findings may be the most significant yet.

Recent research out of the University of California, Berkeley has found that oxytocin may help to heal and reverse atrophic changes in muscles as we age, countering many of the sarcopenic changes in muscle mass and strength that is often found among older adults. This is a particularly important discovery since falls resulting in severe injuries, such as fractures, exist at epidemic proportions in the elderly. Generally, the probability for such falls and injuries, some even resulting in death, are due to muscle weakness associated with aging.    

In studies on mice, injections of oxytocin on a subdermal level enhanced the regenerative potential of muscle in aging mice. Older mice that were given oxytocin injections demonstrated greater muscle healing and regeneration as compared to those older mice that did not receive oxytocin injections. Furthermore, the oxytocin appeared to work on muscle healing and muscle regeneration very quickly. As one of the lead researchers, Christian Elabd stated, "The action of oxytocin was fast ... The repair of muscle in the old mice was at about 80 percent of what we saw in the young mice"1.  This is an incredible reversal, with older mice having a repair and regenerative potential that is 80 percent of the more youthful mice.

The synthetic form of oxytocin has existed for years to assist women with delivery. Since the Food and Drug Administration already has a synthetic agent approved, if the hormone continues to show promising results, using the already approved synthetic form could be very important in bringing it to use for diseases related to aging. Since it already has been brought to market and is in use, the already approved drug could lead to new therapeutic interventions for reversing muscle aging in the near future.      

One of the first clues that oxytocin might have important effects on muscle cells was when scientists noticed that women who had their ovaries removed also experienced a reduction in oxytocin levels. They also noted that the precursor cells to mature muscles cells had oxytocin receptors. Since many ovarectomized women experienced effects that were similar to those found in aging individuals in their muscle tissue, they hypothesized that a connection between oxytocin and muscle aging may exist. 

There is also further good news about the introduction of oxytocin into the bodies of mice. In young mice it did not seem to cause an appreciable effect in changing muscle regeneration. At first this may not seem very encouraging. However, it points to important safety concerns. Since oxytocin appears to focus on aging stem cells without affecting more youthful muscle, this seems to address the issue of whether it may lead to controllable mitotic division, leading to cancerous changes. In this case since it did not appear to do so in the more youthful mice, the drug appears to have answered some important concerns about its safety. 

The reduction of oxytocin in later years may also be strongly genetically driven. The researchers investigated the oxytocin gene and the effects of the gene after it was disabled. They found that when they disabled the gene it did not automatically manifest results when the mice were young. However, as the mice became older, they started to show early senescent changes, aging changes that occurred at ages much earlier than one would anticipate and as compared to a control group of mice who did not experience the genetic manipulation. 

Although these are exciting results, one has to be cautious against using terminology and references to oxytocin as an "anti-aging" drug or hormone. Senescence is a natural process. There is nothing that reverses aging or is an "anti-aging" remedy as some will have you believe through media sources. Yet, the important scientific finding that oxytocin may help regenerate muscle may eventually lead toward helping address many diseases and the symptoms of these diseases that are often associated with aging. Furthermore, it may help prevent many injuries such as falls resulting in fractures, especially of the hip, that often result in premature mortality. 

Oxytocin is an exciting agent. It became known almost exclusively for its biological effects during childbirth and infant feeding. However, recently, just over the last couple of decades, the research on oxytocin has shown that it also has important social effects on individuals, especially regarding bonding and trust. And now comes another connection with this hormone that is growing in stature. In fact, this may be the most important one of all, and may have important implications for enhancing healthy aging and eliminating many common diseases or illnesses associated with aging.  Is it not deserving of being known as the "wonder hormone"?   

Reference

1. Choi, C. (2014/June 11).  Aging Muscles May Just Need a Little 'Love Hormone.'  LiveScience.  Accessed at: http://news.yahoo.com/aging-muscles-may-just-little-love-hormone-140029679.html

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Fasting May Help Boost Immune System Function for Elderly
June 10, 2014 1:53 PM by Brian Garavaglia

Generally speaking, fasting is often viewed quite negatively. However, a new study done by the University of Southern California has found that fasting could help the body fight disease, showing that a two day fast may actually regenerate the immune system. The study sheds some hope for those with compromised immune systems such as those receiving chemotherapy and the elderly.

Studies were done on both mice and humans. It was found that long periods of fasting significantly lowered white blood cell counts, demonstrating that long periods of fasting could have a negative effect on one's immune, subsequently increasing a person's susceptibility to disease.

In mice, it was found that each fasting cycle "flipped a regenerative switch" that led to the regeneration of new white blood cells. Apparently a short period of fasting was found to shock the immune system, renewing the body's defense. It was analogous to the immune system being given a wake-up call, with the fasting period reviving the immune system and more or less communicating to it and saying "you are sluggish and need to get moving." Valter Longo, who is a professor of gerontology at the University of Southern California said, "it gives the OK for the stem cells to go ahead and begin proliferating and rebuild the entire system.  And the good news is that the body got rid of the parts of the system that might be damaged or old, the inefficient parts, during the fasting."   

The study also found that fasting for a short period led to a reduction is the enzyme PKA, as well as reducing levels of IGF-1, all of which have been related to reduced longevity, accelerated aging and cancer cell development. How fasting leads to these reductions was not definitively stated. 

The results appear promising, yet it is too early to start recommending periodic fasting. I think they must be interpreted very cautiously at this point. It must be remembered that overall, nutritional sustenance is typically much more important, and that deprivation of important nutritional components for extended periods of time can have deleterious effects for individuals, including a reduced immune capacity.

It must further be remembered that for many older adults, their immune systems are often compromised by inadequate dietary intake of proper nutrients.  Therefore, the question I would ask the researchers that conducted this study is if fasting would have similar effects for those who fail to take in the proper levels of nutrition in their daily diets. Here again, I do not think any answer to that particular question could be ascertained from the study's very preliminary findings. However, this does not mean that we should be dismissive of the results either. If the results can be further replicated, it may have some important significance for addressing many older adults who need a jump start immunologically to ward off many diseases that they become more susceptible to as a result of aging. However, until more results are found that support this type of intervention, caution and a healthy level of skepticism should continue to guide our approach in this area.        

References

Delhidailynews.com (2014/June 8).  Fasting Twice a Year Rebuilds Immune System.    http://www.delhidailynews.com/news/Fasting-regenerates-immune-system-1402181003/

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Antidepressants May Help Reduce Likelihood of Alzheimer’s Disease
May 21, 2014 9:47 AM by Brian Garavaglia

Recent research that has been conducted at Washington University Medical School and the University of Pennsylvania has found that the use of an commonly prescribed antidepressant medication may help prevent or reduce the likelihood of acquiring one of the most feared diseases-Alzheimer's disease.

Beta amyloid is a protein that has been instrumental in the development of plaques that has been found to exist in the brains of those with Alzheimer's disease, although these plaques have also been found to a lesser degree among those who did not have Alzheimer's disease. Nevertheless, these plaques and the amyloid beta buildup that has contributed to their development, has been strongly associated with Alzheimer's disease. Amyloid beta is normally produced in the brain, but an excessive amount of this protein that builds up in the brain appears to be strongly associated with the impairment in memory and cognition that is found among those with Alzheimer's disease.

Some previous studies have demonstrated that serotonin, a normal neurotransmitter chemical found in the brain and metabolized from tryptophan, an amino acid, has been associated with also helping to alleviate depression as well as calm anxiety. Most new forms of antidepressants have been developed to specifically target serotonin in a much more focused manner than was found with many of the first generation antidepressants.

The researchers worked with mice that were genetically altered to develop Alzheimer's disease. The mice were young and subsequently did not experience age changes normally found within older brains, especially those associated with increased levels of plaque formation. Amazingly, the researchers found that after introducing a serotonin-enhancing antidepressant into the mice, their amyloid beta protein level was reduced on an average by 25 percent after 24 hours of treatment. This was an astonishing result to say the least. 

In a more recent test, using citalopram, the antidepressant commonly known as Celexa, the researchers administered this medication into older mice that already had a significant level of beta amyloid build up and subsequently significant plaque formation in their brains. After administering the medication they tracked the plaque growth over 28 days using a sophisticated type of brain scanning. Here again, the results were quite amazing. The mice that were given citalopram had their existing plaque development halted. However, even more astonishing was new plaque formation was reduced by 78 percent! 

Interestingly, in another phase of the experiment, citalopram was tried on humans. Citalopram was given to 23 human participants between the ages of 18 and 50. Citalopram is a common medication administered to humans for depression and even anxiety, so it is not an experimental medication by any means. In these phases of the experiment, none of the participants in the study suffered any cognitive impairment or depression. After the citralopram was administered, spinal fluid was obtained from the participants 24 hours after the administration of the medication. Here again, the spinal fluid showed that amyloid beta production had dropped in this group as well, by 37 percent!   

However, one of the study's authors, Dr. John Cirrito has stated "There is still much work to do." Cirrito states that, "Antidepressants appear to be significantly reducing amyloid beta production, and that's exciting ... But while antidepressants generally are well tolerated ... they have risks and side effects. Until we can more definitively prove that these drugs help slow or stop Alzheimer's in humans, the risks aren't worth it. There is still much more work to do."

The next step in the research according to the study's authors is that they need to examine more closely if serotonin is truly causing this reduction. If the reduction is directly related to the increase in brain serotonin, than the scientists will have to work out what it is doing on a molecular level that is preventing and halting the development of amyloid beta and its associated plaques.

What is very interesting about this research is not only the preventative and possible treatment modalities associated with enhancing serotonin in the brain toward reducing amyloid beta production, but that we may already have medications that have been in use for some years that could be immediately available to many individuals who suffer from this disease or for those who could benefit from preventative intervention to preclude earlier development of this disease. Furthermore, given that the medications are already available, the need to further research drugs that are already being used helps to decrease the time lag often associated with the development of a new drug. Although these studies are not stating that using serotonergic antidepressant agents by any means is a cure, the encouraging results that have been found to exist in reducing amyloid beta up to this time, which is the protein that when built up to higher levels in the brain is associated with Alzheimer's disease, is very encouraging to say the least. However, as the authors warn, we should not start randomly prescribing these medications. More research is still needed. However, this research up to this point has shined brightly.   

References

McNamee, D. (2014/May). Could a commonly prescribed antidepressant slow onset of Alzheimer's?  Medical News Today. Accessed at: http://www.medicalnewstoday.com/articles/276838.php

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Older Adults are Feeling Younger
April 30, 2014 10:00 AM by Brian Garavaglia

In a recent survey, when centenarians were asked how old they felt, they stated they felt approximately 17 years younger, on average 83 years of age. Also, when those who were 65 years of age were surveyed on how old they felt, they said they felt on average 10 years younger than their chronological age, or approximately 55 years of age. 

The results sound somewhat unwieldy. One may ask how are they measuring these subjective evaluations provided by the older adults surveyed. The results are part of the ninth annual 100@100 survey conducted by United Healthcare, which has polled 65 year olds and 100 year olds to compare the attitudes and lifestyles of American adults who were about to enter retirement with those that have already done so 35 years ago. In other words, the survey compared the subjective statements of the most recently surveyed older adults with those who were surveyed in past years in the previous surveys. The current survey looked at the responses of 104 centenarians and 302 baby boomers entering retirement. 

In evaluating some of the common responses that were found among centenarians, some of the following were found among those surveyed. 

  • When asked how it felt to be 100 years of age, the top three responses given were 1.) blessed at 36 percent, 2.) happy at 31 percent and 3.) surprised at 12 percent.
  • Another interesting common theme found in the responses was that 53 percent of the centenarians felt they had achieved everything in life. However, approximately one-third said 100 years of life was not enough and one in five stated they would like to live just a few more years. So much for the misconceptions that view older adults as inevitably suffering and welcoming death.
  • Another fascinating finding was that the centenarians were far from a totally dependent group. The survey found that 53 percent said they lived independently and were able to carry out their activities of daily living without any assistance!
  • An interesting psychological finding was that not one centenarian described themselves as being sad, and only 3 percent said they experienced feelings of loneliness.

In comparing the responses of the 104 centenarians with the 302 baby boomers on a number of questions, there were some common similarities and some noted differences that were found. For instance, when both the centenarians and the baby boomers were asked to give the three top keys to healthy aging, the centenarians stated:

  • 1) Staying close to friends and family (91 percent)
  • 2) Keeping a sense of independence (88 percent)
  • 3) Eating right (86 percent)

The baby boomers had similar views on this question as well stating the following:

  • 1) Maintaining a sense of independence (87 percent)
  • 2) Laughing and having a sense of humor (87 percent)
  • 3) Staying close to family and friends (84 percent)

Centenarians and baby boomers also appear to be getting much more health conscious, especially on a preventative level. Both of these groups stated they see their family physician at least once each year for a physical examination, as well as maintaining current with their vaccines. Furthermore, both the centenarians and baby boomers are remaining physically active and are apparently becoming more conscious of doing so for their health.  Most stated they walked or hiked at least once each week. In addition, approximately one-third reported engaging in regular strength training weekly.    

Dr. Rhonda Randall, the chief medical officer for the United Healthcare Retiree Solutions was quite encouraged by the results found in this year's 100@100 survey. According to Randall, "This year's 100@100 survey paints an encouraging and exciting view of longevity." Randall is especially optimistic about the number of older adults who are actively involved in their health on a proactive level. The increasing level of self-efficacy found among older adults toward becoming proactively involved in their health to forestall or attenuate disease is very encouraging to Randall, stating, "This is a good reminder for all Americans to take charge of their health now so that they can enjoy life for many years to come"(Paddock, 2014).

It is definitely encouraging that, in this study, older adults were more involved in managing their health more proactively and not just their disease as was often the case in the past. Some of this may be due to a more informed and better educated older adult population, as well a public health measures that have often encouraged greater levels of health consciousness as an important preventative health care measure. However, one must also look at these results cautiously. The sampling methodology may preclude one from generalizing these results beyond the current study's sample. Nevertheless, the current results, as compared to previous 100@100 surveys, demonstrating greater levels of health, activity, independence and demonstrable levels of optimism are to say the least, quite encouraging.

References

Paddock, C. (2014, April 25).  American centenarians and baby boomers feel 'younger than their years.' http://www.medicalnewstoday.com/articles/275940.php

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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. 

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