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NHS Choices: Behind the headlines   + / -  
last updated: Sun, 20 Apr 2014 15:48:04 GMT

 Thu, 17 Apr 2014 10:40:00 GMT Apathy unproven as early warning sign of dementia

“Elderly who lose interest in pastimes could be at risk of Alzheimer's,” reports The Daily Telegraph, with other papers reporting similar headlines.

These incorrect headlines are based on the results of a study that looked for a link between symptoms of apathy and structural brain changes (on brain scans) in over 4,000 older adults who did not have dementia.

The researchers were interested in discovering whether there were a combination of changes in brain volume and reported symptoms of apathy.

These symptoms were defined as:

  • giving up activities and interests
  • preferring to stay at home rather than going out and doing new things 
  • not feeling full of energy

People who reported two or more of the symptoms listed above had significantly smaller total brain volume and grey and white matter volumes, compared to their counterparts.

Our grey matter contains predominantly nerve cell bodies – it is also where memories are stored and where learning takes place in the brain. White matter contains nerve cell fibres and is responsible for communication between different brain regions. People with symptoms of apathy also had more abnormal changes to their white matter.

As symptoms of apathy and structural brain changes were assessed at the same time, we don’t know if the two are directly related or if there are other factors at play.

It’s currently unproven whether keeping both the mind and the body active will prevent dementia, but it can help improve a person’s quality of life.

Read more about how getting active can improve your wellbeing.

 

Where did the story come from?

The study was carried out by researchers from the University Medical Centre Utrecht in the Netherlands; the National Institute on Aging and the Laboratory for Epidemiology, Demography and Biometry in the US; and the Icelandic Heart Association, the University of Iceland, Janus Rehabilitation and Lanspitali University Hospital in Iceland. It was funded by a US National Institutes of Health contract, the US National Institute on Aging Intramural Research Programme, Hjartavernd (the Icelandic Heart Association) and Althingi (the Icelandic Parliament).

The study was published in the peer-reviewed journal Neurology.

This story was covered by The Independent, the Daily Mail and The Times. The Mail and The Independent’s coverage was poor, with both newspaper’s reporting that losing interest in hobbies and other activities in old age could be an early sign of dementia or Alzheimer’s. This study did not investigate whether symptoms of apathy were linked to Alzheimer’s or other dementias. Instead, it looked for a link between apathy symptoms and structural brain changes at a particular point in time.

The Times’ coverage was more measured, as it stressed that a direct causal link between apathy, brain size and dementia risk had not been proven by the study.

 

What kind of research was this?

This was a cross-sectional study of 4,354 older people without dementia who were participating in the Age, Gene/Environment Susceptibility-Reykjavik Study. It aimed to discover if there was a link between apathy symptoms (lack of interest, enthusiasm or concern) and structural brain changes.

Cross-sectional studies only analyse people at one particular point in time. This means that we don’t know whether the appearance of apathy symptoms and brain changes happened at the same time or if one happened before the other. We also don’t know if the two things are directly related or if there are other factors associated with both.

 

What did the research involve?

The researchers studied 4,354 older people (with an average age of 76) without dementia who were participating in the Age, Gene/Environment Susceptibility-Reykjavik Study, which is an ongoing cohort study into the effects of ageing and genetics.

Apathy symptoms were assessed through responses to three items relating to apathy on the Geriatric Depression Scale. The three questions relating to apathy were:

  • Have you dropped many of your activities and interests?
  • Do you prefer to stay at home, rather than going out and doing new things?
  • Do you feel full of energy?

Brain volumes and total white matter lesions (abnormal changes in white matter) were measured from MRI scans [/conditions/MRI-scan/Pages/Introduction.aspx].

The researchers compared people with two or more apathy symptoms to those with fewer than two symptoms, to see if there were differences in brain volume and white matter lesions.

They adjusted their analyses for a wide variety of confounding factors including age, education, skull size, physical activity, depressive symptoms and antidepressant use

What were the basic results?

Just under half of participants (49%) had two or more symptoms of apathy. People with two or more symptoms were older and more likely to be women. They also had lower education, were less physically active, had poorer Mini-Mental State Examination Scores, walked slower and often had high blood pressure, mild cognitive impairment, brain infarcts and antidepressant use, as well as higher depression scores.

After adjusting their analyses for confounders, people with two or more apathy symptoms had significantly smaller total brain volume and grey and white matter volumes than those with fewer than two apathy symptoms. People with two or more symptoms had 0.5% less grey matter and 0.5% less white matter. They also had more white matter lesions.

Differences in grey matter volumes were particularly noticeable in the frontal and temporal lobes. These are two of the main brain regions, with the frontal lobe (at the front of the brain) involved with higher mental processes like thinking, judging and planning, and the temporal lobe at the sides of the brain (near the temples) involved with memory, hearing and language.

Differences in white matter volumes were particularly noticeable in the parietal lobe and the thalamus, both of which are involved in processing sensory information from the body.

How did the researchers interpret the results?
The researchers conclude that: “in this older population without dementia, apathy symptoms are associated with a more diffuse loss of both grey and white matter volumes”.

 

Conclusion

This cross-sectional study found that people who reported at least two symptoms of apathy had significantly smaller total brain volume and grey and white matter volumes than people with fewer than two apathy symptoms. The grey matter contains predominantly nerve cell bodies. It is also where memories are stored and where learning takes place in the brain. White matter contains nerve cell fibres and is responsible for communication between different brain regions. People with symptoms of apathy also had more abnormal changes to their white matter lesions.

As symptoms of apathy and structural brain changes were assessed together, we don’t know if the appearance of apathy symptoms and brain changes happened at the same time, or if one happened before the other. We also don’t know if the two things are directly related or if there are other factors associated with both.

This study has found that apathy symptoms are linked to brain changes. However, this study did not investigate whether apathy symptoms were associated with the development of Alzheimer’s or other types of dementia.

Currently, there is no guaranteed method to prevent dementia. However, evidence suggests that to reduce your risk some forms of dementia you should:

  • eat a healthy diet
  • maintain a healthy weight
  • exercise regularly
  • do not drink too much alcohol
  • stop smoking (if you smoke)
  • make sure you keep your blood pressure at a healthy level

Keeping your mind active may also help. Read more about possible methods to reduce your dementia risk.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Elderly who lose interest in pastimes could be at risk of Alzheimer's Disease. The Daily Telegraph, April 17, 2014

Apathy in old age 'an early sign of dementia': Study shows that losing interest in hobbies could mean Alzheimer's. Daily Mail, April 17 2014

Brain size shrinks in the elderly as apathy grows. The Times, April 17 2014

Links To Science

Grool AM, Geerlings  MJ, Sigurdsson S, et al. Structural MRI correlates of apathy symptoms in older persons without dementia. Neurology. Published online April 16 2014

 Thu, 17 Apr 2014 00:00:00 GMT NICE highlights how hand washing can save lives

“Doctors and nurses should do more to stop hospital patients developing infections, an NHS watchdog says,” BBC News reports.

The National Institute for Health and Care Excellence (NICE) has highlighted how basic hygiene protocols, such as hand washing, may be overlooked by some health professionals, which may threaten patient safety.

NICE points out that one in 16 people being treated on the NHS picks up a hospital acquired infection such as meticillin-resistant staphylococcus (MRSA).

 “It is unacceptable that infection rates are still so high within the NHS” said Professor Gillian Leng, director of Health and Social Care at NICE. “Infections are a costly and avoidable burden. They hinder a patient's recovery, can make underlying conditions worse, and reduce quality of life.”

The measures to reduce infection are laid out by NICE in a “Quality Standard” on “Infection prevention and control” and are outlined below.

 

What has NICE said?

This NICE Quality Standard lays out six specific statements for NHS staff on preventing and controlling infections. They are based on previous more detailed guidance and are listed below:

  • People should be offered antibiotics according to local guidance about which ones are most suitable. They should only be prescribed antibiotics when they are needed and not for self limiting, mild infections such as colds and coughs, earache and sore throats. This measure is aimed at reducing the problem of antibiotic resistance, which is when an infection no longer responds to treatment with one or more types of antibiotic and so is more likely to spread and can become serious.
  • NHS organisations should aim to continually improve their approach to preventing infection (for example, by sharing information with other organisations and monitoring rates of infection).
  • All health care staff should always clean their hands thoroughly, both immediately before and immediately after coming into contact with a patient or carrying out care, and even after wearing gloves. Hands can usually be cleaned with either soap and water or an alcohol-based handrub; but soap and water must be used when the hands are obviously soiled or contaminated with bodily fluids, or when caring for people with diarrhoea or vomiting. All care providers should be trained in effective hand cleaning techniques. Hand hygiene in hospitals has improved in recent years says NICE, but good practice is still not universal.
  • Staff involved in the care of patients with urinary catheters should minimise the risk of infection by carrying out procedures to make sure that the catheter is inserted, looked after and removed correctly and safely. These procedures include cleaning hands, using a lubricant when inserting the catheter, emptying the drainage bag when necessary, and removing the catheter as soon as it is no longer needed. (A urinary catheter is a thin flexible tube used to drain urine from the bladder).
  • Staff involved in the care of patients who need a vascular access device should minimise their risk of infection by making sure that the device is inserted, looked after and removed correctly and safely. These procedures include using sterile procedures when inserting the device, using the correct antiseptics and dressings, and removing the device as soon as it is no longer needed. A vascular access device is a tube that is inserted into a main vein or artery and used to administer fluids and medication, monitor blood pressure and collect blood samples.
  • Health care staff should give people who have a urinary catheter, a vascular access device or an enteral feeding tube, and any family members or carers who help them, information and advice about how to look after the equipment, including advice about how to prevent infection. Enteral feeding is a type of feeding used for people who cannot eat normally or safely (for example they may have trouble swallowing) in which liquid food is given through a tube directly into the stomach or upper parts of the digestive system.

 

What are the dangers of not washing hands?

Bugs (microbes) such as bacteria and viruses can easily be spread by touch. They may be picked up from contaminated surfaces, objects or people, then passed on to others. 

Effective hand decontamination – either by washing with soap and water or with an alcohol-based handrub – is recognised as crucial in the reducing avoidable infection.

 

What hygiene procedures should visitors to hospitals follow?

When visiting someone in hospital, always clean your hands using soap and water or alcohol handrubs. Do this when you enter or leave a patient’s room or other areas of the hospital. Effective hand decontamination relies on an effective technique, which includes:

  • wetting hands with warm water
  • applying an adequate amount of (preferably liquid) soap
  • rubbing this thoroughly onto all hand surfaces (for at least 10 to 15 seconds)
  • rinsing thoroughly
  • drying thoroughly, preferably with disposable paper towel
  • taps should be then turned off with the paper towel to avoid recontaminating the hands

Alcohol handrub can only be used if hands are free from soling. The handrub needs to be thoroughly rubbed into all hand surfaces until hands are completely dry.

If you are concerned about the hand hygiene of doctors, nurses or anyone else who comes into contact with the patient you are visiting, you are encouraged to ask them whether they have cleaned their hands.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To Science

Hospital infection rates must come down, says watchdog. BBC News, April 17 2014

One in 16 pick up a bug in FILTHY hospitals: NICE blames staff hygiene and dirty equipment for thousands of deaths. Mail Online, April 17 2014

Don't forget to wash your hands, nurses told. The Daily Telegraph, April 17 2014

One in 16 patients in NHS hospitals picks up infection, warns watchdog. The Guardian, April 17 2014

Wash your hands to cut infections, nurses told. The Times, April 17 2014

1 in 16 NHS patients pick up infections. ITV News, April 17 2014

Medics told by watchdog to wash hands often to stop spread of infection. Daily Express, April 17 2014

 Wed, 16 Apr 2014 11:30:00 GMT PET scans may improve brain injury diagnosis

“PET scans could predict extent of recovery from brain injury, trials show,” The Guardian reports. Evidence suggests that the advanced scanning devices may be able to detect faint signs of consciousness in people with severe brain injuries.

The paper reports on a study that examined how accurate two specialised brain imaging techniques were at diagnosing the conscious state and chances of recovery in 126 people with severe brain damage.

The people were scanned using Positron Emission Tomography (PET) scans, which use a radioactive tracer to highlight cell activity, and functional Magnetic Resonance Imaging (fMRI) scans, which show blood flow in the brain, to demonstrate areas of activity. The results of these scans were compared for accuracy, with assessments made using an established coma recovery scale.

The study aimed to see if the scans could accurately distinguish between a minimally conscious state (MCS) – in which there is a chance of recovery – from other disorders of consciousness.

PET scans correctly identified 93% of people with MCS and accurately predicted that 74% would make a recovery within the next year. The fMRI scans were slightly less accurate, correctly identifying only 45% with MCS and accurately predicted recovery for just 56% of them.

The brain scans also showed that a third of the 36 people who had been diagnosed as unresponsive by the coma scale actually had brain activity consistent with minimal consciousness, and just over two thirds of these people subsequently recovered consciousness.

This small study suggests that PET scanning, together with existing clinical tests, could help accurately identify people with the potential to recover consciousness.

 

Where did the story come from?

The study was carried out by researchers from the University and University Hospital of Liege (Belgium), University of Western Ontario (Canada) and the University of Copenhagen (Denmark). It was funded by the National Funds for Scientific Research (FNRS) in Belgium, Fonds Léon Fredericq, the European Commission, the James McDonnell Foundation, the Mind Science Foundation, the French Speaking Community Concerted Research Action, the University of Copenhagen and the University of Liège.

The study was published in the peer-reviewed medical journal The Lancet.

It was covered fairly in The Guardian and The Times, which understandably looked at the ethical implications for decisions around switching off life support or giving pain relief.

 

What kind of research was this?

This diagnostic study looked at how accurate two specialised brain imaging techniques – Positron Emission Tomography (PET) and functional Magnetic Resonance Imaging (fMRI) – were at correctly distinguishing between different conscious states and predicting recovery in people with severe brain damage. This included both traumatic brain damage, which is typically caused by a severe head injury, and non-traumatic brain damage, which can have many causes, such as a stroke or heart attack.

The brain imaging results were compared with an established coma recovery scale, which is used in the assessment of people with brain damage.

PET scanning involves injecting a radioactive tracer (fluorodeoxyglucose – which is why the scans are often referred to as FDG-PET), which then produces colourful 3D images that show up cell activity in the body. It is most commonly used in the diagnosis of cancer. fMRI scanning shows up blood flow in the brain, which demonstrates areas of brain activity.

The researchers point out that in people with severe brain damage and a disordered level of consciousness, judging the level of awareness is difficult. In particular, the researchers aimed to see whether the scans could accurately distinguish between “unresponsive wakefulness syndrome” and a “minimally conscious state”.

People with “unresponsive wakefulness syndrome” (previously referred to as a vegetative state) differ from people in a coma in that they have their eyes open and show a normal sleep/wake cycle, but aside from this they show no behavioural signs of awareness. Meanwhile, people in a minimally conscious state (MCS) show fluctuating awareness and response to some stimuli (such as instructions or questions). 

The distinction between them has important therapeutic and ethical implications. As the researchers say, people in MCS are more likely to suffer pain and might therefore benefit from pain-relief and other interventions to improve their quality of life. They are also more likely to recover higher levels of consciousness that those with unresponsive wakefulness syndrome. In several countries, doctors have a legal right to withdraw artificial life support from people with unresponsive wakefulness syndrome, but not those with MCS.

The researchers also say that up to 40% of such patients are misdiagnosed by traditional clinical examinations. Brain imaging methods are now being developed to complement these bedside assessments, which can assess spontaneous brain activity or specific responses to mental tasks.

Such methods may help distinguish between people in an MCS and those with unresponsive wakefulness syndrome.

 

What did the research involve?

The researchers included 126 people with severe brain damage that were diagnosed at the University Hospital of Liège, in Belgium, between January 2008 and June 2012. They included people with both traumatic and non-traumatic causes for their brain damage. The results were:

  • 41 had been diagnosed with unresponsive wakefulness syndrome
  • 81 had been diagnosed as being in a minimally conscious state (MCS)
  • 4 patients had been diagnosed with locked-in syndrome, (a state where the person is fully conscious but behaviourally unresponsive). These people acted as a control group

The researchers carried out repeated clinical assessment of the patients using a behavioural test called the Coma Recovery Scale-Revised (CRS-R). This is thought to be the most validated and sensitive method for diagnosing disorders of consciousness. The scale has 23 items and is used by specialist staff to assess hearing, vision, motor function, verbal function, communication and level of arousal.

The researchers then carried out imaging using PET and fMRI scans, though not all patients were assessed with each technique (if the person moved too much to obtain a reliable scan, the procedure was left out).

  • For the PET, the person was injected with the imaging agent fluorodeoxyglucose before undergoing a scan. The scan from each person was contrasted against 39 healthy adult controls 
  • For the fMRI scan, patients were asked to do various motor and visuospatial tasks during the imaging session – including imagining playing tennis or walking into a house. The patterns of activity in the brain were also compared to those obtained in 16 healthy volunteers

12 months after the initial assessment, the researchers assessed the patients using a validated recovery scale (the Glasgow Outcome Scale – Extended). This assesses their level of recovery and disability and places the person into one of 8 categories ranging from 1 (death) to 8 (having made a good recovery). They also obtained an assessment of each patient’s outcome from medical reports.

The researchers then calculated the diagnostic accuracy of both imaging techniques, using the CRS-R diagnoses as the reference “gold standard”.

 

What were the basic results?

The main results:

  • PET scanning accurately identified 93% of people in a minimally conscious state (95% confidence interval (CI) 85-98) and had a high level of agreement with behavioural CRS-R scores
  • fMRI was less accurate at diagnosing a minimally conscious state (MCS), correctly identifying 45% of patients (95% CI 30-61) and had lower overall agreement with behavioural CRS-R scores than PET imaging
  • PET correctly predicted outcome after 12 months in 74% of patients (95% CI 64-81), and fMRI in 56% of patients (95% CI 43-67)
  • 13 of 42 (32%) of patients who had been diagnosed as unresponsive with CRS-R showed brain activity compatible with minimal consciousness on at least one of the brain scans; 69% of these (9 of 13) people subsequently recovered consciousness
  • The tests correctly identified all patients with locked-in syndrome as conscious

 

How did the researchers interpret the results?

They say the results show that, used together with the Coma Recovery Scale, PET scanning might be a useful diagnostic tool in disorders of consciousness. They also say it would be helpful in predicting which people with MCS might make a long-term recovery.

 

Conclusion

This is a valuable diagnostic study that tested how accurate PET and fMRI imaging are at distinguishing between different levels of conscious state and helping to predict recovery. 

Diagnostic assessments are traditionally made using bedside clinical tests – but as the researchers say, judging the level of awareness in people with severe brain damage can be difficult.

In particular, the researchers wanted to see whether the scans could accurately distinguish between people with “unresponsive wakefulness syndrome” and “minimally conscious state”, as distinguishing between these two states can have important therapeutic and ethical implications. The study found that PET scanning in particular had a high accuracy for diagnosing MCS and for predicting recovery time.

It’s particularly noteworthy that PET scans detected brain activity in some people who had been diagnosed as unresponsive by the standard Coma Recovery Scale test, and two-thirds of these people subsequently recovered consciousness.

However, the study has some limitations, including its small size, some missing data and possible differences between people who were and were not lost to follow-up. As the researchers acknowledge, their study used a complex method of statistical analysis, so there is a risk of false results.

At a practical level, these specialist types of imaging techniques are expensive and complicated to set up, so could have resource implications.

Overall, the findings suggest that PET scanning  could be a promising addition to standard clinical assessments, when trying to diagnose people with severe brain damage and disordered consciousness.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

PET scans could predict extent of recovery from brain injury, trials shows. The Guardian, April 16 2014

Brain scanner can detect signs of hope in vegetative-state patients. The Times, April 16 2014

Links To Science

Stender J, Gosseries O, Bruno M, et al. Diagnostic precision of PET imaging and functional MRI in disorders of consciousness: a clinical validation study. The Lancet. Published online April 16 2014


 

 
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