Hopkins Project Shows House Calls and Good Neighbors Can Benefit Patients and Hospitals

Four-year "J-CHiP" study helps hospitals operate more efficiently while helping patients in their homes...When people with chronic health problems couldn't get around town to their doctors' appointments, a four-year Johns Hopkins program brought the appointments to them

Newswise, January 3, 2017 — Johns Hopkins cardiologist and senior director for accountable care Scott Berkowitz, M.D., has published an extensive report of a four-year, $19 million Centers for Medicare and Medicaid Services grant in the journal Healthcare.

The grant, which wrapped up in late summer, was aimed at providing more efficient, less expensive care for people living with multiple chronic conditions in the Baltimore neighborhoods closest to The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. Over the course of the grant, the Johns Hopkins Community Health Partnership (J-CHiP) provided East Baltimore residents care in community clinics, acute care hospitals, emergency departments, skilled nursing facilities and even people's homes.

J-CHiP had two components: one community-based and one acute-care based. The acute-care based program targeted the 40,000 adult patients admitted annually to The Johns Hopkins Hospital and the Johns Hopkins Bayview Medical Center. 

Those patients were screened for risks of hospital readmission. The community-based component scored 2,000 Medicare and 1,000 Medicaid patients on their risk of hospitalization.

The community-based program centered on community health workers — specially trained neighborhood residents — who helped identify “super users” of health care in the area and intervene. People who used the emergency department frequently, as well as those identified as high risk for hospital admission, were the program’s main targets.

Reducing hospital readmissions is a goal of government, payers and hospitals alike. Many government and private insurance payers are now refusing to pay for second hospital stays for the same condition. Thus, many hospitals are devising strategies to get patients more engaged in their own care, keeping them healthier and out of the hospital.

"The complex health and social needs of an urban community pose many challenges in the delivery of high-quality care," says Berkowitz, who led the study. "We've learned a lot over four years, and we look forward to learning even more, as the data rolls out in the months to come."

In the J-CHiP model, community health workers, paid by the grant, helped super users break down their barriers to paying regular visits to primary care providers. In addition to a community health worker, each super user was assigned a custom team of physicians, nurses, pharmacists and social workers. 

And finally, J-CHiP worked with skilled nursing facilities on standardizing transitions and keeping patients engaged and motivated.

Among Medicaid patients in the J-CHiP program, 38 percent listed transportation as the main barrier they faced to staying engaged with their own health care. In response, JCHiP provided bus tokens, cab vouchers or shuttle support to 550 patients.

Patients also faced barriers like unstable housing situations and an inability to pay for medicines or care. J-CHiP provided social workers, pharmacy assistance programs and pre-programmed mobile phones to patients who faced critical financial barriers.

Berkowitz says that J-CHiP aligned with Johns Hopkins Medicine goals for transforming care and improving population health. "We focused heavily on East Baltimore's health needs, as well as on innovation of care delivery across the settings where care takes place," he says.

In the report, Berkowitz cites Baltimore City Health Department statistics on life expectancy in the city. "The nearly 200,000 residents of East Baltimore, where life expectancy can be as many as 20 years shorter than nearby more affluent Baltimore neighborhoods, face many challenges to health and well-being," he says.

Berkowitz's article includes examples of J-CHiP team members helping patients overcome barriers to care. In one example, a patient with diabetes who made regular visits to her primary care doctor could no longer see well enough to read her insulin prescription. 

Embarrassed, the patient hid this fact from her doctor, who couldn't determine why her diabetes was so poorly managed. A community health worker visited the patient and saw the trouble she had measuring her insulin. 

After switching to a pre-measured pen system for insulin delivery, the patient also got an eye exam. After three months of her new regimen, both her blood sugar and her eyesight improved significantly.

The J-CHiP program was supported by grant number 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The content of this press release is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

To read the full report, click here.

What to Do When a Loved One Is Suddenly Hospitalized

Loyola social worker offers coping tips

Newswise, December 23, 2015 — According to the Centers for Disease Control and Prevention, each year approximately 2.1 million patients in the Emergency Department are transferred to an intensive care unit. When that happens, relatives are also impacted and need a support system, according to Loyola University Health System (LUHS) licensed clinical social worker Kelly McElligott.

“Families are totally unprepared for a sudden injury and overwhelmed when it is a very serious injury,” says McElligott. “Families need a roadmap to guide them through their worst moments, and that is my job as a hospital social worker.”

McElligott works in Loyola’s Burn Center, the largest burn center in Illinois and nationally renowned for treating the most complex wounds. “Our average length of stay is about three weeks but we have many patients who are with us for several months, due to the severity of their condition,” says McElligott.

“The patients and their families have at their disposal a multidisciplinary team of physical therapists, dietitians, psychologists, chaplains and social workers. We all work together with the traditional care team of surgeons, physicians and nurses.” Loyola pioneered the integrated care model that is emulated by hospitals internationally.

Here are McElligott’s top tips for adults who find a loved one suddenly in the hospital:

Take care of yourself. “If you do not take care of yourself, you cannot take care of someone else,” says McElligott. “Many family members, especially parents, feel they need to be at the hospital 24/7 with their loved one,” she says. “Everyone needs to take time to eat, sleep, exercise and be with other people in the outside world.”

When one member is in the hospital, it is important for the whole family to continue to move forward. “Life does not stop because someone is in the hospital. Other family members need attention and support also,” she says.

“Mom and Dad need to be role models more than ever at this time. The hospital team can help support and guide them. And they can feel strengthened and confident to continue to guide their families.”

Accept help from your community. “Friends, relatives, colleagues and others will offer assistance and it is critical to accept help,” says McElligott.

“For example, coming home to a clean house and a meal in the refrigerator is very convenient and also comforting.” Online programs can be useful helpmates, such as those that coordinate meal organization, task and errand running, and communication with family.

“Many times, key family members are reluctant to ask or receive help. Usually there are outgoing neighbors or colleagues who will serve as primary contacts to relieve the burden,” says McElligott.

“People feel better when they have something to do; let them help and everyone will benefit.”

Ask a lot of questions. “Nurses, physicians, social workers and all medical staff are here to answer questions and offer resources,” says McElligott. “No individual could know what to expect when a severe injury occurs. That’s what medical professionals are for.”

Use a notepad or laptop and take notes when meeting with your health team. “Write down questions or concerns as they come to you and share them with your care team,” she says. “As they say in school, there are no bad questions, so do not feel shy or embarrassed. The more you know, the less you will fear.”

Talk to others about your experience. “Reach out to people for support by sharing your experience or what you have witnessed,” says McElligott. “Often, this will help reduce anxiety and build confidence.”

Sharing your story is often difficult and emotional at first, but becomes easier over time. “Talking helps define the event or injury, remove the emotion and perceived stigma, and can help identify next steps to move forward,” she said. “Getting feedback from others also can be reassuring and supportive.”

Use peer support. “Others who have walked the path you are on offer invaluable support, insight and understanding,” says McElligott. For example, Loyola offers a bi-monthly burn support group for patients and their families. “Speakers are brought in to share specific expertise but the greatest benefit comes through the informal talking among families,” she says.

Former burn patients are frequent visitors to the hospital floor and visit with patients and their families. “There are amazing stories of patients and family members who are very withdrawn and depressed who respond positively to our former burn patient volunteers,” she says. “They are able to see that life does go on, there are others who survived much worse injury and are still laughing, socializing and enjoying life.”

McElligott says it is a privilege to meet patients and their families during one of the worst times of their lives, and to guide them through the recovery process. 

“People are very resilient,” she says. “The transformations that happen once the shock wears off are amazing.”

How Can I Tell if She’s Lying? Sarcasm, white lies and teasing can be difficult to identify for those with certain disorders – new video inventory developed at McGill may help

Newswise, December 1, 2015— When she says she loves my new haircut is she telling the truth or being sarcastic? The answer isn’t always obvious.

Especially for men.

Or for those who suffer from diseases like Alzheimer’s or Parkinson’s, or neurodevelopmental conditions such as Autism spectrum disorder. For people with these problems, any form of non-literal speech such as sarcasm, teasing or ‘white lies’ can be very confusing. 

A new video inventory of examples of these forms of indirect speech developed at McGill should help in the diagnosis and clinical testing of those with disorders of this kind.

A ‘truth bias’ underlies much social interaction

“We tend to believe that people tell the truth most of the time,” says Kathrin Rothermich, from McGill’s School of Communication Disorders, who has recently published a paper about the research in PLoS ONE. 

“So sarcasm and white lies seem to go against a basic understanding of what ‘should’ be happening in conversation. This may be part of what makes them so difficult to recognize for some.”

Rothermich has spent the past two years creating and testing the Relational Inference and Social Communication (RISC) video inventory that she and her colleague Marc Pell developed. 

These 926 videos feature short, scripted scenes with four actors interacting in different relationships (as romantic partners, as friends, as colleagues, or as boss/employee).

In each exchange, the actors were asked to convey one specific intention through their speech and actions: to be sincere, to tell ‘white lies’, to tease, or to be sarcastic. 

Rothermich then tested the videos on a group of healthy participants to see whether they were able to identify the speakers’ intentions, and to get feedback about which vocal and facial cues had helped them identify what was going on.

Sarcasm is especially hard to recognize

Participants were generally well able to identify the speakers’ intention either when one of the actors was teasing someone else or when they were telling the truth. 

What proved to be more difficult, and particularly so for men, was identifying when someone was being sarcastic. It was only when sarcasm was used in relationships between friends that participants were better able to recognize it.

“We discovered that the actors found it hardest to perform the scripts where they were being asked to tease one another,” says Rothermich. 

“This may be because teasing doesn’t always fit easily or logically into a conversation. One of the things that some actors did was to speak with exaggerated or fake accents when they were teasing, which is something that other researchers have also reported.”

The researchers believe that this video inventory will provide a useful tool for future research on social cognition, inter-personal communication and the interpretation of a speaker’s intentions in both healthy adult and clinical populations.

Study Offers Insights to How Ovarian Cancer Grows – and Potential to Stop It

Findings support cancer stem cell model, with exceptions

Study offers insights to how ovarian cancer grows – and potential to stop it...

Findings support cancer stem cell model, with exception

Newswise, December 1, 2015 — Can any cancer cell form another tumor, or is it only select cancer stem cells that give rise to new cancer cells? The answer, a new study finds, is both.

Researchers at the University of Michigan Comprehensive Cancer Center looked at human ovarian cancer cells and found that for the most part the cancer cells generate offspring in a predictable and organized fashion: mother cancer cells produced daughter cells and the daughter cells produced granddaughter cells. The grandmother cells are the rare cancer stem cells that can initiate cancer recurrence and the granddaughter cells are the bulk tumor cells.

But in rare exceptions, the daughter cells gave rise to the stem-like grandmother cells.

The question of whether cancer cells divide in a patterned fashion or randomly has been hotly debated.

“Like any nature/nurture question, the answer is always both. In general we observed that cancer cells do not divide randomly. Just like in normal biology, we saw the pattern of stem cells giving rise to daughter cells. But within that hierarchy, we saw rare exceptions that went against the hierarchy,” says senior study author Ronald J. Buckanovich, M.D., Ph.D., associate professor of internal medicine at the University of Michigan Medical School.

“This is very significant for how you design cancer therapies. These stem-like cells are the really critical therapeutic targets, but the non-stem cells need to be addressed as well,” he adds.

The researchers also found that a protein called BMP2 increased the growth of the cancer stem cells and decreased the growth of the granddaughter cells, or the bulk tumor cells. 

It’s like a conversation between the two types of cells: When there are too many granddaughter cells, they trigger BMP2 to increase the number of stem cells. The non-stem cells are helping to support the growth of the stem cells to maintain an equilibrium within the tumor.

“BMP2 tells the cancer to make more grandmothers and stop making granddaughters. So there are fewer bulk cells. But there are more of the aggressive, chemotherapy-resistant cells that have the ability to create new tumors,” Buckanovich says.

When the researcher blocked BMP2, it reduced the ability of the cancer cells to make new stem cells. But blocking BMP2 promotes the growth of the granddaughter bulk cells. 

The challenge is to target the BMP2 inhibitor to the cancer stem cells only. This type of treatment is not currently available to patients. Researchers are examining ways to deliver an inhibitor only to the stem cells.

The study, which is published in PNAS, is unique because it looked at human tissue, rather than mouse models. The cancer researchers tapped into a microfluidic device designed by Euisik Yoon’s group at the University of Michigan College of Engineering. 

The device enabled the cells to be separated and studied individually over time in a manner that would not be possible with traditional methods.

“We could watch cancer cells divide in real time, actually track and watch who’s the mother and who’s the daughter,” Buckanovich says. “This device allowed us to study human cells instead of mouse models. We believe it is the first instance to define a cancer hierarchy using cells from patients.”

Additional authors: Yunjung Choi, Patrick Neal Ingram, Kun Yang, Lan Coffman, Mangala Iyengar, Shoumei Bai, Dafydd Thomas, Euisik Yoon

Funding: Ovarian Cancer Research Fund, National Institutes of Health grants DP200440377 and P30 CA046592

Disclosure: None

Lewy Body Dementia: Unfamiliar With This Common Disorder?

International conference Dec. 1 – 4 brings together experts, patients and caregivers

Newswise, December 1, 2015— Lewy body dementia is the second most common type of dementia after Alzheimer’s disease. 

But if you’re not familiar with it, you’re not alone. “Lewy body dementia is the most common disorder you’ve never heard of,” says Bradley Boeve, M.D., a Mayo Clinic neurologist who will speak at the International Dementia with Lewy Bodies Conference Dec. 1-4 in Fort Lauderdale, Florida.

Lewy body dementia shares similar symptoms of memory issues like Alzheimer’s and slow, stiff movements like Parkinson’s disease. But people with Lewy body dementia may act out their dreams while asleep, or they may have visual hallucinations that can lead to unusual behavior, such as having conversations with deceased loved ones.

Getting an accurate diagnosis is the key to improving patients’ lives, says Dr. Boeve, co-investigator of the Mayo Clinic Dorothy and Harry T. Mangurian Jr. Lewy Body Dementia Program. 

“We want to help patients stop the diagnostic odyssey of seeing many different clinicians, undergoing many different tests over an extended period of time with no clear answers and all of the frustration that goes with this,” Dr. Boeve says.

While there’s no cure today for Lewy body dementia, an accurate diagnosis can help patients receive the right medications. Some medications that don’t work for Alzheimer’s may help improve Lewy body dementia symptoms.

Dr. Boeve explains it this way: In Lewy body dementia, protein deposits – named after Frederick Lewy who discovered them — develop in brain cells. While some brain cells die, others are just not working properly. 

Certain medications, called cholinesterase inhibitors, help trigger nerve impulses from one brain cell to the next — sometimes improving symptoms.

Lewy body dementia symptoms include:

* Visual hallucinations: Seeing colors, shapes, animals or people that aren’t there.
* Movement disorders: Slowed movement, rigid muscles, tremors or shuffling walk.
* Poor regulations of body function: Dizziness, falls and bowel issues.
* Cognitive problems: Confusion, reduced attention span and memory loss.
* Sleep difficulties: Physically acting out dreams while asleep.
* Fluctuating attention: Drowsiness, staring into space, daytime naps and disorganized speech.
* Depression: Persistent sadness and loss of interest.

While the cause of Lewy body dementia is unclear, risk factors include being older than 60, being male and having a family member with Lewy body dementia.

After diagnosis, doctors, patients and caregivers work together to monitor medications and find nondrug approaches.

“Education and empowerment of patients and families are critical,” Dr. Boeve says. 

“For example, if visual hallucinations are present, learning techniques to manage them can help avoid Emergency Department visits or hospitalizations, so it’s cost saving and lessens patients’ and families’ frustration. The education and support by the Lewy Body Dementia Association are also critical.”

The International Dementia with Lewy Bodies Conference includes sessions for health care providers, patients and caregivers. Dr. Boeve and his colleagues in Mayo Clinic’s Lewy Body Dementia Research Program are the hosts, working in conjunction with the staff of the Lewy Body Dementia Association.

Orchestra Helps Boost Confidence and Mood for Those with Dementia

Newswise, November 11, 2015 — A special orchestra for people with dementia has helped boost their confidence and mood, according to a new research project.

The orchestra group has been set up by the Bournemouth University Dementia Institute (BUDI) in Dorset to create a sense of community among participants and also includes professional musicians, carers and students.

A screening of performances from the BUDI Orchestra will be showcased at an event as part of the annual Economic and Social Research Council’s (ESRC) Festival of Social Science.

The orchestra was initially set up in partnership with Bournemouth Symphony Orchestra (BSO) with a repertoire ranging from Ravel’s Bolero to Henry Mancini’s Moon River.

Rehearsals have demonstrated a positive effect on all participants who have also learned new skills and rediscovered old ones.

“Music touches everyone in some way, either by listening or playing – and the BUDI Orchestra has been a life-enhancing project which has benefited everyone,” says Professor Anthea Innes, Head of BUDI.

“Performing and showcasing skills of those with dementia creates a well-deserved opportunity for them to demonstrate their abilities and to challenge the negative public perceptions that surround the diagnostic label of ‘dementia’.

Working together to produce a collaborative output is a powerful way to bring out the best in people - not just in terms of their musical skills, but their communication skills, friendships, care and support for one another.”

Around 850,000 people in the UK currently live with dementia, a figure which is estimated to double by 2050. Dorset has one of the oldest populations in England, so many people in the local community can relate to the challenges caused by the condition.

The arts are being used increasingly to support health and wellbeing, both in healthcare settings and in the community for people with dementia and their families. 

Research has already shown that arts activities, especially music, can reawaken and exercise the brain.

The BUDI Orchestra, funded by Dorset County Council, is one of BUDI’s numerous ongoing creative projects to demonstrate that people with dementia can have fun while learning.

A total of eight people with dementia and seven carers were involved in a course of eight weekly two-hour sessions led by Andy Baker, a former BSO community musician and double bass player. They were also supported by two additional professional musicians, Bournemouth University students and staff volunteers.

Previous workshops with the orchestra have identified that most of the people with dementia learned a new skill and the sessions were highly enjoyed by all who took part.

One of the participants was Jack, a professional bass player who was forced by eye cancer and dementia to leave his bands. His wife also joined BUDI and played the violin for the first time since school.

Both found that the orchestra helped overcome feelings of loneliness, and Jack’s confidence returned as a result of being part of the sessions.

The project has also highlighted that the musicians’ and volunteers’ preconceptions of music learning were positively challenged as a result of their experiences with the BUDI Orchestra.

Professor Innes and her research team have produced a guide in collaboration with the professional musicians for those interested in setting up their own community-based music group.

Dr Michelle Heward, also from BUDI, says: “Our creative projects show that it is possible for people with dementia to take part, learn something new and have fun, all at the same time.”

Jet Lag-Like Sleep Disruptions Spur Alzheimer’s Memory, Learning Loss

Results suggest greater emphasis on managing slumber habits of people with AD risk

Newswise, October 29, 2015 — Chemical changes in brain cells caused by disturbances in the body’s day-night cycle may be a key underlying cause of the learning and memory loss associated with Alzheimer’s disease, according to a University of California, Irvine study.

The research on mice, led by UCI biomedical engineering professor Gregory Brewer, provides the first evidence that circadian rhythm-altering sleep disruptions similar to jet lag promote memory problems and chemical alterations in the brain.

Clinical application of this finding may lead to more emphasis on managing the sleep habits of people at risk for Alzheimer’s disease and those with mild cognitive impairment. Study results appear online in the Journal of Alzheimer’s Disease.

People with Alzheimer’s often have problems with sleeping or may experience changes in their slumber schedule. Scientists do not completely understand why these disturbances occur.

“The issue is whether poor sleep accelerates the development of Alzheimer’s disease or vice versa,” said Brewer, who’s affiliated with UCI’s Institute for Memory Impairments and Neurological Disorders. “It’s a chicken-or-egg dilemma, but our research points to disruption of sleep as the accelerator of memory loss.”

In order to examine the link between learning and memory and circadian disturbances, his team altered normal light-dark patterns with an eight-hour shortening of the dark period every three days for young mouse models of Alzheimer’s disease and normal mice.

The resulting jet lag greatly reduced activity in both sets of mice, and the researchers found that in water maze tests, the AD mouse models had significant learning impairments absent in the AD mouse models not exposed to light-dark variations and in normal mice with jet lag.

In follow-up tissue studies, they saw that jet lag caused a decrease in glutathione levels in the brain cells of all the mice. But these levels were much lower in the AD mouse models and corresponded to poor performance in the water maze tests. Glutathione is a major antioxidant that helps prevent damage to essential cellular components.

Glutathione deficiencies produce redox changes in brain cells. Redox reactions involve the transfer of electrons, which leads to alterations in the oxidation state of atoms and may affect brain metabolism and inflammation.

Brewer pointed to the accelerated oxidative stress as a vital component in Alzheimer’s-related learning and memory loss and noted that potential drug treatments could target these changes in redox reactions.

“This study suggests that clinicians and caregivers should add good sleep habits to regular exercise and a healthy diet to maximize good memory,” he said.

Kelsey LeVault and Shelley Tischkau of the Southern Illinois University School of Medicine contributed to the research, which received support from the National Institutes of Health (grant R01 AG032431).

About the University of California, Irvine: Currently celebrating its 50th anniversary, UCI is the youngest member of the prestigious Association of American Universities. The campus has produced three Nobel laureates and is known for its academic achievement, premier research, innovation and anteater mascot.

Led by Chancellor Howard Gillman, UCI has more than 30,000 students and offers 192 degree programs. It’s located in one of the world’s safest and most economically vibrant communities and is Orange County’s second-largest employer, contributing $4.8 billion annually to the local economy. For more on UCI, visit www.uci.edu.

Media access: Radio programs/stations may, for a fee, use an on-campus ISDN line to interview UC Irvine faculty and experts, subject to availability and university approval. For more UC Irvine news, visit news.uci.edu..

Care More Expensive for Dementia Patients and Families in Last Years of Life

Newswise, October 27, 2015-- The cost of care over the last five years of life for patients with dementia is significantly higher than for patients who die from heart disease, cancer, or other causes, according to a study led by researchers at the Icahn School of Medicine at Mount Sinai, Dartmouth College and University of California, Los Angeles, and published online today in the journal Annals of Internal Medicine. The study was funded by the National Institute on Aging.

In addition to higher total end-of-life costs, the study found that out-of-pocket spending for patients with dementia was 81 percent higher than for those who died from other causes. The burden of this spending, measured as the proportion of household wealth devoted to out-of-pocket costs, was particularly high for dementia patients who were black, had less than a high school education, or were unmarried or widowed women.

This is the first national study which looks at total costs (patient and family expenses, as well as Medicare and Medicaid expenditures) over the last five years of life for those with dementia in comparison to those without, according to the study authors.

It also estimated the cost of family caregiving for patients with dementia, which is defined as a decline in mental ability severe enough to interfere with daily life. Symptoms can include memory loss, as well as declines in language, problem-solving and other cognitive skills. People with Alzheimer’s Disease represent the majority of dementia cases.

“Our study shows that all households, regardless of disease, face substantial financial risks during the last years of life; however, households of those with dementia face an even greater burden of costs, particularly with regard to out-of-pocket expenses and the costs of caregiving,” said Amy Kelley, MD, Associate Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai and lead author of the study.

“Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs--from supervision, to bathing and feeding--may span several years.”

While Medicare provides nearly universal coverage for U.S. adults over age 65, it does not cover health-related expenses most valuable to those with chronic diseases or a life-limiting illness, such as homecare services, equipment and non-rehabilitative nursing home care. People living with dementia often face many years of progressive functional decline and require long-term, supportive care.

Researchers analyzed data from 1,702 Medicare beneficiaries, aged 70 years or older, who died between 2005 and 2010. The group was then subdivided into four main categories: individuals with high probability of dementia, and individuals who died of heart disease, cancer, or other causes. Findings indicated the average total cost for deceased patients with dementia was $287,038 in the last five years of life. This was significantly higher than for those who died of heart disease ($175,136), cancer ($173,383), or other causes ($197,286).

“The families of patients with dementia have more expenses than other families, and the financial burden is greatest among families that may be least able to manage it,” said Dr. Kelley. “The discussion of healthcare reform must include the significant uninsured care needs of older adults with dementia and examine ways to mitigate the financial risk currently faced by Medicare beneficiaries.”

The study was supported by the National Institute on Aging. The study’s data was supplied by the Health and Retirement Study (HRS), a national sample of U.S. adults age 50 linked to Medicare claims. The HRS includes detailed information on out-of-pocket spending and total Medicare spending, as well as information about insurance coverage, socioeconomic status, health and cognitive status, and cause of death.

Collaborators of the study include researchers from the Geriatric Research Education and Clinical Centers at the James J Peters VA Medical Center, the University of California Los Angeles Department of Economics, Dartmouth College Department of Economics and The Dartmouth Institute for Health Policy and Clinical Practice at the Dartmouth Medical School.

About the Mount Sinai Health System


The Mount Sinai Health System is an integrated health system committed to providing distinguished care, conducting transformative research, and advancing biomedical education. Structured around seven hospital campuses and a single medical school, the Health System has an extensive ambulatory network and a range of inpatient and outpatient services—.from community-based facilities to tertiary and quaternary care.

The System includes approximately 6,100 primary and specialty care physicians; 12 minority-owned free-standing ambulatory surgery centers; more than 140 ambulatory practices throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and 31 affiliated community health centers. Physicians are affiliated with the renowned Icahn School of Medicine at Mount Sinai, which is ranked among the highest in the nation in National Institutes of Health funding per investigator. Seven departments at The Mount Sinai Hospital and one at the New York Eye and Ear Infirmary (NYEE) ranked nationally in the top 25 in the 2015-2016 “Best Hospitals” issue of U.S. News & World Report. Mount Sinai’s Kravis Children’s Hospital also is ranked in seven out of ten pediatric specialties by U.S. News & World Report.

For more information, visit http://www.mountsinaihealth.org/or find Mount Sinai on Facebook, Twitter and YouTube.

Three-Minute Test Detects Common Form of Dementia That's Hard to Diagnose

FAU Neuroscientist Develops Lewy Body Composite Risk Score 

Newswise, October 26, 2015 — Although Lewy Body disease (LBD) is the second-most-common degenerative disease after Alzheimer’s disease, it’s not exactly a household name. 

It affects more than 1.3 million Americans, is poorly recognized, and diagnosis is often significantly delayed. Patients with LBD simultaneously experience losses in cognitive function, mobility and behavior. 

The late Robin Williams had this form of dementia as did legendary NHL coach Alger Joseph “Radar” Arbour, which also can cause visual hallucinations and make depression worse. 

Until now, there has been no way to assess or operationalize many of the cognitive and behavioral symptoms of LBD in clinical practice. 

A leading neuroscientist at Florida Atlantic University has developed the “Lewy Body Composite Risk Score” (LBCRS) to quickly and effectively diagnose LBD and Parkinson’s disease dementia (PDD) in about three minutes. 

The LBCRS is a brief rating scale that can be completed by a clinician to assess clinical signs and symptoms highly associated with the pathology of this disease. 

With this important tool, a clinician can assess whether the patient has bradykinesia, rigidity, postural instability, or rest tremor without having to grade each extremity. This simple, one-page survey provides structured yes/no questions for six non-motor features that are present in patients with LBD, but are much less commonly found in other forms of dementia.


The LBCRS study, “Improving the Clinical Detection of Lewy Body Dementia with the Lewy Body Composite Risk Score,” recently published in Alzheimer’s & Dementia, the journal of the Alzheimer’s Association, involved 256 patients who were compared with the clinical dementia rating and gold standard measures of cognition, motor symptoms, function and behavior. 

The test was administered in a “real-world” clinic setting with patients who were referred from the community rather than in a research sample. The clinic sample had a mixture of gender, education, comorbidities, behavioral, affective, motor symptoms, and diagnoses. The LBCRS was able to discriminate between Alzheimer’s disease and LBD with 96.8 percent accuracy, and provided sensitivity of 90 percent and specificity of 87 percent. 

For the study, caregivers completed evaluations to determine the presence and severity of non-cognitive symptoms observed in the patient and their impact on the caregiver. 

Each patient was administered a 30-minute test battery at the time of the office visit to assess their cognitive status. The LBCRS was completed after all other rating scales were scored and the diagnosis was presented to the patient and family. 
“Most patients never receive an evaluation by a neurologist skilled in the diagnosis of Lewy body dementia, and significant delays and misdiagnoses occur in most patients with this disease,” said James E. Galvin, M.D., M.P.H., one of the most prominent neuroscientists in the country who developed the LBCRS, and a professor of clinical biomedical science in FAU’s Charles E. Schmidt College of Medicine and a professor in FAU’s Christine E. Lynn College of Nursing. “This new tool has the potential to provide a clearer, more accurate picture for those patients who are unable to be seen by specialists, hastening the correct diagnosis and reducing the strain and burden placed on patients and caregivers.” 

Another important aspect of the LBCRS is its ability to improve the sensitivity of diagnosis, thereby reducing the risk of exposure to patients with LBD to medications that can have potentially serious adverse consequences. 

The survey also increases the potential opportunity to receive appropriate symptomatic therapies in a timely fashion, and lessens the inappropriate exclusion from and inclusion into clinical trials. 

“Early detection of Lewy body dementias will be important to enable future interventions at the earliest stages when they are likely to be most effective,” said Galvin. “Our study provides evidence-based methodology that will have applications in clinical practice, participation in clinical trials, prevention studies, community surveys, and biomarkers research.”


Galvin is one of the leading international experts on LBD, and has been working to improve clinical detections by combining biomarkers including high density EEG, functional and structural MRI, PET scans and CSF biomarkers to characterize and differentiate LBD from healthy aging and other neurodegenerative diseases. 


Galvin has led efforts to develop a number of dementia screening tools, including the Quick Dementia Rating System (QDRS), AD8, a brief informant interview to translate research findings to community settings. He has done cross-cultural validation of dementia screening methods in comparison with Gold Standard clinical evaluations and biomarker assays.

His team also has developed sophisticated statistical models to explore transition points in clinical, cognitive, functional, behavioral and biological markers of disease in healthy aging, mild cognitive impairment, Alzheimer disease, and Parkinson’s disease.

Critical Care Nurses Can Champion Palliative Care

Article in Critical Care Nurse describes barriers to palliative care consultations, offers strategies to integrate palliative care into critical care

Newswise, October 1, 2015 — Palliative care, a specialized form of medical care providing relief from symptoms or stress of life-threatening illnesses, provides proven benefits to critically ill patients with life-threatening illnesses, yet barriers to palliative care consultations prevent many patients and their families from discussing it with their team of healthcare providers, according to an article in the October issue of Critical Care Nurse(CCN).

The article, “Overcoming Barriers to Palliative Care Consultation,” offers nursing-specific strategies to help hospitals better integrate palliative care into everyday critical care and encourage widespread adoption of palliative care services.

Palliative care has evolved into a service that provides psychological, spiritual, goal-setting and decision-making support to patients with life-threatening illnesses and their families. The benefits of such care include early initiation of comfort-focused treatment goals, decreased length of stay, reduced cost of care without an increase in mortality, and continuity of care.

Unlike hospice care, palliative care is appropriate early in the course of illness, and patients can be simultaneously treated for their condition, including therapies intended to prolong life.

Lead author Kathleen Ouimet Perrin, RN, PhD, CCRN, is a professor of nursing at Saint Anselm College, Manchester, New Hampshire, where she teaches critical care nursing and understanding suffering.

“Patients receiving palliative care have better quality of life and live longer but cost the healthcare system less. Still, many patients are not offered the opportunity to receive a palliative care consultation,” she said.

Misunderstandings about palliative care and not having agreed-upon criteria for referral are common reasons consultations are not suggested to critically ill patients and their families.

The article recommends strategies critical care nurses can use to overcome these barriers, including:
• educating other healthcare providers about the purpose and benefits of palliative care to increase understanding and support
• emphasizing to other healthcare providers and patients’ families that symptom management can improve patient outcomes
• emphasizing to other healthcare providers that palliative care providers have more time and more options for symptom management, which improves the quality of care
• advocating for development and use of specific criteria or trigger situations that require a palliative care consultation
• working with other healthcare providers to ensure that a consistent message is provided to patients and their families

“To overcome barriers to palliative care consultation, critical care nurses need to be champions for palliative care on the policy level of the hospital and the unit and on the level of individual patients,” Perrin said.

The article notes that nurses’ involvement in decision-making discussions related to goals of care can also limit their own moral distress.

The American Association of Critical-Care Nurses, which publishes CCN, offers resources and tools to help nurses care for patients and their families at the most difficult times of their lives, including an e-learning course and a free, online self-assessment tool. For more information on palliative and end-of-life care, please visit www.aacn.org/palliativeedu.

As AACN’s bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org/.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high acuity, progressive and critical care settings. CCN enjoys a circulation of more than 100,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than 500,000 acute and critical care nurses and includes more than 225 chapters worldwide. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. www.aacn.org ; facebook.com/aacnface; twitter.com/aacnme 

Researchers Find Some Evidence of Link Between Stress, Alzheimer’s Disease

Newswise, September 21, 2015 — University of Florida Health researchers have uncovered more evidence of a link between the brain’s stress response and a protein related to Alzheimer’s disease.

The research, conducted on a mouse model and in human cells, found that a stress-coping hormone released by the brain boosts the production of protein fragments. Those protein pieces, known as amyloid beta, clump together and trigger the brain degeneration that leads to Alzheimer’s disease.

The findings were published recently in The EMBO Journalby a group that includes Todd Golde, M.D., Ph.D., director of the UF Center for Translational Research in Neurodegenerative Disease and a professor in the UF College of Medicine’s department of neuroscience.

The research contributes to further understanding the potential relationship between stress and Alzheimer’s disease, a disorder believed to stem from a mix of genetic, lifestyle and environmental factors.

The findings strengthen the idea of a link between stress and Alzheimer’s disease, Golde said.

“It adds detailed insight into the stress mechanisms that might promote at least one of the Alzheimer’s pathologies,” Golde said.

Figuring out the non-genetic factors that heighten the risk of Alzheimer’s disease is especially challenging, and the recent study is one step in a long process of looking at the effects of stress and other environmental factors, according to Golde. It could also point the way to a novel treatment approach in the future, he said.

Here is what researchers found: Stress causes the release of a hormone called corticotrophin releasing factor, or CRF, in the brain.

That, in turn, increases production of amyloid beta. As amyloid beta collects in the brain, it initiates a complex degenerative cascade that leads to Alzheimer’s disease.

During laboratory testing, mouse models that were exposed to acute stress had more of the Alzheimer’s-related protein in their brains than those in a control group, researchers found.

The stressed mice also had more of a specific form of amyloid beta, one that has a particularly pernicious role in the development of Alzheimer’s disease.

To better understand how CRF increases the amount of Alzheimer’s-related proteins, researchers then treated human neurons with CRF.

That caused a significant increase in the amyloid proteins involved in Alzheimer’s disease.

Those and other complex experiments reveal more about the mechanics of a likely relationship between stress and Alzheimer’s disease.

The stress hormone, CRF, causes an enzyme known as gamma secretase to increase its activity. That, in turn, causes more of the Alzheimer’s-related protein to be produced, Golde said.

Modifying environmental factors such as stress is yet another approach to warding off Alzheimer’s disease, and one that is easier than modifying the genes that cause the disorder, Golde said. One possible solution — blocking the CRF receptor that initiates the stress-induced process that generates Alzheimer’s-related proteins — didn’t work. Researchers are now looking at an antibody that could be used to block the stress hormone directly, Golde said.

“These softer, non-genetic factors that may confer risk of Alzheimer’s disease are much harder to address,” Golde said. “But we need more novel approaches in the pipeline than we have now.”

The idea of looking more closely at the mechanism linking stress and Alzheimer’s disease came from Seong-Hun Kim, M.D., Ph.D., a former assistant professor in the College of Medicine’s department of pharmacology and therapeutics and now a psychiatrist in Seattle.

Much of the project’s experiments were done by Hyo-Jin Park, Ph.D., who was a postdoctoral associate during the project and is now an assistant scientist in the College of Medicine’s department of aging and geriatric research. Kevin Felsenstein, Ph.D., an associate professor of neuroscience in UF’s College of Medicine, also made major contributions to the work.

The research was supported by multiple grants from the National Institutes of Health and the U.S. Department of Veterans Affairs.

Identifying Typical Patterns in the Progression Towards Alzheimer's Disease

Newswise, September 21, 2015 — How the brain progresses from mild cognitive impairment (MCI) to Alzheimer's-type dementia has been an enigma for the scientific community.

However, a recent study by the team of Dr. Sylvie Belleville, PhD, Director of the Research Centre at the Institut universitaire de gériatrie de Montréal (Montreal Geriatric Institute) and Professor of Psychology at Université de Montréal, has shed light on this progression by showing the typical patterns of the brain's progression to dementia.

For the study, the team compared changes that occurred over many years in people with stable MCI with changes in people for whom MCI progressed to a diagnosis of Alzheimer's.

Dr. Belleville worked with doctoral student Simon Cloutier and a team of clinician researchers from Montreal. This study was funded by the Canadian Institutes of Health Research (CIHR) and was published in theJournal of Alzheimer’s Disease.

The study showed that different cognitive areas (language, inhibition, visuo-spatial processing, working memory, executive functions, etc.) do not change in a uniform way.

Cognitive decline does not occur in a linear fashion; instead, the path to dementia is complex and may sometimes be characterized by periods of stability followed by accelerated decline one or two years before diagnosis.

“We've identified a profile of changes that characterizes people who progress towards dementia. In reality, a quick decline in episodic and working memory associated with language problems appears to be the typical profile of people who have a high risk of developing dementia within a short amount of time,” the researcher explained.

Instead of seeing this as bad news, Dr. Belleville views these results as hope for seniors who are worried about their memories.

“Many people complain about their memories. However, the presence of a change is what determines the risk of progression.”

This study has let us characterize the parameters of decline in people who will eventually develop Alzheimer's, which means we can better identify both benign symptoms and those that warrant particular attention.

Rapid memory decline suggests that the onset of symptoms is probably due to a loss of the brain's compensatory mechanisms.”
Alzheimer's disease is diagnosed late in its progression and sometimes up to fifteen years after its first effects on the brain. It is important to identify the early indicators so that patients can receive treatment as soon as possible.