Category Archives: Health

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.

Ten Signs Your Client Has Dementia

September 10, 2018

Anxiety during middle age may be linked to higher rates of dementia late in life.

Letha Sgritta McDowell | Jul 19, 2018

A recent study has found that anxiety during middle age may be linked to higher rates of dementia late in life. The study followed almost 30,000 participants for more than a decade, and there was a clear link between anxiety mid-life and dementia later in life. The study wasn’t a controlled study with the intent to calculate the magnitude of increased risk. Instead, the study simply indicated an increased risk without eliminating other factors.

When experiencing anxiety or stress, the body produces the hormone cortisol and prolonged heightened cortisol levels have been linked to weight gain, lower immune function, lower bone density, higher rates of mental illness and depression, higher rates of heart disease and more. Dementia may be another possible side effect of prolonged increased cortisol levels. On the other hand, anxiety is often a symptom of dementia, making the corollary between the two difficult to connect.

Therapy exists to assist individuals with the reduction of anxiety and cortisol levels. For individuals who live with high stress and anxiety, pursuing therapy to reduce these levels is critical due to the host of other health problems which may result. The possibility of reducing the chances of developing dementia later in life is simply an added bonus to reducing stress.

While there’s no way of eliminating the chances of developing dementia, there are some things one can do to aid in prevention. Reducing stress is one and maintaining heart health through diet and exercise is another. The Alzheimer’s Association also recommends education and regularly getting the right amount of sleep.

Ten Signs

How do you recognize dementia? The Alzheimer’s Association has provided 10 signs of dementia which, if you notice any one of them in yourself, a loved one or a client, warrants a visit to a physician for further testing. They are:

Memory loss that disrupts daily life. This includes forgetting recently learned information, important dates or events or repeatedly asking for the same information. This doesn’t include occasionally forgetting a name or an appointment, then remembering later.

Challenges in planning or problem solving. This includes difficulty with following a familiar recipe or keeping track of bills but wouldn’t encompass the occasional math error or learning a new task.

Difficulty completing familiar tasks at home or work.

Confusion with time or place. While it’s common for many to occasionally forget what day it is but then remember later, it isn’t common to forget and not remember at all.

Trouble understanding visual images or spatial relationships. This includes trouble judging distances or determining color contrasts.

New problems with words in speaking or writing. Examples of this are trouble in following a conversation or having trouble finding the right word for something and calling it by the incorrect name.

Misplacing things. While everyone misplaces their keys on occasion, an individual with dementia may place the keys in an inappropriate location (such as the freezer) then later being unable to find them and not have the ability to retrace their steps.

Decreased or poor judgment. This is difficult to ascertain and is an often-missed early sign. Decreased judgment is often what leads individuals to take action such as gifting sums of money when they otherwise wouldn’t do so.

Withdrawal from social activities. This is often as result of having difficulty in following a certain activity or being able to engage in conversation.

Changes in mood or personality. Different from simply becoming irritable when a routine is changed, an individual with dementia may become easily upset, afraid, depressed or fearful, even when in a familiar setting.

While the strength and nature of the link between anxiety and developing dementia remains unknown, it’s certainly cause for you and your clients to take steps to reduce stress and anxiety now. To the extent any preventative measure can be taken, it’s critical to implement. For those who have prolonged exposure to stress and anxiety, be sure to know the early warning signs of dementia and pursue treatment to improve overall quality of life.

Medicare Advantage rankings penalize plans serving disadvantaged populations, study finds

August 3, 2018

with the permission of NAELA News:
Public Release: 9-Jul-2018

PROVIDENCE, R.I. [Brown University] — New research from Brown University suggests that federal rankings of Medicare Advantage plans may unfairly penalize those that enroll a disproportionate number of non-white, poor and rural Americans.

The study, published in Health Affairs, used data collected by the Centers for Medicare and Medicaid Services (CMS) to measure the quality of care provided in Medicare Advantage plans, and adjusted performance rankings for race, neighborhood poverty level and other social risk factors. After the adjustments, plans serving the highest proportions of disadvantaged populations improved considerably in the rankings.

The findings show that existing Medicare Advantage plan rankings may not accurately reflect the quality of care a given plan’s enrollees receive, said Amal Trivedi, an associate professor of health services, policy and practice at Brown and the study’s senior author.

“Policymakers have focused a lot of attention on measuring quality and rewarding better performance among health plans and providers,” Trivedi said. “But in order for these quality assessments to be accurate, they need to take into account the characteristics of the populations that are served.”

Medicare Advantage is a newly popular option among Americans who qualify for Medicare, according to statistics from CMS. Before the 21st century, almost everyone opted for traditional Medicare, which allowed beneficiaries to visit any medical professional they wanted. But today, almost a third of those who qualify for Medicare choose the more affordable Medicare Advantage option. While patients who use Medicare Advantage are restricted to specific networks of doctors, they’re also able to compare dozens of plans and select the best one for their needs based on rankings, cost and other factors.

For the last decade, Trivedi said, CMS rankings have measured a plan’s quality by examining how well its health care providers perform in about 30 categories, including customer service, efficiency in processing claims and appeals, disease screening rates and patients’ body mass indexes. The Brown researchers adjusted for socioeconomic disadvantage in just three of those categories — blood pressure control, cholesterol control and diabetes control — and found that many lower-ranked plans suddenly moved substantially higher in the rankings.

Shayla Durfey, the study’s lead author and a third-year medical student in the primary care-population medicine program at Brown’s Warren Alpert Medical School, said she and her colleagues chose to adjust the data in those three categories because previous literature has shown that disadvantaged populations disproportionately suffer from uncontrolled high blood pressure, high cholesterol levels and diabetes.

“To control diabetes, for example, you need things like good health literacy, access to healthy foods, and access to money that buys healthy foods,” Durfey said. “If you live somewhere rural and have a low-paying job, you have fewer healthy choices near you, and they’re often too expensive to consider.”

Currently, CMS rankings account for just two risk factors: dual eligibility — which indicates that someone qualifies for both Medicare and Medicaid — and disability. Durfey said that while health scholars have long debated which CMS categories should be adjusted to account for social risk, many experts agree CMS should do more.

“The adjustments CMS uses do not fully account for true measures of socioeconomic status, such as income level, education and employment,” Durfey said. “These factors have been shown to play a huge role in a person’s lifetime health.”

Accurate quality rankings are important, Trivedi said, because CMS gives plans an incentive to compete against each other. A plan that receives a five-star rating is rewarded with a sizeable payment bump. A plan that gets a one-star rating, on the other hand, is penalized: All of its enrollees receive letters encouraging them to switch to better plans.

Trivedi said that if plans notice a connection between their low rankings and their socioeconomically disadvantaged enrollees, they’ll have little incentive to continue serving the underserved.

“Medicare plans can’t deny coverage to anyone with a pre-existing condition, but they can operate in areas that are more affluent or have healthier, less disadvantaged populations, leaving poor and rural populations with fewer and fewer options,” he said.

While Trivedi, Durfey and their co-authors say it’s still unclear what precise set of adjustments will lead to the most equitable CMS rankings, they hope the agency soon takes action one way or another. If one thing is clear to them, it’s that determining whether and how to adjust Medicare Advantage plan quality measures for sociodemographic factors is critically important to accuracy and equitable payment.

“There needs to be a lot more research on the topic, especially as we move toward a value-based payment system where dollars are attached to clinical performance,” Trivedi said. “We need to be sensitive to the effects of these policies on disadvantaged populations and the providers that serve them. That’s really the take-home message.”

In addition to Trivedi and Durfey, other study authors included Amy J. H. Kind, Roee Gutman, Kristina Monteiro, William R. Buckingham and Eva H. DuGoff. The work was supported by the National Institutes of Health (P01AG027296, R01AG044374, R01MD010243).