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Illiteracy Tied to a Threefold Increased Risk of Dementia

Individuals who cannot read or write have significantly increase risk of dementia compared with their literate peers, new research shows.

The latest results from the ongoing Washington Heights-Inwood Columbia Aging Project (WHICAP) showed adults age 65 and older who were unable to read or write had a threefold increase of dementia at baseline compared with their literate counterparts

In addition, individuals who were illiterate but had no dementia at baseline were twice as likely to develop incident dementia.

“Illiterate patients may be at increased risk of developing dementia, and should be monitored accordingly,” senior author Jennifer J. Manly, PhD, Columbia University Vagelos College of Physicians and Surgeons, New York, told Medscape Medical News.

People self-reported illiteracy by answering yes or no to the question: “Did you ever learn to read or write?” One of the key take-home messages from the study is that “is that early life educational opportunities have an influence on dementia risk in later life,” she added.

The study was published online November 13 in Neurology.

US Illiteracy Rate High

An estimated 32 million people in the United States are illiterate. Given this, said Manly, the findings may have important public health policy implications for an estimated 10% of the population.

Investigators assessed 983 adults who reported four or fewer years of education who were participants in WHICAP, a community-based, prospective cohort study of dementia in the ethnically diverse neighborhoods of Northern Manhattan, New York. Participants were enrolled in the study at one of three time points — 1992, 1999, or 2009.

An objective reading test administered to a subset of the study population helped validate self-reported literacy status.

Participants also underwent a battery of cognitive, functional, and health measures at baseline and follow-up assessments. Next, the investigators compared rates of baseline dementia, risk for incident dementia, and the rate of cognitive decline between the 237 illiterate participants and 746 literate participants.

A clinical consensus conference of neurologists, psychiatrists, and neuropsychologists diagnosed 95% of affected participants with Alzheimer’s disease (AD) dementia. The remainder had Lewy body or vascular dementia.

The researchers examined prevalent and incident dementia and found an increased likelihood of prevalent dementia in the illiterate group compared with literate participants in an unadjusted model (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.70 – 3.26).

Illiterate participants also remained at increased odds for prevalent dementia in an analysis that adjusted for potential confounders (OR, 2.65; 95% CI, 1.55 – 4.50).

The risk of developing incident dementia also was elevated among illiterate participants compared with literate participants in an unadjusted Cox model (OR, 1.95; 95% CI, 1.46 – 2.60). Adjusting for covariates reduced the risk of dementia (OR, 1.63; 95% CI, 1.12 – 2.36).

 

Closer to the Dementia Threshold

Although several prior studies suggest the effect of education on dementia risk is greater for women vs men, the curSource : Medscaperent research did not show any effect of literacy based on sex or gender.

Interestingly, although Illiterate adults demonstrated worse cognition at baseline, they did not experience a more rapid rate of cognitive decline compared with literate participants.

This finding could mean “illiterate adults are closer to the cognitive and functional thresholds for dementia than literate individuals,” the researchers note.

“This study adds to this literature by associating illiteracy with increased risk of incident dementia and poorer cognitive abilities. The effect of literacy on dementia risk remained robust even after including potential early and later life confounds of literacy (i.e., socioeconomic status, poorer overall health),” they add.

“One of our next goals is to elucidate the neuroanatomical substrates associated with this increased risk of dementia among older adults with low literacy,” Manly said. The researchers are currently evaluating brain MRI scans on a subset of study participants.

“We will be able to evaluate if there are neuroanatomical structural differences among illiterate and literate participants, and whether this is associated with higher dementia risk,” Manly added.

Another future aim is to determine if literacy programs can improve cognitive aging and reduce dementia risk. “We’d love to partner with adult literacy programs to determine if learning to read and write as an adult provides cognitive benefits in older age,” Manly said.

 

Not Surprising

Commenting on the study for Medscape Medical News, Anil K. Nair, MD, director of the Alzheimer’s Disease Center in Quincy, Massachusetts, said the threefold increased dementia risk in individuals who were unable to read and write was not surprising.

“The diagnosis of dementia was by memory test, which is very dependent on language, so it was also a proxy for language,” said Nair, who is also a fellow of the American Academy of Neurology.

Nair added that he would like to see the same study done at the protein levels, noting that it would be interesting to see whether literacy/illiteracy correlates with tau or amyloid protein levels.

Source : Medscape

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No Routine Screening For Thyroid Problems In Asymptomatic Patients

The Canadian Task Force on Preventive Health Care has issued a strong recommendation against routine thyroid screening in nonpregnant adults without symptoms in the primary care setting, saying there is insufficient evidence of clinical benefit from the treatment of thyroid dysfunction in such individuals.

The guideline was published online November 17 in the Canadian Medical Association Journal (CMAJ) and was funded by the Public Health Agency of Canada.

“If you are a clinician who orders thyroid-stimulating hormone (TSH) tests as part of preventive health visits, we would like you to reconsider this practice. The evidence isn’t there to suggest a health benefit for this type of screening as a routine part of care,” says Richard Birtwhistle, MD, chair of the Task Force Thyroid Dysfunction working group, in a press statement from CMAJ.

“Given the lack of clinical effectiveness and the burden on patients, including financial costs, screening patients without symptoms consumes resources that could be better used elsewhere,” added Birtwhistle, professor emeritus of family medicine and public health sciences at Queen’s University, in Kingston, Ontario, Canada.

This advice differs from the recommendations of other groups, as consensus on the issue is lacking, note the authors of an accompanying editorial.

“The recommendation represents a change in thinking about screening for thyroid dysfunction and contradicts other medical society recommendations that favor screening, particularly among older people,” write Juan Brito, MD, and Omar El Kawkgi, MD, of the Department of Endocrinology, Mayo Clinic, in Rochester, Minnesota.

Specifically, the position of the American Thyroid Association (ATA), published as joint guidelines with the American Association of Clinical Endocrinologists (AACE), is that screening for hypothyroidism in patients older than age 60 should be considered.

But Brito and El Kawkgi note that the ATA/AACE guidelines were released in 2012 and therefore “could not consider clinical evidence published over the last 7 years, which has shown lack of benefit of levothyroxine treatment in people with subclinical hypothyroidism.”

However, the US Preventive Services Task Force issued an updated guideline in 2015 recommending against screening for thyroid dysfunction based on insufficient evidence, they point out, and that position has also been endorsed by the American Academy of Family Physicians, editorialist El Kawkgi told Medscape Medical News.

Systematic Review Included 22 Studies

Routine testing for thyroid dysfunction is commonly ordered by checking the “TSH box” on a blood test requisition form, although practice varies by primary care practitioner. An abnormal TSH level may indicate an underactive (hypothyroidism) or overactive thyroid gland (hyperthyroidism).

For its review of the evidence, the Canadian Task Force evaluated findings from 22 eligible studies, including 19 randomized clinical trials (RCTs) and three cohort studies.

Although no trials were identified that directly compared screening to no screening for thyroid dysfunction, the studies provide indirect evidence of a lack of clinical benefit of the treatment of asymptomatic thyroid dysfunction, with follow-up ranging from 3 to 36 months in the RCTs and a median follow-up of 5.0 to 7.6 years in the cohort studies, the task force says.

Evidence against screening includes the observation that factors such as some medications, autoimmune diseases, or assay variations, may explain abnormal TSH levels, and studies show those abnormalities will commonly normalize on their own in subsequent testing.

The new recommendation “is pretty straightforward,” Birtwhistle emphasized in an accompanying CMAJ podcast. “We’re quite confident. Canadian adults who are asymptomatic don’t need to be screened for thyroid dysfunction, either hypothyroidism or hyperthyroidism.”

 

Levothyroxine Overuse an Ongoing Concern

Furthermore, a lack of benefit has been demonstrated in the treatment of subclinical hypothyroidism with levothyroxine, despite the treatment being widely practiced, says the Canadian Task Force.

For example, as reported by Medscape Medical News, an international panel of experts concluded earlier this year that patients with subclinical hypothyroidism should not be routinely offered thyroid replacement therapy, amid evidence of no benefit to quality of life or symptoms.

“Overwhelmingly, there doesn’t seem to be a treatment effect [of levothyroxine],” Birtwhistle notes in the podcast. And levothyroxine overuse is an ongoing concern, El Kawkgi told Medscape Medical News.

“Levothyroxine is the most commonly prescribed medication in the United States, and the number of dispensed prescriptions has increased by around 40% in the last few years,” he said.

“As the prevalence and incidence of overt hypothyroidism are stable, subclinical disease is likely a driver: disease which may have been identified through screening given its lack of presenting symptoms by definition,” El Kawkgi noted.

 

Guideline Not Applicable to Symptomatic Patients

The guideline recommendation does not extend to patients who do have symptoms suggestive of hypo- or hyperthyroidism, including fatigue, cold or heat sensitivity, unexplained weight loss, hair loss, or heart rate irregularities, the task force stresses. Such patients should visit their primary care practitioner.

In addition, the recommendation does not apply to those at higher risk for thyroid dysfunction, including those with previously diagnosed thyroid disease or thyroid surgery; exposure to medications known to affect thyroid function (eg, lithium, amiodarone); exposure to thyroid radioiodine therapy or radiotherapy to the head or neck area; or pituitary or hypothalamic diseases.

 

TSH Screening Common

Although data are lacking on rates of screening for thyroid dysfunction, the editorial cites one primary care study out of Toronto showing as many as 71% of patients over the age of 20 without known thyroid disease not receiving thyroid medication had received TSH testing over a 2-year period.

The new guideline may help prevent unnecessary screening, the editorialists write. “By issuing a strong recommendation against population screening for thyroid dysfunction, the task force may help physicians to stop uncovering a large reservoir of people with mild thyroid dysfunction who are unlikely to benefit from identification or treatment, thereby preventing the overdiagnosis and overtreatment of otherwise healthy people,” they note.

They add that when it comes to the goal of patient-centered care — using the best evidence to respond to the needs and desires of each individual patient — screening for thyroid dysfunction fails to measure up.

“Care that responds poorly to a person’s situation, is not evidence-based, or fails to align with the patient’s priorities and preferences is unlikely to be helpful and could be harmful,” the editorialists write.

“One common practice that may not represent patient-centered care is screening for thyroid dysfunction,” they add.

Birtwhistle concludes in the podcast that although a TSH test is not expensive, “which is a common argument for blood tests…[If] it comes back positive, that’s just the start of the cascade. It may result in further testing, like a thyroid ultrasound. And it can certainly result in lifelong unnecessary treatment.”

Source : Medscape

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India Courts Private Hospitals to Boost Insurance Programme

India will offer incentives to private hospitals to take part in the government’s health insurance programme, potentially the biggest of its kind in the world, a senior government official told Reuters.

Launched last year, the scheme is critical to Prime Minister Narendra Modi’s plans to reform the country’s health system, where private healthcare is too expensive for most people and public hospitals are overburdened and often dilapidated.

The “Modicare” programme offers families health cover of up to 500,000 rupees ($7,000) a year for serious ailments – a significant amount by Indian standards – but the scheme has struggled to gain traction.

India has so far registered about 20% of the eligible 500 million people, due to lack of public awareness of the scheme and low private sector participation, said Indu Bhushan, CEO of the National Health Authority (NHA), which runs the programme.

“There is a challenge of creating awareness and building the required infrastructure,” Bhushan said in an interview. “We need to work more on awareness … give us time.”

Under the programme, more than 6 million people have so far received treatment free of charge, he said.

Currently, 60% of the approximately 20,000 hospitals registered under the programme are in the private sector, Bhushan said, adding that increasing their participation was critical to the scheme’s success.

Private hospitals, however, are concerned about costs. A report by Indian lobby group FICCI and consultants EY said in August that private hospitals complained that treatment rates offered by the NHA covered only 40-80% of their costs.

Bhushan said his agency was in talks with hospitals, industry groups and service providers and was open to revising rates, even though he had last month increased payments offered to hospitals for some treatments.

“We are hoping that private sector would come. If rates are not viable, private sector will not come,” he said.

The NHA’s budget spending also reflects the slow uptake of the scheme. The health agency will spend only 50-55 billion rupees ($766 million) of the allocated 62 billion rupees in the current fiscal year that ends in March, said Bhushan.

In order to expand the scheme more swiftly, however, the NHA was likely to seek at least 80 billion rupees for next year, 30% more than its current annual budget, a senior government source said.

“In the next one year, the scheme should be quite well-known across the country,” Bhushan said.

Source : Medscape

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Exercise Regimens For Astronauts May Help Cancer Patients Too ….

 What do astronauts and cancer patients have in common? Well, maybe mo than one would think, at least when it comes to physical activity.

 According to a new commentary published online in the journal Cell, fitness programs geared to astronauts before taking off into space may be applicable to patients with cancer.

 Both groups experience similar multisystem physiologic toxicities that are driven by comparable pre-flight risk factors, as in the case of astronauts, or pre-diagnosis risk factors for patients with cancer. The direct and indirect consequences of spaceflight or anticancer treatment are also comparable, say the authors, led by Jessica Scott, PhD, an exercise physiology researcher at Memorial Sloan Kettering Cancer Center in New York City.

 The team notes that during the past 6 decades, since the advent of the space program, NASA has developed a sophisticated countermeasures program (CMP) to both characterize and diminish the physiologic consequences of spaceflight. They emphasize that cancer is the only major chronic disease condition in which a comparable CMP is not part of standard care.

  This is surprising, they say, since there are “remarkable similarities” between astronauts and cancer patients. These similarities are seen in both pre-flight and pre-diagnosis risk factors, direct acute harmful exposure, as well as effects caused by the spaceflight itself or cancer therapies that result in multisystem adverse events.

 In their new study, the authors propose a model based on the NASA CMP that can potentially help diminish or even prevent some of the physiologic toxicities associated with both cancer and its treatment.

Multiple Hits

 “Both spaceflight and cancer therapies impact almost every system in the body,” said Scott. “For example, astronauts and cancer patients may have decreases in bone, muscle, and heart size, and astronauts experience something called ‘space fog,’ which is similar to what cancer patients call ‘chemo brain.’ ”

 These changes are caused by what is known as “multiple hits,” explained Scott, who also worked at the NASA Johnson Space Center when doing her postdoctoral fellowship.

 The first hit involves baseline risk factors. Both patients with cancer and astronauts may have a preexisting risk factor such as hypertension. “Back in the 1960s, several astronauts smoked,” she told Medscape Medical News.

 The second is a direct hit, such as chemotherapy in cancer and the absence of gravity for astronauts. The third is an indirect hit, in that patients may feel sick during therapy, which can reduce their activity levels.  “For astronauts, there is no standing up in space, so spaceflight is like lying in bed for months,” said Scott. “When you put these multiple hits together, both astronauts and cancer patients may experience side effects from the head to the toes.”

Prepare for the Mission

 One difference between astronauts and patients with cancer is that a space mission is not an unexpected event. In that sense, they begin preparing far in advance for travel into space and are aware of the health issues that may occur as a result of space travel. In contrast, cancer is something that catches people unprepared and they haven’t been “training” in advance to deal with it.

 But Scott doesn’t see that as an issue and explained that oncologists are like rocket scientists in that they prescribe the appropriate “fuel” to target malignant cells. “At NASA, aerospace engineers also aren’t asked to design an exercise program — individuals called the Astronaut Strength, Conditioning and Rehabilitation specialists (ASCRs) provide exercise programs,” she said. “There is constant communication between groups at NASA, such as how much oxygen is consumed during an exercise session and how that may impact the International Space Station Environmental Control and Life Support System. Each group is responsible for a puzzle piece to ensure mission success.”

 A similar team approach is likely needed in oncology, in which clinicians will ask patients about their current levels of physical activity and then refer them to exercise programs. Importantly, for both astronauts and patients with cancer, “one size of exercise does not fit all.”

 “The goal of a countermeasures program is to identify patients that may benefit from a structured exercise program, and then deliver a more targeted approach to exercise, just like patients receive different types, doses, and schedules of therapy,” Scott said.

Mission Control in Manhattan

 In their study, Scott and her colleagues point out that translating the NASA program to the clinical care setting will require rigorous evidence showing that a cancer-specific CMP is a cost-effective strategy that confers a benefit across clinical outcomes.

 At MSKCC, elements of the NASA countermeasures program are already being implemented in some of their clinical trials. “For example, we are using certain assessments that are identical to those used in astronauts,” she said. “We also started delivering treadmills to patients’ homes and conducting supervised exercise sessions from our ‘mission control’ at Memorial Sloan Kettering in Manhattan with video conferencing, just as astronauts hundreds of miles above Earth have exercise prescriptions delivered.”

 Using this method, patients don’t have to travel three to five times per week to complete their supervised exercise sessions, which in turn substantially decreases the burden for patients currently receiving therapy.

Exercise Still Lagging

 An ever-growing body of evidence points to the benefits of exercise in cancer care, and some professional groups are taking notice. The Clinical Oncology Society of Australia (COSA), the country’s leading organization for cancer professionals, issued a position statement that exercise should now be a part of the standard of care in treating all patients with cancer. Last month, a global coalition of 40 leaders from 17 organizations, spearheaded by the American College of Sports Medicine, also stated that exercise prescriptions should now be standard of care for all appropriate oncology patients and physical activity “should become a vital sign, similar to blood pressure,” recorded at each patient visit.

 But even with the expanded literature on exercise and cancer outcomes and professional groups stepping up to the plate, it is still not standard of care. Scott, however, believes that her team’s work will make a difference. The researchers are exploring the impact of exercise from a rather unique standpoint.

 “Compared to exercise in heart and lung diseases, exercise-oncology is a very young field,” she said. “Evidence to date in cancer patients indicates that increasing exercise by even just an hour per week is better than being sedentary.”

 But there is much research and many clinical trials that need be completed assessing the safety, feasibility, and efficacy of a countermeasures program before incorporating this approach into a standard of care for cancer patients, Scott added.

Source : Medscape