geriatria

Single BMD Scan Predicts Future Fracture Risk in Older Women

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Pam Harrison

A single measurement of bone mineral density (BMD) at the femoral neck in women 67 years of age and older predicts a woman’s risk of having either a nonvertebral or hip fracture over the next 20 to 25 years, respectively, a new analysis of the Study of Osteoporotic Fractures (SOF) indicates.

Also strongly predictive of a woman’s risk of fracture over the long term is a history of any nonvertebral fracture, say Dennis Black, PhD, University of California, San Francisco, and colleagues in their study published online July 18, 2017 in the Journal of Bone and Mineral Research. 

The ability of BMD and other risk factors to predict fracture risk is well-established for 5 to 10 years, but their value in predicting longer-term risk had not previously been studied, they explain.

“We conclude that a single BMD and fracture history assessment [in a woman aged 65 years and older] can predict fracture risk over 20 to 25 years,” they state.

They also discovered that remaining lifetime fracture probability seems to be higher than previously indicated, approximately twice as high, among women over aged 65 years ― who had a 25-year risk of hip fracture of almost 18%.

And in those aged over 80, they found a 25-year risk for hip fracture of 23%, which is at least as high as seen in similar studies.

Dr Black told Medscape Medical News that some healthcare professionals believe that “the 10-year risk of hip fracture goes down as people get older because of competing mortality risks.”

“But this study really dispels this thinking. So one of the important messages from this paper is that physicians should be paying attention to the oldest women, as their risk of hip fracture is very high, and they should be screened [for risk factors] and potentially treated [for osteoporosis] if they meet guideline criteria.”

“Treatment — which has been shown to be safe and effective in the oldest of the old — can prevent the devastating consequence of fracture,” he added.

History of Any Fracture An Important Predictor

Dr Black and colleagues used data from the SOF cohort of 7959 primarily Caucasian women, mean age 73.4 years, among whom BMD was first measured by dual-energy X-ray absorptiometry (DXA) between 1988 to 1990.

Overall, 38.4% of women reported a history of at least one nonvertebral fracture, while 2.3% of the cohort reported a history of experiencing a hip fracture from age 50 years onwards.

Over the next 20 years of follow-up, 43.7% of women had one or more nonvertebral fractures, while 15.9% of the cohort sustained one or more hip fractures over the next 25 years.

There has been some controversy about whether the history of hip fracture is superior to that of nonvertebral fractures in predicting risk of future hip fracture, the authors say.

“Our results showed no important advantage to history of hip fracture compared with history of any nonvertebral fracture for predicting subsequent fracture,” they note.

“Moreover, a history of any fracture is much more common than a history of hip fracture, and therefore will be more useful on a population level as a predictor.”

BMD at Femoral Neck Is Strongly Predictive

BMD at the femoral neck was “strongly predictive” of the long-term risk of both hip and nonvertebral fractures — even after accounting for competing mortality risks.

The long-term risk of having a hip fracture was almost five-fold higher over the next 25 years for women in the lowest BMD quartile (29.6%) compared with those in the highest BMD quartile (7.6%).

Corresponding rates for nonvertebral fracture were almost twice as high among women in the lowest BMD quartile (59.7%) vs the highest BMD quartile (32.9%).

And, “BMD remained very strongly predictive within each age group,” the investigators observe.

For example, in women over age 75 years at baseline, the risk of sustaining a hip fracture over the next 25 years went from a low of 7.1% for women with a femoral neck T-score in excess of –1.0 to a high of 31.5% for women with a T-score below –2.5 at baseline.

Still, “as expected, the cumulative incidence of both hip and nonvertebral fractures was related to age,” the researchers note.

For women over age 80 years at baseline, the risk of sustaining a hip fracture over 25 years was 22.6%, compared with only 13.9% for women under age 70 years at baseline.

For nonvertebral fracture, women over age 80 years at baseline had a 50% risk over the next 20 years, compared with 42.6% of women under age 70 years at baseline.

Only One BMD Measurement Needed

Explaining that their results show just a single BMD measurement is sufficient to predict fracture risk, Dr Black told Medscape Medical News: “Some have suggested that BMD measurements should be done very frequently, such as every year or every 2 years, in older women.”

“But we found that [a single measure of] bone density is a very strong predictor of a very important disease, which is fracture ― particularly hip fracture ― over the long term,” he added.

“And while bone density can suddenly change if, for example, women start using glucocorticoids or there is marked weight loss,” knowing a woman’s single BMD measurement “can help you stratify patients in terms of how worried you are about their fracture risk. And if a woman has a BMD of –1 at the age of 65, you certainly don’t have to worry about her for another 5 years,” he added.

SOF is supported by the National Institutes of Health. Dr Black reports receiving grant support from Alexion and consulting fees from Amgen, Merck, Asahi-Kasei, and Radius.

J Bone Miner Res. Published online July 18, 2017. Abstract

 

Experto en nutrición asegura que “hay que comer lo que comían nuestras abuelas”

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Con más fruta y verdura.

El profesor de Nutrición Alimentaria de la Universidad de Navarra y presidente del Comité Científico de la Sociedad Española de Nutrición Comunitaria (SENC), Javier Aranceta, ha asegurado que “hay que comer lo que comían nuestras abuelas”, aunque “un poco matizado”, y con “más fruta y verdura”.

En este sentido, ha señalado que “hay que cambiar la filosofía de comprar, ir más al mercado, a la pescadería”, poniendo de relieve “la importancia de nuestra dieta tradicional, la dieta mediterránea” y otros factores, como “la necesidad de destinar más tiempo a cocinar o a hacer la compra” porque “al final hablamos de más tiempo destinado a comer mejor y menos tiempo dedicado a la consulta del ambulatorio”.

Aranceta dirige en Laredo un curso sobre Ciencias de la Salud, dentro de los Cursos de Verano de la Universidad de Cantabria (UC), junto a la presidenta de SENC, Mari Carmen Pérez-Rodrigo, para quien “no podemos hablar de alimentación saludable sino hablamos, además, de una alimentación sostenible, solidaria con nosotros mismos y con la gente de nuestro entorno”.

Para Pérez-Rodrigo, “mantener la estacionalidad de los productos que consumimos nos ayudará a cuidarnos mejor y a cuidar mejor nuestro entorno, a mantener puestos de trabajo”.

Una de las claves que se desveló en el monográfico fue la importancia de la planificación a la hora de comprar. “Si hacemos una compra planificada y tratamos de consensuar qué vamos a comprar entre toda la familia, no es tanto tiempo de más el que vamos a necesitar y además es una manera de compartir tiempo con nuestra propia familia”, ha dicho.

Según la profesora, “hemos perdido calidad de convivencia en torno al alimento y eso realmente influye y se refleja en los hábitos alimentarios”. “La comida tradicional basada en los productos de temporada llevaba a una comida racional”, ha añadido.

Para Pérez-Rodríguez es clave sentarse en la mesa a disfrutar de la comida y evitar las prisas y las tareas paralelas mientras nos alimentamos, como puede ser ver la televisión o utilizar el teléfono móvil. “En muchas casas ya sólo se come en familia uno de los dos días del fin de semana, mientras que antes se compartía mesa todos los días”, ha recordado.

#Exercise Benefits Even Older, Extremely # Obese Adults

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Miriam E Tucker

A structured exercise program may improve mobility even among the most obese elderly patients, new data indicate.

Results from a post hoc analysis of a large, prospective, randomized trial examining the impact of physical activity on mobility disability in adults aged 70 to 89 years were published June 26 in Obesity by Stephen B Kritchevsky, PhD, director of the Sticht Center on Aging and professor, Gerontology and Geriatric Medicine Center on Diabetes, Obesity, and Metabolism at Wake Forest University, Winston-Salem, North Carolina, and colleagues.

In the Lifestyle Interventions and Independence for Elders (LIFE) Study, a structured program focused on walking, strength, balance, and flexibility training produced a significant 18% reduction in major mobility disability compared with those randomized to simply a health-education program (JAMA. 2014;311:2387-2396).

Now, in a new analysis in which the subjects from that study were divided into four groups based on baseline body-mass index (BMI) and waist circumference, the findings were contrary to what the authors had hypothesized: rather than benefiting less, those in the highest obesity category (class 2+) actually benefited the most.

That group was the only one to achieve statistical significance, although there was a trend toward benefit for the physical-activity program across the board regardless of body size.

“We wanted to look at different obesity classes because prior data suggest that obesity may blunt the benefits of physical activity for the prevention of mobility disability.…We were surprised to see the strongest apparent benefit of the intervention was in the heaviest group,” Dr Kritchevsky told Medscape Medical News.

The clinical message, he said, is: “You should not give up on an older person just because it looks like the odds are stacked against them….We know from our research that it’s never too late to start.”

Dr Kritchevsky noted that local community senior centers often offer structured exercise programs similar to the one used in the LIFE study and that the National Institute on Aging also has a web page with instructional videos of safe exercises that seniors can perform at home. While some seniors may need to work on strengthening before they can achieve daily walking goals, overall “it doesn’t take a lot to get this benefit,” he noted.

Overall Trend for Greater Mobility, With Significance for Heaviest Group

The current analysis included 1613 inactive adults aged 70 to 89 at high risk for mobility disability based on scoring 9 or less on the 12-point Short Physical Performance Battery (SPPB), comprising tests of walking, rising from a chair without using arms, and standing balance.

Subjects were randomized to a physical-activity program or to a health-education (control) arm.

The physical-activity program focused on walking, strength, balance, and flexibility training, with goals of 30 minutes of walking at moderate intensity, 10 minutes of lower-extremity strength training using ankle weights, and 10 minutes of balance training of major muscle groups. Participants attended twice-weekly in-person sessions and were asked to perform activities at home for three to four times weekly and to keep an activity log.

The health-education arm involved once-weekly 60- to 90-minute in-person discussions on topics such as nutrition, safety, and legal/financial issues related to aging.

The participants were classified into four categories based on BMI and waist circumference:

  • Nonobese without abdominal obesity (BMI <30 kg/m2; n=437).
  • Nonobese with abdominal obesity (waist circumference >102 cm [men], >88 cm [women]; n=434).
  • Class 1 obesity (BMI 30 to <35 kg/m2; n=430).
  • Class 2 to 3 obesity (BMI >35 kg/m2; n=312).

The median follow-up time was 2.7 years. At 24 months, attendance at the scheduled center-based intervention sessions was 63% for the physical-activity program and 73% for the health-education program.

The primary outcome of major mobility disability was defined as the inability to complete a 400-m-walk test within 15 minutes without sitting and without the help of another person or walker. Point estimates for the intervention effect were <1 in each obesity category and the strongest effect was observed in those with class 2+ obesity (hazard ratio, 0.69). Interactions between obesity category and treatment arm did not reach statistical significance (P = .49).

There was no overall effect of the intervention on 400-m-walk speed over the first 24 months of the study (P = .73), nor was there evidence of an interaction between intervention arm and obesity status (P = .36).

However, there was an overall beneficial effect of the physical-activity program on SPPB score (mean change, 0.23; P = .013), with the largest effect on the group with BMI <30 and abdominal obesity. But there was no statistical interaction between intervention arm and obesity category (P = .23).

In the class 2+ obesity group, participants in the health-education arm reported no increase in their walking at 6 months — remaining around 30 minutes/week — while the physical-activity group increased their walking to 135 minutes/week.

Although this level was still below that of the lesser obese categories, it could at least partly explain the mobility benefit seen in the heaviest group, the authors note.

Dr Kritchevsky commented that physicians should advocate for community resources such as senior centers with health-promotion programs if they’re not already available, given that seniors may not feel comfortable at facilities such as YMCAs and gyms that tend to target younger people: “If you don’t have them, let somebody know you need them.”

The LIFE Study is funded by a National Institutes of Health (NIH)/National Institute on Aging Cooperative Agreement and a supplement from the National Heart, Lung, and Blood Institute and sponsored in part by the Intramural Research Program, National Institute on Aging, NIH. The research is partially supported by the Claude D Pepper Older Americans Independence Centers at the University of Florida, Wake Forest University, Tufts University, University of Pittsburgh, and Yale University and the NIH/ National Center for Research Resources Clinical and Translational Science Awards at Stanford University. Investigators have also received support from the Boston Rehabilitation Outcomes Center and the US Department of Agriculture. Dr Kritchevsky has no relevant financial relationships. Disclosures for the coauthors are listed in the paper.  

Obesity. Published online June 26, 2017. Abstract

 

Is sleep a modifiable risk factor for Alzheimer’s disease?

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The authors of a new study suggest targeting poor sleep could delay or diminish symptoms of Alzheimer’s disease.

Much research has explored the links between sleep in Alzheimer’s disease (AD) in recent years, with studies demonstrating that self-reported poor sleep is associated with AD brain pathophysiology.

Findings from a new study have prompted calls for a closer inspection of the impact of sleep hygiene on AD after authors found worse sleep quality, more sleep problems and daytime sleepiness were associated with cerebrospinal fluid (CSF) biomarkers of amyloid deposition in combination with tau pathology, axonal degeneration, and neuroinflammation. The relationship between sleep and AD pathology was present in late midlife in the absence of cognitive impairment. The authors did not however find a relationship between CSF biomarkers and symptoms of obstructive sleep apnoea.

Writing in Neurology , the authors said, as effective strategies exist for improving sleep, sleep health may be a tractable target for early intervention to attenuate AD pathogenesis. “Many effective pharmaceuticals, devices, and behavioural interventions are already available in the clinic for improving sleep quality. Follow-up studies are needed to identify the aspects of sleep that are most amenable to modification and most effective in affecting AD pathology, to ultimately delay AD or diminish AD symptoms,” the authors said.

The digital revolution has largely bypassed the NHS, experts say

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The first report from Google’s Deep Mind Health project says doctors are using Snapchat to send scans.

In the first annual report from Google’s Deep Mind Health  project, a panel of independent authors say, by seeing the benefits technology delivers in their own lives, doctors are keen to bring technology into the workplace and are using social media and lifestyle apps to do so. Snapchat is being used to send scans from one clinician to another, while camera apps are being used to record particular details of patient information in a convenient manner.

The authors say that while it is “difficult to criticise these individuals, given that this makes their job possible”, the practice is not without its downfalls and is “clearly an insecure, risky, and non-auditable way of operating, and cannot continue”.

Deep Mind Health is currently working with the UK’s National Health Service on a number of projects. The authors say the “digital revolution has largely bypassed the NHS”. Digital solutions “have been laid on top of the hundreds of different ageing IT systems employed, even within a single NHS trust or authority,” they say. According to the report, the average NHS Trust has 160 different computer systems in operation.

Lo importante de la longevidad es la calidad de vida y no la cantidad de años

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Hoy más que nunca parece que somos lo que comemos.

Hoy más que nunca parece que somos lo que comemos.

En los últimos años se ha incrementado la esperanza de vida en la mayoría de países desarrollados pero los expertos coinciden en que el debate de la longevidad debe centrarse más en la calidad de vida que en la cantidad de años.

Así lo han reconocido los asistentes al encuentro ‘Vivir más de 100 años. El camino de la longevidad’, organizado por el Observatorio de Bienestar de IMF Business School, donde se ha puesto de manifiesto los avances científicos van a permitir “vivir muchos más años y con mucha más calidad de vida”.

“Hay un aumento de la esperanza de vida gracias a la tecnología y la ciencia, pero las condiciones y el desarrollo económico también influyen”, ha destacado Clara Parapar, investigadora de la Fundación general del Consejo Superior de Investigaciones Científicas (CSIC), que en cambio ha reconocido que a los investigadores no les preocupa tanto la edad a la que se llega sino las condiciones.

En ello influye la nutrición, ha añadido Elisa Blázquez, de la Clínica de Medicina Integrativa de Madrid, ya que “hoy más que nunca parece que somos lo que comemos” y se puede saber cómo evolucionará la salud también gracias a la alimentación.

Además, en las distintas zonas del planeta donde se observa una mayor esperanza de vida se cumplen ciertos patrones comunes, como el consumo de antioxidantes.

En el encuentro también han analizado el papel que puede jugar la criopreservación de cara a una supuesta inmortalidad, ya que hace ya años se empezaron a preservar las células madre del cordón umbilical y actualmente se pueden preservar también óvulos, espermatozoides o células madre de tejido adiposo.

“Por ahora no se pueden preservar los órganos porque se cristalizan, pero se está investigando si se puede criopreservar a una persona”, ha avanzado José Luis Mazuelas, consejero delegado de Fundación Vidaplus.

Oncólogos ponen en valor el papel de la formación en comunicación empática como parte de la labor clínica

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Uno de los retos del siglo XII es humanizar la asistencia oncológica.

Uno de los retos del siglo XII es humanizar la asistencia oncológica.

Uno de los retos del siglo XII es humanizar la asistencia oncológica y, por ello, “es fundamental recuperar la ética y que los oncólogos se formen en comunicación empática y acompañamiento al paciente o aprendan a dar malas noticias como parte de la labor clínica que deben desempeñar”, según han destacado desde la Sociedad Oncológica de Galicia (SOG).

Por ello, especialistas de esta sociedad han elaborado ‘Bioética y Oncología’, que tiene como objetivo dar respuesta a más de la mitad de especialistas que manifiestan explícitamente la necesidad de formarse en esta disciplina, según una reciente encuesta de la Sociedad Española de Oncología Médica.

En este sentido, el 30% de los problemas a los que se enfrenta un médico en la práctica clínica habitual son más éticos que técnicos, a pesar de que “la ética y el humanismo se consideran una pérdida de tiempo, competencias blandas frente a la visión mecanicista de la enfermedad”, ha subrayado el facultativo especialista de Área de Oncología del Complejo Hospitalario Universitario de A Coruña y coautor del libro, Francisco Barón.

Sin embargo, “la parte afectiva y emocional es muy importante, porque el paciente está viviendo una situación grave que puede llegar a comprometer su vida. Si no nos preocupamos por los enfermos ni somos capaces de ponernos en su lugar y ser empáticos, no vamos a ser buenos oncólogos”, ha añadido el Dr. Barón.

Para favorecer esta situación, el paciente debe decidir y el médico hacerlo con él, no por él, ya que le debe ayudar a tomar la mejor decisión teniendo en cuenta su biografía, características de su entorno, situación personal y sus valores, aunque el especialista ha recalcado que esto se convierte en una labor difícil si no se realiza un seguimiento y si no hay una continuidad asistencial.

Por ello, la bioética se vuelve tan fundamental en la oncología, a pesar de que “ha costado mucho integrarla en la cartera de servicios, en la formación, en el corpus de la oncología que, por una gran inercia de la medicina en general, se ha tecnificado”, ha concluido el experto.

El libro, dividido en 15 capítulos, aborda en la primera las delimitaciones de los principios antropológicos, culturales y éticos de la bioética, para así poder comprender las consecuencias que se derivan de ellos y que conforman la segunda parte del libro.

En esta segunda parte, se explica la importancia de las decisiones compartidas con el paciente, la atención al paciente pediátrico, la atención cerca del final de la vida o la confidencialidad, entre otros muchos asuntos.