TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include neuropathy after chemotherapy, a comprehensive approach to dementia care, mortality and falls, and life expectancy and educational attainment.
Program notes:
0:37 Comprehensive care for dementia patients
1:35 Outcome of cognitive impairment progression
2:35 Subgroup analysis
3:30 Mortality and falls
4:30 Older adults at risk
5:30 Increased numbers of older people
6:15 Educational attainment and life expectancy
7:15 Lifespan difference 11 or 12 years
8:15 May have greater access to resources
8:30 Peripheral neuropathy following chemo
9:31 Reporting highest among those treated with platinum-based agents
10:31 Reduce dose or duration?
12:03 End
Transcript:
Elizabeth: How often do people experience neuropathy after they’ve had chemotherapy?
Rick: Does comprehensive care improve outcomes in people with dementia?
Elizabeth: Just how deadly are falls worldwide?
Rick: And life expectancy and its influence by educational attainment.
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, in view of the fact that there are actually two studies relative to dementia in JAMA this week, how about if we start with that?
Rick: Happy to. I teed this up as providing comprehensive care in individuals with dementia.
In 2024, it’s estimated that about almost 7 million U.S. residents have Alzheimer’s dementia. There are other causes of dementia that account for about 20-40% of individuals that experience it. This becomes progressively more important as we age because those individuals that are 90 years or older, 35% of them have dementia. It’s associated with progressive cognitive impairment, behavioral changes, functional decline, immobility falls, swallowing problems. That’s just for the patient and obviously there’s caregiver distress as well.
So there are two studies that looked at providing more comprehensive care. One of these took individuals with dementia and randomized them to receive either usual care, care provided by a health system with trained individuals, or community-based care. The outcome that looked at it was the severity of the cognitive impairment or the Neuropsychiatric Inventory Questionnaire and they also looked at caregiver strain.
The other study did a similar thing, except it provided palliative care in addition to usual care, and, again, with the same outcome, but it also looked to see whether it decreased hospital utilization and emergency department visits. Despite the fact these were very well-designed trials and carried out very well, in neither case did it improve the outcome of the patient. It continued to progress in terms of their dementia.
The one side benefit is when palliative care was provided it did decrease the number of ED [emergency department] visits and hospitalizations. It may decrease cost for those individuals, but that wasn’t studied. Medicare is talking about providing more money to provide more comprehensive care in these patients, but unfortunately, at least in these two design studies, it didn’t seem to improve outcome.
Elizabeth: What about some of the caregiver outcomes? What did they see there?
Rick: Really no benefit there either, Elizabeth. Having said that, when they did a subgroup analysis… and by the way, if the study is negative, you usually don’t look at subgroup analysis and those things don’t provide a definitive answer. They just provide a hypothesis for testing for the next study. But it did suggest that, in fact, individuals that have the worst dementia they may have received a better outcome, specifically with regard to caregiver stress. That’s just a subgroup analysis and needs to be tested in a larger study.
Elizabeth: This is very disappointing because this burden of dementia and also of Alzheimer’s pathology is going to increase, and there’s going to be way more people who are impacted by this. And I think it’s incumbent upon us to get our arms around what are the best strategies for management, particularly as their lifespan is usually in the 10- to 12-year range post-diagnosis.
Rick: Absolutely, and kudos to the investigators that put these trials together. Very well done. But we don’t want to be doing things that aren’t effective. That’s the value of these studies.
Elizabeth: Since we’re talking about older people then, let’s take a look at this study from The Lancet that’s looking at what I described as mortality globally related to falls.
This study utilizes the WHO’s [World Health Organization’s] Mortality Database. It looks at the years from 1990 to 2021. They also utilize this data to forecast trends until 2040 across 59 high-income and upper-middle-income countries. They look at this outcome, fall-related mortality rates per 100,000 people, and this number actually declined from 23.21 in 1990 to 11.01 in 2009. But then it started increasing again and in 2021 it was 12.51. Fall-related mortality rates were consistently higher across this whole period among men, among individuals in high-income countries, and unsurprisingly among older adults.
There definitely is a clear pattern that they’re able to discern regarding these fall-related mortality rates according to sex, income level, and age. We do see that among women, of course, this is increasing and really increasing incredibly 1,434.8% in individuals who are 85 years of age and older. We could call it a consequence of successful aging that you even get to be 85 and then you have this fall risk that’s associated with that.
They also showed positive correlations with their Socio-Demographic Index and an Environmental Performance Index. Clearly, what this is illustrating is that this fall mortality is a big issue. They also prognosticate that it’s going to continue to increase. This increase is going to be attributed to the growth in the population.
Rick: The increase in individuals that are older, and as you mentioned, the number of falls and the mortality associated with that increases with increasing age. So as we have more people entering their 80s and even 90s, the risk of fall and the risk of immortality with it increases.
It was really pretty interesting. As you mentioned, there was about a 53% initial decline and now about a 13% increase over the last decade. This is going to take a multi-faceted approach: geriatric assessments, making the environment safer, better bone health, better muscle tone. I mean, all the things that contribute to the possibility of falling and the mortality associated with it.
Elizabeth: No question about that. So this notion of healthy aging has to come front and center if we’re going to prevent a lot of this. Let’s turn to your next one and that’s also in The Lancet.
Rick: This is a terrific study that looked at life expectancy and educational attainment in the U.S. We’ve known for a long period of time that there’s an association between life expectancy and educational attainment, but this did it on a county-by-county basis across the United States from 2000 to 2019.
This aim of the study was to estimate the life expectancy at age 25 for all U.S. counties for four different educational attainment populations: those that had less than a high school education, those that have been a high school graduate, some college, and then finally those that were college graduates. As has previously been shown, there is a gradient. The individuals that are more likely to have a longer lifespan at age 25 are those that had a college degree versus those that had some college, which did better than those that just had a high school, which did better than those that did not have a high school degree.
Between those that had no high school degree and those that had a college degree, the lifespan difference was about 8 or 9 years and what’s happened over the last two decades is that’s increased even more. So now there’s about an 11- or 12-year difference between those that have a college degree and those that have less than a high school degree. By the way, there’s significant county-by-county variation, but most of that variation isn’t at the college level. It’s individuals that didn’t have a high school degree.
Elizabeth: Let’s explore the county-level data here. Aren’t there areas of the country where this is particularly noteworthy?
Rick: Right. For example, if you happen to live in central Colorado, you have a high life expectancy within every educational attainment population. In contrast, if you go to Appalachia or parts of South Dakota, they have a relatively low life expectancy. This pattern was particularly true for those that had less than a high school education.
Elizabeth: At a policy level then, what do we do about this?
Rick: Well, Elizabeth, first of all, we need to identify what that cause is. Education may improve health longevity because those individuals may have greater access to use of resources if they have a higher income or access to medical care. And if that’s the issue, we need to address it. I don’t want to say just throw in a college degree improves your lifespan. We need to assess exactly what that relationship is and try to address it.
Elizabeth: Finally, let’s turn to the BMJ and let’s take a look at this issue of peripheral neuropathy following chemotherapy. Lots of times when people have chemotherapy, they report that they have peripheral neuropathy, which can vary a lot between just the sensation of pins and needles to really pretty relentless pain that people perceive after they’ve had this kind of treatment.
So these folks took a look at some meta-analysis, 77 studies from 28 countries, and their primary outcome was the pooled prevalence of chronic — that is greater than or equal to 3 months duration — painful chemotherapy-induced peripheral neuropathy in those patients who were diagnosed with this condition.
The overall pooled prevalence is really high, 41.22%. Now, they did note that there was substantial heterogeneity associated with this across their studies. They found that the reporting of persistent peripheral neuropathy was highest among those patients who were treated with platinum-based agents and taxanes. Also among primary cancers, those with lung cancer had the highest prevalence. It underscores our need to really take a look at the balance of using these agents versus the likelihood that you’re going to develop this chronic, painful condition. It also says we need to really take a look at what do we do about this pain and we need to tailor it to patients who are reporting it.
Rick: Yeah. I wasn’t aware that the painful neuropathy occurred so frequently, 40%. Usually you think about a neuropathy, well, there’s a little tingling or loss of sensation, which isn’t as bothersome, but a chronic pain syndrome in cancer survivors is a substantial problem. This is going to force us to figure out what the mechanisms are, and is there ways to mitigate it, perhaps using either different therapies, if there are options, or reducing the dose of the platinum-based therapies. Then there may be people that have a genetic predisposition and the first step is identifying it is a substantial problem.
Elizabeth: The authors note that the development of this condition is impacted by multiple factors. There’s also patient-related factors. So if they’ve got pre-existing neuropathies or they’re using other types of neurotoxic drugs, this can exacerbate the likelihood that people will develop this subsequent to treatment.
They speculate on the mechanisms, as you suggested. They think that there could be direct neurotoxic effects on peripheral nerves, neuroinflammation, mitochondrial damage, ion channel dysfunction. And I think it’s really important to identify exactly what it is that causes this to happen.
Rick: Right. Because we may be able either to find a safer agent that doesn’t affect those same pathways or somehow interrupt those pathways without disturbing the benefits of the chemotherapy.
Elizabeth: Yeah, and I guess I would be hopeful that, given all of our immune-modulating treatments for cancer and targeted therapies, that these kind of broad-brush agents that are taxanes or those that contain platinum I would hope would decrease in how often they’re used.
Rick: Yep.
Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.
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