Low-Dose Whole Brain Radiation Therapy for Alzheimer's Dementia: Results From a Pilot Trial in Humans.

PURPOSE: We report neurocognitive, imaging, ophthalmologic, and safety outcomes following low-dose whole brain radiation therapy (LD-WBRT) for patients with early Alzheimer dementia (eAD) treated in a pilot trial. METHODS AND MATERIALS: Trial-enrolled patients were at least 55 years of age, had eAD meeting NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association) Alzheimer's Criteria with confirmatory fluorodeoxyglucose and florbetapir positron emission tomography findings; had the capacity to complete neurocognitive function, psychological function, and quality-of-life assessments; had a Rosen modified Hachinski score ≤4; and had estimated survival >12 months. RESULTS: Five patients were treated with LD-WBRT (2 Gy × 5 over 1 week; 3 female; mean age, 73.2 years [range, 69-77]). Four of 5 patients had improved (n = 3) or stable (n = 1) Mini-Mental State Examination (second edition) T-scores at 1 year. The posttreatment scores of all 3 patients who improved increased to the average range. There were additional findings of stability of naming and other cognitive skills as well as stability to possible improvement in imaging findings. No safety issues were encountered. The only side effect was temporary epilation with satisfactory hair regrowth. CONCLUSIONS: Our results from 5 patients with eAD treated with LD-WBRT (10 Gy in 5 fractions) demonstrate a positive safety profile and provide preliminary, hypothesis-generating data to suggest that this treatment stabilizes or improves cognition. These findings will require further evaluation in larger, definitive, randomized trials.

Elderly patients have an altered gut-brain axis regardless of the presence of cirrhosis.

Cognitive difficulties manifested by the growing elderly population with cirrhosis could be amnestic (memory-related) or non-amnestic (memory-unrelated). The underlying neuro-biological and gut-brain changes are unclear in this population. We aimed to define gut-brain axis alterations in elderly cirrhotics compared to non-cirrhotic individuals based on presence of cirrhosis and on neuropsychological performance. Age-matched outpatients with/without cirrhosis underwent cognitive testing (amnestic/non-amnestic domains), quality of life (HRQOL), multi-modal MRI (fMRI go/no-go task, volumetry and MR spectroscopy), blood (inflammatory cytokines) and stool collection (for microbiota). Groups were studied based on cirrhosis/not and also based on neuropsychological performance (amnestic-type, amnestic/non-amnestic-type and unimpaired). Cirrhotics were impaired on non-amnestic and selected amnestic tests, HRQOL and systemic inflammation compared to non-cirrhotics. Cirrhotics demonstrated significant changes on MR spectroscopy but not on fMRI or volumetry. Correlation networks showed that Lactobacillales members were positively while Enterobacteriaceae and Porphyromonadaceae were negatively linked with cognition. Using the neuropsychological classification amnestic/non-amnestic-type individuals were majority cirrhosis and had worse HRQOL, higher inflammation and decreased autochthonous taxa relative abundance compared to the rest. This classification also predicted fMRI, MR spectroscopy and volumetry changes between groups. We conclude that gut-brain axis alterations may be associated with the type of neurobehavioral decline or inflamm-aging in elderly cirrhotic subjects.

Training and Assessing Interprofessional Virtual Teams Using a Web-Based Case System.

PURPOSE: Today, clinical care is often provided by interprofessional virtual teams-groups of practitioners who work asynchronously and use technology to communicate. Members of such teams must be competent in interprofessional practice and the use of information technology, two targets for health professions education reform. The authors created a Web-based case system to teach and assess these competencies in health professions students. METHOD: They created a four-module, six-week geriatric learning experience using a Web-based case system. Health professions students were divided into interprofessional virtual teams. Team members received profession-specific information, entered a summary of this information into the case system's electronic health record, answered knowledge questions about the case individually, then collaborated asynchronously to answer the same questions as a team. Individual and team knowledge scores and case activity measures--number of logins, message board posts/replies, views of message board posts--were tracked. RESULTS: During academic year 2012-2013, 80 teams composed of 522 students from medicine, nursing, pharmacy, and social work participated. Knowledge scores varied by profession and within professions. Team scores were higher than individual scores (P < .001). Students and teams with higher knowledge scores had higher case activity measures. Team score was most highly correlated with number of message board posts/replies and was not correlated with number of views of message board posts. CONCLUSIONS: This Web-based case system provided a novel approach to teach and assess the competencies needed for virtual teams. This approach may be a valuable new tool for measuring competency in interprofessional practice.

Improving outcomes and lowering costs by applying advanced models of in-home care.

With advances in monitoring and telemedicine, the complexity of care administered in the home to properly selected patients can approach that delivered in the hospital. The challenges include making sure that qualified personnel regularly visit the patient at home, both individually and in teams; information is accurately communicated among the caregiver teams across venues and over time; and patients understand the information communicated to them by providers. Despite these challenges, the benefits of treating chronically or terminally ill patients at home are significant. Among the most important are improved patient satisfaction and reduced cost. Numerous studies have shown that most patients prefer to spend their convalescence or their last days at home. The financial benefits of enabling patients to recover or to die at home are significant.

New diagnostic and information technology for mobile medical care.

Medicare reimbursement for home visits average around $100 without ancillaries, so making 10 home visits to prevent even a single $1,000 ambulance ride is cost-neutral for Medicare. Home medical care is only an added cost if it fails to offset acute care use. The government's demographic and financial pressure suggests a need to press ahead with the enhanced mobile care model, so the explosion in point-of-care devices should continue. The main challenge is to decide which ones provide dispositive value to patients.

Workforce development in geriatric home care.

With the rapidly aging population, it is anticipated that within two decades several million more individuals in the United States with functional impairment and serious ill health will need home health care. This article discusses workforce development, which is a critical issue for future planning, as recently highlighted by the Institute of Medicine (IOM). Key aspects of recruitment, training, and retention of home care workers are discussed, including those who provide basic support for activities of daily living as well as a variety of skilled professionals: therapists, nurses, pharmacists, and physicians. Although the geriatric workforce shortage affects all care settings, it is especially critical in home health care, in part because we are starting with far too few clinicians to meet the medical needs of homebound elderly. A combination of actions is needed, including educational programs, such as those developed by the American Academy of Home Care Physicians (AAHCP), changes in financial incentives, and changes in the culture and practice of health care, to make the home the primary focus of care for these vulnerable, underserved individuals rather than an afterthought.

Care transitions and home health care.

Transitions of care are becoming recognized as an important area for improvement in health care quality and patient safety. Yet there remains consistent evidence from multiple studies in varied settings of failures to complete safe, effective hand-offs from one location of care to the next. Major lapses include absent or limited clinical information and care plan content, plus errors related to medications. There are identifiable problems with half or more of the transitions that occur between care settings, and adverse consequences occur in 15 to 25 percent of patients. Undoubtedly these lapses contribute to the rates of re-hospitalization in post-acute care which affect 20 to 30 percent of patients within 60 days after hospital discharge. This article reviews models of transitional care intervention that have been tested and shown to be effective including less intensive coaching or guided care approaches, and more intensive case management strategies. Effective transitional care processes, linked with strong home care programs can reduce re-hospitalization by a third in some less intensive models and by half or more in some more intensive models.

Independence at home: community-based care for older adults with severe chronic illness.

By most clinical and economic measures, our health care system is not providing effective or affordable care to Medicare beneficiaries with severe chronic illness. Two million elders, constituting most of the 5% who account for nearly half of Medicare costs, have multiple chronic conditions, functional disability, and average per capita costs of over $50,000 per year. Prior reforms aimed at this population did not change the flawed delivery system, which remains centered in the doctor's office, hospitals, and nursing homes. This article describes a model of coordinated home-based medical care, called Independence at Home (IAH), which operates on a limited basis in many US communities and in the Veterans Affairs system. IAH-type teams deliver a full range of medical and social services at home to seriously ill elders and thereby reduce overall health care costs. We review the evidence that this approach can lower total costs by 25 percent or more while improving patient satisfaction and outcomes. We discuss funding for the new model, which also produces net savings for Medicare. A Medicare reform bill, called the Independence at Home Act, was introduced in the US House and Senate in 2008 to promote replication of this mobile elder care model.

The importance of "high valence" events in a successful program for teaching geriatrics to medical students.

Virginia Commonwealth University developed an enhanced medical student geriatric curriculum that includes required home visits and nursing home visits for second year students (180 per year), an annual Forum on Aging for all first and second year students, and small group exercises. We added 30 hours of basic science material to pre-clinical courses and increased clinical exposure to geriatricians in third and fourth years. Student satisfaction with individual experiences was high. Persistent effects of "high valence" required activities, where emotion played a role, was shown by post-pre survey techniques and focus groups. Fourth year AAMC exit questionnaire items in areas addressed by this curriculum improved markedly between 2002 and 2006, while an internal control changed much less.

Patterns of emergency care use in residential care settings: opportunities to improve quality of transitional care in the elderly.

Emergent care is a prominent feature in the complex matrix of care transitions for vulnerable elders. This article evaluates local patterns of emergent care transport using ambulance transport data for the year 2003, analyzed by residential setting (independent senior apartments, licensed residential care and nursing homes). Significant differences were found between categories and between facilities within categories (p < .001). The more than three-fold difference in ambulance transport rate between nursing homes reinforces the need to recognize these transitions as quality indicators. Differences between senior apartments and licensed residential care settings provide initial insight suggesting opportunities for quality improvement in these community settings.

A research and policy agenda for transitions from nursing homes to home.

More than 1 million adults make the transition from nursing homes to the community every year, often using formal health services including Medicare Part A skilled home health care. Although the need for discharge planning is well described, and the risks associated with care transitions are increasingly recognized, there is very limited information about the process and outcomes as patients move from nursing home to home. This paper reviews pertinent published data and health services research as background information and outlines a research agenda for studying these important transitions.