Health and Disability

The film, an 1961 episode of the TV show Alfred Hitchcock Presentsthat had been condensed down to 8 minutes, is a study in suspense. In it, a 5-year-old totes a partially loaded revolver — which she thinks is a toy — around her suburban neighbourhood, shouting “bang” each time she aims at someone and squeezes the trigger.

One behaviourally non-responsive person, a 20-year-old woman, showed patterns of brain activity only in sensory areas. But another person, a 34-year-old man who has been in a vegetative state since he was 18, had patterns of brain activity in the executive and sensory brain areas, similarly to that of the healthy subjects.

“It was actually indistinguishable from a healthy participant watching the movie,” says Adrian Owen, a neuroscientist at the University of Western Ontario in London, Canada (see: 'Neuroscience: The mind reader').

The majority of hospitals in the U.S. are non-profit or tax-exempt, and to keep that status these facilities must demonstrate their benefit to the communities they serve. The Community Health Needs Assessment (CHNA), a new mandate under the Affordable Care Act (ACA), provides an opportunity for people to engage their local hospitals, not only in assessing and planning programs to address the health needs of residents but also implementing and evaluating the success of those programs over time. The resources on this page will provide some initial guidance to advocates and community-based organizations as they navigate the community benefit planning process.

The idea that Alzheimer's is a form of diabetic disease has been gaining currency in medical circles for almost ten years. The accumulated evidence is now so strong that many specialists are now comfortable referring to Alzheimer's as type 3 diabetes.

This shouldn't come as a surprise. Insulin doesn't merely signal the body's somatic cells to take up glucose; it also governs the brain's uptake of glucose. And glucose is what powers the brain. It's the brain's primary energy molecule.

We've known for some time that the brain itself makes a certain amount of insulin, and various parts of the brain are rich in insulin receptors.

According to a report released by the National Football League Friday, three out of every 10 former NFL players are likely to develop brain conditions, like Parkinson's and Alzheimer's disease, and at earlier ages compared to the general population.

Released as supporting evidence in a class-action suit against the league, the report calculated that the NFL's proposed settlement of $675 million will be sufficient to award damages to affected former players. Out of the 19,400 former league players, the NFL and opposition lawyers estimate that around 28 percent of them, about 6,000 individuals, will develop Alzheimer's disease or some other form of dementia as a consequence of their time playing for the NFL.

When I was a resident, it was routine to place urine catheters (a catheter threaded up the urethra, into the bladder) in older patients when they landed in the hospital.  For some diagnoses, we were even taught that the urine catheter was standard of care.  For example, virtually any patient admitted with a diagnosis of congestive heart failure (CHF) had a urine catheter placed. 

We needed to ask, "does the benefit of getting more information about urine output outweigh the risks of placing the catheter?"  We now know that in the vast majority of cases, the answer to this question is a resounding NO.  But unfortunately, while we are now more aware of the risks of urine catheters, they are still used far too frequently, and we often fail to balance the benefits of the catheter against the very substantial harms.

One of the key harms of the urine catheter is illustrated by a very instructive case vignette published in JAMA Internal Medicine as part of the wonderful Teachable Moments series.  An 80 year old man with was admitted with fluid overload due to kidney disease.  A urine catheter was placed to monitor his fluid status, and after several days he was discharged home in better condition. 

Or so it seemed.  Unfortunately, 5 days later he became seriously ill with an infection that started in his bladder (urinary tract infection) that then spread to his blood (sepsis).  He required care in the intensive care unit.  The value on his prior admission of precisely assessing how much urine he was producing was clearly not worth the risk of this disastrous and life threatening complication.

University of Florida researchers have found a correlation between Medicare and patient access to surgical treatment for subarachnoid hemorrhage, a type of stroke that affects as many as 30,000 Americans each year - often causing death or long-term impairment and disability.

For patients who have suffered this type of stroke, surgical intervention can spell the difference between recovery or long-term disability and death, yet patients on Medicare are less likely than those with private insurance to be referred for surgical treatment, according to findings published in the journal PLOS ONE. This may represent a conscious or unconscious bias against Medicare patients, who are typically older and have preexisting disabilities or chronic illnesses, said Azra Bihorac, M.D., senior author of the study and an associate professor of anesthesiology, medicine and surgery at the UF College of Medicine.

"Not every hospital has skilled neurosurgeons who specialize in subarachnoid hemorrhage," Bihorac said. "If these hospitals don't have the necessary expertise, then they may actually overestimate the risk of a bad prognosis. They may assume that the patient won't do well anyway, so they won't proceed with surgery."

"Although 51 percent reported having no difficulty in the previous month, 29 percent reported receiving help with taking care of themselves or their households or getting around," said U-M researcher Vicki Freedman, co-author of the report with the Urban Institute's Brenda Spillman. "And another 20 percent said they had difficulty carrying out these activities on their own."

I saw this in elderly valium abusers in the 70's. Behavioral convenience, once again.....

Previous research has identified an increased risk of dementia among benzodiazepine users, but the mechanism behind the association - as well as the dosage linked to the risk - has not been clear.

Mainly used to treat anxiety and insomnia, benzodiazepines are widely used in developed countries, particularly among the elderly. Because of strong withdrawal symptoms, and because long-term effectiveness of the benzodiazepines remains unproved, international guidelines recommend only short-term use of the drugs.

The study found that benzodiazepine use for 3 months or more was associated with an increased risk of Alzheimer's disease of up to 51%. The longer the exposure to benzodiazepines, the greater the risk of Alzheimer's. Long-acting benzodiazepines were also found to increase risk more than short-acting benzodiazepines.

The researchers report that adjusting for symptoms that might suggest dementia onset - such as anxiety, depression or sleep disorders - "did not meaningfully alter the results."

The Department of Labor says personal care aide and home health aide positions are the second and third fastest-growing occupations in the country. These occupations also provide between 70 and 80 percent of paid hands on care for older adults and individuals with disabilities. Of the 30 fastest growing occupations, they are also the two least paying (with an average annual median wage in 2012 of $19,900 and $20,800, respectively). Because of low wages, lack of benefits, and often-strenuous work, the vacancy and turnover rates for direct care work is high. It’s estimated that turnover rates amongst home care workers are between 44 and 65 percent. This occurs right at the time when we must be strengthening the workforce to care for older adults, nearly 90 percent of whom want to age at home. 

How can we meet the market demands for more care at home and ensure this critical workforce is respected and recognized for their contribution? The Eldercare Workforce Alliance, in a recently released brief, offers one proposal. While not a cure-all, the creation of an Advanced Direct Care Worker position – a rung in the career ladder above home health or personal care aides - may help to address the challenges we face in providing quality care to older adults across all settings. 

More than half of nursing home residents with advanced dementia (a terminal illness marked by severe cognitive impairment and functional dependence) continue to receive medications of questionable benefit (including medications to treat dementia and lower cholesterol) at substantial financial cost.

The Institute of Medicine recommends clinicians minimize interventions in patients with life-limiting disease and instead focus on maximizing quality of life. Few studies have examined the use of chronic disease medications in patients with advanced dementia. Data also is lacking on the associated costs of such prescribing patterns.