The dementia difference: Investigating imbalances in the treatment of patients with dementia

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The March International Psychogeriatrics Article of the Month is entitled “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” by Bernhard Michalowsky, Tilly Eichler, Jochen René Thyrian, Johannes Hertel, Diana Wucherer, Wolfgang Hoffmann and Steffen Flessa. This blog piece was written for us by one of the paper’s authors, Bernhard Michalowsky.

A precise formal diagnosis of dementia is enormously important to initiate adequate and appropriate treatment and care in dementia. Despite the fact that international standards and evidence based guidelines recommends a precise formal diagnosis, it is well known that dementia is under-diagnosed. Even in high income-countries, fifty to eighty per cent of people with dementia do not receive a formal dementia diagnosis. These persons were unnoticed in most studies, also in cost-of-illness studies. These studies revealed that dementia is associated with substantial and increasing health care costs, which adds to making dementia a serious health care priority. However, are there differences in treatment, in care and in overall healthcare costs between patients formally diagnosed with dementia and those without a formal diagnosis?

We have studied this question in our general-practitioner (GP) based sample of persons who screened positive for dementia and found a significant difference in treatment and care and in medical care cost between patients with and those without a formal dementia diagnosis.

We set out to study this issue within the ongoing DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) trial, a general practitioner-based, cluster-randomized, controlled, intervention trial in the primary care setting. Eligible patients were 70 years or older, living at home and screened in general practitioner (GP) practices for dementia using the DemTect. As published in this month´s issue of the journal we assessed individual data about the utilization of medical and formal health care services of 240 primary care patients. The costs were assessed from the perspective of insurance and the associations between dementia diagnosis and costs were evaluated using multiple linear regression models.

We found that patients formally diagnosed with dementia were treated significantly more often by a neurologist, but less often by all other outpatient specialists, and more often received anti-dementia drugs, but less additional drugs. The higher utilization of anti-dementia drugs and neurologists/ Psychiatrist is in line with the recommendations of evidence-based German guidelines. However, less treatment by outpatient physicians and with additional drugs is out of line with published studies. It is questionable if this corresponds to an inadequate treatment.

Furthermore, we found that diagnosed patients underwent shorter and less frequent planned in-hospital treatments, especially surgeries. This could mean that in hospital a premature discharge is forced and necessary surgeries were possibly omitted or unnecessary surgeries were not conducted because hospitalization is associated with deterioration in health outcomes. Taking all of this into account, dementia diagnosis was significantly associated with less total medical care costs.

What is the take home massage of this research? Actually, it seems to be that there are differences in treatment, care and healthcare cost between persons with dementia and those without a formal dementia diagnosis. Furthermore, dementia diagnosis seems to be beneficial for receiving dementia-specific treatment, but currently insufficient to ensure adequate in-hospital, out-patient specialists and overall medication treatment. This should be validated in further studies and improved in routine care.

The full paper “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” is available free of charge for a limited time here.

The commentary paper “What is the potential for improving care and lowering cost for persons with dementia?” by Karen Davis, Amber Willink and Halima Amjad is also available free of charge here.

Addressing the gender gap in global health leadership – via Global Health, Epidemiology and Genomics

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This post was written by Pascale Allotey andoriginally posted on the Global Health, Epidemiology and Genomics blog – read more at: http://cambridge.org/gheg-journal

In recognition of International Women’s Day 2016, GHEG is inviting submissions for a themed collection on Women in Global Health.

A core mission of global health is to achieve health equity for all people worldwide. Women, particularly in resource-limited settings, experience a disproportionate burden of disease and mortality due to inequities in access to basic health care, nutrition and education.(1) The imbalance in the health burden between genders is therefore a key focus, addressed by both the Millennium Development Goals and more recently, the Sustainable Development Goals.

However, despite this key goal to address gender inequities within the field of global health, women still occupy less than a quarter of global health leadership roles.(1) Ilona Kickbusch’s recent #WGH100 Twitter campaign to identify women leaders working at the forefront of global health, arose from a frustration with the lack of visibility of women in critical public spaces in the field.(2) Like other industries, the reasons for this imbalance include lack of opportunities, family commitments and lack of confidence. Whilst many institutions have attempted to address these issues, tackling the gender gap in leadership still requires a more proactive strategy.

This year’s theme for International Women’s day is Planet 50-50 by 2030: step it up for gender equality. The goal, spearheaded by UN Women, is to achieve gender equality in the next 15 years – by increasing investment in gender equality, striving for parity for women at all levels of decision-making, eliminating discriminatory legislation, and addressing social norms that perpetuate discrimination against women.(3)

The campaign for equality in leadership is important for reasons other than proportional representation. Research in several settings has shown that women in leadership positions are more likely than their male counterparts to invest in infrastructure and programmes that address women’s concerns.(1) Similarly, policies of women in leadership tend to be more responsive to the needs of women and children and recognise women’s responsibility for decision-making when it comes to the health of their families.(1, 2)

In an attempt to address and explore the issues surrounding gender and leadership in global health, GHEG will be publishing a themed collection on Women in Global Health. We invite submissions that explore, among other things, the current landscape, the potential reasons behind the current gender imbalance in global health roles, suggestions for practice and policy that can catalyse change, and descriptions of effective formal partnerships and campaigns on Women in Global Health. The deadline for this call is the 31st May 2016. To find out more visit: http://journals.cambridge.org/gheg/womenglobalhealth-cfp

 
References
1. Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(8):1103-7.
2. Devi S. Twitter campaign highlights top women in global health. Lancet (London, England). 2015;385(9965):318.
3. Press release: World leaders agree: We must close the gender gap [press release]. 2015.

Successful aging at 100 years

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Images: Participants from the PT100 – Oporto Centenarian Study being interviewed

The February International Psychogeriatrics Article of the Month is entitled “Successful aging at 100 years: the relevance of subjectivity and psychological resources” by Lia Araújo, Oscar Ribeiro, Laetitia Teixeira and Constança Paúl. This blog piece was written for us by one of the paper’s authors, Lia Araújo.

Successful aging is a desire that we all aspire for ourselves and for our loved ones. According to Rowe and Kahn’s definition, operationalized through the MacArthur study, individuals who met the three criteria of (i) avoiding disease and disability, (ii) high cognitive and physical functioning and (iii) engagement with life were identified as “successful agers”(1).

Another wish common to many of us is to live longer, why not up to 100!? Indeed, this can be a dream come true for an increasing number of individuals, since the oldest generations are becoming more representative and centenarians are likely to become more common(2).

Both wishes conjointly, a longer and successful aging, motivated the development of the PT100 – Oporto Centenarian Study(3). This population-based study was conducted in the north region of Portugal and included 140 centenarians who were interviewed face-to-face. We began to question ourselves what it means to be “successful” at such an advanced age and quickly got to ask the same question to our study participants. What we found was that sometimes the most relevant outcomes are from the perspective of the subjects themselves; and that together with the concern for problems and needs, we must capitalize on the real strengths of older people.

The criterion of little or no age-related decrements in physiologic function for those aging successfully does not apply to centenarians. However, when considering alternative criteria, based in centenarian´s self-perceptions of health, functional and cognitive capacity, a higher proportion of centenarians might be considered as successful. The paper also presents the influence of the available resources, such as individual strategies and external support, in improving subjective appraisals of successful aging, which confirms that certain internal resources (e.g., self-efficacy and purpose) are not overwhelmed by physical deterioration and may even gain power when corresponding and meaningful perceptions of oneself and one´s life are maintained in late life.

Successful aging at very advanced ages may not mean to stay healthy for even longer but rather to adapt. With that in our minds, as individuals, families, researchers, professionals or policy-makers, longer lives can and will be associated with improved quality of life in all ages and our wishes can become reality for our and next generations.

The full paper “Successful aging at 100 years: the relevance of subjectivity and psychological resources” is available free of charge for a limited time here.

The commentary paper “Success at 100 is easier said than done – comments on Araújo et al: successful aging at 100 years” by Peter Martin and Leonard W. Poon is also available free of charge here.

References
1. Rowe, J.W., & Kahn, R.L. (1997). Successful aging. Gerontologist, 37, 433-440.
2. Serra, V., Watson, J., Sinclair, D., & Kneale, D. (2011). Living Beyond 100: a report on centenarians. London: International Longevity Centre – UK.
3. http://www.pt100.pt

Emotion-processing networks disrupted in sufferers of depression – via UIC News Center

depressed teenage girl

Regions of the brain that normally work together to process emotion become decoupled in people who experience multiple episodes of depression, neuroscientists report. The findings may help identify which patients will benefit from longterm antidepressant treatment to prevent the recurrence of depressive episodes.

The study, led by researchers at the University of Illinois at Chicago, is published in the journal Psychological Medicine.

“Half of people who have a first depressive episode will go on to have another within two years,” says Scott Langenecker, associate professor of psychiatry and psychology at UIC and corresponding author on the study.

Disruptions in the network of areas of the brain that are simultaneously active during problem-solving and emotional processing have been implicated in several mental illnesses, including depression. But in addition, “hyperconnectivity,” or too much connection, within the “resting network,” or areas active during rest and self-reflection, has also been linked to depression.

“If we can identify different network connectivity patterns that are associated with depression, then we may be able to determine which are risk factors for poorer outcomes down the line, such as having multiple episodes, and we can keep those patients on preventive or maintenance medication,” Langenecker explained. “We can also start to see what medications work best for people with different connectivity patterns, to develop more personalized treatment plans.”

In previous research, Langenecker found that the emotional and cognitive brain networks were hyperconnected in young adults who had depression. Areas of the brain related to rumination – thinking about the same thing over and over again – a known risk factor for depression, were also overly connected in adolescents who had experienced depression.

In the new study, Langenecker said he and his coworkers wanted to see if different patterns of network-disruption would show up in young adults who had experienced only one episode of depression versus several episodes.

The researchers used functional magnetic resonance imaging, or fMRI, to scan the brains of 77 young adults (average age: 21.) Seventeen of the participants were experiencing major depression at the time of the scan, while 34 were currently well. Of these 51 patients, 36 had experienced at least one episode of depression in the past, and these individuals were compared  to 26 participants who had never experienced a major depressive episode. None were taking psychiatric medication at the time they were scanned.

All fMRI scans were done in a resting state — to show which areas of the brain are most synchronously active as one relaxes and lets their mind wander.

The researchers found that the amygdala, a region involved in detecting emotion, is decoupled from the emotional network in people who have had multiple episodes of depression. This may cause emotional-information processing to be less accurate, Langenecker said, and could explain “negative processing-bias”  in which depression sufferers perceive even neutral information as negative.

The researchers also saw that participants who had had at least one prior depressive episode — whether or not they were depressed at the time of the scan — exhibited increased connectivity between the resting and cognitive networks.

“This may be an adaptation the brain makes to help regulate emotional biases or rumination,” Langenecker said.

“Since this study provides just a snapshot of the brain at one point in time, longer-term studies are needed, to determine whether the patterns we saw may be predictive of a future of multiple episodes for some patients and might help us identify who should have maintenance treatments and targets for new preventive treatments,” he said.

Rachel Jacobs, Alyssa Barba, Jennifer Gowins, Heide Klumpp, Lisanne Jenkins, Dr. Olusola Ajilore and Dr. K. Luan Phan of the UIC College of Medicine, and Dr. Brian Mickey, Dr. Marta Pecina, Margaret Sikora, Kelly Ryan, David Hsu, Robert Welsh and Jon-Kar Zubieta of the University of Michigan are co-authors on the paper.

This study was funded in part by the UIC Center for Clinical and Translational Science and grants RO1 Q2 601, MH091811 and RO1 MH101487 from the National Institutes of Health. – See more at: http://news.uic.edu/emotion-processing-networks-disrupted-in-sufferers-of-depression#sthash.2snQXaQd.dpuf

Source: Emotion-processing networks disrupted in sufferers of depression | UIC News Center

The full paper, published in Psychological Medicine, “Decoupling of the amygdala to other salience network regions in adolescent-onset recurrent major depressive disorder” by  S. A. Langenecker et al. can be viewed here free of charge until 31st March 2016.

Free Content about the Zika Virus Now Available

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Just 8 days after the public health emergency was declared, this content regarding the Zika virus has been written, reviewed, edited, and released as a freely available resource.

On February 1st, the World Health Organization declared a Public Health Emergency of International Concern related to clusters of microephaly cases in some areas affected by the Zika virus. Like the Ebola virus, there had been very little funding and research on Zika until the recent emergency and associated media and scientific attention – there is therefore a dearth of information and there is neither a vaccine nor prophylactic pharmacotherapy available to prevent Zika virus infection.

In response to concern over the effects of Zika virus infection in pregnant women, the medical publishing team at Cambridge University Press commissioned a brief summary of current evidence and recommendations. Just 8 days after the public health emergency was declared, this content has been written, reviewed, edited and released as a freely available resource. The content has been provided by Professor Bernard Gonik, Fann S. Srere Chair of Perinatal Medicine, Wayne State University School of Medicine.

Released in advance as a freely accessible public resource, this content is part of High-Risk Pregnancy: Management Options – a forthcoming updateable online product from Cambridge University Press. Like all of the content in High-Risk Pregnancy: Management Options, the Zika section will be regularly updated as new information arises.

Read about the Zika Virus Here

 

Announcing the publication of the first papers in GHEG

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We are delighted to announce the publication of the first papers in Global Health, Epidemiology and Genomics. As GHEG is fully Open Access, these papers, and all papers published in the future, are freely accessible online. Here we provide a brief summary of our first three publications.

 A forum for global population health, technological advances and implementation science
 Manjinder Sandhu

A welcome editorial by our Editor in Chief, marking the launch of Global Health, Epidemiology and Genomics. Dr Sandhu highlights the strengths of the broad interdisciplinary scope of the journal and its international editorial board and invites the global health community to engage and contribute to the journal so that it becomes a valuable, practical and informative resource.
Read the full article here

 

favicon Study Profile: The Durban Diabetes Study (DDS): a platform for chronic disease research
 Thomas Hird et al.

A study profile of The Durban Diabetes Study (DDS), an on-going population-based cross-sectional survey of an urban black population in Durban, South Africa. The DDS was established to investigate a broad range of lifestyle, medical and genetic factors and their association with diabetes. It provides a rich platform for investigating the distribution, interrelation and aetiology of other chronic diseases and their risk factors, which can be utilised for other research studies.
Read the full article here

 

Favicon long Capitalizing on Natural Experiments in Low- to Middle- Income Countries to Explore Epigenetic Contributions to Disease Risk in Migrant Populations
 J. Jaime Miranda et al.

 

A commentary on the value of epigenetics as a tool for understanding differential disease risk in migrant populations. The authors highlight the merit of exploring migrant chronic disease risk in low- to middle-income countries, particularly in the context of rural-to-urban migration, with increasing urbanisation in this setting.
Read the full article here
More articles will be published in the coming weeks, and you can be notified when new articles are published by signing up to content alerts here. Here’s a preview of what’s coming soon:

  • H3Africa Multi-Centre Study of the Prevalence and Environmental and Genetic Determinants of Type 2 Diabetes in Sub-Saharan Africa: Study Protocol
    Kenneth Ekoru et al.
  • Regulatory Developments in the Conduct of Clinical Trials in India
    Dhvani Mehta and Ranjit Roy Chaudhury

GHEG accepts original research articles, brief reports, structured reviews and commentaries as well as protocols, research resources and analysis. We are waiving the Article Processing Charge for all articles submitted to GHEG before the end of 2016. We invite contributions from a range of disciplines:
Epidemiology, Clinical trials, Genetics, Observational studies, Qualitative studies, Anthropological studies, Social science, Community intervention, Health systems, Health services, Population genetics, Population history.
For further information on the journal and how to submit please visit our website. Or if you wish to submit your manuscript directly please visit: http://mc.manuscriptcentral.com/gheg.

Mental health implications for older adults after natural disasters

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The January International Psychogeriatrics Article of the Month is entitled “Mental health implications for older adults after natural disasters – a systematic review and meta-analysis” by Georgina Parker, David Lie, Dan J. Siskind, Melinda Martin-Khan, Beverly Raphael, David Crompton and Steve Kisely. This blog piece was written for us by one of the paper’s authors, David Lie.

Our interest in the susceptibility of older adults to disaster arose in the context of an unprecedented spate of natural disasters and dramatic events affecting the Australia- New Zealand region between 2009 and 2011.

New Zealand was affected by an air crash, earthquakes (notably Christchurch) and the Pike River Mine accident. A number of bushfires affected most regions of Australia notably the Black Saturday fires, which itself had followed a heatwave. Flood and cyclone preoccupied other parts of the country (e.g. Cyclone Yasi) amidst economically disruptive events such as volcanic ashclouds. Taken together these events killed hundreds of people and injured or displaced thousands more.

The broad psychological impact of the Tohoku earthquake, tsunami and nuclear disaster complex was the closing parenthesis for a period that demanded we knew more about the psychiatry of extreme events and particularly for older adults. Very little seemed to have been written as overview with the exception of a narrative review by Cherniak (2008) and a book on geriatric aspects of disaster psychiatry (2010).

As we explored the literature, contradictory themes emerged suggesting that older people were as likely, more likely or less likely than younger counterparts in their susceptibility to serious mental health sequelae after disasters.

Four broad theories to explain age-related resilience or vulnerability are outlined in the introduction to our paper which can be summarised as:

  • Experience counts
  • You don’t react emotionally as much as you age which is protective
  • The middle aged are stressed most, caring for their children and parents
  • As you age you become more vulnerable

We chose to analyse the highest quality research to determine broad patterns but much more needs to be learned. Our research (Parker et al., 2016 this issue) showed increased relative risk for PTSD and adjustment disorder but is based on particular disasters in particular contexts and only on natural disasters. Our included studies were characteristically events which were sudden, unheralded and producing significant physical destruction comprising four earthquakes and two tsunamis.

It could be that older adults actually have better outcomes in disasters where evacuation and/or preparation are possible or in areas where natural disasters such as hurricanes or cyclones are recurrent and an eventual part of life for those who live long enough.

We would certainly recommend further development of standardised, validated tools and research protocols for deployment in future disaster psychiatry studies to expedite our understanding. Whatever the reality of climate change, the world is indisputably ageing and increasingly living closer to shorelines and other places that put people “in harm’s way”.

The full paper “Mental health implications for older adults after natural disasters – a systematic review and meta-analysis” is available free of charge for a limited time here.

The commentary paper “Natural disaster, older adults, and mental health–a dangerous combination” by Meaghan L. O’Donnell and David Forbes is also available free of charge here.

References:

Cherniack EP.. The impact of natural disasters on the elderly. Am J Disaster Med. 2008 May-Jun;3(3):133-9.

Parker G, Lie DC, Siskind DJ, Martin-Khan M, Raphael B, Crompton D and Kisely S. Mental health implications for older adults after natural disasters – a systematic review and meta-analysis. Int Psychogeriatrics 2016 (2016), 28:1, 11–20

Geriatric mental health disaster and emergency preparedness. John A. Toner,
editor ; Therese M. Mierswa, associate editor, Judith L. Howe, associate editor.

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