GERIATRICS Dementia cases set to triple by 2050 but still largely ignored Friday, July 20, 2012 | 10:38

am Geneva, 11 April 2012 Worldwide, nearly 35.6 million people live with dementia. This number is expected to double by 2030 (65.7 million) and more than triple by 2050 (115.4 million). Dementia affects people in all countries, with more than half (58%) living in low- and middle-income countries. By 2050, this is likely to rise to more than 70%. Treating and caring for people with dementia currently costs the world more than US$ 604 billion per year. This includes the cost of providing health and social care as well the reduction or loss of income of people with dementia and their caregivers. Only eight countries worldwide currently have national programmes in place to address dementia. A new report "Dementia: a public health priority", published by the World Health Organization (WHO) and Alzheimer's Disease International, recommends that programmes focus on improving early diagnosis; raising public awareness about the disease and reducing stigma; and providing better care and more support to caregivers. Lack of diagnosis is a major problem. Even in high-income countries, only one- fifth to one- half of cases of dementia are routinely recognized. When a diagnosis is made, it often comes at a relatively late stage of the disease. We need to increase our capacity to detect dementia early and to provide the necessary health and social care. Much can be done to decrease the burden of dementia," says Dr Oleg Chestnov, Assistant Director-General, Noncommunicable Diseases and Mental Health at WHO. "Health-care workers are often not adequately trained to recognize dementia." The report points to a general lack of information and understanding about dementia. This fuels stigma, which in turn contributes to the social isolation of both the person with dementia and their caregivers, and can lead to delays in seeking diagnosis, health assistance and social support. "Public awareness about dementia, its symptoms, the importance of getting a diagnosis, and the help available for those with the condition is very limited. It is now vital to tackle the poor levels of public awareness and understanding, and to drastically reduce the stigma associated with dementia," says Marc Wortmann, Executive Director, Alzheimers Disease International. Strengthening care is also key. In every region of the world, most caregiving is provided by informal caregivers - spouses, adult children, other family members and friends. The report notes that people who care for a person with dementia are themselves particularly prone to mental disorders, such as depression and anxiety, and are often in poor physical health themselves. Many caregivers also suffer economically as they may be forced to stop working, cut back on work, or take a less demanding job to care for a family member with dementia. The report recommends involving existing caregivers in designing programmes to provide better support for people with dementia and those looking after them. Community-based services can provide valuable support to families caring for people with dementia in both high- and low-income countries - delaying the need for people to enter into high-cost residential care. At the same time, health workforce training needs to pay closer attention to dementia, and the skills required to provide both clinical and long-term care. Dementia is a syndrome, usually of a chronic nature, caused by a variety of brain illnesses that affect memory, thinking, behaviour and ability to perform everyday activities. Alzheimers disease is the most common cause of dementia and possibly contributes to up to 70% of cases. Although dementia affects people in all countries, more than half (58%) live in low- and middle-income countries. This is likely to rise to more than 70% by 2050. _________________________ Media contacts:

Fadla Chaib, WHO Communications officer. Telephone: + 41 22 791 32 28; Mobile: + 41 79 475 55 56; Email: chaibf@who.int Dr Shekhar Saxena, Director, WHO Department of Mental Health and Substance Abuse. Telephone: + 41 22 791 36 25; Mobile: + 41 79 308 98 65; Email: saxenas@who.int Sarah Smith, Alzheimers Disease International (London), +44 7930 917647, s.smith@alz.co.uk Dementia: a public health priority is available for download as of 11 April at: http://www.who.int/mental_health/publications/dementia_report_2012 About dementia and Alzheimer's disease Dementia is a syndrome that can be caused by a number of progressive disorders that affect memory, thinking, behaviour and the ability to perform everyday activities. Alzheimer's disease is the most common cause of dementia. www.alz.co.uk/about-dementia. The World Health Organization is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. For more information, visit http://www.who.int/about/en/. Alzheimers Disease International (ADI) is the international federation of 78 Alzheimer associations that support people with dementia and their families in their respective countries. Founded in 1984, ADI serves as a network for Alzheimer associations around the world to share and exchange information, resources and skills. Its vision is a better quality of life for people with dementia and their families. ADI is based in London and is registered as a non-profit organization in the state of Illinois, USA. For more information, visit www.alz.co.uk. All WHO information can be found at: www.who.int http://www.medobserver.com/specialtyarticle.php?ArticleID=588

Deep Brain Stimulation for Parkinson Disease: Time to Change Practice A 3-year study shows globus pallidus interna stimulation as successful as subthalamic nucleus stimulation overall and suggests individual needs should drive the choice between the two. Some studies have suggested that deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson disease (PD) has more durable benefits on motor function than DBS of the globus pallidus interna (GPi). However, long-term outcomes from randomized trials have been lacking. Now, researchers have published the long-awaited 3-year findings of the randomized, partially manufacturer-funded Veterans AffairsNational Institute of Neurological Disorders and Stroke trial comparing STN DBS with GPi DBS. Of 198 patients randomized, 159 had 36-month follow-up (89 with GPi DBS and 70 with STN DBS). The primary outcome was motor function while patients were on stimulation and off medication, measured with the Unified Parkinson's Disease Rating Scale motor subscale. At 36 months, motor function had improved similarly in both groups, as was previously reported for 24month outcomes (N Engl J Med 2010; 362:2077). However, the STN group declined significantly faster than the GPi group on the Mattis Dementia Rating Scale and on other neurocognitive measures. Overall, quality of life was improved in both groups, although it was diminished from the 24-month report. The authors ascribed this diminishment mainly to disease progression. Comment: These findings and those of previous studies (Ann Neurol 2009; 65:586 and Arch Neurol 2005; 62:554) collectively demonstrate similar motor efficacy when using either brain target in patients with advanced, fluctuating PD. The field may have prematurely rushed toward adopting STN over GPi DBS, although some had predicted GPi DBS would regain a role in PD treatment (Arch Neurol 2005; 62:533). The current study revealed specific advantages of GPi DBS. The cognitive advantage strongly supports considering potential DBS candidates with previously identified cognitive issues for implantation into the GPi. The current findings show greater flexibility in adjusting medications with the GPi target. This flexibility is likely important as DBS patients experience natural disease worsening due to progression. Moreover, the STN group had a gradual loss of medication's beneficial effect when added to stimulation, leading an editorialist to question whether GPi stimulation would be more compatible with long-term medical therapy. The main limitation of this study was participant attrition, as is seen in other longitudinal studies of advanced PD. The results strongly suggest that, for clinicians weighing the possibility of DBS for their patients, both STN and GPi are viable options. The future of DBS patient and target selection will require a more tailored, symptom-specific approach. Michael S. Okun, MD Published in Journal Watch Neurology June 26, 2012 CITATION(S): Weaver FM et al. Randomized trial of deep brain stimulation for Parkinson disease: Thirty-six-month outcomes. Neurology 2012 Jul 3; 79:55. Tagliati M. Turning tables: Should GPi become the preferred DBS target for Parkinson disease? Neurology 2012 Jul 3; 79:19. http://neurology.jwatch.org/cgi/content/full/2012/626/1

Geriatrics By Michael Tan Philippine Daily Inquirer First Posted 00:54:00 10/28/2009 Filed Under: Health, Senior Citizens, Healthcare Providers,Medical staff, Social Issues Most people appreciate the importance of a pediatrician, often going to great lengths to choose one. After all, the pediatrician becomes a special friend and guardian for our children, a relationship that will extend well into adolescence. Childhood, especially the early years, is certainly a fragile period in a person?s life and modern medicine has responded by creating pediatrics, which in turn has branched off into even more specialized sub-fields, including pediatric cardiology, pediatric oncology (for cancer) and in recent years, even adolescent medicine. In contrast to the attention we give to childhood health and pediatrics, we forget that the elderly also have their special needs. We do go to specialists, for example, a cardiologist, a diabetologist, or one of the other specialists dealing with chronic illnesses that beset the elderly, but these specialists sometimes become so focused on the illness that they forget the patient. Others may not even be aware of very important differences in the way the elderly?s bodies and minds function when compared to younger people. Glamour, drama Last June The New York Times featured an article about the shortage of geriatricians in the United States. The article focused on Dr. Rosanne Leipzig, a geriatrician based at Mt. Sinai School of Medicine in New York who has been pushing hard for medical schools to give more attention to geriatrics. Leipzig admitted that even if medical schools give time to geriatrics, it is not a specialty that too many Americans (and, I suspect, Filipinos) want to go into. Geriatrics doesn?t have the glamour and drama that?s found in other specialties like surgery. I was able to find an article by Leipzig and her associates in the journal, Academic Medicine, which is devoted to medical education. The title of her article is a bit unorthodox: ?Keeping Granny Safe on July 1: A Consensus on Minimum Geriatrics Competencies for Graduating Medical Students.? It urges more attention to some of the skills all doctors should have so they can be more effective with elderly patients. Geriatrics relies much less on laboratory tests and emphasizes physical examination and observation of the patient. In the Philippines, we associate that physical examination with taking blood pressure, but geriatric medicine involves much more, including observation of the patient?s physical activities. One important set of competencies revolves around assessment of a patient?s self-care capacity. The ?tests? here will include something like tying one?s own shoelaces. If the patient has had falls recently, the doctor should be observing if that patient can get up from a chair, and move around. Many of you may have heard of the term homeostasis, which refers to biological feedback mechanisms that maintain equilibrium. For example, when you?re hungry, you eat, and as you eat, your stomach expands and nerves send a message to our brain telling us ?enough, you?re full now,? and you usually stop eating. You do have the option of disregarding those signals but the biological mechanisms generally work well. Aging can result in something different called homeostenosis, where the feedback mechanisms do not function as well or may even be blocked. A geriatrician is more sensitive to these changes, and can therefore spot trouble more quickly. For example, many non-geriatricians miss a serious infection that?s brewing in a patient because they don?t know that in many elderly patients, there may be no fever even with the infection. A fever is actually part of the body?s response system to infections, but because of homeostenosis, lolo?s or lola?s temperature will be normal.

When ill, the elderly will often show signs of distress and disorientation, so even without the fever, a doctor should be looking for an infection in such patients. In societies where the elderly are expected to be stoic and strong, the physician needs to be alert to the possibility that the patient may be suppressing those feelings of distress. Geriatrics is also about developing more autonomy or independence for the elderly. That includes encouraging the elderly to set their own goals for health. This is where problems often arise. Nongeriatricians tend to keep patients passive: take this medicine, don?t take that food, stay in bed. Unfortunately for the elderly people, that passive role often leads to a further deterioration of their health. This is worsened by Filipino cultural norms that also emphasize passivity and dependence for the elderly. Less is more Geriatricians want their patients to be active whenever possible. When it comes to medicines, less is more for geriatricians because of more risks of side effects, and of drugs interacting with each other. Again, this sometimes runs counter to local culture: our elderly sometimes boast that they are taking 10 pills a day. We will need more geriatricians who have both the biomedical skills and cultural competence or sensitivity to care for our elderly. Moreover, geriatricians could play another important role of training caregivers, friends and relatives, somewhat like para-geriatricians. I know The Medical City offers such training workshops from time to time. This takes us to the matter of caregivers. For many years now, thousands of our women have been going overseas to work as nannies, caring for other people?s children even as they leave behind their own very young children. In more recent years, we have been exporting caregivers, both men and women, now specializing in caring for the elderly. Again, this is often at the cost of our own elderly being neglected. Lately, too, there has been talk about training more geriatricians and caregivers to care for elderly foreigners who come to the Philippines to retire. There are already entire subdivisions devoted to these foreign retirees. As usual, it takes an external dollar-driven demand to wake us up to a certain social need, and even then, we forget about Filipinos who have those needs as well. Our elderly?defined as people above the age of 60?is only about 5 percent of the total compared to more than 20 percent in many developed countries. But that 5 percent means about 4.5 million Filipino elderly, and the percentage is going to keep growing. Geriatrics should be integrated into our health care system, all the way down to the barangay health centers. http://opinion.inquirer.net/inquireropinion/columns/view/20091028-232626/Geriatrics