Traumatic Brain Injury and the speed of decline of Alzheimer’s Disease

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The October International Psychogeriatrics Article of the Month is entitled ‘The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County Dementia Progression Study’ by Mac Gilbert, Christine Snyder, Chris Corcoran, Maria C. Norton, Constantine G. Lyketsos and JoAnn T. Tschanz

With a diagnosis of Alzheimer’s dementia comes an understanding that the affected individual will suffer an inevitable and progressive decline in their cognitive and functional abilities. However, what is not known is how fast the decline will occur. Will the person need 24 hour supervision and care shortly after diagnosis or five to ten years in the future?

We have studied this question in our population-based sample of persons with Alzheimer’s dementia and found tremendous variability in the course of decline. It seems that about half of those in our sample declined slowly and a small but significant percentage declined quite rapidly. Is there anything in person’s background that will predict whether they will become a slow or a fast decliner?

We set out to study this issue by examining a person’s medical history, specifically, whether they had a history of concussion or traumatic brain injury (TBI). Several studies have found that those who have had a history of TBI in their lifetimes show an increased risk for Alzheimer’s dementia later in life. However, it was not known whether TBI also predicts the rate of decline after the onset of dementia.

As published in this month’s issue of the journal, we obtained the medical history of persons with Alzheimer’s dementia before onset, and characterized them as either positive or negative for a history of TBI and its severity. We also examined number of TBI (0, 1, 2 or more) and timing of TBI relative to the onset of dementia (none, within 10 years of onset, or greater than 10 years of onset). We repeatedly tested those with Alzheimer’s dementia about every 6 to 18 months, checking their memory, attention, concentration, language and visuospatial abilities. We also rated their functional decline from their caregiver’s report.

We found that a history of TBI predicted more rapid functional decline, but only among those who had experienced a TBI within 10 years of dementia onset. This finding adds to our previous work where a history of TBI was associated with disinhibited behavior after the onset of Alzheimer’s dementia, and persons in better overall health tended to function at higher levels after the onset of dementia.

What is the take home message of this research? While we can’t change the past, we can be proactive by taking steps to prevent TBI and other health problems from occurring. Preventing falls (a major cause of TBI in late life) by ensuring proper foot ware, installing safety bars, and ensuring safe walkways may help prevent new instances of TBI in older adults. Following up with one’s health care provider for any health problems is also suggested. Although there is currently no cure for Alzheimer’s dementia, adopting preventive measures may be one way to slow the progression of decline and optimize one’s level of functioning over the course of the illness.

 

The full paper “The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County Dementia Progression Study” is available free of charge for a limited time here.

The commentary on the paper, “The association of traumatic brain injury with rate of progression of cognitive and functional impairment in a population-based cohort of Alzheimer’s disease: the Cache County dementia progression study by Gilbert et al. Late effects of traumatic brain injury on dementia progression” is also available free of charge for a limited time here.

 

Organically Grown Foods May Offer Greater Health and Safety than Foods Conventionally Grown

Scientists have long recognized the dangers of cadmium (Cd) exposure to the human body. This heavy metal is emerging as a major cause of vascular disorders, common cancers, osteoporosis, and kidney disease, and can also cause damage to the body’s reproductive and neurological systems. While tobacco smoke can be a significant source of exposure for smokers, the primary source of cadmium exposure for nonsmokers is through consumption of contaminated plant-based foods.
A survey of all previous pertinent research (meta-analysis), appearing recently in the British Journal of Nutrition, concluded that organically grown foods are on average 48 percent lower in Cd than conventionally grown foods. Now, in an invited commentary appearing in the same journal, Saint Luke’s Mid America Heart Institute cardiovascular research scientist James J. DiNicolantonio, Pharm.D., and Mark F. McCarty, B.A., place this finding in the context of the growing epidemiology linking Cd exposure to adverse health outcomes, and conclude that consistent consumption of organic foods over a lifetime could be expected to favorably influence health and mortality risk.
“For years, nutritionists and consumers have struggled with the question, ‘is organic really better?’” said Dr. DiNicolantonio. “What analysis of this research reveals is that, due to the serious health impacts of cadmium exposure and the markedly lower levels of Cd in organically grown foods, the long-term consumption of such foods is likely to be notably protective with respect to a wide range of common pathologies.”
Citing previous studies, DiNicolantonio and McCarty suggest that Cd contamination of chemical fertilizers may be primarily responsible for the higher Cd content of conventionally grown foods.
Dietary Cd is found primarily in grains, green vegetables, root vegetables, tubers, organ meat, and shellfish; hence, in nonsmokers, most Cd exposure derives from plant foods usually thought to be healthful. Although tiny amounts of Cd are excreted in the urine, the human body has no physiological mechanism for regulating its Cd levels, so levels tend to accumulate over time, with a half-life of 10-30 years. Clinically available chelation therapies are not helpful for coping with chronic Cd exposure, as most Cd accumulates in the interior of cells where chelating drugs cannot reach. Fortunately, research has shown that dietary zinc functions to counteract Cd toxicity. Cd is an important inducer of oxidative stress, and rodent studies suggest that the antioxidant activity of spirulina may also lessen the adverse health impact of Cd already in the body.
Nonsmokers who consistently choose organic foods throughout life, as compared to nonsmokers who rely on conventional agriculture, could be expected to experience about half the Cd exposure. By surveying recent epidemiological findings correlating body Cd levels with mortality risk, DiNicolantonio and McCarty estimate that consistent use of organic foods could result in a 20 percent reduction in total mortality.
“Choosing organic foods, avoiding tobacco smoke, and preventing or correcting iron deficiency, are three smart strategies for keeping your body burden of Cd relatively low,” DiNicolantonio notes. “Iron deficiency increases the intestines’ absorption of dietary Cd, and this probably explains why women tend to have higher body levels of Cd than men.”
The recent meta-analysis of organic foods also found that such foods tend to be about 30 percent higher in antioxidant phytochemicals, likely because many of these phytochemicals function to protect plants from pests; crops treated with pesticides may have less need for this protection. DiNicolantonio and McCarty point to research suggesting that higher dietary intake of polyphenolic antioxidants such as flavonoids may provide some protection to the vascular system.
The Commentary, “Are organically grown foods safer and more healthful than conventionally grown foods?” is  freely available for 30 days at journals.cambridge.org/bjn/organicSep14

The original review, “Higher antioxidant and lower cadmium concentrations and lower incidence of pesticide residues in organically grown crops: a systematic literature review and meta-analyses” is an open access paper available at journals.cambridge.org/bjn/organic

A positive attitude to ageing

 

Lothian cohort corrected

The September International Psychogeriatrics Article of the Month is entitled ‘Life course influences of physical and cognitive function and personality on attitudes to aging in the Lothian Birth Cohort 1936’ by Susan D. Shenkin, Ken Laidlaw, Mike Allerhand, Gillian E. Mead, John M. Star and Ian J. Deary.

 

The population is ageing, with the proportion of people worldwide aged over 60 rising from 8% in 1950, to 10% in 2000 and 21% in 2050 1. This has led to widespread concern about the negative impact this may have on society. We were interested in exploring whether older people themselves share this negative view of ageing, or whether they might have a more positive outlook. We were also interested to explore what factors throughout their life predicted their attitudes to ageing.

We were able to do this using a group of people who have had detailed information collected about them throughout their life, and asking them to complete (another!) questionnaire. This freely available questionnaire 2 has been widely used to assess the experience and attitudes of older people themselves to ageing. It includes questions in three main areas called Psychosocial Loss (e.g. “Old age is a time of loneliness”), Physical Change (e.g. “I don’t feel old”), and Psychological Growth (e.g. “Wisdom comes with age”), which people scored from ‘strongly disagree’ to ‘strongly agree’.

The group of people who completed the questionnaire were the Lothian Birth Cohort 1936 3. These are people born in 1936 who sat a nationwide test of intelligence when they were aged 11, and have gone on to provide very detailed information about their life, including their health and cognition now they are older.

We found that these people (aged around 75, 51.4% male) were generally positive about the three aspects of ageing. When we explored what predicted these attitudes, we were surprised to find that their social background, IQ test scores and physical health didn’t relate very much to their attitudes. In general, the strongest predictors of their attitudes to ageing was their personality. Personality type is determined by a questionnaire 4.

Psychosocial loss (e.g. “I feel excluded from things” was more common in people with personalities stronger on Neuroticism, and lower on Extraversion, Openness, Agreeableness and Conscientiousness, but also people with higher scores on a questionnaire assessing anxiety and depression, and people with more physical disability.

Physical Change (e.g. “My health is better than I expected”) was predicted by people with personality types of Extraversion, Openness, Agreeableness and Conscientiousness, but also females, social class and less physical disability.

Psychological growth (e.g. “I am more accepting of myself”) was associated with similar personality types, but surprisingly a less affluent environment, living alone, lower prior cognitive ability and slower walking speed.

In general, in this group of relatively healthy volunteers in Scotland aged around 75 we found a positive attitude to ageing. These attitudes were mostly associated with personality type, but social circumstances, physical health and mood also played a role. It will be interesting to explore whether attitudes are similar or different in other groups e.g. in people with poorer physical or mental health, in different countries etc. An intriguing possibility is whether influencing people’s attitudes is possible, and might result in changes to mood or physical health. However, it is clear that we should all share a more positive view of our ageing society.

 

The full paper “Life course influences of physical and cognitive function and personality on attitudes to aging in the Lothian Birth Cohort 1936” is available free of charge for a limited time here.

The commentary on the paper, “Positive attitudes on aging: a life course view” is also available free of charge for a limited time here.

 

References

1) http://www.un.org/esa/population/publications/worldageing19502050/

2) Attitudes to Ageing Questionnaire – AAQ (Laidlaw, K., Power, M. J. and Schmidt, S. (2007). The Attitudes to Ageing Questionnaire (AAQ): development and psychometric properties. International Journal of Geriatric Psychiatry, 22, 367–379

3) http://www.lothianbirthcohort.ed.ac.uk/index.php?option=com_content&view=article&id=7&Itemid=2 and Deary, I. J., Gow, A. J., Pattie, A., & Starr, J. M. (2011). Cohort Profile: The Lothian Birth Cohorts of 1921 and 1936. International Journal of Epidemiology. doi: 10.1093/ije/dyr197

4) (NEO-FFI: Costa, P. T. and McCrae, R. R. (1992). NEO PI-R and Professional Manual (Revised NEO Personality Inventory and NEO Five-Factor Inventory). Odessa, FL: Psychological Assessment Resources).

 

Image: ““Lothian Birth Cohort 1936 at a reunion in Edinburgh, 2007.  Credit: Douglas Robertson/Age UK”

www.lothianbirthcohort.ed.ac.uk

Photographers website: www.douglasinscotland.co.uk

 

40% of women with severe mental illness are victims of rape or attempted rape

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Women with severe mental illness are up to five times more likely than the general population to be victims of sexual assault and two to three times more likely to suffer domestic violence, reveals new research led by UCL and King’s College London funded by the Medical Research Council and the Big Lottery.

The study found that 40% of women surveyed with severe mental illness had suffered rape or attempted rape in adulthood, of whom 53% had attempted suicide as a result. In the general population, 7% of women had been victims of rape or attempted rape, of whom 3% had attempted suicide. 12% of men with severe mental illness had been seriously sexually assaulted, compared with 0.5% of the general population.

The findings are based on a survey of 303 randomly-recruited psychiatric outpatients who had been in contact with community services for a year or more, 60% of whom had a diagnosis of schizophrenia. They were interviewed using the British Crime Survey questionnaire for domestic and sexual violence, and their responses were compared to those from 22,606 respondents to the 2011/12 national crime survey. The results were adjusted for a wide range of socio-economic factors including age, ethnicity and marital status.

“The number of rape victims among women with severe mental illness is staggering,” says lead author Dr Hind Khalifeh of UCL’s Division of Psychiatry. “At the time of the survey, 10% had experienced sexual assault in the past year, showing that the problems continue throughout adulthood. Considering the high rate of suicide attempts among rape victims in this group, clinicians assessing people after a suicide attempt should consider asking them if they have been sexually assaulted. Currently this is not done and so patients may miss opportunities to receive specialist support.”

Men and women with mental illness were also found to be more likely to be victims of domestic violence than the general population. Domestic violence includes emotional, physical and sexual abuse. 69% of women and 49% of men with severe mental illness reported adulthood domestic violence.

Domestic violence from family members (other than partners) made up 63% of total domestic violence cases against psychiatric patients compared with 35% of the general population.

“Most domestic violence prevention policies for adults focus on partner violence, but this study shows that interventions for psychiatric patients also need to target family violence,” says Dr Khalifeh.

The study shows a strong association between mental illness and sexual and domestic violence, but the direction of causality is not certain. In some cases, experiences of violence may have contributed to the onset of mental illness. However, violence experienced in the past year would have been after diagnosis of severe mental illness since all participating patients had been under the care of mental health services for at least a year.

The results were adjusted for drug and alcohol use in the past year, but this did not significantly affect the outcomes and causality is hard to determine. Drug and alcohol use may increase the risk of being a victim, but equally victims of violence may turn to drugs or alcohol as a way of coping.

Senior author Louise Howard, Professor in Women’s Mental Health at King’s College London, says: “This study highlights that patients with severe mental illness are at substantially increased risk of being a victim of domestic and sexual violence. Despite the public’s concern about violence being perpetrated by patients with severe mental illness, the reality for patients is that they are at increased risk of being victims of some of the most damaging types of violence.”

Read the full Open Access paper, “Domestic and sexual violence against patients with severe mental illness”, published in Psychological Medicine, free of charge here.

 

This post is taken from the press release issued by UCL.

 

Good days and bad days in dementia

Jul14 blog pic - Hiscox

The August International Psychogeriatrics Article of the Month is entitled ‘Good days and bad days in dementia: a qualitative chart review of variable symptom expression’ by Kenneth Rockwood, Sherri Fay, Laura Hamilton, Elyse Ross and Paige Moorhouse.

Anyone who works with people with dementia is bound to experience poignant moments. Especially striking is hearing that a person seemingly lost to permanent unknowing – even near muteness – suddenly spoke a full sentence, or sometimes more. Much more common, but still compelling, are reports of people with dementia having remarkably good or bad days.

In what does daily variability consist? For some years, that question has motivated our group. In a paper in this month’s issue, we report the findings of a clinical chart review spanning 30 months, to understand how patients and families experienced variability living with dementia from day to day. This line of inquiry was born from the realization that, for many patients and families, variability was a source of expectations – and often disappointments. Families asked questions that I couldn’t answer: “why can he be so helpful some days, and other days can’t even do for himself?” Often, they had answers as good as anything I could muster: “it’s best if he has a good night’s sleep”, or “I can tell if he’s missed his medications”.

The challenge is to understand the mechanisms of variability. To get there, we need to know just what is happening, and for that we need careful qualitative studies. The area is tricky, because variability threatens reliability, and that undermines measurement, which undermines understanding. Or so the argument goes. Progress however, obliges investigating the variability itself – as is being done in Lewy body dementia – and not just seeking ways to reduce it for testing purposes.

Our study offers some clues. For an important proportion of patients, variability occurs within the same symptom set: a good day is when the symptom is seen less, and a bad day when it occurs more. This makes fluctuation in specific neurochemical transmission seem likely. That some are implicated more than others is suggested by the patterns: most of these symptoms involve social conduct and engagement; other descriptions sound like attentional problems. For a second group of dementia symptoms, a bad day is marked by even a single occurrence of a bad problem: not being struck does not constitute a good day, even if being struck means a bad one.

Our group also gives thought to the mathematics of variable disease expression in dementia. On scales of months and years, a comprehensible, stochastic process can be modeled with high precision. Is what we see clinically another face of that, or does it signal instability that so often heralds more rapid decline, or is it a variation of the fluctuating attention seen in delirium and in Lewy Body dementia?

However it works, we should aim for treatment. Many families believe that some part is modifiable. Are they correct? Aiming for therapies might seem obvious, but against the thankfully fading fashion of rubbishing symptomatic treatments, it’s good to be reminded of how big is the gap between what we offer and what people need. And that is poignant.

Kenneth Rockwood, Dalhousie University, Halifax, Canada

 

The full paper “Good days and bad days in dementia: a qualitative chart review of variable symptom expression” is available free of charge for a limited time here.

The commentary on the paper, “Symptom variability in dementia” is also available free of charge for one month here.

 

Autism rates steady for two decades

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A University of Queensland study has found no evidence of an increase in autism in the past 20 years, countering reports that the rates of autism spectrum disorders (ASDs) are on the rise.

The study was led by Dr Amanda Baxter from UQ’s Queensland Centre for Mental Health Research at the School of Population Health, and was a first-of-its-kind analysis of research data from 1990 to 2010. Dr Baxter and her colleagues found that rates had remained steady, despite reports that the prevalence of ASDs was increasing.

“We found that the prevalence of ASDs in 2010 was one in 132 people, which represents no change from 1990,” Dr Baxter said.

“We also found that better recognition of the disorders and improved diagnostic criteria explain much of the difference in study findings over time.”

Part of the Global Burden of Disease project, this is the largest study to systematically assess rates and disability caused by ASDs in the community, using data collected from global research findings in the past 20 years.

ASDs are chronic, disabling disorders that stem from problems with brain development. They affect people from a young age and are among the world’s 20 most disabling childhood conditions.

The study shows that about 52 million children and adults around the globe meet diagnostic criteria for an ASD.

Dr Baxter said researchers hoped the study would help guide health policy and improve support for those with ASD and their families.

“As ASDs cause substantial lifelong health issues, an accurate understanding of the burden of these disorders can inform public health policy as well as help allocate necessary resources for education, housing and employment.”

The study was a collaboration with the University of Leicester and the University of Washington’s Institute for Health Metrics and Evaluation, and is published in the journal Psychological Medicine.

 

The full paper “The epidemiology and global burden of autism spectrum disorders” can be viewed free of charge for a limited time here.

 

Sociology, Stigma and Innovation – Sam Rowlands on editing a book about abortion

Abortion Care Cover

After last month’s article about the journey of a medical book from an author’s perspective, this month we hear from Sam Rowlands, editor of Abortion Care, about editing a book which boasts more than 40 contributors – and which is about a particularly emotive topic…

There aren’t many medical books dedicated to abortion care. I felt there was a gap in the market for a smaller book that could be easily carried around. I wanted to produce a book that had all the conventional ingredients such as the methods of abortion, complications and so on but also looked at abortion from a wider perspective.

I drew up a list of around 30 chapters and identified potential authors for each. Cambridge were keen for the book to have international appeal so I endeavoured to select recognised specialists from around the world. I am fortunate to have met many of these personally through my career in sexual and reproductive health but still I was delighted (and surprised) that most of the colleagues I chose readily agreed despite their very busy schedules. I was then intrigued by how many chapter authors (15) asked to collaborate with their selected colleagues. This has resulted in an even richer authorship.

I had originally thought I might ask a couple of collaborators to co-edit with me but on reflection decided to edit the book on my own. The advantage of this was that I could be in control and do things my way, especially as I had by now a clear view of how the book would look. The downside was that when more than 20 chapter manuscripts arrived in a rather short space of time, I felt a bit overwhelmed! The lead chapter authors are all authorities in their fields. Some are academics and some are skilled practical clinicians, some both. Some are neither of these, just incredibly knowledgeable and wise. All authors developed their chapters in their own way; I encouraged them but tried not to steer them in any particular direction.

Although the book is mainly for readers with a medical bent, I have tried to include chapters to stretch their minds on topics that they might not necessarily otherwise tackle. Sociological topics are included but the authors of these were banned from using inaccessible terminology! There are two chapters with an epidemiological flavour which are not too daunting even to the numerically-challenged. There are two chapters written by lawyers which really flow, despite references to statute and case law.

Although the book is about a controversial subject and is bound to be serious in most of its content it is written in language that I hope is accessible and uses a lighter touch at times, for example a quote from Monty Python in the ethics chapter. The historical chapter provides a wonderful backdrop, painting a vivid picture of days gone by with some poignant examples of tragic cases. Stigma is a theme that runs through the book. Half a chapter is dedicated to this but reference is also made elsewhere, particularly in the chapter on staff. Although we all know that abortion is stigmatised, it’s only quite recently that it’s been written about and even measured.

I tried to include some innovations in the book and two chapters come up trumps in this respect. One covers abortion care provided by personnel other than doctors, showing that all the evidence points to this being not only safe but actually preferred by many women. The other looks to the future and shows how telemedicine can be applied to facilitate communication and treatment when the clinician and the woman are not in the same place, which has potential to improve access in more rural areas or in those parts of the world with restrictive regimes.

I’ve found it very rewarding to head up this project but don’t claim it is perfect. I invite anyone to make suggestions for a second edition.

Sam Rowlands MBBS, MD, LLM, FRCGP, FFSRH, Clinical Lead in Community Sexual and Reproductive Health, Dorset HealthCare and Visiting Professor, School of Health & Social Care, Bournemouth University

Sam Rowlands is the editor of Abortion Care (out now).

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