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Hospital Testing Overuse Done to Reassure Patients, Families
Clinical Question: What is the extent of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.
Background: Little is known about the extent and drivers of overuse by hospitalists.
Study design: Two vignettes (pre-operative evaluation and syncope) were mailed to hospitalists. They were asked to identify what most hospitalists at their institution would recommend and “the most likely primary driver of the hospitalist’s decision.”
Setting: Random selection of hospitalists from SHM member database and SHM national meeting attendees.
Synopsis: Investigators mailed 1,753 surveys and received a 68% response rate. For the pre-operative evaluation vignette, 52% of hospitalists reported overuse of pre-operative testing. When a family member was a physician and requested further testing, overuse increased significantly to 65%. For the syncope vignette, any choice involving admission was considered overuse.
Eighty-two percent of respondents reported overuse; when the wife was a lawyer or requested further testing, overuse remained the same. Overuse in both cases was more frequent due to a hospitalist’s desire to reassure patients or themselves, rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs. 37%; syncope, 69% vs. 31%, P<0.001).
The survey responses do not necessarily represent actual clinical choices, and the hospitalist sample may not be representative of all hospitalists; however, this study shows that efforts to reduce overuse in hospitals need to move beyond financial incentives and/or informing providers of evidence-based recommendations.
Bottom line: A survey of hospitalists showed substantial overuse in two common clinical situations, syncope and pre-operative evaluation, mostly driven by a desire to reassure patients, families, or themselves.
Citation: Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100-108.
Clinical Question: What is the extent of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.
Background: Little is known about the extent and drivers of overuse by hospitalists.
Study design: Two vignettes (pre-operative evaluation and syncope) were mailed to hospitalists. They were asked to identify what most hospitalists at their institution would recommend and “the most likely primary driver of the hospitalist’s decision.”
Setting: Random selection of hospitalists from SHM member database and SHM national meeting attendees.
Synopsis: Investigators mailed 1,753 surveys and received a 68% response rate. For the pre-operative evaluation vignette, 52% of hospitalists reported overuse of pre-operative testing. When a family member was a physician and requested further testing, overuse increased significantly to 65%. For the syncope vignette, any choice involving admission was considered overuse.
Eighty-two percent of respondents reported overuse; when the wife was a lawyer or requested further testing, overuse remained the same. Overuse in both cases was more frequent due to a hospitalist’s desire to reassure patients or themselves, rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs. 37%; syncope, 69% vs. 31%, P<0.001).
The survey responses do not necessarily represent actual clinical choices, and the hospitalist sample may not be representative of all hospitalists; however, this study shows that efforts to reduce overuse in hospitals need to move beyond financial incentives and/or informing providers of evidence-based recommendations.
Bottom line: A survey of hospitalists showed substantial overuse in two common clinical situations, syncope and pre-operative evaluation, mostly driven by a desire to reassure patients, families, or themselves.
Citation: Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100-108.
Clinical Question: What is the extent of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.
Background: Little is known about the extent and drivers of overuse by hospitalists.
Study design: Two vignettes (pre-operative evaluation and syncope) were mailed to hospitalists. They were asked to identify what most hospitalists at their institution would recommend and “the most likely primary driver of the hospitalist’s decision.”
Setting: Random selection of hospitalists from SHM member database and SHM national meeting attendees.
Synopsis: Investigators mailed 1,753 surveys and received a 68% response rate. For the pre-operative evaluation vignette, 52% of hospitalists reported overuse of pre-operative testing. When a family member was a physician and requested further testing, overuse increased significantly to 65%. For the syncope vignette, any choice involving admission was considered overuse.
Eighty-two percent of respondents reported overuse; when the wife was a lawyer or requested further testing, overuse remained the same. Overuse in both cases was more frequent due to a hospitalist’s desire to reassure patients or themselves, rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs. 37%; syncope, 69% vs. 31%, P<0.001).
The survey responses do not necessarily represent actual clinical choices, and the hospitalist sample may not be representative of all hospitalists; however, this study shows that efforts to reduce overuse in hospitals need to move beyond financial incentives and/or informing providers of evidence-based recommendations.
Bottom line: A survey of hospitalists showed substantial overuse in two common clinical situations, syncope and pre-operative evaluation, mostly driven by a desire to reassure patients, families, or themselves.
Citation: Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100-108.
Functional Impairment Boosts Readmission for Medicare Seniors
Clinical question: Is functional impairment associated with an increased risk of 30-day readmission?
Background: Many Medicare seniors suffer from some level of impairment in functional status, which, in turn, has been linked to high healthcare utilization. Studies that examine the role of functional impairment with readmission rates are limited.
Study design: Prospective, cohort study.
Setting: Seniors enrolled in the Health and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to Dec. 31, 2010.
Synopsis: The primary outcome was readmissions within 30 days of discharge. Activities of daily living (ADL) scale and instrumental ADL were used as measures of functional impairment.
Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty in one or more instrumental ADLs (OR 1.06; 95% CI 0.94-1.20), 14.4% with difficulty in one or more ADLs (OR 1.08; 95% CI 0.96-1.21), 16.5% with dependency in one or two ADLs (OR, 1.26; 95% CI 1.11-1.44), and 18.2% with dependency in three or more ADLs (OR 1.42; 95% CI 1.20-1.69).
This observation was more pronounced in patients admitted for heart failure, MI, and pneumonia (16.9% readmission rate for no impairment vs. 25.7% dependency in three or more ADLs, OR 1.70; 95% CI 1.04-2.78).
Although the study is limited by reliance on survey data and Medicare claim data, functional status may be an important variable in calculating readmission risk and a potential target for intervention.
Bottom line: Functional impairment is associated with an increased risk of 30-day readmission, especially in patients admitted for heart failure, MI, and pneumonia.
Citation: Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565.
Clinical question: Is functional impairment associated with an increased risk of 30-day readmission?
Background: Many Medicare seniors suffer from some level of impairment in functional status, which, in turn, has been linked to high healthcare utilization. Studies that examine the role of functional impairment with readmission rates are limited.
Study design: Prospective, cohort study.
Setting: Seniors enrolled in the Health and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to Dec. 31, 2010.
Synopsis: The primary outcome was readmissions within 30 days of discharge. Activities of daily living (ADL) scale and instrumental ADL were used as measures of functional impairment.
Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty in one or more instrumental ADLs (OR 1.06; 95% CI 0.94-1.20), 14.4% with difficulty in one or more ADLs (OR 1.08; 95% CI 0.96-1.21), 16.5% with dependency in one or two ADLs (OR, 1.26; 95% CI 1.11-1.44), and 18.2% with dependency in three or more ADLs (OR 1.42; 95% CI 1.20-1.69).
This observation was more pronounced in patients admitted for heart failure, MI, and pneumonia (16.9% readmission rate for no impairment vs. 25.7% dependency in three or more ADLs, OR 1.70; 95% CI 1.04-2.78).
Although the study is limited by reliance on survey data and Medicare claim data, functional status may be an important variable in calculating readmission risk and a potential target for intervention.
Bottom line: Functional impairment is associated with an increased risk of 30-day readmission, especially in patients admitted for heart failure, MI, and pneumonia.
Citation: Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565.
Clinical question: Is functional impairment associated with an increased risk of 30-day readmission?
Background: Many Medicare seniors suffer from some level of impairment in functional status, which, in turn, has been linked to high healthcare utilization. Studies that examine the role of functional impairment with readmission rates are limited.
Study design: Prospective, cohort study.
Setting: Seniors enrolled in the Health and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to Dec. 31, 2010.
Synopsis: The primary outcome was readmissions within 30 days of discharge. Activities of daily living (ADL) scale and instrumental ADL were used as measures of functional impairment.
Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty in one or more instrumental ADLs (OR 1.06; 95% CI 0.94-1.20), 14.4% with difficulty in one or more ADLs (OR 1.08; 95% CI 0.96-1.21), 16.5% with dependency in one or two ADLs (OR, 1.26; 95% CI 1.11-1.44), and 18.2% with dependency in three or more ADLs (OR 1.42; 95% CI 1.20-1.69).
This observation was more pronounced in patients admitted for heart failure, MI, and pneumonia (16.9% readmission rate for no impairment vs. 25.7% dependency in three or more ADLs, OR 1.70; 95% CI 1.04-2.78).
Although the study is limited by reliance on survey data and Medicare claim data, functional status may be an important variable in calculating readmission risk and a potential target for intervention.
Bottom line: Functional impairment is associated with an increased risk of 30-day readmission, especially in patients admitted for heart failure, MI, and pneumonia.
Citation: Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565.
Delirium, Falls Reduced by Nonpharmacological Intervention
Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?
Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.
Study design: Systematic literature review and meta-analysis.
Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.
Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.
Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.
Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.
Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?
Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.
Study design: Systematic literature review and meta-analysis.
Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.
Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.
Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.
Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.
Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?
Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.
Study design: Systematic literature review and meta-analysis.
Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.
Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.
Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.
Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.
Bridging Anticoagulation for Patients with Atrial Fibrillation
Clinical question: Is bridging anticoagulation for procedures associated with a higher bleeding risk and increased adverse outcomes compared to no bridging?
Background: Practice guidelines have been published to determine when, how, and on whom to bridge anticoagulation for procedures; however, uncertainty remains as to whether or not bridging changes outcomes.
Study design: Prospective, observational study.
Setting: Outcomes Registry for Better Informed treatment of Atrial Fibrillation (ORBIT-AF) study.
Synopsis: Investigators included 10,132 patients who were 18 years and older, with a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures. Interruptions of oral anticoagulation for a procedure, as well as the use and type of bridging method, were recorded. Six hundred sixty-five patients (24%) used bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated heparin) prior to a procedure. Bridged patients were more likely to have had a mechanical valve replacement (9.6% vs. 2.4%, P<0.0001) and prior stroke (22% vs. 15%, P=0.0003).
Multivariate adjusted analysis showed that bridged patients, compared with non-bridged patients, had higher rates of bleeding (5.0% vs. 1.3%, adjusted odds ratio (OR) 3.84, P<0.0001) and an increased risk for adverse events, including the composite of myocardial infarction (MI), bleeding, stroke or systemic embolism, hospitalization, or death within 30 days (OR 1.94, 95% CI 1.38-271, P=0.0001). Rates of CHADS2 ≥2 or CHA2DS2-VASc score ≥2 were similar between bridged and nonbridged patients.
These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE) study will give us more insight and answers.
Bottom line: Bridging anticoagulation prior to procedures is associated with a higher risk of bleeding and adverse outcomes.
Citation: Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.
Clinical question: Is bridging anticoagulation for procedures associated with a higher bleeding risk and increased adverse outcomes compared to no bridging?
Background: Practice guidelines have been published to determine when, how, and on whom to bridge anticoagulation for procedures; however, uncertainty remains as to whether or not bridging changes outcomes.
Study design: Prospective, observational study.
Setting: Outcomes Registry for Better Informed treatment of Atrial Fibrillation (ORBIT-AF) study.
Synopsis: Investigators included 10,132 patients who were 18 years and older, with a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures. Interruptions of oral anticoagulation for a procedure, as well as the use and type of bridging method, were recorded. Six hundred sixty-five patients (24%) used bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated heparin) prior to a procedure. Bridged patients were more likely to have had a mechanical valve replacement (9.6% vs. 2.4%, P<0.0001) and prior stroke (22% vs. 15%, P=0.0003).
Multivariate adjusted analysis showed that bridged patients, compared with non-bridged patients, had higher rates of bleeding (5.0% vs. 1.3%, adjusted odds ratio (OR) 3.84, P<0.0001) and an increased risk for adverse events, including the composite of myocardial infarction (MI), bleeding, stroke or systemic embolism, hospitalization, or death within 30 days (OR 1.94, 95% CI 1.38-271, P=0.0001). Rates of CHADS2 ≥2 or CHA2DS2-VASc score ≥2 were similar between bridged and nonbridged patients.
These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE) study will give us more insight and answers.
Bottom line: Bridging anticoagulation prior to procedures is associated with a higher risk of bleeding and adverse outcomes.
Citation: Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.
Clinical question: Is bridging anticoagulation for procedures associated with a higher bleeding risk and increased adverse outcomes compared to no bridging?
Background: Practice guidelines have been published to determine when, how, and on whom to bridge anticoagulation for procedures; however, uncertainty remains as to whether or not bridging changes outcomes.
Study design: Prospective, observational study.
Setting: Outcomes Registry for Better Informed treatment of Atrial Fibrillation (ORBIT-AF) study.
Synopsis: Investigators included 10,132 patients who were 18 years and older, with a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures. Interruptions of oral anticoagulation for a procedure, as well as the use and type of bridging method, were recorded. Six hundred sixty-five patients (24%) used bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated heparin) prior to a procedure. Bridged patients were more likely to have had a mechanical valve replacement (9.6% vs. 2.4%, P<0.0001) and prior stroke (22% vs. 15%, P=0.0003).
Multivariate adjusted analysis showed that bridged patients, compared with non-bridged patients, had higher rates of bleeding (5.0% vs. 1.3%, adjusted odds ratio (OR) 3.84, P<0.0001) and an increased risk for adverse events, including the composite of myocardial infarction (MI), bleeding, stroke or systemic embolism, hospitalization, or death within 30 days (OR 1.94, 95% CI 1.38-271, P=0.0001). Rates of CHADS2 ≥2 or CHA2DS2-VASc score ≥2 were similar between bridged and nonbridged patients.
These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE) study will give us more insight and answers.
Bottom line: Bridging anticoagulation prior to procedures is associated with a higher risk of bleeding and adverse outcomes.
Citation: Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.
Olfactory Impairment May Indicate TBI Among Blast-Injured Troops
Decreased ability to identify odors may be a marker of acute structural neuropathology resulting from trauma, according to research published online ahead of print March 18 in Neurology. Quantitative identification olfactometry has limited sensitivity but high specificity in detecting this pathology and could inform decisions about whether advanced neuroimaging is required, said the authors.
Michael S. Xydakis, MD, a colonel in the US Air Force and Associate Professor of Surgery at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and colleagues enrolled 231 consecutive patients with polytrauma in a study to determine whether a quantitative assessment of differential olfactory performance could serve as a reliable antecedent marker for the preclinical detection of intracranial neurotrauma. Participants had been acutely injured from explosions during combat operations in Afghanistan or Iraq, required immediate stateside evacuation, and were enrolled prospectively during two and a half years.
All patients underwent evaluation for possible traumatic brain injury (TBI). The investigators stratified the patients into groups according to severity of TBI and neuroimaging results. Blast-injured troops without TBI who had comparable demographic features and severity of polytrauma formed the comparison control group. An otorhinolaryngologist administered the University of Pennsylvania Smell Identification Test to each patient. Patients were described as having normal, decreased, or absent olfactory function, and the latter two categories were considered to represent olfactory impairment.
Impairment Associated With Frontal and Temporal Lobe Injuries
Approximately 6% of participants had impaired olfactory function. All patients in the mild TBI group and the blast-injured control group had normal olfactory function. Median olfactometric scores did not differ significantly between these two groups. All participants with normal neuroimaging, including 127 patients with mild TBI and 47 controls, had normal olfactory function.
Among the 40 patients with abnormal imaging, 35% had olfactory impairment. Data analysis indicated that olfactometric score predicted abnormal neuroimaging significantly better than chance alone. Olfactory testing was administered to 18 of the patients with abnormal imaging within 14 days after injury. Nine of these patients had impaired function. The remaining 22 soldiers with abnormal imaging underwent testing 15 or more days after injury, and five of them had impaired function. “These results suggest that it is worth testing the hypothesis that sensitivity of olfactory testing to identify patients with structural brain injury may be higher if testing is performed closer to the time of injury,” said Dr. Xydakis.
Approximately 79% of patients with olfactory impairment had injury to the frontal lobe, compared with 42% of patients with normal olfactory function. About 86% of troops with olfactory impairment had either frontal or temporal involvement, compared with 50% of patients with normal function. Approximately 36% of troops with olfactory impairment had both frontal and temporal involvement, compared with 12% of patients with normal function.
Test May Detect Injury Preclinically
“The radiographic findings support a higher-order CNS etiology for the observed impairment,” said Dr. Xydakis. The inclusion of the blast-injured control group with normal olfactometric scores may mitigate the concern that observed impairments resulted from peripheral trauma at the intranasal receptor level.
The finding that only troops with concurrent acute traumatic radiographic abnormalities had olfactory impairment “supports the assertion that impaired olfactory identification is only present in the context of significant intracranial neurotrauma,” he added. “Ultimately, it is the radiographic presence and the radiographic locations of the structural brain injuries that define the probability of subsequent olfactory performance degradation, and not simply the abstract and unquantifiable risk factor of a ‘blow or hit to the head region.’
“The presence of measurable abnormalities with central olfactory dysfunction provides added value to the practicing physician for preclinical detection of intracranial injury and, accordingly, subsequent disease-modifying early interventions,” Dr. Xydakis continued. “While the level of sensitivity for screening purposes is insufficient to exclude all types of post-traumatic neuropathology, the absolute specificity and the association with frontal or temporal lobe injury enhance its value in clinical practice.”
—Erik Greb
Suggested Reading
Xydakis MS, Mulligan LP, Smith AB, et al. Olfactory impairment and traumatic brain injury in blast-injured combat troops: A cohort study. Neurology. 2015 Mar 18 [Epub ahead of print].
Decreased ability to identify odors may be a marker of acute structural neuropathology resulting from trauma, according to research published online ahead of print March 18 in Neurology. Quantitative identification olfactometry has limited sensitivity but high specificity in detecting this pathology and could inform decisions about whether advanced neuroimaging is required, said the authors.
Michael S. Xydakis, MD, a colonel in the US Air Force and Associate Professor of Surgery at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and colleagues enrolled 231 consecutive patients with polytrauma in a study to determine whether a quantitative assessment of differential olfactory performance could serve as a reliable antecedent marker for the preclinical detection of intracranial neurotrauma. Participants had been acutely injured from explosions during combat operations in Afghanistan or Iraq, required immediate stateside evacuation, and were enrolled prospectively during two and a half years.
All patients underwent evaluation for possible traumatic brain injury (TBI). The investigators stratified the patients into groups according to severity of TBI and neuroimaging results. Blast-injured troops without TBI who had comparable demographic features and severity of polytrauma formed the comparison control group. An otorhinolaryngologist administered the University of Pennsylvania Smell Identification Test to each patient. Patients were described as having normal, decreased, or absent olfactory function, and the latter two categories were considered to represent olfactory impairment.
Impairment Associated With Frontal and Temporal Lobe Injuries
Approximately 6% of participants had impaired olfactory function. All patients in the mild TBI group and the blast-injured control group had normal olfactory function. Median olfactometric scores did not differ significantly between these two groups. All participants with normal neuroimaging, including 127 patients with mild TBI and 47 controls, had normal olfactory function.
Among the 40 patients with abnormal imaging, 35% had olfactory impairment. Data analysis indicated that olfactometric score predicted abnormal neuroimaging significantly better than chance alone. Olfactory testing was administered to 18 of the patients with abnormal imaging within 14 days after injury. Nine of these patients had impaired function. The remaining 22 soldiers with abnormal imaging underwent testing 15 or more days after injury, and five of them had impaired function. “These results suggest that it is worth testing the hypothesis that sensitivity of olfactory testing to identify patients with structural brain injury may be higher if testing is performed closer to the time of injury,” said Dr. Xydakis.
Approximately 79% of patients with olfactory impairment had injury to the frontal lobe, compared with 42% of patients with normal olfactory function. About 86% of troops with olfactory impairment had either frontal or temporal involvement, compared with 50% of patients with normal function. Approximately 36% of troops with olfactory impairment had both frontal and temporal involvement, compared with 12% of patients with normal function.
Test May Detect Injury Preclinically
“The radiographic findings support a higher-order CNS etiology for the observed impairment,” said Dr. Xydakis. The inclusion of the blast-injured control group with normal olfactometric scores may mitigate the concern that observed impairments resulted from peripheral trauma at the intranasal receptor level.
The finding that only troops with concurrent acute traumatic radiographic abnormalities had olfactory impairment “supports the assertion that impaired olfactory identification is only present in the context of significant intracranial neurotrauma,” he added. “Ultimately, it is the radiographic presence and the radiographic locations of the structural brain injuries that define the probability of subsequent olfactory performance degradation, and not simply the abstract and unquantifiable risk factor of a ‘blow or hit to the head region.’
“The presence of measurable abnormalities with central olfactory dysfunction provides added value to the practicing physician for preclinical detection of intracranial injury and, accordingly, subsequent disease-modifying early interventions,” Dr. Xydakis continued. “While the level of sensitivity for screening purposes is insufficient to exclude all types of post-traumatic neuropathology, the absolute specificity and the association with frontal or temporal lobe injury enhance its value in clinical practice.”
—Erik Greb
Decreased ability to identify odors may be a marker of acute structural neuropathology resulting from trauma, according to research published online ahead of print March 18 in Neurology. Quantitative identification olfactometry has limited sensitivity but high specificity in detecting this pathology and could inform decisions about whether advanced neuroimaging is required, said the authors.
Michael S. Xydakis, MD, a colonel in the US Air Force and Associate Professor of Surgery at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and colleagues enrolled 231 consecutive patients with polytrauma in a study to determine whether a quantitative assessment of differential olfactory performance could serve as a reliable antecedent marker for the preclinical detection of intracranial neurotrauma. Participants had been acutely injured from explosions during combat operations in Afghanistan or Iraq, required immediate stateside evacuation, and were enrolled prospectively during two and a half years.
All patients underwent evaluation for possible traumatic brain injury (TBI). The investigators stratified the patients into groups according to severity of TBI and neuroimaging results. Blast-injured troops without TBI who had comparable demographic features and severity of polytrauma formed the comparison control group. An otorhinolaryngologist administered the University of Pennsylvania Smell Identification Test to each patient. Patients were described as having normal, decreased, or absent olfactory function, and the latter two categories were considered to represent olfactory impairment.
Impairment Associated With Frontal and Temporal Lobe Injuries
Approximately 6% of participants had impaired olfactory function. All patients in the mild TBI group and the blast-injured control group had normal olfactory function. Median olfactometric scores did not differ significantly between these two groups. All participants with normal neuroimaging, including 127 patients with mild TBI and 47 controls, had normal olfactory function.
Among the 40 patients with abnormal imaging, 35% had olfactory impairment. Data analysis indicated that olfactometric score predicted abnormal neuroimaging significantly better than chance alone. Olfactory testing was administered to 18 of the patients with abnormal imaging within 14 days after injury. Nine of these patients had impaired function. The remaining 22 soldiers with abnormal imaging underwent testing 15 or more days after injury, and five of them had impaired function. “These results suggest that it is worth testing the hypothesis that sensitivity of olfactory testing to identify patients with structural brain injury may be higher if testing is performed closer to the time of injury,” said Dr. Xydakis.
Approximately 79% of patients with olfactory impairment had injury to the frontal lobe, compared with 42% of patients with normal olfactory function. About 86% of troops with olfactory impairment had either frontal or temporal involvement, compared with 50% of patients with normal function. Approximately 36% of troops with olfactory impairment had both frontal and temporal involvement, compared with 12% of patients with normal function.
Test May Detect Injury Preclinically
“The radiographic findings support a higher-order CNS etiology for the observed impairment,” said Dr. Xydakis. The inclusion of the blast-injured control group with normal olfactometric scores may mitigate the concern that observed impairments resulted from peripheral trauma at the intranasal receptor level.
The finding that only troops with concurrent acute traumatic radiographic abnormalities had olfactory impairment “supports the assertion that impaired olfactory identification is only present in the context of significant intracranial neurotrauma,” he added. “Ultimately, it is the radiographic presence and the radiographic locations of the structural brain injuries that define the probability of subsequent olfactory performance degradation, and not simply the abstract and unquantifiable risk factor of a ‘blow or hit to the head region.’
“The presence of measurable abnormalities with central olfactory dysfunction provides added value to the practicing physician for preclinical detection of intracranial injury and, accordingly, subsequent disease-modifying early interventions,” Dr. Xydakis continued. “While the level of sensitivity for screening purposes is insufficient to exclude all types of post-traumatic neuropathology, the absolute specificity and the association with frontal or temporal lobe injury enhance its value in clinical practice.”
—Erik Greb
Suggested Reading
Xydakis MS, Mulligan LP, Smith AB, et al. Olfactory impairment and traumatic brain injury in blast-injured combat troops: A cohort study. Neurology. 2015 Mar 18 [Epub ahead of print].
Suggested Reading
Xydakis MS, Mulligan LP, Smith AB, et al. Olfactory impairment and traumatic brain injury in blast-injured combat troops: A cohort study. Neurology. 2015 Mar 18 [Epub ahead of print].
Sense of Purpose May Reduce Risk of Cerebral Infarcts
A sense of purpose in life may reduce the risk for cerebral infarcts by approximately half, according to data published in the April issue of Stroke. Purpose in life is a psychosocial concept that involves having meaning and being directed toward goals, said the researchers. The association between it and cerebral infarcts appears to be independent of vessel disease.
“Mental health, in particular positive psychological factors such as having a purpose in life, is emerging as a very potent determinant of health outcomes,” said Patricia Boyle, PhD, Associate Professor of Behavioral Sciences at the Rush Alzheimer’s Disease Center of Rush University Medical Center in Chicago. “Clinicians need to be aware of patients’ mental state and encourage behaviors that will increase purpose and other positive emotional states.”
Comparing Psychologic and Neurologic Well-Being
Dr. Boyle and colleagues analyzed data for 453 participants in the Rush Memory and Aging Project, an ongoing clinical–pathologic cohort study of aging and dementia. Eligible participants responded annually to a modified 10-item measure derived from Ryff’s and Keyes’s scales of Psychological Well-Being to assess their degree of purpose in life. After patients died, investigators blinded to clinical information conducted uniform neuropathologic examinations during autopsy to identify macroscopic infarcts and microinfarcts. The researchers used ordinal logistic regression analysis to examine the association between cerebral infarcts and the participants’ first valid scores of purpose.
Approximately 68% of participants were female. Patients’ mean age at baseline was approximately 84, and mean age at death was about 90. Mean score on the measure of purpose in life was 3.5 out of a possible 5 points.
Of the 453 participants, 114 (25.3%) had clinical stroke and 216 had macroscopic or microinfarcts at autopsy (47.7%). Seventy-six participants (16.8%) had one macroscopic infarct, and 78 (17.2%) had two or more macroscopic infarcts. In addition, 81 participants (17.9%) had one microinfarct, and 47 (10.4%) had two or more microinfarcts.
Association Depended on Lacunar Infarcts
After the investigators adjusted their data analysis for demographics, they found that greater purpose in life was associated with lower odds of macroscopic infarcts. A one-point increase of the score for purpose in life reduced the odds of having one or more macroscopic infarcts by approximately 50%. The researchers did not, however, find an association between purpose and microinfarcts, nor did they find any difference in purpose according to gender.
On average, purpose in life declined slightly over time for the population. Adjusting the data for the individual-specific change in purpose in life did not affect the association between purpose and infarcts. “These results support the relatively traitlike property of purpose in life,” said the investigators.
Furthermore, a greater purpose in life was associated with fewer subcortical macroscopic infarcts, but not with cortical macroscopic infarcts. The association was significant only with respect to lacunar infarcts, particularly gray matter lacunar infarcts. In addition, purpose in life was not associated with the measure of arteriolosclerosis or atherosclerosis. Together with previous data, the current study “suggests that purpose in life is protective for silent infarcts, as well as clinical stroke,” said Dr. Boyle.
“The neurobiologic basis of the protective effect of purpose in life and other psychosocial constructs is complex and poorly understood,” she continued. “First, purpose may reduce the risk of infarcts by promoting healthy lifestyles. … Second, purpose may directly be implicated in neuroendocrine function.” Understanding the mechanistic pathway will require future research, she added.
“Purpose in life differs for everyone, and it is important to be thoughtful about what motivates you, such as volunteering, learning new things, or being part of the community, so you can engage in rewarding behaviors,” said Lei Yu, PhD, the lead author and Assistant Professor of Neurological Sciences at the Rush Alzheimer’s Disease Center.
—Erik Greb
Suggested Reading
Yu L, Boyle PA, Wilson RS, et al. Purpose in life and cerebral infarcts in community-dwelling older people. Stroke. 2015;46(4):1071-1076.
A sense of purpose in life may reduce the risk for cerebral infarcts by approximately half, according to data published in the April issue of Stroke. Purpose in life is a psychosocial concept that involves having meaning and being directed toward goals, said the researchers. The association between it and cerebral infarcts appears to be independent of vessel disease.
“Mental health, in particular positive psychological factors such as having a purpose in life, is emerging as a very potent determinant of health outcomes,” said Patricia Boyle, PhD, Associate Professor of Behavioral Sciences at the Rush Alzheimer’s Disease Center of Rush University Medical Center in Chicago. “Clinicians need to be aware of patients’ mental state and encourage behaviors that will increase purpose and other positive emotional states.”
Comparing Psychologic and Neurologic Well-Being
Dr. Boyle and colleagues analyzed data for 453 participants in the Rush Memory and Aging Project, an ongoing clinical–pathologic cohort study of aging and dementia. Eligible participants responded annually to a modified 10-item measure derived from Ryff’s and Keyes’s scales of Psychological Well-Being to assess their degree of purpose in life. After patients died, investigators blinded to clinical information conducted uniform neuropathologic examinations during autopsy to identify macroscopic infarcts and microinfarcts. The researchers used ordinal logistic regression analysis to examine the association between cerebral infarcts and the participants’ first valid scores of purpose.
Approximately 68% of participants were female. Patients’ mean age at baseline was approximately 84, and mean age at death was about 90. Mean score on the measure of purpose in life was 3.5 out of a possible 5 points.
Of the 453 participants, 114 (25.3%) had clinical stroke and 216 had macroscopic or microinfarcts at autopsy (47.7%). Seventy-six participants (16.8%) had one macroscopic infarct, and 78 (17.2%) had two or more macroscopic infarcts. In addition, 81 participants (17.9%) had one microinfarct, and 47 (10.4%) had two or more microinfarcts.
Association Depended on Lacunar Infarcts
After the investigators adjusted their data analysis for demographics, they found that greater purpose in life was associated with lower odds of macroscopic infarcts. A one-point increase of the score for purpose in life reduced the odds of having one or more macroscopic infarcts by approximately 50%. The researchers did not, however, find an association between purpose and microinfarcts, nor did they find any difference in purpose according to gender.
On average, purpose in life declined slightly over time for the population. Adjusting the data for the individual-specific change in purpose in life did not affect the association between purpose and infarcts. “These results support the relatively traitlike property of purpose in life,” said the investigators.
Furthermore, a greater purpose in life was associated with fewer subcortical macroscopic infarcts, but not with cortical macroscopic infarcts. The association was significant only with respect to lacunar infarcts, particularly gray matter lacunar infarcts. In addition, purpose in life was not associated with the measure of arteriolosclerosis or atherosclerosis. Together with previous data, the current study “suggests that purpose in life is protective for silent infarcts, as well as clinical stroke,” said Dr. Boyle.
“The neurobiologic basis of the protective effect of purpose in life and other psychosocial constructs is complex and poorly understood,” she continued. “First, purpose may reduce the risk of infarcts by promoting healthy lifestyles. … Second, purpose may directly be implicated in neuroendocrine function.” Understanding the mechanistic pathway will require future research, she added.
“Purpose in life differs for everyone, and it is important to be thoughtful about what motivates you, such as volunteering, learning new things, or being part of the community, so you can engage in rewarding behaviors,” said Lei Yu, PhD, the lead author and Assistant Professor of Neurological Sciences at the Rush Alzheimer’s Disease Center.
—Erik Greb
A sense of purpose in life may reduce the risk for cerebral infarcts by approximately half, according to data published in the April issue of Stroke. Purpose in life is a psychosocial concept that involves having meaning and being directed toward goals, said the researchers. The association between it and cerebral infarcts appears to be independent of vessel disease.
“Mental health, in particular positive psychological factors such as having a purpose in life, is emerging as a very potent determinant of health outcomes,” said Patricia Boyle, PhD, Associate Professor of Behavioral Sciences at the Rush Alzheimer’s Disease Center of Rush University Medical Center in Chicago. “Clinicians need to be aware of patients’ mental state and encourage behaviors that will increase purpose and other positive emotional states.”
Comparing Psychologic and Neurologic Well-Being
Dr. Boyle and colleagues analyzed data for 453 participants in the Rush Memory and Aging Project, an ongoing clinical–pathologic cohort study of aging and dementia. Eligible participants responded annually to a modified 10-item measure derived from Ryff’s and Keyes’s scales of Psychological Well-Being to assess their degree of purpose in life. After patients died, investigators blinded to clinical information conducted uniform neuropathologic examinations during autopsy to identify macroscopic infarcts and microinfarcts. The researchers used ordinal logistic regression analysis to examine the association between cerebral infarcts and the participants’ first valid scores of purpose.
Approximately 68% of participants were female. Patients’ mean age at baseline was approximately 84, and mean age at death was about 90. Mean score on the measure of purpose in life was 3.5 out of a possible 5 points.
Of the 453 participants, 114 (25.3%) had clinical stroke and 216 had macroscopic or microinfarcts at autopsy (47.7%). Seventy-six participants (16.8%) had one macroscopic infarct, and 78 (17.2%) had two or more macroscopic infarcts. In addition, 81 participants (17.9%) had one microinfarct, and 47 (10.4%) had two or more microinfarcts.
Association Depended on Lacunar Infarcts
After the investigators adjusted their data analysis for demographics, they found that greater purpose in life was associated with lower odds of macroscopic infarcts. A one-point increase of the score for purpose in life reduced the odds of having one or more macroscopic infarcts by approximately 50%. The researchers did not, however, find an association between purpose and microinfarcts, nor did they find any difference in purpose according to gender.
On average, purpose in life declined slightly over time for the population. Adjusting the data for the individual-specific change in purpose in life did not affect the association between purpose and infarcts. “These results support the relatively traitlike property of purpose in life,” said the investigators.
Furthermore, a greater purpose in life was associated with fewer subcortical macroscopic infarcts, but not with cortical macroscopic infarcts. The association was significant only with respect to lacunar infarcts, particularly gray matter lacunar infarcts. In addition, purpose in life was not associated with the measure of arteriolosclerosis or atherosclerosis. Together with previous data, the current study “suggests that purpose in life is protective for silent infarcts, as well as clinical stroke,” said Dr. Boyle.
“The neurobiologic basis of the protective effect of purpose in life and other psychosocial constructs is complex and poorly understood,” she continued. “First, purpose may reduce the risk of infarcts by promoting healthy lifestyles. … Second, purpose may directly be implicated in neuroendocrine function.” Understanding the mechanistic pathway will require future research, she added.
“Purpose in life differs for everyone, and it is important to be thoughtful about what motivates you, such as volunteering, learning new things, or being part of the community, so you can engage in rewarding behaviors,” said Lei Yu, PhD, the lead author and Assistant Professor of Neurological Sciences at the Rush Alzheimer’s Disease Center.
—Erik Greb
Suggested Reading
Yu L, Boyle PA, Wilson RS, et al. Purpose in life and cerebral infarcts in community-dwelling older people. Stroke. 2015;46(4):1071-1076.
Suggested Reading
Yu L, Boyle PA, Wilson RS, et al. Purpose in life and cerebral infarcts in community-dwelling older people. Stroke. 2015;46(4):1071-1076.
Treatments Mitigate Certain Cases of Cerebellar Ataxia
Most cerebellar ataxias cannot be cured, but cases that result from metabolic, hereditary, inflammatory, and immune-mediated etiologies can be treated with disease-modifying therapies, according to a review article published online ahead of print March 11 in Movement Disorders. Effective treatments include prescription drugs, high doses of vitamin E, and gluten-free diets.
“Clinicians must become familiar with these disorders because maximal therapeutic benefit is only possible when done early,” said Adolfo Ramirez-Zamora, MD, Philly Dake Chair in Movement Disorders at Albany Medical Center in New York. The review describes more than a dozen disorders. “These uncommon conditions represent a unique opportunity to treat incurable and progressive diseases.”
Thorough Examination Is Warranted
The initial evaluation of a patient with suspected cerebellar ataxia should include a complete assessment of his or her neurologic and non-neurologic features, said the researchers. The neurologist should determine the rate of onset or progression, family history, specific diagnostic signs, and brain MRI abnormalities. A detailed examination of potential acquired causes, which may include laboratory testing, also is recommended.
Alcohol and other commonly used drugs may cause chronic cerebellar injury, and the treatment is the removal of the drugs. Other drugs associated with ataxia are lithium, phenytoin, amiodarone, toluene, 5-fluorouracil, and cytosine arabinoside. Heavy metals, including organic-lead compounds, mercury, and thallium, may cause ataxia as well.
Treatment May Stop Progression
Ataxia with vitamin E deficiency presents as a slowly progressive spinocerebellar ataxia syndrome similar to Friedreich’s ataxia. Daily 800-mg doses of vitamin E typically stop disease progression and result in neurologic improvement, although recovery may be slow and incomplete, said the investigators. Vitamin E supplementation may be most beneficial if started in patients with less than 15 years of disease duration.
The neurologic symptoms of cerebrotendinous xanthomatosis include cerebellar ataxia, spastic paraparesis, extrapyramidal signs, sensorimotor peripheral neuropathy, seizures, and dementia. The disorder is easily treated with 250 mg of oral chenodeoxycholic acid administered three times daily. Potential side effects include diarrhea, restlessness, and irritability. “Instituting treatment as early as possible is crucial to prevent neurological deterioration,” said Dr. Ramirez-Zamora.
Patients with glucose transporter type 1 (GLUT1) deficiency syndrome may present with intellectual disability, epilepsy, motor impairment, or complex movement disorders. Data indicate that following a ketogenic diet effectively treats the manifestations of GLUT-1 deficiency and halts progression. This regimen can reduce movement disorders by 40% to 70% in most patients, regardless of the syndrome phenotype, the researchers said. Gluten ataxia often manifests as insidious-onset, progressive, pure cerebellar ataxia syndrome. Most patients with gluten ataxia have gaze-evoked nystagmus and other ocular signs of cerebellar dysfunction. Strict adherence to a gluten-free diet is the recommended treatment. In a systematic study, this diet was associated with significant improvement in performance in ataxia scores and on the subjective global clinical impression scale.
Ataxia associated with glutamic acid decarboxylase (GAD) most commonly entails gait ataxia. Limb ataxia, dysarthria, and nystagmus also may be present in patients with GAD-associated ataxia, and symptoms develop over weeks or years. “Patients with subacute presentation are more likely to respond to immunotherapy and achieve long-term response and good functional status,” said Dr. Ramirez-Zamora. The primary treatments, IV immunoglobulin and corticosteroids, have produced marked benefit.
“Recognizing potentially treatable causes of cerebellar ataxia is critical not only to implement targeted treatments, but also to institute management as early as possible to hopefully halt neurologic deterioration,” Dr. Ramirez-Zamora concluded.
—Erik Greb
Suggested Reading
Ramirez-Zamora A, Zeigler W, Desai N, Biller J. Treatable causes of cerebellar ataxia. Mov Disord. 2015 Mar 11 [Epub ahead of print].
Most cerebellar ataxias cannot be cured, but cases that result from metabolic, hereditary, inflammatory, and immune-mediated etiologies can be treated with disease-modifying therapies, according to a review article published online ahead of print March 11 in Movement Disorders. Effective treatments include prescription drugs, high doses of vitamin E, and gluten-free diets.
“Clinicians must become familiar with these disorders because maximal therapeutic benefit is only possible when done early,” said Adolfo Ramirez-Zamora, MD, Philly Dake Chair in Movement Disorders at Albany Medical Center in New York. The review describes more than a dozen disorders. “These uncommon conditions represent a unique opportunity to treat incurable and progressive diseases.”
Thorough Examination Is Warranted
The initial evaluation of a patient with suspected cerebellar ataxia should include a complete assessment of his or her neurologic and non-neurologic features, said the researchers. The neurologist should determine the rate of onset or progression, family history, specific diagnostic signs, and brain MRI abnormalities. A detailed examination of potential acquired causes, which may include laboratory testing, also is recommended.
Alcohol and other commonly used drugs may cause chronic cerebellar injury, and the treatment is the removal of the drugs. Other drugs associated with ataxia are lithium, phenytoin, amiodarone, toluene, 5-fluorouracil, and cytosine arabinoside. Heavy metals, including organic-lead compounds, mercury, and thallium, may cause ataxia as well.
Treatment May Stop Progression
Ataxia with vitamin E deficiency presents as a slowly progressive spinocerebellar ataxia syndrome similar to Friedreich’s ataxia. Daily 800-mg doses of vitamin E typically stop disease progression and result in neurologic improvement, although recovery may be slow and incomplete, said the investigators. Vitamin E supplementation may be most beneficial if started in patients with less than 15 years of disease duration.
The neurologic symptoms of cerebrotendinous xanthomatosis include cerebellar ataxia, spastic paraparesis, extrapyramidal signs, sensorimotor peripheral neuropathy, seizures, and dementia. The disorder is easily treated with 250 mg of oral chenodeoxycholic acid administered three times daily. Potential side effects include diarrhea, restlessness, and irritability. “Instituting treatment as early as possible is crucial to prevent neurological deterioration,” said Dr. Ramirez-Zamora.
Patients with glucose transporter type 1 (GLUT1) deficiency syndrome may present with intellectual disability, epilepsy, motor impairment, or complex movement disorders. Data indicate that following a ketogenic diet effectively treats the manifestations of GLUT-1 deficiency and halts progression. This regimen can reduce movement disorders by 40% to 70% in most patients, regardless of the syndrome phenotype, the researchers said. Gluten ataxia often manifests as insidious-onset, progressive, pure cerebellar ataxia syndrome. Most patients with gluten ataxia have gaze-evoked nystagmus and other ocular signs of cerebellar dysfunction. Strict adherence to a gluten-free diet is the recommended treatment. In a systematic study, this diet was associated with significant improvement in performance in ataxia scores and on the subjective global clinical impression scale.
Ataxia associated with glutamic acid decarboxylase (GAD) most commonly entails gait ataxia. Limb ataxia, dysarthria, and nystagmus also may be present in patients with GAD-associated ataxia, and symptoms develop over weeks or years. “Patients with subacute presentation are more likely to respond to immunotherapy and achieve long-term response and good functional status,” said Dr. Ramirez-Zamora. The primary treatments, IV immunoglobulin and corticosteroids, have produced marked benefit.
“Recognizing potentially treatable causes of cerebellar ataxia is critical not only to implement targeted treatments, but also to institute management as early as possible to hopefully halt neurologic deterioration,” Dr. Ramirez-Zamora concluded.
—Erik Greb
Most cerebellar ataxias cannot be cured, but cases that result from metabolic, hereditary, inflammatory, and immune-mediated etiologies can be treated with disease-modifying therapies, according to a review article published online ahead of print March 11 in Movement Disorders. Effective treatments include prescription drugs, high doses of vitamin E, and gluten-free diets.
“Clinicians must become familiar with these disorders because maximal therapeutic benefit is only possible when done early,” said Adolfo Ramirez-Zamora, MD, Philly Dake Chair in Movement Disorders at Albany Medical Center in New York. The review describes more than a dozen disorders. “These uncommon conditions represent a unique opportunity to treat incurable and progressive diseases.”
Thorough Examination Is Warranted
The initial evaluation of a patient with suspected cerebellar ataxia should include a complete assessment of his or her neurologic and non-neurologic features, said the researchers. The neurologist should determine the rate of onset or progression, family history, specific diagnostic signs, and brain MRI abnormalities. A detailed examination of potential acquired causes, which may include laboratory testing, also is recommended.
Alcohol and other commonly used drugs may cause chronic cerebellar injury, and the treatment is the removal of the drugs. Other drugs associated with ataxia are lithium, phenytoin, amiodarone, toluene, 5-fluorouracil, and cytosine arabinoside. Heavy metals, including organic-lead compounds, mercury, and thallium, may cause ataxia as well.
Treatment May Stop Progression
Ataxia with vitamin E deficiency presents as a slowly progressive spinocerebellar ataxia syndrome similar to Friedreich’s ataxia. Daily 800-mg doses of vitamin E typically stop disease progression and result in neurologic improvement, although recovery may be slow and incomplete, said the investigators. Vitamin E supplementation may be most beneficial if started in patients with less than 15 years of disease duration.
The neurologic symptoms of cerebrotendinous xanthomatosis include cerebellar ataxia, spastic paraparesis, extrapyramidal signs, sensorimotor peripheral neuropathy, seizures, and dementia. The disorder is easily treated with 250 mg of oral chenodeoxycholic acid administered three times daily. Potential side effects include diarrhea, restlessness, and irritability. “Instituting treatment as early as possible is crucial to prevent neurological deterioration,” said Dr. Ramirez-Zamora.
Patients with glucose transporter type 1 (GLUT1) deficiency syndrome may present with intellectual disability, epilepsy, motor impairment, or complex movement disorders. Data indicate that following a ketogenic diet effectively treats the manifestations of GLUT-1 deficiency and halts progression. This regimen can reduce movement disorders by 40% to 70% in most patients, regardless of the syndrome phenotype, the researchers said. Gluten ataxia often manifests as insidious-onset, progressive, pure cerebellar ataxia syndrome. Most patients with gluten ataxia have gaze-evoked nystagmus and other ocular signs of cerebellar dysfunction. Strict adherence to a gluten-free diet is the recommended treatment. In a systematic study, this diet was associated with significant improvement in performance in ataxia scores and on the subjective global clinical impression scale.
Ataxia associated with glutamic acid decarboxylase (GAD) most commonly entails gait ataxia. Limb ataxia, dysarthria, and nystagmus also may be present in patients with GAD-associated ataxia, and symptoms develop over weeks or years. “Patients with subacute presentation are more likely to respond to immunotherapy and achieve long-term response and good functional status,” said Dr. Ramirez-Zamora. The primary treatments, IV immunoglobulin and corticosteroids, have produced marked benefit.
“Recognizing potentially treatable causes of cerebellar ataxia is critical not only to implement targeted treatments, but also to institute management as early as possible to hopefully halt neurologic deterioration,” Dr. Ramirez-Zamora concluded.
—Erik Greb
Suggested Reading
Ramirez-Zamora A, Zeigler W, Desai N, Biller J. Treatable causes of cerebellar ataxia. Mov Disord. 2015 Mar 11 [Epub ahead of print].
Suggested Reading
Ramirez-Zamora A, Zeigler W, Desai N, Biller J. Treatable causes of cerebellar ataxia. Mov Disord. 2015 Mar 11 [Epub ahead of print].
Pediatric Epilepsy Surgeries Have Increased in the Past Decade
The rate of pediatric epilepsy surgery has increased significantly in the United States during the past decade, according to an investigation published in the March issue of Epilepsia. Nevertheless, epilepsy surgery remains an underutilized treatment in children with epilepsy, according to the researchers.
“Continued emphasis on highlighting awareness of epilepsy surgery among pediatricians and pediatric neurologists is as important as ever, as they serve as the main gatekeepers for patients to access specialized epilepsy care,” said Elia M. Pestana Knight, MD, a neurologist at the Cleveland Clinic Epilepsy Center.
An Analysis of a Pediatric Database
Research indicates that the rate of epilepsy surgery in adults has either declined or remained stable in the past decade. Dr. Pestana Knight and colleagues, however, hypothesized that rates of epilepsy surgery in the pediatric population had increased over time. To test this hypothesis, the investigators performed a serial cross-sectional study of pediatric epilepsy surgery using triennial data from the Kids’ Inpatient Database (KID) from 1997 to 2009. They calculated the rates of epilepsy surgery for lobectomies, partial lobectomies, and hemispherectomies in each study year based on the number of prevalent epilepsy cases in the corresponding year. The researchers also estimated age-, race-, and sex-adjusted rates of surgeries.
Dr. Pestana Knight’s group used the Mann-Kendall trend test to identify changes in the rates of surgeries over time. Multivariable regression analysis enabled the group to estimate the effects of time, age, race, and sex on the annual incidence of epilepsy surgery.
Surgeries Increased in All Patient Subgroups
The number of epilepsy surgeries increased steadily from 375 in 1997 to 706 in 2009. The increase in surgeries occurred in all age groups except infants. Whites had the greatest number of surgeries, compared with blacks, Hispanics, and other minorities. Children with private insurance also had the highest number of surgeries performed, compared with children in public insurance programs and children with “other” payers (a category that included the uninsured).
The number of surgeries for each study year was less than 35% of children who are expected to have surgery, based on the estimates from the Connecticut Study of Epilepsy. After the investigators adjusted for age, race, sex, and changes in population distribution during the study period, the rates of pediatric epilepsy surgeries increased significantly from 0.85 epilepsy surgeries per 1,000 children with epilepsy in 1997 to 1.44 epilepsy surgeries per 1,000 children with epilepsy in 2009.
Although the rate of surgery increased in all patient subgroups, the increase was lowest among black children (compared with other races) and among children with public insurance (compared with children with private insurance). Age, race, and sex were independent predictors of surgery. Findings related to race should be interpreted with caution, said the researchers, because some hospitals and states do not provide data on race to the Healthcare Cost and Utilization Project, which encompasses KID.
“This is the first study that provides national estimates of pediatric epilepsy surgery utilization in the United States,” said Dr. Pestana Knight. “An increasing trend of surgical rates in publicly insured children with epilepsy is a hopeful finding that access to specialized epilepsy care in low-income children or patients’ and physicians’ perception and understanding of surgical treatment have improved. … Our findings emphasize that improving access to specialized epilepsy care for all children with epilepsy is as important as ever.”
—Erik Greb
Suggested Reading
Pestana Knight EM, Schiltz NK, Bakaki PM, et al. Increasing utilization of pediatric epilepsy surgery in the United States between 1997 and 2009. Epilepsia. 2015;56(3):375-381.
The rate of pediatric epilepsy surgery has increased significantly in the United States during the past decade, according to an investigation published in the March issue of Epilepsia. Nevertheless, epilepsy surgery remains an underutilized treatment in children with epilepsy, according to the researchers.
“Continued emphasis on highlighting awareness of epilepsy surgery among pediatricians and pediatric neurologists is as important as ever, as they serve as the main gatekeepers for patients to access specialized epilepsy care,” said Elia M. Pestana Knight, MD, a neurologist at the Cleveland Clinic Epilepsy Center.
An Analysis of a Pediatric Database
Research indicates that the rate of epilepsy surgery in adults has either declined or remained stable in the past decade. Dr. Pestana Knight and colleagues, however, hypothesized that rates of epilepsy surgery in the pediatric population had increased over time. To test this hypothesis, the investigators performed a serial cross-sectional study of pediatric epilepsy surgery using triennial data from the Kids’ Inpatient Database (KID) from 1997 to 2009. They calculated the rates of epilepsy surgery for lobectomies, partial lobectomies, and hemispherectomies in each study year based on the number of prevalent epilepsy cases in the corresponding year. The researchers also estimated age-, race-, and sex-adjusted rates of surgeries.
Dr. Pestana Knight’s group used the Mann-Kendall trend test to identify changes in the rates of surgeries over time. Multivariable regression analysis enabled the group to estimate the effects of time, age, race, and sex on the annual incidence of epilepsy surgery.
Surgeries Increased in All Patient Subgroups
The number of epilepsy surgeries increased steadily from 375 in 1997 to 706 in 2009. The increase in surgeries occurred in all age groups except infants. Whites had the greatest number of surgeries, compared with blacks, Hispanics, and other minorities. Children with private insurance also had the highest number of surgeries performed, compared with children in public insurance programs and children with “other” payers (a category that included the uninsured).
The number of surgeries for each study year was less than 35% of children who are expected to have surgery, based on the estimates from the Connecticut Study of Epilepsy. After the investigators adjusted for age, race, sex, and changes in population distribution during the study period, the rates of pediatric epilepsy surgeries increased significantly from 0.85 epilepsy surgeries per 1,000 children with epilepsy in 1997 to 1.44 epilepsy surgeries per 1,000 children with epilepsy in 2009.
Although the rate of surgery increased in all patient subgroups, the increase was lowest among black children (compared with other races) and among children with public insurance (compared with children with private insurance). Age, race, and sex were independent predictors of surgery. Findings related to race should be interpreted with caution, said the researchers, because some hospitals and states do not provide data on race to the Healthcare Cost and Utilization Project, which encompasses KID.
“This is the first study that provides national estimates of pediatric epilepsy surgery utilization in the United States,” said Dr. Pestana Knight. “An increasing trend of surgical rates in publicly insured children with epilepsy is a hopeful finding that access to specialized epilepsy care in low-income children or patients’ and physicians’ perception and understanding of surgical treatment have improved. … Our findings emphasize that improving access to specialized epilepsy care for all children with epilepsy is as important as ever.”
—Erik Greb
The rate of pediatric epilepsy surgery has increased significantly in the United States during the past decade, according to an investigation published in the March issue of Epilepsia. Nevertheless, epilepsy surgery remains an underutilized treatment in children with epilepsy, according to the researchers.
“Continued emphasis on highlighting awareness of epilepsy surgery among pediatricians and pediatric neurologists is as important as ever, as they serve as the main gatekeepers for patients to access specialized epilepsy care,” said Elia M. Pestana Knight, MD, a neurologist at the Cleveland Clinic Epilepsy Center.
An Analysis of a Pediatric Database
Research indicates that the rate of epilepsy surgery in adults has either declined or remained stable in the past decade. Dr. Pestana Knight and colleagues, however, hypothesized that rates of epilepsy surgery in the pediatric population had increased over time. To test this hypothesis, the investigators performed a serial cross-sectional study of pediatric epilepsy surgery using triennial data from the Kids’ Inpatient Database (KID) from 1997 to 2009. They calculated the rates of epilepsy surgery for lobectomies, partial lobectomies, and hemispherectomies in each study year based on the number of prevalent epilepsy cases in the corresponding year. The researchers also estimated age-, race-, and sex-adjusted rates of surgeries.
Dr. Pestana Knight’s group used the Mann-Kendall trend test to identify changes in the rates of surgeries over time. Multivariable regression analysis enabled the group to estimate the effects of time, age, race, and sex on the annual incidence of epilepsy surgery.
Surgeries Increased in All Patient Subgroups
The number of epilepsy surgeries increased steadily from 375 in 1997 to 706 in 2009. The increase in surgeries occurred in all age groups except infants. Whites had the greatest number of surgeries, compared with blacks, Hispanics, and other minorities. Children with private insurance also had the highest number of surgeries performed, compared with children in public insurance programs and children with “other” payers (a category that included the uninsured).
The number of surgeries for each study year was less than 35% of children who are expected to have surgery, based on the estimates from the Connecticut Study of Epilepsy. After the investigators adjusted for age, race, sex, and changes in population distribution during the study period, the rates of pediatric epilepsy surgeries increased significantly from 0.85 epilepsy surgeries per 1,000 children with epilepsy in 1997 to 1.44 epilepsy surgeries per 1,000 children with epilepsy in 2009.
Although the rate of surgery increased in all patient subgroups, the increase was lowest among black children (compared with other races) and among children with public insurance (compared with children with private insurance). Age, race, and sex were independent predictors of surgery. Findings related to race should be interpreted with caution, said the researchers, because some hospitals and states do not provide data on race to the Healthcare Cost and Utilization Project, which encompasses KID.
“This is the first study that provides national estimates of pediatric epilepsy surgery utilization in the United States,” said Dr. Pestana Knight. “An increasing trend of surgical rates in publicly insured children with epilepsy is a hopeful finding that access to specialized epilepsy care in low-income children or patients’ and physicians’ perception and understanding of surgical treatment have improved. … Our findings emphasize that improving access to specialized epilepsy care for all children with epilepsy is as important as ever.”
—Erik Greb
Suggested Reading
Pestana Knight EM, Schiltz NK, Bakaki PM, et al. Increasing utilization of pediatric epilepsy surgery in the United States between 1997 and 2009. Epilepsia. 2015;56(3):375-381.
Suggested Reading
Pestana Knight EM, Schiltz NK, Bakaki PM, et al. Increasing utilization of pediatric epilepsy surgery in the United States between 1997 and 2009. Epilepsia. 2015;56(3):375-381.
Switch to Oral Fingolimod May Improve MS Outcomes
For patients who have active multiple sclerosis (MS) despite using injectable immunomodulators, switching to the oral immunomodulator fingolimod yields fewer relapses and less disability than does switching to a different injectable immunomodulator, according to a report published in the April issue of JAMA Neurology.
To compare MS outcomes using different treatment regimens, researchers used information from the MSBase registry, which collects observational data on the disorder as part of routine patient care. For this study, the investigators retrospectively analyzed data entered between 1996 and 2014 for 527 patients with MS who had breakthrough disease while receiving injectable immunomodulators (typically an interferon beta or glatiramer acetate preparation) and who switched to either oral fingolimod (148 patients) or a different interferon beta or glatiramer agent (379 patients) up to 12 months after on-treatment clinical disease activity.
The two groups were propensity matched for baseline clinical and demographic variables, including patient age, area of residence, disease duration, total number of previous treatments, disability score, number of relapses, and previous medications. The groups were followed for a median of 13 months (range, three to 80 months) after switching therapies, said Anna He, MBBS, a neurologist at Royal Melbourne Hospital in Australia, and her associates. Head-to-head analyses of relapse and disability outcomes used paired, weighted, negative binomial models or frailty proportional hazards models adjusted for MRI variables.
Patients who switched to fingolimod had a lower mean annualized relapse rate, compared with the other patients (0.31 vs 0.42). The fingolimod group had a decreased risk of relapse (hazard ratio [HR], 0.74), compared with patients who switched to a different injectable therapy. Patients who switched to fingolimod also had a 47% decreased risk of progression of disability. In addition, the fingolimod group had a markedly increased likelihood of disability regression (HR, 2.0). Furthermore, the rate of continuing on the new treatment at two years was higher with fingolimod (82.5%) than with a different injectable (73.2%), said Dr. He and her associates.
“Although analyses of observational data do not serve as a substitute for trial data, our study provides real-world evidence, representative of clinical practice in tertiary MS centers, to support clinical decision-making that is highly relevant to the management of active MS,” said the investigators.
—Mary Ann Moon
Suggested Reading
He A, Spelman T, Jokubaitis V, et al. Comparison of switch to fingolimod or interferon beta/glatiramer acetate in active multiple sclerosis. JAMA Neurol. 2015; 72(4):405-413.
For patients who have active multiple sclerosis (MS) despite using injectable immunomodulators, switching to the oral immunomodulator fingolimod yields fewer relapses and less disability than does switching to a different injectable immunomodulator, according to a report published in the April issue of JAMA Neurology.
To compare MS outcomes using different treatment regimens, researchers used information from the MSBase registry, which collects observational data on the disorder as part of routine patient care. For this study, the investigators retrospectively analyzed data entered between 1996 and 2014 for 527 patients with MS who had breakthrough disease while receiving injectable immunomodulators (typically an interferon beta or glatiramer acetate preparation) and who switched to either oral fingolimod (148 patients) or a different interferon beta or glatiramer agent (379 patients) up to 12 months after on-treatment clinical disease activity.
The two groups were propensity matched for baseline clinical and demographic variables, including patient age, area of residence, disease duration, total number of previous treatments, disability score, number of relapses, and previous medications. The groups were followed for a median of 13 months (range, three to 80 months) after switching therapies, said Anna He, MBBS, a neurologist at Royal Melbourne Hospital in Australia, and her associates. Head-to-head analyses of relapse and disability outcomes used paired, weighted, negative binomial models or frailty proportional hazards models adjusted for MRI variables.
Patients who switched to fingolimod had a lower mean annualized relapse rate, compared with the other patients (0.31 vs 0.42). The fingolimod group had a decreased risk of relapse (hazard ratio [HR], 0.74), compared with patients who switched to a different injectable therapy. Patients who switched to fingolimod also had a 47% decreased risk of progression of disability. In addition, the fingolimod group had a markedly increased likelihood of disability regression (HR, 2.0). Furthermore, the rate of continuing on the new treatment at two years was higher with fingolimod (82.5%) than with a different injectable (73.2%), said Dr. He and her associates.
“Although analyses of observational data do not serve as a substitute for trial data, our study provides real-world evidence, representative of clinical practice in tertiary MS centers, to support clinical decision-making that is highly relevant to the management of active MS,” said the investigators.
—Mary Ann Moon
For patients who have active multiple sclerosis (MS) despite using injectable immunomodulators, switching to the oral immunomodulator fingolimod yields fewer relapses and less disability than does switching to a different injectable immunomodulator, according to a report published in the April issue of JAMA Neurology.
To compare MS outcomes using different treatment regimens, researchers used information from the MSBase registry, which collects observational data on the disorder as part of routine patient care. For this study, the investigators retrospectively analyzed data entered between 1996 and 2014 for 527 patients with MS who had breakthrough disease while receiving injectable immunomodulators (typically an interferon beta or glatiramer acetate preparation) and who switched to either oral fingolimod (148 patients) or a different interferon beta or glatiramer agent (379 patients) up to 12 months after on-treatment clinical disease activity.
The two groups were propensity matched for baseline clinical and demographic variables, including patient age, area of residence, disease duration, total number of previous treatments, disability score, number of relapses, and previous medications. The groups were followed for a median of 13 months (range, three to 80 months) after switching therapies, said Anna He, MBBS, a neurologist at Royal Melbourne Hospital in Australia, and her associates. Head-to-head analyses of relapse and disability outcomes used paired, weighted, negative binomial models or frailty proportional hazards models adjusted for MRI variables.
Patients who switched to fingolimod had a lower mean annualized relapse rate, compared with the other patients (0.31 vs 0.42). The fingolimod group had a decreased risk of relapse (hazard ratio [HR], 0.74), compared with patients who switched to a different injectable therapy. Patients who switched to fingolimod also had a 47% decreased risk of progression of disability. In addition, the fingolimod group had a markedly increased likelihood of disability regression (HR, 2.0). Furthermore, the rate of continuing on the new treatment at two years was higher with fingolimod (82.5%) than with a different injectable (73.2%), said Dr. He and her associates.
“Although analyses of observational data do not serve as a substitute for trial data, our study provides real-world evidence, representative of clinical practice in tertiary MS centers, to support clinical decision-making that is highly relevant to the management of active MS,” said the investigators.
—Mary Ann Moon
Suggested Reading
He A, Spelman T, Jokubaitis V, et al. Comparison of switch to fingolimod or interferon beta/glatiramer acetate in active multiple sclerosis. JAMA Neurol. 2015; 72(4):405-413.
Suggested Reading
He A, Spelman T, Jokubaitis V, et al. Comparison of switch to fingolimod or interferon beta/glatiramer acetate in active multiple sclerosis. JAMA Neurol. 2015; 72(4):405-413.
Moderate Adherence to MIND Diet May Protect Against Alzheimer’s Disease
Moderate adherence to a diet that combines elements of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet may significantly lower the risk of developing Alzheimer’s disease, according to research published online ahead of print February 11 in Alzheimer’s & Dementia. In addition, high adherence to all three diets may reduce the risk of developing Alzheimer’s disease, researchers concluded.
Martha Clare Morris, PhD, a nutritional epidemiologist at Rush University Medical Center in Chicago, and colleagues used food frequency questionnaires to evaluate what 923 people, ages 58 to 98, already were eating and scored how closely each participant’s diet adhered to the Mediterranean and DASH diets and to the hybrid diet, called MIND, for Mediterranean-DASH Intervention for Neurodegenerative Delay. Dr. Morris and her team designed the MIND diet to emphasize foods that prior studies have found to be associated with brain health, including leafy green vegetables and berries.
The participants were volunteers in the ongoing Rush Memory and Aging Project (MAP), a study of people living in retirement communities and senior public housing in the Chicago area. Participants did not have Alzheimer’s disease at baseline. Clinicians determined diagnoses of probable Alzheimer’s disease at annual neurologic examinations. A total of 144 cases of Alzheimer’s disease developed over an average follow-up of four and a half years.
Diet Scores Based on Food Frequency Questionnaire
Diet adherence scores were computed from responses to a modified version of the Harvard food frequency questionnaire that was validated for use in older Chicago community residents. Participants were asked to report usual frequency of intake over the previous year of 144 food items.
The MIND diet score had 15 dietary components, including 10 brain-healthy food groups (ie, green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, fish, poultry, olive oil, and wine) and five unhealthy food groups (ie, red meats, butter and stick margarine, cheese, pastries and sweets, and fried or fast food). Researchers assigned a concordance score of 0, 0.5, or 1, for a total score ranging from 0 to 15. The DASH diet scoring was based on seven food groups and three dietary components (ie, total fat, saturated fat, and sodium), each scored 0, 0.5, or 1, for a total score ranging from 0 to 10. The Mediterranean diet score was based on scoring that used serving quantities of the traditional Greek Mediterranean diet as the standard. It included 11 dietary components, each scored from 0 to 5, for a total score ranging from 0 to 55.
For each diet, researchers sorted participants’ scores into the top, middle, and bottom tertiles. The top tertiles comprised scores that represented the highest adherence to the diets. For the MIND diet, the estimated effect—adjusted for age, sex, education, APOE ε4, total energy intake, physical activity, and participation in cognitively stimulating activities—was a 53% reduction in the rate of Alzheimer’s disease for those in the top tertile, compared with those in the bottom tertile. For the middle tertile, there was a 35% reduction in risk, compared with the bottom tertile.
For the Mediterranean diet, those in the top tertile had a 54% reduced risk of developing Alzheimer’s disease, compared with those in the bottom tertile. For the DASH diet, the top tertile had a 39% reduced risk of developing Alzheimer’s disease, compared with the bottom tertile. The middle tertiles for the DASH and Mediterranean diets were not associated with significantly reduced risk.
“One of the more exciting things about this [study] is that people who adhered even moderately to the MIND diet had a reduction in their risk for Alzheimer’s disease,” said Dr. Morris.
An Emphasis on Neuroprotection
Like the Mediterranean and DASH diets, the MIND diet emphasizes natural plant-based foods and limited intake of animal-based foods and foods high in saturated fat. The MIND diet, however, does not specify high fruit consumption (compared with three to four servings per day in the DASH and Mediterranean diets), high dairy consumption (compared with two or more servings per day in DASH), high potato consumption (compared with two servings per day in the Mediterranean diet), or more than one fish meal per week (compared with six meals per week in the Mediterranean diet).
To determine whether the observed effects of the MIND diet on Alzheimer’s disease could be caused by dietary changes in participants with preclinical Alzheimer’s disease, the researchers reanalyzed the data after eliminating 33 patients who were diagnosed with Alzheimer’s disease within two years. Eliminating those cases did not change the overall results. Further elimination of 60 patients with Alzheimer’s disease who were diagnosed within three years had minimal impact on the estimated effects, although the reduced risk for the middle tertile was only marginally statistically significant when those cases were eliminated.
While the study had a relatively short follow-up period, in an earlier study of the MAP participants, the researchers reported slower cognitive decline with higher MIND scores over as long as 10 years of follow-up. In that prior study, the authors observed a stronger inverse association between the MIND diet and cognitive decline than for either the Mediterranean or DASH diets. “This [result] suggests that the MIND diet is not specific to the underlying pathology of Alzheimer’s disease, but perhaps [to] better overall functioning and protection of the brain,” the authors said.
Randomized dietary intervention trials are needed to attribute causal effects of the diet patterns to the development of Alzheimer’s disease, the authors said. The authors noted that limited information from the food frequency questionnaire was among the study’s limitations. For example, the question about berry consumption was based on a single item for strawberries, not other berry types, and the response options ranged from “never” to “two or more times per week.”
“Based on this study, high-quality diets such as the Mediterranean and DASH diets can be modified, such as in the MIND diet, to provide better protection against dementia,” the authors concluded.
Suggested Reading
Morris MC, Tangney CC, Wang Y, et al. MIND diet associated with reduced incidence of Alzheimer’s disease. Alzheimers Dement. 2015 February 11 [Epub ahead of print].
Moderate adherence to a diet that combines elements of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet may significantly lower the risk of developing Alzheimer’s disease, according to research published online ahead of print February 11 in Alzheimer’s & Dementia. In addition, high adherence to all three diets may reduce the risk of developing Alzheimer’s disease, researchers concluded.
Martha Clare Morris, PhD, a nutritional epidemiologist at Rush University Medical Center in Chicago, and colleagues used food frequency questionnaires to evaluate what 923 people, ages 58 to 98, already were eating and scored how closely each participant’s diet adhered to the Mediterranean and DASH diets and to the hybrid diet, called MIND, for Mediterranean-DASH Intervention for Neurodegenerative Delay. Dr. Morris and her team designed the MIND diet to emphasize foods that prior studies have found to be associated with brain health, including leafy green vegetables and berries.
The participants were volunteers in the ongoing Rush Memory and Aging Project (MAP), a study of people living in retirement communities and senior public housing in the Chicago area. Participants did not have Alzheimer’s disease at baseline. Clinicians determined diagnoses of probable Alzheimer’s disease at annual neurologic examinations. A total of 144 cases of Alzheimer’s disease developed over an average follow-up of four and a half years.
Diet Scores Based on Food Frequency Questionnaire
Diet adherence scores were computed from responses to a modified version of the Harvard food frequency questionnaire that was validated for use in older Chicago community residents. Participants were asked to report usual frequency of intake over the previous year of 144 food items.
The MIND diet score had 15 dietary components, including 10 brain-healthy food groups (ie, green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, fish, poultry, olive oil, and wine) and five unhealthy food groups (ie, red meats, butter and stick margarine, cheese, pastries and sweets, and fried or fast food). Researchers assigned a concordance score of 0, 0.5, or 1, for a total score ranging from 0 to 15. The DASH diet scoring was based on seven food groups and three dietary components (ie, total fat, saturated fat, and sodium), each scored 0, 0.5, or 1, for a total score ranging from 0 to 10. The Mediterranean diet score was based on scoring that used serving quantities of the traditional Greek Mediterranean diet as the standard. It included 11 dietary components, each scored from 0 to 5, for a total score ranging from 0 to 55.
For each diet, researchers sorted participants’ scores into the top, middle, and bottom tertiles. The top tertiles comprised scores that represented the highest adherence to the diets. For the MIND diet, the estimated effect—adjusted for age, sex, education, APOE ε4, total energy intake, physical activity, and participation in cognitively stimulating activities—was a 53% reduction in the rate of Alzheimer’s disease for those in the top tertile, compared with those in the bottom tertile. For the middle tertile, there was a 35% reduction in risk, compared with the bottom tertile.
For the Mediterranean diet, those in the top tertile had a 54% reduced risk of developing Alzheimer’s disease, compared with those in the bottom tertile. For the DASH diet, the top tertile had a 39% reduced risk of developing Alzheimer’s disease, compared with the bottom tertile. The middle tertiles for the DASH and Mediterranean diets were not associated with significantly reduced risk.
“One of the more exciting things about this [study] is that people who adhered even moderately to the MIND diet had a reduction in their risk for Alzheimer’s disease,” said Dr. Morris.
An Emphasis on Neuroprotection
Like the Mediterranean and DASH diets, the MIND diet emphasizes natural plant-based foods and limited intake of animal-based foods and foods high in saturated fat. The MIND diet, however, does not specify high fruit consumption (compared with three to four servings per day in the DASH and Mediterranean diets), high dairy consumption (compared with two or more servings per day in DASH), high potato consumption (compared with two servings per day in the Mediterranean diet), or more than one fish meal per week (compared with six meals per week in the Mediterranean diet).
To determine whether the observed effects of the MIND diet on Alzheimer’s disease could be caused by dietary changes in participants with preclinical Alzheimer’s disease, the researchers reanalyzed the data after eliminating 33 patients who were diagnosed with Alzheimer’s disease within two years. Eliminating those cases did not change the overall results. Further elimination of 60 patients with Alzheimer’s disease who were diagnosed within three years had minimal impact on the estimated effects, although the reduced risk for the middle tertile was only marginally statistically significant when those cases were eliminated.
While the study had a relatively short follow-up period, in an earlier study of the MAP participants, the researchers reported slower cognitive decline with higher MIND scores over as long as 10 years of follow-up. In that prior study, the authors observed a stronger inverse association between the MIND diet and cognitive decline than for either the Mediterranean or DASH diets. “This [result] suggests that the MIND diet is not specific to the underlying pathology of Alzheimer’s disease, but perhaps [to] better overall functioning and protection of the brain,” the authors said.
Randomized dietary intervention trials are needed to attribute causal effects of the diet patterns to the development of Alzheimer’s disease, the authors said. The authors noted that limited information from the food frequency questionnaire was among the study’s limitations. For example, the question about berry consumption was based on a single item for strawberries, not other berry types, and the response options ranged from “never” to “two or more times per week.”
“Based on this study, high-quality diets such as the Mediterranean and DASH diets can be modified, such as in the MIND diet, to provide better protection against dementia,” the authors concluded.
Moderate adherence to a diet that combines elements of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet may significantly lower the risk of developing Alzheimer’s disease, according to research published online ahead of print February 11 in Alzheimer’s & Dementia. In addition, high adherence to all three diets may reduce the risk of developing Alzheimer’s disease, researchers concluded.
Martha Clare Morris, PhD, a nutritional epidemiologist at Rush University Medical Center in Chicago, and colleagues used food frequency questionnaires to evaluate what 923 people, ages 58 to 98, already were eating and scored how closely each participant’s diet adhered to the Mediterranean and DASH diets and to the hybrid diet, called MIND, for Mediterranean-DASH Intervention for Neurodegenerative Delay. Dr. Morris and her team designed the MIND diet to emphasize foods that prior studies have found to be associated with brain health, including leafy green vegetables and berries.
The participants were volunteers in the ongoing Rush Memory and Aging Project (MAP), a study of people living in retirement communities and senior public housing in the Chicago area. Participants did not have Alzheimer’s disease at baseline. Clinicians determined diagnoses of probable Alzheimer’s disease at annual neurologic examinations. A total of 144 cases of Alzheimer’s disease developed over an average follow-up of four and a half years.
Diet Scores Based on Food Frequency Questionnaire
Diet adherence scores were computed from responses to a modified version of the Harvard food frequency questionnaire that was validated for use in older Chicago community residents. Participants were asked to report usual frequency of intake over the previous year of 144 food items.
The MIND diet score had 15 dietary components, including 10 brain-healthy food groups (ie, green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, fish, poultry, olive oil, and wine) and five unhealthy food groups (ie, red meats, butter and stick margarine, cheese, pastries and sweets, and fried or fast food). Researchers assigned a concordance score of 0, 0.5, or 1, for a total score ranging from 0 to 15. The DASH diet scoring was based on seven food groups and three dietary components (ie, total fat, saturated fat, and sodium), each scored 0, 0.5, or 1, for a total score ranging from 0 to 10. The Mediterranean diet score was based on scoring that used serving quantities of the traditional Greek Mediterranean diet as the standard. It included 11 dietary components, each scored from 0 to 5, for a total score ranging from 0 to 55.
For each diet, researchers sorted participants’ scores into the top, middle, and bottom tertiles. The top tertiles comprised scores that represented the highest adherence to the diets. For the MIND diet, the estimated effect—adjusted for age, sex, education, APOE ε4, total energy intake, physical activity, and participation in cognitively stimulating activities—was a 53% reduction in the rate of Alzheimer’s disease for those in the top tertile, compared with those in the bottom tertile. For the middle tertile, there was a 35% reduction in risk, compared with the bottom tertile.
For the Mediterranean diet, those in the top tertile had a 54% reduced risk of developing Alzheimer’s disease, compared with those in the bottom tertile. For the DASH diet, the top tertile had a 39% reduced risk of developing Alzheimer’s disease, compared with the bottom tertile. The middle tertiles for the DASH and Mediterranean diets were not associated with significantly reduced risk.
“One of the more exciting things about this [study] is that people who adhered even moderately to the MIND diet had a reduction in their risk for Alzheimer’s disease,” said Dr. Morris.
An Emphasis on Neuroprotection
Like the Mediterranean and DASH diets, the MIND diet emphasizes natural plant-based foods and limited intake of animal-based foods and foods high in saturated fat. The MIND diet, however, does not specify high fruit consumption (compared with three to four servings per day in the DASH and Mediterranean diets), high dairy consumption (compared with two or more servings per day in DASH), high potato consumption (compared with two servings per day in the Mediterranean diet), or more than one fish meal per week (compared with six meals per week in the Mediterranean diet).
To determine whether the observed effects of the MIND diet on Alzheimer’s disease could be caused by dietary changes in participants with preclinical Alzheimer’s disease, the researchers reanalyzed the data after eliminating 33 patients who were diagnosed with Alzheimer’s disease within two years. Eliminating those cases did not change the overall results. Further elimination of 60 patients with Alzheimer’s disease who were diagnosed within three years had minimal impact on the estimated effects, although the reduced risk for the middle tertile was only marginally statistically significant when those cases were eliminated.
While the study had a relatively short follow-up period, in an earlier study of the MAP participants, the researchers reported slower cognitive decline with higher MIND scores over as long as 10 years of follow-up. In that prior study, the authors observed a stronger inverse association between the MIND diet and cognitive decline than for either the Mediterranean or DASH diets. “This [result] suggests that the MIND diet is not specific to the underlying pathology of Alzheimer’s disease, but perhaps [to] better overall functioning and protection of the brain,” the authors said.
Randomized dietary intervention trials are needed to attribute causal effects of the diet patterns to the development of Alzheimer’s disease, the authors said. The authors noted that limited information from the food frequency questionnaire was among the study’s limitations. For example, the question about berry consumption was based on a single item for strawberries, not other berry types, and the response options ranged from “never” to “two or more times per week.”
“Based on this study, high-quality diets such as the Mediterranean and DASH diets can be modified, such as in the MIND diet, to provide better protection against dementia,” the authors concluded.
Suggested Reading
Morris MC, Tangney CC, Wang Y, et al. MIND diet associated with reduced incidence of Alzheimer’s disease. Alzheimers Dement. 2015 February 11 [Epub ahead of print].
Suggested Reading
Morris MC, Tangney CC, Wang Y, et al. MIND diet associated with reduced incidence of Alzheimer’s disease. Alzheimers Dement. 2015 February 11 [Epub ahead of print].
