Archives for January 2017

Vitamin E for Alzheimer’s Dementia and Mild Cognitive Impairment

Cochrane Database Syst Rev. 2017 Jan 27;1:CD002854. doi: 10.1002/14651858.CD002854.pub4. [Epub ahead of print]

Vitamin E for Alzheimer’s dementia and mild cognitive impairment.

Farina N1, Llewellyn D2, Isaac MG3, Tabet N1.

Abstract

Background

Vitamin E occurs naturally in the diet. It has several biological activities, including functioning as an antioxidant to scavenge toxic free radicals. Evidence that free radicals may contribute to the pathological processes behind cognitive impairment has led to interest in the use of vitamin E supplements to treat mild cognitive impairment (MCI) and Alzheimer’s disease (AD). This is an update of a Cochrane Review first published in 2000, and previously updated in 2006 and 2012.

Objectives

To assess the efficacy of vitamin E in the treatment of MCI and dementia due to AD.

Search Methods

We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as many trials databases and grey literature sources on 22 April 2016 using the terms: “Vitamin E”, vitamin-E, alpha-tocopherol.

Selection Criteria

We included all double-blind, randomised trials in which treatment with any dose of vitamin E was compared with placebo in people with AD or MCI.

Data Collection and Analysis

We used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of the evidence using the GRADE approach. Where appropriate we attempted to contact authors to obtain missing information.

Main Results

Four trials met the inclusion criteria, but we could only extract outcome data in accordance with our protocol from two trials, one in an AD population (n = 304) and one in an MCI population (n = 516). Both trials had an overall low to unclear risk of bias. It was not possible to pool data across studies owing to a lack of comparable outcome measures.

In people with AD, we found no evidence of any clinically important effect of vitamin E on cognition, measured with change from baseline in the Alzheimer’s Disease Assessment Scale – Cognitive subscale (ADAS-Cog) over six to 48 months (mean difference (MD) -1.81, 95% confidence interval (CI) -3.75 to 0.13, P = 0.07, 1 study, n = 272; moderate quality evidence).

There was no evidence of a difference between vitamin E and placebo groups in the risk of experiencing at least one serious adverse event over six to 48 months (risk ratio (RR) 0.86, 95% CI 0.71 to 1.05, P = 0.13, 1 study, n = 304; moderate quality evidence), or in the risk of death (RR 0.84, 95% CI 0.52 to 1.34, P = 0.46, 1 study, n = 304; moderate quality evidence). People with AD receiving vitamin E showed less functional decline on the Alzheimer’s Disease Cooperative Study/Activities of Daily Living Inventory than people receiving placebo at six to 48 months (mean difference (MD) 3.15, 95% CI 0.07 to 6.23, P = 0.04, 1 study, n = 280; moderate quality evidence).

There was no evidence of any clinically important effect on neuropsychiatric symptoms measured with the Neuropsychiatric Inventory (MD -1.47, 95% CI -4.26 to 1.32, P = 0.30, 1 study, n = 280; moderate quality evidence).

We found no evidence that vitamin E affected the probability of progression from MCI to probable dementia due to AD over 36 months (RR 1.03, 95% CI 0.79 to 1.35, P = 0.81, 1 study, n = 516; moderate quality evidence). Five deaths occurred in each of the vitamin E and placebo groups over the 36 months (RR 1.01, 95% CI 0.30 to 3.44, P = 0.99, 1 study, n = 516; moderate quality evidence).

We were unable to extract data in accordance with the review protocol for other outcomes. However, the study authors found no evidence that vitamin E differed from placebo in its effect on cognitive function, global severity or activities of daily living . There was also no evidence of a difference between groups in the more commonly reported adverse events.

Author’s Conclusions

We found no evidence that the alpha-tocopherol form of vitamin E given to people with MCI prevents progression to dementia, or that it improves cognitive function in people with MCI or dementia due to AD. However, there is moderate quality evidence from a single study that it may slow functional decline in AD.

Vitamin E was not associated with an increased risk of serious adverse events or mortality in the trials in this review. These conclusions have changed since the previous update, however they are still based on small numbers of trials and participants and further research is quite likely to affect the results.

Citation

https://www.ncbi.nlm.nih.gov/pubmed/28128435

 

Advance Care Planning Tips

(NIH) Advance care planning is not just about old age. At any age, a medical crisis could leave someone too ill to make his or her own healthcare decisions. Even if you are not sick now, making healthcare plans for the future is an important step toward making sure you get the medical care you would want, even when doctors and family members are making the decisions for you.

More than one out of four older Americans face questions about medical treatment near the end of life but are not capable of making those decisions. This tip sheet will discuss some questions you can think about now and describe ways to share your wishes with others. Write them down or at least talk about them with someone who would make the decisions for you. Knowing how you would decide might take some of the burden off family and friends.

What Is Advance Care Planning?

Advance care planning involves learning about the types of decisions that might need to be made, considering those decisions ahead of time, and then letting others know about your preferences, often by putting them into an advance directive. An advance directive is a legal document that goes into effect only if you are incapacitated and unable to speak for yourself. This could be the result of disease or severe injury—no matter how old you are. It helps others know what type of medical care you want. It also allows you to express your values and desires related to end-of-life care. You might think of an advance directive as a living document—one that you can adjust as your situation changes because of new information or a change in your health.

Medical Research and Advance Care Planning

Medical research plays an important role in the health of Americans of all ages. Because of advances in medicine and in public health, Americans are living longer and staying healthier as they grow older. The National Institute on Aging (NIA) supports much of the research around the country that looks at how people age and how to improve their health in their later years. NIA is part of the National Institutes of Health (NIH), the nation’s medical research agency.

Some NIA-supported research focuses on advance care planning, including examining why people might complete advance directives and the effect of these directives on end-of-life care. In one study, for example, scientists funded by NIA found that advance directives can make a difference and that people who document their preferences in this way are more likely to get the care they prefer at the end of life than people who do not.

Decisions That Could Come Up Near Death

Sometimes when doctors believe a cure is no longer possible and you are dying, decisions must be made about the use of emergency treatments to keep you alive. Doctors can use several artificial or mechanical ways to try to do this. Decisions that might come up at this time relate to:

  • CPR (cardiopulmonary resuscitation)
  • ventilator use
  • artificial nutrition (tube feeding) or artificial hydration (intravenous fluids)
  • comfort care

CPR. CPR (cardiopulmonary resuscitation) might restore your heartbeat if your heart stops or is in a life-threatening abnormal rhythm. The heart of a young, otherwise healthy person might resume beating normally after CPR. An otherwise healthy older person, whose heart is beating erratically or not beating at all, might also be helped by CPR. CPR is less likely to work for an older person who is ill, can’t be successfully treated, and is already close to death. It involves repeatedly pushing on the chest with force, while putting air into the lungs. This force has to be quite strong, and sometimes ribs are broken or a lung collapses. Electric shocks known as defibrillation and medicines might also be used as part of the process.

Ventilator use. Ventilators are machines that help you breathe. A tube connected to the ventilator is put through the throat into the trachea (windpipe) so the machine can force air into the lungs. Putting the tube down the throat is called intubation. Because the tube is uncomfortable, medicines are used to keep you sedated (unconscious) while on a ventilator. If you can’t breathe on your own after a few days, a doctor may perform a tracheotomy or “trach” (rhymes with “make”). During this bedside surgery, the tube is inserted directly into the trachea through a hole in the neck. For long-term help with breathing, a trach is more comfortable, and sedation is not needed. People using such a breathing tube aren’t able to speak without special help because exhaled air goes out of the trach rather than past their vocal cords.

Artificial nutrition or artificial hydration. A feeding tube and/or intravenous (IV) liquids are sometimes used to provide nutrition when a person is not able to eat or drink. These measures can be helpful if you are recovering from an illness. However, if you are near death, these could actually make you more uncomfortable. For example, IV liquids, which are given through a plastic tube put into a vein, can increase the burden on failing kidneys. Or if the body is shutting down near death, it is not able to digest food properly, even when provided through a feeding tube. At first, the feeding tube is threaded through the nose down to the stomach. In time, if tube feeding is still needed, the tube is surgically inserted into the stomach.

Comfort care. Comfort care is anything that can be done to soothe you and relieve suffering while staying in line with your wishes. Comfort care includes managing shortness of breath; offering ice chips for dry mouth; limiting medical testing; providing spiritual and emotional counseling; and giving medication for pain, anxiety, nausea, or constipation. Often this is done through hospice, which may be offered in the home, in a hospice facility, in a skilled nursing facility, or in a hospital. With hospice, a team of healthcare providers works together to provide the best possible quality of life in a patient’s final days, weeks, or months. After death, the hospice team continues to offer support to the family. Learn more about providing comfort at the end of life.

What Is Hospice Care? What Is Palliative Care?

Hospice care is intended to provide comfort to you and your family during a life-threatening illness, rather than provide treatments to cure the illness. Palliative care is similar to comfort care in hospice, but it is offered along with any medical treatments you might be receiving for a life-threatening illness, such as chemotherapy for cancer or dialysis for kidney failure. The main goal of both hospice and palliative care is to keep you comfortable. In addition, you can always choose to move from hospice to palliative care if you want to pursue treatments to cure your illness.

Getting Started

Start by thinking about what kind of treatment you do or do not want in a medical emergency. It might help to talk with your doctor about how your present health conditions might influence your health in the future. For example, what decisions would you or your family face if your high blood pressure leads to a stroke?

If you don’t have any medical issues now, your family medical history might be a clue to thinking about the future. Talk to your doctor about decisions that might come up if you develop health problems similar to those of other family members.

In considering treatment decisions, your personal values are key. Is your main desire to have the most days of life, or to have the most life in your days? What if an illness leaves you paralyzed or in a permanent coma and you need to be on a ventilator? Would you want that?

What makes life meaningful to you? You might want doctors to try CPR if your heart stops or to try using a ventilator for a short time if you’ve had trouble breathing, if that means that, in the future, you could be well enough to spend time with your family. Even if the emergency leaves you simply able to spend your days listening to books on tape or gazing out the window watching the birds and squirrels compete for seeds in the bird feeder, you might be content with that.

But, there are many other scenarios. Here are a few. What would you decide?

  • If a stroke leaves you paralyzed and then your heart stops, would you want CPR? What if you were also mentally impaired by a stroke—does your decision change?
  • What if you develop dementia, don’t recognize family and friends, and, in time, cannot feed yourself? Would you want a feeding tube used to give you nutrition?
  • What if you are permanently unconscious and then develop pneumonia? Would you want antibiotics and a ventilator used?

For some people, staying alive as long as medically possible is the most important thing. An advance directive can help make sure that happens.

Your decisions about how to handle any of these situations could be different at age 40 than at age 85. Or they could be different if you have an incurable condition as opposed to being generally healthy. An advance directive allows you to provide instructions for these types of situations and then to change the instructions as you get older or if your viewpoint changes.

Do you or a family member have Alzheimer’s disease?

Many people are unprepared to deal with the legal and financial consequences of a serious illness such as Alzheimer’s disease. Advance planning can help people with Alzheimer’s and their families clarify their wishes and make well-informed decisions about health care and financial arrangements.

Learn more about legal and financial planning for people with Alzheimer’s disease.

Making Your Wishes Known

There are two elements in an advance directive—a living will and a durable power of attorney for health care. There are also other documents that can supplement your advance directive or stand alone. You can choose which documents to create, depending on how you want decisions to be made. These documents include:

  • living will
  • durable power of attorney for health care
  • other documents discussing DNR (do not resuscitate) orders, organ and tissue donation, dialysis, and blood transfusions

Living will. A living will is a written document that helps you tell doctors how you want to be treated if you are dying or permanently unconscious and cannot make decisions about emergency treatment. In a living will, you can say which of the procedures described above you would want, which ones you wouldn’t want, and under which conditions each of your choices applies.

Durable power of attorney for health care. A durable power of attorney for health care is a legal document naming a healthcare proxy, someone to make medical decisions for you at times when you might not be able to do so. Your proxy, also known as a surrogate or agent, should be familiar with your values and wishes. This means that he or she will be able to decide as you would when treatment decisions need to be made. A proxy can be chosen in addition to or instead of a living will. Having a healthcare proxy helps you plan for situations that cannot be foreseen, like a serious auto accident.

A durable power of attorney for health care enables you to be more specific about your medical treatment than a living will.

Some people are reluctant to put specific health decisions in writing. For them, naming a healthcare agent might be a good approach, especially if there is someone they feel comfortable talking with about their values and preferences.

Other advance care planning documents. You might also want to prepare separate documents to express your wishes about a single medical issue or something not already covered in your advance directive. A living will usually covers only the specific life-sustaining treatments discussed earlier. You might want to give your healthcare proxy specific instructions about other issues, such as blood transfusion or kidney dialysis. This is especially important if your doctor suggests that, given your health condition, such treatments might be needed in the future.

Two medical issues that might arise at the end of life are DNR orders and organ and tissue donation.

A DNR (do not resuscitate) order tells medical staff in a hospital or nursing facility that you do not want them to try to return your heart to a normal rhythm if it stops or is beating unevenly. Even though a living will might say CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your bed might avoid confusion in an emergency situation. Without a DNR order, medical staff will make every effort to restore the normal rhythm of your heart. A non-hospital DNR will alert emergency medical personnel to your wishes regarding CPR and other measures to restore your heartbeat if you are not in the hospital. A similar document that is less familiar is called a DNI (do not intubate) order. A DNI tells medical staff in a hospital or nursing facility that you do not want to be put on a breathing machine.

Organ and tissue donation allows organs or body parts from a generally healthy person who has died to be transplanted into people who need them. Commonly, the heart, lungs, pancreas, kidneys, corneas, liver, and skin are donated. There is no age limit for organ and tissue donation. You can carry a donation card in your wallet. Some states allow you to add this decision to your driver’s license. Some people also include organ donation in their advance care planning documents. At the time of death, family may be asked about organ donation. If those close to you, especially your proxy, know how you feel about organ donation, they will be ready to respond.

What About Pacemakers and ICDs?

Some people have pacemakers to help their hearts beat regularly. If you have one and are near death, it may not necessarily keep you alive. But, you might have an ICD (implantable cardioverter-defibrillator) placed under your skin to shock your heart back into regular beatings if the rhythm becomes irregular. If other life-sustaining measures are not used, the ICD may also be turned off. You need to state in your advance directive what you want done if the doctor suggests it is time to turn it off.

Selecting Your Healthcare Proxy

If you decide to choose a proxy, think about people you know who share your views and values about life and medical decisions. Your proxy might be a family member, a friend, your lawyer, or someone with whom you worship. It’s a good idea to also name an alternate proxy. It is especially important to have a detailed living will if you choose not to name a proxy.

You can decide how much authority your proxy has over your medical care—whether he or she is entitled to make a wide range of decisions or only a few specific ones. Try not to include guidelines that make it impossible for the proxy to fulfill his or her duties. For example, it’s probably not unusual for someone to say in conversation, “I don’t want to go to a nursing home,” but think carefully about whether you want a restriction like that in your advance directive. Sometimes, for financial or medical reasons, that may be the best choice for you.

Of course, check with those you choose as your healthcare proxy and alternate before you name them officially. Make sure they are comfortable with this responsibility.

Making It Official

Once you have talked with your doctor and have an idea of the types of decisions that could come up in the future and whom you would like as a proxy, if you want one at all, the next step is to fill out the legal forms detailing your wishes. A lawyer can help but is not required. If you decide to use a lawyer, don’t depend on him or her to help you understand different medical treatments. That’s why you should start the planning process by talking with your doctor.

Many states have their own advance directive forms. Your local Area Agency on Aging can help you locate the right forms. You can find your area agency phone number by calling the Eldercare Locator toll-free at 1-800-677-1116 or going online at www.eldercare.gov.

Some states want your advance directive to be witnessed; some want your signature notarized. A notary is a person licensed by the state to witness signatures. You might find a notary at your bank, post office, or local library, or call your insurance agent. Some notaries charge a fee.

Some people spend a lot of time in more than one state—for example, visiting children and grandchildren. If that’s your situation also, you might consider preparing an advance directive using forms for each state—and keep a copy in each place, too.

Future Directions

A number of states are developing or starting to use an advance care planning form known as POLST (Physician Orders for Life-Sustaining Treatment) or MOLST (Medical Orders for Life-Sustaining Treatment). These forms serve in addition to your advance directive. They make it possible for you to provide more detailed guidance about your medical care preferences. Your doctor will talk with you and/or your family for guidance, but the form is filled out by the doctor or, sometimes, a nurse practitioner or physician’s assistant. Once signed by your doctor, this form has the force of any other medical order. These forms are often printed on brightly colored paper so they are easily found in a medical or hospital file. Check with your state department of health to find out if this form is available where you live.

After You Set Up Your Advance Directive

There are key people who should be told that you have an advance directive. Give copies to your healthcare proxy and alternate proxy. Give your doctor a copy for your medical records. Tell key family members and friends where you keep a copy. If you have to go to the hospital, give staff there a copy to include in your records. Because you might change your advance directive in the future, it’s a good idea to keep track of who receives a copy.

Review your advance care planning decisions from time to time—for example, every 10 years, if not more often. You might want to revise your preferences for care if your situation or your health changes. Or, you might want to make adjustments if you receive a serious diagnosis; if you get married, separated, or divorced; if your spouse dies; or if something happens to your proxy or alternate. If your preferences change, you will want to make sure your doctor, proxy, and family know about them.

Still Not Sure?

What happens if you have no advance directive or have made no plans and you become unable to speak for yourself? In such cases, the state where you live will assign someone to make medical decisions on your behalf. This will probably be your spouse, your parents if they are available, or your children if they are adults. If you have no family members, the state will choose someone to represent your best interests.

Always remember, an advance directive is only used if you are in danger of dying and need certain emergency or special measures to keep you alive but are not able to make those decisions on your own. An advance directive allows you to continue to make your wishes about medical treatment known.

Looking Toward the Future

Nobody can predict the future. You may never face a medical situation where you are unable to speak for yourself and make your wishes known. But having an advance directive may give you and those close to you some peace of mind.

Advance Directive Wallet Card

You might want to make a card to carry in your wallet indicating that you have an advance directive and where it is kept. Here is a slightly revised example of the wallet card offered by the Office of the Attorney General in Maryland. It uses the phrase “healthcare agent” instead of “healthcare proxy.” You might want to print this one to fill out and carry with you. It can also be found online at www.oag.state.md.us/Healthpol/adDir_cards.pdf (PDF, 178K).

Printable wallet card specifying advance directive information

 

For More Information

Other federal and non-federal resources with information about advance directives include:

Caring Connections
National Hospice and Palliative Care Organization

1-800-658-8898 (toll-free)
1-877-658-8896 (toll-free/multilingual)
www.caringinfo.org

Caring Conversations
Center for Practical Bioethics

Harzfeld Building
1111 Main Street, Suite 500
Kansas City, MO 64105-2116
1-800-344-3829 (toll-free)
www.practicalbioethics.org

American Bar Association
321 North Clark Street
Chicago, IL 60654
1-800-285-2221
www.americanbar.org
(search for “Consumer’s Tool Kit for Health Care Advance Planning”)

Donate Life America
701 East Byrd Street, 16th floor
Richmond, VA 23219
1-804-377-3580
www.donatelife.net

National Legal Resource Center
www.nlrc.aoa.gov

OrganDonor.gov
Health Resources and Services Administration
1-888-275-4772 (toll-free)
www.organdonor.gov

POLST (Physician Orders for Life-Sustaining Treatment)
www.polst.org

Put It In Writing
American Hospital Association

155 North Wacker Drive
Chicago, IL 60606
1-800-424-4301 (toll-free)
www.putitinwriting.org

The Living Bank
P.O. Box 6725
Houston, TX 77265
1-800-528-2971 (toll-free)
www.livingbank.org

For more information about health and aging, contact:

National Institute on Aging Information Center
P.O. Box 8057
Gaithersburg, MD 20898-8057
1-800-222-2225 (toll-free)
1-800-222-4225 (TTY/toll-free)
www.nia.nih.gov
www.nia.nih.gov/espanol

To order free publications (in English or Spanish) or sign up for email alerts, go to: www.nia.nih.gov/health

Visit www.nihseniorhealth.gov a senior-friendly website from the National Institute on Aging and the National Library of Medicine. This website has health and wellness information for older adults. Special features make it simple to use. For example, you can click on a button to make the type larger.

Citation

https://www.nia.nih.gov/health/publication/advance-care-planning

National Institute on Aging

 

Medicare Now Provides Coverage for Critical Alzheimer’s Care and Support Services

(Alzheimer’s Association) For the over five million American living with Alzheimer’s disease and their families, early detection and diagnosis is an important first step to managing their health. Currently, less than half of seniors diagnosed with dementia, or their caregivers, are aware of the diagnosis, even though Medicare covers the process for getting diagnosed.

Why is that? Studies show that one reason doctors don’t disclose the diagnosis of Alzheimer’s or a related dementia, is because of the insufficient time and resources to provide support to patients and caregivers at the time of diagnosis, including a discussion of treatment options and support services.

However, recent developments show promise in addressing this critical gap in care and support. Starting this month, Medicare will reimburse doctors for taking the time to test for dementia, document the diagnosis and discuss care planning with their patients.

Care planning and documentation of a diagnosis are crucial to improving outcomes and quality of care. Care planning allows people to learn about treatment options, enroll in clinical trials and access support services. Studies suggest that care planning can improve the long-term health of caregivers, as well.

Documentation ensures all health care providers know of the diagnosis and can more effectively coordinate care and properly manage other chronic conditions, medications and care transitions.

Among people with Alzheimer’s or a related dementia, over 85% have one or more other chronic conditions. Alzheimer’s complicates the management of these conditions, and thus increases cost. For example, care for a senior with diabetes and Alzheimer’s costs Medicare 81% more than the care for a senior who has diabetes but no Alzheimer’s.

The updates on Medicare coverage would help reduce cost by ensuring that critical steps are taken by health care providers to help families immediately after a diagnosis. This recent development is a result of the HOPE for Alzheimer’s Act (Health Outcomes, Planning and Education for Alzheimer’s Act S. 857 / H.R. 1559).

Specifically, under the Hope for Alzheimer’s Act, Medicare beneficiaries, who are newly diagnosed with Alzheimer’s disease, would receive coverage for comprehensive care planning services for themselves and their caregivers.

In an analysis by former Congressional Budget Office staff, this new legislation is estimated to reduce federal spending by $692 million over the next ten years. Savings would come from reduced hospitalizations and emergency room visits among seniors, and some savings resulting from better medication and other chronic condition management.

Alzheimer’s Association grassroots advocates and staff have held thousands of congressional meetings to secure support for the HOPE for Alzheimer’s Act since the bill’s introduction, and have worked tirelessly to secure support for the benefit at The Centers for Medicare & Medicaid Services (CMS). We will continue to engage CMS to ensure the service’s maximum impact for people living with the disease and their caregivers.

Alzheimer’s Association

We can Help:

Citation

http://www.alzheimersblog.org/2017/01/10/ medicare-coverage-critical-alzheimers-care-support-services/

Alzheimer’s Association of Northern California and Northern Nevada © 2016. All Rights Reserved.

 

Talking With Your Parents About Independent Living

(AARP) Your parents might have lived in their home for decades, so it’s understandable that they are not eager to move to a new place when they get older. Even if the house is getting difficult to maintain or doesn’t meet their needs, there are years of memories there. Change can be hard.

t’s good to talk with your parents while they are still healthy about what might be needed to remain living independently — often parents and loved ones find some peace of mind in discussing those issues when things are going well. If you wait until a crisis occurs, you will have to make decisions quickly and you might not know your loved one’s wishes.

Many adult children don’t know how to bring up the subject of independent living with their parents. Here are some tips for starting this difficult dialogue, keeping focused and dealing with resistance.

Beginning the Conversation

Raise the issues indirectly
Mention a friend’s mother who recently hired in-home help, or an article that you read about programs at a nearby senior center. Example: “Is that something that you might be interested in learning more about?”

Find small ways to bridge the issue
Example: “I know you’re taking pills for arthritis, your heart and cholesterol. Would it help if you had one of those medication organizers you can buy in the drugstore?”

Share your own emotions
Example:  “Dad, it’s hard for me to see you slowing down and I know you’ve always prided yourself on being independent. I imagine it’s difficult for you to ask for help, but what are some things that we can do?”

Set the right tone
Once the topic has been brought up, listen to how your parents feel about their current needs, concerns, worries and hopes for the future. Don’t guess or make assumptions about your parents’ preferences. Ask open-ended questions that get them to express their perceptions.

Use communication that states your concern and avoids criticism
Example: “I’m feeling concerned that you may fall coming down the stairs. I could put a 100-watt bulb at the bottom of the stairs and install a handrail.” Don’t say: “Going upstairs in your condition is ridiculous. You’re sure to fall.”

Avoid role reversal
Helping out doesn’t mean you are “parenting” your parents. The most productive interactions come when parents and adult children are equal in the relationship.

Focus on These Key Issues

While each situation is unique, here are some common issues that can affect an older person’s ability to remain independent that you may want to discuss as your parents’ situation changes.

Where they live
Ask: Is your home still appropriate for your needs?
Are there any safety hazards in the house that could be removed?
Have you thought about eventually living somewhere else?

Their everyday activities
Ask: Do you need help with household chores?
Does impaired vision interfere with your cooking?
Can you hear a knock at the door or the telephone ring?

How they get around
Ask: Do you feel comfortable driving?
Would you like me to take you to your doctor appointments?
Are there vans or discounted senior taxi services you could use for shopping or to get to religious services?

Their health
Ask: Are your prescriptions current?
Have you been to your doctor lately? What did he or she say about your health?

Their finances
Ask: What are your current bills like and can you cover everything you need?
Have you thought about how you might need money in the future to help pay for assistance with everyday activities you might not be able to do yourself?
Would it be useful to consult with a financial planner?

How they pay for health care
Ask: What kind of health insurance do you have? Has it paid your health care bills so far? Do you have any questions about Medicare or Medicaid?

Dealing with Resistance

Your parents may not want to talk about these issues. Some resistance is normal.

  • Respect your parents’ feelings when they make it clear they want to avoid a subject. Try again later using another approach.
  • Consider pushing the issue if your parents’ health or safety is at risk. While your parents have a right to be in charge of their own lives, some crisis situations — such as health care expenses depleting a bank account — may call for you to intervene. If so, act firmly but with compassion.
  • Involve other family members or friends. You may want to hold a family meeting where everyone can discuss concerns and develop a plan to help.
  • Find out about community resources to help your parents remain independent, such as transportation or home health care, and share the options with them.
  • Be prepared to let your parents make their own life choices, even if you don’t agree with them. You should set your own limits as to how involved you can be. If the living situation is unsafe, you may need to bring in a third party to intervene.
Citation

http://www.aarp.org/home-family/caregiving/info-05-2012/talking-about-independent-living.html

Copyright 2017 AARP

 

New Antibody Design Opens Door for Brain Treatments

(Uppsala Universitet) Immunotherapy has proven to be effective against many serious diseases. But to treat diseases in the brain, the antibodies must first get past the obstacle of the blood-brain barrier. In a new study, a research group at Uppsala University describes their development of a new antibody design that increases brain uptake of antibodies almost 100-fold.

Immunotherapy entails treatment with antibodies; it is the fastest growing field in pharmaceutical development. In recent years, immunotherapy has successfully been used to treat cancer and rheumatoid arthritis, and the results of clinical studies look very promising for several other diseases. Antibodies are unique in that they can be modified to strongly bind to almost any disease-causing protein. In other words, major potential exists for new antibody-based medicines.

The problem with immunotherapy for diseases affecting the brain is that the brain is protected by a very tight layer of cells, called the blood-brain barrier. The blood-brain barrier effectively prevents large molecules, such as antibodies, from passing from the bloodstream into the brain. It has therefore been difficult to use immunotherapy to treat Alzheimer’s and Parkinson’s disease, which affect the brain, as well as cancerous tumours in the brain.

It has been known for a long time that some large proteins are actively transported across the blood-brain barrier. These include a protein called transferrin, whose primary task is to bind to iron in the blood and then transport it to the brain. The research group behind this new study has taken advantage of this process and modified the antibodies they want to transport into the brain using components that bind to the transferrin receptor. Then, like a Trojan horse, the receptor transports antibodies into the brain. The number of modifications to and placement of the antibodies have proven to be important factors for making this process as effective as possible.

“We’ve placed them so that each antibody only binds with one modification at a time, despite being modified in two places. Our design thus doubles the chances of the antibody binding to the transferrin receptor compared with only one modification. We’ve successfully increased the amount of antibodies in the brain almost 100-fold, which is the largest uptake improvement that has ever been shown,” says Greta Hultqvist, researcher at the Department of Public Health and Caring Sciences at Uppsala University.

To try out the new format, researchers have used it on an antibody that binds to a protein involved in the course of Alzheimer’s disease. Without the modification, they could only detect very small quantities of antibody in the brain in a mouse model of Alzheimer’s disease, while they could detect high levels of the modified antibody in the same mice.

“From a long-term perspective, it’s likely that the new format can be used to effectively treat not only Alzheimer’s disease, but also other diseases affecting the brain,” says Dag Sehlin, researcher at the Department of Public Health and Caring Sciences at Uppsala University.

Citation

https://www.uu.se/en/media/news/article/?id=8020&typ=artikel

Journal Reference:

Greta Hultqvist, Stina Syvänen, Xiaotian T Fang, Lars Lannfelt, Dag Sehlin. Bivalent Brain Shuttle Increases Antibody Uptake by Monovalent Binding to the Transferrin Receptor. Theranostics, 2017; 7 (2): 308 DOI: 10.7150/thno.17155

© Uppsala University

 

Deep Brain Stimulation Studies in Alzheimer’s Disease Pose Ethical Challenges

(Journal of Alzheimer’s Disease) Promising, early studies of deep brain stimulation (DBS) for the treatment of Alzheimer’s disease have paved a path for future clinical trials, but there are unique ethical challenges with this vulnerable population regarding decision making and post-study treatment access that need to be addressed as they ramp up, Penn Medicine researchers argue in a new review in the Journal of Alzheimer’s Disease.

Does the patient still have the capacity to make an informed decision half way through the trial? Are there any misconceptions about its therapeutic benefit? Will the device remain after the trial ends, and who will pay for it?

These are the questions posed in an ethics review piece that also lays out guidelines for investigators to consider when enrolling Alzheimer’s patients in DBS trials. The article is authored Andrew M. Siegel, MD, an assistant professor of Clinical Psychiatry in the Perelman School of Medicine at the University of Pennsylvania, Marna S. Barrett, PhD, an adjunct associate professor of Psychology in Psychiatry at Penn, and Mahendra T. Bhati, MD, a former assistant professor of Clinical Psychiatry at Penn, who is now at Stanford University, in an ethics review piece that also lays out guidelines for investigators to consider when enrolling Alzheimer’s patients in DBS trials.

Approved for the treatment of movement and neuropsychiatric disorders, such as Parkinson’s disease, DBS is an invasive, surgical procedure involving the implantation of a microstimulator that sends electrical impulses to specific targets in the brain. Driven by the urgent need for effective therapies and the success of recent studies, DBS has now emerged as a possible treatment for Alzheimer’s.

“As the number of people affected by Alzheimer’s continues to grow, along with its substantial costs to individuals, their families, and society, novel therapies are urgently needed. DBS is one such treatment modality that has shown promising early results,” Siegel said.

“However, this enthusiasm should be tempered by prudent ethical considerations to help better protect the patients.”

The authors call out three ethical issues that should be addressed and recommendations.

Ensuring the trial subjects possess adequate decision-making capacity is important, the authors said, because such individuals have cognitive deficits that may reasonably limit that capacity and thereby compromise informed consent. DBS for trials must have a robust mechanism for both detecting loss of decision-making capacity and protecting the interest of the patients during the trial, they wrote. Suggestions include an Institutional Review Board (IRB)-mandated use of a validated decision-making capacity assessment, such as the MacCAT-CR interview, and an “auxiliary consenter,” someone not affiliated with the study to determine the patient’s knowledge about the procedures, risks, and the device.

Therapeutic misconception is another concern. Patients with Alzheimer’s, desperate for relief and without an effective alternative, may agree to DBS as a last resort. Such desperation may alter their perception that the primary goal of the study is for health benefits and not knowledge about the efficacy of the device. Left unchecked, it could distort patients’ understanding of the risks and benefits of DBS.

“It may be necessary to directly inform patients during study consent that ‘scientific goals will have priority over therapeutic goals’,” the authors wrote.

A “cooling off” period, where patients have adequate time to process all the information that has been given to them, may also prove effective.

Another question to be asked at the end of the trial is whether patients who have benefited from the device should continue to receive treatment. This question is particularly salient considering the high cost of DBS and the fact that the device may be with the patient for many years after the trial ends. The authors believe denying a patient access to the only intervention known to alleviate their suffering is tantamount to violating the sacrosanct principle of “do no harm.”

“Providing post-trial access to the subset of patients shown to benefit in a failed trial is not only ethically appropriate,” Siegel said, “but it would allow for the collection of longitudinal safety and efficacy data not captured in the original study.”

Once post-trial access is accepted by a research team, the challenge is financial responsibility. Patients, together with sponsors, investigators, health care systems, insurance, governments, and non-profit organizations must partner to share responsibility and negotiate continued access arrangements prior to study enrollment, the authors said.

This model has worked in the past – the HIV Netherlands, Australia, Thailand Research Collaboration is one example.

“We hope this review facilitates the development of study designs and IRB oversight procedures that best protect research subjects,” Siegel said.

“A reasonable next step is for research centers and hospitals to examine their current practice and policies guiding DBS in Alzheimer’s research. Our review could act as a guide in helping them ask the relevant questions about their current state of oversight and to consider changes as appropriate.”

Citation

http://www.j-alz.com/content/deep-brain-stimulation-studies-alzheimer%E2%80%99s-disease-pose-ethical-challenges

Siegel AM, Barrett MS, Bhati MT (2017) Deep Brain Stimulation for Alzheimer’s Disease: Ethical Challenges for Clinical Research. J Alzheimers Dis 56, 429-439.

Journal of Alzheimer’s Disease is published by IOS Press

Copyright © 2017

 

Drug Compound Halts Alzheimer’s-related Damage in Mice

(Washington University School of Medicine) Under ordinary circumstances, the protein tau contributes to the normal, healthy functioning of brain neurons. In some people, though, it collects into toxic tangles that damage brain cells. Such tangles are a hallmark of Alzheimer’s and other neurodegenerative diseases.

But researchers at Washington University School of Medicine in St. Louis have shown that levels of the tau protein can be reduced – and some of the neurological damage caused by tau even reversed ­- by a synthetic molecule that targets the genetic instructions for building tau before the protein is made.

Neurons that contain the synthetic molecule (here shown in red) have no tau tangles (shown in green).
Image credit: Sarah DeVos

The study, in mice and monkeys, is published Jan. 25 in Science Translational Medicine. The findings suggest that the molecule – known as an antisense oligonucleotide – potentially could treat neurodegenerative diseases characterized by abnormal tau, including Alzheimer’s.

“We’ve shown that this molecule lowers levels of the tau protein, preventing and, in some cases, reversing the neurological damage,” said Timothy Miller, MD, PhD, the David Clayson Professor of Neurology and the study’s senior author.

“This compound is the first that has been shown to reverse tau-related damage to the brain that also has the potential to be used as a therapeutic in people.”

Miller, then-graduate student Sarah DeVos, PhD, and colleagues studied genetically modified mice that produce a mutant form of human tau that easily clumps together. These mice start showing tau tangles at around 6 months of age and exhibit some neuronal damage by 9 months.

To reduce tau, the researchers used an antisense oligonucleotide, a kind of molecule that interferes with the instructions for building proteins. Genes in the DNA are copied into RNA, a messenger molecule that carries the instructions for building a protein. Antisense oligonucleotides bind to the messenger RNA and target it for destruction before the protein can be built. Such oligonucleotides can be designed to target the RNA for almost any protein.

The researchers administered a dose of the anti-tau oligonucleotide to 9-month-old mice every day for a month and then measured the amount of tau RNA, total tau protein and tangles of tau protein in their brains when the mice were 12 months old. The levels of all three were significantly reduced in the treated mice compared with mice that received a placebo.

Importantly, levels of total tau and tau tangles in the brains of treated 12-month-old mice were lower than in untreated 9-month-old mice, suggesting that the treatment not only had stopped but reversed the buildup of tau.

By the time this strain of genetically modified mice reaches 9 months of age, the hippocampus – a part of the brain important for memory – typically is visibly shrunken and shows dying neurons. But with the oligonucleotide treatment, the shrinkage and cell death were halted. There was not, however, any evidence of reversal of neuronal death.

The treated mice lived an average of 36 days longer than untreated mice, and they were better at building nests, which reflects a combination of social behavior, cognitive performance and motor capabilities. All of these functions can be impaired in people with Alzheimer’s disease and other tau-related neurodegenerative diseases.

Oligonucleotide treatments recently have been approved by the Food and Drug Administration for two neuromuscular diseases: Duchenne’s muscular dystrophy and spinal muscular atrophy (SMA). The oligonucleotide for SMA was discovered by Ionis Pharmaceuticals, which partnered with Miller to develop the oligonucleotide treatment for tau-related neurological diseases. Washington University holds joint patent applications with Ionis Pharmaceuticals on the use of oligonucleotides for reducing tau levels.

Human trials of oligonucleotides for several other neurological diseases are underway, including Huntington’s disease and amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig’s disease. Miller co-leads the ALS trial.

Miller and colleagues were intrigued by the possibility of designing studies to lower tau in people, but first they needed to see how the oligonucleotide worked in an animal more similar to people than a mouse.

The researchers treated groups of healthy cynomolgus monkeys – also known as crab-eating macaques – with two doses of placebo or oligonucleotide, one week apart, directly into the cerebrospinal fluid that surrounds the spinal cord and brain, just as would be done with human patients. Two weeks later, they measured the amount of tau protein and RNA in the monkeys’ brains and cerebrospinal fluid.

The oligonucleotide reduced both tau RNA and protein in the brain, and this reduction was mirrored in the cerebrospinal fluid.

“The monkey study showed us that lower tau in the cerebrospinal fluid correlates with lower tau in the brain,” Miller said.

“This is important if we’re going to evaluate this treatment approach in people, because there’s no non-invasive way of measuring tau levels in the brain. This correlation tells us that we can use levels of tau in the cerebrospinal fluid as a proxy for levels of tau in the brain.”

Elevated tau is associated not just with Alzheimer’s but with a range of lesser-known neurodegenerative diseases, such as progressive supranuclear palsy and corticobasal ganglionic degeneration. Tau levels also increase in the aftermath of traumatic brain injury, which can lead to dementia.

“Tau tangles correlate with cognitive decline in several diseases,” Miller said.

“This is a promising new approach to lowering tau, but we have to test whether it is safe in people, and whether it actually lowers tau, as it is designed to do, before we get to the question of whether it has any effect on the disease. But everything we’ve seen so far says that this is worth investigating as a potential treatment for people.”

Citation

https://www.eurekalert.org/pub_releases/2017-01/wuso-dch012017.php

Copyright © 2017 by the American Association for the Advancement of Science (AAAS)

 

Roots of Alzheimer’s Disease Can Extend as Far Back as the Womb

(University of British Columbia) Biochemical reactions that cause Alzheimer’s disease could begin in the womb or just after birth if the fetus or newborn does not get enough vitamin A, according to new research from the University of British Columbia.

These new findings, based on studies of genetically-engineered mice, also demonstrate that supplements given to newborns with low levels of vitamin A could be effective in slowing the degenerative brain disease.

“Our study clearly shows that marginal deficiency of vitamin A, even as early as in pregnancy, has a detrimental effect on brain development and has long-lasting effect that may facilitate Alzheimer’s disease in later life,” said Dr. Weihong Song, a professor of psychiatry and Canada Research Chair in Alzheimer’s Disease.

For this research, Song built on previous studies that have linked low levels of vitamin A with cognitive impairments. In collaboration with Dr. Tingyu Li and others at Children’s Hospital of Chongqing Medical University, they examined the effects of vitamin A deprivation in the womb and infancy on Alzheimer’s model mice. These early developmental stages are crucial periods during which brain tissue is “programmed” for the rest of a person’s life.

The researchers found that even a mild vitamin A deficiency increased the production of amyloid beta, the protein that forms plaques that smother and ultimately kill neurons in Alzheimer’s disease. He also found that these mice, when deprived of vitamin A, performed worse as adults on a standard test of learning and memory.

Even when the mice deprived of vitamin A in the womb were given a normal diet as pups, they performed worse than mice who received a normal amount of the nutrient in the womb but were deprived after birth. In other words, the damage had already been done in the womb.

Still, Song and his collaborators also showed that some reversal is possible: Mice who were deprived in utero but then given supplements immediately after birth performed better on the tests than mice who weren’t given such supplements.

“In some cases, providing supplements to the newborn Alzheimer’s disease model mice could reduce the amyloid beta level and improve learning and memory deficits,” said Song. “It’s a matter of the earlier, the better.”

The study, published today in Acta Neuropathologica, also included new evidence in humans of the vitamin A-dementia connection in later years. Examining 330 elderly people in Chongqing, Song and his collaborators found that 75 per cent of those with either mild or significant vitamin A deficiency had cognitive impairment, compared to 47 per cent of those with normal vitamin A levels.

However, Dr. Song cautions against overreacting to this news. Vitamin A deficiency, though common in many low-income regions of the world, is rare in North America, and excess intake of the nutrient could be harmful. Pregnant women in particular should not take excessive vitamin A supplements. A balanced diet is the best way to ensure adequate levels of the nutrient.

A portion of the research was funded by the National Natural Science Foundation of China and Canadian Institutes of Health Research.

Citation

http://news.ubc.ca/2017/01/27/ the-roots-of-alzheimers-disease-can-extend-as-far-back-as-the-womb/

Journal Reference:

Jiaying Zeng, Li Chen, Zhe Wang, Qian Chen, Zhen Fan, Hongpeng Jiang, Yili Wu, Lan Ren, Jie Chen, Tingyu Li, Weihong Song. Marginal vitamin A deficiency facilitates Alzheimer’s pathogenesis. Acta Neuropathologica, 2017; DOI: 10.1007/s00401-017-1669-y

Copyright University of British Columbia