The document discusses potential approaches for preventing Alzheimer's disease and dementia. It notes that while some observational studies have found associations between certain factors and reduced dementia risk, large randomized controlled trials have not shown that anti-inflammatory agents, antioxidants, or estrogen therapy can prevent Alzheimer's disease. The document does provide evidence from randomized trials that treating hypertension through blood pressure lowering agents can reduce incidence of dementia. It summarizes trials showing reduced dementia risk when treating hypertension with calcium channel blockers, ACE inhibitors, and diuretics.
1) Women admitted for acute myocardial infarction have 40-100% higher 30-day mortality than men, though this difference is reduced after adjusting for age and comorbidities.
2) When patients are matched based on clinical characteristics, the differences in treatments received and mortality between men and women are reduced, but women still receive less invasive procedures and reperfusion.
3) When patients are matched on both characteristics and treatments, men and women have similar in-hospital and 30-day mortality, suggesting increased use of invasive treatments could reduce the gender gap in outcomes.
Social and Behaviour factor predicting healthy agingGiorgio De Gobbi
1) The document discusses the roles of socioeconomic status and physical activity in predicting healthy aging. It provides data on life expectancy, active life expectancy, and rates of mortality from various causes in different socioeconomic groups.
2) Lower socioeconomic status is associated with higher mortality rates and shorter life expectancies. Those with less education and in manual/lower income jobs had worse health outcomes.
3) Engaging in physical activity is linked to longer, disability-free life expectancy and lower risks of poor health. Childhood social factors also influence late-life physical function and risk of disability.
1) The document discusses the continuum of pain care for military service members and veterans, from the battlefield through transitions to different healthcare systems.
2) It describes reforms to the DoD and VA healthcare systems that implement a "medical home" model and "stepped care" approach to pain management, with primary care coordinating with pain medicine and rehabilitation specialists.
3) Key challenges include managing acute pain from battlefield injuries, preventing the transition to chronic pain, and ensuring continuity of care as service members move between active military health systems and the VA system.
Atrial fibrillation (AF) is a complex cardiac condition that is increasing in prevalence and burden. It is associated with numerous cardiovascular risk factors and comorbidities such as hypertension, obesity, diabetes, and sleep apnea. These conditions can promote atrial remodeling and inflammation, increasing the risk of AF. While treatments target cardiovascular risk, managing AF also requires consideration of upstream therapies that may prevent AF onset through mechanisms like reducing inflammation, stabilizing the endocardium, and decreasing autonomic nervous system activity. The growing prevalence and costs of AF highlight the need for prompt, comprehensive management of patients.
This presentation by Gavin Giovannoni looks at the new treatment paradigm for MS. It includes: arguments for early treatment in multiple sclerosis, the effect of MS on quality of life and whether highly-effective treatments stabilise MS.
It was presented at the MS Trust Annual Conference in November 2013.
This document discusses diabetes, its rising prevalence globally and in India, and its significant economic and social impacts. It notes that diabetes prevalence is increasing most rapidly in younger people and in developing countries. Complications from uncontrolled diabetes can include blindness, heart disease, stroke, kidney failure and amputation. The costs of caring for diabetes and its complications places a large economic burden on individuals and families. Left untreated, diabetes can reduce quality of life and even lead people to extreme measures like using a speeding train to amputate a gangrenous foot due to lack of access to medical care.
1) Women admitted for acute myocardial infarction have 40-100% higher 30-day mortality than men, though this difference is reduced after adjusting for age and comorbidities.
2) When patients are matched based on clinical characteristics, the differences in treatments received and mortality between men and women are reduced, but women still receive less invasive procedures and reperfusion.
3) When patients are matched on both characteristics and treatments, men and women have similar in-hospital and 30-day mortality, suggesting increased use of invasive treatments could reduce the gender gap in outcomes.
Social and Behaviour factor predicting healthy agingGiorgio De Gobbi
1) The document discusses the roles of socioeconomic status and physical activity in predicting healthy aging. It provides data on life expectancy, active life expectancy, and rates of mortality from various causes in different socioeconomic groups.
2) Lower socioeconomic status is associated with higher mortality rates and shorter life expectancies. Those with less education and in manual/lower income jobs had worse health outcomes.
3) Engaging in physical activity is linked to longer, disability-free life expectancy and lower risks of poor health. Childhood social factors also influence late-life physical function and risk of disability.
1) The document discusses the continuum of pain care for military service members and veterans, from the battlefield through transitions to different healthcare systems.
2) It describes reforms to the DoD and VA healthcare systems that implement a "medical home" model and "stepped care" approach to pain management, with primary care coordinating with pain medicine and rehabilitation specialists.
3) Key challenges include managing acute pain from battlefield injuries, preventing the transition to chronic pain, and ensuring continuity of care as service members move between active military health systems and the VA system.
Atrial fibrillation (AF) is a complex cardiac condition that is increasing in prevalence and burden. It is associated with numerous cardiovascular risk factors and comorbidities such as hypertension, obesity, diabetes, and sleep apnea. These conditions can promote atrial remodeling and inflammation, increasing the risk of AF. While treatments target cardiovascular risk, managing AF also requires consideration of upstream therapies that may prevent AF onset through mechanisms like reducing inflammation, stabilizing the endocardium, and decreasing autonomic nervous system activity. The growing prevalence and costs of AF highlight the need for prompt, comprehensive management of patients.
This presentation by Gavin Giovannoni looks at the new treatment paradigm for MS. It includes: arguments for early treatment in multiple sclerosis, the effect of MS on quality of life and whether highly-effective treatments stabilise MS.
It was presented at the MS Trust Annual Conference in November 2013.
This document discusses diabetes, its rising prevalence globally and in India, and its significant economic and social impacts. It notes that diabetes prevalence is increasing most rapidly in younger people and in developing countries. Complications from uncontrolled diabetes can include blindness, heart disease, stroke, kidney failure and amputation. The costs of caring for diabetes and its complications places a large economic burden on individuals and families. Left untreated, diabetes can reduce quality of life and even lead people to extreme measures like using a speeding train to amputate a gangrenous foot due to lack of access to medical care.
DRUG PROFILE IN MYOCARDIAL INFARCTION WITH MONITORING OF POSTLYSIS COMPLICATI...Sameer Shete
This document presents a retrospective observational study on drug profiles and post-lysis complications in patients with myocardial infarction. The study analyzed 100 patients admitted with ST elevation myocardial infarction. The most common drugs administered were streptokinase, aspirin, clopidogrel, and atorvastatin. The most frequent post-lysis complications observed were bleeding (68% of patients) and hypotension (53% of patients). The study aims to evaluate treatment efficacy and risks associated with myocardial infarction by analyzing patient drug regimens and complications.
The LANCELOT-ACS trial investigated the safety and tolerability of the PAR-1 inhibitor atopaxar in 603 patients with acute coronary syndrome. The trial found that atopaxar achieved potent platelet inhibition through PAR-1 without significantly increasing bleeding risk compared to placebo. There were favorable trends for reduced major cardiac events but dose-dependent increases in liver enzymes and QTc interval prolongation at higher doses. Further studies are still needed to fully establish the safety and efficacy of atopaxar.
The document discusses age, comorbidity, and frailty in elderly patients. It introduces tools like the Preoperative Assessment of Cancer in the Elderly (PACE) and the Groningen Frailty Index (GFI) that are used to assess frailty in elderly surgical patients. The PACE evaluates factors like cognition, activities of daily living, mood, and fatigue. Research found certain components of the PACE like dependency in activities of daily living were associated with increased hospital stay and complications. The GFI contains 15 questions assessing domains like mobility, nutrition, and cognition. A GFI score of 3 or higher indicates frailty. The tools aim to identify frailty preoperatively to predict outcomes and prevent functional decline.
The future: Presentation by Gavin GiovannoniMS Trust
This document summarizes information from a presentation on multiple sclerosis (MS). It begins with disclosures from the presenter regarding compensation received from pharmaceutical companies. It then provides images and diagrams on various topics related to MS, including: cortical lesions; brain atrophy across disease stages; remyelination pathways and targets like LINGO-1; and study designs testing potential neuroprotective and remyelinating agents. One study examines the drug phenytoin in acute optic neuritis to assess neuroprotection by measuring retinal nerve fiber layer thickness. In summary, the document reviews MS pathology and potential new therapeutic strategies targeting remyelination and neuroprotection that are being investigated in clinical trials.
The document summarizes clinical outcomes data from the RESOLUTE US trial regarding patients with diabetes mellitus who received the Resolute ZES stent. Key findings from the 3-year follow-up include that diabetic patients experienced higher rates of death, myocardial infarction, and target lesion revascularization compared to non-diabetic patients, however stent thrombosis rates were low across all groups. The Resolute stent demonstrated safety and efficacy in diabetic patients out to 3 years following the procedure.
The document summarizes key findings from the CHARISMA clinical trial which evaluated the benefits of dual antiplatelet therapy with clopidogrel and aspirin compared to aspirin alone in patients at risk of cardiovascular events. The trial found no significant reduction in the primary endpoint of heart attack, stroke or cardiovascular death in the overall population, but did see a reduction in the secondary endpoint which included hospitalizations. Subgroup analysis found dual therapy beneficial for patients with established cardiovascular disease but not for those with multiple risk factors only. The REACH registry aims to study characteristics and management of stable patients at risk of atherosclerotic events globally.
Presentation by Lenny Recupero, M.Ed.
Community Injury Prevention Coordinator
Division of Injury and Violence Prevention
Virginia Department of Health
A Snapshot of Fall-Related
Injuries Among Older Adults
Dr Trevor Pickersgill - Diagnosing a RelapseMS Trust
1) Diagnosing relapses in multiple sclerosis (MS) patients can be complex, as relapses can mimic other conditions and symptoms are not always clearly MS-related.
2) It is important to properly diagnose relapses to determine the MS disease course, guide treatment decisions, and understand the patient's prognosis.
3) In addition to traditional relapses, atypical presentations must be considered, such as relapses related to MS treatments, infections, neurological conditions mimicking MS, and non-neurological or functional issues. A thorough examination is needed.
Challenges in delivering mental health services to plhiv in custodial setting...Hidzuan Hashim
This document discusses healthcare issues for prisoners with HIV/AIDS or substance abuse disorders. It notes that rates of psychiatric illness and HIV are higher in prisons than in the general population. A study examined demographic data and health diagnoses for 200 HIV-positive prisoners and 200 HIV-negative prisoners in Malaysia. It found higher rates of substance use disorders and longer incarceration times among HIV-positive prisoners. The document calls for enhancing health services in prisons, addressing mental illness, and providing intervention programs for prisoners with high-risk behaviors to address issues like recidivism and transmission of diseases like HIV and hepatitis C.
Can brain atrophy measurement help us in monitoring MS progression in routine...MS Trust
This presentation by Dana Horáková, Department of Neurology and Centre of Clinical Neuroscience at the Charles University in Prague, looks at why and how we should measure brain atrophy.
It was presented at the MS Trust Annual Conference in November 2014.
This document summarizes key differences between primary care systems in Scotland and England. While both countries implemented a UK-wide GMS contract, Scotland has taken a more integrated approach, with unified health boards and a focus on managed clinical networks, anticipatory care programs, and reducing health inequalities. Scotland also takes a softer approach to monitoring quality targets compared to more rigid monitoring in England. The document discusses opportunities to further improve primary care in both countries, such as increasing public involvement and integrating health and social services.
Closer look at stroke in maine for maine stroke alliance 2019 finalGillian Gordon Perue
Presented to the leadership of the State of Maine; this presentation describes the epidemiology of patients admitted with stroke in Maine from 2010-2014. It exams independent predictors of mortality.
This document discusses medical complexity and complications experienced by patients with traumatically induced disorders of consciousness. It begins with an overview and definitions of various disorders of consciousness including coma, vegetative state, and minimally conscious state. It then discusses outcomes from studies showing high rates of medical complications in these patients that can impact recovery. Several key points are made: 1) Patients with disorders of consciousness have high rates of rehospitalization, often for infections, seizures, or neurological issues; 2) They experience many medical complications like spasticity, dysautonomia, and pulmonary embolisms; 3) Active duty military with disorders of consciousness from combat injuries face even higher medical complexity. Proper assessment and medical stabilization is crucial for
This document discusses using mobile apps to help manage chronic conditions like diabetes and hypertension. It summarizes studies showing tight control of blood glucose, blood pressure, and other factors can significantly reduce health risks. However, blood pressure control may be even more important. The document advocates using phone cameras to easily track home blood pressure readings, which better predict health outcomes than office readings. It also discusses a trial where patients safely titrated their own antihypertensive medications using an app, maintaining control with fewer visits. The ideal prescription app would partner with physicians using a public, validated algorithm to safely adjust medications.
This document summarizes the treatment of Alzheimer's disease and related dementias. It discusses the history and neuropathology of Alzheimer's disease, prevalence and treatment rates, disease progression, clinical diagnosis, differential diagnosis, approved drug therapies including cholinesterase inhibitors, guidelines for treatment, and links between vascular risk factors and the pathology of Alzheimer's disease. Management includes education, safety measures, medications, and screening for behaviors, depression, and driving ability.
The document summarizes the results of clinical trials evaluating bioresorbable vascular scaffolds (BVS). It describes improvements made to the BVS device and platform (Cohort B) based on the findings of an initial clinical study (Cohort A), including making the strut distribution more uniform and the scaffold stronger initially to reduce late lumen loss. Results showed Cohort B had less reduction in scaffold area at 6 months compared to Cohort A and late lumen enlargement between 6 months and 2 years. The studies provide evidence that BVS devices can fully degrade and resorb over time while maintaining vessel patency.
Differences in clinical characteristics and its effect for outcomesdrucsamal
The document summarizes differences in characteristics and outcomes between Western and Korean patients with acute heart failure based on an analysis of registry data. It finds that compared to Western registries, Korean patients tended to be relatively younger (mean age 69 years old), with a higher rate of first-time heart failure presentations (52.1%) and lower rates of hypertension and coronary artery disease as the cause of heart failure. Korean patients also presented with lower blood pressures on admission. In-hospital mortality rates were similar at around 5%, though Korean patients had lower 90-day mortality. Factors like creatinine levels, blood pressure, BMI and sodium levels similarly predicted outcomes. Rates of beta blocker use at discharge were also lower for Korean
This document summarizes a presentation on the physical consequences of depression, stress, and anxiety. The presentation discusses how these mental health issues are associated with increased rates of cardiovascular disease, diabetes, obesity, and some cancers. Conditions like depression can also complicate the course of physical illnesses and impact mortality. Some of the main physical pathways discussed include inflammation, insulin resistance, and hypothalamic-pituitary-adrenal axis dysfunction.
This document discusses ways to prevent Alzheimer's disease through 2050. It suggests that antioxidants and omega-3 fatty acids like DHA may help reduce free radicals and decrease the risk of dementia. The document calls for further research and action to address the growing problem of Alzheimer's as the population ages.
Dementia - what can Public Health do to respond to the scope for Prevention? - Olga Cleary
IPH, Open, Conference, Belfast, Northern, Ireland, Dublin, Titanic, October, 2014, Public, Health
Presentatie gegeven door Martin van Vliem tijdens System Center User Group NL over HP Converged System One.
HP ConvergedSystem ONE is an integrated building block of best-in-class HP servers, storage, networking and management.
DRUG PROFILE IN MYOCARDIAL INFARCTION WITH MONITORING OF POSTLYSIS COMPLICATI...Sameer Shete
This document presents a retrospective observational study on drug profiles and post-lysis complications in patients with myocardial infarction. The study analyzed 100 patients admitted with ST elevation myocardial infarction. The most common drugs administered were streptokinase, aspirin, clopidogrel, and atorvastatin. The most frequent post-lysis complications observed were bleeding (68% of patients) and hypotension (53% of patients). The study aims to evaluate treatment efficacy and risks associated with myocardial infarction by analyzing patient drug regimens and complications.
The LANCELOT-ACS trial investigated the safety and tolerability of the PAR-1 inhibitor atopaxar in 603 patients with acute coronary syndrome. The trial found that atopaxar achieved potent platelet inhibition through PAR-1 without significantly increasing bleeding risk compared to placebo. There were favorable trends for reduced major cardiac events but dose-dependent increases in liver enzymes and QTc interval prolongation at higher doses. Further studies are still needed to fully establish the safety and efficacy of atopaxar.
The document discusses age, comorbidity, and frailty in elderly patients. It introduces tools like the Preoperative Assessment of Cancer in the Elderly (PACE) and the Groningen Frailty Index (GFI) that are used to assess frailty in elderly surgical patients. The PACE evaluates factors like cognition, activities of daily living, mood, and fatigue. Research found certain components of the PACE like dependency in activities of daily living were associated with increased hospital stay and complications. The GFI contains 15 questions assessing domains like mobility, nutrition, and cognition. A GFI score of 3 or higher indicates frailty. The tools aim to identify frailty preoperatively to predict outcomes and prevent functional decline.
The future: Presentation by Gavin GiovannoniMS Trust
This document summarizes information from a presentation on multiple sclerosis (MS). It begins with disclosures from the presenter regarding compensation received from pharmaceutical companies. It then provides images and diagrams on various topics related to MS, including: cortical lesions; brain atrophy across disease stages; remyelination pathways and targets like LINGO-1; and study designs testing potential neuroprotective and remyelinating agents. One study examines the drug phenytoin in acute optic neuritis to assess neuroprotection by measuring retinal nerve fiber layer thickness. In summary, the document reviews MS pathology and potential new therapeutic strategies targeting remyelination and neuroprotection that are being investigated in clinical trials.
The document summarizes clinical outcomes data from the RESOLUTE US trial regarding patients with diabetes mellitus who received the Resolute ZES stent. Key findings from the 3-year follow-up include that diabetic patients experienced higher rates of death, myocardial infarction, and target lesion revascularization compared to non-diabetic patients, however stent thrombosis rates were low across all groups. The Resolute stent demonstrated safety and efficacy in diabetic patients out to 3 years following the procedure.
The document summarizes key findings from the CHARISMA clinical trial which evaluated the benefits of dual antiplatelet therapy with clopidogrel and aspirin compared to aspirin alone in patients at risk of cardiovascular events. The trial found no significant reduction in the primary endpoint of heart attack, stroke or cardiovascular death in the overall population, but did see a reduction in the secondary endpoint which included hospitalizations. Subgroup analysis found dual therapy beneficial for patients with established cardiovascular disease but not for those with multiple risk factors only. The REACH registry aims to study characteristics and management of stable patients at risk of atherosclerotic events globally.
Presentation by Lenny Recupero, M.Ed.
Community Injury Prevention Coordinator
Division of Injury and Violence Prevention
Virginia Department of Health
A Snapshot of Fall-Related
Injuries Among Older Adults
Dr Trevor Pickersgill - Diagnosing a RelapseMS Trust
1) Diagnosing relapses in multiple sclerosis (MS) patients can be complex, as relapses can mimic other conditions and symptoms are not always clearly MS-related.
2) It is important to properly diagnose relapses to determine the MS disease course, guide treatment decisions, and understand the patient's prognosis.
3) In addition to traditional relapses, atypical presentations must be considered, such as relapses related to MS treatments, infections, neurological conditions mimicking MS, and non-neurological or functional issues. A thorough examination is needed.
Challenges in delivering mental health services to plhiv in custodial setting...Hidzuan Hashim
This document discusses healthcare issues for prisoners with HIV/AIDS or substance abuse disorders. It notes that rates of psychiatric illness and HIV are higher in prisons than in the general population. A study examined demographic data and health diagnoses for 200 HIV-positive prisoners and 200 HIV-negative prisoners in Malaysia. It found higher rates of substance use disorders and longer incarceration times among HIV-positive prisoners. The document calls for enhancing health services in prisons, addressing mental illness, and providing intervention programs for prisoners with high-risk behaviors to address issues like recidivism and transmission of diseases like HIV and hepatitis C.
Can brain atrophy measurement help us in monitoring MS progression in routine...MS Trust
This presentation by Dana Horáková, Department of Neurology and Centre of Clinical Neuroscience at the Charles University in Prague, looks at why and how we should measure brain atrophy.
It was presented at the MS Trust Annual Conference in November 2014.
This document summarizes key differences between primary care systems in Scotland and England. While both countries implemented a UK-wide GMS contract, Scotland has taken a more integrated approach, with unified health boards and a focus on managed clinical networks, anticipatory care programs, and reducing health inequalities. Scotland also takes a softer approach to monitoring quality targets compared to more rigid monitoring in England. The document discusses opportunities to further improve primary care in both countries, such as increasing public involvement and integrating health and social services.
Closer look at stroke in maine for maine stroke alliance 2019 finalGillian Gordon Perue
Presented to the leadership of the State of Maine; this presentation describes the epidemiology of patients admitted with stroke in Maine from 2010-2014. It exams independent predictors of mortality.
This document discusses medical complexity and complications experienced by patients with traumatically induced disorders of consciousness. It begins with an overview and definitions of various disorders of consciousness including coma, vegetative state, and minimally conscious state. It then discusses outcomes from studies showing high rates of medical complications in these patients that can impact recovery. Several key points are made: 1) Patients with disorders of consciousness have high rates of rehospitalization, often for infections, seizures, or neurological issues; 2) They experience many medical complications like spasticity, dysautonomia, and pulmonary embolisms; 3) Active duty military with disorders of consciousness from combat injuries face even higher medical complexity. Proper assessment and medical stabilization is crucial for
This document discusses using mobile apps to help manage chronic conditions like diabetes and hypertension. It summarizes studies showing tight control of blood glucose, blood pressure, and other factors can significantly reduce health risks. However, blood pressure control may be even more important. The document advocates using phone cameras to easily track home blood pressure readings, which better predict health outcomes than office readings. It also discusses a trial where patients safely titrated their own antihypertensive medications using an app, maintaining control with fewer visits. The ideal prescription app would partner with physicians using a public, validated algorithm to safely adjust medications.
This document summarizes the treatment of Alzheimer's disease and related dementias. It discusses the history and neuropathology of Alzheimer's disease, prevalence and treatment rates, disease progression, clinical diagnosis, differential diagnosis, approved drug therapies including cholinesterase inhibitors, guidelines for treatment, and links between vascular risk factors and the pathology of Alzheimer's disease. Management includes education, safety measures, medications, and screening for behaviors, depression, and driving ability.
The document summarizes the results of clinical trials evaluating bioresorbable vascular scaffolds (BVS). It describes improvements made to the BVS device and platform (Cohort B) based on the findings of an initial clinical study (Cohort A), including making the strut distribution more uniform and the scaffold stronger initially to reduce late lumen loss. Results showed Cohort B had less reduction in scaffold area at 6 months compared to Cohort A and late lumen enlargement between 6 months and 2 years. The studies provide evidence that BVS devices can fully degrade and resorb over time while maintaining vessel patency.
Differences in clinical characteristics and its effect for outcomesdrucsamal
The document summarizes differences in characteristics and outcomes between Western and Korean patients with acute heart failure based on an analysis of registry data. It finds that compared to Western registries, Korean patients tended to be relatively younger (mean age 69 years old), with a higher rate of first-time heart failure presentations (52.1%) and lower rates of hypertension and coronary artery disease as the cause of heart failure. Korean patients also presented with lower blood pressures on admission. In-hospital mortality rates were similar at around 5%, though Korean patients had lower 90-day mortality. Factors like creatinine levels, blood pressure, BMI and sodium levels similarly predicted outcomes. Rates of beta blocker use at discharge were also lower for Korean
This document summarizes a presentation on the physical consequences of depression, stress, and anxiety. The presentation discusses how these mental health issues are associated with increased rates of cardiovascular disease, diabetes, obesity, and some cancers. Conditions like depression can also complicate the course of physical illnesses and impact mortality. Some of the main physical pathways discussed include inflammation, insulin resistance, and hypothalamic-pituitary-adrenal axis dysfunction.
This document discusses ways to prevent Alzheimer's disease through 2050. It suggests that antioxidants and omega-3 fatty acids like DHA may help reduce free radicals and decrease the risk of dementia. The document calls for further research and action to address the growing problem of Alzheimer's as the population ages.
Dementia - what can Public Health do to respond to the scope for Prevention? - Olga Cleary
IPH, Open, Conference, Belfast, Northern, Ireland, Dublin, Titanic, October, 2014, Public, Health
Presentatie gegeven door Martin van Vliem tijdens System Center User Group NL over HP Converged System One.
HP ConvergedSystem ONE is an integrated building block of best-in-class HP servers, storage, networking and management.
Gaining More Value from your Ariba Network ConnectionSAP Ariba
Join this session to hear Ariba solution experts, sellers, and partners share tips and tricks for better management of business growth, risk, and visibility. Learn more about the value-added services and features Ariba now offers with your Ariba Network subscription, including business valuation reports, data enrichment, and integration.
Panel topics include: how small sellers get more value from Ariba with the BizEquity Business Valuation Engine, how integrating to the Ariba Network improves customer satisfaction, retention, and accelerates your order-to-cash cycle, and how improving your catalog can help drive up customer satisfaction and growth in accounts.
How to Build OpenStack Clouds and how to manage and control “shadow IT”Kenneth de Brucq
Dell Solutions Tour 2014 Norge
Paul Brook
Responsible for Cloud and Big Data business programs across Europe, Middle East and Africa [EMEA].
The OpenStack cloud community is one of the world’s fastest growing open source communities. This is one of the reasons so many organisations see OpenStack as a viable Enterprise Cloud product. This breakout will describe how Dell and our Partners can provide a straight forward process for planning and building an open source cloud. A process that can take you from concept, though Pilot to Production.” We will also discuss how an organisation can encourage cloud utilization whilst maintaining control and governance across the organisation
Data Movement, Management and Governance In The Cloud: DocuSign Case StudyDell World
Learn how DocuSign, a leader in digital transaction management, has scaled its IT infrastructure for growth, automated business processes and created extendable efficiencies by implementing Dell Boomi AtomSphere as its integration platform as a service. In this session, you will learn how DocuSign went from managing a host of disparate applications to automating data movement, management and governance across them, while establishing an enterprise-grade IT infrastructure—and how you can, too.
Dementia introduction slides by swapnakishore released cc-by-nc-saSwapna Kishore
Dementia awareness presentation intended for general public/ patients/ potential and existing caregivers/ volunteers interested in spreading dementia awareness.
Visit my site for more information: http://dementiacarenotes.in
Using Force.com and Dell Boomi MDM to Drive Better Master Data ManagementRob Saker
Crossmark had grown its technology ecosystem organically over 15 years resulting in point-to-point integrations between various systems containing master data. They began a digital transformation initiative 18 months ago to move to a cloud-first approach on the Force.com platform and address traditional master data management challenges by implementing a centralized approach using Force.com and Dell Boomi MDM. This would help establish consistent definitions of places and other master data across the organization.
Is it time to transform your career? Successfully navigating a career change requires preparation and planning. We've put together 10 steps to help you give your career a much-needed makeover. View this slideshare for advice on how to get started and, when you're ready, visit www.getsmarter.co.za.
Cognitive reserve is the brain's ability to cope with brain damage or pathology. It allows some individuals to maintain cognitive function despite significant Alzheimer's disease pathology. The document discusses theories of cognitive reserve including brain reserve capacity and cognitive reserve models. It describes measures of reserve like education and occupation. Epidemiological evidence shows factors like higher education are associated with lower dementia risk. Imaging studies provide further support, finding relationships between cognitive reserve proxies and brain activation patterns. Maintaining cognitive stimulation through activities across life may help increase cognitive reserve and resilience against cognitive decline.
The document discusses HP CloudSystem Matrix, a private cloud solution. It provides an overview of key features such as provisioning infrastructure and applications in minutes, reducing TCO by up to 56%, and accelerating deployment with unified management. HP CloudSystem Matrix integrates with existing infrastructure and supports common virtualization, storage, and networking standards.
50 Ways to Become More Professionally ExcellentLeslie Bradshaw
This presentation will give you practical, next-level tips to help you become the best version of your professional self.
After powering through it, you will be armed with the tactics you need to grow and nurture your network, deliver world class work product, earn trust and respect, successfully collaborate, and generally take your game up a notch so you advance your career (and have plenty of fun along the way).
Insights will come from successful professionals, pop culture, and Bradshaw's own learnings as a sought-after employee, effective leader, and industry-recognized pioneer.
This presentation was originally delivered as a part of the University of Chicago Alumni Career Program on May 19, 2015.
Efficacy and safety of microvascular decompression for trigeminal in patients...neurologia segura
This study evaluated the efficacy and safety of microvascular decompression (MVD) for treating trigeminal neuralgia in patients with morbid obesity. The study found that while MVD surgery took longer and had higher risks in obese patients, it was still effective at reducing pain. Specifically, obese patients had longer surgery/anesthesia times, more pre-existing health issues, and higher complication rates during intubation. However, obese patients still experienced significant pain relief following surgery similar to non-obese patients, with over 65% reporting an excellent outcome. The study concluded that MVD should be considered for obese patients with TN when it is the only effective treatment option, and can be performed safely in specialized medical centers.
This document discusses risk factors for stroke and summarizes data from multiple studies on 5-year and 10-year risks of all stroke and ischemic stroke. Key findings include:
- Hypertension, smoking, age, diabetes and atrial fibrillation are important risk factors for increased stroke risk.
- The 5-year and 10-year risks of all stroke and ischemic stroke varied across different cohorts but were generally around 3% and 7-11% respectively.
- Risk factors like age, smoking, pre-existing cardiovascular disease and atrial fibrillation were associated with higher 10-year risks of stroke in most cohorts studied.
Watch the video of the presentation on Youtube: https://www.youtube.com/watch?v=WRegqg5yvRs
El Dr Welte té nombroses publicacions en àrees diverses relacionades amb el malalt crític. Particularment interessants són els seus estudis en relació al trasplantament pulmonar, així com els seus estudis sobre pneumònia i sèpsia. Així mateix, participa activament en la xarxa alemanya Capnetz, emprada per a l'elaboració d'estudis multicèntrics relacionats amb la pneumònia adquirida a la comunitat.
Which Chest Pain Can Be Safely Discharged From EdRashidi Ahmad
This document discusses strategies for evaluating and safely discharging chest pain patients from the emergency department (ED). It notes that over 30% of medical admissions are for chest pain, but only 50% actually have acute coronary syndrome (ACS). The diagnostic challenges include non-specific symptoms, limitations of electrocardiograms and cardiac markers in the early stages of ACS. Risk prediction tools like the TIMI score can help determine which low-risk patients may be safely discharged. Younger patients with no cardiac risk factors and normal initial tests have a very low 0.14% risk of ACS. Stress tests and echocardiography have limitations in the ED setting but may help rule out problems in some patients. The goal is to
Associated Factors of Stroke Severity Among Young Adult Stroke Patients in Malaysia from National Neurology Registry 2014 - 2018
Presentation Slides by Ms Fara Waheda Jusoh, presented on the 14th National Conference for Clinical Research (NCCR) 2021 Dr Wu Lien Teh Youth Investigator Awards (YIA) on 19th August 2021
Following are the links for this presentation on Zenodo Repository:
Presentation Slides: https://zenodo.org/record/5348488
E-Poster: https://zenodo.org/record/5348580
Holly Thacker, Update on: Menopause, Hormone Therapy, Sex, Politics, and the ...Cleveland HeartLab, Inc.
This document provides an overview and summary of a presentation on menopause, hormone therapy, cardiovascular health, and women's health issues. It discusses the aftermath of the Women's Health Initiative study 12 years later, compares risks of hormone therapy to other medications, and examines risk/benefit ratios of hormone therapy for cardiovascular disease. It also addresses politics surrounding women's health issues and "war on women" narratives related to hormone therapy. The presentation aims to provide an updated perspective on these issues based on newer research findings.
Aula de Radiofrequencia em Nódulos TireoidianosLeonardo Rangel
This systematic review analyzed nine studies on the use of radiofrequency ablation (RFA) to treat benign thyroid nodules. The studies included two randomized controlled trials and six prospective observational studies, with a total of 306 RFA treatments. Meta-analysis found statistically significant reductions in nodule size from baseline to follow-up, including in "hot" and "cold" nodule subgroups. Symptom and cosmetic scores also significantly improved, and patients were able to withdraw from antithyroid medication. Twelve adverse events occurred but none required hospitalization or caused death. The review concluded that RFA is safe and effective for symptomatic benign thyroid nodules, but noted a lack of high-level evidence comparing it to surgery or other
This systematic review analyzed nine studies on the use of radiofrequency ablation (RFA) to treat benign thyroid nodules. The studies included two randomized controlled trials and six prospective observational studies, with a total of 306 RFA treatments. Meta-analysis found statistically significant reductions in nodule size from baseline to follow-up, including in "hot" and "cold" nodule subgroups. Minor adverse events occurred in 12 treatments but none required hospitalization. RFA was concluded to be a safe and effective treatment for symptomatic benign thyroid nodules, though more high-quality studies are needed comparing it to surgery or other nonsurgical options.
This document discusses the consequences of cancer treatment and late effects. It notes that late effects currently affect 400,000 people in the UK and have a significant impact on survivors' daily lives. Late effects are underappreciated and can be managed through early intervention to prevent long-term impacts. The risks of late effects depend on treatment factors like radiation dose and chemotherapy drugs, as well as individual patient factors. Common late effects include scarring, functional disability, lymphedema, cardiac issues, and gastrointestinal problems. The document calls for improved assessment, management, and services to address late effects.
A talk by Pratik Pandharipande at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
El 17 de octubre de 2014, la Fundación Ramón Areces celebró una nueva conferencia del ciclo 'Envejecimiento, Sociedad y Salud: envejecimiento y enfermedad', que organiza en colaboración con el Centro de Estudios del Envejecimiento. En esta ocasión, el doctor Valentín Fuster, director del Centro Nacional de Investigaciones Cardiovasculares Carlos III- CNIC, habló sobre 'Enfermedad subclínica de corazón y cerebro: el reto de la década'. En esta entrevista previa a su intervención, deja claro que nunca es tarde para cuidarse y que la clave no está tanto en el corazón, sino en el cerebro, donde se toman las decisiones para llevar hábitos de vida saludables.
This document discusses chronic kidney disease (CKD) in the elderly. It begins by noting that public perception and healthcare discrimination can impact older patients. It then reviews the burden of CKD based on registry data showing increased prevalence with age. Various sections discuss age-related changes to organs like the kidney and how this impacts disease. Treatment targets for conditions like hypertension in older patients are reviewed based on clinical trial evidence. The challenges of comorbidities in older patients with CKD are also discussed. The document considers quality of life versus longevity and factors like living arrangements that influence end-of-life care decisions in this population.
A great deal is happening in lupus-related research. This presentation will update participants on recent research developments and their impact on those affected by lupus. Dr. Petri will provide an overview of current lupus research and the prospects for the future of lupus treatments. Learn how to better manage your lupus and make knowledgeable decisions regarding your treatment plan.
Introduction to a conference at the University of York on September 4, 2014 on men's health and long-term conditions - including mortality rates, cancer, heart disease, suicide and diabetes
Weight diabetes and metabolic problems in patients taking atypical antipsycho...Alex J Mitchell
Free slide show on weight gain, diabetes and metabolic problems in those taking atypical antipsychotic medication in schizophrenia, bipolar disorder and related conditions. Image credits retained by original authors. Please give correct acknolwedgements if you present any material from here.
Using linked medical records, this study explored outcomes for people with mental illness discharged from inpatient care over several decades. Some key findings include:
- There is significant risk of death within the first year of discharge, especially from natural causes.
- Mortality rates within 30 days of discharge have markedly decreased over time, especially from natural causes.
- Admission rates for those over 65 with mental illness have significantly decreased while rates of community-based care have increased.
- Working with encrypted medical records presents challenges for outcomes research but record linkage is still advantageous for studying mental health outcomes over long periods.
This document summarizes psoriatic arthritis, including its clinical features, patterns, epidemiology and comparison to rheumatoid arthritis. Psoriatic arthritis is an inflammatory arthritis associated with psoriasis that is typically seronegative for rheumatoid factor. It can present as oligoarticular, distal interphalangeal-predominant, polyarticular, spondylitic or arthritis mutilans patterns. Studies show 20% of patients develop deformities within 10 years. Psoriatic arthritis is classified with other seronegative spondyloarthropathies due to characteristics like HLA-B27 positivity and sacroiliitis.
This document summarizes key findings regarding dose-limiting toxicities from radiation therapy for various brain structures and tumors. It notes that necrosis rates for brain tumors start around 5% at 60 Gy, with various structures like the optic nerves and endocrine system showing toxicity starting at doses of 50-45 Gy. Late toxicities from a phase III trial escalating glioblastoma radiation from 60 to 72 Gy showed slightly higher rates of neurological and other toxicities in the higher dose arm. Further evidence is discussed relating radiation dose and fractionation to risks of dementia, cochlear dysfunction, and other issues. Intensity modulated radiation therapy may help reduce doses to critical structures like the optic chiasm compared to 3D conformal radiation therapy based
This document provides an overview and summary of treatment guidelines for gout. It discusses the different stages of gout including asymptomatic hyperuricemia, acute gout, interval gout, and chronic gout. It reviews guidelines for treating acute gout flares using monotherapy or combination therapies. It also summarizes recommendations for preventing flares and lowering serum uric acid levels through dietary changes and use of urate-lowering therapies such as allopurinol, febuxostat, probenecid, and pegloticase. Head-to-head trials comparing allopurinol and febuxostat are reviewed showing febuxostat is more effective at lowering uric acid levels but has a higher
Similar to 3 forette prevention of alzheimer ifa 2012] 2 (20)
This document lists the president, past president, vice presidents, treasurer, directors, honorary directors, and directors at large of an organization. It provides names and titles for 18 individuals in leadership roles, including the president, vice presidents overseeing different regions, the treasurer, and various directors.
This document discusses policy interventions to address poverty among the elderly in Portugal. It summarizes the aims, methodology, and key findings of an ongoing research project analyzing aging, poverty, and social exclusion. The summary outlines Portugal's increasing aging population and dependency ratio. It also notes policy efforts like the National Inclusion Plan and Integrated Support Services Plan, and some strategic programs developed. However, it finds current measures only address basic needs and underestimate involvement in decision-making. The conclusion calls for more needs-based, participatory, and integrated policies and services to better address aging poverty amid financial crises.
The document discusses issues facing senior citizens in India as the traditional joint family system breaks down and medical advances increase lifespans. It notes that while developed western countries have enacted strong social support systems for seniors, India has implemented few support schemes despite 60 years of independence. Non-governmental organizations (NGOs) serving the elderly thus play a crucial role. Lions Club International actively supports NGOs serving seniors in India. Senior citizen forums and townships specifically for elders could also help address the needs of India's growing elderly population.
This study explored the use of telehealth monitoring among older clients receiving home care and their informal caregivers. The study found a 12% failure rate in telehealth readings, which was not significantly different between clients with or without caregivers. Safety issues were identified related to the reliability of monitoring equipment and need for staff to follow up on missed readings. The presence of a caregiver did not guarantee improved reliability of telehealth readings.
This document presents the TeleSCoPE project which aims to develop a code of practice for telehealth services in Europe. A consortium of 12 partners from 7 countries worked to create the code over 3 years. The code provides a framework to guide telehealth services in key areas like ethics, governance, data protection, staffing and more. It was validated with over 20 existing telehealth services and will be officially launched in 2013 to help more services meet quality standards and build public trust in telehealth.
This document discusses using web 2.0 and social networking to improve healthcare, specifically for aging populations. It provides examples of how connecting patients online can reduce healthcare costs and improve outcomes. Intel is studying a VA home healthcare program to see how health IT tools could help the program scale to more veterans by improving care coordination and quality. The document advocates that ultrabook-based services can minimize web 2.0 risks for end users and maximize its benefits for healthcare.
This document outlines the creation and evolution of the "Be Inspired!" campaign by the Aged and Community Care Victoria (ACCV) Marketing & Communications Industry Reference Group. The campaign began in 2009 by granting residents' wishes and garnering local media coverage. It grew into a larger collaborative effort in 2010 featuring residents riding Harley Davidson motorcycles through Melbourne to promote positive aging. The successful campaign continued in 2011 with residents driving V8 cars around a racetrack and engaging activities at an information booth. The campaign enhanced the image of the aged care industry and demonstrated the benefits of industry partnerships.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
This 5 minute YouTube video shows a man demonstrating how to properly fold a fitted sheet. He explains that most people find folding fitted sheets challenging due to their elastic edges. The video then walks through the step-by-step process to fold the sheet into a neat, compact square using several folds along the length and width of the sheet.
2012 05-29 global challenges-ageing and shrinking lf_final rmifa2012
The document discusses global demographic trends, including population growth and aging. It notes that while the world's population grew from 6 to 7 billion people recently, Europe, Russia and Japan's populations have started shrinking. It also discusses how life expectancy has risen to over 70 years globally while fertility rates have halved to 2 children per woman in most places, leading to population aging. Finally, it notes Europe and Japan currently have the oldest populations as a share of those over 65, while developing nations still have younger populations.
The document discusses the need for affordable housing for older people in urban areas of South Africa as urbanization and the aging population are increasing. It notes Durban has a shortage of suitable housing for vulnerable older residents. The TAFTA organization worked to address this by partnering with local groups to convert an existing inner-city building into affordable housing with 37 units and on-site care services. This helped provide shelter for the elderly while also contributing to urban renewal efforts.
Foot health is essential for older adults to maintain functional ability and manage daily activities. A review of literature on foot health in older people without long-term foot diseases found that foot problems can cause disability, poorer functional status, and increased risk of falls. Foot problems were also shown to negatively impact quality of life, overall health, and wellbeing. Specifically, different foot problems increased disabling foot pain and affected the toes. The conclusion is that untreated foot problems can hamper older adults' safe living and affect general wellbeing and functional ability. Therefore, regular foot health assessments and prevention of foot problems are important.
1) The document discusses how technology has dramatically increased life expectancy over the past century, from 43 years in 1945 to 75 years currently.
2) It credits technologies like water supply, vaccines, and early disease detection with controlling death and improving health, leading to both increased life expectancy and a decline in fertility rates.
3) However, hundreds of millions of older people around the world still do not have access to the technologies that could help them, and in developing countries 80% of older persons do not have a basic income.
The document outlines 15 steps for setting up an intergenerational child care center in a retirement community. The steps include developing a proposal, obtaining approval from the board, establishing a non-profit corporation, identifying an initial team, approaching funding sources, completing site plans and construction documents, soliciting bids, securing insurance, establishing contacts, preparing documentation, obtaining licensing, lining up services, recruiting staff and volunteers, enrollment, and scheduling an open house.
The document presents an empirical analysis of gender gaps using microdata from the Survey of Health, Ageing and Retirement in Europe (SHARE). It discusses (1) defining appropriate measures of gender gaps for older populations, (2) examining social mobility patterns from childhood to older ages, and (3) using regression analysis to quantify the effects of various determinants on end-of-life gender gaps across European countries. The analysis finds significant gender gaps in personal income among older Europeans and that these gaps are influenced by factors throughout the life course such as childhood conditions, education, employment, and pensions.
5 tarrant-global conf on aging presentationifa2012
The document discusses the potential benefits of using video remote monitoring to manage chronic diseases. It suggests that video remote monitoring could help integrate health services, collect health data, and connect patients to social and medical support networks. The document summarizes research showing that video remote monitoring may decrease hospitalizations and emergency room visits for conditions like COPD, CHF, diabetes, and wounds. It estimates a potential cost savings of $800 per high-risk patient per month from reduced hospitalizations when using video remote monitoring for patients with multiple chronic conditions.
This document summarizes research on housing provided by the state of Chile for vulnerable senior citizens. The researchers evaluated how architectural design impacts seniors' ability to perform basic daily living activities. They studied housing from 1990, 1997, and 2007 and assessed dimensions, layouts, and equipment. They found that design features like inadequate heights, sizes, and furniture placement created difficulties for seniors and increased risks. Without proper accommodations for reduced mobility and strength, housing design can undermine seniors' independence and autonomy. The researchers developed guidelines to help housing better support seniors based on their needs and abilities.
5 o´ryan-a phenomenological exploration of aging 5.25.12ifa2012
This document summarizes a presentation on a phenomenological study exploring perspectives on aging and spirituality from a global cultural and spiritual lens. The study involved interviews with elders from the Middle East, Scandinavia, and Hispanic cultures. Preliminary analysis identified five primary themes: deep self-knowledge and understanding of others; the path of wisdom; detachment leading to peace; recognition of responsibility to others; and aging as a decision-making process. The presentation discusses implications for using common spiritual themes among elders as a basis for interfaith dialogue and addressing global challenges in an era of increased globalization.
HKCSS has operated since 1947 and constitutes an umbrella organization of around 400 agency members that provide over 90% of social welfare services in Hong Kong. It aims to make Hong Kong more age-friendly by developing inclusive communities and enabling environments for older residents through various initiatives and partnerships between government, businesses, and community organizations. Upcoming efforts include establishing an age-friendly business circle and index to track trends in aging friendliness. The organization highlights its work in establishing older people platforms, conducting community audits and surveys, and producing educational materials and films involving youth.
The document discusses Malta's experience with multi-sectoral education in aging. It describes how Malta has played a leading role internationally on aging issues since 1969. This includes establishing the International Institute on Aging in 1987 to provide training to personnel from developing countries. The Institute offers various programs in Malta and other countries. Malta also established the Institute of Gerontology and Geriatrics in 1986 to provide multi-disciplinary education. The Institute runs academic programs, in-service training for caregivers, and educational programs for older adults. Malta's approach aims to provide multi-sectoral education to benefit professionals, caregivers, and older adults themselves.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
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Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
1. Prevention of Alzheimer’s
disease and dementias
IFA 2012 Prague
Françoise Forette, MD,
CEO ILC-France,
Director of the National Foundation of Gerontology
Professor, University Paris V
francoise.forette@gmail.com
2. Prevalence of dementia
increases with age
60
Prevalence of dementia (%)
50
40 Europe
USA
30
Asia
20 Africa
10
0
Age (years)
Fratiglioni et al. Drugs Aging 1999; 15: 365–75
3. Alzheimer’s disease is the first cause of loss
of autonomy
• More than 70% of institutionalizations are due to
Alzheimer’s disease and other dementia
• Cost : $ 173 billion in US (up to 1 trillion in 2050),
€ 18 billion in France
• Prevention of Alzheimer is one of the most
important challenges that scientists,
researchers, gerontologists, geriatricians have to
meet, facing the Longevity revolution.
4. Is there evidence that AD could be a
preventable disease?
• According to the NIH State-of-the-Science
Conference: “Preventing Alzheimer’s
Disease and Cognitive Decline” held on
April 26–28, 2010
The answer is NO
Is it possible to challenge this assertion ?
5. Prevention Approaches
1 Approaches based on epidemiologic studies
- Estrogens
- Anti-inflammatory agents
- Anti-oxidants
-Cholesterol lowering agents:Statins
-Blood pressure lowering agents
2 Approaches aimed at increasing the cognitive
“reserve”
-Cognitive stimulation
-Physical activity
- Social network, professional activity
3 Brain lesions modifying approaches
- Anti-Amyloid approach (Vaccin, secretase
inhibitors)
- Anti - Tau approach
6. Many cardiovascular diseases have been related to the
incidence of VD or AD
• Vascular dementia • Alzheimer disease
- Atrial fibrillation - Atrial fibrillation
Ott 1996 Ott 1996
- Coronary diseases - Coronary diseases
Brayne 1998, Ross Spark 1990, Soneira
1998 1996
- Atherosclerosis - Atherosclerosis
Hofman 1997 Hofman 1997
- White matter lesions
Leys 1998, Breteler - White matter lesions
2000 Leys 1998, Breteler
- Smoking 2000
Meyer 1998
8. Diabetes and dementia
Longitudinal surveys
Alzheimer Disease RR (95% IC)
Hisayama Study (n=828) 2.2 (1,0-4.9)
Arvanitakis (n=824) 1.65 (1.10-2.47)
Rochester Study (n=1455) 1,7 (1,3-2,1)
Medicare (n=1138) 3.8 (1.8-8.2)
Rotterdam Study (n=6370) 1.9 (1.2-3.1)
Kaiser medical care (n=8845) 1.46 (1.2 – 1.8)
9. N=11 140, HBA1C < 6.5% vs
standart care VS optimal care
66 years old, Follow-up : 4.3 ans,
N Engl J Med 2008;358:2560-72.
10. Cholesterol and Alzheimer’s
disease
Conflicting results between the
observational studies and the
randomized controlled trials
11. Cholesterol and dementia
Longitudinal Surveys
Référence nombre Âge Suivi Dosage Diagnostic Associa RR (95%CI)
(ans) (ans) tion
Moroney, 111 75 7 LDL-C VaD 3.1 (1.5-6.1)
1999 +
Reitz 2004 2820 78 4.8 LDL-C VaD 2.45 (1.05-5.70)
+
Notolka 1998 444 40-59 30 CT MA 3.1(1.2-8.5)
+
Kivipelto 2002 1449 53 21 CT MA 2.8 (1.2-8.5)
+
Kalminjn 2000 8006 52.7 26 CT démence ns 1.10 (0.95-1.26)
Tan, 2003 1023 76 8 CT MA ns 0.97 (0.90-1.05)
Mielke 2005 392 70 18 CT démence 0.31 (0.11-0.85)
-
Duron E, Hanon O Vasc Health Risk Manag. 2008;4(2):363-81
12. Statins and cognitive health
• Growing body of epidemiological and
biological evidence that statins may reduce
dementia
- Jick et al. Lancet 2000; 356: 1627–31
- Wolozin et al. Arch Neurol 2000; 57: 1439–43
- Rockwood et al. Arch Neurol 2002; 59:223-227
- Rodriguez et al. JAGS 2002; 50:1852-56
- Hajjar et al. J Gerontol 2002; 57A: M414-18
- Fassbender et al. PNAS 2001; 98: 5856–61
- Refolo LM Neurobiology of Disease 2000; 7:21
13. Statins and dementia: Randomised trials
• MRC/HBF Heart Protection Study of cholesterol
lowering with simvastatin in 20 536 high-risk
individuals: a randomised placebo-controlled study
Lancet 2002; 360:7-22
• Pravastatin in elderly individuals at risk of vascular
disease (PROSPER): a randomised controlled trial
Lancet 2002; 360:1623-30
No reduction of dementia or cognitive deficit
Limitations: Short follow-up in PROSPER
No patients > 82 years
Cognition=secondary outcome
• Randomized controlled trial of atorvastatin in
mild to moderate Alzheimer disease: LEADe.
Neurology. 2010 23;74:956-64. Negative results (cognition)
14. Statins and Alzheimer’s disease
• There is no evidence up to now that
statins be effective in the prevention or
treatment of AD
• Given the biological data, more research is
needed with other outcomes
• Statins are nevertheless a powerful
approach to reduce incidence of
cardiovascular diseases.
15. Estrogens and Alzheimer’s disease
• This issue raises two questions: How and
when an estrogen treatment should be
considered?: The timing hypothesis
16. There was a considerable amount of evidence that
estrogens could maintain Cognitive Health
RR 0.66 (0.53-0.82)
Leblanc ES, JAMA 2001; 285:1489-99
17. Women’s Health Initiative
4 532 women 65 years, 4 year follow-up
23 additional dementia cases / 10 000 patient years
Shumaker S JAMA 2003 289:2651-62
18. The timing hypothesis may explain the
discrepancy between observational and RCTs
• Rocca WA (Neurodegener Dis. 2010;7:163-6)
– Case control and cohort studies show a neuroprotective effect in
the early menopause phase
– Estrogen treatment in the late postmenopause phase is
associated with an increased risk of dementia and cognitive
decline
– The neuroprotective effects of estrogen depend of age, type and
stage of menopause
• Henderson V W (Biochim Biophys Acta. 2009)
– Estrogen exposure in the early menopause raises the possibility
of cognitive benefit later in life
– After about the age of 65 years, hormone therapy increases
dementia risk
– Further research is needed to understand short
tem and long term effects but estrogen therapy
should not be initiated after age 65 to prevent
dementia or remediate cognitive aging.
20. Hypertension and cognitive decline
longitudinal studies
References n Age (ans) Suivi Correlation
Wilkie 1971 202 68 10 years Cognitive decline
Elias 1993 1702 55-88 12-14 years Cognitive decline
Launer 1995 3735 50 20-28 years Cognitive decline /dementia
Starr 1997 603 > 69 4 years Cognitive decline
Kilander 1998 999 50 20 years Cognitive decline
Swan 1998 717 45 25-30 years Cognitive decline
Tzourio 1999 1373 59-71 4 years Cognitive decline
Knopman 2001 10 963 47-70 6 years Cognitive decline
Kivipelto 2001 1 449 53 21 years Dementia
Reinprecht 2003 186 68 years 13 years Cognitive decline
Piguet 2003 377 75 years 6 years Cognitive decline
Qiu 2003 1 270 81 6 years Dementia
Whitmer 2005 8 845 44-44 30 years Dementia
Luchshinger 2005 1 138 76 6 years Dementia
21. Relationship between hypertension and
Alzheimer’s disease
References n Type of study Correlation
Kokmen 1991 415 Cross sectional study +
Prince 1994 1545 Cross sectional study +
Sparks 1995 231 Histopathological study +
Skoog 1996 382 Longitudinal study /15 years +
Launer 2000 3703 Longitudinal study /25 years +
Kivipelto 2001 1449 Longitudinal study /21 years +
Yoshikate 1995 828 Longitudinal study /7 years 0
Landin 1993 71 Cross sectional study -
Guo 1999 1642 Longitudinal study/ 3 years -
22. Antihypertensive treatment and
dementia: observational studies
• Reduced risk of cognitive impairment or dementia
in treated hypertensive patients
– Guo et al. (Kungsholmen project)
Arch Neurol 1999; 56: 991–6
– Tzourio et al. (EVA study)
Neurology 1999; 53: 1948–52
– Launer et al. (Honolulu–Asia Aging study)
Neurobiol Aging 2000; 21: 49–55
– Richards et al. (African–American study)
J Am Geriatr Soc 2000; 48: 1035–41
– In’t Veld et al. (Rotterdam study)
Neurobiol Aging 2001; 22: 407–12
23. Prevention of dementia in controlled
hypertension trials
• SHEP (Applegate et al.)
Arch Intern Med 1994; 154: 2154–60
• MRC (Prince et al.)
BMJ 1996; 312: 801–5
• Syst-Eur (Forette et al.)
Lancet 1998; 352: 1347–51
• PROGRESS (C Tzourio)
Arch Intern Med 2003; 163:1069-1075
• SCOPE (Hansson et al)
J Hypertens 2003;21:875-886
• HYVET(Peters et al)
LANCET 2008. 7:683-89
24. Blood pressure-lowering agents and
dementia
• Two randomised placebo-controlled studies
demonstrated a reduction in the incidence of dementia
- Syst-Eur
Based on calcium-channel blocker nitrendipine possibly
associated with ACE-inhibitor enalapril and/or diuretic
Forette et al. Lancet 1998; 352:1347–51. Forette et al. Arch Intern Med 2002;
162: 2046-52
- PROGRESS
Run on post-stroke patients and based on ACE-inhibitor
perindopril and diuretic indapamide
Tzourio et al Collaborative Group. Arch Intern Med 2003; 163:1069-1075
25. Syst-Eur 2 : Incidence of dementia
Median
follow-up : BP difference :
3.9 years 7/3.2 mmHg
Forette Arch Intern Med. 2002 14;162:2046-52
26. PROGRESS
Tzourio C et Al Arch Intern Med. 2003;163:1069-75.
Dementia and cognitive decline
Events Favors treatment Favors Odds ratio
Active placebo placebo (95 % CI)
Dementia
With recurrent strokes 43 65 0.66 (0.40-0.87)
Other dementias 150 152 0.99 (0.78-1.24)
bitherapie 106 136 0.77 (0.59-1.0)
Total 193 217 0.88 (0.72-1.08)
Cognitive decline
With recurrent strokes 43 88 0.65 (0.39-0.79)
Without recurrent strikes 233 246 0.91 (0.78-1.10)
Total 276 334 0.81 (0.68-0.88)
0.5 1.0 2.0
Odds ratio
27. HYVET
HYVET COG (n=3336 > 80 years without dementia)
HR 0.86 (0.67-1.09),
• Dementia: p=0.21
– HR 0.86 [95% CI 0.67-1.09],
(p=0.21).
• Dementia (ajusted):
– HR 0.85 [95% CI 0.67-1.09]
Lancet Neurol. 2008 Aug;7(8):683-9.
28. Potentialisation of vascular and degenerative
lesions
By treating the vascular component of cognitive impairment
antihypertensive treatment might delay the onset of dementia
Cognition
Aging
Degenerative lesions
Vascular lesions
Dementia
Threshold
Time (years)
29. No evidence that other pharmacological
approaches prevent Alzheimer’s disease
• Anti-inflammatory agents
• Aspirin
• Anti-oxidant
• Folates
30. Anti-inflammatory agents do not
prevent Alzheimer’s disease
• Epidemiological evidence (Skezely 2010)
– Observational studies found an association of NSAID use and a
reduced risk of AD
– By contrast RCTs are not effective in treating or preventing AD
• Aisen P (JAMA 2003;21: 2819-26). RCT with rofecoxib or naproxen does not
slow cognitive decline in AD patients
• ADAPT trial. (Arch Neurol 2008;65:896-905) RCT with naproxen or
celecoxib does not improve cognitive function
• It is hypothesized that NSAIDs may be beneficial in normal brain but
detrimental when the Abeta deposition process has started because
of their inhibiting activity on microglia which mediates Abeta
clearance. Imbimbo 2009:
32. Selegiline Vit E
341 randomized AD patients, 2 year follow up,
placebo, selegiline (10mg/j), vit E (2000 IU/j), les 2
selegiline Vit E Vit E + seg placebo
MMSE 12.7 11.3 12.9 13.3*
Time to institution, 655 days 670 days 585 days 440 days
ADL, CDR (p=0.012) (p=0.001) (p=0.049)
deterioration
Sano M NEJM 1997;336:1216-22
33. Honolulu Asia Aging Study
3385 subjects 71 - 93 years ; 3 - 5 year FU
DV D Mixtes MA
Vit E 1.28 (0.35-4.69) 0.86 (0.25-2.92) 0.84 (0.19-3.77)
Vit C 0.83 (0.27-2.57) 0.75 (0.29-1.96) 1.61 (0.67-3.87)
Vit E + C 0.12 (0.02-0.88) 0.31 (0.11-0.89) 1.81 (0.91-3.62)
Masaki KH Neurology 2000;54:1265-72
3734 subjects 71 - 93 years old, 5 year FU
DV D Mixtes MA
Vit E + C 0.95 (0.43-2.13) 0.91 (0.59-1.41) 1.05 (0.64-1.75)
Laurin D JAMA 2002;288:2266-8
34. May Life Style prevent dementia ?
• Physical Activity
• Diet
35. “Preliminary evidence suggests a beneficial
association of physical activity with the preservation of
cognitive function” (NIH 2010)
• A six month program of physical activity provided a modest
improvement of cognition over a 18 month follow up period in 170
adults with subjective memory impairment. Lautenshlager . JAMA
2008
• Exercise at midlife may reduce the odds of dementia in older
adultwood in a case control analysis . Andel J Gerontol 2008
• Aerobic exercise improves executive control process in 33 older
adults at risk of cognitive impairment. Baker Arch Neurol 2010
• In a case-control study any frequency of exercise performed in mid
life or later life was associated with a reduced odds of having MCI.
Geda Arch Neurol 2010.
• However in a recent prospective study on Italian cohort, physical
activity is associated with a lower risk of vascular dementia but not
AD (Ravaglia G and coll. Neurology 2008;70(19 Pt 2):1786-94).
36. Nutrition and lifestyle : Are they able to
decrease the risk of Alzheimer's disease?
• A number of studies have shown that consumption of fish and
adequate intake of fruits and vegetables might be associated with a
decreased risk of developing the disease. (Morris Arch Neurol
2003;60(7):940-6). - Larrieu J Nutr Health Aging 2004;8(3):150-4.,
Barberger-Gateau Neurol. 2007; 69:1921-30, Hughes Am geriat psychiatry
2010;18:413-20))
• Combination of higher physical activity and Mediterranean type of
diet are independently associated with reduced risk for AD.
(Scarmeas JAMA 2009;302:627-37)
37. Alcohol and AD
3 777 subjects 65 years 3 year follow up
PAQUID study (Bordeaux, France)
Wine intake RR p
absence 1.00 -
light 0.55 < 0.05
(1 to 2 verres/j)
moderate 0.25 < 0.03
(3 to 4 verres/j)
Orgogozo JM Rev Neurol 1997;153:185-92
38. Alcohol consumption and risk of dementia 7
983 subjects 55 years, 6 year follow up
Rotterdam Study
Alcohol intake RR (95% IC) Reduction
<1 glass/week 0.82 (0.56-1.22) -
1-3 0.58 (0.38-0.90) - 42%
glasses/week
4 glasses/week 1.00 (0.39-2.59) -
All dementias : AD/ Vascular dementia
Ruitenberg A Lancet 2002;359:281-86
39. Approaches aimed at increasing the
cognitive “reserve”
• Cognitive stimulation
• Leisure activities
• Social interaction
• Professional activities
40. Cognitive stimulation and AD
(Petrosini et al. 2009 for a review)
• A number of studies have shown the importance of early cognitive
enrichment to maintain cognitive performances later in life
(Borenstein 2006, Mc Dowell2007, Roe 2007)
• Formal education is a positive predictor of age-associated cognitive
decline (Bennet 2003, Bruander 2008, Katzman 1993, ….)
• Education does not prevent the onset of AD but provides protection
against the expression of clinical symptoms. With the same lesions
highly educated subjects become demented later (Letenneur 1999,
Snowdown 1996, Stern 1994)
• Post mortem analyses report marked neuropathological features of
AD in individuals who have never shown signs of cognitive
impairment (Del Ser 1999, katzman 1993, Neuropathology group 2001…)
• These data provide the foundation for the reserve theory (Fratiglioni
2007, Stern, 2002, 2003, 2006)
41. Neuroplasticity, Cognitive Reserve and
Cognitive Training
• The Concept of Cognitive reserve was proposed to explain
epidemiological data indicating that individuals engaged in higher
level of mental and physical activity were at lower risk of developing
AD and other dementia. (Nithianantharajah, Prog Neurobiol 2009)
• Neuroplasticity refers to the physiological ability of the brain to
strengthen and form dendritic connections, produce beneficial
.
morphologic changes and increases brain reserve (Vance, J
Psychosoc Nurs Ment Health Serv 2010 )
42. Cognitive training may preserve the
cognitive functioning and ADL abilities
• The five year, randomized, controlled, single-blind
ACTIVE study supports the effectiveness and durability
of the cognitive training interventions in improving
targeted cognitive abilities in older independent-living
adults (Ball et al. JAMA 2002; 288:2271-81).
• The ACTIVE study also confirmed that reasoning training
resulted in less functional decline in self-reported IADL.
Compared with the control group, cognitive training
resulted in improved cognitive abilities that continued 5
years after the initiation of the intervention.
(Willis et al. JAMA 2006; 296:2805-14)
43. Leisure activities seem as well promising
• The three city study in community-dwelling elders of
65+ free of dementia shows that:
stimulating leisure activities at least twice a week such as
:
- crosswords,
- playing cards,
- attending exhibitions,
- going to a show,
- doing artcraft,
decreases by 50% the incidence of dementia and by
40% AD compared with the incidence in people engaged
in such activities less than once a week,
(Akbaraly TN and coll. Neurology 2009;73(11):854-61)
44. Social activities, environment and AD
• A number of longitudinal studies have shown that an extensive social
network may protect against dementia. (Bassuk SS and coll. Ann Intern
Med 1999;131(3):165-73. - Zunzunegui MV and coll. J Gerontol B Psychol
Sci Soc Sci 2003;58(2):S93-S100.).
• Individuals living alone with no friends or relatives seem more at risk
of developing dementia (Fratiglioni L and coll. Lancet
2000;355(9212):1315-9.)
• In the Honolulu Study only the decreased social engagement from
mid life to late life was associated with an increased risk of dementia
(Saczynski JS and coll. the Honolulu-Asia Aging Study. Am J Epidemiol
2006;163(5):433-40.)
45. Influence of the professional activities
This is one of the new very promising approaches
• A recent study, only in men observed a significant effect
of delaying the age of retirement: each additional year in
employment delayed by 0.13 year the onset of AD.
(Lupton. Int J Geriatr Psychiatry;25(1):30-6.)
• Moreover, mentally demanding occupations have a
direct and relatively early effect on the neuropathology of
Alzheimer's disease. (Smyth KA and coll. Neurology
2004;63(3):498-503.)
46. ORLANDO Study
“Is Older age Retirement reLated to delAyed
cliNical Dementia Onset ? “
• The study is based 400,000 men and women from
the databases of RSI that allow to
cross “disease” data and "retirement" data
managed by the same organization.
• This work determines if there is a difference in the
age of retirement between people with AD and a
control population, matched on age,
gender, socio-professional category.
• The very promising results will be published soon.
48. Brain lesions modifying approaches
• The future disease-modifying treatments of Alzheimer’s
diseases will constitute the very prevention treatment.
• This will necessitate a very early diagnosis, years before
the onset of symptoms.
• Hence, the importance of the development of biological
and neuroimaging markers
• The disease-modifying treatments offer serious hope of
considerable progress in preventing pre-symptomatic AD
but none of them is close to be released.
50. Drugs in preclinical and clinical
development for AD
Mangialasche et al. Lancet Neurol 2010
51. Biomarkers of Alzheimer’s disease are available
for research
M.S. Albert et al. / Alzheimer’s & Dementia- (2011) 1–10
52. Biomarker model of the preclinical stage of AD
Hypothetical model of dynamic biomarkers of the AD expanded to explicate the preclinical phase.
-Aß as identified by cerebrospinal fluid Aß42 assay or PET amyloid imaging.
-Synaptic dysfunction evidenced by fluorodeoxyglucose (F18) positron emission tomography
(FDG-PET) or functional magnetic resonance imaging (fMRI), with a dashed line to indicate that synaptic
dysfunction may be detectable in carriers of the Ɛ4 allele of the apolipoprotein E gene before detectable Aß
deposition.
-Neuronal injury is evidenced by cerebrospinal fluid tau or phospho-tau,
-Brain structure is evidenced by structural magnetic resonance imaging.
Figure adapted with permission from Jack et al.
R.A. Sperling et al. / Alzheimer’s & Dementia- (2011) 1–13
53. Recommendations
• Estrogens, anti-inflammatory agents and anti-
oxidant cannot yet be recommended to maintain
cognitive health in the light of published studies.
• Some other trials are ongoing.
54. Recommendations
• Statins should be recommended to prevent
cardiac diseases since all controlled trials (CARE,
LIPID, WOSCOPS, PPP, HPS PROSPER) have
demonstrated that the benefit on cardiovascular
complications persisted after 60 years
• Up to now there is no evidence that statins
prevent dementias. Other trials on
cognition should be encouraged.
55. Recommendations
• Treatment of hypertension should be strongly
recommended at all ages
• Two controlled trials have demonstrated the
effectiveness in preventing dementia in
addition to the reduction of strokes and
cardiovascular complications
• Other trials should confirm the specific role of
the different classes of antihypertensive
drugs on the degenerative process
56. Recommendations
• The benefit of cognitive stimulation has been proven by
controlled trials.
• Physical activity, leisure activity, social interactions should be
encouraged on the grounds of their favourable action on health,
fitness, quality of life and cognitive activities.
• Prolongation of professional activities may be the
strongest tool to maintain cognition and postpone
deterioration,
• Controlled trials on these approaches should be
encouraged.
57. Conclusion
• Maintaining cognitive health remains the most
stimulating challenge of the Century.
• More research is needed in this field.
• Large information of the public is necessary.
58.
59. Possible Risk factors for Cognitive
Decline and/or Dementia
• Age and sex
• Level of education
• Mild Cognitive Impairment (MCI)
• Genetic factors (ApoE4 Allele)
• Oxidative stress
• Inflammation
• Menopause
• Vascular factors (hypertension)
• Metabolic factors (diabetes, obesity, cholesterol..)
• Depression
• ?
60. Pathophysiological sequence leading to cognitive impairment. This model postulates that
amyloid beta (Aß) accumulation is an “upstream” event in the cascade that is associated with
“downstream” synaptic dysfunction, neurodegeneration, and eventual neuronal loss.
Age and genetics, as well as other specific host factors, such as brain and cognitive reserve, or
other brain diseases may influence the response to Aß and/or the pace of progression toward
the clinical manifestations of AD.
R.A. Sperling et al. / Alzheimer’s & Dementia- (2011) 1–13
61. Intellectually demanding work and
cognitive reserve
• In a recent study, intellectually demanding work was
associated with greater benefit to cognitive performance
in later life independently of related factors like education
and intelligence.
• This suggests that in individual with lower education and
intellectual aptitudes, behavior may enhance intellectual
reserve, even years after the peak of intellectual activity.
(Potter GG and coll. Neurology 2008;70(19 Pt 2):1803-8 )
62. Alzheimer’s disease in the world
4.6 million of new cases by year
1 case every 7 seconds
One in 85 people by 2050
8081 millions
million
24 millions
20 million
2001 2020 2040
Lancet. 2005 ; 366:2112-7
63. Achieving and maintening cognitive health with
aging : Possible strategies
Early detection of individuals at risk
- Neuropsychological testing
- Neuroimaging
- Biomarkers
- Genetic markers
Lifestyle management
- Build “cognitive reserve” by remaining intellectually and socially active
- Continue lifelong learning
- Engage in regular mental exercises
- Maintain active social networks
- Remain involved in the community by occupational or voluntary activity
- Engage in regular physical exercise
- Reduce or minimise the effects of stress
- Ensure appropriate nutrition and avoid nutritional deficiencies
Manage medical co-morbidities
- Hypertension
- Diabetes
- Hyperlididemia
- Depression
- Sleep disorders
- Polypharmacy
- Sensory impairments
- Avoid alcohol, smoking and illicit drug abuse
Pharmaceutical approaches
- Cognitive enhancers
- Neurotrophins
- Anti-inflammatory agents
- Antioxidants
- Hormones
Fillit MH, Butler RN et al. Mayo Clinic Proc 2002
64. Necessary conditions to consider that a risk
factor is a good candidate for prevention
• A statistical association between the
exposure to the factor and the risk of
dementia is present without bias
• Exposure to the factor occurred before the
onset of the disease
• The association must be plausible and
coherent with the natural history and biology
of the disease
• The preventive effect of the risk factor
modification must be confirmed by at least
two randomized controlled studies
JF Dartigues et al. Epidemiology of dementia. Protective factors. In Alzheimer’s Disease and related Disorders
Annual. Ed. Gauthier S Cummings J. Pub; Martin Dunitz 2002 pp 67-76
65. Diabetes is associated with cognitive
impairment
• Knopman et al. Neurology 2001; 56: 42–8
ARIC study: Total n=10,729, follow up=6 years: significant
decrease in delayed recall and word fluency
• Gregg et al. Arch Intern Med 2000; 24: 174–80
Total n=9679, follow up=3–6 years. Lower baseline scores
and significant decrease in digit symbol test and trail B
• Wahlin et al. Neuropsychology 2002; 16: 208–16
Total n=338; diabetics n=31 vs controls n=307.
Lower verbal fluency and episodic memory
• Sinclair et al. Diabetes Res Clin Pract 2000; 50: 203–12
Aware study: case-control study. Total n=579; diabetics n=283
and control subjects n=296. Significant impairment in MMSE
score and clock testing
68. Should research on the
hormonal approach be continued?
• Absolute risk for cardiovascular events not very high (7 to
8 additional cases for 10,000 P/years)
• American population “at risk” of cardiovascular diseases:
– 70% obese (BMI> 25)
– 35% hypertensive
– 66% 65 years and over
• Hormones used (conjugated equine estrogens and
medroxyprogesterone acetate) and oral route of
administration known to increase the thromboembolic risk
Question: should a study using the usual European
treatment (natural hormones and patch or spray
administration) be set up on a less vulnerable
population?
69. Should research on the
hormonal approach be continued?
• Absolute risk for cardiovascular events not very high (7 to
8 additional cases for 10,000 P/years)
• American population “at risk” of cardiovascular diseases:
– 70% obese (BMI> 25)
– 35% hypertensive
– 66% 65 years and over
• Hormones used (conjugated equine estrogens and
medroxyprogesterone acetate) and oral route of
administration known to increase the thromboembolic risk
Question: should a study using the usual European
treatment (natural hormones and patch or spray
administration) be set up on a less vulnerable
population?
70. Hypertension risk of vascular
Dementia (VaD)
• Positive association
– - Yoshitake et al. (Hisayama study)
Neurology 1995; 45: 1161–8
– - Skoog et al. (Gothenburg study)
Lancet 1996; 27; 347: 1141–5
– - Hebert et al. (Canadian study on health
and aging)
Stroke 2000; 31: 1487–93
– - Launer et al. (Honolulu Asia study)
Neurobiol Aging 2000; 21: 49–55
– - Posner et al.
Neurology 2002; 58: 1175–81
71. Necessary requirements to consider
that hypertension is a good target for
prevention trials
• A statistical association between the
exposure to the factor and the risk of
dementia must be present without bias
• The exposure to the factor occurred before
the onset of the disease
• The association must be plausible and
coherent with the natural history and biology
of the disease
• Is the preventive effect of the risk factor
modification proven by a controlled trial
confirmed by at least one other study?
JF Dartigues et al. Epidemiology of dementia. Protective factors. In Alzheimer’s Disease and related
Disorders Annual. Ed. Gauthier S Cummings J. Pub; Martin Dunitz 2002 pp 67-76)
72. Syst-Eur
Causes of dementia
Number of
new cases
30 Intention-to-treat Per-protocol
21 Vascular
20 2 dementia
4 Mixed
15
dementia
2
15 11 Alzheimer’s
10 13 dementia
3
7
8 2
5
0
Placebo Active Placebo Active
treatment treatment
73. Education’s level and cognitive decline in AD
The level of education is strongly associated to the level of
cognitive function
Neurology 72 February 3, 2009. Wilson and coll
77. Theoretic illustration of how cognitive reserve
may delay the clinical expression but not the rate of decline
Person with high reserve
Point of inflection
Person with low reserve
Memory test score
Incident Dementia
AD Neuropathology
La Rue A. Clin.Geriatr.Med 26 (2010) 99-111
78. Diet and Alzheimer’s
disease
Dietary intake of OMEGA3 and weekly
consumption of fish may reduce the risk of
AD up to 60%
Omega 3
Arch Neurol. 2003;60:940-946
79. Diet and Alzheimer’s disease
The three city cohort study , n=8 085 > 65 years
without dementia, 4 year follow up
Neurology 2007;69:1921–1930
80. Relation of higher Folate intake to lower risk
of AD in the Elderly (Observational study)
n=965 without dementia , 6 year follow up
Arch Neurol. 2007;64:86-92
81. Antihypertensive treatment and
Alzheimer’s disease
• More studies are needed to confirm that the BP
lowering agents may prevent Alzheimer’s
disease.
• Incidence of dementia should constitute the
primary outcome of future long term trials
comparing different classes of antihypertensive
drugs in order to better determine the
mechanism of dementia prevention