Category Archives: Health

Hearing loss tied to increased risk for depression

May 1, 2019

NAELA News:

(Reuters Health) – Older adults with hearing loss may be more likely than peers without hearing difficulty to develop symptoms of depression, a research review suggests.

Globally, more than 1.3 billion people currently live with some form of hearing loss, and their ranks are expected to rise with the aging population, the study team notes in The Gerontologist. About 13 percent of adults 40 to 49 years old have hearing loss, as do 45 percent of people 60 to 69 years old and 90 percent of adults 80 and older, the authors write.

To assess the connection between hearing loss and depression, researchers analyzed data from 35 previous studies with a total of 147,148 participants who were at least 60 years old.

Compared to people without hearing loss, older adults with some form of hearing loss were 47 percent more likely to have symptoms of depression, the study found.

“We know that older adults with hearing loss often withdraw from social occasions, like family events because they have trouble understanding others in noisy situations, which can lead to emotional and social loneliness,” said lead study author Blake Lawrence of the Ear Science Institute Australia, in Subiaco, and the University of Western Australia in Crawley.

“We also know that older adults with hearing loss are more likely to experience mild cognitive decline and difficulty completing daily activities, which can have an additional negative impact on their quality of life and increase the risk of developing depression,” Lawrence said by email.

“It is therefore possible that changes during older age that are often described as a ‘normal part of aging’ may actually be contributing to the development of depressive symptoms in older adults with hearing loss,” Lawrence said.

The connection between hearing loss and depression didn’t appear to be influenced by whether people used hearing aids, the study also found.

One limitation of the analysis is that it included studies with a wide variety of methods for assessing hearing loss and symptoms of depression.

Still, the results of the analysis do add to evidence suggesting that there is a link between hearing loss and depression, said Dr. Nicholas Reed of the Cochlear Center for Hearing and Public Health at Johns Hopkins University School of Medicine in Baltimore.

First, hearing loss impairs communication and influences balance, which can lead to social isolation and decreased physical activity that, in turn, result in depression, Reed said.

Hearing loss may also cause tinnitus, or perceived ringing or buzzing in the ear, that can be especially debilitating in some cases and contribute to depression, Reed, who wasn’t involved in the study, said by email.

In addition, hearing loss may trigger changes in the brain that contribute to depression.

“When we experience hearing loss, it also means that we’re sending a weaker auditory signal to our brains for processing,” Reed said. “This weak signal may mean our brains have to go into overdrive to understand sound (i.e. speech) which may come at the expense of another neural process (i.e., working memory). Also, the weak signal may cause certain neural areas and pathways to reorganize, which could change how our brain, including aspects that regulate depression, function.”

While the study doesn’t examine whether treating hearing loss can prevent depression or other health problems, people should still seek help for hearing difficulties, said David Loughrey, a researcher at the Global Brain Health Institute at Trinity College Dublin who wasn’t involved in the study.

“Hearing loss has been linked to difficulties in daily life including difficulty with socializing and fatigue due to the increased mental effort required to understand speech, especially in noisy environments,” Loughrey said by email. “If someone is experiencing difficulties due to hearing loss or if they have any concerns about their mental wellbeing, they should consult a medical professional who can assist them.”

The Cost Of Seniors’ Health Care May Be Moderating But The Need For Long-Term Care May Be Growing

March 28, 2019

The pace of medical spending for older adults is slowing, and one highly-respected health economist gives much of the credit to the increased use of medications that reduce the risk of heart disease. That is good news, but it largely ignores the growing costs of long-term care and the increasing burden on family caregivers, whose assistance is not included in this analysis.

To put it simply: The increased use of drugs such as statins is improving heart health. Not only will that slow the growth of medical costs for seniors, it may help them live longer. However, it will not keep them healthy forever. They will, in effect, live long enough to suffer from frailty of old age. And that means they will need more personal care that most often is delivered by family members.

To oversimplify: Instead of dying of heart attacks at 60, more of us will live to 85, when we will get dementia. That’s why we need to shift resources from medical care to long-term supports and services.

Less heart disease

In the study published in the February edition of the journal Health Affairs, Harvard University health economist David Cutler and his co-authors calculated that the per beneficiary growth rate of Medicare spending slowed substantially from 1992-2012. Until 2004, program spending per enrollee rose by 3.8 percent annually. From 2005-2012, it grew by only 1.1 percent.

Overall Medicare spending grew much faster, largely because so many more people turned 65 and enrolled in the program. But spending for each beneficiary grew far more slowly than many predicted. By 2012, actual Medicare spending was about $3,000 less than forecast.

Cutler and his colleges dug into the data (and made some important adjustments to the available numbers) to try to understand why. This is what they found:

Half of the lower-the-expected spending was due to fewer acute cardiovascular-related medical events, such as strokes, heart attacks, or acute episodes of congestive heart failure. And they attributed half of that savings to greater use of medications that prevent or control conditions such as high blood pressure, high cholesterol, or diabetes.

More use of drugs

Few new drug therapies were developed for these diseases during this period. But consumers used existing drugs more frequently, in part to lower prices and creation of the Medicare Part D drug benefit.

Better heart health means less hospital care, fewer heart surgeries, and less need for post-acute care. Hospital admissions for heart disease are off by 56 percent since 1999, and admissions for strokes declined by 41 percent, the study reports.

And, the authors’ add, there is more opportunity to improve heart health and save money. Only 55-60 percent of American are controlling their risk factors for cardiovascular disease.

While the news on the health cost side is positive, there is another side to the story. Cutler and colleagues looked at a broad definition of medical spending that mimics the government’s National Health Expenditure Accounts. But personal health spending generally excludes long-term care services and supports. And it entirely ignores personal care provided by family members.

And that’s where matters get interesting. Widespread use of medications to prevent heart attacks or strokes keeps us healthier for longer. But it doesn’t make us immortal or immune from the frailty of old age.

A growing challenge

We will live longer in old age, and indeed life expectancy among older adults in the US continues to increase (though it has reversed a bit in the past few years for those under 65). Longer lives, however, make more of us susceptible to chronic conditions of very old age such as Alzheimer’s disease and some other dementias, pulmonary disease, and severe arthritis. It even is true with heart failure. Medications can reduce repeated hospitalizations for the disease but they won’t prevent it from slowly and inexorably sapping a senior’s strength.

We are left then, with a growing challenge. Medical costs for those with chronic conditions and functional or cognitive limitations are two- to three-times higher than for those with chronic conditions alone. Cutler and colleagues attempt to adjust their data for demographic changes but because they looked backward to 2012, they did not capture the coming explosion in the population of those 80 and older—when those limitations are most common.

We are left with a classic good news/bad news story. For example, some dementias, such as stroke-related or vascular dementia, may also become less common as medications prevent the underlying conditions. But Alzheimer’s may become more common as more of us live to a very old age.

While Cutler and his colleagues didn’t put it this way, their research strengthens the argument that the US needs to shift resources from medical care to long-term supports and services.

by Howard Gleckman

Scans Show Female Brains Remain Youthful As Male Brains Wind Down

February 26, 2019

A cross section of the human brain shows fiber tracts involved in aging.
Sherbrooke Connectivity Imaging /Getty Images/Cultura RF

Women tend to have more youthful brains than their male counterparts — at least when it comes to metabolism.

While age reduces the metabolism of all brains, women retain a higher rate throughout the lifespan, researchers reported Monday in the journal Proceedings of the National Academy of Sciences.

“Females had a younger brain age relative to males,” says Dr. Manu Goyal, an assistant professor of radiology and neurology at Washington University School of Medicine in St. Louis. And that may mean women are better equipped to learn and be creative in later life, he says.

The finding is “great news for many women,” says Roberta Diaz Brinton, who wasn’t connected with the study and directs the Center for Innovation in Brain Science at the University of Arizona Health Sciences. But she cautions that even though women’s brain metabolism is higher overall, some women’s brains experience a dramatic metabolic decline around menopause, leaving them vulnerable to Alzheimer’s.

The study came after Goyal and a team of researchers studied the brain scans of 205 people whose ages ranged from 20 to 82. Positron emission tomography scans of these people assessed metabolism by measuring how much oxygen and glucose was being used at many different locations in the brain.

The team initially hoped to use the metabolic information to predict a person’s age. So they had a computer study how metabolism changed in both men and women.

Then they reversed the process and had the computer estimate a person’s age based on brain metabolism data.
The approach worked. “It was highly predictive of age,” Goyal says.

Even so, for some people there was a big difference between their brain age and their chronological age. And Goyal says the team wondered whether this difference was more pronounced in men or women.

So they checked.

“When we looked at males vs. females, we did find an effect,” Goyal says. “We found in fact that females had a younger brain age relative to males.”

Women’s brains appeared about four years younger, on average. But it’s still not clear why.

“It makes us wonder, are hormones involved in brain metabolism and how it ages?” Goyal says. Or is it something else, like genetics?

Whatever the cause, higher metabolism may give female brains an edge when it comes to learning and creativity in later life, Goyal says.

“But it might also set up the brain for certain vulnerabilities,” he says, including a higher risk of developing Alzheimer’s disease.

Brinton sees it differently. She thinks women’s higher brain metabolism protects them from Alzheimer’s when they are young.

But menopause, she says, causes an “energy transition in the brain,” one that affects the brain metabolism of some women far more than others.

Brinton’s research suggests that the women most likely to experience a dramatic drop are those who carry a gene variant called APOE4, which increases a person’s risk of developing Alzheimer’s, or those who have risk factors for Type 2 diabetes.

“It’s those women who will begin to develop the pathology of Alzheimer’s disease earlier,” she says.

As brain metabolism decreases in these women, Brinton says, there’s an increase in the sticky proteins that are associated with Alzheimer’s.

“This is a process that starts very early in the aging process for some women,” Brinton says. “And we can intervene.”

How? The steps are a lot like those intended to prevent diabetes, Brinton says. They include diet, exercise and drugs that help the brain and body metabolize sugar.

Jason Frank Presses Maryland Senate for “Aging in Place”

January 28, 2019

by Federico Salas, J.D.

On January 17, 2019, the Maryland Senate Finance Committee held a briefing that, among other topics, addressed the Home and Community Based Options Waiver (HCBOW). Jason A. Frank, Esq. specifically discussed the problems with the HCBOW that he expects will be fixed by current proposed legislation that:

  • Ensures that those people who lose Community First Choice services because of aging into Medicare can access the HCBOW and continue to receive services in the community; and
  • Eliminates the 22,000-person HCBOW Registry (waiting list) and serves eligible people who want services directly in the community without first entering a nursing home.

Resources from the Briefing

View the recording of the Senate Finance Committee briefing (presentations on the HCBOW begin at 1:23:00).

Download Mr. Frank’s presentation on Aging in Place (PDF, 24 pages).

Senate Bill 699

This is a summary of SB 699 regarding Maryland’s Community First Choice program:

The Problem

Marylanders who have community Medicaid, including Medicaid Expansion, and get long-term care services through the Community First Choice (CFC) program for as little help as having someone to assist in bathing and dressing at home, will lose all access to services if both: (1) they get Medicare and (2) they have too much income or assets. For individuals in 2019, CFC-Medicaid Expansion enrollees who have a monthly income between $791–$1,396 per month or assets greater than $2,000 are at risk of losing services. The Home & Community Based Options Waiver (HCBOW) program can provide the needed services to Marylanders with disabilities at home, but it has an 8-year, 22,000-person waiting list (“the Registry”).

Currently, there is no way for Marylanders living at home to bypass the 8-year, 22,000-person waiting list and stay at home, except by unnecessarily entering a nursing home. This means that the people who lose CFC when they get Medicare must choose between having to enter a nursing home or go without help for 8 years in order to continue getting the help that they need.

The Solution

Permit certain individuals who are affected, or will be affected, by “the CFC problem” to bypass the 8-year, 22,000-person waiting list in order maintain CFC services WITHOUT having to wait out the 8-year Registry or go through unnecessary and extremely costly nursing home admission just to transfer back out into the community.

Senate Bill 700

This is a summary of SB 700 regarding Maryland’s HCBOW:

The Problem

Most Marylanders who need as little help as having someone to assist them in bathing and dressing—but lack the money to pay for it—must choose between entering a nursing home or going without help for 8 years. The Maryland Medicaid Home & Community Based Services Options Waiver (HCBOW) program can provide the needed services to Marylanders with disabilities at home, but it has an 8-year, 22,000-person waiting list (“the Registry”). The HCBOW has an 8-year-long waiting list because the HCBOW is not required to meet the demand for services.

This year, the HCBOW can serve 5,659 individuals. When the Maryland Department of Health (MDH) readjusts HCBOW program availability every few years, it does not count eligible people on the 8-year, 22,000-person waiting list. In 2016, the MDH actually reduced program availability DESPITE the size of the 8-year, 22,000-person waiting list.

There is no way for Marylanders living at home to bypass the 8-year, 22,000-person waiting list and stay at home, except by unnecessarily entering a nursing home. While on the Registry, registrants are also in the dark for 8 years regarding where they are on the waiting list.

The Solution

  • Require registrants to come off the Registry at a rate that would eliminate the 8-year waiting list within 12 months;
  • Require the HCBOW to meet the projected “demand” for services;
  • Require services to HCBOW-eligible individuals within 30 days; and
  • Provide information for registrants about their exact place on the Registry or when they might expect to receive services.

Handbook for Helping People Living Alone with Dementia Who Have No Known Support

January 2, 2019

2018 NADRC:
Handbook for Helping People Living Alone with Dementia Who Have No Known Support

The Handbook for Helping People Living Alone with Dementia Who Have No Known Support provides practical guidance as well as tools for helping a person living alone who does not have informal supports, including people with dementia who have a caregiver that cannot provide support. The handbook includes practical strategies for identifying people who are living alone without support, assessing risk, building trust, identifying family and friends willing to help, determining decision-making capacity, options for helping the person maintain their independence, and the basics of guardianship or conservatorship.

Also: Living Alone: living alone with dementia, live alone, single, widowhood, unmarried, no support, no family, autonomy, capacity, care planning, competency, ethics, financial capacity, informed consentFile: 

File

2018 NADRC: Handbook for Helping People Living Alone with Dementia Who Have No Known Support

Doctors’ Office Dementia Tests Are Often Wrong: Study

December 24, 2018

By Alan Mozes
HealthDay Reporter

WEDNESDAY, Nov. 28, 2018 (HealthDay News) — Fast tests designed to help primary care doctors rapidly spot dementia in their elderly patients often get it wrong, a new British report contends.

The finding concerns three widely used quick dementia tests: the “Mini-Mental State Examination” (intended to assess mental orientation and verbal memory); the “Memory Impairment Screen” (which tests verbal memory); and “Animal Naming” (which gives patients one minute to quickly name as many animals as they can).

The result: more than one-third of the patients were misclassified — as either having or not having dementia — by at least one of the rapid tests in question.

“Dementia can be difficult to accurately detect, particularly in a primary care setting,” said study lead author Janice Ranson. But the rapid tests “are important screening tools to help clinicians decide who is likely to benefit from further testing for dementia,” she acknowledged.

“Our results suggest that some of the misclassification is due to test biases, such as a patient’s age, ethnicity or education level,” she added.

Ranson is a doctoral researcher in clinical epidemiology at the University of Exeter Medical School in England.

She and her colleagues reported their findings in the Nov. 28 online issue of the journal Neurology: Clinical Practice.

Ranson said quick tests are “routinely used” by primary care doctors as an initial screening. And if signs of dementia are found, a “full dementia investigation” typically ensues.

The study included just over 800 patients in the United States who underwent the tests. The participants ranged in age from 70 to 110, with an average age of 82.

The patients initially underwent comprehensive three- to four-hour dementia assessments. These involved a neurological exam, blood pressure readings, a medication review, DNA sampling, depression screening and lifestyle/family history interviews.

These comprehensive assessments revealed that about one-third of the patients had dementia.

All of the participants subsequently underwent each of the three quick dementia tests.

But when the research team compared the quick test results with the in-depth results, they found that 36 percent of the patients were mistakenly diagnosed by at least one of the quick tests.

Interestingly, the researchers found that individually, each quick test actually had a misdiagnosis rate of 14 to 21 percent, and only 2 percent of the patients were misdiagnosed by all three tests.

Why? Each test appeared to have a different problematic bias, the study authors said. For example, while one test appeared to underdiagnose dementia in highly educated patients, others appeared to miss the mark based on patient age, race or nursing home status.

“Each test is biased in different ways,” said Ranson, “and so some tests are more accurate than others for certain patient groups. While these results are at first concerning, knowing the specific limitations for each test will help clinicians decide which is the most appropriate for their patient.”

Still, she said there’s definitely room for improvement.

“We desperately need more accurate and less biased ways of detecting dementia swiftly in clinic,” said Ranson. “We are therefore developing new technology, using data science and artificial intelligence, to help clinicians get the best outcome for their patients. We are working hard to improve these tests with a more personalized approach to cognitive testing.”

Keith Fargo is director of scientific programs and outreach with the Alzheimer’s Association, in Chicago. “Diagnosing Alzheimer’s and other forms of dementia is an incredibly complex process, and not something that can be done on the quick,” he said.

“Simple cognitive tests can be a helpful first step toward diagnosis, but as the study points out, are imperfect,” Fargo explained.

“The Alzheimer’s Association supports efforts to better understand and account for potential biases in short assessments for cognitive impairment,” Fargo added. “Ensuring a timely and accurate diagnosis is critical, and this study identifies important biases that need to be considered when using these preliminary assessments.”

More information

To learn more about dementia and dementia diagnosis, visit the Alzheimer’s Association.

SOURCES: Janice Ranson, M.Sc., doctoral researcher, clinical epidemiology, University of Exeter Medical School, Exeter, England; Keith Fargo, Ph.D., director of scientific programs and outreach, Alzheimer’s Association, Chicago; Nov. 28, 2018, Neurology: Clinical Practice, online

Day-Tripping To The Dispensary: Seniors In Pain Hop Aboard The Canna-Bus

November 1, 2018

Shirley Avedon, 90,­­ had never been a cannabis user. But carpal tunnel syndrome that sends shooting pains into both of her hands and an aversion to conventional steroid and surgical treatments is prompting her to consider some new options.

“It’s very painful, sometimes I can’t even open my hand,” Avedon said.

So for the second time in two months, she’s climbed on board a bus that provides seniors at the Laguna Woods Village retirement community in Orange County, Calif., with a free shuttle to a nearby marijuana dispensary.

The retired manager of an oncology office says she’s seeking the same relief she saw cancer patients get from smoking marijuana 25 years ago.

“At that time [marijuana] wasn’t legal, so they used to get it off their children,” she said with a laugh. “It was fantastic what it did for them.”

Avedon, who doesn’t want to get high from anything she uses, picked up a topical cream on her first trip that was sold as a pain reliever. It contained cannabidiol, or CBD, but was formulated without THC, or tetrahydrocannabinol, marijuana’s psychoactive ingredient.

“It helped a little,” she said. “Now I’m going back for the second time hoping they have something better.”

As more states legalize marijuana for medical or recreational use — 30 states plus the District of Columbia to date — the cannabis industry is booming. Among the fastest growing group of users: people over 50, with especially steep increases among those 65 and older. And some dispensaries are tailoring their pitches to seniors like Avedon who are seeking alternative treatments for their aches, pains and other medical conditions.

On this particular morning, about 35 seniors climb on board the free shuttle — paid for by Bud and Bloom, a licensed cannabis dispensary in Santa Ana. After about a half-hour drive, the large white bus pulls up to the parking lot of the dispensary.

About half of the seniors on board today are repeat customers; the other half are cannabis newbies who’ve never tried it before, said Kandice Hawes, director of community outreach for Bud and Bloom.

“Not everybody is coming to be a customer,” Hawes said. “A lot are just coming to be educated.”

Among them, Layla Sabet, 72, a first-timer seeking relief from back pain that keeps her awake at night, she said.

“I’m taking so much medication to sleep and still I can’t sleep,” she said. “So I’m trying it for the back pain and the sleep.”

Hawes invited the seniors into a large room with chairs and a table set up with free sandwiches and drinks. As they ate, she gave a presentation focused on the potential benefits of cannabis as a reliever of anxiety, insomnia and chronic pain and the various ways people can consume it.

Several vendors on site took turns speaking to the group about the goods they sell. Then, the seniors entered the dispensary for the chance to buy everything from old-school rolled joints and high-tech vaporizer pens to liquid sublingual tinctures, topical creams and an assortment of sweet, cannabis-infused edibles.

Jim Lebowitz, 75, is a return customer who suffers pain from back surgery two years ago.

He prefers to eat his cannabis, he said.

“I got chocolate and I got gummies,” he told a visitor. “Never had the chocolate before, but I’ve had the gummies and they worked pretty good.”

“Gummies” are cannabis-infused chewy candies. His contain both the CBD and THC, two active ingredients in marijuana.

Derek Tauchman rings up sales at one of several Bud and Bloom registers in the dispensary. Fear of getting high is the biggest concern expressed by senior consumers, who make up the bulk of the dispensary’s new business, he said.

“What they don’t realize is there’s so many different ways to medicate now that you don’t have to actually get high to relieve all your aches and pains,” he said.

But despite such enthusiasm, marijuana isn’t well researched, said Dr. David Reuben, the Archstone Foundation professor of medicine and geriatrics at UCLA’s David Geffen School of Medicine.

While cannabis is legal both medically and recreationally in California, it remains a Schedule 1 substance — meaning it’s illegal under federal law. And that makes it harder to study.

The limited research that exists suggests that marijuana may be helpful in treating pain and nausea, according to a research overview published last year by the National Academies of Sciences, Engineering and Medicine. Less conclusive research points to it helping with sleep problems and anxiety.

Reuben said he sees a growing number of patients interested in using it for things like anxiety, chronic pain and depression.

“I am, in general, fairly supportive of this because these are conditions [for which] there aren’t good alternatives,” he said.

But Reuben cautions his patients that products bought at marijuana dispensaries aren’t FDA-regulated, as are prescription drugs. That means dose and consistency can vary.

“There’s still so much left to learn about how to package, how to ensure quality and standards,” he said. “So the question is how to make sure the people are getting high-quality product and then testing its effectiveness.”

And there are risks associated with cannabis use too, said Dr. Elinore McCance-Katz, who directs the Substance Abuse and Mental Health Services Administration.

“When you have an industry that does nothing but blanket our society with messages about the medicinal value of marijuana, people get the idea this is a safe substance to use. And that’s not true,” she said.

Side effects can include increased heart rate, nausea and vomiting, and with long-term use, there’s a potential for addiction, some studies say. Research suggests that between 9 and 30 percent of those who use marijuana may develop some degree of marijuana use disorder.

Still, Reuben said, if it gets patients off more addictive and potentially dangerous prescription drugs — like opioids — all the better.

Jim Levy, 71, suffers a pinched nerve that shoots pain down both his legs. He uses a topical cream and ingests cannabis gelatin capsules and lozenges.

“I have no way to measure, but I’d say it gets rid of 90 percent of the pain,” said Levy, who — like other seniors here — pays for these products out-of-pocket, as Medicare doesn’t cover cannabis.

“I got something they say is wonderful and I hope it works,” said Shirley Avedon. “It’s a cream.”

The price tag: $90. Avedon said if it helps ease the carpal tunnel pain she suffers, it’ll be worth it.

“It’s better than having surgery,” she said.

Precautions To Keep In Mind

Though marijuana use remains illegal under federal law, it’s legal in some form in 30 states and the District of Columbia. And a growing number of Americans are considering trying it for health reasons. For people who are, doctors advise the following cautions.

Talk to your doctor. Tell your doctor you’re thinking about trying medical marijuana. Although he or she may have some concerns, most doctors won’t judge you for seeking out alternative treatments.

Make sure your prescriber is aware of all the medications you take. Marijuana might have dangerous interactions with prescription medications, particularly medicines that can be sedating, said Dr. Benjamin Han, a geriatrician at New York University School of Medicine who studies marijuana use in the elderly.

Watch out for dosing. Older adults metabolize drugs differently than young people. If your doctor gives you the go-ahead, try the lowest possible dose first to avoid feeling intoxicated. And be especially careful with edibles. They can have very concentrated doses that don’t take effect right away.

Elderly people are also more sensitive to side effects. If you start to feel unwell, talk to your doctor right away. “When you’re older, you’re more vulnerable to the side effects of everything,” Han said. “I’m cautious about everything.”

Look for licensed providers. In some states like California, licensed dispensaries must test for contaminants. Be especially careful with marijuana bought illegally. “If you’re just buying marijuana down the street … you don’t really know what’s in that,” said Dr. Joshua Briscoe, a palliative care doctor at Duke University School of Medicine who has studied the use of marijuana for pain and nausea in older patients. “Buyer, beware.”

Bottom line: The research on medical marijuana is limited. There’s even less we know about marijuana use in older people. Proceed with caution.

Jenny Gold and Mara Gordon contributed to this report.

This story is part of a partnership that includes NPR and Kaiser Health News.

Special Report: Recent Changes in Law, Regulations and Guidance Relating to Medicare Advantage and the Prescription Drug Benefit Program

October 8, 2018

NAELA News:

Numerous changes were made to Medicare law, regulations and guidance during the first half of 2018. The changes are particularly noteworthy regarding Part C, governing private Medicare plans, known as Medicare Advantage (MA), and Part D, the prescription drug benefit.

Click here for the entire article

An Ancient Art May Work Best to Prevent Falls in Old Age

October 5, 2018

By Dennis Thompson
HealthDay Reporter
NAELA News:

MONDAY, Sept. 10, 2018 (HealthDay News) — The ancient practice of tai chi may beat strength training and aerobics for preventing falls among seniors, a new trial shows.

A modified senior-centered tai chi program reduced falls nearly a third better in a head-to-head comparison with an exercise regimen that combined aerobics, strength training and balance drills, the researchers reported.

“This tai chi program better addressed the deficits that were contributing to fall risk,” said senior researcher Kerri Winters-Stone, a professor with the Oregon Health & Science University School of Nursing.

Tai chi is a centuries-old Chinese tradition that involves a graceful series of movements. People performing tai chi flow between different postures in a slow and focused manner, keeping their body in constant motion and frequently challenging their balance.

Researchers have long suspected that tai chi can help reduce risk of falling, said co-researcher Peter Harmer, a professor of exercise and health science with Willamette University in Salem, Ore.

Annually, about 28 percent of U.S. seniors report falling, and 2 out of 5 falls result in injuries leading to an ER visit, hospitalization or death, researchers said in background notes.

“Falling in adults age 65 and older is significantly associated with loss of independence, premature mortality and big health care costs,” Harmer said.

The movements of tai chi require people to move in all directions, while traditional exercise programs focus more on forward and backward motion, Winters-Stone and Harmer said.

“The reality of how falls happen tends to be quite varied and a bit unpredictable. In tai chi, the movements are in these multiple planes,” Winters-Stone said. “You’re moving your body outside of your center of gravity and then you’re pulling it back. There’s a lot of postural responses.

“If you accidentally started to fall, if you had been trained in tai chi you would probably be better at starting to counteract that movement and regain your balance,” Winters-Stone continued.

But classical tai chi can involve upwards of 100 different movements, which can be challenging for seniors to learn, Harmer said.

So, the research team for this clinical trial developed a pared-down form of tai chi that focuses on eight fundamental movements most related to fall prevention, Harmer said. The trademarked program is called Tai Ji Quan: Moving for Better Balance.

To see how well the program works, researchers tested it against both a traditional exercise program and a control group that only performed stretching exercises.

Researchers recruited 670 Oregonians with an average age of nearly 78 and assigned them to one of the three programs. “This was a more at-risk group than we’ve worked with before,” based on both their age and screening for fall risk, Harmer said.

After six months, the tai chi group was 58 percent less likely to have a fall than the stretching group, and the traditional exercise group was 40 percent less likely to fall than people who only stretched.

Compared against each other, the tai chi program outperformed traditional exercise. People taking tai chi suffered 31 percent fewer falls than those who took strength training and aerobics courses.

“Not falling is a pretty complex physiological behavior,” Harmer said, noting that you combine muscle strength with feedback from muscles and joints, eyesight and even hearing to regain your balance. “Tai chi directly challenges the integration of all those things.”

Although tai chi did work better, people following a traditional exercise program still gain a benefit, noted Nathan LeBrasseur, a physical medicine and rehabilitation researcher with the Mayo Clinic in Rochester, Minn.

“I would not discourage people who are actively participating in a strength and aerobic exercise program to throw in the towel and say, ‘Now I need to do tai chi,'” said LeBrasseur, who wasn’t involved in the study. “The real challenge is getting people to adopt and stick to an exercise program.”

Harmer said tai chi not only improves balance, but also improves confidence.

“We’ve found a major risk factor for people falling is fear of falling,” Harmer said. “People might have had a fall. They’re scared then of falling again, so they start doing fewer physical things so they don’t fall. It kind of becomes a self-fulfilling prophecy.”

The modified tai chi program requires people to push themselves out of their comfort zone, breaking the negative cycle, Harmer said.

LeBrasseur agreed that whatever the exercise, more should be asked of seniors if they want to protect their health.

“I do think we tend to hold back across multiple exercise interventions in terms of really challenging and pushing older adults with the notion it will lead to harm and injury, when in fact it probably will drive beneficial adaptations,” LeBrasseur said.

The new study was published Sept. 10 in the journal JAMA Internal Medicine.

New Alzheimer’s Drug Slows Memory Loss in Early Trial Results

September 10, 2018

The new drug slowed cognitive decline and reduced amyloid plaques, shown lower right in a colored light micrograph of an Alzheimer’s patient.CreditCreditSimon Fraser/Science Source

By Pam Belluck

ELA News

July 25, 2018

The long, discouraging quest for a medication that works to treat Alzheimer’s reached a potentially promising milestone on Wednesday. For the first time in a large clinical trial, a drug was able to both reduce the plaques in the brains of patients and slow the progression of dementia.

More extensive trials will be needed to know if the new drug is truly effective, but if the results, presented Wednesday at the Alzheimer’s Association International Conference in Chicago, are borne out, the drug may be the first to successfully attack both the brain changes and the symptoms of Alzheimer’s.

“This trial shows you can both clear plaque and change cognition,” said Dr. Reisa Sperling, director of the Center for Alzheimer Research and Treatment at Brigham and Women’s Hospital in Boston, who was not involved in the study. “I don’t know that we’ve hit a home run yet. It’s important not to over-conclude on the data. But as a proof of concept, I feel like this is very encouraging.”

Aside from a couple of medications that can slow memory decline for a few months, there is no effective treatment for Alzheimer’s, which affects about 44 million people worldwide, including 5.5 million Americans. It is estimated that those numbers will triple by 2050.

The trial involved 856 patients from the United States, Europe and Japan with early symptoms of cognitive decline. They were diagnosed with either mild cognitive impairment or mild Alzheimer’s dementia, and all had significant accumulations of the amyloid protein that clumps into plaques in people with the disease, said Dr. Lynn Kramer, chief medical officer of Eisai, a Japan-based company that developed the drug, known as BAN2401, along with Biogen, based in Cambridge, Mass.

Many other drugs have managed to reduce amyloid levels but they did not ease memory decline or other cognitive difficulties. In the data presented Wednesday, the highest of the five doses of the new drug — an injection every two weeks of 10 milligrams per kilogram of a patient’s weight — both reduced amyloid levels and slowed cognitive decline when compared to patients who received placebo.

Of the 161 patients in the group taking the highest dose, 81 percent showed such significant drops in amyloid levels that they “converted from amyloid positive to amyloid negative,” Dr. Kramer said in an interview, meaning that the patients’ amyloid levels dropped from being considered high enough to correlate to dementia to a level below that dementia threshold.

And on a battery of cognitive and functional tests measuring memory and skills like planning and reasoning, the performance of the high-dose group declined at a rate that was 30 percent slower than the rate of decline in the placebo group.

Dr. Sperling, who briefly advised Eisai last year on a different drug, called the reductions in amyloid “dramatic,” but said the cognitive results were less momentous. Still, she said, “If you could really slow decline by 30 percent for people who are still normal or very mildly impaired, that would be clinically important.”

Dr. Samuel Gandy, associate director of the Mount Sinai Alzheimer’s Disease Research Center, said that for the drug to really be effective, it would have to allow patients to function longer independently without needing caregivers to help them with basic daily activities. That kind of practical application was not reflected in the data presented Wednesday.

“I wouldn’t say this is a quantum leap,” he said. “It is a convincing moving of the needle. But it’s not clear that the needle has moved far enough to make a difference in people’s lives.”

Dr. Kramer said the results were statistically significant 18 months after patients began taking the drug, but improvement began to be noticed after about six months. The 253 patients in the group receiving the second-highest dose also had amyloid and cognitive results that followed a similar trend.

In December 2017, the companies reported that a statistical analysis of the trial at the 12-month mark projected that the drug would not result in a statistically significant slowing of dementia. That meant that the trial did not meet its primary benchmark, which caused some experts and investors to voice skepticism about the drug. The 18-month results allayed some of that skepticism, although the Alzheimer’s Association issued a statement expressing caution and saying the results were “not large enough to definitely demonstrate cognitive efficacy.”

The results came from a Phase 2 trial, which measures both the safety and the efficacy of a drug, but is typically considered an intermediate step to larger and more extensive Phase 3 trials. Other drugs have shown promise in Phase 2, only to disappoint in Phase 3.

In this trial, patients were randomized into six groups, with 247 patients receiving placebo injections while the other five groups received varying doses of the drug.

One unusual aspect of the trial raised questions for some experts. Eisai and Biogen used a cognitive assessment they devised. Called the Alzheimer’s Disease Composite Score (Adcoms), it draws on elements from three other, more established cognitive tests.

Dr. Kramer said Adcoms was developed to compile the measures from those three tests that were sensitive enough to measure change at such an early stage of dementia. The data presented on Wednesday indicated that the patients also showed positive results on two of the three established tests, when those were looked at separately.

Some potential Alzheimer’s treatments have resulted in serious side effects that may cause dangerous swelling or bleeding in the brain. Fewer than 10 percent of the patients taking the new drug experienced such effects, the companies reported, making it relatively safe.

The drug works by attacking the stringy amyloid tendrils that form before they begin sticking together into plaques. The results of the trial add evidence to the idea that treatment for Alzheimer’s is most likely to succeed if it starts early in the disease process, because the brain begins to deteriorate years or even decades before full-blown dementia occurs. Some other drugs have failed because they were tried on patients with more advanced Alzheimer’s; others attacked the amyloid at later points in its progression.

Even if study results continue to be positive, making the drug widely available to patients could take years. Dr. Kramer and Ivan Cheung, the chairman and chief executive of Eisai, said that the companies recently submitted a request to meet with the Food and Drug Administration to learn what steps they need to get the drug approved.

“It’s a bit premature to talk about at this point, but our goal is to bring BAN2401 to patients and families as soon as possible,” Mr. Cheung said.

The F.D.A. typically requires Phase 3 clinical trial data to demonstrate safety and effectiveness. However, the agency does have processes for expediting the review of drugs, said a spokeswoman, who declined to comment on this drug or on conditions that would be taken into consideration for an Alzheimer’s drug.

Eisai is the maker of Aricept, which is one of the few drugs that can help slow early memory decline, but which is effective for only about six to nine months. Biogen is the maker of another Alzheimer’s treatment, aducanumab, that has shown early promise in a small Phase 1 trial in both reducing amyloid and slowing cognitive decline. Many in the Alzheimer’s field are intently anticipating the outcome of two large clinical trials of aducanumab, expected to be able to report results in 2020.

Dr. Gandy said the BAN2401 results were encouraging for the prospects of aducanumab because it suggests that there are at least two compounds that may be able to attack both amyloid buildup and cognitive decline.

In early July, when the companies announced they would soon present positive results from the BAN2401 trial, the stock prices of both companies rose by about 20 percent. They have since stayed roughly at that level.