Brain Stimulation Used Like a Scalpel to Improve Memory

Precise memory is enhanced with targeted non-invasive brain stimulation

Newswise, February 15, 2017 — CHICAGO - Northwestern Medicine scientists showed for the first time that non-invasive brain stimulation can be used like a scalpel, rather than like a hammer, to cause a specific improvement in precise memory.

Precise memory, rather than general memory, is critical for knowing details such as the specific color, shape and location of a building you are looking for, rather than simply knowing the part of town it’s in.

This type of memory is crucial for normal functioning, and it is often lost in people with serious memory disorders.

“We show that it is possible to target the portion of the brain responsible for this type of memory and to improve it,” said lead author Joel Voss, assistant professor of medical social sciences at Northwestern University Feinberg School of Medicine.

“People with brain injuries have problems with precise memory as do individuals with dementia, and so our findings could be useful in developing new treatments for these conditions.”

Red highlights the "core" of the memory network. " Blue indicates where electromagnetic pulses were applied.

By stimulating the brain network responsible for spatial memory with powerful electromagnets, scientists improved the precision of people's memory for identifying locations.

This benefit lasted a full 24 hours after receiving stimulation and corresponded to changes in brain activity.

“We improved people’s memory in a very specific and important way a full day after we stimulated their brains,” Voss said.

The paper was published Jan. 19 in Current Biology.

The research enhances scientific understanding of how memory can be improved using noninvasive stimulation. Most previous studies of noninvasive brain stimulation have found only very general and short-lived effects on thinking abilities, rather than highly specific and long-lasting effects on an ability such as precise memory.

The memory test that showed improvements due to stimulation. 

Subjects studied ~100 objects, each at specific screen location, and were tested for their ability to recall these locations after a delay.The scientists used MRI to identify memory-related brain networks then stimulated them with noninvasive electromagnetic stimulation. Detailed memory tests were used to show that this improved spatial precision memory, and EEG was used to show that these memory improvements corresponded to indicators of improved brain network function.

Other Northwestern authors include first author Aneesha S. Nilakantan, Donna J. Bridge, Elise P. Gagnon and Stephen A. VanHaerents.

The research was supported by grants P50-MH094263, R01-MH106512, and R01-MH111790 from the National Institute of Mental Health, T32-AG20506 from the National Institute on Aging and F32-NS087885 from the National Institute of Neurological Disorders and Stroke, all of the National Institutes of Health.

Women’s Cognitive Decline Begins Earlier Than Previously Believed

 Newswise, February 15, 2017 — UCLA researchers have found that mental sharpness in women begins to decline as early as their 50s. The study, which followed the same group of healthy women for 10 years after menopause, found that their average decline in mental processing ability was 5 percent during the decade-long period.

Cognitive processing speed, which includes speed of perception and reaction, showed an average decline of around 1 percent every two years and verbal memory declined on average around 1 percent every five years.

Previous longitudinal studies in midlife women had failed to consistently detect these cognitive declines.

For this study, the researchers accounted for what are called “practice effects,” which is when repeat testing using the same tests in the same individuals influence the results.

Practice effects mask some effects of the menopause transition. In this way they were able to uncover evidence of declines in two domains of cognitive functioning — processing speed and verbal memory.

The researchers examined data on more than 2,000 healthy women enrolled in the Study of Women’s Health Across the Nation, or SWAN, who were tested regularly over several years to measure cognitive changes. The women were in their 40s when they enrolled in 1996 and were followed every one to two years for a median period of 6.5 years.

Women in their 40s and 50s who find they are forgetting things more often or think they are slower to react may only be experiencing usual aging, analogous to gradual slowing of physical reaction time, running speed, metabolic rate, and other declines that we all experience in midlife.

The authors of the study were Arun Karlamangla, WeiJuan Han, MeiHua Huang and Gail Greendale of UCLA, and Margie Lachman of Brandeis University

The study is published in the journal PLOS ONE.

SWAN has grant support from the National Institutes of Health (NIH),  the National Institute on Aging, the National Institute of Nursing Research and the NIH Office of Research on Women's Health (Grants U01NR004061; U01AG012505, U01AG012535, U01AG012531, U01AG012539, U01AG012546, 01AG012553, U01AG012554, U01AG012495).

AARP Outlines Priorities to President-elect Trump

Includes Protection of Social Security, Medicare Benefits, Access to Affordable Health Care, Prescription Costs

WASHINGTON, February 13, 2017 /PRNewswire-USNewswire/ -- In a letter to President-elect Donald J. Trump, AARP CEO Jo Ann Jenkins outlines AARP's priorities for Americans age 50 and older including protecting Medicare and Social Security, ensuring access to affordable health care coverage, and lowering the cost of prescription drugs.

In the letter Jenkins writes to President-elect Trump that "Our nearly 38 million members nationwide and all older Americans are counting on you to protect their Medicare and Social Security benefits, protect their access to affordable health care, and to tackle the high cost of prescription drugs.

Throughout the campaign, your statements on these important issues of health and financial security set you apart from many other candidates. Now, as you assume office, older Americans are looking to you to protect them from efforts to cut their benefits, increase their costs, or otherwise harm the crucial programs they rely on."

The full text of the letter to President-elect Trump is below:
President-elect Donald J. Trump 
Presidential Transition Headquarters 
Washington, DC

Dear President-elect Trump:

Congratulations on your election. We look forward to working with you on your campaign promises to America's seniors. Our nearly 38 million members nationwide and all older Americans are counting on you to protect their Medicare and Social Security benefits, protect their access to affordable health care, and to tackle the high cost of prescription drugs.

Throughout the campaign, your statements on these important issues of health and financial security set you apart from many other candidates. Now, as you assume office, older Americans are looking to you to protect them from efforts to cut their benefits, increase their costs, or otherwise harm the crucial programs they rely on.

Medicare and Social Security 

Our members count on these programs and they believe Social Security and Medicare must be protected and strengthened for today's seniors and future generations. Unfortunately, some congressional leaders have discussed plans to use the health care debate to fundamentally change the Medicare program and undermine the contract made with generations of Americans. Proposals creating a defined contribution premium-support program; restricting access by raising the age of eligibility; or allowing hospitals and providers to arbitrarily charge consumers higher prices than Medicare; all betray the promise made to older Americans who have paid into Medicare their entire working lives. Indeed, these proposals do little to actually lower the cost of health care. Rather, they simply shift costs from Medicare onto individuals – many of whom cannot afford to pay more for their care. Again, we are ready to stand with you to oppose attempts to cut the Medicare program or otherwise harm seniors.

The average senior, with an annual income of under $25,000 and already spending one out of every six dollars on health care, counts on Social Security for the majority of their income and on Medicare for access to affordable health coverage. We will continue to oppose changes to current law that cut benefits, increase costs, or reduce the ability of these critical programs to deliver on their benefit promises. We urge you to continue to do so as well.

Prescription Drugs 

Older Americans use prescription drugs more than any other segment of the U.S. population, typically on a chronic basis. In 2015, retail prices for 268 brand name prescription drugs widely used by older Americans increased by an average of 15.5 percent. In contrast, the general inflation rate was 0.1 percent over the same period. For older adults, affordable prescription drugs are critical in managing their chronic conditions, curing diseases, keeping them healthy and improving their quality of life. As you have stated, older Americans and the American people deserve a better deal on prescription drug costs.

Again, we stand ready to work with you to lower drug prices. For example, AARP supports providing the Secretary of Health and Human Services with the authority to negotiate lower drug prices on behalf of millions of Medicare beneficiaries. In addition, we agree with you that we should reduce barriers to better pricing competition worldwide by allowing for the safe importation of lower priced drugs. American seniors should not have to continue paying the highest Rx prices in the world.

Access to Health Care pre-Medicare
Millions of older Americans age 50 and older have gained access to affordable health coverage through important changes in the health insurance market, including the ban on pre-existing condition exclusions, the ban on lifetime and annual coverage limits, the restriction on charging working as well as retired older Americans many times more for insurance than younger persons (through important limits on age rating), and additional help for those who cannot afford insurance. We urge you to protect these vulnerable older Americans (many who have lost their jobs, are self-employed or own their own businesses) from losing health coverage by maintaining these important insurance market reforms in any new health legislation.

Medicaid and Long-Term Services and Supports
Medicaid serves as a critical safety net for millions of people in every state, including over 17 million children with disabilities, adults with disabilities and poor elderly who rely on vital Medicaid health and long-term care services. We urge you to continue to protect these vulnerable populations.

Efforts to reduce or cap Medicaid funding could endanger the health, safety, and care of millions of individuals who depend on the essential services provided through this program. Furthermore, caps would likely result in overwhelming cost-shifts to state governments unable to shoulder the costs of care without sufficient federal support. As your Administration considers changes to Medicaid, we urge that home and community-based services be available to individuals in the same way they can access nursing home funding. Any health law changes should ensure that more individuals are able to receive services in their homes and communities rather than costly institutional care.

We look forward to working with you to protect Medicare and Social Security, to lower prescription drug prices, and to maintain older American's affordable access to quality health coverage.

Sincerely,
Jo Ann C. Jenkins 
Chief Executive Officer

Physician’s Near-Death Experience Inspires Campaign to Boost More Effective Patient Communication

Newswise, February 13, 2017 – In an article to be published in the Jan. 5 edition of the New England Journal of Medicine, a Henry Ford Hospital critical care medicine physician describes in candid detail about how her own near-death experience inspired an organizational campaign to help health professionals communicate more effectively and demonstrate more empathy to their patients.

Rana Awdish, M.D., director of the hospital’s Pulmonary Hypertension Program, writes in “A View from the Edge: Creating a Culture of Caring” that as a patient “I learned that though we do many difficult, technical things so perfectly right, we fail our patients in many ways.”

In 2008 Dr. Awdish nearly died when a tumor ruptured in her liver, leading to multisystem organ failure. The care team worked frantically to save her but could not save the baby she was carrying. Her recovery would include five major surgeries and multiple hospitalizations in intensive care. She also experienced something unexpected: a kind of casual indifference.

“I was privy to failures that I’d been blind to as a clinician,” she says. “There were disturbing deficits in communication, dis-coordinated care, occasionally an apparently complete absence of empathy. I recognized myself in many of those failures.”

Dr. Awdish says her patient experience inspired her to champion a shift in culture for helping health professionals talk more effectively with their patients at Henry Ford Hospital and throughout its parent organization, the Detroit-based Henry Ford Health System. She used her experience to drive home the point to leaders and others that “everything matters, always. Every person, every time.”

Henry Ford’s Physician Communication and Peer Support curriculum, launched in 2013, is guided by empathy and compassion, beginning with an understanding of what matters most to patients and aligning them with patient values. It’s geared for physicians, residents, fellows, nurses and other health professionals. Courses include:

• CLEAR Conversations. CLEAR stands for Connect, Listen, Empathize, Align and Respect. A course in which health care workers test their communication skills in stimulated conversation exercises with Detroit-based improvisational actors who portray patients and family members. It teaches how to navigate difficult questions and respond to expressions of emotion. These exercises are videotaped, allowing for immediate feedback. A mobile app offers easy access to tips and videos for effective communication.
• A skilled communication workshop based on the 4 Habits of Effective Physician Communication model.
• Real-time shadowing. A trained observer shadows the provider during a series of patient interactions. Best practice behaviors and empathic communication skills are evaluated, and best practice feedback is shared during a one-on-one debriefing.
• New-hire orientation, during which employees are taught their value and purpose within the organization, not just to their job. Discussions emphasize learning to recognize avoidable and unavoidable forms of patient suffering. New employees are tasked with reducing avoidable suffering.

“My experience changed me,” says Dr. Awdish, who also serves as medical director of Care Experience, which directs the patient communications initiative across the health system. “It changed my vision of what I wanted our organization to be, to embody.”

She says her experience is a teachable moment across the spectrum of health care as the focus shifts to respecting patients as more than just someone with an illness or disease.

“By focusing on our missteps, we can ensure that the path ahead is one of compassionate, coordinated care,” Dr. Awdish says.

“When we are ashamed, we can’t tell our stories. In the wake of painful experience, we all seek meaning. It is the human thing to do, but it is also the job of great organizations. The stories we tell do more than restore our faith in ourselves. They have the power to transform.”

Many Kidney Failure Patients Lack Advance Directives Near the End of Life

• Among nursing home residents in the last year of life, patients with kidney failure were far less likely to have advance directives that put limitations on treatments and designated surrogate decision makers compared with other nursing home residents with serious illnesses.
• Advance directives with these components were associated with a lower use of intensive interventions at the end of life.
• Nearly all kidney failure patients with an advance directive putting limitations on treatment received end-of-life care that was concordant with their preferences.

More than 80,000 Americans die each year while receiving dialysis therapy for end-stage renal disease.

Newswise, February 3, 2017— A new study indicates that many nursing home residents receiving dialysis do not have advance directives that sufficiently address end-of-life treatment decisions.

Those with advance directives that put limitations on treatments and designated surrogate decision makers had fewer hospitalizations, intensive procedures, and inpatient deaths, and they were more likely to use hospice and discontinue dialysis prior to death.

The study, which appears in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), found that nearly all patients with an advance directive requesting treatment limitations received end-of-life care that was in line with their preferences.

Advance directives outlining individuals’ preferences related to end-of-life care are often promoted for patients with serious illnesses such as kidney failure as a means to avoid interventions that are unwanted or of limited benefit.

Little is known about the relation between the content of advance directives and later treatment decisions among kidney failure patients, however.

To investigate, Manjula Kurella Tamura, MD, MPH (VA Palo Alto Health Care System and Stanford University) and her colleagues examined the prevalence and content of advance directives among 30,716 nursing home residents with end-stage renal disease (ESRD), and30,825 nursing home residents with other serious illnesses during the year before death.

The investigators also linked the content of advance directives to Medicare claims to determine which treatments ESRD patients received in the last month of life.

In the last year of life, 47% of patients with ESRD vs. 59%-70% of patients with other serious illnesses had any form of advance directive. In addition, 36% of nursing home residents with ESRD had a treatment-limiting directive, 22% had a surrogate decision maker, and 13% had both.

These estimates were 13%-27%, 5%-11%, and 6%-13% lower, respectively, than for patients with other serious illnesses. For patients with ESRD who had both a treatment limiting directive and surrogate decision maker, the frequencies of hospitalization, intensive care unit admission, intensive procedures, and inpatient death were lower by 13%, 17%, 13% and 14%, respectively, and hospice use and dialysis discontinuation were 5% and 7% higher compared with patients with ESRD who lacked both components.

“We found that advance directives indicating treatment limitations and/or documenting surrogate decision makers were associated with less intensive end-of-life care among nursing home residents with ESRD, but these were in place much less often than for nursing home residents with other serious illnesses,” said Dr. Tamura.

“Because the vast majority of patients with a treatment limiting directive received care that was consistent with their advance directive, our findings suggest that efforts to increase engagement in advance care planning and expand the use of advance directives among patients receiving dialysis may offer untapped opportunities to better align end-of-life care with patient preferences and values.”

Study co-authors include Maria Montez-Rath, PhD, Yoshio Hall, MD, MS, Ronit Katz, DPhil, and Ann O’Hare, MD, MA.

Disclosures: The authors reported no financial disclosures.

The article, entitled “Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis,” will appear online at http://cjasn.asnjournals.org/ on January 5, 2017, doi: 10.2215/CJN.07510716.

Final Arrangements Study helps consumers navigate funeral homes’ prices and language

Newswise, February 2, 2017 — Family members experience many emotions when a loved one dies. What can be lost during the grieving are decisions about final arrangements.

A new report from the University of Iowa aims to ease the stress for individuals and families wrestling with end-of-life decisions, from choosing a funeral home to paying for services, burial, and related expenses.

The report, from the UI’s School of Social Work, is intended to help social workers who are responsible for discharge planning in health care settings, where 80 percent of deaths occur.

The report’s lead author, Mercedes Bern-Klug, also casts it as a news-you-can-use guide to help people navigate funeral homes’ pricing and terminology so they can make wiser decisions about after-death expenses.

“(End-of-life arrangements) are not the kind of thing that people are comfortable discussing,” says Bern-Klug, an associate professor at the UI who has studied aging and older-adult issues for two decades.

“We think it will be useful to have this information ahead of time so individuals and families know they have options, and which ones might be best suited to meet their loved one’s wishes.”

Among the highlights, the report:

• Defines funeral homes’ terminology, such as “basic services”
• Explains federal and Iowa state laws surrounding funeral, burial, and other after-death options
• Includes a checklist of “Things to Do” when a loved one dies
• Includes tips for those who want to keep costs as low as possible

This is Bern-Klug’s third report on end-of-life arrangements and funeral home pricing. The previous one was published in 2011.

Bern-Klug says most funeral homes don’t publish their price lists online, even though they’re required by federal law to provide their rates to anyone who asks for it in person. They’ll also give out the information over the phone, she adds.

One way to save money is to scrutinize the “basic services” charge, according to the report. This item is a standard charge by funeral homes, but the UI report found the actual price ranges from $300 to $3,000—a 10-fold difference

.

“This is not something that most people even know to ask about,” Bern-Klug says.

Besides being more familiar with funeral homes’ services and prices, Bern-Klug recommends planning in advance as much as possible.

At the very least, she says, document your loved one’s vital statistics and know the plans for the body (burial, cremation, donation for science) and final dispositions (a funeral service, burial plans, and site, etc.).

The report includes a checklist to help simplify the process.

“One of reasons we included (the checklist) is to help people understand a lot has to happen right around the time of death,” she says. “If you’re inclined to get this organized ahead of time, you can share or delegate tasks, and it will make it easier on you or somebody else.”

The report also includes tips for saving money, including asking about burying more than one person in a plot, acquiring a temporary grave marker, exploring casket choices, and asking funeral home directors about all of the options available to you.

“Information is power. It’s in everybody’s best interest to have that transparency,” Bern-Klug says.

The study is available on the School of Social Work website.

Worker-Owned Cooperatives May Help Address Elder Care Deficit

 Model popular in other parts of the world

Newswise, February 2, 2017 – A growing elder care shortage could be eased by worker-owned cooperatives, a little-used business model that also improves the working conditions and the quality of life for caregivers.

That’s the conclusion reached by University of Georgia faculty member Rebecca Matthew and Vanessa Bransburg, a cooperative development specialist, in a recent, award-winning case study.

Matthew, an assistant professor at the UGA School of Social Work, and Bransburg, a staff member at Democracy at Work Institute in San Diego, California, looked for a successful system of home-based caring labor that puts equal emphasis on the well-being of both the care recipient and the provider.

They examined the most popular forms of paid child care—for-profit and nonprofit services—alongside worker-owned child care cooperatives.

The latter system is popular in other parts of the world, but represents a fraction of the caregiving services available in the U.S.

The cooperatives, which give employees greater control over their working conditions and a share in profits, improved the quality of life of both care recipients and providers.

As an example, they cited a case study of the Beyond Care Childcare Cooperative, an organization that provides home-based child care services to the Sunset Park community in Brooklyn, New York.

Women who joined the BCCC as worker-owners reported a 58 percent increase in hourly wages. As wages grew, more than half of the employee-owners—primarily immigrant women—were able to reduce their work hours, enabling them to spend more time with their own children and families.

The model could also be applied to the provision of elder care, said Matthew and Bransburg, pointing out that nearly half of people employed in that job sector rely on public benefits such as Medicaid to support themselves and their families.

Since home care for the elderly is expected to grow from nearly 40 million jobs now to 73 million by 2030, the potential impact of worker-owned cooperatives could be huge.

“Worker-owned cooperatives provide a truly promising alternative through which to provide quality jobs and care,” said Matthew.

The study, “Democratizing Caring Labor: The Promise Of Community-Based, Worker-Owned Childcare Cooperatives,” won the Council for Social Work Education’s 2016 Feminist Manuscript Award. It was published online before print in Affilia: Journal of Women and Social Work.

UGA School of Social Work
Founded in 1964, the University of Georgia School of Social Work provides instruction, research and hands-on training in social work practice while emphasizing the integration of social work with social justice. For more information, see http://ssw.uga.edu/. 

Sociology Professor Addresses Caregiving Burden From Personal Perspective

Newswise, February 2, 2017— It’s not every day a researcher draws from their own experiences as the basis for a published study but that’s exactly what Miles Taylor, associate professor of sociology at Florida State University, has done in her latest paper addressing what she calls the structural burden of caregiving.

The study, “The Structural Burden of Caregiving: Shared Challenges in the United States and Canada,” published in the January edition of The Gerontologist, examines the caregiving stress associated with navigating the health care system in the United States and the social care system in Canada.

A call for papers from The Gerontologist prompted Taylor and her colleague Amélie Quesnel-Vallée, sociology professor at McGill University in Quebec, to consider their own experiences caring for aging parents and to see if those experiences exposed gaps in aging literature.

For Taylor and Quesnel-Vallée, the most noticeable void lay in the area of emphasis and quantifiable data on the amount of time caregivers spend negotiating treatment and services for their care recipients.

“Research up until now has really defined caregiving burden in terms of the amount of time and stress it takes to actually provide care to another person — helping with daily tasks and how especially difficult it can be when they need help with things that are very personal, like bathing,” Taylor said.

Taylor said previous models of caregiving burden have done a good job of notating interpersonal stresses, such as strained relationships and the demands in the caregiver’s life.

But what about the time spent negotiating health care systems, getting the care, getting treatments, figuring out when treatments will be covered and under which circumstances? That part of the caregiving burden, Taylor and Quesnel-Vallée say, isn’t well-articulated or measured.

It was 2010 when Taylor began caring for her grandmother, her only living parent, off and on for about 5 years. That was about the same time Quesnel-Vallée began caring for her mother in Canada. The two found their caregiving trajectories and experiences lined up so much, they decided to put their experiences in this paper.

Although they knew providing the direct care would be difficult, they were not prepared for how much time and stress they would spend trying to understand, negotiate and manage medical and related care for their loved ones. They contrasted the two care settings. Ultimately, they concluded that Canada offers more services for older adults and there is more transparency about what is and what is not covered.

However, there were some common themes among the Canadian and American systems. In both systems the researchers found that a great deal of time was spent negotiating and managing care and services but the burden often went unrecognized. They also found in their experience as caregivers that the systems were characterized by discontinuous and fragmented care.

The final common theme researchers noted was the gross potential for inequity for both the caregivers and care recipients.

“We kept telling each other over the course of the past six years, if we felt like this was so difficult and if we had such a hard time, how in the world would other folks begin to deal with this? It must be so much more burdensome,” Taylor said.

Taylor and Quesnel-Vallée felt their education, income and even their race gave them more social currency and health care literacy to help them gain information and access services.

The pair want the paper to not only inform health care professionals and policymakers about the aforementioned issues with the two care systems, but also the caregivers themselves.

“We hope caregivers will understand this part of caregiving, the stress involved in managing care and negotiating services, constitutes caregiving time and stress,” Taylor said. “Often, we felt it wasn’t counted in terms of how much time is spent caring for someone else.”

Through their testimony, Taylor and Quesnel-Vallée also hope other scholars will move forward and try to measure this time and stress related to managing care better. Right now, most surveys only question how much time caregivers take feeding or bathing their care recipient or providing other daily tasks such as taking out the trash.

“I think that now we should increasingly ask how much time and stress did you spend negotiating with medical care, and Medicare, and trying to figure out which services were available and when,” Taylor said.

Taylor says a number of people are experiencing the structural burden of caregiving even though it’s not clearly in the literature yet. They hope caregiving theory can broaden and consider this structural burden, especially considering advanced medical practices are causing people to live longer.

“There was a very recent caregiving report that said over half of caregivers are actually engaged in these kinds of tasks, yet we don’t quantify that,” Taylor said. “We don’t say how much time is this taking up? So that’s what we’re hoping to do, shed more light on it — and I think when you give something a name and a clear theme and definition — that’s when you can get the ball rolling to help people to talk about it more.”