More Evidence that Dementia Case Numbers Are Falling

Numerous studies have reported a dip in dementia incidence in the developed world. When did this trend begin? In the September 5 JAMA Neurology, researchers led by Carol Derby at Albert Einstein College of Medicine in New York help address this. The researchers analyzed birth cohort data from the Einstein Aging Study, which enrolls cognitively healthy older adults living in the Bronx. Surprisingly, people born after 1928 were 85 percent less likely to develop dementia than those born before that year. The reason for such a stark drop in incidence is unclear. Neither better education nor improved cardiovascular health accounted for the effect.

A growing number of studies have reported a drop in dementia incidence in the U.S. and Europe over the last two or three decades (e.g., Feb 2016 newsApr 2016 newsNov 2016 news). Researchers have speculated that this may be due to better public health, particularly cardiovascular health (May 2013 newsJul 2014 conference news). The finding is not uniform, however, with a handful of studies reporting higher dementia incidence that may be due to greater recognition of the disease or a larger number of people reaching old age (Mar 2017 newsMay 2017 newsAbdulrahman 2014). 

“Changes in diet, especially for the mother during pregnancy, may be a crucial factor,” agreed Walter Rocca at the Mayo Clinic in Rochester, Minnesota. In addition, Rocca pointed out that people born in 1929 or after would have been teenagers or younger at the end of World War II, and thus their developing brains may have particularly reaped the benefits of the societal and medical changes that occurred at that time (see full comment below).

While previous epidemiological studies did not specifically examine birth years, those older findings are roughly congruent with the Einstein Aging Study data, reporting the greatest drop in dementia cases after 1990, the authors noted. People born after 1929 would have entered their 60s in that decade. Most cases of late-onset dementia occur after age 60. The Rotterdam Study found a 25 percent decrease in dementia incidence in the 1990s, while the Framingham Heart Study recently reported that incidence dropped starting in the late 1980s and continued to decline into the 2010s (Schrijvers et al., 2012Satizabal et al., 2016). 

Controlling blood pressure with fewer side effects

Interesting approach. Undermines the standard approach of pharmacy companies to view each drug as a separate profit center....

Approximately one in three Americans has high blood pressure, but only about half of those who do have the condition under control. One common reason: they stop taking their medications, often because of troublesome side effects such as weakness, fatigue, or a dry cough. However, taking smaller doses of several different blood pressure drugs may be a good way to address these issues, a new analysis suggests.

Researchers found that taking a quarter-dose of a two-drug combination was just as effective at lowering blood pressure as taking a full dose of one drug. Taking a quarter-dose of a four-drug combination was even more effective (although it's important to note that this finding came from a single, small trial). People who took smaller doses of multiple drugs had fewer side effects than those taking a single drug at the full dose. In fact, their side effects were similar to those of people who took placebos. The study was published in the July 2017 issue of Hypertension.

Disabled Iowans could be exempted from private Medicaid management

Iowa might resume direct oversight of care for people with serious disabilities instead of having private Medicaid-management companies continue doing it, the state’s human-services director said Wednesday.

Many of the most serious complaints about Iowa’s privatized Medicaid system have come from disabled Iowans and their families. Numerous families have reported having their services cut and their hassles multiplied by the management companies. Their plight has sparked a federal lawsuit against the state.

“We are examining patients that may not be the right mix” for managed care-companies to oversee, Department of Human Services Director Jerry Foxhoven told an advisory council for his agency Wednesday.

Foxhoven, who recently became the department’s director, said the Medicaid management companies could succeed at saving money by helping many other Iowans improve their health, such as by encouraging them to quit smoking. “But somebody who’s a quadriplegic and is on a ventilator, there’s probably not much you’re going to do to improve their health or bring costs down,” Foxhoven told the Council on Human Services.

Iowa shifted last year to having three private companies manage its Medicaid program, which covers health care for nearly 600,000 poor or disabled Iowans. The change has been intensely controversial, especially in regards to how it has affected care for Iowans with serious disabilities.

Foxhoven raised the possibility of exempting some recipients from managed care during a discussion Wednesday of extended negotiations over new payment rates for the for-profit management companies. Those new rates were supposed to take effect July 1. The management companies have been demanding more money, saying they’ve lost hundreds of millions of dollars on the project.

Senate Finance Committee Leaders Agree to Five-Year CHIP Extension

With funding for the Children’s Health Insurance Program (CHIP) nearing its expiration at the end of September, Senate Finance Committee leaders have announced a bipartisan proposal to reauthorize funding for the program for five years. Formal legislation has not yet been released, but Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) have committed to help move the proposal through Congress this month. An identical proposal must also pass the House and be signed by President Trump. 


A program with bipartisan support, CHIP currently provides affordable, comprehensive health coverage to roughly 9 million children and pregnant women who do not qualify for Medicaid, but whose families cannot afford other forms of health insurance. Since CHIP’s inception in 1997, the uninsured rate of children from ages 0 to 17 dropped from 13.9 percent that year to 4.5 percent in 2015. CHIP is currently funded in part by states, who receive federal funds at specific matching rates, much like Medicaid. 

Under the Affordable Care Act (ACA), the federal match rate for CHIP was increased by 23 percent to help incentivize states to expand their coverage programs for children. The current federal match for CHIP is set to expire after September 30, which would leave states with limited funds to continue administering the program if no deal is reached. 

Senate Finance Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) announced their proposal on Wednesday in hopes to ensure stability for states by extending federal funding for CHIP for five years. To reach a bipartisan agreement, the current proposal would reduce the increased 23 percent match rate over the life of the extension, dropping to 11.5 percent in 2020, and eliminating the increase by 2022.

“I Can Take Care of Myself!”: Patients’ Refusals of Home Health Care Services

When patients who have been discharged from inpatient care refuse home health care services, they may experience higher rates of readmission to the hospital and a lower quality of life. This issue is not well studied or understood, and in December 2016 UHF’s Families and Health Care Project and the Alliance for Home Health Quality and Innovation sponsored a roundtable examining it. This report summarizes the discussion and findings of that roundtable.

The report also contains a number of recommendations, among them interventions that improve communication about care challenges and home health care services, qualitative and quantitative research on all aspects of home health care refusals, policy changes to increase access and coordination, and continuity across providers and care settings.

Read the press release.

Published: 05.15.2017 


Potential New Therapy Relieves Chronic Itch

FDA-approved arthritis drug may work in new ways to fight itch.

The roots of chronic itching have long remained a mystery. Meanwhile, those with the condition suffer from an unrelenting and sometimes debilitating urge to scratch. Now, new research at Washington University School of Medicine in St. Louis has identified immune signaling molecules that are essential for activating neurons in the skin to cause chronic itching.

In a small study, the researchers also discovered that people with a type of itch from an unknown cause, a condition called chronic idiopathic pruritus, improve when given tofacitinib (Xeljanz), a drug approved for rheumatoid arthritis. Earlier attempts to treat their itching with other anti-inflammatory drugs had not been successful, but within one month of taking tofacitinib, all five patients in the study experienced marked relief from severe itching.

The findings are published Sept. 8 in the journal Cell.

“These patients often itch day and night, and for some of them, the urge to scratch never goes away,” said senior investigator Brian S. Kim, MD, an assistant professor of medicine and co-director of Washington University’s Center for the Study of Itch. “Although this was a small study, the patients taking tofacitinib experienced dramatic improvements in terms of their itch, allowing them to sleep, stop scratching and return to living more productive lives. Obviously, we’ll need to do a larger study, but the early results are very encouraging.”

The findings also explain why an earlier study found that itching dissipates dramatically in eczema patients treated with the new drug dupilumab (Dupixent). Eczema patients have itchy, scaly rashes. The Washington University researchers found that drugs such as tofacitinib and dupilumab work so well, where many other drugs have failed, because they act directly on the nerves rather than only on the immune system.

Chronic itch affects up to 15 percent of the population and is most often caused by inflammatory conditions such as eczema and psoriasis but also is associated with kidney failure, liver disease and certain cancers and nerve disorders. However, cases of chronic itching for which there are no known causes are particularly puzzling and among the most difficult to treat.

The PAINS Project

Better chronic pain treatment will improve the lives of millions of Americans, save billions of dollars, and reduce opioid prescribing.

Change the beliefs, attitudes, and perceptions of media about chronic pain as a disease.

Increase media coverage and support evidence based reporting of chronic pain

Change the beliefs, attitudes, and perceptions of the media about the relationship between chronic pain and the opioid epidemic

Decrease media coverage that conflates the opioid epidemic with chronic pain

Data Support that Diet Can Reverse Heart Disease

We are writing to provide our perspectives in response to a recent interview by Steven Nissen, MD, in MedPage Today that we hope will be useful to its readers. We have great respect for Nissen and honor his many contributions to the field.

Like Nissen, we have devoted our careers to factually-accurate, science-based medicine. We agree with his comments that statins are of proven benefit in many patients with coronary heart disease. We share his concern that patients may be misled by irresponsible health claims made by some (but not all) supplement manufacturers and by some promoters of different diet and lifestyle programs.

However, Nissen's statement that, "There is no diet that's been shown to reverse heart disease" is not supported by the data.

Used appropriately, statins can be useful, and other medications can be lifesaving, but so are comprehensive lifestyle changes. Informed physicians will optimize all of these for their patients. Even pharma companies recommend that if one can achieve optimal reductions in LDL-cholesterol by diet and lifestyle, that should be the first step.

The problem is that many physicians do not recommend diet and lifestyle changes intensive enough to have an effect. In our randomized, controlled trials, we found a 40% average reduction in LDL (i.e., comparable to statins) in patients who were asked to consume a whole foods plant-based diet low in both fat and refined carbohydrates (along with moderate exercise, meditation/yoga, and social support).

One of us (Williams) decreased his LDL-cholesterol from 170 to 90 mg/dl by making these changes in diet.

Randomized controlled trials conducted at the non-profit Preventive Medicine Research Institute and UCSF documented that patients with moderate to severe coronary heart disease who made these lifestyle changes showed statistically significant and clinically significant reversal of their coronary heart disease and its ischemic manifestations in all measures of coronary anatomy and physiology.

Antidepressants could delay Parkinson's progression

A 50-year-old antidepressant could stop the buildup of a brain protein involved in Parkinson's disease, marking a discovery that could bring us closer to slowing the condition.

A new study led by researchers from Michigan State University in Grand Rapids found that people treated with tricyclic antidepressants were less likely to require drug treatment for Parkinson's disease.

On further investigation, the researchers found that rats treated with the tricyclic antidepressant nortriptyline demonstrated a reduction in levels of abnormal alpha-synuclein (a-synuclein) protein in the brain.

Lead study author Tim Collier, of the Department of Translational Science and Molecular Medicine at Michigan State University, and colleagues recently reported their findings in the journal Neurobiology of Disease.

Parkinson's disease is a progressive neurological disorder characterized by tremors, limb stiffness, and problems with movement and coordination.

Around 60,000 people in the United States are diagnosed with Parkinson's every year, and up to 1 million people in the U.S. are living with the disease.

A buildup of the protein a-synuclein is considered a hallmark of Parkinson's disease. Though this protein is present in the healthy brain, in the brains of people with Parkinson's, it can form toxic clusters that destroy nerve cells.

As such, researchers are on the hunt for ways to reduce a-synuclein buildup in the brain, with the aim of slowing Parkinson's disease progression. The new study from Collier and team may have identified such a strategy.