Clinical Psychiatry News

TOPLINE:

A case series highlights the features of severe, necrotic skin wounds among hospitalized adults associated with xylazine exposure, including 9% that involved exposed deep structures such as bone or tendon.

METHODOLOGY:

• The alpha-2 agonist xylazine, a veterinary sedative, is increasingly detected in fentanyl used illicitly in the United States and may be causing necrotizing wounds in drug users.
• To characterize specific clinical features of xylazine-associated wounds, researchers conducted a case series at three academic medical hospitals in Philadelphia from April 2022 to February 2023.
• They included 29 patients with confirmed xylazine exposure and a chief complaint that was wound-related, seen as inpatients or in the emergency department.

TAKEAWAY:

• The 29 patients (mean age, 39.4 years; 52% men) had a total of 59 wounds, 90% were located on the arms and legs, and 69% were on the posterior upper or anterior lower extremities. Five wounds (9%) involved exposed deep structures such as the bone or tendon.
• Of the 57 wounds with available photographs, 60% had wound beds with predominantly devitalized tissue (eschar or slough), 11% were blisters, 9% had granulation tissue, and 21% had mixed tissue or other types of wound beds. Devitalized tissue was more commonly observed in medium or large wounds (odds ratio [OR], 5.2; P = .02) than in small wounds.
• As reported by patients, 48% were acute wounds, 20% were subacute, and 29% were chronic (present for 3 months or longer). Subacute and chronic wounds were often medium or large compared with acute wounds (OR, 48.5; P < .001) and contained devitalized tissue (OR, 9.5; P < .001).
• Of the 39 wounds with patient-reported etiology, 34 (87%) occurred at drug injection sites.

IN PRACTICE:

To the best of their knowledge, this is “the largest study of wounds among patients with confirmed exposure to xylazine and the first to systematically describe wound characteristics,” the authors wrote. The results, they concluded, “may help identify xylazine exposure and can guide research on the etiology and management of these wounds.”

SOURCE:

This study was conducted by Lydia Lutz, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland, and coinvestigators and was published online in JAMA Dermatology.

LIMITATIONS:

This single-city, retrospective study limited generalizability, and the selection of the largest wounds may bias results. Additionally, chronicity data relied on patient recall, potentially introducing recall bias.

DISCLOSURES:

Two authors received support from the National Institute on Drug Abuse for the study. The authors declared no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

A case series highlights the features of severe, necrotic skin wounds among hospitalized adults associated with xylazine exposure, including 9% that involved exposed deep structures such as bone or tendon.

METHODOLOGY:

• The alpha-2 agonist xylazine, a veterinary sedative, is increasingly detected in fentanyl used illicitly in the United States and may be causing necrotizing wounds in drug users.
• To characterize specific clinical features of xylazine-associated wounds, researchers conducted a case series at three academic medical hospitals in Philadelphia from April 2022 to February 2023.
• They included 29 patients with confirmed xylazine exposure and a chief complaint that was wound-related, seen as inpatients or in the emergency department.

TAKEAWAY:

• The 29 patients (mean age, 39.4 years; 52% men) had a total of 59 wounds, 90% were located on the arms and legs, and 69% were on the posterior upper or anterior lower extremities. Five wounds (9%) involved exposed deep structures such as the bone or tendon.
• Of the 57 wounds with available photographs, 60% had wound beds with predominantly devitalized tissue (eschar or slough), 11% were blisters, 9% had granulation tissue, and 21% had mixed tissue or other types of wound beds. Devitalized tissue was more commonly observed in medium or large wounds (odds ratio [OR], 5.2; P = .02) than in small wounds.
• As reported by patients, 48% were acute wounds, 20% were subacute, and 29% were chronic (present for 3 months or longer). Subacute and chronic wounds were often medium or large compared with acute wounds (OR, 48.5; P < .001) and contained devitalized tissue (OR, 9.5; P < .001).
• Of the 39 wounds with patient-reported etiology, 34 (87%) occurred at drug injection sites.

IN PRACTICE:

To the best of their knowledge, this is “the largest study of wounds among patients with confirmed exposure to xylazine and the first to systematically describe wound characteristics,” the authors wrote. The results, they concluded, “may help identify xylazine exposure and can guide research on the etiology and management of these wounds.”

SOURCE:

This study was conducted by Lydia Lutz, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland, and coinvestigators and was published online in JAMA Dermatology.

LIMITATIONS:

This single-city, retrospective study limited generalizability, and the selection of the largest wounds may bias results. Additionally, chronicity data relied on patient recall, potentially introducing recall bias.

DISCLOSURES:

Two authors received support from the National Institute on Drug Abuse for the study. The authors declared no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

A case series highlights the features of severe, necrotic skin wounds among hospitalized adults associated with xylazine exposure, including 9% that involved exposed deep structures such as bone or tendon.

METHODOLOGY:

• The alpha-2 agonist xylazine, a veterinary sedative, is increasingly detected in fentanyl used illicitly in the United States and may be causing necrotizing wounds in drug users.
• To characterize specific clinical features of xylazine-associated wounds, researchers conducted a case series at three academic medical hospitals in Philadelphia from April 2022 to February 2023.
• They included 29 patients with confirmed xylazine exposure and a chief complaint that was wound-related, seen as inpatients or in the emergency department.

TAKEAWAY:

• The 29 patients (mean age, 39.4 years; 52% men) had a total of 59 wounds, 90% were located on the arms and legs, and 69% were on the posterior upper or anterior lower extremities. Five wounds (9%) involved exposed deep structures such as the bone or tendon.
• Of the 57 wounds with available photographs, 60% had wound beds with predominantly devitalized tissue (eschar or slough), 11% were blisters, 9% had granulation tissue, and 21% had mixed tissue or other types of wound beds. Devitalized tissue was more commonly observed in medium or large wounds (odds ratio [OR], 5.2; P = .02) than in small wounds.
• As reported by patients, 48% were acute wounds, 20% were subacute, and 29% were chronic (present for 3 months or longer). Subacute and chronic wounds were often medium or large compared with acute wounds (OR, 48.5; P < .001) and contained devitalized tissue (OR, 9.5; P < .001).
• Of the 39 wounds with patient-reported etiology, 34 (87%) occurred at drug injection sites.

IN PRACTICE:

To the best of their knowledge, this is “the largest study of wounds among patients with confirmed exposure to xylazine and the first to systematically describe wound characteristics,” the authors wrote. The results, they concluded, “may help identify xylazine exposure and can guide research on the etiology and management of these wounds.”

SOURCE:

This study was conducted by Lydia Lutz, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland, and coinvestigators and was published online in JAMA Dermatology.

LIMITATIONS:

This single-city, retrospective study limited generalizability, and the selection of the largest wounds may bias results. Additionally, chronicity data relied on patient recall, potentially introducing recall bias.

DISCLOSURES:

Two authors received support from the National Institute on Drug Abuse for the study. The authors declared no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Combining transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) was associated with a greater reduction in symptoms of major depressive disorder (MDD) than either treatment alone, a new study showed.

 

METHODOLOGY:

• Researchers conducted a double-blind, sham-controlled randomized clinical trial from 2021 to 2023 at three hospitals in China with 240 participants with MDD (mean age, 32.5 years; 58% women).
• Participants received active tDCS + active rTMS, sham tDCS + active rTMS, active tDCS + sham rTMS, or sham tDCS + sham rTMS with treatments administered five times per week for 2 weeks.
• tDCS was administered in 20-minute sessions using a 2-mA direct current stimulator, whereas rTMS involved 1600 pulses of 10-Hz stimulation targeting the left dorsolateral prefrontal cortex. Sham treatments used a pseudostimulation coil and only emitted sound.
• The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HDRS-24) total score from baseline to week 2.
• Secondary outcomes included HDRS-24 total score change at week 4, remission rate (HDRS-24 total score ≤ 9), response rate (≥ 50% reduction in HDRS-24 total score), and adverse events.

TAKEAWAY:

• The active tDCS + active rTMS group demonstrated the greatest reduction in mean HDRS-24 score (18.33 ± 5.39) at week 2 compared with sham tDCS + active rTMS, active tDCS + sham rTMS, and sham tDCS + sham rTMS (P < .001).
• Response rates at week 2 were notably higher in the active tDCS + active rTMS group (85%) than in the active tDCS + sham rTMS (30%) and sham tDCS + sham rTMS groups (32%).
• The remission rate at week 4 reached 83% in the active tDCS + active rTMS group, which was significantly higher than the remission rates with the other interventions (P < .001).
• The treatments were well tolerated, with no serious adverse events, seizures, or manic symptoms reported across all intervention groups.

IN PRACTICE:

This trial “was the first to evaluate the safety, feasibility, and efficacy of combining tDCS and rTMS in treating depression. Future studies should focus on investigating the mechanism of this synergistic effect and improving the stimulation parameters to optimize the therapeutic effect,” the investigators wrote.

 

SOURCE:

This study was led by Dongsheng Zhou, MD, Ningbo Kangning Hospital, Ningbo, China. It was published online in JAMA Network Open.

 

LIMITATIONS:

The brief treatment duration involving 10 sessions may have been insufficient for tDCS and rTMS to demonstrate their full antidepressant potential. The inability to regulate participants’ antidepressant medications throughout the study period presented another limitation. Additionally, the lack of stratified randomization and adjustment for center effects may have introduced variability in the results.

 

DISCLOSURES:

This study received support from multiple grants, including from the Natural Science Foundation of Zhejiang Province, Basic Public Welfare Research Project of Zhejiang Province, Ningbo Medical and Health Brand Discipline, Ningbo Clinical Medical Research Centre for Mental Health, Ningbo Top Medical and Health Research Program, and the Zhejiang Medical and Health Science and Technology Plan Project. The authors reported no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Combining transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) was associated with a greater reduction in symptoms of major depressive disorder (MDD) than either treatment alone, a new study showed.

 

METHODOLOGY:

• Researchers conducted a double-blind, sham-controlled randomized clinical trial from 2021 to 2023 at three hospitals in China with 240 participants with MDD (mean age, 32.5 years; 58% women).
• Participants received active tDCS + active rTMS, sham tDCS + active rTMS, active tDCS + sham rTMS, or sham tDCS + sham rTMS with treatments administered five times per week for 2 weeks.
• tDCS was administered in 20-minute sessions using a 2-mA direct current stimulator, whereas rTMS involved 1600 pulses of 10-Hz stimulation targeting the left dorsolateral prefrontal cortex. Sham treatments used a pseudostimulation coil and only emitted sound.
• The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HDRS-24) total score from baseline to week 2.
• Secondary outcomes included HDRS-24 total score change at week 4, remission rate (HDRS-24 total score ≤ 9), response rate (≥ 50% reduction in HDRS-24 total score), and adverse events.

TAKEAWAY:

• The active tDCS + active rTMS group demonstrated the greatest reduction in mean HDRS-24 score (18.33 ± 5.39) at week 2 compared with sham tDCS + active rTMS, active tDCS + sham rTMS, and sham tDCS + sham rTMS (P < .001).
• Response rates at week 2 were notably higher in the active tDCS + active rTMS group (85%) than in the active tDCS + sham rTMS (30%) and sham tDCS + sham rTMS groups (32%).
• The remission rate at week 4 reached 83% in the active tDCS + active rTMS group, which was significantly higher than the remission rates with the other interventions (P < .001).
• The treatments were well tolerated, with no serious adverse events, seizures, or manic symptoms reported across all intervention groups.

IN PRACTICE:

This trial “was the first to evaluate the safety, feasibility, and efficacy of combining tDCS and rTMS in treating depression. Future studies should focus on investigating the mechanism of this synergistic effect and improving the stimulation parameters to optimize the therapeutic effect,” the investigators wrote.

 

SOURCE:

This study was led by Dongsheng Zhou, MD, Ningbo Kangning Hospital, Ningbo, China. It was published online in JAMA Network Open.

 

LIMITATIONS:

The brief treatment duration involving 10 sessions may have been insufficient for tDCS and rTMS to demonstrate their full antidepressant potential. The inability to regulate participants’ antidepressant medications throughout the study period presented another limitation. Additionally, the lack of stratified randomization and adjustment for center effects may have introduced variability in the results.

 

DISCLOSURES:

This study received support from multiple grants, including from the Natural Science Foundation of Zhejiang Province, Basic Public Welfare Research Project of Zhejiang Province, Ningbo Medical and Health Brand Discipline, Ningbo Clinical Medical Research Centre for Mental Health, Ningbo Top Medical and Health Research Program, and the Zhejiang Medical and Health Science and Technology Plan Project. The authors reported no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Combining transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) was associated with a greater reduction in symptoms of major depressive disorder (MDD) than either treatment alone, a new study showed.

 

METHODOLOGY:

• Researchers conducted a double-blind, sham-controlled randomized clinical trial from 2021 to 2023 at three hospitals in China with 240 participants with MDD (mean age, 32.5 years; 58% women).
• Participants received active tDCS + active rTMS, sham tDCS + active rTMS, active tDCS + sham rTMS, or sham tDCS + sham rTMS with treatments administered five times per week for 2 weeks.
• tDCS was administered in 20-minute sessions using a 2-mA direct current stimulator, whereas rTMS involved 1600 pulses of 10-Hz stimulation targeting the left dorsolateral prefrontal cortex. Sham treatments used a pseudostimulation coil and only emitted sound.
• The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HDRS-24) total score from baseline to week 2.
• Secondary outcomes included HDRS-24 total score change at week 4, remission rate (HDRS-24 total score ≤ 9), response rate (≥ 50% reduction in HDRS-24 total score), and adverse events.

TAKEAWAY:

• The active tDCS + active rTMS group demonstrated the greatest reduction in mean HDRS-24 score (18.33 ± 5.39) at week 2 compared with sham tDCS + active rTMS, active tDCS + sham rTMS, and sham tDCS + sham rTMS (P < .001).
• Response rates at week 2 were notably higher in the active tDCS + active rTMS group (85%) than in the active tDCS + sham rTMS (30%) and sham tDCS + sham rTMS groups (32%).
• The remission rate at week 4 reached 83% in the active tDCS + active rTMS group, which was significantly higher than the remission rates with the other interventions (P < .001).
• The treatments were well tolerated, with no serious adverse events, seizures, or manic symptoms reported across all intervention groups.

IN PRACTICE:

This trial “was the first to evaluate the safety, feasibility, and efficacy of combining tDCS and rTMS in treating depression. Future studies should focus on investigating the mechanism of this synergistic effect and improving the stimulation parameters to optimize the therapeutic effect,” the investigators wrote.

 

SOURCE:

This study was led by Dongsheng Zhou, MD, Ningbo Kangning Hospital, Ningbo, China. It was published online in JAMA Network Open.

 

LIMITATIONS:

The brief treatment duration involving 10 sessions may have been insufficient for tDCS and rTMS to demonstrate their full antidepressant potential. The inability to regulate participants’ antidepressant medications throughout the study period presented another limitation. Additionally, the lack of stratified randomization and adjustment for center effects may have introduced variability in the results.

 

DISCLOSURES:

This study received support from multiple grants, including from the Natural Science Foundation of Zhejiang Province, Basic Public Welfare Research Project of Zhejiang Province, Ningbo Medical and Health Brand Discipline, Ningbo Clinical Medical Research Centre for Mental Health, Ningbo Top Medical and Health Research Program, and the Zhejiang Medical and Health Science and Technology Plan Project. The authors reported no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Nursing is a competitive field. In 2022, nursing schools rejected more than 78,000 qualified applications, and the students whose applications were accepted faced demanding schedules and rigorous academics and clinical rotations. Is this a recipe for depression?

In 2024, 38% of nursing students experienced depression — a 9.3% increase over 2019, according to research from higher education research group Degreechoices. Catherine A. Stubin, PhD, RN, assistant professor of nursing at Rutgers University–Camden in New Jersey, calls it “a mental health crisis in nursing.”

“Nursing is a very rigorous, difficult, psychologically and physically demanding profession,” she said. “If students don’t have the tools and resources to adequately deal with these stressors in nursing school, it’s going to carry over to their professional practice.”

A growing recognition of the toll that nursing programs may have on students’ mental health has led schools to launch initiatives to better support the next generation of nurses.

 

Diagnosing the Problem

Higher than average rates of depression among nursing students are not new. Nursing students often work long shifts with limited breaks. The academic rigors and clinical demands of caring for patients with acute and chronic conditions while instructors evaluate and watch for mistakes can cause high levels of stress, Stubin told this news organization. “Eventually, something has to give, and it’s usually their mental health.”

Clinical practicums often start when nursing students are still freshmen, and asking 18-year-old students to provide patient care in often-chaotic clinical environments is “overwhelming,” according to Stubin. The COVID-19 pandemic further exacerbated the issue.

During lockdown, more than half the nursing students reported moderate to severe symptoms of anxiety and depression, which was attributed to the transition to online learning, fear of infection, burnout, and the psychological distress of lockdown.

“The pandemic exacerbated existing mental health problems in undergraduate nursing students,” said Stubin. “In the wake of it ... a lot of [registered nurses] have mental health issues and are leaving the profession.”

 

Helping Nurses Heal

A significant shift in the willingness to talk about mental health and seek treatment could help. In 2011, just one third of students participated in the treatment for a mental health disorder. The latest data show that 61% of students experiencing symptoms of depression or anxiety take medication or seek therapy or counseling.

Incoming health sciences students at Ohio State University (OSU), Columbus, are screened for depression, anxiety, and suicidal ideation and directed to campus health services as needed. Bernadette Mazurek Melnyk, PhD, APRN-CNP, OSU’s chief wellness officer and former dean in the College of Nursing, believes it’s an essential step in supporting students, adding, “If you don’t screen, you don’t know the students are suffering, and we’re able to get help to the students who need it quickly.”

 

Prioritizing Solutions

Counseling services available through campus health centers are just one part of a multipronged approach that nursing schools have taken to improve the health and well-being of students. Nursing programs have also introduced initiatives to lower stress, prevent burnout, and relieve emotional trauma.

“In nursing education, we have to lay the groundwork for the self-care, wellness, and resilience practices that can, hopefully, be carried over into their professional practices,” Stubin said.

At Rutgers University–Camden, the wellness center provides counseling services, and the Student Nursing Association offers a pet therapy program. Stubin also incorporates self-care, resilience-building strategies, and wellness programming into the curriculum.

During the pandemic, the University of Colorado College of Nursing, Aurora, created a class called Stress Impact and Care for COVID-19 to provide content, exercises, and support groups for nursing students. The class was so popular that it was adapted and integrated into the curriculum.

The University of Vermont, Burlington, introduced the Benson-Henry Institute Stress Management and Resiliency Training program in 2021. The 8-week program was designed to teach nursing students coping strategies to reduce stress.

Offering stress management programs to first-year nursing students has been linked to improved problem-solving skills and fewer emotional and social behavioral symptoms. However, for programs to be effective, Melnyk believes that they need to be integrated into the curriculum, not offered as electives.

“We know mindfulness works, we know cognitive behavior skills-building works, and these types of evidence-based programs with such efficacy behind them should not be optional,” she said. “Students are overwhelmed just with their coursework, so if these programs exist for extra credit, students won’t take them.”

 

Creating a Culture of Wellness

Teaching nursing students how to manage stress and providing the resources to combat depression and anxiety is just the first step in building a healthy, resilient nursing workforce.

Prioritizing wellness in nursing isn’t just essential for addressing the nationwide nursing shortage. Burnout in the medical field costs the United States healthcare system $4.6 billion per year, and preventable medical errors are the third leading cause of death in the United States.

“There is a nice movement across the United States to reduce these mental health issues because they’re so costly,” Melnyk said.

There are also national efforts to address the issue. The National Academy of Medicine introduced the Action Collaborative on Clinician Well-Being and Resilience, which has grown to include more than 200 organizations committed to reversing burnout and improving mental health in the clinical workforce. The American Nurses Foundation created The Nurse Well-Being: Building Peer and Leadership Support Program to provide resources and peer support to help nurses manage stress.

Health systems and hospitals also need to prioritize clinical well-being to reduce stress and burnout — and these efforts must be ongoing.

“These resources have to be extended into the working world ... and not just once a year for Nurses Week in May, but on a regular continued basis,” said Stubin. “Healthcare corporations and hospitals have to continue these resources and this help; it has to be a priority.”

Until the culture changes, Stubin fears that nursing students will continue facing barriers to completing their programs and maintaining nursing careers. Currently, 43% of college students considered leaving their program for mental health reasons, and 21.7% of nurses reported suicidal ideation.

“There’s a nursing shortage, and the acuity of patient care is increasing, so the stressors in the clinical area aren’t going to decrease,” Stubin said. “We as nursing faculty must teach our students how to manage these stressors to build a resilient, mentally and physically healthy workforce.”

A version of this article first appeared on Medscape.com.

Nursing is a competitive field. In 2022, nursing schools rejected more than 78,000 qualified applications, and the students whose applications were accepted faced demanding schedules and rigorous academics and clinical rotations. Is this a recipe for depression?

In 2024, 38% of nursing students experienced depression — a 9.3% increase over 2019, according to research from higher education research group Degreechoices. Catherine A. Stubin, PhD, RN, assistant professor of nursing at Rutgers University–Camden in New Jersey, calls it “a mental health crisis in nursing.”

“Nursing is a very rigorous, difficult, psychologically and physically demanding profession,” she said. “If students don’t have the tools and resources to adequately deal with these stressors in nursing school, it’s going to carry over to their professional practice.”

A growing recognition of the toll that nursing programs may have on students’ mental health has led schools to launch initiatives to better support the next generation of nurses.

 

Diagnosing the Problem

Higher than average rates of depression among nursing students are not new. Nursing students often work long shifts with limited breaks. The academic rigors and clinical demands of caring for patients with acute and chronic conditions while instructors evaluate and watch for mistakes can cause high levels of stress, Stubin told this news organization. “Eventually, something has to give, and it’s usually their mental health.”

Clinical practicums often start when nursing students are still freshmen, and asking 18-year-old students to provide patient care in often-chaotic clinical environments is “overwhelming,” according to Stubin. The COVID-19 pandemic further exacerbated the issue.

During lockdown, more than half the nursing students reported moderate to severe symptoms of anxiety and depression, which was attributed to the transition to online learning, fear of infection, burnout, and the psychological distress of lockdown.

“The pandemic exacerbated existing mental health problems in undergraduate nursing students,” said Stubin. “In the wake of it ... a lot of [registered nurses] have mental health issues and are leaving the profession.”

 

Helping Nurses Heal

A significant shift in the willingness to talk about mental health and seek treatment could help. In 2011, just one third of students participated in the treatment for a mental health disorder. The latest data show that 61% of students experiencing symptoms of depression or anxiety take medication or seek therapy or counseling.

Incoming health sciences students at Ohio State University (OSU), Columbus, are screened for depression, anxiety, and suicidal ideation and directed to campus health services as needed. Bernadette Mazurek Melnyk, PhD, APRN-CNP, OSU’s chief wellness officer and former dean in the College of Nursing, believes it’s an essential step in supporting students, adding, “If you don’t screen, you don’t know the students are suffering, and we’re able to get help to the students who need it quickly.”

 

Prioritizing Solutions

Counseling services available through campus health centers are just one part of a multipronged approach that nursing schools have taken to improve the health and well-being of students. Nursing programs have also introduced initiatives to lower stress, prevent burnout, and relieve emotional trauma.

“In nursing education, we have to lay the groundwork for the self-care, wellness, and resilience practices that can, hopefully, be carried over into their professional practices,” Stubin said.

At Rutgers University–Camden, the wellness center provides counseling services, and the Student Nursing Association offers a pet therapy program. Stubin also incorporates self-care, resilience-building strategies, and wellness programming into the curriculum.

During the pandemic, the University of Colorado College of Nursing, Aurora, created a class called Stress Impact and Care for COVID-19 to provide content, exercises, and support groups for nursing students. The class was so popular that it was adapted and integrated into the curriculum.

The University of Vermont, Burlington, introduced the Benson-Henry Institute Stress Management and Resiliency Training program in 2021. The 8-week program was designed to teach nursing students coping strategies to reduce stress.

Offering stress management programs to first-year nursing students has been linked to improved problem-solving skills and fewer emotional and social behavioral symptoms. However, for programs to be effective, Melnyk believes that they need to be integrated into the curriculum, not offered as electives.

“We know mindfulness works, we know cognitive behavior skills-building works, and these types of evidence-based programs with such efficacy behind them should not be optional,” she said. “Students are overwhelmed just with their coursework, so if these programs exist for extra credit, students won’t take them.”

 

Creating a Culture of Wellness

Teaching nursing students how to manage stress and providing the resources to combat depression and anxiety is just the first step in building a healthy, resilient nursing workforce.

Prioritizing wellness in nursing isn’t just essential for addressing the nationwide nursing shortage. Burnout in the medical field costs the United States healthcare system $4.6 billion per year, and preventable medical errors are the third leading cause of death in the United States.

“There is a nice movement across the United States to reduce these mental health issues because they’re so costly,” Melnyk said.

There are also national efforts to address the issue. The National Academy of Medicine introduced the Action Collaborative on Clinician Well-Being and Resilience, which has grown to include more than 200 organizations committed to reversing burnout and improving mental health in the clinical workforce. The American Nurses Foundation created The Nurse Well-Being: Building Peer and Leadership Support Program to provide resources and peer support to help nurses manage stress.

Health systems and hospitals also need to prioritize clinical well-being to reduce stress and burnout — and these efforts must be ongoing.

“These resources have to be extended into the working world ... and not just once a year for Nurses Week in May, but on a regular continued basis,” said Stubin. “Healthcare corporations and hospitals have to continue these resources and this help; it has to be a priority.”

Until the culture changes, Stubin fears that nursing students will continue facing barriers to completing their programs and maintaining nursing careers. Currently, 43% of college students considered leaving their program for mental health reasons, and 21.7% of nurses reported suicidal ideation.

“There’s a nursing shortage, and the acuity of patient care is increasing, so the stressors in the clinical area aren’t going to decrease,” Stubin said. “We as nursing faculty must teach our students how to manage these stressors to build a resilient, mentally and physically healthy workforce.”

A version of this article first appeared on Medscape.com.

Nursing is a competitive field. In 2022, nursing schools rejected more than 78,000 qualified applications, and the students whose applications were accepted faced demanding schedules and rigorous academics and clinical rotations. Is this a recipe for depression?

In 2024, 38% of nursing students experienced depression — a 9.3% increase over 2019, according to research from higher education research group Degreechoices. Catherine A. Stubin, PhD, RN, assistant professor of nursing at Rutgers University–Camden in New Jersey, calls it “a mental health crisis in nursing.”

“Nursing is a very rigorous, difficult, psychologically and physically demanding profession,” she said. “If students don’t have the tools and resources to adequately deal with these stressors in nursing school, it’s going to carry over to their professional practice.”

A growing recognition of the toll that nursing programs may have on students’ mental health has led schools to launch initiatives to better support the next generation of nurses.

 

Diagnosing the Problem

Higher than average rates of depression among nursing students are not new. Nursing students often work long shifts with limited breaks. The academic rigors and clinical demands of caring for patients with acute and chronic conditions while instructors evaluate and watch for mistakes can cause high levels of stress, Stubin told this news organization. “Eventually, something has to give, and it’s usually their mental health.”

Clinical practicums often start when nursing students are still freshmen, and asking 18-year-old students to provide patient care in often-chaotic clinical environments is “overwhelming,” according to Stubin. The COVID-19 pandemic further exacerbated the issue.

During lockdown, more than half the nursing students reported moderate to severe symptoms of anxiety and depression, which was attributed to the transition to online learning, fear of infection, burnout, and the psychological distress of lockdown.

“The pandemic exacerbated existing mental health problems in undergraduate nursing students,” said Stubin. “In the wake of it ... a lot of [registered nurses] have mental health issues and are leaving the profession.”

 

Helping Nurses Heal

A significant shift in the willingness to talk about mental health and seek treatment could help. In 2011, just one third of students participated in the treatment for a mental health disorder. The latest data show that 61% of students experiencing symptoms of depression or anxiety take medication or seek therapy or counseling.

Incoming health sciences students at Ohio State University (OSU), Columbus, are screened for depression, anxiety, and suicidal ideation and directed to campus health services as needed. Bernadette Mazurek Melnyk, PhD, APRN-CNP, OSU’s chief wellness officer and former dean in the College of Nursing, believes it’s an essential step in supporting students, adding, “If you don’t screen, you don’t know the students are suffering, and we’re able to get help to the students who need it quickly.”

 

Prioritizing Solutions

Counseling services available through campus health centers are just one part of a multipronged approach that nursing schools have taken to improve the health and well-being of students. Nursing programs have also introduced initiatives to lower stress, prevent burnout, and relieve emotional trauma.

“In nursing education, we have to lay the groundwork for the self-care, wellness, and resilience practices that can, hopefully, be carried over into their professional practices,” Stubin said.

At Rutgers University–Camden, the wellness center provides counseling services, and the Student Nursing Association offers a pet therapy program. Stubin also incorporates self-care, resilience-building strategies, and wellness programming into the curriculum.

During the pandemic, the University of Colorado College of Nursing, Aurora, created a class called Stress Impact and Care for COVID-19 to provide content, exercises, and support groups for nursing students. The class was so popular that it was adapted and integrated into the curriculum.

The University of Vermont, Burlington, introduced the Benson-Henry Institute Stress Management and Resiliency Training program in 2021. The 8-week program was designed to teach nursing students coping strategies to reduce stress.

Offering stress management programs to first-year nursing students has been linked to improved problem-solving skills and fewer emotional and social behavioral symptoms. However, for programs to be effective, Melnyk believes that they need to be integrated into the curriculum, not offered as electives.

“We know mindfulness works, we know cognitive behavior skills-building works, and these types of evidence-based programs with such efficacy behind them should not be optional,” she said. “Students are overwhelmed just with their coursework, so if these programs exist for extra credit, students won’t take them.”

 

Creating a Culture of Wellness

Teaching nursing students how to manage stress and providing the resources to combat depression and anxiety is just the first step in building a healthy, resilient nursing workforce.

Prioritizing wellness in nursing isn’t just essential for addressing the nationwide nursing shortage. Burnout in the medical field costs the United States healthcare system $4.6 billion per year, and preventable medical errors are the third leading cause of death in the United States.

“There is a nice movement across the United States to reduce these mental health issues because they’re so costly,” Melnyk said.

There are also national efforts to address the issue. The National Academy of Medicine introduced the Action Collaborative on Clinician Well-Being and Resilience, which has grown to include more than 200 organizations committed to reversing burnout and improving mental health in the clinical workforce. The American Nurses Foundation created The Nurse Well-Being: Building Peer and Leadership Support Program to provide resources and peer support to help nurses manage stress.

Health systems and hospitals also need to prioritize clinical well-being to reduce stress and burnout — and these efforts must be ongoing.

“These resources have to be extended into the working world ... and not just once a year for Nurses Week in May, but on a regular continued basis,” said Stubin. “Healthcare corporations and hospitals have to continue these resources and this help; it has to be a priority.”

Until the culture changes, Stubin fears that nursing students will continue facing barriers to completing their programs and maintaining nursing careers. Currently, 43% of college students considered leaving their program for mental health reasons, and 21.7% of nurses reported suicidal ideation.

“There’s a nursing shortage, and the acuity of patient care is increasing, so the stressors in the clinical area aren’t going to decrease,” Stubin said. “We as nursing faculty must teach our students how to manage these stressors to build a resilient, mentally and physically healthy workforce.”

A version of this article first appeared on Medscape.com.

TOPLINE:

Sleep-related daytime dysfunction is associated with an almost threefold higher risk for motoric cognitive risk (MCR) syndrome, a predementia condition characterized by slow gait and cognitive issues, a new study shows.

METHODOLOGY:

• Researchers included 445 older adults without dementia (mean age, 76 years; 57% women).
• Sleep components were assessed, and participants were classified as poor or good sleepers using the Pittsburgh Sleep Quality Index questionnaire.
• The primary outcome was incidence of MCR syndrome.
• The mean follow-up duration was 2.9 years.

TAKEAWAY:

• During the study period, 36 participants developed MCR syndrome.
• Poor sleepers had a higher risk for incident MCR syndrome, compared with good sleepers, after adjustment for age, sex, and educational level (adjusted hazard ratio [aHR], 2.6; 95% CI, 1.3-5.0; P < .05). However, this association was no longer significant after further adjustment for depressive symptoms.
• Sleep-related daytime dysfunction, defined as excessive sleepiness and lower enthusiasm for activities, was the only sleep component linked to a significant risk for MCR syndrome in fully adjusted models (aHR, 3.3; 95% CI, 1.5-7.4; P < .05).
• Prevalent MCR syndrome was not significantly associated with poor sleep quality (odds ratio, 1.1), suggesting that the relationship is unidirectional.

IN PRACTICE:

“Establishing the relationship between sleep dysfunction and MCR [syndrome] risk is important because early intervention may offer the best hope for preventing dementia,” the investigators wrote.

“Our findings emphasize the need for screening for sleep issues. There’s potential that people could get help with their sleep issues and prevent cognitive decline later in life,” lead author Victoire Leroy, MD, PhD, Albert Einstein College of Medicine, New York City, added in a press release. 

 

SOURCE:

The study was published online in Neurology.

LIMITATIONS: 

Study limitations included the lack of objective sleep measurements and potential recall bias in self-reported sleep complaints, particularly among participants with cognitive issues. In addition, the relatively short follow-up period may have resulted in a lower number of incident MCR syndrome cases. The sample population was also predominantly White (80%), which may have limited the generalizability of the findings to other populations.

DISCLOSURES:

The study was funded by the National Institute on Aging. No conflicts of interest were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Sleep-related daytime dysfunction is associated with an almost threefold higher risk for motoric cognitive risk (MCR) syndrome, a predementia condition characterized by slow gait and cognitive issues, a new study shows.

METHODOLOGY:

• Researchers included 445 older adults without dementia (mean age, 76 years; 57% women).
• Sleep components were assessed, and participants were classified as poor or good sleepers using the Pittsburgh Sleep Quality Index questionnaire.
• The primary outcome was incidence of MCR syndrome.
• The mean follow-up duration was 2.9 years.

TAKEAWAY:

• During the study period, 36 participants developed MCR syndrome.
• Poor sleepers had a higher risk for incident MCR syndrome, compared with good sleepers, after adjustment for age, sex, and educational level (adjusted hazard ratio [aHR], 2.6; 95% CI, 1.3-5.0; P < .05). However, this association was no longer significant after further adjustment for depressive symptoms.
• Sleep-related daytime dysfunction, defined as excessive sleepiness and lower enthusiasm for activities, was the only sleep component linked to a significant risk for MCR syndrome in fully adjusted models (aHR, 3.3; 95% CI, 1.5-7.4; P < .05).
• Prevalent MCR syndrome was not significantly associated with poor sleep quality (odds ratio, 1.1), suggesting that the relationship is unidirectional.

IN PRACTICE:

“Establishing the relationship between sleep dysfunction and MCR [syndrome] risk is important because early intervention may offer the best hope for preventing dementia,” the investigators wrote.

“Our findings emphasize the need for screening for sleep issues. There’s potential that people could get help with their sleep issues and prevent cognitive decline later in life,” lead author Victoire Leroy, MD, PhD, Albert Einstein College of Medicine, New York City, added in a press release. 

 

SOURCE:

The study was published online in Neurology.

LIMITATIONS: 

Study limitations included the lack of objective sleep measurements and potential recall bias in self-reported sleep complaints, particularly among participants with cognitive issues. In addition, the relatively short follow-up period may have resulted in a lower number of incident MCR syndrome cases. The sample population was also predominantly White (80%), which may have limited the generalizability of the findings to other populations.

DISCLOSURES:

The study was funded by the National Institute on Aging. No conflicts of interest were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Sleep-related daytime dysfunction is associated with an almost threefold higher risk for motoric cognitive risk (MCR) syndrome, a predementia condition characterized by slow gait and cognitive issues, a new study shows.

METHODOLOGY:

• Researchers included 445 older adults without dementia (mean age, 76 years; 57% women).
• Sleep components were assessed, and participants were classified as poor or good sleepers using the Pittsburgh Sleep Quality Index questionnaire.
• The primary outcome was incidence of MCR syndrome.
• The mean follow-up duration was 2.9 years.

TAKEAWAY:

• During the study period, 36 participants developed MCR syndrome.
• Poor sleepers had a higher risk for incident MCR syndrome, compared with good sleepers, after adjustment for age, sex, and educational level (adjusted hazard ratio [aHR], 2.6; 95% CI, 1.3-5.0; P < .05). However, this association was no longer significant after further adjustment for depressive symptoms.
• Sleep-related daytime dysfunction, defined as excessive sleepiness and lower enthusiasm for activities, was the only sleep component linked to a significant risk for MCR syndrome in fully adjusted models (aHR, 3.3; 95% CI, 1.5-7.4; P < .05).
• Prevalent MCR syndrome was not significantly associated with poor sleep quality (odds ratio, 1.1), suggesting that the relationship is unidirectional.

IN PRACTICE:

“Establishing the relationship between sleep dysfunction and MCR [syndrome] risk is important because early intervention may offer the best hope for preventing dementia,” the investigators wrote.

“Our findings emphasize the need for screening for sleep issues. There’s potential that people could get help with their sleep issues and prevent cognitive decline later in life,” lead author Victoire Leroy, MD, PhD, Albert Einstein College of Medicine, New York City, added in a press release. 

 

SOURCE:

The study was published online in Neurology.

LIMITATIONS: 

Study limitations included the lack of objective sleep measurements and potential recall bias in self-reported sleep complaints, particularly among participants with cognitive issues. In addition, the relatively short follow-up period may have resulted in a lower number of incident MCR syndrome cases. The sample population was also predominantly White (80%), which may have limited the generalizability of the findings to other populations.

DISCLOSURES:

The study was funded by the National Institute on Aging. No conflicts of interest were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

SAN DIEGO — The prevalence of and number of deaths from alcohol-associated liver disease (ALD) and alcohol use disorder (AUD) are growing among people age 70 and older in the United States, according to the results of a new study.

Even as mortality rates decline globally, AUD deaths rose in the United States, increasing 1.63% per year between 2010 and 2019. Deaths from cirrhosis increased by 0.56% each year, and deaths from primary liver cancer associated with alcohol increased by 3.09% per year.

Several factors, such as an aging US population and increasing alcohol consumption, play a major role in the uptick in mortality, said lead author Pojsakorn Danpanichkul, MD, an internal medicine resident at Texas Tech University Health Sciences Center, Lubbock, who presented the findings at The Liver Meeting 2024: American Association for the Study of Liver Diseases (AASLD).

“Healthcare providers should increase screening for alcohol use among older adults and consider the added risks of alcohol consumption. Public health strategies should target alcohol prevention and treatment programs tailored to older adults,” he said.

“Older adults are more vulnerable to the harmful effects of alcohol due to natural declines in liver function and metabolism, leading to a higher risk of liver disease and complications,” he explained. However, “little research has focused on this issue.”

 

Trends in US Not Seen Globally

Danpanichkul and colleagues analyzed data from the Global Burden of Disease Study for 2010-2019, calculating the annual percent change for the burden of AUD, ALD, and liver cancer from alcohol in patients age 70 and older. The research team then compared data in the United States to global estimates for these same diseases.

In 2019, there were 556,340 cases of AUD, 112,560 cases of ALD, and 3720 cases of liver cancer from alcohol in older adults in the United States. In addition, there were 1750 deaths attributed to AUD, 4860 deaths from ALD, and 3010 deaths caused by primary liver cancer from alcohol.

The age-standardized prevalence rates (ASPRs) per 100,000 people were 1547 cases of AUD, 313 cases of ALD, and 10 cases of primary liver cancer caused by alcohol.

The age-standardized death rates (ASDRs) per 100,000 people were 4.88 for AUD, 13.52 for ALD, and 8.38 for primary liver cancer.

During the time period studied, upward trends occurred in the United States, with annual ASPRs increasing by 2.52% for AUD, 1.78% for ALD, and 3.31% for primary liver cancer due to alcohol. Globally, the trends were lower, with annual increases of 0.2% for AUD, 0.38% for ALD, and 0.67% for primary liver cancer from alcohol.

During the same time, ASDRs also increased in all three categories in the United States, while global trends showed a 0.91% decline in AUD deaths and 0.6% decline in ALD deaths. Liver cancer deaths, however, increased by 0.3% worldwide.

Targeted strategies are essential to reduce this growing health burden, especially in an aging population, Danpanichkul said. “These interventions should focus on early detection, intervention, and management for individuals at risk or already affected by ALD and AUD.”

Future studies should investigate alcohol consumption and mortality trends in other age groups, including by sex, location (such as state or territory), and race and ethnicity, he said. Data for more recent years would be compelling as well.

 

Increased Alcohol Use During and After Pandemic

Numerous studies have indicated that alcohol use increased in 2020 during the COVID-19 pandemic and has remained elevated since then. 

In a study published in the Annals of Internal Medicine, for instance, alcohol use per 100 people increased 2.69% in 2020 and 2.96% in 2022, as compared with 2018. Increases occurred across all subgroups, including age, sex, race, ethnicity, and US region.

“During the COVID-19 pandemic, many people stayed at home, watched the television, and increased their alcohol intake” — in the United States and also in Japan — said Hisanori Muto, MD, senior assistant professor of gastroenterology at Fujita Health University in Nagoya, Japan, who wasn’t involved with this study.

“Although the global numbers may appear lower, we’re also seeing an increase in AUD and ALD in Japan, similar to the United States,” he said. “It’s very important to watch these trends and address these diseases.”

Danpanichkul and Muto reported no relevant disclosures.

A version of this article appeared on Medscape.com.

SAN DIEGO — The prevalence of and number of deaths from alcohol-associated liver disease (ALD) and alcohol use disorder (AUD) are growing among people age 70 and older in the United States, according to the results of a new study.

Even as mortality rates decline globally, AUD deaths rose in the United States, increasing 1.63% per year between 2010 and 2019. Deaths from cirrhosis increased by 0.56% each year, and deaths from primary liver cancer associated with alcohol increased by 3.09% per year.

Several factors, such as an aging US population and increasing alcohol consumption, play a major role in the uptick in mortality, said lead author Pojsakorn Danpanichkul, MD, an internal medicine resident at Texas Tech University Health Sciences Center, Lubbock, who presented the findings at The Liver Meeting 2024: American Association for the Study of Liver Diseases (AASLD).

“Healthcare providers should increase screening for alcohol use among older adults and consider the added risks of alcohol consumption. Public health strategies should target alcohol prevention and treatment programs tailored to older adults,” he said.

“Older adults are more vulnerable to the harmful effects of alcohol due to natural declines in liver function and metabolism, leading to a higher risk of liver disease and complications,” he explained. However, “little research has focused on this issue.”

 

Trends in US Not Seen Globally

Danpanichkul and colleagues analyzed data from the Global Burden of Disease Study for 2010-2019, calculating the annual percent change for the burden of AUD, ALD, and liver cancer from alcohol in patients age 70 and older. The research team then compared data in the United States to global estimates for these same diseases.

In 2019, there were 556,340 cases of AUD, 112,560 cases of ALD, and 3720 cases of liver cancer from alcohol in older adults in the United States. In addition, there were 1750 deaths attributed to AUD, 4860 deaths from ALD, and 3010 deaths caused by primary liver cancer from alcohol.

The age-standardized prevalence rates (ASPRs) per 100,000 people were 1547 cases of AUD, 313 cases of ALD, and 10 cases of primary liver cancer caused by alcohol.

The age-standardized death rates (ASDRs) per 100,000 people were 4.88 for AUD, 13.52 for ALD, and 8.38 for primary liver cancer.

During the time period studied, upward trends occurred in the United States, with annual ASPRs increasing by 2.52% for AUD, 1.78% for ALD, and 3.31% for primary liver cancer due to alcohol. Globally, the trends were lower, with annual increases of 0.2% for AUD, 0.38% for ALD, and 0.67% for primary liver cancer from alcohol.

During the same time, ASDRs also increased in all three categories in the United States, while global trends showed a 0.91% decline in AUD deaths and 0.6% decline in ALD deaths. Liver cancer deaths, however, increased by 0.3% worldwide.

Targeted strategies are essential to reduce this growing health burden, especially in an aging population, Danpanichkul said. “These interventions should focus on early detection, intervention, and management for individuals at risk or already affected by ALD and AUD.”

Future studies should investigate alcohol consumption and mortality trends in other age groups, including by sex, location (such as state or territory), and race and ethnicity, he said. Data for more recent years would be compelling as well.

 

Increased Alcohol Use During and After Pandemic

Numerous studies have indicated that alcohol use increased in 2020 during the COVID-19 pandemic and has remained elevated since then. 

In a study published in the Annals of Internal Medicine, for instance, alcohol use per 100 people increased 2.69% in 2020 and 2.96% in 2022, as compared with 2018. Increases occurred across all subgroups, including age, sex, race, ethnicity, and US region.

“During the COVID-19 pandemic, many people stayed at home, watched the television, and increased their alcohol intake” — in the United States and also in Japan — said Hisanori Muto, MD, senior assistant professor of gastroenterology at Fujita Health University in Nagoya, Japan, who wasn’t involved with this study.

“Although the global numbers may appear lower, we’re also seeing an increase in AUD and ALD in Japan, similar to the United States,” he said. “It’s very important to watch these trends and address these diseases.”

Danpanichkul and Muto reported no relevant disclosures.

A version of this article appeared on Medscape.com.

SAN DIEGO — The prevalence of and number of deaths from alcohol-associated liver disease (ALD) and alcohol use disorder (AUD) are growing among people age 70 and older in the United States, according to the results of a new study.

Even as mortality rates decline globally, AUD deaths rose in the United States, increasing 1.63% per year between 2010 and 2019. Deaths from cirrhosis increased by 0.56% each year, and deaths from primary liver cancer associated with alcohol increased by 3.09% per year.

Several factors, such as an aging US population and increasing alcohol consumption, play a major role in the uptick in mortality, said lead author Pojsakorn Danpanichkul, MD, an internal medicine resident at Texas Tech University Health Sciences Center, Lubbock, who presented the findings at The Liver Meeting 2024: American Association for the Study of Liver Diseases (AASLD).

“Healthcare providers should increase screening for alcohol use among older adults and consider the added risks of alcohol consumption. Public health strategies should target alcohol prevention and treatment programs tailored to older adults,” he said.

“Older adults are more vulnerable to the harmful effects of alcohol due to natural declines in liver function and metabolism, leading to a higher risk of liver disease and complications,” he explained. However, “little research has focused on this issue.”

 

Trends in US Not Seen Globally

Danpanichkul and colleagues analyzed data from the Global Burden of Disease Study for 2010-2019, calculating the annual percent change for the burden of AUD, ALD, and liver cancer from alcohol in patients age 70 and older. The research team then compared data in the United States to global estimates for these same diseases.

In 2019, there were 556,340 cases of AUD, 112,560 cases of ALD, and 3720 cases of liver cancer from alcohol in older adults in the United States. In addition, there were 1750 deaths attributed to AUD, 4860 deaths from ALD, and 3010 deaths caused by primary liver cancer from alcohol.

The age-standardized prevalence rates (ASPRs) per 100,000 people were 1547 cases of AUD, 313 cases of ALD, and 10 cases of primary liver cancer caused by alcohol.

The age-standardized death rates (ASDRs) per 100,000 people were 4.88 for AUD, 13.52 for ALD, and 8.38 for primary liver cancer.

During the time period studied, upward trends occurred in the United States, with annual ASPRs increasing by 2.52% for AUD, 1.78% for ALD, and 3.31% for primary liver cancer due to alcohol. Globally, the trends were lower, with annual increases of 0.2% for AUD, 0.38% for ALD, and 0.67% for primary liver cancer from alcohol.

During the same time, ASDRs also increased in all three categories in the United States, while global trends showed a 0.91% decline in AUD deaths and 0.6% decline in ALD deaths. Liver cancer deaths, however, increased by 0.3% worldwide.

Targeted strategies are essential to reduce this growing health burden, especially in an aging population, Danpanichkul said. “These interventions should focus on early detection, intervention, and management for individuals at risk or already affected by ALD and AUD.”

Future studies should investigate alcohol consumption and mortality trends in other age groups, including by sex, location (such as state or territory), and race and ethnicity, he said. Data for more recent years would be compelling as well.

 

Increased Alcohol Use During and After Pandemic

Numerous studies have indicated that alcohol use increased in 2020 during the COVID-19 pandemic and has remained elevated since then. 

In a study published in the Annals of Internal Medicine, for instance, alcohol use per 100 people increased 2.69% in 2020 and 2.96% in 2022, as compared with 2018. Increases occurred across all subgroups, including age, sex, race, ethnicity, and US region.

“During the COVID-19 pandemic, many people stayed at home, watched the television, and increased their alcohol intake” — in the United States and also in Japan — said Hisanori Muto, MD, senior assistant professor of gastroenterology at Fujita Health University in Nagoya, Japan, who wasn’t involved with this study.

“Although the global numbers may appear lower, we’re also seeing an increase in AUD and ALD in Japan, similar to the United States,” he said. “It’s very important to watch these trends and address these diseases.”

Danpanichkul and Muto reported no relevant disclosures.

A version of this article appeared on Medscape.com.

SEATTLE — A novel, quick, and low-cost dementia screening test could significantly improve early detection of Alzheimer’s disease in primary care settings, according to research presented at the Gerontological Society of America (GSA) 2024 Annual Scientific Meeting.

The test, called qBEANS — short for Quick Behavioral Exam to Advance Neuropsychological Screening — involves patients spooning raw kidney beans into small plastic cups in a specific sequence to assess motor learning, visuospatial memory, and executive function. It requires no technology or wearable sensors, making it accessible and easy to implement.

Previous research has shown qBEANS to be sensitive and specific to Alzheimer’s disease pathology, as well as predictive of cognitive and functional decline, the researchers said.

However, the current version of the test takes around 7 minutes to administer, which is too long for use in primary care, according to study author Sydney Schaefer, PhD, associate professor in the School of Biological and Health Systems Engineering at Arizona State University, Tempe, Arizona.

“The purpose of this study was to identify the minimum number of trials needed for reliability relative to the original longer version,” said Schaefer.

The study involved 48 participants without dementia, 77% of whom were women, and an average age of 75.4 years.

The researchers found that the shortened version of the qBEANS test takes only about 3.85 minutes on average — nearly 48% faster than the original version — while still maintaining high reliability (intraclass correlation of 0.85).

With its brevity and simplicity, the test could be easily administered by medical assistants during patient check-in, potentially increasing early dementia detection rates in primary care, said Schaefer.

While the shortened qBEANS test shows promise, further research is needed to assess its acceptability in primary care settings.

“The findings also warrant further development of the BEAN as a direct-to-consumer product, given its low cost and ease of administration,” said Schaefer.

However, Carla Perissinotto, MD, MHS, professor in the Division of Geriatrics at the University of California, San Francisco, cautioned that direct-to-consumer plans “could lead to participants not knowing what to do with the results out of context and without clinical input.”

“I’m not sure that we need to have a new evaluation tool, but instead, greater adoption of known and existing tools,” said Perissinotto, who was not involved in the study.

According to Perissinotto, existing cognitive screening tools Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are more commonly used to evaluate cognition and are also relatively quick to administer.

“If [qBEANS] is not benchmarked to other standard tools like the MMSE or MoCA, clinicians may have trouble interpreting results,” said Perissinotto.

Study co-authors Schaefer and Jill Love are co-founders and managing members of Neurosessments LLC, which developed the qBEANS test.

 

A version of this article appeared on Medscape.com.

SEATTLE — A novel, quick, and low-cost dementia screening test could significantly improve early detection of Alzheimer’s disease in primary care settings, according to research presented at the Gerontological Society of America (GSA) 2024 Annual Scientific Meeting.

The test, called qBEANS — short for Quick Behavioral Exam to Advance Neuropsychological Screening — involves patients spooning raw kidney beans into small plastic cups in a specific sequence to assess motor learning, visuospatial memory, and executive function. It requires no technology or wearable sensors, making it accessible and easy to implement.

Previous research has shown qBEANS to be sensitive and specific to Alzheimer’s disease pathology, as well as predictive of cognitive and functional decline, the researchers said.

However, the current version of the test takes around 7 minutes to administer, which is too long for use in primary care, according to study author Sydney Schaefer, PhD, associate professor in the School of Biological and Health Systems Engineering at Arizona State University, Tempe, Arizona.

“The purpose of this study was to identify the minimum number of trials needed for reliability relative to the original longer version,” said Schaefer.

The study involved 48 participants without dementia, 77% of whom were women, and an average age of 75.4 years.

The researchers found that the shortened version of the qBEANS test takes only about 3.85 minutes on average — nearly 48% faster than the original version — while still maintaining high reliability (intraclass correlation of 0.85).

With its brevity and simplicity, the test could be easily administered by medical assistants during patient check-in, potentially increasing early dementia detection rates in primary care, said Schaefer.

While the shortened qBEANS test shows promise, further research is needed to assess its acceptability in primary care settings.

“The findings also warrant further development of the BEAN as a direct-to-consumer product, given its low cost and ease of administration,” said Schaefer.

However, Carla Perissinotto, MD, MHS, professor in the Division of Geriatrics at the University of California, San Francisco, cautioned that direct-to-consumer plans “could lead to participants not knowing what to do with the results out of context and without clinical input.”

“I’m not sure that we need to have a new evaluation tool, but instead, greater adoption of known and existing tools,” said Perissinotto, who was not involved in the study.

According to Perissinotto, existing cognitive screening tools Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are more commonly used to evaluate cognition and are also relatively quick to administer.

“If [qBEANS] is not benchmarked to other standard tools like the MMSE or MoCA, clinicians may have trouble interpreting results,” said Perissinotto.

Study co-authors Schaefer and Jill Love are co-founders and managing members of Neurosessments LLC, which developed the qBEANS test.

 

A version of this article appeared on Medscape.com.

SEATTLE — A novel, quick, and low-cost dementia screening test could significantly improve early detection of Alzheimer’s disease in primary care settings, according to research presented at the Gerontological Society of America (GSA) 2024 Annual Scientific Meeting.

The test, called qBEANS — short for Quick Behavioral Exam to Advance Neuropsychological Screening — involves patients spooning raw kidney beans into small plastic cups in a specific sequence to assess motor learning, visuospatial memory, and executive function. It requires no technology or wearable sensors, making it accessible and easy to implement.

Previous research has shown qBEANS to be sensitive and specific to Alzheimer’s disease pathology, as well as predictive of cognitive and functional decline, the researchers said.

However, the current version of the test takes around 7 minutes to administer, which is too long for use in primary care, according to study author Sydney Schaefer, PhD, associate professor in the School of Biological and Health Systems Engineering at Arizona State University, Tempe, Arizona.

“The purpose of this study was to identify the minimum number of trials needed for reliability relative to the original longer version,” said Schaefer.

The study involved 48 participants without dementia, 77% of whom were women, and an average age of 75.4 years.

The researchers found that the shortened version of the qBEANS test takes only about 3.85 minutes on average — nearly 48% faster than the original version — while still maintaining high reliability (intraclass correlation of 0.85).

With its brevity and simplicity, the test could be easily administered by medical assistants during patient check-in, potentially increasing early dementia detection rates in primary care, said Schaefer.

While the shortened qBEANS test shows promise, further research is needed to assess its acceptability in primary care settings.

“The findings also warrant further development of the BEAN as a direct-to-consumer product, given its low cost and ease of administration,” said Schaefer.

However, Carla Perissinotto, MD, MHS, professor in the Division of Geriatrics at the University of California, San Francisco, cautioned that direct-to-consumer plans “could lead to participants not knowing what to do with the results out of context and without clinical input.”

“I’m not sure that we need to have a new evaluation tool, but instead, greater adoption of known and existing tools,” said Perissinotto, who was not involved in the study.

According to Perissinotto, existing cognitive screening tools Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are more commonly used to evaluate cognition and are also relatively quick to administer.

“If [qBEANS] is not benchmarked to other standard tools like the MMSE or MoCA, clinicians may have trouble interpreting results,” said Perissinotto.

Study co-authors Schaefer and Jill Love are co-founders and managing members of Neurosessments LLC, which developed the qBEANS test.

 

A version of this article appeared on Medscape.com.

VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.

Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.

“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).

“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.

A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.

In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.

 

Deprescribing Medications

Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”

Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.

About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.

“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”

 

Preventing Hospitalizations

Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”

Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.

Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.

“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”

Gurau reported having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.

Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.

“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).

“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.

A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.

In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.

 

Deprescribing Medications

Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”

Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.

About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.

“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”

 

Preventing Hospitalizations

Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”

Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.

Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.

“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”

Gurau reported having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.

Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.

“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).

“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.

A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.

In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.

 

Deprescribing Medications

Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”

Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.

About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.

“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”

 

Preventing Hospitalizations

Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”

Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.

Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.

“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”

Gurau reported having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.

Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.

“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.

The findings were published online in JAMA Neurology.

 

A Promising Biomarker

An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.

To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).

The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.

Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.

Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.

Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.

After adjustment for potential confounders, frailty scores were modeled using backward time scales.

Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.

When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).

Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.

In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.

Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.

In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.

 

The ‘Four Pillars’ of Prevention

The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.

To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.

Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.

Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.

 

Unclear Pathway

Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.

The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.

“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.

The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.

 

A version of this article appeared on Medscape.com.

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.

Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.

“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.

The findings were published online in JAMA Neurology.

 

A Promising Biomarker

An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.

To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).

The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.

Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.

Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.

Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.

After adjustment for potential confounders, frailty scores were modeled using backward time scales.

Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.

When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).

Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.

In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.

Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.

In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.

 

The ‘Four Pillars’ of Prevention

The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.

To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.

Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.

Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.

 

Unclear Pathway

Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.

The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.

“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.

The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.

 

A version of this article appeared on Medscape.com.

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.

Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.

“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.

The findings were published online in JAMA Neurology.

 

A Promising Biomarker

An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.

To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).

The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.

Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.

Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.

Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.

After adjustment for potential confounders, frailty scores were modeled using backward time scales.

Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.

When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).

Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.

In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.

Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.

In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.

 

The ‘Four Pillars’ of Prevention

The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.

To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.

Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.

Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.

 

Unclear Pathway

Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.

The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.

“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.

The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.

 

A version of this article appeared on Medscape.com.

Canada’s National Guideline for the Clinical Management of Opioid Use Disorder (OUD) has been updated to reflect the latest literature. The new document recommends buprenorphine and methadone as first-line treatments for OUD.

Opioid use and OUD remain the leading causes of drug-related death worldwide. In Canada, the number of apparent opioid-related deaths increased from 2831 in 2016 to 8049 in 2023. Despite the expansion of treatment options, including the lifting of restrictions on methadone prescribing in 2018, there has been a substantial surge in opioid-related harms, the authors wrote.

“OUD and opioid-related harms have devastating outcomes for our communities across Canada,” author Ginette Poulin, MD, a family physician at the University of Manitoba in Winnipeg, Manitoba, Canada, said in a statement. “With the growing dangers associated with the illicit market, we need to ensure we are sharing the most relevant therapeutic tools and up-to-date knowledge to help providers and communities address this complex issue.”

The 2024 update, which was drafted by the Canadian Research Initiative in Substance Matters (CRISM), was published  in CMAJ.

 

Expanding Access

The COVID-19 pandemic marked an increase in opioid-related harms, senior author Julie Bruneau, MD, Canada research chair in addiction medicine and professor of family and emergency medicine at the Université de Montréal, in Quebec, Canada, told this news organization. Access to essential services and support for people with OUD became restricted, and the drug supply became toxic and volatile.

“In March 2018, CRISM published the first Canadian national clinical practice guideline to assist clinicians in making informed decisions regarding the clinical management of OUD, and recommendations were made in light of existing evidence on prioritizing available treatments,” said Bruneau.

“This guideline is intended for use by healthcare providers, including physicians, nurse practitioners, pharmacists, clinical psychologists, social workers, medical educators, and clinical care case managers with or without specialized experience in addiction treatment. We hope it will help expand access to evidence-based interventions for people with OUD beyond tertiary care,” she said.

Bruneau added that integrating first-line opioid agonist treatment into primary care could reduce stigma, increase early screening and patient retention, and help reduce Canada’s opioid crisis.

The CRISM guideline development team carried out a comprehensive systematic review of the literature published from January 1, 2017, to September 14, 2023. The team, which included patients with OUD, drafted and graded their recommendations using the Grading of Recommendations, Assessment, Development and Evaluation approach.

“First, OUD management should be based on a patient-centered approach, which includes respect for the patient’s rights, preferences, and dignity,” said Bruneau.

Highlights of the guideline include the following recommendations:

• Buprenorphine, with or without naloxone, and methadone can be used as standard first-line treatment options.
• Opioid agonist treatment with slow-release oral morphine should be made available and offered as a second-line option.
• Patients with OUD should not be offered withdrawal management as stand-alone treatment because it is associated with increased rates of relapse, morbidity, and mortality.
• Psychosocial treatment, interventions, and supports can be offered as adjunct treatments but should not be a mandatory component of standard treatment for OUD and should not prevent access to opioid agonist therapy.
• Harm reduction strategies should be offered as part of the continuum of care for patients with OUD.
• Pregnant people can be offered buprenorphine or methadone as treatment options.

Treating More Patients

“Too many people die from untreated opioid addiction in Canada,” coauthor Peter Selby, MD, director of medical education at the Centre for Addiction and Mental Health, said in a statement. “We have medicines that help people stop using, but too few patients are treated due to stigma and lack of prescribers knowing what to do. These national guidelines help them use proven medications to not only prevent death but also help people recover.”

“That both buprenorphine and methadone are now to be considered first-line therapy for the management of OUD is an important change to the guideline,” said Abhimanyu Sud, MD, PhD, research chair in primary care and population health systems at Humber River Health and assistant professor of family and community medicine at the University of Toronto. He did not participate in drafting the guidelines.

“There is a lot of good evidence that these agents are effective for the management of OUD. We had this idea that methadone was harder or somehow more unsafe than buprenorphine, and that buprenorphine was therefore a safer therapy that should be used more widely. Now we have very high-potency opioids that are circulating, and methadone, as a strong opioid agonist, has an important role to play. Clinical experience has borne that out, and this is reflected in the guidelines,” said Sud. 

“When we treat patients who are using fentanyl, for example, or fentanyl analogs, or they’re not sure what they are using because the drug supply has been so contaminated, you sometimes need another agent. Also, a lot of patients do not respond very well to buprenorphine, so for many people, a full agonist like methadone is needed,” he added.

Giving higher priority to slow-release morphine is a good move, and the drug’s use is likely to be safe when administered by a skilled clinician, said Akash Goel, MD, staff physician in the Department of Anesthesiology and Pain Medicine at St. Michael’s Hospital and assistant professor of anesthesiology and pain medicine at the University of Toronto. Goel was not involved in drafting the guideline. 

The updated document will empower patients to make informed decisions about their care, he said. “Buprenorphine, for example, may not be the right selection for all patients. The updated guideline recognizes this. So, for patients who are at risk of failing OUD therapy and going back to using, buprenorphine may not be the best option. The new guideline gives patients the opportunity to have a conversation with their healthcare providers and then decide what’s the best way forward for them.” 

The guideline was supported by Health Canada and the Canadian Institutes of Health Research (CIHR) via CRISM. Poulin reported receiving honoraria for presentations from the Master Clinician Alliance and Indivior outside this work. Bruneau reported receiving a CIHR research grant and a grant from Health Canada’s Substance Use and Addictions Program. Outside this work, Bruneau received a National Institutes of Health research grant and consulting fees for Gilead Sciences and AbbVie.

A version of this article first appeared on Medscape.com.

Canada’s National Guideline for the Clinical Management of Opioid Use Disorder (OUD) has been updated to reflect the latest literature. The new document recommends buprenorphine and methadone as first-line treatments for OUD.

Opioid use and OUD remain the leading causes of drug-related death worldwide. In Canada, the number of apparent opioid-related deaths increased from 2831 in 2016 to 8049 in 2023. Despite the expansion of treatment options, including the lifting of restrictions on methadone prescribing in 2018, there has been a substantial surge in opioid-related harms, the authors wrote.

“OUD and opioid-related harms have devastating outcomes for our communities across Canada,” author Ginette Poulin, MD, a family physician at the University of Manitoba in Winnipeg, Manitoba, Canada, said in a statement. “With the growing dangers associated with the illicit market, we need to ensure we are sharing the most relevant therapeutic tools and up-to-date knowledge to help providers and communities address this complex issue.”

The 2024 update, which was drafted by the Canadian Research Initiative in Substance Matters (CRISM), was published  in CMAJ.

 

Expanding Access

The COVID-19 pandemic marked an increase in opioid-related harms, senior author Julie Bruneau, MD, Canada research chair in addiction medicine and professor of family and emergency medicine at the Université de Montréal, in Quebec, Canada, told this news organization. Access to essential services and support for people with OUD became restricted, and the drug supply became toxic and volatile.

“In March 2018, CRISM published the first Canadian national clinical practice guideline to assist clinicians in making informed decisions regarding the clinical management of OUD, and recommendations were made in light of existing evidence on prioritizing available treatments,” said Bruneau.

“This guideline is intended for use by healthcare providers, including physicians, nurse practitioners, pharmacists, clinical psychologists, social workers, medical educators, and clinical care case managers with or without specialized experience in addiction treatment. We hope it will help expand access to evidence-based interventions for people with OUD beyond tertiary care,” she said.

Bruneau added that integrating first-line opioid agonist treatment into primary care could reduce stigma, increase early screening and patient retention, and help reduce Canada’s opioid crisis.

The CRISM guideline development team carried out a comprehensive systematic review of the literature published from January 1, 2017, to September 14, 2023. The team, which included patients with OUD, drafted and graded their recommendations using the Grading of Recommendations, Assessment, Development and Evaluation approach.

“First, OUD management should be based on a patient-centered approach, which includes respect for the patient’s rights, preferences, and dignity,” said Bruneau.

Highlights of the guideline include the following recommendations:

• Buprenorphine, with or without naloxone, and methadone can be used as standard first-line treatment options.
• Opioid agonist treatment with slow-release oral morphine should be made available and offered as a second-line option.
• Patients with OUD should not be offered withdrawal management as stand-alone treatment because it is associated with increased rates of relapse, morbidity, and mortality.
• Psychosocial treatment, interventions, and supports can be offered as adjunct treatments but should not be a mandatory component of standard treatment for OUD and should not prevent access to opioid agonist therapy.
• Harm reduction strategies should be offered as part of the continuum of care for patients with OUD.
• Pregnant people can be offered buprenorphine or methadone as treatment options.

Treating More Patients

“Too many people die from untreated opioid addiction in Canada,” coauthor Peter Selby, MD, director of medical education at the Centre for Addiction and Mental Health, said in a statement. “We have medicines that help people stop using, but too few patients are treated due to stigma and lack of prescribers knowing what to do. These national guidelines help them use proven medications to not only prevent death but also help people recover.”

“That both buprenorphine and methadone are now to be considered first-line therapy for the management of OUD is an important change to the guideline,” said Abhimanyu Sud, MD, PhD, research chair in primary care and population health systems at Humber River Health and assistant professor of family and community medicine at the University of Toronto. He did not participate in drafting the guidelines.

“There is a lot of good evidence that these agents are effective for the management of OUD. We had this idea that methadone was harder or somehow more unsafe than buprenorphine, and that buprenorphine was therefore a safer therapy that should be used more widely. Now we have very high-potency opioids that are circulating, and methadone, as a strong opioid agonist, has an important role to play. Clinical experience has borne that out, and this is reflected in the guidelines,” said Sud. 

“When we treat patients who are using fentanyl, for example, or fentanyl analogs, or they’re not sure what they are using because the drug supply has been so contaminated, you sometimes need another agent. Also, a lot of patients do not respond very well to buprenorphine, so for many people, a full agonist like methadone is needed,” he added.

Giving higher priority to slow-release morphine is a good move, and the drug’s use is likely to be safe when administered by a skilled clinician, said Akash Goel, MD, staff physician in the Department of Anesthesiology and Pain Medicine at St. Michael’s Hospital and assistant professor of anesthesiology and pain medicine at the University of Toronto. Goel was not involved in drafting the guideline. 

The updated document will empower patients to make informed decisions about their care, he said. “Buprenorphine, for example, may not be the right selection for all patients. The updated guideline recognizes this. So, for patients who are at risk of failing OUD therapy and going back to using, buprenorphine may not be the best option. The new guideline gives patients the opportunity to have a conversation with their healthcare providers and then decide what’s the best way forward for them.” 

The guideline was supported by Health Canada and the Canadian Institutes of Health Research (CIHR) via CRISM. Poulin reported receiving honoraria for presentations from the Master Clinician Alliance and Indivior outside this work. Bruneau reported receiving a CIHR research grant and a grant from Health Canada’s Substance Use and Addictions Program. Outside this work, Bruneau received a National Institutes of Health research grant and consulting fees for Gilead Sciences and AbbVie.

A version of this article first appeared on Medscape.com.

Canada’s National Guideline for the Clinical Management of Opioid Use Disorder (OUD) has been updated to reflect the latest literature. The new document recommends buprenorphine and methadone as first-line treatments for OUD.

Opioid use and OUD remain the leading causes of drug-related death worldwide. In Canada, the number of apparent opioid-related deaths increased from 2831 in 2016 to 8049 in 2023. Despite the expansion of treatment options, including the lifting of restrictions on methadone prescribing in 2018, there has been a substantial surge in opioid-related harms, the authors wrote.

“OUD and opioid-related harms have devastating outcomes for our communities across Canada,” author Ginette Poulin, MD, a family physician at the University of Manitoba in Winnipeg, Manitoba, Canada, said in a statement. “With the growing dangers associated with the illicit market, we need to ensure we are sharing the most relevant therapeutic tools and up-to-date knowledge to help providers and communities address this complex issue.”

The 2024 update, which was drafted by the Canadian Research Initiative in Substance Matters (CRISM), was published  in CMAJ.

 

Expanding Access

The COVID-19 pandemic marked an increase in opioid-related harms, senior author Julie Bruneau, MD, Canada research chair in addiction medicine and professor of family and emergency medicine at the Université de Montréal, in Quebec, Canada, told this news organization. Access to essential services and support for people with OUD became restricted, and the drug supply became toxic and volatile.

“In March 2018, CRISM published the first Canadian national clinical practice guideline to assist clinicians in making informed decisions regarding the clinical management of OUD, and recommendations were made in light of existing evidence on prioritizing available treatments,” said Bruneau.

“This guideline is intended for use by healthcare providers, including physicians, nurse practitioners, pharmacists, clinical psychologists, social workers, medical educators, and clinical care case managers with or without specialized experience in addiction treatment. We hope it will help expand access to evidence-based interventions for people with OUD beyond tertiary care,” she said.

Bruneau added that integrating first-line opioid agonist treatment into primary care could reduce stigma, increase early screening and patient retention, and help reduce Canada’s opioid crisis.

The CRISM guideline development team carried out a comprehensive systematic review of the literature published from January 1, 2017, to September 14, 2023. The team, which included patients with OUD, drafted and graded their recommendations using the Grading of Recommendations, Assessment, Development and Evaluation approach.

“First, OUD management should be based on a patient-centered approach, which includes respect for the patient’s rights, preferences, and dignity,” said Bruneau.

Highlights of the guideline include the following recommendations:

• Buprenorphine, with or without naloxone, and methadone can be used as standard first-line treatment options.
• Opioid agonist treatment with slow-release oral morphine should be made available and offered as a second-line option.
• Patients with OUD should not be offered withdrawal management as stand-alone treatment because it is associated with increased rates of relapse, morbidity, and mortality.
• Psychosocial treatment, interventions, and supports can be offered as adjunct treatments but should not be a mandatory component of standard treatment for OUD and should not prevent access to opioid agonist therapy.
• Harm reduction strategies should be offered as part of the continuum of care for patients with OUD.
• Pregnant people can be offered buprenorphine or methadone as treatment options.

Treating More Patients

“Too many people die from untreated opioid addiction in Canada,” coauthor Peter Selby, MD, director of medical education at the Centre for Addiction and Mental Health, said in a statement. “We have medicines that help people stop using, but too few patients are treated due to stigma and lack of prescribers knowing what to do. These national guidelines help them use proven medications to not only prevent death but also help people recover.”

“That both buprenorphine and methadone are now to be considered first-line therapy for the management of OUD is an important change to the guideline,” said Abhimanyu Sud, MD, PhD, research chair in primary care and population health systems at Humber River Health and assistant professor of family and community medicine at the University of Toronto. He did not participate in drafting the guidelines.

“There is a lot of good evidence that these agents are effective for the management of OUD. We had this idea that methadone was harder or somehow more unsafe than buprenorphine, and that buprenorphine was therefore a safer therapy that should be used more widely. Now we have very high-potency opioids that are circulating, and methadone, as a strong opioid agonist, has an important role to play. Clinical experience has borne that out, and this is reflected in the guidelines,” said Sud. 

“When we treat patients who are using fentanyl, for example, or fentanyl analogs, or they’re not sure what they are using because the drug supply has been so contaminated, you sometimes need another agent. Also, a lot of patients do not respond very well to buprenorphine, so for many people, a full agonist like methadone is needed,” he added.

Giving higher priority to slow-release morphine is a good move, and the drug’s use is likely to be safe when administered by a skilled clinician, said Akash Goel, MD, staff physician in the Department of Anesthesiology and Pain Medicine at St. Michael’s Hospital and assistant professor of anesthesiology and pain medicine at the University of Toronto. Goel was not involved in drafting the guideline. 

The updated document will empower patients to make informed decisions about their care, he said. “Buprenorphine, for example, may not be the right selection for all patients. The updated guideline recognizes this. So, for patients who are at risk of failing OUD therapy and going back to using, buprenorphine may not be the best option. The new guideline gives patients the opportunity to have a conversation with their healthcare providers and then decide what’s the best way forward for them.” 

The guideline was supported by Health Canada and the Canadian Institutes of Health Research (CIHR) via CRISM. Poulin reported receiving honoraria for presentations from the Master Clinician Alliance and Indivior outside this work. Bruneau reported receiving a CIHR research grant and a grant from Health Canada’s Substance Use and Addictions Program. Outside this work, Bruneau received a National Institutes of Health research grant and consulting fees for Gilead Sciences and AbbVie.

A version of this article first appeared on Medscape.com.