Friday, August 23, 2019

Increasing evidence shows age-related diseases--rather than age itself--may be the key cause of cognitive decline


Declining mental sharpness "just comes with age," right? Not so fast, say geriatrics researchers and clinicians gathered at a prestigious 2018 conference hosted by the American Geriatrics Society (AGS) with support from the National Institute on Aging (NIA). In a report published in the Journal of the American Geriatrics Society (JAGS), attendees of a conference for the NIA's Grants for Early Medical/Surgical Specialists Transition into Aging Research (GEMSSTAR) program describe how increasing evidence shows age-related diseases--rather than age itself--may be the key cause of cognitive decline. And while old age remains a primary risk factor for cognitive impairment, researchers believe future research--and sustained funding--could illuminate more complex, nuanced connections between cognitive health, overall health, and how we approach age.

"We've long been taught that cognitive issues are 'just part of aging,'" explains Christopher R. Carpenter, MD, MSc, who helped coordinate the conference. "But contemporary medical research shows how bodily changes that lead to diseases like dementia appear long before the symptoms we associate with 'old age.' This begs the question: Is it really age that causes cognitive decline, or is it ultimately the diseases we now associate with age--in large part because we see them with increasing frequency now that we live longer? That's what we wanted to tackle coming together for this meeting."

Hosted by the AGS and NIA in 2018 as the third conference in a three-part series for GEMSSTAR scholars, the NIA "U13" conference brought together NIA experts and more than 100 scholars, researchers, and leaders representing 13 medical specialties to explore experiences with cognitive impairment across health care. Conference findings, published in JAGS (DOI: 10.1111/jgs.16093), detail early thinking on the two-way relationship between cognitive health and the health of other organ systems, as well as opportunities for moving science and practice forward.
According to attendees, several themes emerged:
  • Researchers and clinicians from across health care noted the critical relationship between two of their top concerns: Dementia and delirium (the medical term for abrupt, rapid-onset confusion or an altered mental state, which affects millions of older adults annually). Research now suggests delirium and dementia are mutually inclusive risk factors, with cases of one prompting risks for the other. Thus, prevention of delirium may offer the unprecedented opportunity to prevent or lessen future cognitive decline.
  • Still, as one of the conference attendees noted, "[T]he brain is not an island." Because the conference focused on the impact of cognitive impairment across specialties, a critical focal point for scholars was the complex, bi-directional relationship between cognition and the rest of the body. Cognitive impairments can serve as indicators or influencers in the course of other diseases and conditions. For example, cognitive impairment is perhaps "the strongest independent predictor" of hospital readmission and mortality for older people living with heart failure.
  • As the field progresses, however, a major barrier remains: A dearth of research owing to the exclusion of potential study participants who are cognitively impaired. Though obtaining informed consent (the term used to describe a person's willingness to participate in a study after confirming they understand all the possible risks and benefits) remains challenging, researchers pointed to data that willingness to participate remains high. Coupled with suggestions for tailoring consent safeguards to the types of studies and potential participants thus holds promise for protecting against exploitation while continuing to move cutting-edge care principles forward.
As the GEMSSTAR conference attendees concluded, "The aging of the U.S. population and the growing burden of dementia make this an area of critical research focus...[U]nderstanding and addressing cognitive health and its relationship with the health of other organ systems will require multidisciplinary team science...[and new] study designs..."

Cannabis flower is an effective medication for pain



Using the largest database of real-time recordings of the effects of common and commercially available cannabis products in the United States (U.S.), researchers at The University of New Mexico (UNM) found strong evidence that cannabis can significantly alleviate pain, with the average user experiencing a three-point drop in pain suffering on a 0-10 point scale immediately following cannabis consumption.
With a mounting opioid epidemic at full force and relatively few alternative pain medications available to the general public, scientists found conclusive support that cannabis is very effective at reducing pain caused by different types of health conditions, with relatively minimal negative side effects.
Chronic pain afflicts more than 20 percent of adults and is the most financially burdensome health condition that the U.S faces; exceeding, for example, the combined costs of treating heart disease and cancer.
"Our country has been flooded with an over-prescription of opioids medications, which then often leads to non-prescription opioid and heroin use for many people. This man-made disaster is killing our families and friends, regardless of socio-economic status, skin tone, and other superficial human differences" said Jacob Miguel Vigil, one of the lead investigators of the study, titled "The Effectiveness of Self-Directed Medical Cannabis Treatment for Pain," published in the journal Complementary Therapies in Medicine.
Vigil explains, "Cannabis offers the average patient an effective alternative to using opioids for general use in the treatment of pain with very minimal negative side effects for most people."
The researchers relied on information collected with Releaf App, a mobile software program developed by co-authors Franco Brockelman, Keenan Keeling and Branden Hall. The app. enables cannabis users to monitor the real-time effects of the breadth of available cannabis-based products, which are always variable, of course, given the complexity of the Cannabis plant from which these products are obtained.
Since its release in 2016, the commercially developed Releaf App has been the only publicly available, incentive-free app for educating patients on how different types of products (e.g., flower or concentrate), combustion methods, cannabis subspecies (Indica, Sativa, and hybrid), and major cannabinoid contents (THC and CBD) affect their symptom severity levels, providing the user invaluable feedback on their health status, medication choices, and the clinical outcomes of those choices as measured by symptom relief and side effects.
Scientifically, software like the Releaf App enables researchers to overcome the inherent limitations of government-funded clinical trials on the real-time effects of Cannabis, which are rare in general, but also often limited by onerous federal regulations, including its Schedule I status (no accepted medical use and a high abuse potential) and the mandate that investigators use the notoriously poor quality and low potency cannabis products supplied by the National Institute of Drug Abuse.
"Even just rescheduling cannabis just from Schedule I to Schedule II, i.e., classifying it with fentanyl, oxycodone, and cocaine rather than heroin and ecstasy, could dramatically improve our ability to conduct research and only would require that the DEA recognizes that accepted medical uses for cannabis exist, as clearly evidenced by our results and the flourishing medical cannabis programs in the majority of U.S. states," pointed out co-author Sarah Stith.
Among the study's findings the greatest analgesic responses were reported by people that used whole dried cannabis flower, or 'buds,' and particularly cannabis with relatively high levels of tetrahydrocannabinol, otherwise known as THC. The more recently popularized cannabinoid, cannabidiol or CBD, in contrast, showed little association with the momentary changes in pain intensity, based on the massive database explored in the study.
"Cannabis likely has numerous constituents that possess analgesic properties beyond THC, including terpenes and flavonoids, which likely act synergistically for people that use whole dried cannabis flower," said Vigil, "Our results confirm that cannabis use is a relatively safe and effective medication for alleviating pain, and that is the most important message to learn from our results. It can only benefit the public for people to be able to responsibly weigh the true risks and benefits of their pain medication choices, and when given this opportunity, I've seen numerous chronic pain patients substitute away from opioid use, among many other classes of medications, in favor of medical cannabis."
"Perhaps the most surprising result is just how widespread relief was with symptom relief reported in about 95 percent of cannabis administration sessions and across a wide variety of different types of pain," added lead author of the study, Xiaoxue Li.
The authors do caution that cannabis use does carry the risks of addiction and short-term impairments in cognitive and behavioral functioning, and may not be effective for everyone. However, there are multiple mechanisms by which cannabis alleviates pain suffering. In addition to its anti-inflammatory properties, cannabis activates receptors that are colocalized with opioid receptors in the brain. "Cannabis with high THC also causes mood elevation and adjusts attentional demands, likely distracting patients from the aversive sensations that people refer to "pain," explains Vigil.
"When compared to the negative health risks associated with opioid use, which currently takes the lives of over 115 Americans a day, cannabis may be an obvious value to patients. Chronic opioid use is associated with poorer quality of life, social isolation, lower immune functioning and early morbidity. In contrast, my own ongoing research increasingly suggests that cannabis use is associated with a reversal of each of these potential outcomes," said Vigil

Physical activity at any intensity linked to lower risk of early death


But being sedentary for several hours a day linked to increased risk


Clear evidence that higher levels of physical activity -- regardless of intensity -- are associated with a lower risk of early death in middle aged and older people, is published by The BMJ today.
The findings also show that being sedentary, for example sitting still, for 9.5 hours or more a day (excluding sleeping time) is associated with an increased risk of death.
Previous studies have repeatedly suggested that sedentary behaviour is bad and physical activity is good for health and long life.
Guidelines recommend at least 150 minutes of moderate intensity or 75 minutes of vigorous physical activity each week, but are based mainly on self reported activity, which is often imprecise. So exactly how much activity (and at what intensity) is needed to protect health remains unclear.
To explore this further, researchers led by Professor Ulf Ekelund at the Norwegian School of Sport Sciences in Oslo analysed observational studies assessing physical activity and sedentary time with death ("all cause mortality").
Studies used accelerometers (a wearable device that tracks the volume and intensity of activity during waking hours) to measure total activity in counts per minute (cpm) of wear time. Intensity is usually separated into light, moderate and vigorous -- and the time in these intensities is then estimated.
Examples of light intensity activity includes walking slowly or light tasks such as cooking or washing dishes. Moderate activity includes brisk walking, vacuuming or mowing the lawn, while vigorous activity includes jogging, carrying heavy loads or digging.
Data from eight high quality studies involving 36,383 adults aged at least 40 years (average age 62) were included. Activity levels were categorised into quarters, from least to most active, and participants were tracked for an average of 5.8 years.
During follow-up, 2149 (5.9%) participants died. After adjusting for potentially influential factors, the researchers found that any level of physical activity, regardless of intensity, was associated with a substantially lower risk of death.
Deaths fell steeply as total activity increased up to a plateau at 300 cpm, similar to the average activity levels in a population-based sample of US men and about 10-15% lower than that observed in Scandinavian men and women.
A similarly steep decrease in deaths occurred with increasing duration of light physical activity up to a plateau of about 300 minutes (5 hours) per day and of moderate intensity physical activity of about 24 minutes per day.
The largest reduction in risk of death (about 60-70%) was between the first quarter (least active) and the fourth quarter (most active), with approximately five times more deaths in those being inactive compared with those most active. This strengthens the view that any physical activity is beneficial and likely achievable for large segments of the population say the researchers.
In contrast, spending 9.5 hours or more each day sedentary was associated with a statistically significant increased risk of death.
The researchers point to some limitations. For example, all studies were conducted in the US and western Europe, and included adults who were at least 40 years old, so findings may not apply to other populations or to younger people.
Nevertheless, they say the large sample size and device based measures of sedentary time and physical activity provide more precise results than previous studies.
As such, they say their results provide important data for informing public health recommendations, and suggest that the public health message might simply be "sit less and move more and more often."
These findings are important and easy to interpret, say researchers in a linked editorial. However, questions remain, particularly over whether the effect of physical activity continues above a certain threshold.
They acknowledge that increasing activity at the population level is challenging, but say walking is one promising target for intervention, as it is simple, affordable (free), achievable even for older adults, and rarely contraindicated.
"Developing ways to limit sedentary time and increase activity at any level could considerably improve health and reduce mortality," they conclude.

Thursday, August 22, 2019

Lower levels of dietary vitamins and antioxidants are linked to frailty in older adults


Researchers from The Irish Longitudinal Study on Ageing (TILDA) at Trinity College Dublin have shown in the largest study to date that lower levels of specific dietary vitamins and antioxidants are associated with frailty.
Frailty is a common chronic syndrome which affects up to 25% of adults over 65 years and over half of adults over 80. Frailty is characterised by an overall decline in physical function and a loss of ability to bounce back after experiencing a stressful event such as infection, a fall or surgery. It is associated with poor health, disability and death. The TILDA study examined the association of vitamin B12, folate, vitamin D, lutein and zeaxanthin levels with frailty.
The B vitamins (B12 and folate) are important for several cellular processes throughout the body including DNA repair and energy metabolism. Vitamin D is essential for bone metabolism, muscle strength and mood. Lutein and zeaxanthin have antioxidant and anti-inflammatory properties important in eye health and brain health. Low levels of all of these vitamins and antioxidants is common among Irish adults.
In this new research lower levels of lutein, zeaxanthin, and vitamin D were consistently associated with not only frailty but also earlier stages of 'pre-frailty' (a subclinical precursor of frailty). Low levels of B vitamins were associated with pre-frailty. Furthermore, the accumulation of micronutrient insufficiencies - having low levels of more than one micronutrient - was progressively associated with severity stages of frailty.
This data raises the question of the role of dietary supplementation and contributes to the ongoing policy discussions regarding fortification.
Lead author of the study and Senior Research Fellow at TILDA, Dr Aisling O'Halloran, said: "We have presented evidence in the largest study to date that lower levels of specific vitamins and antioxidants - and having low levels of more than one micronutrient - is consistently and progressively associated with the most commonly used methods for measuring frailty. Our data suggest that low micronutrient status may act as an easily modified marker and intervention target for frailty among adults aged 50 years and over".
Principal Investigator of TILDA, Professor Rose-Anne Kenny said:
"Frailty occurs when a number of systems in the body lose reserve capacity and therefore the ability to 'bounce back' after even trivial illnesses. It is an important and challenging state; commonly associated with ageing but also common in patients of any age who have major surgery, cancer treatments and severe infections. The hall mark of frailty is muscle weakness. If it is recognised in its early stages, it can be reversed. However, the longer it is present, the more difficult is it to 'bounce back' and generalised weakness and fatigue become progressively worse. This research suggests new potential treatments for a common and important condition."
Co-author of the study Dr Eamon Laird said "Again we see that micronutrients (including vitamin D) are associated with better health outcomes in older adults. However we still lack a food fortification policy in Ireland and whilst this continues, we miss the opportunity of a cost-effective strategy to prevent and intervene in the progression of these conditions. As of yet there is no sign that the Irish government or the FSAI (Food Safety Authority Ireland) intend to advise or implement on such a strategy".

New report finds 100% juice helps improve children's diet quality

The Juice Products Association

A new report published in the July issue of the Journal of the American College of Nutrition by pediatrician Dr. Robert D. Murray supports existing scientific data maintaining juice as part of a healthy diet. The report reinforces that claims that 100% juice may be associated with childhood weight gain or negative health outcomes have not been supported by recent scientific research including a number of systematic reviews and meta-analyses.
"Juice has recently been cast in a negative light without scientific evidence to support these claims," said Dr. Robert Murray, pediatric nutritionist and immediate past president of the Ohio Chapter of the American Academy of Pediatrics. "This report encourages parents and other consumers to look at a child's total diet before judging foods or beverages "good" or "bad." Foods should be judged not on individual attributes such as fat or sugar but on their contributions to the diet as a whole."
"Drinking 100% fruit juice has many positive attributes that improve overall diet quality," Dr. Murray stated, "When juice is eliminated from a child's diet, it can have unintended negative nutritional consequences, especially for low-income populations."
National surveys show many Americans have poor quality diets. The report notes that while juices do lack fiber, they retain the majority of the same health-promoting nutrients, bioactives and phytochemicals found in whole fruit. Fruit juice drinkers also have better quality diets, consume more whole fruit, less added sugar and saturated fat and greater amounts of vitamin C, magnesium, potassium, and fiber than non-juice drinkers.
"Over the past three decades, fruit juice consumption has fallen substantially yet the gap has not been filled by the consumption of whole fruit. A combination of whole fruit and juice is the best way for children and adults to meet their daily-recommended fruit servings and improve their overall diet," said Dr. Murray. "Young children are typically the biggest juice drinkers. They are also the only age group in the United States consuming enough servings of fruit."

Monday, August 19, 2019

Gastroesophageal reflux associated with chronic pain in temporomandibular joint


Gastroesophageal reflux (GERD) is associated with chronic, painful temporomandibular disorder -- pain in the temporomandibular joint -- and anxiety and poor sleep contribute to this association, according to a study in CMAJ (Canadian Medical Association Journal) http://www.cmaj.ca/lookup/doi/10.1503/cmaj.181535. Pain from temporomandibular disorder (TMD) affects about 13% of Canada's population. Reflux is an uncomfortable condition in which stomach contents are regurgitated into the throat. Evidence indicates that anxiety, somatization and depression are linked to GERD.
Researchers from China and the United States looked at data on 1522 patients with chronic TMD, of whom 69% (1048) were women, to understand the relationship between chronic TMD and GERD and to determine if anxiety, somatization and depression influence the association. They found symptomatic GERD was a risk factor for TMD, and people with a longer history of GERD had a higher risk of TMD than those with a shorter history.
"The interactions between chronic musculoskeletal diseases, gastrointestinal diseases, mental disorders and sleep problems are complicated," writes Dr. Jihua Chen, The Dental College of Georgia, Augusta, Georgia, and The Fourth Military Medical University, Xi'an, China, with coauthors. "There is evidence to support the bidirectional nature of the associations among these comorbidities, and patients may be stuck in a cycle in which undermined sleep, somatization and anxiety exacerbate the pain, with the pain also leading to sleep problems and mental disorders."
The authors suggest physicians need to be aware of the association and consider multidisciplinary management programs to help patients with TMD and chronic pain.
"Physicians and patients may overlook the association between chronic musculoskeletal disease and gastrointestinal symptoms," write the authors. "Patients with both chronic TMD and reflux symptoms may be underdiagnosed, resulting in deferred effective treatment and a prolonged disease course."
"Associations among gastroesophageal reflux disease, mental disorders, sleep and chronic temporomandibular disorder: a case-control study" is published August 19, 2019.

Insomnia tied to higher risk of heart disease and stroke


People suffering from insomnia may have an increased risk of coronary artery disease, heart failure and stroke, according to new research in the American Heart Association's journal Circulation.
Previous observational studies have found an association between insomnia, which affects up to 30% of the general population, and an increased risk of developing heart disease and stroke. These observational studies were unable to determine whether insomnia is a cause, or if it is just associated with them, explained Susanna Larsson, Ph.D., lead study author and associate professor of cardiovascular and nutritional epidemiology at Karolinska Institutet in Stockholm, Sweden.
In this first-of-its-kind study on insomnia, Larsson and a colleague applied Mendelian randomization, a technique that uses genetic variants known to be connected with a potential risk factor, such as insomnia, to reduce bias in the results. The 1.3 million participants with or without heart disease and stroke were drawn from four major public studies and groups.
Researchers found genetic variants for insomnia were associated with significantly higher odds of coronary artery disease, heart failure and ischemic stroke - particularly large artery stroke, but not atrial fibrillation.
"It's important to identify the underlying reason for insomnia and treat it," Larsson said. "Sleep is a behavior that can be changed by new habits and stress management."
A limitation to this study is that the results represent a genetic variant link to insomnia rather than insomnia itself. According to Larsson, it was not possible to determine whether or not the individuals with cardiovascular disease had insomnia.