Journal Highlights | Volume 16, ISSUE 9, P22, September 2015

From the September Issue of JAMDA

        Cognitive Health Panel

        When combined with medical and lifestyle interventions, identification of early cognitive impairment through case findings is an important step toward enhancing brain health among older individuals. This was the consensus of a panel convened by the International Association of Gerontology and Geriatrics (IAGG) and its Global Aging Research Network (GARN).
        The panel, which met in St. Louis earlier this year, consisted of neurologists, psychiatrists, geriatricians, social workers, and psychologists. Using a survey of the panelists and results of focus groups made up of individuals with dementia, caregivers, and nursing home staff and volunteers, the IAGG-GARN panel examined the importance of early recognition of impaired cognitive health.
        Key Areas Addressed
        • Screening vs. case finding. The panel was divided about which was more essential for identifying early cognitive dysfunction: universal screening of all individuals within a certain category, such as age, or case finding among individuals with known risk factors, such as family history of dementia.
        “Basically, there has been a lot of argument about whether there should be screening or case function for people with early cognitive dysfunction,” said panel co-chair and JAMDA's chief medical editor, John E. Morley, MD, of Saint Louis University School of Medicine. “It's very hard to accept that physicians can't make the diagnosis, that they must have some sort of structured way.”
        The panel recommended using any of the validated screening tests that take 3 to 7 minutes to administer. “The committee recommended anything that takes under 5 to 6 minutes,” Dr. Morley said. “[In] any family care practice, the quicker you can screen the better.”
        The panel also decided that a combination of patient- and information-based screens is the most appropriate approach for identifying early cognitive impairment.
        • Brain health. The panel believed that using the term “cognitive health” rather than “mild cognitive impairment” might reduce public fears and encourage early detection and taking positive steps toward preserving cognitive function.
        “We feel brain health is what this is about because there are things that clearly help everybody's brain,” Dr. Morley said. “This is really a brain health initiative as well as to pick up [not only] people who may be going on to develop Alzheimer's but who may have a more treatable cause of cognitive dysfunction.”
        Indeed, research has shown numerous potentially reversible causes of cognitive impairment, especially when discovered early. Reversible causes include anticholinergic medications, polypharmacy, metabolic disorders, circulatory disorders, ischemic brain disorders, infections, sleep apnea, and depression, to name a few.
        The consensus group also believed that health care providers can suggest preventive measures against cognitive decline. For example, studies have shown that adoption of a Mediterranean type diet can slow the progress of cognitive impairment, and that development of cognitive impairment is less likely in individuals who follow this diet. Some additional measures include physical activity, engagement in intellectual activity, learning to play a musical instrument, and even use of video games — all of which have been shown to slow cognitive decline.
        “It makes no sense not to tell the patient they can do these things,” Dr. Morley said.
        • Cognitive frailty. This term considers potential parallel links between cognitive decline and physical frailty. Research suggests that a subgroup of individuals with cognitive impairment have reduced resilience and functional decline that coincide with physical frailty; converging evidence suggests that the cognitive status represents an important dimension of the frailty syndrome. Dr. Morley and the panel said that there isn't enough data to recommend screening for cognitive frailty and that more research is needed.
        In addition to identifying early cognitive dysfunction in health care offices, Dr. Morley said, these concepts are essential in nursing homes to detect reversible causes of cognitive decline, enable temporary residents to leave sooner, take steps to slow the progress of the decline, and maintain quality of life.
        Source: Brain Health: The Importance of Recognizing Cognitive Impairment, an IAGG Consensus Conference — Morley JE, et al.

        Diabetes and Frailty

        Individuals with diabetes mellitus are more likely to become frail than nondiabetic individuals, but they can reduce this risk by improving how well they control their disease, according to a prospective cohort study in Spain.
        Led by Esther García-Esquinas, PhD, of Universidad Autónoma de Madrid (Autonomous University of Madrid), researchers analyzed data on 346 individuals 60 and older who had diabetes, and 1,404 individuals without the disease. During a mean 3.5 years of follow-up, they identified 76 cases of frailty among the diabetic individuals, and 39 cases among those without diabetes.
        After adjusting for age, sex, and educational level, participants with diabetes had 2.18 times the risk of developing frailty. This odds ratio dropped to as low as 1.01 after adjusting for obesity; health behaviors, such as smoking and alcohol consumption; morbidity at baseline; cardiometabolic biomarkers, especially HbA1c, lipoproteins, and triglycerides; and treatment with oral antidiabetic agents. The odds ratio increased to 1.64 when adjusting for nutritional therapy.
        The increased risk of frailty was partly explained by unhealthy behaviors and obesity, poor glucose control, and altered serum lipid profile among diabetic individuals, the researchers said. High concentrations of glucose also might lead to chronic inflammation, a risk factor for frailty, and loss of skeletal muscle strengths.
        “Our results suggest that the increased risk of frailty observed among diabetic individuals is mainly driven by reductions in walking speed and, to a lesser extent, by an increased risk of unintentional weight loss and weakness,” the researchers wrote.
        Nutritional therapy, however, might lessen these risks due to improved blood glucose and cholesterol control, the researchers said, adding that individuals who initiate nutritional therapy are likely to make other lifestyle changes such as regular exercise, smoking cessation, and weight loss, which also reduce the risk of frailty.
        Source: Diabetes and Risk of Frailty and Its Potential Mechanisms: A Prospective Cohort Study of Older Adults — García-Esquinas E, et al.
        Jeffrey S. Eisenberg is a freelance medical writer in the Philadelphia area.