Geriatrics

This article discusses updates in geriatrics from studies published in 2022 to early 2023. The topics covered include vitamin D supplementation and incident fractures, the association of social isolation and dementia, and the release of lecanemab, the second disease-modifying therapy for mild Alzheimer dementia.

Vitamin D supplementation and incident fractures

Vitamin D supplementation is a commonly recommended intervention for bone health, but data to support its impact on reducing fracture risk has been variable.

A study in the New England Journal of Medicine by LeBoff and colleagues has garnered much attention since its publication in July 2022.¹ In the ancillary study of the Vitamin D and Omega-3-Trial (VITAL), the authors examined the impact of vitamin D supplementation versus placebo on incident fractures. The study found that vitamin D supplementation, as compared with placebo, led to no significant difference in the incidence of total, nonvertebral, and hip fractures in midlife and older adults over the 5-year period of follow-up.

The generalizability of these findings has been raised as a concern as the study does not describe adults at higher risk for fracture. The authors of the study specified in their conclusion that vitamin D supplementation does not reduce fracture risk in “generally healthy midlife and older adults who were not selected for vitamin D deficiency, low bone mass or osteoporosis.”

With a mean participant age of 67 and exclusion of participants with a history of cardiovascular disease, stroke, cirrhosis and other serious illnesses, the study does not reflect the multimorbid older adult population that geriatricians typically care for. Furthermore, efficacy of vitamin D supplementation on fracture risk may be the most impactful in those with osteoporosis and with severe vitamin D deficiency (defined by vitamin D 25[OH]D level less than 12 ng/mL).

In post hoc analyses, there was no significant difference in fracture risk in these subgroups, however the authors acknowledged that the findings may be limited by the small percentage of participants with severe vitamin D deficiency (2.4%) and osteoporosis included in the study (5%).
 

Lecanemab for mild cognitive impairment and early Alzheimer’s dementia

On Jan. 6, 2023, the Food and Drug Administration approved lecanemab, the second-ever disease-modifying treatment for Alzheimer’s dementia following the approval of aducanumab in 2021. Lecanemab is a monoclonal antibody targeting larger amyloid-beta oligomers, which has been shown in vitro to have higher affinity for amyloid-beta, compared with aducanumab. FDA approval followed shortly after the publication of the CLARITY-AD trial, which investigated the effect of lecanemab versus placebo on cognitive decline and burden of amyloid in adults with mild cognitive impairment and mild Alzheimer’s dementia. Over an 18-month period, the study found that participants who received lecanemab, compared with placebo, had a significantly smaller decline in cognition and function, and reduction in amyloid burden on PET CT.²

The clinical significance of these findings, however, is unclear. As noted by an editorial published in the Lancet in 2022, the difference in Clinical Dementia Rating-Sum of Boxes (CDR-SB) scale between the treatment and placebo groups was 0.45. On an 18-point scale, prior research has noted that a minimal clinically significance difference of 0.98 is necessary in those with mild cognitive impairment and 1.63 in mild Alzheimer dementia.³

Additionally, the CLARITY-AD trial reported that lecanemab resulted in infusion reactions in 26.4% of participants and brain edema (an amyloid-related imaging abnormality referred to as ARIA-E) in 12.6% of participants. This finding highlights concerns for safety and the need for close monitoring, as well as ongoing implications of economic feasibility and equitable access for all those who qualify for treatment.²

Social isolation and dementia risk

There is growing awareness of the impact of social isolation on health outcomes, particularly among older adults. Prior research has reported that one in four older adults are considered socially isolated and that social isolation increases risk of premature death, dementia, depression, and cardiovascular disease.⁴

A study by Huang and colleagues is the first nationally representative cohort study examining the association between social isolation and incident dementia for older adults in community dwelling settings. A cohort of 5,022 older adults participating in the National Health and Aging Trends Study was followed from 2011 to 2020. When adjusting for demographic and health factors, including race, level of education, and number of chronic health conditions, socially isolated adults had a greater risk of developing dementia, compared with adults who were not socially isolated (hazard ratio, 1.27; 95% confidence interval, 1.08-1.49). Potential mechanisms to explain this association include the increased risk of cardiovascular disease and depression in older adults who are socially isolated, thereby increasing dementia risk.

Decreased cognitive activity/engagement and access to resources such as caregiving and health care may also be linked to the increased risk of dementia in socially isolated older adults.⁵

Another observational cohort study from the National Health and Aging Trends Study investigated whether access and use of technology can lower the risk of social isolation. The study found that older adults who used email or text messaging had a lower risk of social isolation than older adults who did not use technology (incidence rate ratio, 0.64; 95% CI, 0.51-0.80).⁶ These findings highlight the importance of addressing social isolation as an important modifiable health risk factor, and the need for providing equitable access to technology in vulnerable populations as health intervention.

Dr. Mengru “Ruru” Wang is a geriatrician and internist at the University of Washington, Seattle. She practices full-spectrum medicine, seeing patients in primary care, nursing homes, and acute care. Dr. Wang has no disclosures related to this piece.

References

1. LeBoff MS et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-30.

2. van Dyck CH et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21.

3. The Lancet. Lecanemab for Alzheimer’s disease: tempering hype and hope. Lancet. 2022; 400:1899.

4. National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: 2020, The National Academies Press.

5. Huang, AR et al. Social isolation and 9-year dementia risk in community dwelling Medicare beneficiaries in the United States. J Am Geriatr Soc. 2023 Jan 11. doi: 10.1111/jgs18140.

6. Umoh ME etal. Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study. J Am Geriatr Soc. 2022 Dec 15. doi 10.1111/jgs.18179.

This article discusses updates in geriatrics from studies published in 2022 to early 2023. The topics covered include vitamin D supplementation and incident fractures, the association of social isolation and dementia, and the release of lecanemab, the second disease-modifying therapy for mild Alzheimer dementia.

Vitamin D supplementation and incident fractures

Vitamin D supplementation is a commonly recommended intervention for bone health, but data to support its impact on reducing fracture risk has been variable.

A study in the New England Journal of Medicine by LeBoff and colleagues has garnered much attention since its publication in July 2022.¹ In the ancillary study of the Vitamin D and Omega-3-Trial (VITAL), the authors examined the impact of vitamin D supplementation versus placebo on incident fractures. The study found that vitamin D supplementation, as compared with placebo, led to no significant difference in the incidence of total, nonvertebral, and hip fractures in midlife and older adults over the 5-year period of follow-up.

The generalizability of these findings has been raised as a concern as the study does not describe adults at higher risk for fracture. The authors of the study specified in their conclusion that vitamin D supplementation does not reduce fracture risk in “generally healthy midlife and older adults who were not selected for vitamin D deficiency, low bone mass or osteoporosis.”

With a mean participant age of 67 and exclusion of participants with a history of cardiovascular disease, stroke, cirrhosis and other serious illnesses, the study does not reflect the multimorbid older adult population that geriatricians typically care for. Furthermore, efficacy of vitamin D supplementation on fracture risk may be the most impactful in those with osteoporosis and with severe vitamin D deficiency (defined by vitamin D 25[OH]D level less than 12 ng/mL).

In post hoc analyses, there was no significant difference in fracture risk in these subgroups, however the authors acknowledged that the findings may be limited by the small percentage of participants with severe vitamin D deficiency (2.4%) and osteoporosis included in the study (5%).
 

Lecanemab for mild cognitive impairment and early Alzheimer’s dementia

On Jan. 6, 2023, the Food and Drug Administration approved lecanemab, the second-ever disease-modifying treatment for Alzheimer’s dementia following the approval of aducanumab in 2021. Lecanemab is a monoclonal antibody targeting larger amyloid-beta oligomers, which has been shown in vitro to have higher affinity for amyloid-beta, compared with aducanumab. FDA approval followed shortly after the publication of the CLARITY-AD trial, which investigated the effect of lecanemab versus placebo on cognitive decline and burden of amyloid in adults with mild cognitive impairment and mild Alzheimer’s dementia. Over an 18-month period, the study found that participants who received lecanemab, compared with placebo, had a significantly smaller decline in cognition and function, and reduction in amyloid burden on PET CT.²

The clinical significance of these findings, however, is unclear. As noted by an editorial published in the Lancet in 2022, the difference in Clinical Dementia Rating-Sum of Boxes (CDR-SB) scale between the treatment and placebo groups was 0.45. On an 18-point scale, prior research has noted that a minimal clinically significance difference of 0.98 is necessary in those with mild cognitive impairment and 1.63 in mild Alzheimer dementia.³

Additionally, the CLARITY-AD trial reported that lecanemab resulted in infusion reactions in 26.4% of participants and brain edema (an amyloid-related imaging abnormality referred to as ARIA-E) in 12.6% of participants. This finding highlights concerns for safety and the need for close monitoring, as well as ongoing implications of economic feasibility and equitable access for all those who qualify for treatment.²

Social isolation and dementia risk

There is growing awareness of the impact of social isolation on health outcomes, particularly among older adults. Prior research has reported that one in four older adults are considered socially isolated and that social isolation increases risk of premature death, dementia, depression, and cardiovascular disease.⁴

A study by Huang and colleagues is the first nationally representative cohort study examining the association between social isolation and incident dementia for older adults in community dwelling settings. A cohort of 5,022 older adults participating in the National Health and Aging Trends Study was followed from 2011 to 2020. When adjusting for demographic and health factors, including race, level of education, and number of chronic health conditions, socially isolated adults had a greater risk of developing dementia, compared with adults who were not socially isolated (hazard ratio, 1.27; 95% confidence interval, 1.08-1.49). Potential mechanisms to explain this association include the increased risk of cardiovascular disease and depression in older adults who are socially isolated, thereby increasing dementia risk.

Decreased cognitive activity/engagement and access to resources such as caregiving and health care may also be linked to the increased risk of dementia in socially isolated older adults.⁵

Another observational cohort study from the National Health and Aging Trends Study investigated whether access and use of technology can lower the risk of social isolation. The study found that older adults who used email or text messaging had a lower risk of social isolation than older adults who did not use technology (incidence rate ratio, 0.64; 95% CI, 0.51-0.80).⁶ These findings highlight the importance of addressing social isolation as an important modifiable health risk factor, and the need for providing equitable access to technology in vulnerable populations as health intervention.

Dr. Mengru “Ruru” Wang is a geriatrician and internist at the University of Washington, Seattle. She practices full-spectrum medicine, seeing patients in primary care, nursing homes, and acute care. Dr. Wang has no disclosures related to this piece.

References

1. LeBoff MS et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-30.

2. van Dyck CH et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21.

3. The Lancet. Lecanemab for Alzheimer’s disease: tempering hype and hope. Lancet. 2022; 400:1899.

4. National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: 2020, The National Academies Press.

5. Huang, AR et al. Social isolation and 9-year dementia risk in community dwelling Medicare beneficiaries in the United States. J Am Geriatr Soc. 2023 Jan 11. doi: 10.1111/jgs18140.

6. Umoh ME etal. Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study. J Am Geriatr Soc. 2022 Dec 15. doi 10.1111/jgs.18179.

This article discusses updates in geriatrics from studies published in 2022 to early 2023. The topics covered include vitamin D supplementation and incident fractures, the association of social isolation and dementia, and the release of lecanemab, the second disease-modifying therapy for mild Alzheimer dementia.

Vitamin D supplementation and incident fractures

Vitamin D supplementation is a commonly recommended intervention for bone health, but data to support its impact on reducing fracture risk has been variable.

A study in the New England Journal of Medicine by LeBoff and colleagues has garnered much attention since its publication in July 2022.¹ In the ancillary study of the Vitamin D and Omega-3-Trial (VITAL), the authors examined the impact of vitamin D supplementation versus placebo on incident fractures. The study found that vitamin D supplementation, as compared with placebo, led to no significant difference in the incidence of total, nonvertebral, and hip fractures in midlife and older adults over the 5-year period of follow-up.

The generalizability of these findings has been raised as a concern as the study does not describe adults at higher risk for fracture. The authors of the study specified in their conclusion that vitamin D supplementation does not reduce fracture risk in “generally healthy midlife and older adults who were not selected for vitamin D deficiency, low bone mass or osteoporosis.”

With a mean participant age of 67 and exclusion of participants with a history of cardiovascular disease, stroke, cirrhosis and other serious illnesses, the study does not reflect the multimorbid older adult population that geriatricians typically care for. Furthermore, efficacy of vitamin D supplementation on fracture risk may be the most impactful in those with osteoporosis and with severe vitamin D deficiency (defined by vitamin D 25[OH]D level less than 12 ng/mL).

In post hoc analyses, there was no significant difference in fracture risk in these subgroups, however the authors acknowledged that the findings may be limited by the small percentage of participants with severe vitamin D deficiency (2.4%) and osteoporosis included in the study (5%).
 

Lecanemab for mild cognitive impairment and early Alzheimer’s dementia

On Jan. 6, 2023, the Food and Drug Administration approved lecanemab, the second-ever disease-modifying treatment for Alzheimer’s dementia following the approval of aducanumab in 2021. Lecanemab is a monoclonal antibody targeting larger amyloid-beta oligomers, which has been shown in vitro to have higher affinity for amyloid-beta, compared with aducanumab. FDA approval followed shortly after the publication of the CLARITY-AD trial, which investigated the effect of lecanemab versus placebo on cognitive decline and burden of amyloid in adults with mild cognitive impairment and mild Alzheimer’s dementia. Over an 18-month period, the study found that participants who received lecanemab, compared with placebo, had a significantly smaller decline in cognition and function, and reduction in amyloid burden on PET CT.²

The clinical significance of these findings, however, is unclear. As noted by an editorial published in the Lancet in 2022, the difference in Clinical Dementia Rating-Sum of Boxes (CDR-SB) scale between the treatment and placebo groups was 0.45. On an 18-point scale, prior research has noted that a minimal clinically significance difference of 0.98 is necessary in those with mild cognitive impairment and 1.63 in mild Alzheimer dementia.³

Additionally, the CLARITY-AD trial reported that lecanemab resulted in infusion reactions in 26.4% of participants and brain edema (an amyloid-related imaging abnormality referred to as ARIA-E) in 12.6% of participants. This finding highlights concerns for safety and the need for close monitoring, as well as ongoing implications of economic feasibility and equitable access for all those who qualify for treatment.²

Social isolation and dementia risk

There is growing awareness of the impact of social isolation on health outcomes, particularly among older adults. Prior research has reported that one in four older adults are considered socially isolated and that social isolation increases risk of premature death, dementia, depression, and cardiovascular disease.⁴

A study by Huang and colleagues is the first nationally representative cohort study examining the association between social isolation and incident dementia for older adults in community dwelling settings. A cohort of 5,022 older adults participating in the National Health and Aging Trends Study was followed from 2011 to 2020. When adjusting for demographic and health factors, including race, level of education, and number of chronic health conditions, socially isolated adults had a greater risk of developing dementia, compared with adults who were not socially isolated (hazard ratio, 1.27; 95% confidence interval, 1.08-1.49). Potential mechanisms to explain this association include the increased risk of cardiovascular disease and depression in older adults who are socially isolated, thereby increasing dementia risk.

Decreased cognitive activity/engagement and access to resources such as caregiving and health care may also be linked to the increased risk of dementia in socially isolated older adults.⁵

Another observational cohort study from the National Health and Aging Trends Study investigated whether access and use of technology can lower the risk of social isolation. The study found that older adults who used email or text messaging had a lower risk of social isolation than older adults who did not use technology (incidence rate ratio, 0.64; 95% CI, 0.51-0.80).⁶ These findings highlight the importance of addressing social isolation as an important modifiable health risk factor, and the need for providing equitable access to technology in vulnerable populations as health intervention.

Dr. Mengru “Ruru” Wang is a geriatrician and internist at the University of Washington, Seattle. She practices full-spectrum medicine, seeing patients in primary care, nursing homes, and acute care. Dr. Wang has no disclosures related to this piece.

References

1. LeBoff MS et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-30.

2. van Dyck CH et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21.

3. The Lancet. Lecanemab for Alzheimer’s disease: tempering hype and hope. Lancet. 2022; 400:1899.

4. National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: 2020, The National Academies Press.

5. Huang, AR et al. Social isolation and 9-year dementia risk in community dwelling Medicare beneficiaries in the United States. J Am Geriatr Soc. 2023 Jan 11. doi: 10.1111/jgs18140.

6. Umoh ME etal. Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study. J Am Geriatr Soc. 2022 Dec 15. doi 10.1111/jgs.18179.

Social isolation in older adults increases the risk for developing dementia, new research suggests. Results from a longitudinal study that included more than 5,000 United States–based seniors showed that nearly one-quarter were socially isolated.

After adjusting for demographic and health factors, social isolation was found to be associated with a 28% higher risk for developing dementia over a 9-year period, compared with non-isolation. In addition, this finding held true regardless of race or ethnicity.

“Social connections are increasingly understood as a critical factor for the health of individuals as they age,” senior study author Thomas K.M. Cudjoe, MD, Robert and Jane Meyerhoff Endowed Professor and assistant professor of medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, said in a press release. “Our study expands our understanding of the deleterious impact of social isolation on one’s risk for dementia over time,” Dr. Cudjoe added.

The findings were published online  in the Journal of the American Geriatric Society.
 

Upstream resources, downstream outcomes

Social isolation is a “multidimensional construct” characterized by factors such as social connections, social support, resource sharing, and relationship strain. It also affects approximately a quarter of older adults, the investigators noted.

Although prior studies have pointed to an association between socially isolated older adults and increased risk for incident dementia, no study has described this longitudinal association in a nationally representative cohort of U.S. seniors. 

Dr. Cudjoe said he was motivated to conduct the current study because he wondered whether or not older adults throughout the United States were similar to some of his patients “who might be at risk for worse cognitive outcomes because they lacked social contact with friends, family, or neighbors.”

The study was also “informed by conceptual foundation that upstream social and personal resources are linked to downstream health outcomes, including cognitive health and function,” the researchers added.

They turned to 2011-2020 data from the National Health and Aging Trends Study, a nationally representative, longitudinal cohort of U.S. Medicare beneficiaries. The sample was drawn from the Medicare enrollment file and incorporated 95 counties and 655 zip codes.

Participants (n = 5,022; mean age, 76.4 years; 57.2% women; 71.7% White, non-Hispanic; 42.4% having more than a college education) were community-dwelling older adults who completed annual 2-hour interviews that included assessment of function, economic health status, and well-being. To be included, they had to attend at least the baseline and first follow-up visits.

NHATS “includes domains that are relevant for the characterization of social isolation,” the investigators wrote. It used a typology of structural social isolation that is informed by the Berkman-Syme Social Network Index.

Included domains were living arrangements, discussion networks, and participation. All are “clinically relevant, practical, and components of a comprehensive social history,” the researchers noted.

They added that individuals classified as “socially isolated” often live alone, have no one or only one person that they can rely upon to discuss important matters, and have limited or no engagement in social or religious groups.

Social isolation in the study was characterized using questions about living with at least one other person, talking to two or more other people about “important matters” in the past year, attending religious services in the past month, and participating in the past month in such things as clubs, meetings, group activities, or volunteer work.
 

Wake-up call

Study participants received 1 point for each item/domain, with a sum score of 0 or 1 classified as “socially isolated” and 2 or more points considered “not socially isolated.” They were classified as having probable dementia based either on self-report or lower-than-mean performance in 2 or more cognitive domains, or a score indicating probable dementia on the AD8 Dementia Screening Interview.

Covariates included demographic factors, education, and health factors. Mean follow-up was 5.1 years.

Results showed close to one-quarter (23.3%) of the study population was classified as socially isolated, with one-fifth (21.1%) developing dementia by the end of the follow-up period.

Compared with non-isolated older adults, those who were socially isolated were more likely to develop dementia during the follow-up period (19.6% vs. 25.9%, respectively).

After adjusting for demographic factors, social isolation was significantly associated with a higher risk for incident dementia (hazard ratio, 1.33; 95% confidence interval, 1.13-1.56). This association persisted after further adjustment for health factors (HR, 1.27; 95% CI, 1.08-1.49). Race and ethnicity had no bearing on the association.

In addition to the association between social isolation and dementia, the researchers also estimated the cause-specific hazard of death before dementia and found that, overall, 18% of participants died prior to dementia over the follow-up period. In particular, the social isolation–associated cause-specific HR of death before dementia was 1.28 (95% CI, 1.2-1.5).

Dr. Cudjoe noted that the mechanism behind the association between social isolation and dementia in this population needs further study. Still, he hopes that the findings will “serve as a wake-up call for all of us to be more thoughtful of the role of social connections on our cognitive health.”

Clinicians “should be thinking about and assessing the presence or absence of social connections in their patients,” Dr. Cudjoe added.
 

‘Instrumental role’

Commenting on the study, Nicole Purcell, DO, neurologist and senior director of clinical practice at the Alzheimer’s Association, said the study “contributes to the growing body of evidence that finds social isolation is a serious public health risk for many seniors living in the United States, increasing their risk for dementia and other serious mental conditions.”

Dr. Purcell, who was not involved with the study, added that “health care systems and medical professionals can play an instrumental role in identifying individuals at risk for social isolation.”

She noted that for those experiencing social isolation, “interaction with health care providers may be one of the few opportunities those individuals have for social engagement, [so] using these interactions to identify individuals at risk for social isolation and referring them to local resources and groups that promote engagement, well-being, and access to senior services may help decrease dementia risk for vulnerable seniors.”

Dr. Purcell added that the Alzheimer’s Association offers early-stage programs throughout the country, including support groups, education, art, music, and other socially engaging activities.

The study was funded by the National Institute on Aging, National Institute on Minority Health and Health Disparities, and Secunda Family Foundation. The investigators and Dr. Purcell have reported no relevant financial relationships.

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

Social isolation in older adults increases the risk for developing dementia, new research suggests. Results from a longitudinal study that included more than 5,000 United States–based seniors showed that nearly one-quarter were socially isolated.

After adjusting for demographic and health factors, social isolation was found to be associated with a 28% higher risk for developing dementia over a 9-year period, compared with non-isolation. In addition, this finding held true regardless of race or ethnicity.

“Social connections are increasingly understood as a critical factor for the health of individuals as they age,” senior study author Thomas K.M. Cudjoe, MD, Robert and Jane Meyerhoff Endowed Professor and assistant professor of medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, said in a press release. “Our study expands our understanding of the deleterious impact of social isolation on one’s risk for dementia over time,” Dr. Cudjoe added.

The findings were published online  in the Journal of the American Geriatric Society.
 

Upstream resources, downstream outcomes

Social isolation is a “multidimensional construct” characterized by factors such as social connections, social support, resource sharing, and relationship strain. It also affects approximately a quarter of older adults, the investigators noted.

Although prior studies have pointed to an association between socially isolated older adults and increased risk for incident dementia, no study has described this longitudinal association in a nationally representative cohort of U.S. seniors. 

Dr. Cudjoe said he was motivated to conduct the current study because he wondered whether or not older adults throughout the United States were similar to some of his patients “who might be at risk for worse cognitive outcomes because they lacked social contact with friends, family, or neighbors.”

The study was also “informed by conceptual foundation that upstream social and personal resources are linked to downstream health outcomes, including cognitive health and function,” the researchers added.

They turned to 2011-2020 data from the National Health and Aging Trends Study, a nationally representative, longitudinal cohort of U.S. Medicare beneficiaries. The sample was drawn from the Medicare enrollment file and incorporated 95 counties and 655 zip codes.

Participants (n = 5,022; mean age, 76.4 years; 57.2% women; 71.7% White, non-Hispanic; 42.4% having more than a college education) were community-dwelling older adults who completed annual 2-hour interviews that included assessment of function, economic health status, and well-being. To be included, they had to attend at least the baseline and first follow-up visits.

NHATS “includes domains that are relevant for the characterization of social isolation,” the investigators wrote. It used a typology of structural social isolation that is informed by the Berkman-Syme Social Network Index.

Included domains were living arrangements, discussion networks, and participation. All are “clinically relevant, practical, and components of a comprehensive social history,” the researchers noted.

They added that individuals classified as “socially isolated” often live alone, have no one or only one person that they can rely upon to discuss important matters, and have limited or no engagement in social or religious groups.

Social isolation in the study was characterized using questions about living with at least one other person, talking to two or more other people about “important matters” in the past year, attending religious services in the past month, and participating in the past month in such things as clubs, meetings, group activities, or volunteer work.
 

Wake-up call

Study participants received 1 point for each item/domain, with a sum score of 0 or 1 classified as “socially isolated” and 2 or more points considered “not socially isolated.” They were classified as having probable dementia based either on self-report or lower-than-mean performance in 2 or more cognitive domains, or a score indicating probable dementia on the AD8 Dementia Screening Interview.

Covariates included demographic factors, education, and health factors. Mean follow-up was 5.1 years.

Results showed close to one-quarter (23.3%) of the study population was classified as socially isolated, with one-fifth (21.1%) developing dementia by the end of the follow-up period.

Compared with non-isolated older adults, those who were socially isolated were more likely to develop dementia during the follow-up period (19.6% vs. 25.9%, respectively).

After adjusting for demographic factors, social isolation was significantly associated with a higher risk for incident dementia (hazard ratio, 1.33; 95% confidence interval, 1.13-1.56). This association persisted after further adjustment for health factors (HR, 1.27; 95% CI, 1.08-1.49). Race and ethnicity had no bearing on the association.

In addition to the association between social isolation and dementia, the researchers also estimated the cause-specific hazard of death before dementia and found that, overall, 18% of participants died prior to dementia over the follow-up period. In particular, the social isolation–associated cause-specific HR of death before dementia was 1.28 (95% CI, 1.2-1.5).

Dr. Cudjoe noted that the mechanism behind the association between social isolation and dementia in this population needs further study. Still, he hopes that the findings will “serve as a wake-up call for all of us to be more thoughtful of the role of social connections on our cognitive health.”

Clinicians “should be thinking about and assessing the presence or absence of social connections in their patients,” Dr. Cudjoe added.
 

‘Instrumental role’

Commenting on the study, Nicole Purcell, DO, neurologist and senior director of clinical practice at the Alzheimer’s Association, said the study “contributes to the growing body of evidence that finds social isolation is a serious public health risk for many seniors living in the United States, increasing their risk for dementia and other serious mental conditions.”

Dr. Purcell, who was not involved with the study, added that “health care systems and medical professionals can play an instrumental role in identifying individuals at risk for social isolation.”

She noted that for those experiencing social isolation, “interaction with health care providers may be one of the few opportunities those individuals have for social engagement, [so] using these interactions to identify individuals at risk for social isolation and referring them to local resources and groups that promote engagement, well-being, and access to senior services may help decrease dementia risk for vulnerable seniors.”

Dr. Purcell added that the Alzheimer’s Association offers early-stage programs throughout the country, including support groups, education, art, music, and other socially engaging activities.

The study was funded by the National Institute on Aging, National Institute on Minority Health and Health Disparities, and Secunda Family Foundation. The investigators and Dr. Purcell have reported no relevant financial relationships.

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

Social isolation in older adults increases the risk for developing dementia, new research suggests. Results from a longitudinal study that included more than 5,000 United States–based seniors showed that nearly one-quarter were socially isolated.

After adjusting for demographic and health factors, social isolation was found to be associated with a 28% higher risk for developing dementia over a 9-year period, compared with non-isolation. In addition, this finding held true regardless of race or ethnicity.

“Social connections are increasingly understood as a critical factor for the health of individuals as they age,” senior study author Thomas K.M. Cudjoe, MD, Robert and Jane Meyerhoff Endowed Professor and assistant professor of medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, said in a press release. “Our study expands our understanding of the deleterious impact of social isolation on one’s risk for dementia over time,” Dr. Cudjoe added.

The findings were published online  in the Journal of the American Geriatric Society.
 

Upstream resources, downstream outcomes

Social isolation is a “multidimensional construct” characterized by factors such as social connections, social support, resource sharing, and relationship strain. It also affects approximately a quarter of older adults, the investigators noted.

Although prior studies have pointed to an association between socially isolated older adults and increased risk for incident dementia, no study has described this longitudinal association in a nationally representative cohort of U.S. seniors. 

Dr. Cudjoe said he was motivated to conduct the current study because he wondered whether or not older adults throughout the United States were similar to some of his patients “who might be at risk for worse cognitive outcomes because they lacked social contact with friends, family, or neighbors.”

The study was also “informed by conceptual foundation that upstream social and personal resources are linked to downstream health outcomes, including cognitive health and function,” the researchers added.

They turned to 2011-2020 data from the National Health and Aging Trends Study, a nationally representative, longitudinal cohort of U.S. Medicare beneficiaries. The sample was drawn from the Medicare enrollment file and incorporated 95 counties and 655 zip codes.

Participants (n = 5,022; mean age, 76.4 years; 57.2% women; 71.7% White, non-Hispanic; 42.4% having more than a college education) were community-dwelling older adults who completed annual 2-hour interviews that included assessment of function, economic health status, and well-being. To be included, they had to attend at least the baseline and first follow-up visits.

NHATS “includes domains that are relevant for the characterization of social isolation,” the investigators wrote. It used a typology of structural social isolation that is informed by the Berkman-Syme Social Network Index.

Included domains were living arrangements, discussion networks, and participation. All are “clinically relevant, practical, and components of a comprehensive social history,” the researchers noted.

They added that individuals classified as “socially isolated” often live alone, have no one or only one person that they can rely upon to discuss important matters, and have limited or no engagement in social or religious groups.

Social isolation in the study was characterized using questions about living with at least one other person, talking to two or more other people about “important matters” in the past year, attending religious services in the past month, and participating in the past month in such things as clubs, meetings, group activities, or volunteer work.
 

Wake-up call

Study participants received 1 point for each item/domain, with a sum score of 0 or 1 classified as “socially isolated” and 2 or more points considered “not socially isolated.” They were classified as having probable dementia based either on self-report or lower-than-mean performance in 2 or more cognitive domains, or a score indicating probable dementia on the AD8 Dementia Screening Interview.

Covariates included demographic factors, education, and health factors. Mean follow-up was 5.1 years.

Results showed close to one-quarter (23.3%) of the study population was classified as socially isolated, with one-fifth (21.1%) developing dementia by the end of the follow-up period.

Compared with non-isolated older adults, those who were socially isolated were more likely to develop dementia during the follow-up period (19.6% vs. 25.9%, respectively).

After adjusting for demographic factors, social isolation was significantly associated with a higher risk for incident dementia (hazard ratio, 1.33; 95% confidence interval, 1.13-1.56). This association persisted after further adjustment for health factors (HR, 1.27; 95% CI, 1.08-1.49). Race and ethnicity had no bearing on the association.

In addition to the association between social isolation and dementia, the researchers also estimated the cause-specific hazard of death before dementia and found that, overall, 18% of participants died prior to dementia over the follow-up period. In particular, the social isolation–associated cause-specific HR of death before dementia was 1.28 (95% CI, 1.2-1.5).

Dr. Cudjoe noted that the mechanism behind the association between social isolation and dementia in this population needs further study. Still, he hopes that the findings will “serve as a wake-up call for all of us to be more thoughtful of the role of social connections on our cognitive health.”

Clinicians “should be thinking about and assessing the presence or absence of social connections in their patients,” Dr. Cudjoe added.
 

‘Instrumental role’

Commenting on the study, Nicole Purcell, DO, neurologist and senior director of clinical practice at the Alzheimer’s Association, said the study “contributes to the growing body of evidence that finds social isolation is a serious public health risk for many seniors living in the United States, increasing their risk for dementia and other serious mental conditions.”

Dr. Purcell, who was not involved with the study, added that “health care systems and medical professionals can play an instrumental role in identifying individuals at risk for social isolation.”

She noted that for those experiencing social isolation, “interaction with health care providers may be one of the few opportunities those individuals have for social engagement, [so] using these interactions to identify individuals at risk for social isolation and referring them to local resources and groups that promote engagement, well-being, and access to senior services may help decrease dementia risk for vulnerable seniors.”

Dr. Purcell added that the Alzheimer’s Association offers early-stage programs throughout the country, including support groups, education, art, music, and other socially engaging activities.

The study was funded by the National Institute on Aging, National Institute on Minority Health and Health Disparities, and Secunda Family Foundation. The investigators and Dr. Purcell have reported no relevant financial relationships.

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

Approximately one-fifth of cervical cancer cases are diagnosed in women aged 65 years or older, and most of the cases are late-stage disease associated with poor survival rates. The new finding calls into question yet again the many national screening guidelines that advise physicians to halt cervical screening at age 65.

The findings emerged from an analysis of the California Cancer Registry for 2009-2018. The authors, from the University of California, Davis, who manage the registry on behalf of the state, found that 17% of women diagnosed with a first primary cancer were aged 65 years or older.

Up to 71% of these older women had late-stage disease vs. 34%-to 59% of women aged 21-64.

The team also found that older patients, even those with early disease, had much poorer survival after they were diagnosed with cervical cancer than their younger counterparts. For example, patients aged between 65 and 69 with stage I cervical cancer had a 5-year relative survival – that is, survival adjusted for noncancer causes of death – of 82%. By contrast, 94% of women aged 20-39 survived for at least 5 years.

The study was published on January 9 in Cancer Epidemiology, Biomarkers & Prevention.

These new data echo similar findings from other recent cervical cancer studies out of California, Massachusetts, Ohio, and nationally. Those studies show that, in comparison with younger patients, rates of late-stage disease are higher and survival is poorer among women aged 65 and older.

Even so, a coauthor of the present study, Frances Maguire, PhD, who is an epidemiologist at the University of California, Davis, said she and her colleagues were surprised by what they found.

“There are a lot of women in this older-age category who are being diagnosed, and they’re being diagnosed later stage and their survival is worse,” Dr. Maguire said. “That was surprising to all of us,” given that the current recommendations are to stop screening once women reach the age of 65, and yet this age group is “doing quite poorly.”

The American Cancer Society, the U.S. Preventive Services Task Force, and the American College of Obstetricians and Gynecologists all recommend that cervical screening stop at aged 65 for patients with “adequate prior screening.”

Adequate screening is defined as having three consecutive normal Pap tests or two consecutive negative human papillomavirus tests or two consecutive negative cotests within the prior 10 years, with the most recent screening within 5 years and having no precancerous lesions in the past 25 years.

However, as many as 23% of women aged 60-64 report that their last Pap test was administered more than 5 years ago, according to a recent study by Alex Francoeur, MD, and colleagues at the University of California, Los Angeles.

When asked to comment on the new article, Dr. Francoeur said, “There is literature that increasing comorbidities and visits to the doctor [with age] decrease the likelihood of getting a Pap test, which is concerning, as these may be the highest-risk women.”

Said study author Dr. Maguire, “It could be that [the guidelines] are perfectly fine if women were properly screened before they hit 65, so that’s one of our big questions. Perhaps this group are not properly screened before age 65, and then they hit 65, they don’t screen, and this is the result we’re seeing.”

The situation is compounded by the lack of continuity in care at this crucial juncture, said Alexander Olawaiye, MD, a professor in the division of gynecologic oncology at the University of Pittsburgh, who was also approached for comment.

At age 65, many women retire, move across the country, or access new health care providers through Medicare, which kicks in at age 65, so the woman’s new physician doesn’t have access to her screening history, he commented.

This means that a physician needs to rely on the patient’s memory.

This is unrealistic, said Dr. Olawaiye: “Let’s forget about the 65-year-old women for now. Let’s talk about young women with sharp minds. Half of these young adults cannot even remember correctly their last monthly period. And these are the people you want to recollect accurately [at age 65] the number of tests they’ve had over 10 years and the results of those tests? Are you kidding me?” said Dr. Olawaiye. “Is that the kind of verification that you rely on?”

Dr. Olawaiye has consistently advocated for scrapping the 65+ screening moratorium in past and current versions of the cervical screening guidelines. He is puzzled by the national unwillingness to do so and rejects the economic argument, pointing out that a handful of extra tests is a lot cheaper than caring for a patient with advanced cervical cancer.

“Most American women will die around 84-85 years of age,” Dr. Olawaiye commented. “So between 65 and 85, you will need five screens, maybe four. What are you saving by not doing that?”

Dr. Maguire, Dr. Francoeur, and Dr. Olawaiye have disclosed no relevant financial relationships.

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

Approximately one-fifth of cervical cancer cases are diagnosed in women aged 65 years or older, and most of the cases are late-stage disease associated with poor survival rates. The new finding calls into question yet again the many national screening guidelines that advise physicians to halt cervical screening at age 65.

The findings emerged from an analysis of the California Cancer Registry for 2009-2018. The authors, from the University of California, Davis, who manage the registry on behalf of the state, found that 17% of women diagnosed with a first primary cancer were aged 65 years or older.

Up to 71% of these older women had late-stage disease vs. 34%-to 59% of women aged 21-64.

The team also found that older patients, even those with early disease, had much poorer survival after they were diagnosed with cervical cancer than their younger counterparts. For example, patients aged between 65 and 69 with stage I cervical cancer had a 5-year relative survival – that is, survival adjusted for noncancer causes of death – of 82%. By contrast, 94% of women aged 20-39 survived for at least 5 years.

The study was published on January 9 in Cancer Epidemiology, Biomarkers & Prevention.

These new data echo similar findings from other recent cervical cancer studies out of California, Massachusetts, Ohio, and nationally. Those studies show that, in comparison with younger patients, rates of late-stage disease are higher and survival is poorer among women aged 65 and older.

Even so, a coauthor of the present study, Frances Maguire, PhD, who is an epidemiologist at the University of California, Davis, said she and her colleagues were surprised by what they found.

“There are a lot of women in this older-age category who are being diagnosed, and they’re being diagnosed later stage and their survival is worse,” Dr. Maguire said. “That was surprising to all of us,” given that the current recommendations are to stop screening once women reach the age of 65, and yet this age group is “doing quite poorly.”

The American Cancer Society, the U.S. Preventive Services Task Force, and the American College of Obstetricians and Gynecologists all recommend that cervical screening stop at aged 65 for patients with “adequate prior screening.”

Adequate screening is defined as having three consecutive normal Pap tests or two consecutive negative human papillomavirus tests or two consecutive negative cotests within the prior 10 years, with the most recent screening within 5 years and having no precancerous lesions in the past 25 years.

However, as many as 23% of women aged 60-64 report that their last Pap test was administered more than 5 years ago, according to a recent study by Alex Francoeur, MD, and colleagues at the University of California, Los Angeles.

When asked to comment on the new article, Dr. Francoeur said, “There is literature that increasing comorbidities and visits to the doctor [with age] decrease the likelihood of getting a Pap test, which is concerning, as these may be the highest-risk women.”

Said study author Dr. Maguire, “It could be that [the guidelines] are perfectly fine if women were properly screened before they hit 65, so that’s one of our big questions. Perhaps this group are not properly screened before age 65, and then they hit 65, they don’t screen, and this is the result we’re seeing.”

The situation is compounded by the lack of continuity in care at this crucial juncture, said Alexander Olawaiye, MD, a professor in the division of gynecologic oncology at the University of Pittsburgh, who was also approached for comment.

At age 65, many women retire, move across the country, or access new health care providers through Medicare, which kicks in at age 65, so the woman’s new physician doesn’t have access to her screening history, he commented.

This means that a physician needs to rely on the patient’s memory.

This is unrealistic, said Dr. Olawaiye: “Let’s forget about the 65-year-old women for now. Let’s talk about young women with sharp minds. Half of these young adults cannot even remember correctly their last monthly period. And these are the people you want to recollect accurately [at age 65] the number of tests they’ve had over 10 years and the results of those tests? Are you kidding me?” said Dr. Olawaiye. “Is that the kind of verification that you rely on?”

Dr. Olawaiye has consistently advocated for scrapping the 65+ screening moratorium in past and current versions of the cervical screening guidelines. He is puzzled by the national unwillingness to do so and rejects the economic argument, pointing out that a handful of extra tests is a lot cheaper than caring for a patient with advanced cervical cancer.

“Most American women will die around 84-85 years of age,” Dr. Olawaiye commented. “So between 65 and 85, you will need five screens, maybe four. What are you saving by not doing that?”

Dr. Maguire, Dr. Francoeur, and Dr. Olawaiye have disclosed no relevant financial relationships.

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

Approximately one-fifth of cervical cancer cases are diagnosed in women aged 65 years or older, and most of the cases are late-stage disease associated with poor survival rates. The new finding calls into question yet again the many national screening guidelines that advise physicians to halt cervical screening at age 65.

The findings emerged from an analysis of the California Cancer Registry for 2009-2018. The authors, from the University of California, Davis, who manage the registry on behalf of the state, found that 17% of women diagnosed with a first primary cancer were aged 65 years or older.

Up to 71% of these older women had late-stage disease vs. 34%-to 59% of women aged 21-64.

The team also found that older patients, even those with early disease, had much poorer survival after they were diagnosed with cervical cancer than their younger counterparts. For example, patients aged between 65 and 69 with stage I cervical cancer had a 5-year relative survival – that is, survival adjusted for noncancer causes of death – of 82%. By contrast, 94% of women aged 20-39 survived for at least 5 years.

The study was published on January 9 in Cancer Epidemiology, Biomarkers & Prevention.

These new data echo similar findings from other recent cervical cancer studies out of California, Massachusetts, Ohio, and nationally. Those studies show that, in comparison with younger patients, rates of late-stage disease are higher and survival is poorer among women aged 65 and older.

Even so, a coauthor of the present study, Frances Maguire, PhD, who is an epidemiologist at the University of California, Davis, said she and her colleagues were surprised by what they found.

“There are a lot of women in this older-age category who are being diagnosed, and they’re being diagnosed later stage and their survival is worse,” Dr. Maguire said. “That was surprising to all of us,” given that the current recommendations are to stop screening once women reach the age of 65, and yet this age group is “doing quite poorly.”

The American Cancer Society, the U.S. Preventive Services Task Force, and the American College of Obstetricians and Gynecologists all recommend that cervical screening stop at aged 65 for patients with “adequate prior screening.”

Adequate screening is defined as having three consecutive normal Pap tests or two consecutive negative human papillomavirus tests or two consecutive negative cotests within the prior 10 years, with the most recent screening within 5 years and having no precancerous lesions in the past 25 years.

However, as many as 23% of women aged 60-64 report that their last Pap test was administered more than 5 years ago, according to a recent study by Alex Francoeur, MD, and colleagues at the University of California, Los Angeles.

When asked to comment on the new article, Dr. Francoeur said, “There is literature that increasing comorbidities and visits to the doctor [with age] decrease the likelihood of getting a Pap test, which is concerning, as these may be the highest-risk women.”

Said study author Dr. Maguire, “It could be that [the guidelines] are perfectly fine if women were properly screened before they hit 65, so that’s one of our big questions. Perhaps this group are not properly screened before age 65, and then they hit 65, they don’t screen, and this is the result we’re seeing.”

The situation is compounded by the lack of continuity in care at this crucial juncture, said Alexander Olawaiye, MD, a professor in the division of gynecologic oncology at the University of Pittsburgh, who was also approached for comment.

At age 65, many women retire, move across the country, or access new health care providers through Medicare, which kicks in at age 65, so the woman’s new physician doesn’t have access to her screening history, he commented.

This means that a physician needs to rely on the patient’s memory.

This is unrealistic, said Dr. Olawaiye: “Let’s forget about the 65-year-old women for now. Let’s talk about young women with sharp minds. Half of these young adults cannot even remember correctly their last monthly period. And these are the people you want to recollect accurately [at age 65] the number of tests they’ve had over 10 years and the results of those tests? Are you kidding me?” said Dr. Olawaiye. “Is that the kind of verification that you rely on?”

Dr. Olawaiye has consistently advocated for scrapping the 65+ screening moratorium in past and current versions of the cervical screening guidelines. He is puzzled by the national unwillingness to do so and rejects the economic argument, pointing out that a handful of extra tests is a lot cheaper than caring for a patient with advanced cervical cancer.

“Most American women will die around 84-85 years of age,” Dr. Olawaiye commented. “So between 65 and 85, you will need five screens, maybe four. What are you saving by not doing that?”

Dr. Maguire, Dr. Francoeur, and Dr. Olawaiye have disclosed no relevant financial relationships.

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

A vaccine database found a possible link between the Pfizer/BioNTech bivalent COVID-19 vaccine and ischemic strokes in people over 65 who got the shot, the Centers for Disease Control and Prevention and the Food and Drug Administration said in a joint news release.

The release did not recommend people change their vaccine practices, saying the database finding probably did not represent a “true clinical risk.” The CDC said everybody, including people over 65, should stay up to date on their COVID vaccines, including the bivalent booster.

The news release said the Vaccine Safety Datalink (VSD), “a near real-time surveillance system,” raised a safety concern about the Pfizer/BioNTech booster.

“Rapid-response investigation of the signal in the VSD raised a question of whether people 65 and older who have received the Pfizer-BioNTech COVID-19 Vaccine, Bivalent were more likely to have an ischemic stroke in the 21 days following vaccination compared with days 22-44 following vaccination,” the news release said.

Ischemic strokes are blockages of blood to the brain, often caused by blood clots.

“Although the totality of the data currently suggests that it is very unlikely that the signal in VSD (Vaccine Safety Datalink) represents a true clinical risk, we believe it is important to share this information with the public, as we have in the past, when one of our safety monitoring systems detects a signal,” the release said.

No higher likelihood of strokes linked to the Pfizer bivalent vaccine had been found by Pfizer/BioNTech, the Department of Veterans Affairs, the Vaccine Adverse Event Reporting System maintained by the CDC and the FDA, or other agencies that monitor reactions of vaccines, the news release said. No safety issues about strokes have been identified with the Moderna bivalent vaccine. 

CNN, citing a CDC official, reported that about 550,000 seniors who got Pfizer bivalent boosters were tracked by the VSD, and 130 of them had strokes within 3 weeks of getting the shot. None of those 130 people died, CNN said. The official spoke on the condition of anonymity because they weren’t authorized to share the data. 

The issue will be discussed at the January meeting of the FDA’s Vaccines and Related Biological Products Advisory Committee.

In a joint statement, Pfizer and BioNTech said: “Neither Pfizer and BioNTech nor the CDC or FDA have observed similar findings across numerous other monitoring systems in the U.S. and globally and there is no evidence to conclude that ischemic stroke is associated with the use of the companies’ COVID-19 vaccines.”

Bivalent boosters contain two strains of vaccine – one to protect against the original COVID-19 virus and another targeting Omicron subvariants.

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

A vaccine database found a possible link between the Pfizer/BioNTech bivalent COVID-19 vaccine and ischemic strokes in people over 65 who got the shot, the Centers for Disease Control and Prevention and the Food and Drug Administration said in a joint news release.

The release did not recommend people change their vaccine practices, saying the database finding probably did not represent a “true clinical risk.” The CDC said everybody, including people over 65, should stay up to date on their COVID vaccines, including the bivalent booster.

The news release said the Vaccine Safety Datalink (VSD), “a near real-time surveillance system,” raised a safety concern about the Pfizer/BioNTech booster.

“Rapid-response investigation of the signal in the VSD raised a question of whether people 65 and older who have received the Pfizer-BioNTech COVID-19 Vaccine, Bivalent were more likely to have an ischemic stroke in the 21 days following vaccination compared with days 22-44 following vaccination,” the news release said.

Ischemic strokes are blockages of blood to the brain, often caused by blood clots.

“Although the totality of the data currently suggests that it is very unlikely that the signal in VSD (Vaccine Safety Datalink) represents a true clinical risk, we believe it is important to share this information with the public, as we have in the past, when one of our safety monitoring systems detects a signal,” the release said.

No higher likelihood of strokes linked to the Pfizer bivalent vaccine had been found by Pfizer/BioNTech, the Department of Veterans Affairs, the Vaccine Adverse Event Reporting System maintained by the CDC and the FDA, or other agencies that monitor reactions of vaccines, the news release said. No safety issues about strokes have been identified with the Moderna bivalent vaccine. 

CNN, citing a CDC official, reported that about 550,000 seniors who got Pfizer bivalent boosters were tracked by the VSD, and 130 of them had strokes within 3 weeks of getting the shot. None of those 130 people died, CNN said. The official spoke on the condition of anonymity because they weren’t authorized to share the data. 

The issue will be discussed at the January meeting of the FDA’s Vaccines and Related Biological Products Advisory Committee.

In a joint statement, Pfizer and BioNTech said: “Neither Pfizer and BioNTech nor the CDC or FDA have observed similar findings across numerous other monitoring systems in the U.S. and globally and there is no evidence to conclude that ischemic stroke is associated with the use of the companies’ COVID-19 vaccines.”

Bivalent boosters contain two strains of vaccine – one to protect against the original COVID-19 virus and another targeting Omicron subvariants.

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

A vaccine database found a possible link between the Pfizer/BioNTech bivalent COVID-19 vaccine and ischemic strokes in people over 65 who got the shot, the Centers for Disease Control and Prevention and the Food and Drug Administration said in a joint news release.

The release did not recommend people change their vaccine practices, saying the database finding probably did not represent a “true clinical risk.” The CDC said everybody, including people over 65, should stay up to date on their COVID vaccines, including the bivalent booster.

The news release said the Vaccine Safety Datalink (VSD), “a near real-time surveillance system,” raised a safety concern about the Pfizer/BioNTech booster.

“Rapid-response investigation of the signal in the VSD raised a question of whether people 65 and older who have received the Pfizer-BioNTech COVID-19 Vaccine, Bivalent were more likely to have an ischemic stroke in the 21 days following vaccination compared with days 22-44 following vaccination,” the news release said.

Ischemic strokes are blockages of blood to the brain, often caused by blood clots.

“Although the totality of the data currently suggests that it is very unlikely that the signal in VSD (Vaccine Safety Datalink) represents a true clinical risk, we believe it is important to share this information with the public, as we have in the past, when one of our safety monitoring systems detects a signal,” the release said.

No higher likelihood of strokes linked to the Pfizer bivalent vaccine had been found by Pfizer/BioNTech, the Department of Veterans Affairs, the Vaccine Adverse Event Reporting System maintained by the CDC and the FDA, or other agencies that monitor reactions of vaccines, the news release said. No safety issues about strokes have been identified with the Moderna bivalent vaccine. 

CNN, citing a CDC official, reported that about 550,000 seniors who got Pfizer bivalent boosters were tracked by the VSD, and 130 of them had strokes within 3 weeks of getting the shot. None of those 130 people died, CNN said. The official spoke on the condition of anonymity because they weren’t authorized to share the data. 

The issue will be discussed at the January meeting of the FDA’s Vaccines and Related Biological Products Advisory Committee.

In a joint statement, Pfizer and BioNTech said: “Neither Pfizer and BioNTech nor the CDC or FDA have observed similar findings across numerous other monitoring systems in the U.S. and globally and there is no evidence to conclude that ischemic stroke is associated with the use of the companies’ COVID-19 vaccines.”

Bivalent boosters contain two strains of vaccine – one to protect against the original COVID-19 virus and another targeting Omicron subvariants.

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

Dementia prevalence is 61% higher among older people with moderate to severe hearing loss compared with those with normal hearing, new national data show. Investigators also found that even mild hearing loss was associated with increased dementia risk, although it was not statistically significant, and that hearing aid use was tied to a 32% decrease in dementia prevalence.

“Every 10-decibel increase in hearing loss was associated with 16% greater prevalence of dementia, such that prevalence of dementia in older adults with moderate or greater hearing loss was 61% higher than prevalence in those with normal hearing,” said lead investigator Alison Huang, PhD, senior research associate in epidemiology at Johns Hopkins Bloomberg School of Public Health and core faculty in the Cochlear Center for Hearing and Public Health, Baltimore.

The findings were published online in JAMA.
 

Dose dependent effect

For their study, researchers analyzed data on 2,413 community-dwelling participants in the National Health and Aging Trends Study, a nationally representative, continuous panel study of U.S. Medicare beneficiaries aged 65 and older.

Data from the study was collected during in-home interviews, setting it apart from previous work that relied on data collected in a clinical setting, Dr. Huang said.

“This study was able to capture more vulnerable populations, such as the oldest old and older adults with disabilities, typically excluded from prior epidemiologic studies of the hearing loss–dementia association that use clinic-based data collection, which only captures people who have the ability and means to get to clinics,” Dr. Huang said.

Weighted hearing loss prevalence was 36.7% for mild and 29.8% for moderate to severe hearing loss, and weighted prevalence of dementia was 10.3%.

Those with moderate to severe hearing loss were 61% more likely to have dementia than were those with normal hearing (prevalence ratio, 1.61; 95% confidence interval [CI], 1.09-2.38).

Dementia prevalence increased with increasing severity of hearing loss: Normal hearing: 6.19% (95% CI, 4.31-8.80); mild hearing loss: 8.93% (95% CI, 6.99-11.34); moderate to severe hearing loss: 16.52% (95% CI, 13.81-19.64). But only moderate to severe hearing loss showed a statistically significant association with dementia (P = .02).

Dementia prevalence increased 16% per 10-decibel increase in hearing loss (prevalence ratio 1.16; P < .001).

Among the 853 individuals in the study with moderate to severe hearing loss, those who used hearing aids (n = 414) had a 32% lower risk of dementia compared with those who didn’t use assisted devices (prevalence ratio, 0.68; 95% CI, 0.47-1.00). Similar data were published in JAMA Neurology, suggesting that hearing aids reduce dementia risk.

“With this study, we were able to refine our understanding of the strength of the hearing loss–dementia association in a study more representative of older adults in the United States,” said Dr. Huang.
 

Robust association

Commenting on the findings, Justin S. Golub, MD, associate professor in the department of otolaryngology–head and neck surgery at Columbia University, New York, said the study supports earlier research and suggests a “robust” association between hearing loss and dementia.

“The particular advantage of this study was that it was high quality and nationally representative,” Dr. Golub said. “It is also among a smaller set of studies that have shown hearing aid use to be associated with lower risk of dementia.”

Although not statistically significant, researchers did find increasing prevalence of dementia among people with only mild hearing loss, and clinicians should take note, said Dr. Golub, who was not involved with this study.

“We would expect the relationship between mild hearing loss and dementia to be weaker than severe hearing loss and dementia and, as a result, it might take more participants to show an association among the mild group,” Dr. Golub said.

“Even though this particular study did not specifically find a relationship between mild hearing loss and dementia, I would still recommend people to start treating their hearing loss when it is early,” Dr. Golub added.

The study was funded by the National Institute on Aging. Dr. Golub reports no relevant financial relationships. Full disclosures for study authors are included in the original article.

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

Dementia prevalence is 61% higher among older people with moderate to severe hearing loss compared with those with normal hearing, new national data show. Investigators also found that even mild hearing loss was associated with increased dementia risk, although it was not statistically significant, and that hearing aid use was tied to a 32% decrease in dementia prevalence.

“Every 10-decibel increase in hearing loss was associated with 16% greater prevalence of dementia, such that prevalence of dementia in older adults with moderate or greater hearing loss was 61% higher than prevalence in those with normal hearing,” said lead investigator Alison Huang, PhD, senior research associate in epidemiology at Johns Hopkins Bloomberg School of Public Health and core faculty in the Cochlear Center for Hearing and Public Health, Baltimore.

The findings were published online in JAMA.
 

Dose dependent effect

For their study, researchers analyzed data on 2,413 community-dwelling participants in the National Health and Aging Trends Study, a nationally representative, continuous panel study of U.S. Medicare beneficiaries aged 65 and older.

Data from the study was collected during in-home interviews, setting it apart from previous work that relied on data collected in a clinical setting, Dr. Huang said.

“This study was able to capture more vulnerable populations, such as the oldest old and older adults with disabilities, typically excluded from prior epidemiologic studies of the hearing loss–dementia association that use clinic-based data collection, which only captures people who have the ability and means to get to clinics,” Dr. Huang said.

Weighted hearing loss prevalence was 36.7% for mild and 29.8% for moderate to severe hearing loss, and weighted prevalence of dementia was 10.3%.

Those with moderate to severe hearing loss were 61% more likely to have dementia than were those with normal hearing (prevalence ratio, 1.61; 95% confidence interval [CI], 1.09-2.38).

Dementia prevalence increased with increasing severity of hearing loss: Normal hearing: 6.19% (95% CI, 4.31-8.80); mild hearing loss: 8.93% (95% CI, 6.99-11.34); moderate to severe hearing loss: 16.52% (95% CI, 13.81-19.64). But only moderate to severe hearing loss showed a statistically significant association with dementia (P = .02).

Dementia prevalence increased 16% per 10-decibel increase in hearing loss (prevalence ratio 1.16; P < .001).

Among the 853 individuals in the study with moderate to severe hearing loss, those who used hearing aids (n = 414) had a 32% lower risk of dementia compared with those who didn’t use assisted devices (prevalence ratio, 0.68; 95% CI, 0.47-1.00). Similar data were published in JAMA Neurology, suggesting that hearing aids reduce dementia risk.

“With this study, we were able to refine our understanding of the strength of the hearing loss–dementia association in a study more representative of older adults in the United States,” said Dr. Huang.
 

Robust association

Commenting on the findings, Justin S. Golub, MD, associate professor in the department of otolaryngology–head and neck surgery at Columbia University, New York, said the study supports earlier research and suggests a “robust” association between hearing loss and dementia.

“The particular advantage of this study was that it was high quality and nationally representative,” Dr. Golub said. “It is also among a smaller set of studies that have shown hearing aid use to be associated with lower risk of dementia.”

Although not statistically significant, researchers did find increasing prevalence of dementia among people with only mild hearing loss, and clinicians should take note, said Dr. Golub, who was not involved with this study.

“We would expect the relationship between mild hearing loss and dementia to be weaker than severe hearing loss and dementia and, as a result, it might take more participants to show an association among the mild group,” Dr. Golub said.

“Even though this particular study did not specifically find a relationship between mild hearing loss and dementia, I would still recommend people to start treating their hearing loss when it is early,” Dr. Golub added.

The study was funded by the National Institute on Aging. Dr. Golub reports no relevant financial relationships. Full disclosures for study authors are included in the original article.

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

Dementia prevalence is 61% higher among older people with moderate to severe hearing loss compared with those with normal hearing, new national data show. Investigators also found that even mild hearing loss was associated with increased dementia risk, although it was not statistically significant, and that hearing aid use was tied to a 32% decrease in dementia prevalence.

“Every 10-decibel increase in hearing loss was associated with 16% greater prevalence of dementia, such that prevalence of dementia in older adults with moderate or greater hearing loss was 61% higher than prevalence in those with normal hearing,” said lead investigator Alison Huang, PhD, senior research associate in epidemiology at Johns Hopkins Bloomberg School of Public Health and core faculty in the Cochlear Center for Hearing and Public Health, Baltimore.

The findings were published online in JAMA.
 

Dose dependent effect

For their study, researchers analyzed data on 2,413 community-dwelling participants in the National Health and Aging Trends Study, a nationally representative, continuous panel study of U.S. Medicare beneficiaries aged 65 and older.

Data from the study was collected during in-home interviews, setting it apart from previous work that relied on data collected in a clinical setting, Dr. Huang said.

“This study was able to capture more vulnerable populations, such as the oldest old and older adults with disabilities, typically excluded from prior epidemiologic studies of the hearing loss–dementia association that use clinic-based data collection, which only captures people who have the ability and means to get to clinics,” Dr. Huang said.

Weighted hearing loss prevalence was 36.7% for mild and 29.8% for moderate to severe hearing loss, and weighted prevalence of dementia was 10.3%.

Those with moderate to severe hearing loss were 61% more likely to have dementia than were those with normal hearing (prevalence ratio, 1.61; 95% confidence interval [CI], 1.09-2.38).

Dementia prevalence increased with increasing severity of hearing loss: Normal hearing: 6.19% (95% CI, 4.31-8.80); mild hearing loss: 8.93% (95% CI, 6.99-11.34); moderate to severe hearing loss: 16.52% (95% CI, 13.81-19.64). But only moderate to severe hearing loss showed a statistically significant association with dementia (P = .02).

Dementia prevalence increased 16% per 10-decibel increase in hearing loss (prevalence ratio 1.16; P < .001).

Among the 853 individuals in the study with moderate to severe hearing loss, those who used hearing aids (n = 414) had a 32% lower risk of dementia compared with those who didn’t use assisted devices (prevalence ratio, 0.68; 95% CI, 0.47-1.00). Similar data were published in JAMA Neurology, suggesting that hearing aids reduce dementia risk.

“With this study, we were able to refine our understanding of the strength of the hearing loss–dementia association in a study more representative of older adults in the United States,” said Dr. Huang.
 

Robust association

Commenting on the findings, Justin S. Golub, MD, associate professor in the department of otolaryngology–head and neck surgery at Columbia University, New York, said the study supports earlier research and suggests a “robust” association between hearing loss and dementia.

“The particular advantage of this study was that it was high quality and nationally representative,” Dr. Golub said. “It is also among a smaller set of studies that have shown hearing aid use to be associated with lower risk of dementia.”

Although not statistically significant, researchers did find increasing prevalence of dementia among people with only mild hearing loss, and clinicians should take note, said Dr. Golub, who was not involved with this study.

“We would expect the relationship between mild hearing loss and dementia to be weaker than severe hearing loss and dementia and, as a result, it might take more participants to show an association among the mild group,” Dr. Golub said.

“Even though this particular study did not specifically find a relationship between mild hearing loss and dementia, I would still recommend people to start treating their hearing loss when it is early,” Dr. Golub added.

The study was funded by the National Institute on Aging. Dr. Golub reports no relevant financial relationships. Full disclosures for study authors are included in the original article.

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

The ‘scheme’ in the name should have been a clue

Retirement. The shiny reward to a lifetime’s worth of working and saving. We’re all literally working to get there, some of us more to get there early, but current research reveals that early retirement isn’t the relaxing finish line we dream about, cognitively speaking.

FatCamera/Getty Images

Researchers at Binghamton (N.Y.) University set out to examine just how retirement plans affect cognitive performance. They started off with China’s New Rural Pension Scheme (scheme probably has a less negative connotation in Chinese), a plan that financially aids the growing rural retirement-age population in the country. Then they looked at data from the Chinese Health and Retirement Longitudinal Survey, which tests cognition with a focus on episodic memory and parts of intact mental status.

What they found was the opposite of what you would expect out of retirees with nothing but time on their hands.

The pension program, which had been in place for almost a decade, led to delayed recall, especially among women, supporting “the mental retirement hypothesis that decreased mental activity results in worsening cognitive skills,” the investigators said in a written statement.

There also was a drop in social engagement, with lower rates of volunteering and social interaction than people who didn’t receive the pension. Some behaviors, like regular alcohol consumption, did improve over the previous year, as did total health in general, but “the adverse effects of early retirement on mental and social engagement significantly outweigh the program’s protective effect on various health behaviors,” Plamen Nikolov, PhD, said about his research.

So if you’re looking to retire early, don’t skimp on the crosswords and the bingo nights. Stay busy in a good way. Your brain will thank you.
 

Indiana Jones and the First Smallpox Ancestor

Smallpox was, not that long ago, one of the most devastating diseases known to humanity, killing 300 million people in the 20th century alone. Eradicating it has to be one of medicine’s crowning achievements. Now it can only be found in museums, which is where it belongs.

J. Nakano, USCDCP/Pixnio

Here’s the thing with smallpox though: For all it did to us, we know frustratingly little about where it came from. Until very recently, the best available genetic evidence placed its emergence in the 17th century, which clashes with historical data. You know what that means, right? It’s time to dig out the fedora and whip, cue the music, and dig into a recently published study spanning continents in search of the mythical smallpox origin story.

We pick up in 2020, when genetic evidence definitively showed smallpox in a Viking burial site, moving the disease’s emergence a thousand years earlier. Which is all well and good, but there’s solid visual evidence that Egyptian pharaohs were dying of smallpox, as their bodies show the signature scarring. Historians were pretty sure smallpox went back about 4,000 years, but there was no genetic material to prove it.

Since there aren’t any 4,000-year-old smallpox germs laying around, the researchers chose to attack the problem another way – by burning down a Venetian catacomb, er, conducting a analysis of historical smallpox genetics to find the virus’s origin. By analyzing the genomes of various strains at different periods of time, they were able to determine that the variola virus had a definitive common ancestor. Some of the genetic components in the Viking-age sample, for example, persisted until the 18th century.

Armed with this information, the scientists determined that the first smallpox ancestor emerged about 3,800 years ago. That’s very close to the historians’ estimate for the disease’s emergence. Proof at last of smallpox’s truly ancient origin. One might even say the researchers chose wisely.
 

The only hall of fame that really matters

LOTME loves the holiday season – the food, the gifts, the radio stations that play nothing but Christmas music – but for us the most wonderful time of the year comes just a bit later. No, it’s not our annual Golden Globes slap bet. Nope, not even the “excitement” of the College Football Playoff National Championship. It’s time for the National Inventors Hall of Fame to announce its latest inductees, and we could hardly sleep last night after putting cookies out for Thomas Edison. Fasten your seatbelts!

National Inventors Hall of Fame

• Robert G. Bryant is a NASA chemist who developed Langley Research Center-Soluble Imide (yes, that’s the actual name) a polymer used as an insulation material for leads in implantable cardiac resynchronization therapy devices.
• Rory Cooper is a biomedical engineer who was paralyzed in a bicycle accident. His work has improved manual and electric wheelchairs and advanced the health, mobility, and social inclusion of people with disabilities and older adults. He is also the first NIHF inductee named Rory.
• Katalin Karikó, a biochemist, and Drew Weissman, an immunologist, “discovered how to enable messenger ribonucleic acid (mRNA) to enter cells without triggering the body’s immune system,” NIHF said, and that laid the foundation for the mRNA COVID-19 vaccines developed by Pfizer-BioNTech and Moderna. That, of course, led to the antivax movement, which has provided so much LOTME fodder over the years.
• Angela Hartley Brodie was a biochemist who discovered and developed a class of drugs called aromatase inhibitors, which can stop the production of hormones that fuel cancer cell growth and are used to treat breast cancer in 500,000 women worldwide each year.

We can’t mention all of the inductees for 2023 (our editor made that very clear), but we would like to offer a special shout-out to brothers Cyril (the first Cyril in the NIHF, by the way) and Louis Keller, who invented the world’s first compact loader, which eventually became the Bobcat skid-steer loader. Not really medical, you’re probably thinking, but we’re sure that someone, somewhere, at some time, used one to build a hospital, landscape a hospital, or clean up after the demolition of a hospital.

The ‘scheme’ in the name should have been a clue

Retirement. The shiny reward to a lifetime’s worth of working and saving. We’re all literally working to get there, some of us more to get there early, but current research reveals that early retirement isn’t the relaxing finish line we dream about, cognitively speaking.

FatCamera/Getty Images

Researchers at Binghamton (N.Y.) University set out to examine just how retirement plans affect cognitive performance. They started off with China’s New Rural Pension Scheme (scheme probably has a less negative connotation in Chinese), a plan that financially aids the growing rural retirement-age population in the country. Then they looked at data from the Chinese Health and Retirement Longitudinal Survey, which tests cognition with a focus on episodic memory and parts of intact mental status.

What they found was the opposite of what you would expect out of retirees with nothing but time on their hands.

The pension program, which had been in place for almost a decade, led to delayed recall, especially among women, supporting “the mental retirement hypothesis that decreased mental activity results in worsening cognitive skills,” the investigators said in a written statement.

There also was a drop in social engagement, with lower rates of volunteering and social interaction than people who didn’t receive the pension. Some behaviors, like regular alcohol consumption, did improve over the previous year, as did total health in general, but “the adverse effects of early retirement on mental and social engagement significantly outweigh the program’s protective effect on various health behaviors,” Plamen Nikolov, PhD, said about his research.

So if you’re looking to retire early, don’t skimp on the crosswords and the bingo nights. Stay busy in a good way. Your brain will thank you.
 

Indiana Jones and the First Smallpox Ancestor

Smallpox was, not that long ago, one of the most devastating diseases known to humanity, killing 300 million people in the 20th century alone. Eradicating it has to be one of medicine’s crowning achievements. Now it can only be found in museums, which is where it belongs.

J. Nakano, USCDCP/Pixnio

Here’s the thing with smallpox though: For all it did to us, we know frustratingly little about where it came from. Until very recently, the best available genetic evidence placed its emergence in the 17th century, which clashes with historical data. You know what that means, right? It’s time to dig out the fedora and whip, cue the music, and dig into a recently published study spanning continents in search of the mythical smallpox origin story.

We pick up in 2020, when genetic evidence definitively showed smallpox in a Viking burial site, moving the disease’s emergence a thousand years earlier. Which is all well and good, but there’s solid visual evidence that Egyptian pharaohs were dying of smallpox, as their bodies show the signature scarring. Historians were pretty sure smallpox went back about 4,000 years, but there was no genetic material to prove it.

Since there aren’t any 4,000-year-old smallpox germs laying around, the researchers chose to attack the problem another way – by burning down a Venetian catacomb, er, conducting a analysis of historical smallpox genetics to find the virus’s origin. By analyzing the genomes of various strains at different periods of time, they were able to determine that the variola virus had a definitive common ancestor. Some of the genetic components in the Viking-age sample, for example, persisted until the 18th century.

Armed with this information, the scientists determined that the first smallpox ancestor emerged about 3,800 years ago. That’s very close to the historians’ estimate for the disease’s emergence. Proof at last of smallpox’s truly ancient origin. One might even say the researchers chose wisely.
 

The only hall of fame that really matters

LOTME loves the holiday season – the food, the gifts, the radio stations that play nothing but Christmas music – but for us the most wonderful time of the year comes just a bit later. No, it’s not our annual Golden Globes slap bet. Nope, not even the “excitement” of the College Football Playoff National Championship. It’s time for the National Inventors Hall of Fame to announce its latest inductees, and we could hardly sleep last night after putting cookies out for Thomas Edison. Fasten your seatbelts!

National Inventors Hall of Fame

• Robert G. Bryant is a NASA chemist who developed Langley Research Center-Soluble Imide (yes, that’s the actual name) a polymer used as an insulation material for leads in implantable cardiac resynchronization therapy devices.
• Rory Cooper is a biomedical engineer who was paralyzed in a bicycle accident. His work has improved manual and electric wheelchairs and advanced the health, mobility, and social inclusion of people with disabilities and older adults. He is also the first NIHF inductee named Rory.
• Katalin Karikó, a biochemist, and Drew Weissman, an immunologist, “discovered how to enable messenger ribonucleic acid (mRNA) to enter cells without triggering the body’s immune system,” NIHF said, and that laid the foundation for the mRNA COVID-19 vaccines developed by Pfizer-BioNTech and Moderna. That, of course, led to the antivax movement, which has provided so much LOTME fodder over the years.
• Angela Hartley Brodie was a biochemist who discovered and developed a class of drugs called aromatase inhibitors, which can stop the production of hormones that fuel cancer cell growth and are used to treat breast cancer in 500,000 women worldwide each year.

We can’t mention all of the inductees for 2023 (our editor made that very clear), but we would like to offer a special shout-out to brothers Cyril (the first Cyril in the NIHF, by the way) and Louis Keller, who invented the world’s first compact loader, which eventually became the Bobcat skid-steer loader. Not really medical, you’re probably thinking, but we’re sure that someone, somewhere, at some time, used one to build a hospital, landscape a hospital, or clean up after the demolition of a hospital.

The ‘scheme’ in the name should have been a clue

Retirement. The shiny reward to a lifetime’s worth of working and saving. We’re all literally working to get there, some of us more to get there early, but current research reveals that early retirement isn’t the relaxing finish line we dream about, cognitively speaking.

FatCamera/Getty Images

Researchers at Binghamton (N.Y.) University set out to examine just how retirement plans affect cognitive performance. They started off with China’s New Rural Pension Scheme (scheme probably has a less negative connotation in Chinese), a plan that financially aids the growing rural retirement-age population in the country. Then they looked at data from the Chinese Health and Retirement Longitudinal Survey, which tests cognition with a focus on episodic memory and parts of intact mental status.

What they found was the opposite of what you would expect out of retirees with nothing but time on their hands.

The pension program, which had been in place for almost a decade, led to delayed recall, especially among women, supporting “the mental retirement hypothesis that decreased mental activity results in worsening cognitive skills,” the investigators said in a written statement.

There also was a drop in social engagement, with lower rates of volunteering and social interaction than people who didn’t receive the pension. Some behaviors, like regular alcohol consumption, did improve over the previous year, as did total health in general, but “the adverse effects of early retirement on mental and social engagement significantly outweigh the program’s protective effect on various health behaviors,” Plamen Nikolov, PhD, said about his research.

So if you’re looking to retire early, don’t skimp on the crosswords and the bingo nights. Stay busy in a good way. Your brain will thank you.
 

Indiana Jones and the First Smallpox Ancestor

Smallpox was, not that long ago, one of the most devastating diseases known to humanity, killing 300 million people in the 20th century alone. Eradicating it has to be one of medicine’s crowning achievements. Now it can only be found in museums, which is where it belongs.

J. Nakano, USCDCP/Pixnio

Here’s the thing with smallpox though: For all it did to us, we know frustratingly little about where it came from. Until very recently, the best available genetic evidence placed its emergence in the 17th century, which clashes with historical data. You know what that means, right? It’s time to dig out the fedora and whip, cue the music, and dig into a recently published study spanning continents in search of the mythical smallpox origin story.

We pick up in 2020, when genetic evidence definitively showed smallpox in a Viking burial site, moving the disease’s emergence a thousand years earlier. Which is all well and good, but there’s solid visual evidence that Egyptian pharaohs were dying of smallpox, as their bodies show the signature scarring. Historians were pretty sure smallpox went back about 4,000 years, but there was no genetic material to prove it.

Since there aren’t any 4,000-year-old smallpox germs laying around, the researchers chose to attack the problem another way – by burning down a Venetian catacomb, er, conducting a analysis of historical smallpox genetics to find the virus’s origin. By analyzing the genomes of various strains at different periods of time, they were able to determine that the variola virus had a definitive common ancestor. Some of the genetic components in the Viking-age sample, for example, persisted until the 18th century.

Armed with this information, the scientists determined that the first smallpox ancestor emerged about 3,800 years ago. That’s very close to the historians’ estimate for the disease’s emergence. Proof at last of smallpox’s truly ancient origin. One might even say the researchers chose wisely.
 

The only hall of fame that really matters

LOTME loves the holiday season – the food, the gifts, the radio stations that play nothing but Christmas music – but for us the most wonderful time of the year comes just a bit later. No, it’s not our annual Golden Globes slap bet. Nope, not even the “excitement” of the College Football Playoff National Championship. It’s time for the National Inventors Hall of Fame to announce its latest inductees, and we could hardly sleep last night after putting cookies out for Thomas Edison. Fasten your seatbelts!

National Inventors Hall of Fame

• Robert G. Bryant is a NASA chemist who developed Langley Research Center-Soluble Imide (yes, that’s the actual name) a polymer used as an insulation material for leads in implantable cardiac resynchronization therapy devices.
• Rory Cooper is a biomedical engineer who was paralyzed in a bicycle accident. His work has improved manual and electric wheelchairs and advanced the health, mobility, and social inclusion of people with disabilities and older adults. He is also the first NIHF inductee named Rory.
• Katalin Karikó, a biochemist, and Drew Weissman, an immunologist, “discovered how to enable messenger ribonucleic acid (mRNA) to enter cells without triggering the body’s immune system,” NIHF said, and that laid the foundation for the mRNA COVID-19 vaccines developed by Pfizer-BioNTech and Moderna. That, of course, led to the antivax movement, which has provided so much LOTME fodder over the years.
• Angela Hartley Brodie was a biochemist who discovered and developed a class of drugs called aromatase inhibitors, which can stop the production of hormones that fuel cancer cell growth and are used to treat breast cancer in 500,000 women worldwide each year.

We can’t mention all of the inductees for 2023 (our editor made that very clear), but we would like to offer a special shout-out to brothers Cyril (the first Cyril in the NIHF, by the way) and Louis Keller, who invented the world’s first compact loader, which eventually became the Bobcat skid-steer loader. Not really medical, you’re probably thinking, but we’re sure that someone, somewhere, at some time, used one to build a hospital, landscape a hospital, or clean up after the demolition of a hospital.

Patients with acute decompensated heart failure who were frail at baseline improved more with targeted, early physical rehabilitation than those who were prefrail, a new analysis of the REHAB-HF study suggests.

“The robust response to the intervention by frail patients exceeded our expectations,” Gordon R. Reeves, MD, PT, of Novant Health Heart and Vascular Institute, Charlotte, N.C., told this news organization. “The effect size from improvement in physical function among frail patients was very large, with at least four times the minimal meaningful improvement, based on the Short Physical Performance Battery (SPPB).”

Furthermore, the interaction between baseline frailty status and treatment in REHAB-HF was such that a 2.6-fold larger improvement in SPPB was seen among frail versus prefrail patients.

However, Dr. Reeves noted, “We need to further evaluate safety and efficacy as it relates to adverse clinical events. Specifically, we observed a numerically higher number of deaths with the REHAB-HF intervention, which warrants further investigation before the intervention is implemented in clinical practice.”

The study was published online  in JAMA Cardiology.
 

Interpret with caution

Dr. Reeves and colleagues conducted a prespecified secondary analysis of the previously published Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a multicenter, randomized controlled trial that showed that a 3-month early, transitional, tailored, multidomain physical rehabilitation intervention improved physical function and quality of life (QoL), compared with usual care. The secondary analysis aimed to evaluate whether baseline frailty altered the benefits of the intervention or was associated with risk of adverse outcomes.

According to Dr. Reeves, REHAB-HF differs from more traditional cardiac rehab programs in several ways.

• The intervention targets patients with acute HF, including HF with preserved ejection fraction (HFpEF). Medicare policy limits standard cardiac rehabilitation in HF to long-term patients with HF with reduced ejection fraction (HFrEF) only who have been stabilized for 6 weeks or longer after a recent hospitalization.
• It addresses multiple physical function domains, including balance, mobility, functional strength, and endurance. Standard cardiac rehab is primarily focused on endurance training, which can result in injuries and falls if deficits in balance, mobility, and strength are not addressed first.
• It is delivered one to one rather than in a group setting and primarily by physical therapists who are experts in the rehabilitation of medically complex patients.
• It is transitional, beginning in the hospital, then moving to the outpatient setting, then to home and includes a home assessment.

For the analysis, the Fried phenotype model was used to assess baseline frailty across five domains: unintentional weight loss during the past year; self-reported exhaustion; grip strength; slowness, as assessed by gait speed; and low physical activity, as assessed by the Short Form-12 Physical Composite Score.

At the baseline visit, patients were categorized as frail if they met three or more of these criteria. They were categorized as prefrail if they met one or two criteria and as nonfrail if they met none of the criteria. Because of the small number of nonfrail participants, the analysis included only frail and prefrail participants.

The analysis included 337 participants (mean age, 72; 54%, women; 50%, Black). At baseline, 57% were frail, and 43% were prefrail.

A significant interaction was seen between baseline frailty and the intervention for the primary trial endpoint of overall SPPB score, with a 2.6-fold larger improvement in SPPB among frail (2.1) versus prefrail (0.8) patients.

Trends favored a larger intervention effect size, with significant improvement among frail versus prefrail participants for 6-minute walk distance, QoL, and the geriatric depression score.

“However, we must interpret these findings with caution,” the authors write. “The REHAB-HF trial was not adequately powered to determine the effect of the intervention on clinical events.” This plus the number of deaths “underscore the need for additional research, including prospective clinical trials, investigating the effect of physical function interventions on clinical events among frail patients with HF.”

To address this need, the researchers recently launched a larger clinical trial, called REHAB-HFpEF, which is powered to assess the impact of the intervention on clinical events, according to Dr. Reeves. “As the name implies,” he said, “this trial is focused on older patients recently hospitalized with HFpEF, who, [compared with HFrEF] also showed a more robust response to the intervention, with worse physical function and very high prevalence of frailty near the time of hospital discharge.”
 

‘Never too old or sick to benefit’

Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health’s Rusk Rehabilitation, said, “We have seen in clinical practice and in other (non–heart failure) clinical areas that frail older patients do improve proportionally more than younger and less frail patients with rehabilitation programs. Encouragingly, this very much supports the practice that patients are never too old or too sick to benefit from an individualized multidisciplinary rehabilitation program.”

However, he noted, “patients had to be independent with basic activities of daily living to be included in the study,” so many frail, elderly patients with heart failure who are not independent were not included in the study. It also wasn’t clear whether patients who received postacute care at a rehab facility before going home were included in the trial.

Furthermore, he said, outcomes over 1 to 5 years are needed to understand the long-term impact of the intervention.

On the other hand, he added, the fact that about half of participants were Black and were women is a “tremendous strength.”

“Repeating this study in population groups at high risk for frailty with different diagnoses, such as chronic lung diseases, interstitial lung diseases, chronic kidney disease, and rheumatologic disorders will further support the value of rehabilitation in improving patient health, function, quality of life, and reducing rehospitalizations and health care costs,” Dr. Whiteson concluded.

The study was supported by grants from the National Key R&D program. The authors have disclosed no relevant financial relationships.

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

Patients with acute decompensated heart failure who were frail at baseline improved more with targeted, early physical rehabilitation than those who were prefrail, a new analysis of the REHAB-HF study suggests.

“The robust response to the intervention by frail patients exceeded our expectations,” Gordon R. Reeves, MD, PT, of Novant Health Heart and Vascular Institute, Charlotte, N.C., told this news organization. “The effect size from improvement in physical function among frail patients was very large, with at least four times the minimal meaningful improvement, based on the Short Physical Performance Battery (SPPB).”

Furthermore, the interaction between baseline frailty status and treatment in REHAB-HF was such that a 2.6-fold larger improvement in SPPB was seen among frail versus prefrail patients.

However, Dr. Reeves noted, “We need to further evaluate safety and efficacy as it relates to adverse clinical events. Specifically, we observed a numerically higher number of deaths with the REHAB-HF intervention, which warrants further investigation before the intervention is implemented in clinical practice.”

The study was published online  in JAMA Cardiology.
 

Interpret with caution

Dr. Reeves and colleagues conducted a prespecified secondary analysis of the previously published Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a multicenter, randomized controlled trial that showed that a 3-month early, transitional, tailored, multidomain physical rehabilitation intervention improved physical function and quality of life (QoL), compared with usual care. The secondary analysis aimed to evaluate whether baseline frailty altered the benefits of the intervention or was associated with risk of adverse outcomes.

According to Dr. Reeves, REHAB-HF differs from more traditional cardiac rehab programs in several ways.

• The intervention targets patients with acute HF, including HF with preserved ejection fraction (HFpEF). Medicare policy limits standard cardiac rehabilitation in HF to long-term patients with HF with reduced ejection fraction (HFrEF) only who have been stabilized for 6 weeks or longer after a recent hospitalization.
• It addresses multiple physical function domains, including balance, mobility, functional strength, and endurance. Standard cardiac rehab is primarily focused on endurance training, which can result in injuries and falls if deficits in balance, mobility, and strength are not addressed first.
• It is delivered one to one rather than in a group setting and primarily by physical therapists who are experts in the rehabilitation of medically complex patients.
• It is transitional, beginning in the hospital, then moving to the outpatient setting, then to home and includes a home assessment.

For the analysis, the Fried phenotype model was used to assess baseline frailty across five domains: unintentional weight loss during the past year; self-reported exhaustion; grip strength; slowness, as assessed by gait speed; and low physical activity, as assessed by the Short Form-12 Physical Composite Score.

At the baseline visit, patients were categorized as frail if they met three or more of these criteria. They were categorized as prefrail if they met one or two criteria and as nonfrail if they met none of the criteria. Because of the small number of nonfrail participants, the analysis included only frail and prefrail participants.

The analysis included 337 participants (mean age, 72; 54%, women; 50%, Black). At baseline, 57% were frail, and 43% were prefrail.

A significant interaction was seen between baseline frailty and the intervention for the primary trial endpoint of overall SPPB score, with a 2.6-fold larger improvement in SPPB among frail (2.1) versus prefrail (0.8) patients.

Trends favored a larger intervention effect size, with significant improvement among frail versus prefrail participants for 6-minute walk distance, QoL, and the geriatric depression score.

“However, we must interpret these findings with caution,” the authors write. “The REHAB-HF trial was not adequately powered to determine the effect of the intervention on clinical events.” This plus the number of deaths “underscore the need for additional research, including prospective clinical trials, investigating the effect of physical function interventions on clinical events among frail patients with HF.”

To address this need, the researchers recently launched a larger clinical trial, called REHAB-HFpEF, which is powered to assess the impact of the intervention on clinical events, according to Dr. Reeves. “As the name implies,” he said, “this trial is focused on older patients recently hospitalized with HFpEF, who, [compared with HFrEF] also showed a more robust response to the intervention, with worse physical function and very high prevalence of frailty near the time of hospital discharge.”
 

‘Never too old or sick to benefit’

Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health’s Rusk Rehabilitation, said, “We have seen in clinical practice and in other (non–heart failure) clinical areas that frail older patients do improve proportionally more than younger and less frail patients with rehabilitation programs. Encouragingly, this very much supports the practice that patients are never too old or too sick to benefit from an individualized multidisciplinary rehabilitation program.”

However, he noted, “patients had to be independent with basic activities of daily living to be included in the study,” so many frail, elderly patients with heart failure who are not independent were not included in the study. It also wasn’t clear whether patients who received postacute care at a rehab facility before going home were included in the trial.

Furthermore, he said, outcomes over 1 to 5 years are needed to understand the long-term impact of the intervention.

On the other hand, he added, the fact that about half of participants were Black and were women is a “tremendous strength.”

“Repeating this study in population groups at high risk for frailty with different diagnoses, such as chronic lung diseases, interstitial lung diseases, chronic kidney disease, and rheumatologic disorders will further support the value of rehabilitation in improving patient health, function, quality of life, and reducing rehospitalizations and health care costs,” Dr. Whiteson concluded.

The study was supported by grants from the National Key R&D program. The authors have disclosed no relevant financial relationships.

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

Patients with acute decompensated heart failure who were frail at baseline improved more with targeted, early physical rehabilitation than those who were prefrail, a new analysis of the REHAB-HF study suggests.

“The robust response to the intervention by frail patients exceeded our expectations,” Gordon R. Reeves, MD, PT, of Novant Health Heart and Vascular Institute, Charlotte, N.C., told this news organization. “The effect size from improvement in physical function among frail patients was very large, with at least four times the minimal meaningful improvement, based on the Short Physical Performance Battery (SPPB).”

Furthermore, the interaction between baseline frailty status and treatment in REHAB-HF was such that a 2.6-fold larger improvement in SPPB was seen among frail versus prefrail patients.

However, Dr. Reeves noted, “We need to further evaluate safety and efficacy as it relates to adverse clinical events. Specifically, we observed a numerically higher number of deaths with the REHAB-HF intervention, which warrants further investigation before the intervention is implemented in clinical practice.”

The study was published online  in JAMA Cardiology.
 

Interpret with caution

Dr. Reeves and colleagues conducted a prespecified secondary analysis of the previously published Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a multicenter, randomized controlled trial that showed that a 3-month early, transitional, tailored, multidomain physical rehabilitation intervention improved physical function and quality of life (QoL), compared with usual care. The secondary analysis aimed to evaluate whether baseline frailty altered the benefits of the intervention or was associated with risk of adverse outcomes.

According to Dr. Reeves, REHAB-HF differs from more traditional cardiac rehab programs in several ways.

• The intervention targets patients with acute HF, including HF with preserved ejection fraction (HFpEF). Medicare policy limits standard cardiac rehabilitation in HF to long-term patients with HF with reduced ejection fraction (HFrEF) only who have been stabilized for 6 weeks or longer after a recent hospitalization.
• It addresses multiple physical function domains, including balance, mobility, functional strength, and endurance. Standard cardiac rehab is primarily focused on endurance training, which can result in injuries and falls if deficits in balance, mobility, and strength are not addressed first.
• It is delivered one to one rather than in a group setting and primarily by physical therapists who are experts in the rehabilitation of medically complex patients.
• It is transitional, beginning in the hospital, then moving to the outpatient setting, then to home and includes a home assessment.

For the analysis, the Fried phenotype model was used to assess baseline frailty across five domains: unintentional weight loss during the past year; self-reported exhaustion; grip strength; slowness, as assessed by gait speed; and low physical activity, as assessed by the Short Form-12 Physical Composite Score.

At the baseline visit, patients were categorized as frail if they met three or more of these criteria. They were categorized as prefrail if they met one or two criteria and as nonfrail if they met none of the criteria. Because of the small number of nonfrail participants, the analysis included only frail and prefrail participants.

The analysis included 337 participants (mean age, 72; 54%, women; 50%, Black). At baseline, 57% were frail, and 43% were prefrail.

A significant interaction was seen between baseline frailty and the intervention for the primary trial endpoint of overall SPPB score, with a 2.6-fold larger improvement in SPPB among frail (2.1) versus prefrail (0.8) patients.

Trends favored a larger intervention effect size, with significant improvement among frail versus prefrail participants for 6-minute walk distance, QoL, and the geriatric depression score.

“However, we must interpret these findings with caution,” the authors write. “The REHAB-HF trial was not adequately powered to determine the effect of the intervention on clinical events.” This plus the number of deaths “underscore the need for additional research, including prospective clinical trials, investigating the effect of physical function interventions on clinical events among frail patients with HF.”

To address this need, the researchers recently launched a larger clinical trial, called REHAB-HFpEF, which is powered to assess the impact of the intervention on clinical events, according to Dr. Reeves. “As the name implies,” he said, “this trial is focused on older patients recently hospitalized with HFpEF, who, [compared with HFrEF] also showed a more robust response to the intervention, with worse physical function and very high prevalence of frailty near the time of hospital discharge.”
 

‘Never too old or sick to benefit’

Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health’s Rusk Rehabilitation, said, “We have seen in clinical practice and in other (non–heart failure) clinical areas that frail older patients do improve proportionally more than younger and less frail patients with rehabilitation programs. Encouragingly, this very much supports the practice that patients are never too old or too sick to benefit from an individualized multidisciplinary rehabilitation program.”

However, he noted, “patients had to be independent with basic activities of daily living to be included in the study,” so many frail, elderly patients with heart failure who are not independent were not included in the study. It also wasn’t clear whether patients who received postacute care at a rehab facility before going home were included in the trial.

Furthermore, he said, outcomes over 1 to 5 years are needed to understand the long-term impact of the intervention.

On the other hand, he added, the fact that about half of participants were Black and were women is a “tremendous strength.”

“Repeating this study in population groups at high risk for frailty with different diagnoses, such as chronic lung diseases, interstitial lung diseases, chronic kidney disease, and rheumatologic disorders will further support the value of rehabilitation in improving patient health, function, quality of life, and reducing rehospitalizations and health care costs,” Dr. Whiteson concluded.

The study was supported by grants from the National Key R&D program. The authors have disclosed no relevant financial relationships.

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

Antihypertensive medications that stimulate rather than inhibit type 2 and 4 angiotensin II receptors can lower the rate of dementia among new users of these medications, new research suggests.

Results from a cohort study of more than 57,000 older Medicare beneficiaries showed that the initiation of antihypertensives that stimulate the receptors was linked to a 16% lower risk for incident Alzheimer’s disease and related dementia (ADRD) and an 18% lower risk for vascular dementia compared with those that inhibit the receptors.

“Achieving appropriate blood pressure control is essential for maximizing brain health, and this promising research suggests certain antihypertensives could yield brain benefit compared to others,” lead study author Zachary A. Marcum, PharmD, PhD, associate professor, University of Washington School of Pharmacy, Seattle, told this news organization.

The findings were published online in JAMA Network Open.
 

Medicare beneficiaries

Previous observational studies showed that antihypertensive medications that stimulate type 2 and 4 angiotensin II receptors, in comparison with those that don’t, were associated with lower rates of dementia. However, those studies included individuals with prevalent hypertension and were relatively small.

The new retrospective cohort study included a random sample of 57,773 Medicare beneficiaries aged at least 65 years with new-onset hypertension. The mean age of participants was 73.8 years, 62.9% were women, and 86.9% were White.

Over the course of the study, some participants filled at least one prescription for a stimulating angiotensin II receptor type 2 and 4, such as angiotensin II receptor type 1 blockers, dihydropyridine calcium channel blockers, and thiazide diuretics.

Others participants filled a prescription for an inhibiting type 2 and 4 angiotensin II receptors, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and nondihydropyridine calcium channel blockers.

“All these medications lower blood pressure, but they do it in different ways,” said Dr. Marcum.

The researchers were interested in the varying activity of these drugs at the type 2 and 4 angiotensin II receptors.

For each 30-day interval, they categorized beneficiaries into four groups: a stimulating medication group (n = 4,879) consisting of individuals mostly taking stimulating antihypertensives; an inhibiting medication group (n = 10,303) that mostly included individuals prescribed this type of antihypertensive; a mixed group (n = 2,179) that included a combination of the first two classifications; and a nonuser group (n = 40,413) of individuals who were not using either type of drug.

The primary outcome was time to first occurrence of ADRD. The secondary outcome was time to first occurrence of vascular dementia.

Researchers controlled for cardiovascular risk factors and sociodemographic characteristics, such as age, sex, race/ethnicity, and receipt of low-income subsidy.
 

Unanswered questions

After adjustments, results showed that initiation of an antihypertensive medication regimen that exclusively stimulates, rather than inhibits, type 2 and 4 angiotensin II receptors was associated with a 16% lower risk for incident ADRD over a follow-up of just under 7 years (hazard ratio, 0.84; 95% confidence interval, 0.79-0.90; P < .001).

The mixed regimen was also associated with statistically significant (P = .001) reduced odds of ADRD compared with the inhibiting medications.

As for vascular dementia, use of stimulating vs. inhibiting medications was associated with an 18% lower risk (HR, 0.82; 95% CI, 0.69-0.96; P = .02).

Again, use of the mixed regimen was associated with reduced risk of vascular dementia compared with the inhibiting medications (P = .03).

A variety of potential mechanisms might explain the superiority of stimulating agents when it comes to dementia risk, said Dr. Marcum. These could include, for example, increased blood flow to the brain and reduced amyloid.

“But more mechanistic work is needed as well as evaluation of dose responses, because that’s not something we looked at in this study,” Dr. Marcum said. “There are still a lot of unanswered questions.”
 

Stimulators instead of inhibitors?

The results of the current analysis come on the heels of some previous work showing the benefits of lowering blood pressure. For example, the Systolic Blood Pressure Intervention Trial (SPRINT) showed that targeting a systolic blood pressure below 120 mm Hg significantly reduces risk for heart disease, stroke, and death from these diseases.

But in contrast to previous research, the current study included only beneficiaries with incident hypertension and new use of antihypertensive medications, and it adjusted for time-varying confounding.

Prescribing stimulating instead of inhibiting treatments could make a difference at the population level, Dr. Marcum noted.

“If we could shift the prescribing a little bit from inhibiting to stimulating, that could possibly reduce dementia risk,” he said.

However, “we’re not suggesting [that all patients] have their regimen switched,” he added.

That’s because inhibiting medications still have an important place in the antihypertensive treatment armamentarium, Dr. Marcum noted. As an example, beta-blockers are used post heart attack.

As well, factors such as cost and side effects should be taken into consideration when prescribing an antihypertensive drug.

The new results could be used to set up a comparison in a future randomized controlled trial that would provide the strongest evidence for estimating causal effects of treatments, said Dr. Marcum.
 

‘More convincing’

Carlos G. Santos-Gallego, MD, Icahn School of Medicine at Mount Sinai, New York, said the study is “more convincing” than previous related research, as it has a larger sample size and a longer follow-up.

“And the exquisite statistical analysis gives more robustness, more solidity, to the hypothesis that drugs that stimulate type 2 and 4 angiotensin II receptors might be protective for dementia,” said Dr. Santos-Gallego, who was not involved with the research.

However, he noted that the retrospective study had some limitations, including the underdiagnosis of dementia. “The diagnosis of dementia is, honestly, very poorly done in the clinical setting,” he said.

As well, the study could be subject to “confounding by indication,” Dr. Santos-Gallego said. “There could be a third variable, another confounding factor, that’s responsible both for the dementia and for the prescription of these drugs,” he added.

For example, he noted that comorbidities such as atrial fibrillation, myocardial infarction, and heart failure might increase the risk of dementia.

He agreed with the investigators that a randomized clinical trial would address these limitations. “All comorbidities would be equally shared” in the randomized groups, and all participants would be given “a specific test for dementia at the same time,” Dr. Santos-Gallego said.

Still, he noted that the new results are in keeping with hypertension guidelines that recommend stimulating drugs.

“This trial definitely shows that the current hypertension guidelines are good treatment for our patients, not only to control blood pressure and not only to prevent infarction to prevent stroke but also to prevent dementia,” said Dr. Santos-Gallego.

Also commenting for this news organization, Heather Snyder, PhD, vice president of medical and scientific relations at the Alzheimer’s Association, said the new data provide “clarity” on why previous research had differing results on the effect of antihypertensives on cognition.

Among the caveats of this new analysis is that “it’s unclear if the demographics in this study are fully representative of Medicare beneficiaries,” said Dr. Snyder.

She, too, said a clinical trial is important “to understand if there is a preventative and/or treatment potential in the medications that stimulate type 2 and 4 angiotensin II receptors.”

The study received funding from the National Institute on Aging. Dr. Marcum and Dr. Santos-Gallego have reported no relevant financial relationships.

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

Antihypertensive medications that stimulate rather than inhibit type 2 and 4 angiotensin II receptors can lower the rate of dementia among new users of these medications, new research suggests.

Results from a cohort study of more than 57,000 older Medicare beneficiaries showed that the initiation of antihypertensives that stimulate the receptors was linked to a 16% lower risk for incident Alzheimer’s disease and related dementia (ADRD) and an 18% lower risk for vascular dementia compared with those that inhibit the receptors.

“Achieving appropriate blood pressure control is essential for maximizing brain health, and this promising research suggests certain antihypertensives could yield brain benefit compared to others,” lead study author Zachary A. Marcum, PharmD, PhD, associate professor, University of Washington School of Pharmacy, Seattle, told this news organization.

The findings were published online in JAMA Network Open.
 

Medicare beneficiaries

Previous observational studies showed that antihypertensive medications that stimulate type 2 and 4 angiotensin II receptors, in comparison with those that don’t, were associated with lower rates of dementia. However, those studies included individuals with prevalent hypertension and were relatively small.

The new retrospective cohort study included a random sample of 57,773 Medicare beneficiaries aged at least 65 years with new-onset hypertension. The mean age of participants was 73.8 years, 62.9% were women, and 86.9% were White.

Over the course of the study, some participants filled at least one prescription for a stimulating angiotensin II receptor type 2 and 4, such as angiotensin II receptor type 1 blockers, dihydropyridine calcium channel blockers, and thiazide diuretics.

Others participants filled a prescription for an inhibiting type 2 and 4 angiotensin II receptors, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and nondihydropyridine calcium channel blockers.

“All these medications lower blood pressure, but they do it in different ways,” said Dr. Marcum.

The researchers were interested in the varying activity of these drugs at the type 2 and 4 angiotensin II receptors.

For each 30-day interval, they categorized beneficiaries into four groups: a stimulating medication group (n = 4,879) consisting of individuals mostly taking stimulating antihypertensives; an inhibiting medication group (n = 10,303) that mostly included individuals prescribed this type of antihypertensive; a mixed group (n = 2,179) that included a combination of the first two classifications; and a nonuser group (n = 40,413) of individuals who were not using either type of drug.

The primary outcome was time to first occurrence of ADRD. The secondary outcome was time to first occurrence of vascular dementia.

Researchers controlled for cardiovascular risk factors and sociodemographic characteristics, such as age, sex, race/ethnicity, and receipt of low-income subsidy.
 

Unanswered questions

After adjustments, results showed that initiation of an antihypertensive medication regimen that exclusively stimulates, rather than inhibits, type 2 and 4 angiotensin II receptors was associated with a 16% lower risk for incident ADRD over a follow-up of just under 7 years (hazard ratio, 0.84; 95% confidence interval, 0.79-0.90; P < .001).

The mixed regimen was also associated with statistically significant (P = .001) reduced odds of ADRD compared with the inhibiting medications.

As for vascular dementia, use of stimulating vs. inhibiting medications was associated with an 18% lower risk (HR, 0.82; 95% CI, 0.69-0.96; P = .02).

Again, use of the mixed regimen was associated with reduced risk of vascular dementia compared with the inhibiting medications (P = .03).

A variety of potential mechanisms might explain the superiority of stimulating agents when it comes to dementia risk, said Dr. Marcum. These could include, for example, increased blood flow to the brain and reduced amyloid.

“But more mechanistic work is needed as well as evaluation of dose responses, because that’s not something we looked at in this study,” Dr. Marcum said. “There are still a lot of unanswered questions.”
 

Stimulators instead of inhibitors?

The results of the current analysis come on the heels of some previous work showing the benefits of lowering blood pressure. For example, the Systolic Blood Pressure Intervention Trial (SPRINT) showed that targeting a systolic blood pressure below 120 mm Hg significantly reduces risk for heart disease, stroke, and death from these diseases.

But in contrast to previous research, the current study included only beneficiaries with incident hypertension and new use of antihypertensive medications, and it adjusted for time-varying confounding.

Prescribing stimulating instead of inhibiting treatments could make a difference at the population level, Dr. Marcum noted.

“If we could shift the prescribing a little bit from inhibiting to stimulating, that could possibly reduce dementia risk,” he said.

However, “we’re not suggesting [that all patients] have their regimen switched,” he added.

That’s because inhibiting medications still have an important place in the antihypertensive treatment armamentarium, Dr. Marcum noted. As an example, beta-blockers are used post heart attack.

As well, factors such as cost and side effects should be taken into consideration when prescribing an antihypertensive drug.

The new results could be used to set up a comparison in a future randomized controlled trial that would provide the strongest evidence for estimating causal effects of treatments, said Dr. Marcum.
 

‘More convincing’

Carlos G. Santos-Gallego, MD, Icahn School of Medicine at Mount Sinai, New York, said the study is “more convincing” than previous related research, as it has a larger sample size and a longer follow-up.

“And the exquisite statistical analysis gives more robustness, more solidity, to the hypothesis that drugs that stimulate type 2 and 4 angiotensin II receptors might be protective for dementia,” said Dr. Santos-Gallego, who was not involved with the research.

However, he noted that the retrospective study had some limitations, including the underdiagnosis of dementia. “The diagnosis of dementia is, honestly, very poorly done in the clinical setting,” he said.

As well, the study could be subject to “confounding by indication,” Dr. Santos-Gallego said. “There could be a third variable, another confounding factor, that’s responsible both for the dementia and for the prescription of these drugs,” he added.

For example, he noted that comorbidities such as atrial fibrillation, myocardial infarction, and heart failure might increase the risk of dementia.

He agreed with the investigators that a randomized clinical trial would address these limitations. “All comorbidities would be equally shared” in the randomized groups, and all participants would be given “a specific test for dementia at the same time,” Dr. Santos-Gallego said.

Still, he noted that the new results are in keeping with hypertension guidelines that recommend stimulating drugs.

“This trial definitely shows that the current hypertension guidelines are good treatment for our patients, not only to control blood pressure and not only to prevent infarction to prevent stroke but also to prevent dementia,” said Dr. Santos-Gallego.

Also commenting for this news organization, Heather Snyder, PhD, vice president of medical and scientific relations at the Alzheimer’s Association, said the new data provide “clarity” on why previous research had differing results on the effect of antihypertensives on cognition.

Among the caveats of this new analysis is that “it’s unclear if the demographics in this study are fully representative of Medicare beneficiaries,” said Dr. Snyder.

She, too, said a clinical trial is important “to understand if there is a preventative and/or treatment potential in the medications that stimulate type 2 and 4 angiotensin II receptors.”

The study received funding from the National Institute on Aging. Dr. Marcum and Dr. Santos-Gallego have reported no relevant financial relationships.

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

Antihypertensive medications that stimulate rather than inhibit type 2 and 4 angiotensin II receptors can lower the rate of dementia among new users of these medications, new research suggests.

Results from a cohort study of more than 57,000 older Medicare beneficiaries showed that the initiation of antihypertensives that stimulate the receptors was linked to a 16% lower risk for incident Alzheimer’s disease and related dementia (ADRD) and an 18% lower risk for vascular dementia compared with those that inhibit the receptors.

“Achieving appropriate blood pressure control is essential for maximizing brain health, and this promising research suggests certain antihypertensives could yield brain benefit compared to others,” lead study author Zachary A. Marcum, PharmD, PhD, associate professor, University of Washington School of Pharmacy, Seattle, told this news organization.

The findings were published online in JAMA Network Open.
 

Medicare beneficiaries

Previous observational studies showed that antihypertensive medications that stimulate type 2 and 4 angiotensin II receptors, in comparison with those that don’t, were associated with lower rates of dementia. However, those studies included individuals with prevalent hypertension and were relatively small.

The new retrospective cohort study included a random sample of 57,773 Medicare beneficiaries aged at least 65 years with new-onset hypertension. The mean age of participants was 73.8 years, 62.9% were women, and 86.9% were White.

Over the course of the study, some participants filled at least one prescription for a stimulating angiotensin II receptor type 2 and 4, such as angiotensin II receptor type 1 blockers, dihydropyridine calcium channel blockers, and thiazide diuretics.

Others participants filled a prescription for an inhibiting type 2 and 4 angiotensin II receptors, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and nondihydropyridine calcium channel blockers.

“All these medications lower blood pressure, but they do it in different ways,” said Dr. Marcum.

The researchers were interested in the varying activity of these drugs at the type 2 and 4 angiotensin II receptors.

For each 30-day interval, they categorized beneficiaries into four groups: a stimulating medication group (n = 4,879) consisting of individuals mostly taking stimulating antihypertensives; an inhibiting medication group (n = 10,303) that mostly included individuals prescribed this type of antihypertensive; a mixed group (n = 2,179) that included a combination of the first two classifications; and a nonuser group (n = 40,413) of individuals who were not using either type of drug.

The primary outcome was time to first occurrence of ADRD. The secondary outcome was time to first occurrence of vascular dementia.

Researchers controlled for cardiovascular risk factors and sociodemographic characteristics, such as age, sex, race/ethnicity, and receipt of low-income subsidy.
 

Unanswered questions

After adjustments, results showed that initiation of an antihypertensive medication regimen that exclusively stimulates, rather than inhibits, type 2 and 4 angiotensin II receptors was associated with a 16% lower risk for incident ADRD over a follow-up of just under 7 years (hazard ratio, 0.84; 95% confidence interval, 0.79-0.90; P < .001).

The mixed regimen was also associated with statistically significant (P = .001) reduced odds of ADRD compared with the inhibiting medications.

As for vascular dementia, use of stimulating vs. inhibiting medications was associated with an 18% lower risk (HR, 0.82; 95% CI, 0.69-0.96; P = .02).

Again, use of the mixed regimen was associated with reduced risk of vascular dementia compared with the inhibiting medications (P = .03).

A variety of potential mechanisms might explain the superiority of stimulating agents when it comes to dementia risk, said Dr. Marcum. These could include, for example, increased blood flow to the brain and reduced amyloid.

“But more mechanistic work is needed as well as evaluation of dose responses, because that’s not something we looked at in this study,” Dr. Marcum said. “There are still a lot of unanswered questions.”
 

Stimulators instead of inhibitors?

The results of the current analysis come on the heels of some previous work showing the benefits of lowering blood pressure. For example, the Systolic Blood Pressure Intervention Trial (SPRINT) showed that targeting a systolic blood pressure below 120 mm Hg significantly reduces risk for heart disease, stroke, and death from these diseases.

But in contrast to previous research, the current study included only beneficiaries with incident hypertension and new use of antihypertensive medications, and it adjusted for time-varying confounding.

Prescribing stimulating instead of inhibiting treatments could make a difference at the population level, Dr. Marcum noted.

“If we could shift the prescribing a little bit from inhibiting to stimulating, that could possibly reduce dementia risk,” he said.

However, “we’re not suggesting [that all patients] have their regimen switched,” he added.

That’s because inhibiting medications still have an important place in the antihypertensive treatment armamentarium, Dr. Marcum noted. As an example, beta-blockers are used post heart attack.

As well, factors such as cost and side effects should be taken into consideration when prescribing an antihypertensive drug.

The new results could be used to set up a comparison in a future randomized controlled trial that would provide the strongest evidence for estimating causal effects of treatments, said Dr. Marcum.
 

‘More convincing’

Carlos G. Santos-Gallego, MD, Icahn School of Medicine at Mount Sinai, New York, said the study is “more convincing” than previous related research, as it has a larger sample size and a longer follow-up.

“And the exquisite statistical analysis gives more robustness, more solidity, to the hypothesis that drugs that stimulate type 2 and 4 angiotensin II receptors might be protective for dementia,” said Dr. Santos-Gallego, who was not involved with the research.

However, he noted that the retrospective study had some limitations, including the underdiagnosis of dementia. “The diagnosis of dementia is, honestly, very poorly done in the clinical setting,” he said.

As well, the study could be subject to “confounding by indication,” Dr. Santos-Gallego said. “There could be a third variable, another confounding factor, that’s responsible both for the dementia and for the prescription of these drugs,” he added.

For example, he noted that comorbidities such as atrial fibrillation, myocardial infarction, and heart failure might increase the risk of dementia.

He agreed with the investigators that a randomized clinical trial would address these limitations. “All comorbidities would be equally shared” in the randomized groups, and all participants would be given “a specific test for dementia at the same time,” Dr. Santos-Gallego said.

Still, he noted that the new results are in keeping with hypertension guidelines that recommend stimulating drugs.

“This trial definitely shows that the current hypertension guidelines are good treatment for our patients, not only to control blood pressure and not only to prevent infarction to prevent stroke but also to prevent dementia,” said Dr. Santos-Gallego.

Also commenting for this news organization, Heather Snyder, PhD, vice president of medical and scientific relations at the Alzheimer’s Association, said the new data provide “clarity” on why previous research had differing results on the effect of antihypertensives on cognition.

Among the caveats of this new analysis is that “it’s unclear if the demographics in this study are fully representative of Medicare beneficiaries,” said Dr. Snyder.

She, too, said a clinical trial is important “to understand if there is a preventative and/or treatment potential in the medications that stimulate type 2 and 4 angiotensin II receptors.”

The study received funding from the National Institute on Aging. Dr. Marcum and Dr. Santos-Gallego have reported no relevant financial relationships.

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

Dementia prevalence is 61% higher among older people with moderate to severe hearing loss compared with those with normal hearing, new national data show.

Investigators also found that even mild hearing loss was associated with increased dementia risk, although it was not statistically significant, and that hearing aid use was tied to a 32% decrease in dementia prevalence.

“Every 10-decibel increase in hearing loss was associated with 16% greater prevalence of dementia, such that prevalence of dementia in older adults with moderate or greater hearing loss was 61% higher than prevalence in those with normal hearing,” lead investigator Alison Huang, PhD, senior research associate in epidemiology at Johns Hopkins Bloomberg School of Public Health and core faculty in the Cochlear Center for Hearing and Public Health, Baltimore, Md., told this news organization.

The findings were published online in JAMA.
 

Dose-dependent effect

For the study, researchers analyzed data on 2,413 community-dwelling participants in the National Health and Aging Trends Study, a nationally representative, continuous panel study of U.S. Medicare beneficiaries aged 65 and older.

Data from the study were collected during in-home interviews, setting it apart from previous work that relied on data collected in a clinical setting, Dr. Huang said.

“This study was able to capture more vulnerable populations, such as the oldest old and older adults with disabilities, typically excluded from prior epidemiologic studies of the hearing loss–dementia association that use clinic-based data collection, which only captures people who have the ability and means to get to clinics,” Dr. Huang said.

Weighted hearing loss prevalence was 36.7% for mild and 29.8% for moderate to severe hearing loss, and weighted prevalence of dementia was 10.3%.

Those with moderate to severe hearing loss were 61% more likely to have dementia than those with normal hearing (prevalence ratio, 1.61; 95% confidence interval, 1.09-2.38).

Dementia prevalence increased with increasing severity of hearing loss: normal hearing: 6.19% (95% CI, 4.31-8.80); mild hearing loss: 8.93% (95% CI, 6.99-11.34); moderate/severe hearing loss: 16.52% (95% CI, 13.81-19.64). But only moderate to severe hearing loss showed a statistically significant association with dementia (P = .02).

Dementia prevalence increased 16% per 10-decibel increase in hearing loss (prevalence ratio 1.16; P < .001).

Among the 853 individuals in the study with moderate to severe hearing loss, those who used hearing aids (n = 414) had a 32% lower risk of dementia compared with those who didn’t use assistive devices (prevalence ratio, 0.68; 95% CI, 0.47-1.00). This news organization last month reported on similar data published in JAMA Neurology suggesting that hearing aids reduce dementia risk.

“With this study, we were able to refine our understanding of the strength of the hearing loss–dementia association in a study more representative of older adults in the United States,” said Dr. Huang.
 

Robust association

Commenting on the findings, Justin S. Golub, MD, associate professor in the department of otolaryngology–head and neck surgery at Columbia University, New York, said the study supports earlier research and suggests a “robust” association between hearing loss and dementia.

“The particular advantage of this study was that it was high quality and nationally representative,” Dr. Golub said. “It is also among a smaller set of studies that have shown hearing aid use to be associated with lower risk of dementia.”

Although not statistically significant, researchers did find increasing prevalence of dementia among people with only mild hearing loss, and clinicians should take note, said Dr. Golub, who was not involved with this study.

“We would expect the relationship between mild hearing loss and dementia to be weaker than severe hearing loss and dementia and, as a result, it might take more participants to show an association among the mild group,” Dr. Golub said.

“Even though this particular study did not specifically find a relationship between mild hearing loss and dementia, I would still recommend people to start treating their hearing loss when it is early,” Dr. Golub added.

The study was funded by the National Institute on Aging. Dr. Golub reports no relevant financial relationships.

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

Dementia prevalence is 61% higher among older people with moderate to severe hearing loss compared with those with normal hearing, new national data show.

Investigators also found that even mild hearing loss was associated with increased dementia risk, although it was not statistically significant, and that hearing aid use was tied to a 32% decrease in dementia prevalence.

“Every 10-decibel increase in hearing loss was associated with 16% greater prevalence of dementia, such that prevalence of dementia in older adults with moderate or greater hearing loss was 61% higher than prevalence in those with normal hearing,” lead investigator Alison Huang, PhD, senior research associate in epidemiology at Johns Hopkins Bloomberg School of Public Health and core faculty in the Cochlear Center for Hearing and Public Health, Baltimore, Md., told this news organization.

The findings were published online in JAMA.
 

Dose-dependent effect

For the study, researchers analyzed data on 2,413 community-dwelling participants in the National Health and Aging Trends Study, a nationally representative, continuous panel study of U.S. Medicare beneficiaries aged 65 and older.

Data from the study were collected during in-home interviews, setting it apart from previous work that relied on data collected in a clinical setting, Dr. Huang said.

“This study was able to capture more vulnerable populations, such as the oldest old and older adults with disabilities, typically excluded from prior epidemiologic studies of the hearing loss–dementia association that use clinic-based data collection, which only captures people who have the ability and means to get to clinics,” Dr. Huang said.

Weighted hearing loss prevalence was 36.7% for mild and 29.8% for moderate to severe hearing loss, and weighted prevalence of dementia was 10.3%.

Those with moderate to severe hearing loss were 61% more likely to have dementia than those with normal hearing (prevalence ratio, 1.61; 95% confidence interval, 1.09-2.38).

Dementia prevalence increased with increasing severity of hearing loss: normal hearing: 6.19% (95% CI, 4.31-8.80); mild hearing loss: 8.93% (95% CI, 6.99-11.34); moderate/severe hearing loss: 16.52% (95% CI, 13.81-19.64). But only moderate to severe hearing loss showed a statistically significant association with dementia (P = .02).

Dementia prevalence increased 16% per 10-decibel increase in hearing loss (prevalence ratio 1.16; P < .001).

Among the 853 individuals in the study with moderate to severe hearing loss, those who used hearing aids (n = 414) had a 32% lower risk of dementia compared with those who didn’t use assistive devices (prevalence ratio, 0.68; 95% CI, 0.47-1.00). This news organization last month reported on similar data published in JAMA Neurology suggesting that hearing aids reduce dementia risk.

“With this study, we were able to refine our understanding of the strength of the hearing loss–dementia association in a study more representative of older adults in the United States,” said Dr. Huang.
 

Robust association

Commenting on the findings, Justin S. Golub, MD, associate professor in the department of otolaryngology–head and neck surgery at Columbia University, New York, said the study supports earlier research and suggests a “robust” association between hearing loss and dementia.

“The particular advantage of this study was that it was high quality and nationally representative,” Dr. Golub said. “It is also among a smaller set of studies that have shown hearing aid use to be associated with lower risk of dementia.”

Although not statistically significant, researchers did find increasing prevalence of dementia among people with only mild hearing loss, and clinicians should take note, said Dr. Golub, who was not involved with this study.

“We would expect the relationship between mild hearing loss and dementia to be weaker than severe hearing loss and dementia and, as a result, it might take more participants to show an association among the mild group,” Dr. Golub said.

“Even though this particular study did not specifically find a relationship between mild hearing loss and dementia, I would still recommend people to start treating their hearing loss when it is early,” Dr. Golub added.

The study was funded by the National Institute on Aging. Dr. Golub reports no relevant financial relationships.

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

Dementia prevalence is 61% higher among older people with moderate to severe hearing loss compared with those with normal hearing, new national data show.

Investigators also found that even mild hearing loss was associated with increased dementia risk, although it was not statistically significant, and that hearing aid use was tied to a 32% decrease in dementia prevalence.

“Every 10-decibel increase in hearing loss was associated with 16% greater prevalence of dementia, such that prevalence of dementia in older adults with moderate or greater hearing loss was 61% higher than prevalence in those with normal hearing,” lead investigator Alison Huang, PhD, senior research associate in epidemiology at Johns Hopkins Bloomberg School of Public Health and core faculty in the Cochlear Center for Hearing and Public Health, Baltimore, Md., told this news organization.

The findings were published online in JAMA.
 

Dose-dependent effect

For the study, researchers analyzed data on 2,413 community-dwelling participants in the National Health and Aging Trends Study, a nationally representative, continuous panel study of U.S. Medicare beneficiaries aged 65 and older.

Data from the study were collected during in-home interviews, setting it apart from previous work that relied on data collected in a clinical setting, Dr. Huang said.

“This study was able to capture more vulnerable populations, such as the oldest old and older adults with disabilities, typically excluded from prior epidemiologic studies of the hearing loss–dementia association that use clinic-based data collection, which only captures people who have the ability and means to get to clinics,” Dr. Huang said.

Weighted hearing loss prevalence was 36.7% for mild and 29.8% for moderate to severe hearing loss, and weighted prevalence of dementia was 10.3%.

Those with moderate to severe hearing loss were 61% more likely to have dementia than those with normal hearing (prevalence ratio, 1.61; 95% confidence interval, 1.09-2.38).

Dementia prevalence increased with increasing severity of hearing loss: normal hearing: 6.19% (95% CI, 4.31-8.80); mild hearing loss: 8.93% (95% CI, 6.99-11.34); moderate/severe hearing loss: 16.52% (95% CI, 13.81-19.64). But only moderate to severe hearing loss showed a statistically significant association with dementia (P = .02).

Dementia prevalence increased 16% per 10-decibel increase in hearing loss (prevalence ratio 1.16; P < .001).

Among the 853 individuals in the study with moderate to severe hearing loss, those who used hearing aids (n = 414) had a 32% lower risk of dementia compared with those who didn’t use assistive devices (prevalence ratio, 0.68; 95% CI, 0.47-1.00). This news organization last month reported on similar data published in JAMA Neurology suggesting that hearing aids reduce dementia risk.

“With this study, we were able to refine our understanding of the strength of the hearing loss–dementia association in a study more representative of older adults in the United States,” said Dr. Huang.
 

Robust association

Commenting on the findings, Justin S. Golub, MD, associate professor in the department of otolaryngology–head and neck surgery at Columbia University, New York, said the study supports earlier research and suggests a “robust” association between hearing loss and dementia.

“The particular advantage of this study was that it was high quality and nationally representative,” Dr. Golub said. “It is also among a smaller set of studies that have shown hearing aid use to be associated with lower risk of dementia.”

Although not statistically significant, researchers did find increasing prevalence of dementia among people with only mild hearing loss, and clinicians should take note, said Dr. Golub, who was not involved with this study.

“We would expect the relationship between mild hearing loss and dementia to be weaker than severe hearing loss and dementia and, as a result, it might take more participants to show an association among the mild group,” Dr. Golub said.

“Even though this particular study did not specifically find a relationship between mild hearing loss and dementia, I would still recommend people to start treating their hearing loss when it is early,” Dr. Golub added.

The study was funded by the National Institute on Aging. Dr. Golub reports no relevant financial relationships.

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

This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I’m Dr. Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today is Sandeep Jauhar, a practicing cardiologist and professor of medicine at Northwell Health, a frequent New York Times op-ed contributor, and highly regarded author of the upcoming book “My Father’s Brain: Life in the Shadow of Alzheimer’s.”

We are here today to discuss the rationale for age competency exams for practicing physicians.

Sandeep Jauhar, MD: Thanks for having me.

Dr. Glatter: Your recent op-ed piece in the New York Times caught my eye. In your piece, you refer to a 2020 survey in which almost one-third of licensed doctors in the United States were 60 years of age or older, up from a quarter in 2010. You also state that, due to a 20% prevalence of mild cognitive impairment in persons older than 65, practicing physicians above this age should probably be screened by a battery of tests to ensure that their reasoning and cognitive abilities are intact. The title of the article is “How Would You Feel About a 100-Year-Old Doctor?”

How would you envision such a process? What aspects of day-to-day functioning would the exams truly be evaluating?

Dr. Jauhar: A significant number of people over 65 have measurable cognitive impairment. By cognitive impairment, we’re not talking about dementia. The best estimates are that 1 in 10 people over age 65 have dementia, and roughly 1 in 5 have what’s called MCI, or mild cognitive impairment, which is cognitive impairment out of proportion to what you’d expect from normal aging. It’s a significant issue.

The argument that I made in the op-ed is that neurocognitive assessment is important. That’s not to say that everyone over age 65 has significant cognitive impairment or that older doctors can’t practice medicine safely and effectively. They absolutely can. The question is, do we leave neurocognitive assessment to physicians who may possibly be suffering from impairment?

In dementia, people very often have impaired self-awareness, a condition called anosognosia, which is a neurological term for not being aware of your own impairment because of your impairment.

I would argue that, instead of having voluntary neurocognitive screening, it should be mandated. The question is how to do that effectively, fairly, and transparently.

One could argue a gerontocracy in medicine today, where there are so many older physicians. What do we do about that? That really is something that I think needs to be debated.

Dr. Glatter: The question I have is, if we (that is, physicians and the health care profession) don’t take care of this, someone’s going to do it for us. We need to jump on this now while we have the opportunity. The AMA has been opposed to this, except when you have reason to suspect cognitive decline or are concerned about patient safety. A mandatory age of retirement is certainly something they’re not for, and we know this.

Your argument in your op-ed piece is very well thought out, and you lay the groundwork for testing (looking at someone’s memory, coordination, processing speed, and other executive functions). Certainly, for a psychiatrist, hearing is important, and for a dermatologist, vision is important. For a surgeon, there are other issues. Based on the specialty, we must be careful to see the important aspects of functioning. I am sure you would agree with this.

Dr. Jauhar: Obviously, the hand skills that are important for ophthalmological surgery certainly aren’t required for office-based psychological counseling, for example. We have to be smart about how we assess impairment.

You describe the spectrum of actions. On the one hand, there’s mandatory retirement at the age of 65 or 70 years. We know that commercial pilots are mandated to essentially retire at 65, and air-traffic controllers must retire in their late 50s.

We know that there’s a large amount of variability in competence. There are internists in their 80s with whom I’ve worked, and I’m absolutely wowed by their experience and judgment. There are new medical resident graduates who don’t really seem to have the requisite level of competence that would make me feel comfortable to have them as my doctor or a doctor for a member of my family.

To mandate retirement, I think the AMA is absolutely right. To not call for any kind of competency testing, to me, seems equally unwise. Because at the end of the day, you have to balance individual physician needs or wants to continue practicing with patient safety. I haven’t really come across too many physicians who say, “There’s absolutely no need for a competency testing.”

We have to meet somewhere in the middle. The middle is either voluntary cognitive competency testing or mandatory. I would argue that, because we know that as the brain changes we have cognitive impairment, but we’re not always aware that we need help, mandatory testing is the way.

One other thing that you mentioned was about having the solution imposed on us. You and I are doctors. We deal with bureaucracy. We deal with poorly thought-out solutions to issues in health care that make our lives that much more difficult. I don’t want that solution imposed on us by some outside agency. I think we need to figure this out within medicine and figure out the right way of doing it.

The AMA is on board with this. They haven’t called for mandatory testing, but they have said that if testing were to occur, these are the guidelines. The guidelines are fair and equitable, not too time-consuming, transparent, and not punitive. If someone comes out and doesn’t test well, we shouldn’t force them out of the profession. We can find ways to use their experience to help train younger doctors, for example.

Dr. Glatter: I wanted to segue to an area where there has been some challenge to the legality of these mandatory types of age restrictions and imposing the exams as well. There’s been a lawsuit as well by the EEOC [Equal Employment Opportunity Commission], on behalf of Yale. Basically, there’s been a concern that ageism is part of what’s going on. Yale now screens their providers beginning at age 70, and they have a program. UCSD [University of California, San Diego] has a program in place. Obviously, these institutions are looking at it. This is a very small part of the overall picture.

Health care systems overall, we’re talking about a fraction of them in the country are really addressing the issue of competency exams. The question is, where do we go from here? How do we get engagement or adoption and get physicians as a whole to embrace this concept?

Dr. Jauhar: The EEOC filed a lawsuit on behalf of the Yale medical staff that argued that Yale’s plan to do vision testing and neurocognitive screening – there may be a physical exam also – constitutes age discrimination because it’s reserved for doctors over the age of 70. Those are the physicians who are most likely to have cognitive impairment.

We have rules already for impaired physicians who are, for example, addicted to illicit drugs or have alcohol abuse. We already have some of those measures in place. This is focused on cognitive impairment in aging physicians because cognitive impairment is an issue that arises with aging. We have to be clear about that.

Most younger physicians will not have measurable cognitive impairment that would impair their ability to practice. To force young physicians (for example, physicians in their forties) to undergo such screening, all in the name of preventing age discrimination, doesn’t strike me as being a good use of resources. They’re more likely to be false positives, as you know from Bayesian statistics. When you have low pretest probability, you’re more likely to get false positives.

How are we going to screen hundreds of thousands of physicians? We have to make a choice about the group that really is more likely to benefit from such screening. Very few hospitals are addressing this issue and it’s going to become more important.

Dr. Glatter: Surgeons have been particularly active in pushing for age-based screening. In 2016, the American College of Surgeons started making surgeons at age 65-70 undergo voluntary health and neurocognitive assessments, and encouraged physicians to disclose any concerning findings as part of their professional obligation, which is pretty impressive in my mind.

Surgeons’ skill set is quite demanding physically and technically. That the Society of Surgical Chairs took it upon themselves to institute this is pretty telling.

Dr. Jauhar: The overall society called for screening, but then in a separate survey of surgical chairs, the idea was advanced that we should have mandatory retirement. Now, I don’t particularly agree with that.

I’ve seen it, where you have the aging surgeon who was a star in their day, and no one wants to say anything when their skills have visibly degraded, and no one wants to carry that torch and tell them that they need to retire. What happens is people whisper, and unfortunately, bad outcomes have to occur before people tend to get involved, and that’s what I’m trying to prevent.

Dr. Glatter: The question is whether older physicians have worse patient outcomes. The evidence is inconclusive, but studies have shown higher mortality rates for cardiovascular surgeons in terms of the procedures that they do. On the flip side, there are also higher mortality rates for GI surgery performed by younger surgeons. It’s a mixed bag.

Dr. Jauhar: For specialized surgery, you need the accrual of a certain amount of experience. The optimal age is about 60, because they’ve seen many things and they’ve seen complications. They don’t have a hand tremor yet so they’re still functioning well, and they’ve accrued a lot of experience. We have to be smart about who we screen.

There’s a learning curve in surgery. By no means am I arguing that younger surgeons are better surgeons. I would say that there’s probably a tipping point where once you get past a certain age and physical deterioration starts to take effect, that can overshadow the accrual of cognitive and surgical experience. We have to balance those things.

I would say neurocognitive screening and vision testing are important, but exactly what do you measure? How much of a hand tremor would constitute a risk? These things have to be figured out. I just want doctors to be leading the charge here and not have this imposed by bureaucrats.

Dr. Glatter: I was reading that some doctors have had these exams administered and they can really pass cognitive aspects of the exam, but there have been nuances in the actual practicing of medicine, day-to-day functioning, which they’re not good at.

Someone made a comment that the only way to know if a doctor can do well in practice is to observe their practice and observe them taking care of patients. In other words, you can game the system and pass the cognitive exam in some form but then have a problem practicing medicine.

Dr. Jauhar: Ultimately, outcomes have to be measured. We can’t adopt such a granular approach for every aging physician. There has to be some sort of screening that maybe raises a red flag and then hospitals and department chairs need to investigate further. What are the outcomes? What are people saying in the operating room? I think the screening is just that; it’s a way of opening the door to further investigation, but it’s not a witch hunt.

I have the highest respect for older physicians, and I learn from them every day, honestly, especially in my field (cardiology), because some of the older physicians can hear and see things on physical exam that I didn’t even know existed. There’s much to be learned from them.

This is not intended to be a witch hunt or to try to get rid of older physicians – by any means. We want to avoid some of the outcomes that I read about in the New York Times comments section. It’s not fair to our patients not to do at least some sort of screening to prevent those kinds of mistakes.

Dr. Glatter: I wanted to go back to data from Yale between October 2016 and January 2019, where 141 Yale clinicians who ranged in age from 69 to 92 years completed cognitive assessments. Of those, 18 clinicians, or about 13% of those tested, demonstrated cognitive deficits that were “deemed likely to impair their ability to practice medicine independently.” That’s telling. These are subtleties, but they’re important to identify. I would love to get your comment on that.

Dr. Jauhar: It’s in keeping with what we know about the proportion of our older citizens who have cognitive impairment. About 10% have dementia and about 20% have at least mild cognitive impairment. That’s in keeping with what we know, and this was a general screening.

There are certain programs, like in San Diego, for example, where physicians are referred, and so there’s a selection bias. But this was just general screening. It’s worrisome. I’m an aging physician myself. I want fairness in this process because I’m going to be assessed as well.

I just don’t really understand yet why there’s so much circling of the wagons and so much resistance. It seems like it would be good for physicians also to be removed from situations where they might get into potential litigation because of mistakes and physical or visual impairment. It seems like it’d be good for patients and physicians alike.

Dr. Glatter: It’s difficult to give up your profession, change fields, or become administrative at some point, and [decide] when to make that transition. As we all get older, we’re not going to have the ability to do what we did in our 20s, 30s, and so forth.

Dr. Jauhar: Much of the resistance is coming from doctors who are used to high levels of autonomy. I’m certainly sympathetic to that because I don’t want anyone telling me how to practice. The reason this is coming up and hasn’t come up in the past is not because of loss of autonomy but because of an actual demographic change. Many physicians were trained in the 1960s, ’70s, or ’80s. They’re getting to retirement age but they’re not retiring, and we can speculate as to why that is.

In America’s educational system, doctors incur a huge amount of debt. I know physicians who are still paying off their debt and they’re in their 50s and 60s, so I’m very sympathetic to that. I’m not trying to force doctors out of practicing. I just want whoever is practicing to be competent and to practice safely. We have to figure out how to do that.

Dr. Glatter: The fact that there is a shortage of physicians forecast in the next 10-15 years makes many physicians reluctant to retire. They feel like they want to be part of that support network and we don’t want to have a dire situation, especially in the rural areas. We’re not immune from aging. We’re human beings. We all have to realize that.

Dr. Jauhar: I know that the ACC is starting to debate this issue, in part because of my op-ed. My hope is that it will start a conversation and we will institute a plan that comes from physicians and serves our patients, and doesn’t serve some cottage industry of testing or serve the needs of insurers or bureaucrats. It has to serve the doctor-patient relationship.

Dr. Glatter: In some random surveys that I’ve read, up to 30%-40% of physicians do support some type of age-based screening or competency assessment. The needle’s moving. It’s just not there yet. I think that wider adoption is coming.

Dr. Jauhar: Data are coming as more hospitals start to adopt these late practitioner programs. Some of the data that came out of Yale, for example, are very important. We’re going to see more published data in this area, and it will clarify what we need to do and how big the problem is.

Dr. Glatter: I want to thank you again for your time and for writing the op-ed because it certainly was well read and opened the eyes of not only physicians, but also the public at large. It’s a conversation that has to be had. Thank you for doing this.

Dr. Jauhar: Thanks for inviting me, Robert. It was a pleasure to talk to you.

Dr. Glatter is assistant professor of emergency medicine, department of emergency medicine, at Hofstra University, Hempstead, N.Y. Dr. Jauhar is director of the heart failure program, Long Island Jewish Medical Center, New Hyde Park, N.Y. Neither Dr. Glatter nor Dr. Jauhar reported any relevant conflicts of interest.

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

This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I’m Dr. Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today is Sandeep Jauhar, a practicing cardiologist and professor of medicine at Northwell Health, a frequent New York Times op-ed contributor, and highly regarded author of the upcoming book “My Father’s Brain: Life in the Shadow of Alzheimer’s.”

We are here today to discuss the rationale for age competency exams for practicing physicians.

Sandeep Jauhar, MD: Thanks for having me.

Dr. Glatter: Your recent op-ed piece in the New York Times caught my eye. In your piece, you refer to a 2020 survey in which almost one-third of licensed doctors in the United States were 60 years of age or older, up from a quarter in 2010. You also state that, due to a 20% prevalence of mild cognitive impairment in persons older than 65, practicing physicians above this age should probably be screened by a battery of tests to ensure that their reasoning and cognitive abilities are intact. The title of the article is “How Would You Feel About a 100-Year-Old Doctor?”

How would you envision such a process? What aspects of day-to-day functioning would the exams truly be evaluating?

Dr. Jauhar: A significant number of people over 65 have measurable cognitive impairment. By cognitive impairment, we’re not talking about dementia. The best estimates are that 1 in 10 people over age 65 have dementia, and roughly 1 in 5 have what’s called MCI, or mild cognitive impairment, which is cognitive impairment out of proportion to what you’d expect from normal aging. It’s a significant issue.

The argument that I made in the op-ed is that neurocognitive assessment is important. That’s not to say that everyone over age 65 has significant cognitive impairment or that older doctors can’t practice medicine safely and effectively. They absolutely can. The question is, do we leave neurocognitive assessment to physicians who may possibly be suffering from impairment?

In dementia, people very often have impaired self-awareness, a condition called anosognosia, which is a neurological term for not being aware of your own impairment because of your impairment.

I would argue that, instead of having voluntary neurocognitive screening, it should be mandated. The question is how to do that effectively, fairly, and transparently.

One could argue a gerontocracy in medicine today, where there are so many older physicians. What do we do about that? That really is something that I think needs to be debated.

Dr. Glatter: The question I have is, if we (that is, physicians and the health care profession) don’t take care of this, someone’s going to do it for us. We need to jump on this now while we have the opportunity. The AMA has been opposed to this, except when you have reason to suspect cognitive decline or are concerned about patient safety. A mandatory age of retirement is certainly something they’re not for, and we know this.

Your argument in your op-ed piece is very well thought out, and you lay the groundwork for testing (looking at someone’s memory, coordination, processing speed, and other executive functions). Certainly, for a psychiatrist, hearing is important, and for a dermatologist, vision is important. For a surgeon, there are other issues. Based on the specialty, we must be careful to see the important aspects of functioning. I am sure you would agree with this.

Dr. Jauhar: Obviously, the hand skills that are important for ophthalmological surgery certainly aren’t required for office-based psychological counseling, for example. We have to be smart about how we assess impairment.

You describe the spectrum of actions. On the one hand, there’s mandatory retirement at the age of 65 or 70 years. We know that commercial pilots are mandated to essentially retire at 65, and air-traffic controllers must retire in their late 50s.

We know that there’s a large amount of variability in competence. There are internists in their 80s with whom I’ve worked, and I’m absolutely wowed by their experience and judgment. There are new medical resident graduates who don’t really seem to have the requisite level of competence that would make me feel comfortable to have them as my doctor or a doctor for a member of my family.

To mandate retirement, I think the AMA is absolutely right. To not call for any kind of competency testing, to me, seems equally unwise. Because at the end of the day, you have to balance individual physician needs or wants to continue practicing with patient safety. I haven’t really come across too many physicians who say, “There’s absolutely no need for a competency testing.”

We have to meet somewhere in the middle. The middle is either voluntary cognitive competency testing or mandatory. I would argue that, because we know that as the brain changes we have cognitive impairment, but we’re not always aware that we need help, mandatory testing is the way.

One other thing that you mentioned was about having the solution imposed on us. You and I are doctors. We deal with bureaucracy. We deal with poorly thought-out solutions to issues in health care that make our lives that much more difficult. I don’t want that solution imposed on us by some outside agency. I think we need to figure this out within medicine and figure out the right way of doing it.

The AMA is on board with this. They haven’t called for mandatory testing, but they have said that if testing were to occur, these are the guidelines. The guidelines are fair and equitable, not too time-consuming, transparent, and not punitive. If someone comes out and doesn’t test well, we shouldn’t force them out of the profession. We can find ways to use their experience to help train younger doctors, for example.

Dr. Glatter: I wanted to segue to an area where there has been some challenge to the legality of these mandatory types of age restrictions and imposing the exams as well. There’s been a lawsuit as well by the EEOC [Equal Employment Opportunity Commission], on behalf of Yale. Basically, there’s been a concern that ageism is part of what’s going on. Yale now screens their providers beginning at age 70, and they have a program. UCSD [University of California, San Diego] has a program in place. Obviously, these institutions are looking at it. This is a very small part of the overall picture.

Health care systems overall, we’re talking about a fraction of them in the country are really addressing the issue of competency exams. The question is, where do we go from here? How do we get engagement or adoption and get physicians as a whole to embrace this concept?

Dr. Jauhar: The EEOC filed a lawsuit on behalf of the Yale medical staff that argued that Yale’s plan to do vision testing and neurocognitive screening – there may be a physical exam also – constitutes age discrimination because it’s reserved for doctors over the age of 70. Those are the physicians who are most likely to have cognitive impairment.

We have rules already for impaired physicians who are, for example, addicted to illicit drugs or have alcohol abuse. We already have some of those measures in place. This is focused on cognitive impairment in aging physicians because cognitive impairment is an issue that arises with aging. We have to be clear about that.

Most younger physicians will not have measurable cognitive impairment that would impair their ability to practice. To force young physicians (for example, physicians in their forties) to undergo such screening, all in the name of preventing age discrimination, doesn’t strike me as being a good use of resources. They’re more likely to be false positives, as you know from Bayesian statistics. When you have low pretest probability, you’re more likely to get false positives.

How are we going to screen hundreds of thousands of physicians? We have to make a choice about the group that really is more likely to benefit from such screening. Very few hospitals are addressing this issue and it’s going to become more important.

Dr. Glatter: Surgeons have been particularly active in pushing for age-based screening. In 2016, the American College of Surgeons started making surgeons at age 65-70 undergo voluntary health and neurocognitive assessments, and encouraged physicians to disclose any concerning findings as part of their professional obligation, which is pretty impressive in my mind.

Surgeons’ skill set is quite demanding physically and technically. That the Society of Surgical Chairs took it upon themselves to institute this is pretty telling.

Dr. Jauhar: The overall society called for screening, but then in a separate survey of surgical chairs, the idea was advanced that we should have mandatory retirement. Now, I don’t particularly agree with that.

I’ve seen it, where you have the aging surgeon who was a star in their day, and no one wants to say anything when their skills have visibly degraded, and no one wants to carry that torch and tell them that they need to retire. What happens is people whisper, and unfortunately, bad outcomes have to occur before people tend to get involved, and that’s what I’m trying to prevent.

Dr. Glatter: The question is whether older physicians have worse patient outcomes. The evidence is inconclusive, but studies have shown higher mortality rates for cardiovascular surgeons in terms of the procedures that they do. On the flip side, there are also higher mortality rates for GI surgery performed by younger surgeons. It’s a mixed bag.

Dr. Jauhar: For specialized surgery, you need the accrual of a certain amount of experience. The optimal age is about 60, because they’ve seen many things and they’ve seen complications. They don’t have a hand tremor yet so they’re still functioning well, and they’ve accrued a lot of experience. We have to be smart about who we screen.

There’s a learning curve in surgery. By no means am I arguing that younger surgeons are better surgeons. I would say that there’s probably a tipping point where once you get past a certain age and physical deterioration starts to take effect, that can overshadow the accrual of cognitive and surgical experience. We have to balance those things.

I would say neurocognitive screening and vision testing are important, but exactly what do you measure? How much of a hand tremor would constitute a risk? These things have to be figured out. I just want doctors to be leading the charge here and not have this imposed by bureaucrats.

Dr. Glatter: I was reading that some doctors have had these exams administered and they can really pass cognitive aspects of the exam, but there have been nuances in the actual practicing of medicine, day-to-day functioning, which they’re not good at.

Someone made a comment that the only way to know if a doctor can do well in practice is to observe their practice and observe them taking care of patients. In other words, you can game the system and pass the cognitive exam in some form but then have a problem practicing medicine.

Dr. Jauhar: Ultimately, outcomes have to be measured. We can’t adopt such a granular approach for every aging physician. There has to be some sort of screening that maybe raises a red flag and then hospitals and department chairs need to investigate further. What are the outcomes? What are people saying in the operating room? I think the screening is just that; it’s a way of opening the door to further investigation, but it’s not a witch hunt.

I have the highest respect for older physicians, and I learn from them every day, honestly, especially in my field (cardiology), because some of the older physicians can hear and see things on physical exam that I didn’t even know existed. There’s much to be learned from them.

This is not intended to be a witch hunt or to try to get rid of older physicians – by any means. We want to avoid some of the outcomes that I read about in the New York Times comments section. It’s not fair to our patients not to do at least some sort of screening to prevent those kinds of mistakes.

Dr. Glatter: I wanted to go back to data from Yale between October 2016 and January 2019, where 141 Yale clinicians who ranged in age from 69 to 92 years completed cognitive assessments. Of those, 18 clinicians, or about 13% of those tested, demonstrated cognitive deficits that were “deemed likely to impair their ability to practice medicine independently.” That’s telling. These are subtleties, but they’re important to identify. I would love to get your comment on that.

Dr. Jauhar: It’s in keeping with what we know about the proportion of our older citizens who have cognitive impairment. About 10% have dementia and about 20% have at least mild cognitive impairment. That’s in keeping with what we know, and this was a general screening.

There are certain programs, like in San Diego, for example, where physicians are referred, and so there’s a selection bias. But this was just general screening. It’s worrisome. I’m an aging physician myself. I want fairness in this process because I’m going to be assessed as well.

I just don’t really understand yet why there’s so much circling of the wagons and so much resistance. It seems like it would be good for physicians also to be removed from situations where they might get into potential litigation because of mistakes and physical or visual impairment. It seems like it’d be good for patients and physicians alike.

Dr. Glatter: It’s difficult to give up your profession, change fields, or become administrative at some point, and [decide] when to make that transition. As we all get older, we’re not going to have the ability to do what we did in our 20s, 30s, and so forth.

Dr. Jauhar: Much of the resistance is coming from doctors who are used to high levels of autonomy. I’m certainly sympathetic to that because I don’t want anyone telling me how to practice. The reason this is coming up and hasn’t come up in the past is not because of loss of autonomy but because of an actual demographic change. Many physicians were trained in the 1960s, ’70s, or ’80s. They’re getting to retirement age but they’re not retiring, and we can speculate as to why that is.

In America’s educational system, doctors incur a huge amount of debt. I know physicians who are still paying off their debt and they’re in their 50s and 60s, so I’m very sympathetic to that. I’m not trying to force doctors out of practicing. I just want whoever is practicing to be competent and to practice safely. We have to figure out how to do that.

Dr. Glatter: The fact that there is a shortage of physicians forecast in the next 10-15 years makes many physicians reluctant to retire. They feel like they want to be part of that support network and we don’t want to have a dire situation, especially in the rural areas. We’re not immune from aging. We’re human beings. We all have to realize that.

Dr. Jauhar: I know that the ACC is starting to debate this issue, in part because of my op-ed. My hope is that it will start a conversation and we will institute a plan that comes from physicians and serves our patients, and doesn’t serve some cottage industry of testing or serve the needs of insurers or bureaucrats. It has to serve the doctor-patient relationship.

Dr. Glatter: In some random surveys that I’ve read, up to 30%-40% of physicians do support some type of age-based screening or competency assessment. The needle’s moving. It’s just not there yet. I think that wider adoption is coming.

Dr. Jauhar: Data are coming as more hospitals start to adopt these late practitioner programs. Some of the data that came out of Yale, for example, are very important. We’re going to see more published data in this area, and it will clarify what we need to do and how big the problem is.

Dr. Glatter: I want to thank you again for your time and for writing the op-ed because it certainly was well read and opened the eyes of not only physicians, but also the public at large. It’s a conversation that has to be had. Thank you for doing this.

Dr. Jauhar: Thanks for inviting me, Robert. It was a pleasure to talk to you.

Dr. Glatter is assistant professor of emergency medicine, department of emergency medicine, at Hofstra University, Hempstead, N.Y. Dr. Jauhar is director of the heart failure program, Long Island Jewish Medical Center, New Hyde Park, N.Y. Neither Dr. Glatter nor Dr. Jauhar reported any relevant conflicts of interest.

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

This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I’m Dr. Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today is Sandeep Jauhar, a practicing cardiologist and professor of medicine at Northwell Health, a frequent New York Times op-ed contributor, and highly regarded author of the upcoming book “My Father’s Brain: Life in the Shadow of Alzheimer’s.”

We are here today to discuss the rationale for age competency exams for practicing physicians.

Sandeep Jauhar, MD: Thanks for having me.

Dr. Glatter: Your recent op-ed piece in the New York Times caught my eye. In your piece, you refer to a 2020 survey in which almost one-third of licensed doctors in the United States were 60 years of age or older, up from a quarter in 2010. You also state that, due to a 20% prevalence of mild cognitive impairment in persons older than 65, practicing physicians above this age should probably be screened by a battery of tests to ensure that their reasoning and cognitive abilities are intact. The title of the article is “How Would You Feel About a 100-Year-Old Doctor?”

How would you envision such a process? What aspects of day-to-day functioning would the exams truly be evaluating?

Dr. Jauhar: A significant number of people over 65 have measurable cognitive impairment. By cognitive impairment, we’re not talking about dementia. The best estimates are that 1 in 10 people over age 65 have dementia, and roughly 1 in 5 have what’s called MCI, or mild cognitive impairment, which is cognitive impairment out of proportion to what you’d expect from normal aging. It’s a significant issue.

The argument that I made in the op-ed is that neurocognitive assessment is important. That’s not to say that everyone over age 65 has significant cognitive impairment or that older doctors can’t practice medicine safely and effectively. They absolutely can. The question is, do we leave neurocognitive assessment to physicians who may possibly be suffering from impairment?

In dementia, people very often have impaired self-awareness, a condition called anosognosia, which is a neurological term for not being aware of your own impairment because of your impairment.

I would argue that, instead of having voluntary neurocognitive screening, it should be mandated. The question is how to do that effectively, fairly, and transparently.

One could argue a gerontocracy in medicine today, where there are so many older physicians. What do we do about that? That really is something that I think needs to be debated.

Dr. Glatter: The question I have is, if we (that is, physicians and the health care profession) don’t take care of this, someone’s going to do it for us. We need to jump on this now while we have the opportunity. The AMA has been opposed to this, except when you have reason to suspect cognitive decline or are concerned about patient safety. A mandatory age of retirement is certainly something they’re not for, and we know this.

Your argument in your op-ed piece is very well thought out, and you lay the groundwork for testing (looking at someone’s memory, coordination, processing speed, and other executive functions). Certainly, for a psychiatrist, hearing is important, and for a dermatologist, vision is important. For a surgeon, there are other issues. Based on the specialty, we must be careful to see the important aspects of functioning. I am sure you would agree with this.

Dr. Jauhar: Obviously, the hand skills that are important for ophthalmological surgery certainly aren’t required for office-based psychological counseling, for example. We have to be smart about how we assess impairment.

You describe the spectrum of actions. On the one hand, there’s mandatory retirement at the age of 65 or 70 years. We know that commercial pilots are mandated to essentially retire at 65, and air-traffic controllers must retire in their late 50s.

We know that there’s a large amount of variability in competence. There are internists in their 80s with whom I’ve worked, and I’m absolutely wowed by their experience and judgment. There are new medical resident graduates who don’t really seem to have the requisite level of competence that would make me feel comfortable to have them as my doctor or a doctor for a member of my family.

To mandate retirement, I think the AMA is absolutely right. To not call for any kind of competency testing, to me, seems equally unwise. Because at the end of the day, you have to balance individual physician needs or wants to continue practicing with patient safety. I haven’t really come across too many physicians who say, “There’s absolutely no need for a competency testing.”

We have to meet somewhere in the middle. The middle is either voluntary cognitive competency testing or mandatory. I would argue that, because we know that as the brain changes we have cognitive impairment, but we’re not always aware that we need help, mandatory testing is the way.

One other thing that you mentioned was about having the solution imposed on us. You and I are doctors. We deal with bureaucracy. We deal with poorly thought-out solutions to issues in health care that make our lives that much more difficult. I don’t want that solution imposed on us by some outside agency. I think we need to figure this out within medicine and figure out the right way of doing it.

The AMA is on board with this. They haven’t called for mandatory testing, but they have said that if testing were to occur, these are the guidelines. The guidelines are fair and equitable, not too time-consuming, transparent, and not punitive. If someone comes out and doesn’t test well, we shouldn’t force them out of the profession. We can find ways to use their experience to help train younger doctors, for example.

Dr. Glatter: I wanted to segue to an area where there has been some challenge to the legality of these mandatory types of age restrictions and imposing the exams as well. There’s been a lawsuit as well by the EEOC [Equal Employment Opportunity Commission], on behalf of Yale. Basically, there’s been a concern that ageism is part of what’s going on. Yale now screens their providers beginning at age 70, and they have a program. UCSD [University of California, San Diego] has a program in place. Obviously, these institutions are looking at it. This is a very small part of the overall picture.

Health care systems overall, we’re talking about a fraction of them in the country are really addressing the issue of competency exams. The question is, where do we go from here? How do we get engagement or adoption and get physicians as a whole to embrace this concept?

Dr. Jauhar: The EEOC filed a lawsuit on behalf of the Yale medical staff that argued that Yale’s plan to do vision testing and neurocognitive screening – there may be a physical exam also – constitutes age discrimination because it’s reserved for doctors over the age of 70. Those are the physicians who are most likely to have cognitive impairment.

We have rules already for impaired physicians who are, for example, addicted to illicit drugs or have alcohol abuse. We already have some of those measures in place. This is focused on cognitive impairment in aging physicians because cognitive impairment is an issue that arises with aging. We have to be clear about that.

Most younger physicians will not have measurable cognitive impairment that would impair their ability to practice. To force young physicians (for example, physicians in their forties) to undergo such screening, all in the name of preventing age discrimination, doesn’t strike me as being a good use of resources. They’re more likely to be false positives, as you know from Bayesian statistics. When you have low pretest probability, you’re more likely to get false positives.

How are we going to screen hundreds of thousands of physicians? We have to make a choice about the group that really is more likely to benefit from such screening. Very few hospitals are addressing this issue and it’s going to become more important.

Dr. Glatter: Surgeons have been particularly active in pushing for age-based screening. In 2016, the American College of Surgeons started making surgeons at age 65-70 undergo voluntary health and neurocognitive assessments, and encouraged physicians to disclose any concerning findings as part of their professional obligation, which is pretty impressive in my mind.

Surgeons’ skill set is quite demanding physically and technically. That the Society of Surgical Chairs took it upon themselves to institute this is pretty telling.

Dr. Jauhar: The overall society called for screening, but then in a separate survey of surgical chairs, the idea was advanced that we should have mandatory retirement. Now, I don’t particularly agree with that.

I’ve seen it, where you have the aging surgeon who was a star in their day, and no one wants to say anything when their skills have visibly degraded, and no one wants to carry that torch and tell them that they need to retire. What happens is people whisper, and unfortunately, bad outcomes have to occur before people tend to get involved, and that’s what I’m trying to prevent.

Dr. Glatter: The question is whether older physicians have worse patient outcomes. The evidence is inconclusive, but studies have shown higher mortality rates for cardiovascular surgeons in terms of the procedures that they do. On the flip side, there are also higher mortality rates for GI surgery performed by younger surgeons. It’s a mixed bag.

Dr. Jauhar: For specialized surgery, you need the accrual of a certain amount of experience. The optimal age is about 60, because they’ve seen many things and they’ve seen complications. They don’t have a hand tremor yet so they’re still functioning well, and they’ve accrued a lot of experience. We have to be smart about who we screen.

There’s a learning curve in surgery. By no means am I arguing that younger surgeons are better surgeons. I would say that there’s probably a tipping point where once you get past a certain age and physical deterioration starts to take effect, that can overshadow the accrual of cognitive and surgical experience. We have to balance those things.

I would say neurocognitive screening and vision testing are important, but exactly what do you measure? How much of a hand tremor would constitute a risk? These things have to be figured out. I just want doctors to be leading the charge here and not have this imposed by bureaucrats.

Dr. Glatter: I was reading that some doctors have had these exams administered and they can really pass cognitive aspects of the exam, but there have been nuances in the actual practicing of medicine, day-to-day functioning, which they’re not good at.

Someone made a comment that the only way to know if a doctor can do well in practice is to observe their practice and observe them taking care of patients. In other words, you can game the system and pass the cognitive exam in some form but then have a problem practicing medicine.

Dr. Jauhar: Ultimately, outcomes have to be measured. We can’t adopt such a granular approach for every aging physician. There has to be some sort of screening that maybe raises a red flag and then hospitals and department chairs need to investigate further. What are the outcomes? What are people saying in the operating room? I think the screening is just that; it’s a way of opening the door to further investigation, but it’s not a witch hunt.

I have the highest respect for older physicians, and I learn from them every day, honestly, especially in my field (cardiology), because some of the older physicians can hear and see things on physical exam that I didn’t even know existed. There’s much to be learned from them.

This is not intended to be a witch hunt or to try to get rid of older physicians – by any means. We want to avoid some of the outcomes that I read about in the New York Times comments section. It’s not fair to our patients not to do at least some sort of screening to prevent those kinds of mistakes.

Dr. Glatter: I wanted to go back to data from Yale between October 2016 and January 2019, where 141 Yale clinicians who ranged in age from 69 to 92 years completed cognitive assessments. Of those, 18 clinicians, or about 13% of those tested, demonstrated cognitive deficits that were “deemed likely to impair their ability to practice medicine independently.” That’s telling. These are subtleties, but they’re important to identify. I would love to get your comment on that.

Dr. Jauhar: It’s in keeping with what we know about the proportion of our older citizens who have cognitive impairment. About 10% have dementia and about 20% have at least mild cognitive impairment. That’s in keeping with what we know, and this was a general screening.

There are certain programs, like in San Diego, for example, where physicians are referred, and so there’s a selection bias. But this was just general screening. It’s worrisome. I’m an aging physician myself. I want fairness in this process because I’m going to be assessed as well.

I just don’t really understand yet why there’s so much circling of the wagons and so much resistance. It seems like it would be good for physicians also to be removed from situations where they might get into potential litigation because of mistakes and physical or visual impairment. It seems like it’d be good for patients and physicians alike.

Dr. Glatter: It’s difficult to give up your profession, change fields, or become administrative at some point, and [decide] when to make that transition. As we all get older, we’re not going to have the ability to do what we did in our 20s, 30s, and so forth.

Dr. Jauhar: Much of the resistance is coming from doctors who are used to high levels of autonomy. I’m certainly sympathetic to that because I don’t want anyone telling me how to practice. The reason this is coming up and hasn’t come up in the past is not because of loss of autonomy but because of an actual demographic change. Many physicians were trained in the 1960s, ’70s, or ’80s. They’re getting to retirement age but they’re not retiring, and we can speculate as to why that is.

In America’s educational system, doctors incur a huge amount of debt. I know physicians who are still paying off their debt and they’re in their 50s and 60s, so I’m very sympathetic to that. I’m not trying to force doctors out of practicing. I just want whoever is practicing to be competent and to practice safely. We have to figure out how to do that.

Dr. Glatter: The fact that there is a shortage of physicians forecast in the next 10-15 years makes many physicians reluctant to retire. They feel like they want to be part of that support network and we don’t want to have a dire situation, especially in the rural areas. We’re not immune from aging. We’re human beings. We all have to realize that.

Dr. Jauhar: I know that the ACC is starting to debate this issue, in part because of my op-ed. My hope is that it will start a conversation and we will institute a plan that comes from physicians and serves our patients, and doesn’t serve some cottage industry of testing or serve the needs of insurers or bureaucrats. It has to serve the doctor-patient relationship.

Dr. Glatter: In some random surveys that I’ve read, up to 30%-40% of physicians do support some type of age-based screening or competency assessment. The needle’s moving. It’s just not there yet. I think that wider adoption is coming.

Dr. Jauhar: Data are coming as more hospitals start to adopt these late practitioner programs. Some of the data that came out of Yale, for example, are very important. We’re going to see more published data in this area, and it will clarify what we need to do and how big the problem is.

Dr. Glatter: I want to thank you again for your time and for writing the op-ed because it certainly was well read and opened the eyes of not only physicians, but also the public at large. It’s a conversation that has to be had. Thank you for doing this.

Dr. Jauhar: Thanks for inviting me, Robert. It was a pleasure to talk to you.

Dr. Glatter is assistant professor of emergency medicine, department of emergency medicine, at Hofstra University, Hempstead, N.Y. Dr. Jauhar is director of the heart failure program, Long Island Jewish Medical Center, New Hyde Park, N.Y. Neither Dr. Glatter nor Dr. Jauhar reported any relevant conflicts of interest.

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