Publications by authors named "Esther S Oh"

75 Publications

Post-acute Sequelae of SARS-CoV-2 Infection and Subjective Memory Problems.

JAMA Netw Open 2021 07 1;4(7):e2119335. Epub 2021 Jul 1.

Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2021.19335DOI Listing
July 2021

Hearing Impairment and Cognition in an Aging World.

J Assoc Res Otolaryngol 2021 Jul 18;22(4):387-403. Epub 2021 May 18.

Department, of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

With the increasing number of older adults around the world, the overall number of dementia cases is expected to rise dramatically in the next 40 years. In 2020, nearly 6 million individuals in the USA were living with Alzheimer's disease, the most common type of dementia, with anticipated growth to nearly 14 million by year 2050. This increasing prevalence, coupled with high societal burden, makes prevention and intervention of dementia a medical and public health priority. As clinicians and researchers, we will continue to see more individuals with hearing loss with other comorbidities including dementia. Epidemiologic evidence suggests an association between hearing loss and increased risk of dementia, presenting opportunity for targeted intervention for hearing loss to play a fundamental role in dementia prevention. In this discussion, we summarize current research on the association between hearing loss and dementia and review potential casual mechanisms behind the association (e.g., sensory-deprivation hypothesis, information-degradation hypothesis, common cause). We emphasize key areas of research which might best inform our investigation of this potential casual association. These selected research priorities include examination of the causal mechanism, measurement of co-existing hearing loss and cognitive impairment, and potential of aural rehabilitation. Addressing these research gaps and how results are then translated for clinical use is paramount for dementia prevention and overall health of older adults.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10162-021-00799-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8329135PMC
July 2021

Medicare Beneficiaries With Self-Reported Functional Hearing Difficulty Have Unmet Health Care Needs.

Health Aff (Millwood) 2021 05;40(5):786-794

Amber Willink is an associate professor at the Menzies Centre for Health Policy and Economics, University of Sydney, in New South Wales, Australia.

Hearing loss is associated with higher health care spending and use, but little is known about the unmet health care needs of people with hearing loss or difficulty. Analysis of 2016 Medicare Current Beneficiary Survey data for beneficiaries ages sixty-five and older reveals that those who reported a lot of trouble hearing in the past year were 49 percent more likely than those who reported no trouble hearing to indicate not having a usual source of care. Compared with those who reported no trouble hearing, those who reported some trouble hearing were more likely to indicate not having obtained medical care in the past year when they thought it was needed, as well as not filling a prescription, with the risk for both behaviors being greater among those reporting a lot of trouble hearing versus a little. Interventions that improve access to hearing services and aid communication may help older Medicare beneficiaries meet their health care needs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1377/hlthaff.2020.02371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323057PMC
May 2021

Healthcare-Seeking Behaviors Among Medicare Beneficiaries by Functional Hearing Status.

J Aging Health 2021 Oct 29;33(9):764-771. Epub 2021 Apr 29.

Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Hearing loss is associated with higher health expenditures and poor healthcare utilization. This study aims to build on these findings by characterizing the association between hearing status and healthcare-seeking behaviors among Medicare beneficiaries. Cross-sectional log-binominal regression was used to assess the association between self-report hearing and healthcare-seeking behaviors (avoidance or delay of care, personal health concerns, and sharing health status) using the 2016 Medicare Current Beneficiary Survey ( = 12,140). Beneficiaries with trouble hearing had significantly higher risks of avoiding and delaying health care compared to those without trouble hearing. Conversely, trouble hearing was not associated with concern for health status or sharing health status. These findings may help explain higher costs associated with hearing loss as avoidance of care can exacerbate health problems. Further work is needed to understand underlying causes and whether addressing hearing loss modifies the observed association.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/08982643211011799DOI Listing
October 2021

Telemedicine and Dementia Care: A Systematic Review of Barriers and Facilitators.

J Am Med Dir Assoc 2021 07 20;22(7):1396-1402.e18. Epub 2021 Apr 20.

Cochlear Center for Hearing & Public Health-Johns Hopkins University School of Public Health, Baltimore, MD, USA; Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objectives: An increasing reliance on telemedicine for older adults with cognitive impairment requires a better understanding of the barriers and facilitators for this unique patient population.

Design: The study team queried PubMed, Embase, the Cochrane Library, PsycINFO, CINAHL, Scopus, and ClinicalTrials.gov on May 1, 2020, for studies in English published from January 2010 to May 2020.

Setting And Participants: We conducted a systematic review of articles investigating the use of telemedicine among older adults with Alzheimer's disease and related dementia (ADRD) or mild cognitive impairment (MCI) that focused on the patient and care partner perspectives.

Methods: Telemedicine encounter purpose, technological requirements, and findings regarding sensory needs were extracted. The Cochrane Collaboration's Risk of Bias Tool was applied for quality assessment.

Results: The search yielded 3551 abstracts, from which 90 articles were reviewed and 17 were included. The purpose of telemedicine encounters included routine care, cognitive assessment, and telerehabilitation. All studies reported successful implementation of telemedicine, supported by patient and care partner satisfaction, similar results on cognitive assessment and diagnosis compared to in-person visits, and improvement in outcome measures following rehabilitation. Sixteen studies relied on staff and care partners to navigate technologies. Six studies reported participants reporting difficulty hearing the provider during the telemedicine visits. Five studies excluded participants with visual or hearing impairment because of the potential difficulty of using telemedicine technology. No studies reported technological adaptations to account for sensory impairment.

Conclusions And Implications: Telemedicine is well received among patients and care partners, but successful delivery incorporates support staff and the care partners to navigate technologies. The exclusion of older adults with sensory impairment, especially given that it is highly prevalent, in developing telemedicine systems may further exacerbate access to care in this population. Adapting technologies for sensory needs is critical to the advancement of accessible dementia care through telemedicine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamda.2021.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8292189PMC
July 2021

Detection of Wandering Behaviors Using a Body-Worn Inertial Sensor in Patients With Cognitive Impairment: A Feasibility Study.

Front Neurol 2021 11;12:529661. Epub 2021 Mar 11.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States.

Patients with Alzheimer's disease (AD) and AD related dementias (ADRD) often experience spatial disorientation that can lead to wandering behavior, characterized by aimless or purposeless movement. Wandering behavior has been associated with falls, caregiver burden, and nursing home placement. Despite the substantial clinical consequences of wandering, there is currently no standardized approach to objectively quantify wandering behavior. In this pilot feasibility study, we used a lightweight inertial sensor to examine mobility characteristics of a small group of 12 older adults with ADRD and mild cognitive impairment in their homes. Specifically, we evaluated their compliance with wearing a sensor for a minimum of 4 days. We also examined the ability of the sensor to measure turning frequency and direction changes, given that frequent turns and direction changes during walking have been observed in patients who wander. We found that all patients were able to wear the sensor yielding quantitative turn data including number of turns over time, mean turn duration, mean peak turn speed, and mean turn angle. We found that wanderers make more frequent, quicker turns compared to non-wanderers, which is consistent with pacing or lapping behavior. This study provides preliminary evidence that continuous monitoring in patients with dementia is feasible using a wearable sensor. More studies are needed to explore if objective measures of turning behaviors collected using inertial sensors can be used to identify wandering behavior.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fneur.2021.529661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7991404PMC
March 2021

United States Preventive Services Task Force Recommendation for Hearing-Loss Screening Among Older Adults: An Opportunity in Insufficient Evidence.

JAMA Otolaryngol Head Neck Surg 2021 06;147(6):500-501

Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaoto.2021.0258DOI Listing
June 2021

Association of CSF Alzheimer's disease biomarkers with postoperative delirium in older adults.

Alzheimers Dement (N Y) 2021 17;7(1):e12125. Epub 2021 Mar 17.

Aging Brain Center, Institute for Aging Research Hebrew SeniorLife Boston Massachusetts USA.

Introduction: The interaction between delirium and dementia is complex. We examined if Alzheimer's disease (AD) biomarkers in patients without clinical dementia are associated with increased risk of postoperative delirium, and whether AD biomarkers demonstrate a graded association with delirium severity.

Methods: Participants ( = 59) were free of clinical dementia, age 70 years, and scheduled for elective total knee or hip arthroplasties. Cerebrospinal fluid (CSF) was collected at the time of induction for spinal anesthesia. CSF AD biomarkers were measured by enzyme-linked immunosorbent assay (ELISA) (ADX/Euroimmun); cut points for amyloid, tau, and neurodegeneration (ATN) biomarker status were  = amyloid beta (Aβ) <175 pg/mL or Aβ ratio <0.07;  = p-tau >80 pg/mL; and  = t-tau >700 pg/mL. Confusion Assessment Method (CAM) and CAM-Severity (CAM-S) were rated daily post-operatively for delirium and delirium severity, respectively.

Results: Aβ, tau, and p-tau mean pg/mL (SD) were 361.5 (326.1), 618.3 (237.1), and 97.1 (66.1), respectively, for those with delirium, and 550.4 (291.6), 518.3 (213.5), and 54.6 (34.5), respectively, for those without delirium. Thirteen participants (22%) were ATN positive. Delirium severity by peak CAM-S [mean difference (95% confidence interval)] was 1.48 points higher (0.29-2.67),  = 0.02 among the ATN positive. Delirium in the ATN-positive group trended toward but did not reach statistical significance (23% vs. 7%, p = 0.10). Peak CAM-S [mean (SD)] in the delirium group was 7 (2.8) compared to no delirium group 2.5 (1.3), but when groups were further classified by ATN status, an incremental effect on delirium severity was observed, such that patients who were both ATN and delirium negative had the lowest mean (SD) peak CAM-S scores of 2.5 (1.3) points, whereas those who were ATN and delirium positive had CAM-S scores of 8.7 (2.3) points; other groups (either ATN or delirium positive) had intermediate CAM-S scores.

Discussion: The presence of AD biomarkers adds important information in predicting delirium severity. Future studies are needed to confirm this relationship and to better understand the role of AD biomarkers, even in pre-clinical phase, in delirium.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/trc2.12125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968120PMC
March 2021

A Geriatrician's Guide to Hearing Loss.

J Am Geriatr Soc 2021 May 9;69(5):1190-1198. Epub 2021 Mar 9.

Cochlear Center for Hearing and Public Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.

The high prevalence of hearing loss among older adults creates a perception that it is simply a benign consequence of aging, which leads to unaddressed communication needs. Strategies to address hearing loss as part of routine clinical care are pertinent to the geriatric care setting where hearing loss is prevalent in two out of every three patients 70 years and older. Our objectives are to briefly discuss the pathophysiology of hearing loss, describe the epidemiologic prevalence and impact, identify statutory barriers facing older adults in accessing hearing care, discuss current progress on legislation to address accessibility issues, and provide actionable strategies for addressing hearing loss as a barrier to effective communication. Simple steps can be taken to improve hearing care accessibility for older adults with hearing loss and can optimize understanding in daily communication, re-engage patients in being actively involved in their care, and promote patient autonomy in informed decision- making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.17073DOI Listing
May 2021

Multiple Neurodegenerative Pathologies in an Alzheimer's Disease Patient Treated with Fornical Deep Brain Stimulation.

J Alzheimers Dis 2021 ;80(4):1383-1387

Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA.

As an established treatment for movement disorders, deep brain stimulation (DBS) has been adapted for the treatment of Alzheimer's disease (AD) by modulating fornix activity. Although it is generally regarded as a safe intervention in patients over 65 years of age, the complex neurophysiology and interconnection within circuits connected to the fornix warrants a careful ongoing evaluation of the true benefit and risk potential of DBS on slowing cognitive decline in AD patients. Here we report on a patient who died long after being implanted with a DBS device who donated her brain for neuropathologic study. The autopsy confirmed multiple proteinopathies including AD-related change, diffuse neocortical Lewy body disease, TDP-43 proteinopathy, and a nonspecific tauopathy. We discuss the possible mechanisms of these overlapping neurodegenerative disorders and caution that future studies of DBS for AD will need to take these findings into consideration.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3233/JAD-201415DOI Listing
September 2021

Association of Depressive Symptoms With Postoperative Delirium and CSF Biomarkers for Alzheimer's Disease Among Hip Fracture Patients.

Am J Geriatr Psychiatry 2021 Feb 4. Epub 2021 Feb 4.

Departments of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University School of Nursing, Baltimore MD. Electronic address:

Objectives: While there is growing evidence of an association between depressive symptoms and postoperative delirium, the underlying pathophysiological mechanisms remain unknown. The goal of this study was to explore the association between depression and postoperative delirium in hip fracture patients, and to examine Alzheimer's disease (AD) pathology as a potential underlying mechanism linking depressive symptoms and delirium.

Methods: Patients 65 years old or older (N = 199) who were undergoing hip fracture repair and enrolled in the study "A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients" completed the 15-item Geriatric Depression Scale (GDS-15) preoperatively. Cerebrospinal fluid (CSF) was obtained during spinal anesthesia and assayed for amyloid-beta (Aβ) 40, 42, total tau (t-tau), and phosphorylated tau (p-tau).

Results: For every one point increase in GDS-15, there was a 13% increase in odds of postoperative delirium, adjusted for baseline cognition (MMSE), age, sex, race, education and CSF AD biomarkers (OR = 1.13, 95%CI = 1.02-1.25). Both CSF Aβ42/t-tau (β = -1.52, 95%CI = -2.1 to -0.05) and Aβ42/p-tau (β = -0.29, 95%CI = -0.48 to -0.09) were inversely associated with higher GDS-15 scores, where lower ratios indicate greater AD pathology. In an analysis to identify the strongest predictors of delirium out of 18 variables, GDS-15 had the highest classification accuracy for postoperative delirium and was a stronger predictor of delirium than both cognition and AD biomarkers.

Conclusions: In older adults undergoing hip fracture repair, depressive symptoms were associated with underlying AD pathology and postoperative delirium. Mild baseline depressive symptoms were the strongest predictor of postoperative delirium, and may represent a dementia prodrome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jagp.2021.02.001DOI Listing
February 2021

Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review.

Heliyon 2021 Feb 13;7(2):e06230. Epub 2021 Feb 13.

Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objectives: To determine the outcomes of chronically ventilated patients outside the setting of intensive care units.

Design: Systematic review.

Setting And Participants: Studies evaluating patients on chronic invasive mechanical ventilation in different care settings.

Methods: A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion.

Results: Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death.

Conclusions And Implications: Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.heliyon.2021.e06230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880845PMC
February 2021

Psychotropic Medication and Cognitive, Functional, and Neuropsychiatric Outcomes in Alzheimer's Disease (AD).

J Am Geriatr Soc 2021 04 31;69(4):955-963. Epub 2020 Dec 31.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background/objectives: There are growing concerns about the safety and efficacy of psychotropic medications in Alzheimer's disease (AD). We sought to examine associations between psychotropic medication exposure and longitudinal change in cognitive, functional, and neuropsychiatric outcomes in a large clinical AD cohort.

Design: Longitudinal observational study.

Setting: National Alzheimer's Disease Coordinating Center combining data from 39 Alzheimer's disease centers.

Participants: 8,034 participants with AD dementia.

Measurements: Mini-Mental State Exam (MMSE), Clinical Dementia Rating Scale-Sum of Boxes (CDR-SB), and Neuropsychiatric Inventory Questionnaire (NPI-Q) Total. Probability of exposure to medication (the propensity score, PS) calculated via logistic regression. Medication classes included all antipsychotics (atypical vs conventional), antidepressants (Selective Serotonin Reuptake Inhibitor [SSRI] vs non-SSRI), and benzodiazepines. Participants treated with a medication class were matched with participants not treated with that class with the closest-matched PS. The effect of medication treatment was assessed using linear mixed-effects models.

Results: Participants had a mean (SD) age of 75.5 (9.8) years, and mean (SD) scores of MMSE 21.3 (5.7), CDR-SB 5.5 (3.4), and NPI-Q Total 4.5 (4.4). Mean duration of follow-up was 2.9-3.3 years depending on medication class. Non-SSRI antidepressant use was associated with better CDR-SB (2-year difference in change-DIC: -0.38 [-0.61, -0.15], P = .001). Atypical antipsychotic use was associated with greater decline on MMSE (DIC: -0.91 [-1.54, -0.28] P = .005) and CDR-SB scores (DIC: 0.50 [0.14, 0.86], P = .006). Notably, no drug class was associated with better NPI-Q scores.

Conclusions: Use of atypical antipsychotics was associated with poorer cognition and function, and no drug class was associated with improvement in neuropsychiatric symptoms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.16970DOI Listing
April 2021

Hearing Loss.

Ann Intern Med 2020 12;173(11):ITC81-ITC96

Johns Hopkins University School of Medicine, Baltimore, Maryland (C.L.N., E.S.O.).

Hearing loss is highly prevalent and may significantly affect how we age. Although the population is aging, relatively few adults receive treatment for hearing loss. Internists are a critical partner to audiologists and otolaryngologists in caring for the adult population with hearing loss. This review provides a primer on diagnosing and managing hearing loss.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7326/AITC202012010DOI Listing
December 2020

Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment.

Am J Geriatr Psychiatry 2021 06 14;29(6):544-553. Epub 2020 Oct 14.

Cochlear Center for Hearing and Public Health (ASK, EEGM, FRL, NSR, ESO, CLN), Baltimore, MD; Department of Otolaryngology-Head and Neck Surgery (FRL, CLN), Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD.

Objective: This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center.

Design, Setting, And Participants: Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017.

Outcome Measurements: Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia.

Results: Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89).

Conclusion: Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jagp.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044263PMC
June 2021

Brain Renin-Angiotensin System at the Intersect of Physical and Cognitive Frailty.

Front Neurosci 2020 30;14:586314. Epub 2020 Sep 30.

Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

The renin-angiotensin system (RAS) was initially considered to be part of the endocrine system regulating water and electrolyte balance, systemic vascular resistance, blood pressure, and cardiovascular homeostasis. It was later discovered that intracrine and local forms of RAS exist in the brain apart from the endocrine RAS. This brain-specific RAS plays essential roles in brain homeostasis by acting mainly through four angiotensin receptor subtypes; ATR, ATR, MasR, and ATR. These receptors have opposing effects; ATR promotes vasoconstriction, proliferation, inflammation, and oxidative stress while ATR and MasR counteract the effects of ATR. ATR is critical for dopamine and acetylcholine release and mediates learning and memory consolidation. Consequently, aging-associated dysregulation of the angiotensin receptor subtypes may lead to adverse clinical outcomes such as Alzheimer's disease and frailty via excessive oxidative stress, neuroinflammation, endothelial dysfunction, microglial polarization, and alterations in neurotransmitter secretion. In this article, we review the brain RAS from this standpoint. After discussing the functions of individual brain RAS components and their intracellular and intracranial locations, we focus on the relationships among brain RAS, aging, frailty, and specific neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease, and vascular cognitive impairment, through oxidative stress, neuroinflammation, and vascular dysfunction. Finally, we discuss the effects of RAS-modulating drugs on the brain RAS and their use in novel treatment approaches.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fnins.2020.586314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561440PMC
September 2020

Kidney Function Modifies the Effect of Intraoperative Opioid Dosage on Postoperative Delirium.

J Am Geriatr Soc 2021 01 11;69(1):191-196. Epub 2020 Oct 11.

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.

Background: There are few studies demonstrating how kidney function affects the risk of developing delirium in older adult surgical patients administered opioids. This study determined whether baseline kidney function influences the relationship between morphine equivalent dose and the development of delirium on postoperative day (POD) 2 in patients with hip fracture.

Methods: This retrospective study analyzed emergency department (ED) estimated glomerular filtration rate (eGFR), perioperative serum creatinine, intravenous morphine equivalents, and POD2 delirium assessment by the Confusion Assessment Method in 652 patients aged 65 years or older without preoperative delirium. ED eGFR was used to divide subjects into groups by presence or absence of chronic kidney disease (CKD), and associations of opioid dose with POD2 delirium were compared using multivariable logistic regression.

Results: POD2 delirium incidence was 29.8% (N = 194). Intraoperative and postanesthesia care unit (PACU) morphine equivalent dosage as well as ED eGFR were similar comparing patients with and without POD2 delirium. Age, American Society of Anesthesiologists status, and dementia were associated with delirium on POD2. The odds of POD2 delirium increased significantly with increase of intraoperative opioid in patients with CKD (odds ratio = 1.6; 95% confidence interval = 1.2-2.2), but not in patients without CKD (P-interaction = .04). PACU or POD1 opioid doses were not associated with POD2 delirium after covariate adjustment.

Conclusion: This study suggests that incremental increases in intraoperative opioids combined with CKD increase odds of POD2 delirium after hip fracture repair, compared with patients without CKD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.16870DOI Listing
January 2021

Association of Subjective Cognitive Decline With Postoperative Complications Could Herald Dementia Risk.

Am J Geriatr Psychiatry 2021 04 19;29(4):362-364. Epub 2020 Sep 19.

Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jagp.2020.09.013DOI Listing
April 2021

Response to Comment: "Assessing Preventative Effect of Ramelteon on Postoperative Delirium in Older Patients: Methodology is Important".

Am J Geriatr Psychiatry 2021 04 5;29(4):413. Epub 2020 Sep 5.

Psychiatry and Behavioral Sciences (JML, KJN), Johns Hopkins University School of Medicine, Baltimore, MD.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jagp.2020.09.003DOI Listing
April 2021

Satisfaction With Quality of Health Care Among Medicare Beneficiaries With Functional Hearing Loss.

Med Care 2021 01;59(1):22-28

Cochlear Center for Hearing and Public Health, Johns Hopkins University Bloomberg School of Public Health.

Background/objectives: Nearly 38 million Americans have hearing loss. Understanding how sensory deficits such as hearing loss, which limit communication, impact satisfaction has implications for Medicare value-based reimbursement mechanisms. The aim of this study was to characterize the association of functional hearing loss and dissatisfaction with quality of health care over the past year among Medicare beneficiaries.

Methods: Cross-sectional study of satisfaction with quality of health care among Medicare beneficiaries with self-reported trouble hearing from the 2015 Medicare Current Beneficiaries Survey. There were 11,441 Medicare beneficiaries representing a 48.6 million total weighted nationally representative sample.

Results: Forty-eight percent of Medicare beneficiaries reported a little or a lot of trouble hearing. Medicare beneficiaries with a little trouble hearing (odds ratio=1.496; 95% confidence interval, 1.079-2.073; P=0.016) and a lot of trouble hearing (odds ratio=1.769; 95% confidence interval, 1.175-2.664; P=0.007) had 49.6% and 76.9% higher odds of being dissatisfied with the quality of their health care over the previous year, respectively.

Conclusions: Medicare beneficiaries with functional hearing loss had higher odds of dissatisfaction with health care over the past year compared to those without functional hearing loss. Given Medicare's reliance on patient satisfaction as a value-based measure for hospital reimbursement, interventions to address hearing loss in the health care system are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MLR.0000000000001419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736070PMC
January 2021

Connecting With Older Adults via Telemedicine.

Ann Intern Med 2020 11 11;173(10):831-832. Epub 2020 Aug 11.

Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (C.L.N., E.S.O.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7326/M20-1322DOI Listing
November 2020

Addressing Hearing Loss to Improve Communication During the COVID-19 Pandemic.

J Am Geriatr Soc 2020 09 2;68(9):1924-1926. Epub 2020 Jul 2.

Cochlear Center for Hearing and Public Health, The Johns Hopkins University, Baltimore, Maryland, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.16674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323388PMC
September 2020

Age-Related Hearing Loss and the Listening Environment: Communication Challenges in a Group Care Setting for Older Adults.

Ann Longterm Care 2019 Nov 16;27(11):e8-e13. Epub 2019 Sep 16.

Johns Hopkins University, Center on Aging and Health, Baltimore, MD.

Ensuring that older adults in long-term care settings can effectively communicate is important. The goal of this study was to characterize key modifiable factors that could affect verbal communication in an adult day care setting, namely prevalence of audiometric hearing loss and the acoustic characteristics in the activity hall. The prevalence of age-related hearing loss among participants (n=51) was 71%, although only 15% of enrollees at the group care setting (n=21 of 140) used amplification. The noise and reverberation characteristics of the activity hall revealed signal-to-noise ratios of -3.1 decibels (dB) and -2.4 dB during morning activity and lunch, respectively, which are poorer than the recommended levels for understanding speech in background noise. Older adults attending adult day services are likely to spend the day in a room with acoustics that are too challenging to understand speech clearly. Opportunities to improve listening environments in group care settings for older adults are discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295162PMC
November 2019

Effects of Ramelteon on the Prevention of Postoperative Delirium in Older Patients Undergoing Orthopedic Surgery: The RECOVER Randomized Controlled Trial.

Am J Geriatr Psychiatry 2021 01 16;29(1):90-100. Epub 2020 May 16.

Departments of Psychiatry and Behavioral Sciences (ESO, JML, PBR, KJN), Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University School of Nursing (ESO, KJN), Baltimore, MD.

Objectives: Postoperative delirium, associated with negative consequences including longer hospital stays and worse cognitive and physical outcomes, is frequently accompanied by sleep-wake disturbance. Our objective was to evaluate the efficacy and short-term safety of ramelteon, a melatonin receptor agonist, for the prevention of postoperative delirium in older patients undergoing orthopedic surgery.

Design: A quadruple-masked randomized placebo-controlled trial (Clinical Trials.gov NCT02324153) conducted from March 2017 to June 2019.

Setting: Tertiary academic medical center.

Participants: Patients aged 65 years or older, undergoing elective primary or revision hip or knee replacement.

Intervention: Ramelteon (8 mg) or placebo MEASUREMENTS: Eighty participants were randomized to an oral gel cap of ramelteon or placebo for 3 consecutive nights starting the night before surgery. Trained research staff conducted delirium assessments for 3 consecutive days starting on postoperative day (POD) 0, after recovery from anesthesia, and on to POD2. A delirium diagnosis was based upon DSM-5 criteria determined by expert panel consensus.

Results: Of 80 participants, five withdrew consent (one placebo, four ramelteon) and four were excluded (four ramelteon) after randomization. Delirium incidence during the 2 days following surgery was 7% (5 of 71) with no difference between the ramelteon versus placebo: 9% (3 of 33) and 5% (2 of 38), respectively. The adjusted odds ratio for postoperative delirium as a function of assignment to the ramelteon treatment arm was 1.28 (95% confidence interval: 0.21-7.93; z-value 0.27; p-value = 0.79). Adverse events were similar between the two groups.

Conclusion: In older patients undergoing elective primary or revision hip or knee replacement, ramelteon was not efficacious in preventing postoperative delirium.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jagp.2020.05.006DOI Listing
January 2021

Effect of baseline cognitive impairment on association between predicted propofol effect site concentration and Bispectral index or sedation score.

BMC Anesthesiol 2020 05 28;20(1):129. Epub 2020 May 28.

Medicine, Biostatistics and Epidemiology, The Johns Hopkins University, 2024 E. Monument Street, Suite 2-500, Baltimore, MD, 21287, USA.

Background: This study determined whether the relationship between predicted propofol effect site concentration (Ce) and observer's assessment of alertness/sedation scale (OAA/S) or Bispectral Index (BIS) was similar comparing cognitively intact vs impaired patients undergoing hip fracture repair with spinal anesthesia and sedation.

Methods: Following informed consent baseline mini-mental status exam (MMSE), Clinical Dementia Rating (CDR) and geriatric depression scale (GDS) were obtained. Intraoperatively OAA/S, BIS, and propofol (timing and exact amounts) administered were recorded. Cerebrospinal fluid was collected for Alzheimer's (AD) biomarkers. Mean Ce level (AvgCe) during surgery was calculated using the area under the Ce measurement series from incision to closure, divided by surgical time. Average OAA/S (AvgOAA/S), and BIS (AvgBIS) were similarly calculated. Pearson correlations of AvgCe with AvgOAA/S and AvgBIS were calculated overall and by CDR. Nonparametric locally weighted scatterplot smoothing (LOWESS) fits of AvgOAA/S and AvgBIS on AvgCe were produced, stratified by CDR. Multivariable regression incorporating baseline cognitive measurements or AD biomarkers assessed AvgOAA/S or AvgBIS associations with AvgCe.

Results: In 186 participants AvgBIS and AvgOAA/S correlated with AvgCe (Pearson ρ = - 0.72; p < 0.0001 and Pearson ρ = - 0.81; p < 0.0001, respectively), and remained unchanged across CDR levels. Association patterns of AvgOAA/S or AvgBIS on AvgCe guided by LOWESS fits and modeled through regression, were similar when stratified by CDR (p = 0.16). Multivariable modeling found no independent effect on AvgBIS or AvgOAA/S by MMSE, CDR, GDS, or AD biomarkers after accounting for AvgCe.

Conclusions: When administering sedation in conjunction with spinal anesthesia, cognitive impairment does not affect the relationship between predicted propofol AvgCe and AvgOAA/S or AvgBIS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12871-020-01043-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254641PMC
May 2020

Preoperative Evaluation of the Frail Patient.

Anesth Analg 2020 06;130(6):1493-1503

From the Departments of Medicine.

Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty-a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve-has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000004735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362306PMC
June 2020

A roadmap to advance delirium research: Recommendations from the NIDUS Scientific Think Tank.

Alzheimers Dement 2020 05 14;16(5):726-733. Epub 2020 Apr 14.

Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.

Delirium is an acute disorder of attention and cognition. It occurs across the life span, yet it is particularly common among older adults, and is closely linked with underlying neurocognitive disorders. Evidence is mounting that intervening on delirium may represent an important opportunity for delaying the onset or progression of dementia. To accelerate the current understanding of delirium, the Network for Investigation of Delirium: Unifying Scientists (NIDUS) held a conference "Advancing Delirium Research: A Scientific Think Tank" in June 2019. This White Paper encompasses the major knowledge and research gaps identified at the conference: advancing delirium definition and measurement, understanding delirium pathophysiology, and prevention and treatment of delirium. A roadmap of research priorities is proposed to advance the field in a systematic, interdisciplinary, and coordinated fashion. A call is made for an international consortium and biobank targeted to delirium, as well as a public health campaign to advance the field.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/alz.12076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317361PMC
May 2020

Delirium in the Elderly.

Clin Geriatr Med 2020 05;36(2):183-199

Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University School of Medicine, Mason F. Lord Building, 5200 Eastern Avenue, 7th Floor, Room 721, Baltimore, MD 21224, USA.

Delirium is defined as an acute disturbance in attention and cognition, with significant associated morbidity and mortality. This article discusses the basic epidemiology of delirium and approaches to diagnosing, assessing, and working up patients for delirium. It delineates the pathophysiology and underlying predisposing and precipitating factors for delirium. It also discusses recent advances in prevention and treatment, particularly multicomponent, nonpharmacological interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cger.2019.11.001DOI Listing
May 2020
-->