Negative Wealth Shock and Cognitive Decline and Dementia in Middle-Aged and Older US Adults

Pan, L., Gao, B., Zhu, J., & Guo, J. (2023).

JAMA network open, 6(12), e2349258.

https://doi.org/10.1001/jamanetworkopen.2023.49258

Key Points

Question

Is an experience of negative wealth shock—a loss of 75% or more in total wealth over a 2-year period—associated with cognitive decline and dementia risks among middle-aged and older US adults?

Findings

In this cohort study of 8082 participants, those with negative wealth shock had faster decline in cognition and elevated risks of dementia when compared with those who had positive wealth without shock.

Meaning

These findings suggest that negative wealth shock is a risk factor for cognitive decline and dementia in middle-aged and older adults.

The research is linked above.

-----------------------

Key findings:

• Negative wealth shock, defined as losing 75% or more of total wealth within two years, was associated with accelerated cognitive decline and higher risks of dementia.
• This association was stronger for younger participants (under 65) and white participants compared to older and non-white participants.

While the study offers valuable insights, it also has limitations:

• The study is observational, not causal, so it cannot prove cause and effect.
• Wealth changes after negative wealth shock were not considered, potentially impacting results.

Overall, the study suggests that negative wealth shock may be a risk factor for cognitive decline and dementia, highlighting the potential impacts of financial hardship on brain health. Further research is needed to confirm these findings and explore underlying mechanisms.

Additional points:

• The study used data from the Health and Retirement Study, which tracked over 8,000 participants for 14 years.
• Participants with negative wealth shock had a 27% higher risk of developing dementia compared to those without wealth shock.

The study suggests potential social and psychological mechanisms linking financial hardship to cognitive decline, such as stress, depression, and reduced access to healthcare.

Lawsuit Challenges New Jersey’s Out-of-State Telehealth Licensing Law

A. Vaidya

mhealthintelligence.com

Originally posted 18 DEC 23

Here is an excerpt:

The lawsuit states that J.A. was diagnosed with pineoblastoma, an aggressive brain tumor, at 18 months old. His physicians referred him to MacDonald in Boston. The treatment enabled J.A. to beat his cancer. However, he must continue to undergo scans once a year for the rest of his life to monitor the cancer’s return.

New Jersey’s current telehealth licensing law requires patients seeking specialty care out of state to decide whether to incur the cost of traveling to meet with the specialist for initial or follow-up consultations.

“Without telemedicine, patients suffering from rare cancers and diseases like J.A. must either forego lifesaving treatment or suffer by traveling out of state every time an appointment with a national specialist like Dr. MacDonald is needed,” the suit states. “Many cannot bear the burdens of frequent travel.”

Without the option of telehealth, J.A. and his family would not have been able to consult with all the specialists they needed due to “financial and time constraints,” the lawsuit further states. Even more recently, telehealth enabled J.A. to consult with MacDonald when an anomaly appeared on one of his scans.

Maintaining multiple licenses in different states places an administrative and financial burden on physicians, especially for specialists like MacDonald and Gardner, “who have national practices and only occasionally consult with or treat patients from New Jersey,” the suit notes.

Thus, the lawsuit argues that the licensing law violates the Dormant Commerce Clause and Privileges and Immunities Clause, which prohibits states from enacting laws that excessively burden interstate commerce in relation to local benefits. It also violates the First Amendment, which prevents the government from restricting conversations between patients and their providers, and the 14th Amendment’s Due Process Clause, which bans the government from limiting the ability of parents to direct their children’s medical care.

“Plaintiffs, who are New Jersey citizens and out-of-state specialists with patients in New Jersey, seek to vindicate their constitutional rights — and ensure they can continue to provide and receive — lifesaving care,” the lawsuit states.

The article is here.

Two in three UK doctors suffer ‘moral distress’ due to overstretched NHS, study finds

Denis Campbell

The Guardian

Originally posted 28 Dec 23

Two in three UK doctors are suffering “moral distress” caused by the enfeebled state of the NHS and the damage the cost of living crisis is inflicting on patients’ health, research has found.

Large numbers are ending up psychologically damaged by feeling they cannot give patients the best possible care because of problems they cannot overcome, such as long waits for treatment or lack of drugs or the fact that poverty or bad housing is making them ill.

A new survey found that 65% of doctors overall, including nearly four in five (78%) GPs and more than half (56%) of hospital doctors, have experienced “moral distress” as a direct result of situations they have encountered working in the NHS.

Seeing patients with malnutrition or hypothermia, or stuck on trolleys in A&E corridors asking for help or forced to choose between heating their home or getting a prescription dispensed are among the events triggering their distress, medics said.

“There’s barely a doctor at work in the NHS today who doesn’t see or experience this distress on a daily basis,” said Prof Philip Banfield, the leader of the British Medical Association.

The NHS is “impossibly overstretched”, has thousands of vacancies for doctors and has a quarter fewer doctors a head of population than Germany, he added.

“In practice that means we can almost never give the standard of care we would want, only ever the care we can manage. That takes its toll, as we see here,” Banfield said.

The info is here.

Key points:

The study also found that:

• Nearly half (47%) of doctors believe the cost of living crisis is contributing to their moral distress.
• 72% of doctors say being unhappy at work has affected their mental health.
• 85% of doctors have experienced fatigue as a result of their work.

Causes of moral distress:

• Doctors are often in situations where they have to make difficult decisions about who to treat first, or whether they can afford to give a patient the treatment they need.
• They may also feel that they are not able to provide the level of care that they would like to because of the lack of resources in the NHS.

Impact of moral distress:

• Moral distress can lead to burnout, depression, and anxiety.
• It can also make it difficult for doctors to continue working in the NHS.

Americans are lonely and it’s killing them. How the US can combat this new epidemic.

Adrianna Rodriguez

USA Today

Originally posted 24 Dec 23

America has a new epidemic. It can’t be treated using traditional therapies even though it has debilitating and even deadly consequences.

The problem seeping in at the corners of our communities is loneliness and U.S. Surgeon General Dr. Vivek Murthy is hoping to generate awareness and offer remedies before it claims more lives.

“Most of us probably think of loneliness as just a bad feeling,” he told USA TODAY. “It turns out that loneliness has far greater implications for our health when we struggle with a sense of social disconnection, being lonely or isolated.”

Loneliness is detrimental to mental and physical health, experts say, leading to an increased risk of heart disease, dementia, stroke and premature death. As researchers track record levels of self-reported loneliness, public health leaders are banding together to develop a public health framework to address the epidemic.

“The world is becoming lonelier and there’s some very, very worrisome consequences,” said Dr. Jeremy Nobel, founder of The Foundation for Art and Healing, a nonprofit that addresses public health concerns through creative expression, which launched an initiative called Project Unlonely.

“It won’t just make you miserable, but loneliness will kill you," he said. "And that’s why it’s a crisis."

The info is here.

Key points:

• Loneliness Crisis: America faces a growing epidemic of loneliness impacting mental and physical health, leading to increased risks of heart disease, dementia, stroke, and premature death.
• Diverse and Widespread: Loneliness affects various demographics, from young adults to older populations, and isn't limited by social media interaction.
• Health Risks: The Surgeon General reports loneliness raises risk of premature death by 26%, equivalent to smoking 15 cigarettes daily. Heart disease and stroke risks also increase significantly.
• Causes: Numerous factors contribute, including societal changes, technology overuse, remote work, and lack of genuine social connection.
• Solutions: Individual actions like reaching out and mindful interactions help. Additionally, public health strategies like "social prescribing" and community initiatives are crucial.
• Collective Effort Needed: Overcoming the epidemic requires collaboration across sectors, fostering stronger social connections within communities and digital spaces.

Alcohol overuse causes 140,000 American deaths annually. Why is it so undertreated?

Melinda Fawcett

Psychiatry.ufl.edu

Originally posted 28 Nov 23

Here is an excerpt:

How to treat the disorder

In the last decade, the medical community has come to recognize AUD as a disease that (like all others) needs medical treatment through a range of interventions. With new treatments coming out every day, hope exists that in the years to come more and more people will receive the care they need.

For those with the most severe forms of AUD, treatment aims at stopping the individual’s alcohol consumption entirely (while recognizing that having a drink or breaking abstinence isn’t a failure, but an almost inevitable part of the recovery cycle).

“What’s happened in the last probably 50 years or so is there’s a more medicalized understanding,” said Humphreys. “So there’s been the rise of neuroscience that looks at things like how the brain changes with repeated administration of alcohol, how that limits things like self-control, how that increases phenomena like craving.”

And as with any other mental health diagnosis, successful treatment for AUD often boils down to a combination of therapy and medication, the experts Vox spoke to said. Just as depression is treated with medication to balance chemicals in the brain, and therapy to help patients unlearn harmful behaviors, AUD often needs the same combination of treatments, said Disselkoen.

The Federal Drug Administration approved the first medication to treat AUD, disulfiram, in 1951. Disulfiram, whose brand name is Antabuse, is a daily pill that causes someone to fall ill — face redness, headache, nausea, sweating, and more — if they drink even a small amount of alcohol. Disulfiram is safe and effective, but the same characteristic that makes it successful (the way it induces illness) also makes it unpopular among patients, said Nixon.

The info is here.

Key points:

• Alarming death toll: 140,000 Americans die annually from alcohol overuse, highlighting a major public health crisis.
• Undertreatment disparity: Unlike other dangerous substances, alcohol issues lack the same attention and treatment resources.
• Neurological changes: Repeated alcohol misuse alters the brain, making it a serious health condition, not just a social issue.
• Market forces: The powerful alcohol industry and its growing revenue contribute to lax regulations and limited intervention.
• Policy gap: Inadequate taxation fails to curb consumption, while other harmful substances face stricter controls.
• Blind spot in drug policy: Recognizing alcohol as a harmful drug with addiction potential is crucial for tackling the problem.

This Is Your Brain on Zoom

Leah Croll

MedScape.com

Originally posted 21 Dec 23

Here is an excerpt:

Zoom vs In-Person Brain Activity

The researchers took 28 healthy volunteers and recorded multiple neural response signals of them speaking in person vs on Zoom to see whether face-processing mechanisms differ depending upon social context. They used sophisticated imaging and neuromonitoring tools to monitor the real-time brain activity of the same pairs discussing the same exact things, once in person and once over Zoom.

When study participants were face-to-face, they had higher levels of synchronized neural activity, spent more time looking directly at each other, and demonstrated increased arousal (as indicated by larger pupil diameters), suggestive of heightened engagement and increased mutual exchange of social cues. In keeping with these behavioral findings, the study also found that face-to-face meetings produced more activation of the dorsal-parietal cortex on functional near-infrared spectroscopy. Similarly, in-person encounters were associated with more theta oscillations seen on electroencephalography, which are associated with face processing. These multimodal findings led the authors to conclude that there are probably separable neuroprocessing pathways for live faces presented in person and for the same live faces presented over virtual media.

It makes sense that virtual interfaces would disrupt the exchange of social cues. After all, it is nearly impossible to make eye contact in a Zoom meeting; in order to look directly at your partner, you need to look into the camera where you cannot see your partner's expressions and reactions. Perhaps current virtual technology limits our ability to detect more subtle facial movements. Plus, the downward angle of the typical webcam may distort the visual information that we are able to glean over virtual encounters. Face-to-face meetings, on the other hand, offer a direct line of sight that allows for optimal exchange of subtle social cues rooted in the eyes and facial expressions.

The info is here.

Key findings:

• Zoom meetings are less stimulating for the brain than face-to-face interactions. A study by Yale University found that brain activity associated with social processing is lower during Zoom calls compared to in-person conversations.
• Reduced social cues on Zoom lead to increased cognitive effort. The lack of subtle nonverbal cues, like facial expressions and body language, makes it harder to read others and understand their intentions on Zoom. This requires the brain to work harder to compensate.
• Constant video calls can be mentally taxing. Studies have shown that back-to-back Zoom meetings can increase stress and fatigue. This is likely due to the cognitive demands of processing visual information and the constant pressure to be "on."

Implications:

• Be mindful of Zoom fatigue. Schedule breaks between meetings and allow time for your brain to recover.
• Use Zoom strategically. Don't use Zoom for every meeting or interaction. When possible, opt for face-to-face conversations.
• Enhance social cues on Zoom. Use good lighting and a clear webcam to make it easier for others to see your face and expressions. Use gestures and nonverbal cues to communicate more effectively.

Listen, explain, involve, and evaluate: why respecting autonomy benefits suicidal patients

Samuel J. Knapp (2024)

Ethics & Behavior, 34:1, 18-27

DOI: 10.1080/10508422.2022.2152338

Abstract

Out of a concern for keeping suicidal patients alive, some psychotherapists may use hard persuasion or coercion to keep them in treatment. However, more recent evidence-supported interventions have made respect for patient autonomy a cornerstone, showing that the effective interventions that promote the wellbeing of suicidal patients also prioritize respect for patient autonomy. This article details how psychotherapists can incorporate respect for patient autonomy in the effective treatment of suicidal patients by listening to them, explaining treatments to them, involving them in decisions, and inviting evaluations from them on the process and progress of their treatment. It also describes how processes that respect patient autonomy can supplement interventions that directly address some of the drivers of suicide.

Public Impact Statement

Treatments for suicidal patients have improved in recent years, in part, because they emphasize promoting patient autonomy. This article explains why respecting patient autonomy is important in the treatment of suicidal patients and how psychotherapists can integrate respect for patient autonomy in their treatments.

My lengthy summary, because the article is paywalled here.

Dr. Knapp's article discusses the importance of respecting patient autonomy in the treatment of suicidal patients within the framework of principle-based ethics. It highlights the ethical principles of beneficence, nonmaleficence, justice, respecting patient autonomy, and professional-patient relationships. The article emphasizes the challenges psychotherapists face in balancing the promotion of patient well-being with the need to respect autonomy, especially when dealing with suicidal patients.

Fear and stress in treating suicidal patients may lead psychotherapists to prioritize more restrictive interventions, potentially disregarding the importance of patient autonomy. The article argues that actions minimizing respect for patient autonomy may reflect a paternalistic attitude, which is implementing interventions without patient consent for the sake of well-being.

The problems associated with paternalistic interventions are discussed, emphasizing the importance of patients' internal motivation to change. The article advocates for autonomy-focused interventions, such as cognitive behavior therapy and dialectical behavior therapy, which have been shown to reduce suicide risk and improve outcomes. It suggests that involving patients in treatment decisions, listening to their experiences, and validating their feelings contribute to more effective interventions.

The article provides recommendations on how psychotherapists can respect patient autonomy, including listening carefully to patients, explaining treatment processes, involving patients in decisions, and inviting them to evaluate their progress. The ongoing nature of the informed consent process is stressed, along with the benefits of incorporating patient feedback into treatment. The article concludes by acknowledging the need for a balance between beneficence and respect for patient autonomy, particularly in cases of imminent danger, where temporary prioritization of beneficence may be necessary.

In summary, the article underscores the significance of respecting patient autonomy in the treatment of suicidal patients and provides practical guidance for psychotherapists to achieve this while promoting patient well-being.

Salve Lucrum: The Existential Threat of Greed in US Health Care

Berwick DM.

JAMA. 2023;329(8):629–630.

doi:10.1001/jama.2023.0846

Here is an excerpt:

Particularly costly has been profiteering among insurance companies participating in the Medicare Advantage (MA) program. Originally intended to give Medicare beneficiaries the choice of access to well-managed care at lower cost, MA has mushroomed into a massive program, now about to cover more than 50% of all Medicare beneficiaries and costing far more per beneficiary than traditional Medicare ever has. By gaming Medicare risk codes and the ways in which comparative “benchmarks” are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies. According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare. Opinions differ about whether MA enrollees experience better care and outcomes than those in traditional Medicare, but the weight of evidence is that they do not.

Hospital pricing games are also widespread. Hospitals claim large operating losses, especially in the COVID pandemic period, but large systems sit on balance sheets with tens of billions of dollars in the bank or invested. Hospital prices for the top 37 infused cancer drugs averaged 86.2% higher per unit than in physician offices. A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose. To drive up their own revenues, many hospitals serving wealthy populations take advantage of a federal subsidy program originally intended to reduce drug costs for people with low income.

Recent New York Times investigations have reported on nonprofit hospitals’ reducing and closing services in poor areas while opening new ones in wealthy suburbs and on their use of collection agencies for pursuing payment from patients with low income. The Massachusetts Health Policy Commission reported in 2022 that hospital prices and revenues increased during a decade at almost 4 times the rate of inflation.

Windfall profits also appear in salaries and benefits for many health care executives. Of the 10 highest paid among all corporate executives in the US in 2020, 3 were from Oak Street Health, and salary and benefits included, reportedly, $568 million for the chief executive officer (CEO). Executives in large hospital systems commonly have salaries and benefits of several million dollars a year. Some academic medical centers’ boards allow their CEO to serve for 6-figure stipends and multimillion-dollar stock options on outside company boards, including ones that supply products and services to the medical center.

The info is here.

My summary and warnings are here:

Greed is not good, especially in healthcare. This article outlines the concerning issue of greed pervading the US healthcare system. It argues that prioritizing profit over patient well-being has become widespread, impacting everything from drug companies to hospitals. The author contends that this greed is detrimental to both patients and the healthcare system as a whole. To address this, the article proposes solutions like fostering greater transparency and accountability, along with reevaluating how healthcare is financed.

What Is It That You Want Me To Do? Guidance for Ethics Consultants in Complex Discharge Cases

Omelianchuk, A., Ansari, A.A. & Parsi, K.

HEC Forum (2023).

https://doi.org/10.1007/s10730-023-09517-y

Abstract

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

The article is paywalled.  Please contact the author for full copy.

Here is my summary:

• Ethics consultants face diverse patient situations, including lack of desire to leave, potential mental health issues, and financial/space constraints.
• Fair discharge processes are crucial, through mediation or multidisciplinary committees, balancing patient needs with system limitations.
• "Conveyor belt" healthcare can strain trust and create discharge complexities.
• The ethics consultant role is valuable but limited, suggesting standing "complex case committees" with diverse expertise for effective, creative solutions.

In essence, this summary highlights the need for a more nuanced and collaborative approach to complex discharges, prioritizing patient well-being while recognizing systemic constraints.