Friday, 12 February 2016

BrainHealth & ClinicSpeak: how should we treat MS in old age?

How should we manage MS in old age? #BrainHealth #ClinicSpeak #MSBlog 

"Public Health England (PHE) published their life expectancy report today. It shows life expectancy increasing. In parallel the latest data from the Framingham study showing the decreasing incidence of dementia. This Framingham data confirms recent dementia trends in the UK. Will this apply to MS? Will pwMS be living longer with a lower incidence of dementia? I don't know. I suspect that life expectancy in pwMS will have been increased by the impact of DMTs. We know already that simply being treated with interferon-beta 3-years earlier increases your chances of being alive at 21-years by close to 50%, compared to pwMS with delayed access to IFNbeta. However, survival, or mortality, data says nothing about the state of  cognition in pwMS in old age. How many pwMS when the get to 60 have dementia? How should we manage pwMS when they are old? How healthy are their bones? Have they all signed-up to an advanced directive? And the list goes on. These issues raise the thorny philosophical question about whether ageing is a comorbidity or disease, or is a physiological process? These issues are not trivial; if ageing is a disease it becomes a druggable problem that pharma can commercialise. If it is not a disease then pharma will have no incentive to develop drugs to target ageing; healthcare payers only pay for drugs and services linked to diseases. This is why pharma are lobbying so hard to get old-age classified as a disease."

"What about pwMS? What happens to them when they get older? Because MS reduces brain and spinal cord reserve pwMS are more susceptible to the ravages of ageing. This is something people with MS should think about now. How do you want to live your life when you are older? It makes sense to do everything in your power in the now to optimise your brain health for later. This rallying call should be a general one to everyone reading this post. How healthy are you and what are you doing to improve your brain health? Have you joined the brain health challenge?"


"Someone asked the other day how things are going with my brain health challenge. Very well. I have lost some weight, but have some way to go until I get down to my target weight of 1993; the year I arrived in London. I am exercising 4+ times a week; I do more rowing that running, simply to protect my hip. I have changed my diet; it tends to be a high-fat, high-protein, high-fibre and low carbohydrate diet. I have cut down massively on processed carbohydrates; I have virtually stopped eating bread.  I have not adopted a ketogenic, or gluten-free, or any other fad diet; I not convinced by the evidence. I have reduced my alcohol intake and only drink on ~3 or 4 days of the week. I don't smoke. My blood pressure is normal. I am due to have my cholesterol checked next month and if still high I may still need a statin. I am taking my supplements on most day of the week (vitamin D, metamucil and glucosamine/chondroitin); please note the metamucil and glucosamine/chondroitin have been prescribed for my diverticular disease and joints, respectively. I still struggling with sleep hygiene; I try to get at least 6 hours of sleep a night, but have several 4 hour nights a week. I am doing a lot of leisure reading to keep my mind from thinking about MS too much. With spring arriving I will have a lot of gardening to do. I haven't managed to complete my online JavaScript (computer coding) course; this was my New Year's challenge to myself. Overall I am feeling better than I have for some years. So yes, my brain health campaign is going well. What about wellness? Do I feel well? No not yet I still have too much work-related stress and a work-load that is unstainable."

Public Health England. Recent Trends in Life Expectancyat Older Ages. February 2015

Key Points:

  • Over the last 30 years there has been an upward trend in life expectancy at older ages in England. Life expectancy among those aged 65 has increased at an average rate of 1.2% per year for men and 0.7% per year for women 
  • within England, although female life expectancy at age 65, 75, 85 and 95 fell in 2012, and for males it fell at ages 85 and 95 and remained static at ages 65 and 75, it is too early to say whether this represents a slowing down in the upward trend or the start of a downward trend 
  • the overall upward trend and the fall described for 2012 in England were reflected across many of the countries of the European Union 
  • between 2008 to 2010 and 2011 to 2013, 89% of lower tier and unitary local authorities had an increase in male life expectancy at 65 years, and 81% had an increase in female life expectancy at this age. There does not appear to be a relationship between change in life expectancy at age 65 and the level of life expectancy in 2008 to 2010 or level of deprivation for a local authority. Local authorities that did not show an increase are not confined to specific areas of the country 
  • PHE will continue to monitor life expectancy and mortality in England and other geographies, and will make the findings available in future reports 

Satizabal et al. Incidence of Dementia over Three Decades in the Framingham Heart Study. N Engl J Med. 2016 Feb 11;374(6):523-32.

BACKGROUND: The prevalence of dementia is expected to soar as the average life expectancy increases, but recent estimates suggest that the age-specific incidence of dementia is declining in high-income countries. Temporal trends are best derived through continuous monitoring of a population over a long period with the use of consistent diagnostic criteria. We describe temporal trends in the incidence of dementia over three decades among participants in the Framingham Heart Study.

METHODS: Participants in the Framingham Heart Study have been under surveillance for incident dementia since 1975. In this analysis, which included 5205 persons 60 years of age or older, we used Cox proportional-hazards models adjusted for age and sex to determine the 5-year incidence of dementia during each of four epochs. We also explored the interactions between epoch and age, sex, apolipoprotein E ε4 status, and educational level, and we examined the effects of these interactions, as well as the effects of vascular risk factors and cardiovascular disease, on temporal trends.

RESULTS: The 5-year age- and sex-adjusted cumulative hazard rates for dementia were 3.6 per 100 persons during the first epoch (late 1970s and early 1980s), 2.8 per 100 persons during the second epoch (late 1980s and early 1990s), 2.2 per 100 persons during the third epoch (late 1990s and early 2000s), and 2.0 per 100 persons during the fourth epoch (late 2000s and early 2010s). Relative to the incidence during the first epoch, the incidence declined by 22%, 38%, and 44% during the second, third, and fourth epochs, respectively. This risk reduction was observed only among persons who had at least a high school diploma (hazard ratio, 0.77; 95% confidence interval, 0.67 to 0.88). The prevalence of most vascular risk factors (except obesity and diabetes) and the risk of dementia associated with stroke, atrial fibrillation, or heart failure have decreased over time, but none of these trends completely explain the decrease in the incidence of dementia.

CONCLUSIONS: Among participants in the Framingham Heart Study, the incidence of dementia has declined over the course of three decades. The factors contributing to this decline have not been completely identified. (Funded by the National Institutes of Health.).

28 comments:

  1. We're often told that pwMS die younger than the rest of the population, but never why. What are the causes of death?

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    1. Normally its the usual causes, pneumonia, infections, septicaemia etc. ie secondary to MS.Most commonly as a result of being bed bound. You see the same thing in most other conditions.

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  2. So.... the advice would seem to be: keep exercising and doing crosswords, get your power of attorney and will sorted and do everything you can to stay fit and well. Then stop fretting (because otherwise, this is doom and gloom). I just keep booking the holidays.... (a 65-year old with RRMS).

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  3. Who wants to live forever anyway? Just watching the news headlines makes me think that with the ongoing war, migration crisis, fascist Islamisation, and deepening economic despairing, mankind may not make it out of this century.

    MSers are more likely to take their health and wellbeing more seriously than the general population. They're more clued up and exacting.

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    1. Cheer up, its Friday and the rugby is on the telly tomorrow ;-)

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    2. MD2 - thugby is just another form of footbrawl......

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    3. OK, the 6 Nations needlework championships are on the telly ;-)

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    4. https://www.youtube.com/watch?v=i_2mWhfOhGU

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  4. I plan on having my brain uploaded to The Matrix before I get that old. Organic brains and bodies are so 2016!

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  5. Prof G - I'm curious as to what made you choose a high-fat, high-protein, high-fibre and low carbohydrate diet" over various other options being pushed at us every day from multiple sources? It sounds like you are wandering towards the Paleo/Terry Wahls department! If you are convinced about your choices, don't go near the Forks Over Knives website - that will have you really confused - especially as they seem convinced that Vit D supplementation is a waste of time and money, and are trotting out cherry-picked research which claims that Vit D supplementation increases the risk of fractures - especially in the elderly!

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    1. Re: "....high-fat, high-protein, high-fibre and low carbohydrate diet..."

      I have been reading some of Tim Noakes' work; he is one of my idols. He is a sports physiologist from the University of Cape Town and a runner. His book the 'Lore of Running' was like a bible to me when I was running mad; he admits that he made a big mistake in books about high carbohydrate diets. He is now on a mission to get rid of processed carbohydrates from our diet. I have a lot of time for scientists who when they realise have got it wrong make amends; Tim Noakes is one of them. I am not sure if I recall the term paleo in his writings. I will check.

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    2. Mediterranean diet has lots of carbs ... just not pure white sugar. Your cholesterol will not budge on a high fat diet, I have seen it in my patients.

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  6. "I am doing a lot of leisure reading to keep my mind from thinking about MS too much. With spring arriving I will have a lot of gardening to do."

    Snap! My spring bulbs are starting to bloom, and I bought dormant Bleeding Heart (_Dicentra_) roots to plant from Tesco.

    As far as my brain health challenge goes, I've no weight to lose, I eat a vegan diet apart from fish and honey, I'm teetotal, and get outdoors as much as I can. Fresh air is a great therapy. Given my love of homemade bread, I could never cut out carbohydrates. To me, that would be inhumane. Otherwise, I enjoy my hobbies as much as possible and yes, try not to think about MS too much. That's very important!

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    1. Also snap! I love my garden and am waiting for my Hepatica seeds to germinate and my Welsh poppy seeds to arrive.

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    2. Hepatica - how interesting - I've never tried them! Looking online now. I'm going crazy for Eschscholzia, the Californian poppies, and I found pink Icelandic ones.

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    3. Try Chiltern seeds http://www.chilternseeds.co.uk/
      I'm also going to have another go at growing Himalayan Blue poppies from seed which is some task!

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    4. Perhaps we should start a weekly Garden advice post? :-)

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    5. Thank you for the tip! Himalayan poppies from seed is tricky I think - I've asked the local garden centre for plug plants of them! But my sister did manage to germinate one. Yes - we definitely need a regular gardening feature on here. And any tips on keeping cats out of the garden would be most welcome. Just not those ultrasonic devices - I can hear those, and it's not a pleasant sound!

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    6. Short of getting a dog I'm afraid the only reliable solution was an ultrasonic scarer. Worked a treat.

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    7. You have pine martens in your garden? How unusual! I hope they don't also use your flower beds as litter trays! They might be good cat scarers? But I've no big trees for them to live in. Maybe a stuffed one would do?

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    8. Maybe run a garden photo competition to supply the seasonally influenced pics used for the monthly Unrelated Blogger comments.....

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  7. Thank you sooooo much for answering my question. I didn't expect an entire blog post for it! You have made my day :)

    I am curious what constitutes as high fat in your diet. I stopped eating meat after my MS diagnosis. I also drastically cut back on saturated fats. No more cheese, fried foods, or desserts for me :). Having a high energy toddler at home has pretty much put an end to eating out. I take Tecfidera so I eat avocado or peanut butter along with it to avoid any side effects. I am also thinking of taking flaxseed oil. It would be nice to know what kind of fats you are eating so I can try them as well!

    All the work you are doing for MS is absolutely awesome. I really like reading this blog and I hope you are able to find some quality time for yourself.

    BTW, I am a computer programmer and I would love to offload your JavaScript stress :)

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  8. Since the Agricultural Revolution, our diets consist of merely three cereals: wheat, corn and rice. We were evolutionary designed to have way more variety, including more sorts of meats and birds.

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    1. Forgive my pedantry but design has nothing to do with evolution.

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  9. This is an interesting topic for many reasons and we have done some cursory investigation and opening some doors. Geriatric MS is a term one just doesnt tend to see except in the more rare form of benign MS, which, according to a few neuro's here often starts to move in older age.

    Since the more effective DMT's are relatively new on the scene a long life expectancy may well be the result and its a relative unknown according to the geriatric Doc we've been talking to.

    In many aspects geriatric docs (or at least this one) understand considerably better mental / brain aspects of aging than any general prac and in fact, even two neuro's we speak with.

    Just the other day I was shown a video by a neuro (name escapes me at the moment) who'd shown in his practice (Ebers? I think) that the interferons were essentially not of much if any help in MS pathology towards transition times to SPMS and from SPMS to death. Once SPMS was entered the graphs he displayed showed nearly the same time / outcomes as PPMS in as far as time to demise.

    I have no idea how credible the neuro is, I did not yet research that.

    In the few conversations thus far with a local geriatric as I noted, his statements towards us is there are simply too many unknowns related to the existing therapies long term implications of use and long term efficacy.

    He "believes" that MS represents a special case .vs. Alzheimer's and Parkinson's for example because plaques will exist and the new DMT's may pose a significant complications. Usage alone may be complicated to even apply to geriatric level care w/ DMT's. The fact the DMT's ultimately may extend years of life by reducing disease progression yet plaques will still exist will according to him represent a special complication towards elder years.

    He told us these are special questions that lay completely unaddressed. Usage of these meds in clinical trials with geriatric aged patients is non-existent. He believes it is intentionally non-existent for two reasons. 1. That attempting such trials pharma more than likely considers dangerous both to patients and prospect revenues with possibilities of adverse events. 2. That the may already be aware that sequestering and/or reducing immune system efficacy is simply a very bad idea towards aging.

    He'd stated that clinical trials tend have a few people who are in transition from adulthood towards the changes within the body with MS. But actually having a significant portion of the cohort actually be geriatric just doesnt happen. The risks of adverse events he says can skew that they want see as outcomes. If DMT "xxx" had 5 geriatrics aged 70 average take part and 1 had an adverse event, and two died they need explain this and even if they find the adverse events were not directly causal due to the DMT it is not excluded in the trial. Towards marketing its not a nice feature.

    His statements towards us has been it IS something that neurologists and geriatrics need to really start collaborating towards BEFORE the 40-55 populations taking these therapies move towards geriatric level care. He said not doing so is irresponsible yet he believes that is exactly what will happen.

    When we asked him why he says that he cited that 1. The HMO and insurer communities like nothing better than emergencies that "We were unaware might come forth" because it allows an out. 2. As people get impacted by complications of the new DMD usage he believes as early as geriatric ENTRY (as the body has entered into significant changes) that mean ages towards demise will not result in extended life at all. That it will either be same as it has been, 10-15 years less mean avg lifetime or LESS <----.

    These are apparently discussions that need to take place and just are not happening.

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