Health Fitness InfoCentre

The Framingham Risk Score, the crystal ball that helps physicians determine who is most and least in need of intervention to reduce the chance of a heart attack, is the subject of increasing debate over how to make it more accurate.

"We are humbled when patients at low risk have events, and we know that the sensitivity of the score is a problem," said James De Lemos, MD, a cardiologist and associate professor of medicine at the University of Texas Southwestern Medical Center at Dallas.

A version of the calculator, a product of six decades of research conducted as part of the Framingham Heart Study, was first proposed in several papers appearing in 1976 in the American Journal of Cardiology. The articles detailed how various factors could be used to profile an individual patient's risks. The goal was to identify those most in need of prevention and give peace of mind to those who may have one elevated factor but otherwise are healthy.

"The importance of risk stratification is that it helps you focus without needlessly alarming or falsely reassuring people," said William Kannel, MD, MPH, then the director and now a senior investigator with the project.

Subsequent versions have been published over the years. The most recent one was in the May 12, 1998, Circulation. That risk calculator iteration was then simplified and incorporated into a report by the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, which was published in the May 16, 2001, Journal of the American Medical Association. The current assessment incorporates age; total and HDL cholesterol; smoking status; systolic blood pressure; and whether a patient is taking an anti-hypertensive drug. Experts believe this tool is one of the reasons heart attack death rates have decreased. Still, a great deal of talk focuses on the tool's next revision.

Most people who have heart attacks and strokes were not considered high risk.

"The risk algorithm should continually be re-examined if new evidence comes along," said Christopher O'Donnell, MD, associate director of the Framingham Heart Study. "And I think there are three areas that are going to frame the next decade of risk assessment -- blood biomarkers, vascular imaging and genetic markers."

Experts also say an update is due for reasons beyond the fact that time has passed and additional data are available. The focus of risk assessment is changing, with researchers wanting to devise one tool to determine the risk of all cardiovascular conditions, not just myocardial infarction. In addition, a great deal of work is going into attempts to design more accurate assessments of those identified as having intermediate risk.

A paper published in the Feb. 14, 2007, JAMA by a group at Brigham and Women's Hospital in Boston, and another online Jan. 22 in Circulation by Framingham researchers, outlined strategies to determine the 10-year risk of any cardiovascular event. The JAMA paper, for instance, outlined the Reynolds Risk Score for women, incorporating traditional risk factors along with family history and C-reactive protein, both of which are the most likely candidates to be included in future versions of Framingham. Approximately 40% to 50% of women at intermediate risk were reclassified as having a high or low chance of a cardiovascular event. A men's version was released at the American Heart Assn. meeting in New Orleans last month.

"The bottom line of both [Framingham and Reynolds] risk scores is getting the right drug to the right patient at the right time," said Paul Ridker, MD, lead author of the JAMA paper and director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital. "The majority of heart attacks and strokes occur in apparently healthy men and women of intermediate risk. How can we better define high and low risk within the intermediate risk group? We did it with greatly improved accuracy by adding two simple things to do a better job of getting patients stratified."

Researchers also want to create tools that don't require blood draws or multiple patient visits. The more recent Circulation document provided two means of risk assessment. One relied on the usual Framingham risk factors, and the other substituted body mass index for cholesterol numbers.

Washington -- Understanding the medical care, technology and economic wherewithal it takes to age well in the U.S. is the goal of a new survey funded by the National Institute on Aging and led by Johns Hopkins University's Bloomberg School of Public Health in Baltimore.

NIA intends to provide about $24 million over the next five years to develop and implement the survey. Still in its earliest phase, the survey aims to further understanding of how older people overcome obstacles in daily life -- whether by installing grab bars in a bathroom or by having joint replacement surgery.

The surveyors also plan to include measures related to social interactions by asking, for example, whether a person does any volunteer work.

Since nearly 40 million people in the nation are already 65 or older, and most are expected to live about 20 more years, finding ways for people to continue to function is in everyone's interest. The AMA is putting forth a major effort to guide physicians as they care for aging patients, with resources ranging from guidelines on the use of assistive technology and the safety of older drivers to dementia and assistance to caregivers.

The new survey will pick up on trends noted in the "1982-2004 National Long-Term Care Survey," which showed a major decline in disability among people 65 and older.

Nearly 40 million people in the U.S. are 65 or older.

"Our aim is to provide scientific evidence that can help in reducing disability and improving the daily lives of older people," said the project's principal investigator Judy Kasper, PhD, professor in the Dept. of Health Policy and Management at Hopkins' School of Public Health.

Data released earlier this year by the Federal Interagency Forum on Aging-Related Statistics also show that as life expectancy increased, older people were, for the most part, enjoying better health and financial security than in the past.

The new study will try to zero in on how people are achieving these gains. "We hope that this study will play a critical role in maintaining or accelerating this trend as we address the challenges of our aging population," said Richard Suzman, PhD, director of the Division of Behavioral and Social Research at NIA.

Questions on the economic consequences of aging also will be asked, said Kasper. For example: "How do people pay for services when they need them for long-term disability problems?"

Evidence from earlier reports also revealed that while disabilities have been declining, gains were not as great for blacks and Hispanics or for low-income seniors as for others.

To address these disparities, the survey population will include more people from minority and low-income groups to ensure they are well-represented, said Kasper.

Today's generation of people 65 and older is less likely to be disabled than this age group was before 1984.

The first phase of the study will sign up 12,000 Medicare enrollees who will be followed annually. The enrollees will be grouped by age. As people age into older groups, researchers will bring in younger people to replace them.

The resulting database is expected to prove valuable to researchers and policymakers, said Kasper. "In addition to design and data collection, an important piece is the dissemination of data to the research community and workshops to get people interested in using the data."

It's rare to start a new national survey of this size given the current constraints on research funding, said Kasper. "The NIA deserves a lot of credit for recognizing that our existing national surveys are not designed to address the kinds of issues this survey is designed to address."

The undertaking will include investigators from the University of Medicine and Dentistry of New Jersey; Brown University in Providence, R.I.; Columbia University in New York City; the Medical College of Wisconsin; the Urban Institute, a nonpartisan economic and social policy research group in Washington, D.C.; the University of Iowa; Syracuse University in New York; and the survey research firm, Westat in Maryland.

Washington -- Add another strong incentive to the list of reasons for women smokers to quit: abdominal aortic aneurysms.

A study posted online Oct. 14 in the British Medical Journal found that women who smoke were four times more likely to have an abdominal aortic aneurysm repair or rupture than women who had stopped. Women smokers also were eight times more likely to have the serious medical emergency occur than were women who had never smoked.

Most studies of AAA have focused on men. This study is believed to be the largest conducted on women.

"We've known that smoking confers a very high risk of AAA," said the study's lead author, Frank Lederle, MD, professor of medicine at the University of Minnesota and an internist at the Minneapolis VA Medical Center. The study's aim was to reach a better understanding of factors associated with AAA in women, the authors write.

"This study does provide another reason to quit smoking," he said.

Aortic aneurysms cause 15,000 deaths a year in the U.S.

The ballooning of the artery wall is more common in men older than 60 but may be more deadly for women, possibly rupturing at a smaller diameter. Aortic aneurysms cause about 15,000 deaths a year in the United States, with most originating in the abdomen. About 40% of the deaths occur in women.

"Women may not be getting the attention they should, especially women with a family history for AAA and who are smokers. They should be considered for screening," said David Neschis, MD, a vascular surgeon and associate professor of surgery at the University of Maryland's School of Medicine. Dr. Neschis was not involved with the study.

AAA has a high risk of mortality. Only a small number of people make it to the hospital alive, and those who do have about a 50-50 chance of death, Dr. Neschis said. "So the best way to treat these patients is to identify them before rupture and fix them." The bulging arteries are difficult to detect in a physical exam, so ultrasound scans of the abdomen are recommended.

"A screening ultrasound of the belly takes minutes, has no risk, is inexpensive in medical terms and is available at even the smallest community hospital," Dr. Neschis said.

The Agency for Healthcare Research and Quality recommends against routine screening in women but does recommend a one-time screening for men ages 65 to 75 who have ever smoked.

Reinforcing old warnings

The study's authors used data collected on 161,808 postmenopausal women enrolled in the Women's Health Initiative, a clinical trial that studied the effects of estrogen therapy, diet and vitamin D on heart disease, fractures, breast and cervical cancer. The main study ended in 2005.

During 7.8 years of follow-up, Dr. Lederle and colleagues found that 184 abdominal aneurysm repairs or ruptures were reported. The AAA's were strongly linked to age and smoking. Women in their late 60s were more likely to have been affected than were younger women.

Women smokers are 8 times more likely to have an abdominal aortic aneurysm than those who never smoked.

The principal messages for physicians are not new, said Janet Powell, MD, PhD, a professor of vascular surgery at the Imperial College in London and an author of an accompanying editorial. "More efforts must be made to stop women from smoking, and AAA must be high on the list of differential diagnoses in older women smokers who present with collapse and abdominal or back pain."

The connection between smoking and the entire world of heart disease isn't a surprise, said Vincent Bufalino, MD, an American Heart Assn. spokesman and president and CEO of Midwest Heart Specialists in Naperville, Ill. "Of the women I see with heart disease, far and away the majority are smokers. Either diabetes or smoking are the two biggest predictors of coronary heart disease."

Joel Dunnington, MD, a consultant on smoking issues for the Texas Medical Assn., would like physicians to counsel patients about the many risks of smoking, including AAA. And patients should be told that if they quit smoking at age 40, 50 or even 60, their risk levels quickly decline, he said. Dr. Dunnington is also an associate professor of radiology at the M.D. Anderson Cancer Center at the University of Texas in Houston.

The study also turned up a couple of other findings, Dr. Lederle said. For example, it was determined that hormone therapy provided protection from AAA events. This conclusion was in contrast to previous smaller studies, which found that estrogen alone may increase risk.

"That was a surprise," Dr. Lederle said. "It hadn't been shown before and needs to be confirmed. We certainly aren't suggesting that people go out and take hormones, but it does suggest there is a role for female hormones in providing protection from AAA, which might explain why there are fewer in women."

In another finding, diabetes also conveyed protection to women. Although this has been seen in previous studies among men, whether it occurred among women had been uncertain, the researchers write. But why this negative association occurs has yet to be explained.

Washington -- The outlook for treating extensively drug-resistant tuberculosis turned gloomier with a new study that confirms earlier reports of the poor prognosis associated with the disease.

The study, the largest to date on the most lethal form of TB, determined that patients with XDR-TB are four times more likely to fail treatment and three times more likely to die than are patients with other strains of multidrug-resistant TB. The study was in the Nov. 15 American Journal of Respiratory and Critical Care Medicine, a journal of the American Thoracic Society.

Despite efforts to control all forms of TB, the disease remains the worldwide leading cause of death from an infectious agent. An estimated 8 million to 9 million new cases develop annually and 2 million patients die, the study authors noted.

As drug-resistant cases increase, physicians find treatment options limited. An editorial in the same journal issue raised a related concern. Does the rise of XDR-TB portend the reversal of progress made at combating TB? The high mortality rate for XDR-TB mirrors TB deaths of decades ago, before there were any drugs, said editorial co-author D'Arcy Richardson, RN, technical director for TB programs at PATH, a nonprofit, international global health organization. "We are looking at, more or less, the natural history of TB."

For their study, "Treatment Outcomes and Long-term Survival in Patients with Extensively Drug-resistant Tuberculosis," researchers reviewed medical records of 1,407 patients in South Korea who were diagnosed with resistant forms of TB between 2000 and 2002, and 75 patients who had XDR strains.

Researchers monitored patients for up to seven years after treatment began. Among the findings: XDR-TB patients were older than MDR-TB patients, more likely to have a history of treatment with second-line TB drugs and more likely to have a history of being treated for TB two or more times.

"One of the most important take-away messages ... is to treat TB carefully the first time around so you don't end up with multidrug-resistant or extensively drug-resistant TB," Richardson said.

The brain -- containing 100 billion neurons, 900 billion glial cells, 100 trillion branches and 1,000 trillion receptors -- reacts to stimuli in a series of electrical bursts, spanning a complex map of connections. Whether calculating an algorithmic equation or learning the tango, our brain continuously changes in response to our ideas, actions and activities.

Each time a dance step is learned, for instance, new pathways are formed. "Dancing is excellent for the brain and body," says Vincent Fortanasce, MD, clinical professor of neurology at the University of Southern California in Los Angeles. He wrote the Anti-Alzheimer's Prescription. "Not only are you moving around more, your brain is in constant motion as it recalls steps and movements."

It's an example that highlights a wave of new thinking about the importance of brain fitness.

Until recently, conventional wisdom held that our brains were intractable, hard-wired computers. What we were born with was all we got. Age wore down memory and the ability to understand, and few interventions could reverse this process. But increasingly, evidence suggests that physical and mental exercise can alter specific brain regions, making radical improvements in cognitive function. "When you challenge the brain with new skills and new ways of doing things, it increases connections in the brain," says Ericka P. Simpson, MD, a neurologist who co-directs the MDA Neuromuscular Clinics and directs the ALS clinical research division at the Methodist Hospital System Neurological Institute in Houston. "It increases synaptic density."

With nearly 72 million Americans turning 65 over the next two decades, physicians need the tools to handle growing patient concerns about how to best maintain brain health. Armed with this new brand of science, frontline physicians will be better equipped to address the needs of aging baby boomers, already in the throes of the brain fitness revolution. "They are the gatekeepers of information, and people listen," says Eduardo Locatelli, MD, MPH, a neurologist and medical director of the Florida Neuroscience Center in Fort Lauderdale. Dr. Locatelli implements brain fitness techniques for his postsurgery epilepsy patients as well as patients who present with mild- to moderate-stage Alzheimer's and dementia. "Encourage new experiences. ... Use it or lose it. Challenge it and gain."

The plastic brain

Within the brain, the pathways and regions that are most utilized generally grow and become stronger while other parts shrink. "The brain is very Darwinian, it's survival of the fittest," says Edward Taub, PhD, a behavioral neuroscientist at the University of Alabama at Birmingham, who has researched neuroplasticity since the 1970s. "At one time it was believed we did not use 90% of our brain. That is false. The brain is a zero sum game. Every part of the brain is used. It has enormous plasticity."

Thus, by challenging the brain and forcing the use of different pathways, brain maps can be altered. And such changes offer young and old -- even brain-injured individuals -- an opportunity to learn or re-learn things. "Vocabulary can increase into age 90," says Gary J. Kennedy, MD, a professor in the Dept. of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine. He also directs the geriatric psychiatry division at Montefiore Medical Center in the Bronx, N.Y. "As people age they may be slower, but they are capable of more and more complex projects."

Brain volume shrinks up to 1% every year after age 65.

To best illustrate neuroplasticity, consider stroke patients with damaged limbs. Contrary to traditional therapy, which works to strengthen the good limb, Taub restrains the uncompromised limb, forcing patients to use the damaged arm or leg. The therapy, constraint-induced movement therapy, also known as CI therapy, helps to rewire the brain.

"The more you use it, more neurons are available ... the more demand for cortical space and the more the patient is able to use the [damaged] arm," Taub said. Over time, small steps lead to improvements in activities of daily living. Ultimately, the damaged limb, at least in part, recovers because, although the brain does not regrow damaged areas, it re-routes around them.

When the brains of CI patients were examined, a tremendous increase in grey matter was detected, and interestingly, Taub says, the healthy part of the brain was recruited for the task. Some of Taub's research was published in the Nov. 1, 2006, Journal of the American Medical Association.

CI applications are now being explored for other forms of brain injury.

Young brains, old brains?

Mental agility begins declining around age 24, says Dr. Fortanasce. But there is a big difference between agility and capacity. "I may be slower, but what I know now far outweighs what I knew at 24," he says. "Some individuals perform their greatest creative work in late life. Verdi, for example, composed Othello at 73 and Falstaff at 79."

Greg Jicha, MD, PhD, assistant professor of neurology at the University of Kentucky College of Medicine, shares related stories, such as that of an 82-year-old who learned to play the trumpet. "I've heard people say, 'You can't teach an old dog new tricks.' That can't be further from the truth," says Dr. Jicha, who also heads the healthy brain aging research group at the university's Sanders-Brown Center on Aging. "When you look at the plasticity of the adult brain, it is amazing."

Mental agility, but not capacity, begins declining around age 24.

But age also brings anatomic changes. Brain weight and blood flow to the brain decrease by 20%. The number of fibers and nerves decrease by 37%. And brain volume shrinks up to 1% every year after age 65. Dr. Fortanasce also points to hormonal shifts, with the presence of dopamine and serotonin diminishing as cortisol, an aging hormone, increases. "Between age 20 and 70, we lose nearly 90% of youth hormones."

So what keeps some brains younger than their chronology? Experts point to a prescription of neurobics. This concept includes life-long learning, trying new things, a healthy diet, social interactions, sleep and physical activity. "Exercise can actually increase neurogenesis and increase the size of the hippocampus," says Dr. Fortanasce, who promotes isometrics and weight-bearing exercise. "Exercise also increases youth hormones. And novelty, doing new things, builds branches."

In a 2006 study in the Journal of Aging and Physical Activity, Brandeis University researchers found that strength training increased the participants' working memory span. The higher the level of resistance, the more memory improved, suggesting that strength training benefits not only the muscles but also the mind.

Dr. Locatelli suggests reversing daily patterns. People who take the same route to work every day need to push themselves beyond their comfort zones. A person can try to eat using his or her weaker hand, for instance. Or someone could listen to another type of music than the type usually favored. Activate unfamiliar areas of the brain, Dr. Locatelli says. The key is new places, socializing with different people, and reading new things.

And primary care physicians can help communicate this message.

"When a patient expresses concern about memory loss, never cast it off as associated with age," says Tom Perls, MD, MPH, associate professor of medicine at Boston University Medical Center. Dr. Perls also heads the New England Centenarian Study. "This is an incredibly serious issue. Losing brain function is devastating." Ask about memory. And rule out other conditions like depression or low thyroid first. "Encourage them to exercise the brain in novel and complex ways," he says.

Exercising new connections

So what about dance steps? At McGill University in Montreal, researchers found that the tango may be better than walking for improving execution of complex tasks because it incorporates elements found in standard neurological rehabilitation programs. It's also fun and social.

Participants, ages 62 to 90, were randomly assigned to a walking group or a tango dancing group, meeting two hours twice a week for 10 weeks. The tango group improved in balance, posture and motor coordination, as well as cognition.

Physical and mental exercise improve cognitive function.

According to new research published in the October issue of the journal Nature Neuroscience, University College London scientists say complex brain processes that enable the memorization and replication of activities such as playing the piano or riding a bicycle require the execution of complicated sequences of movements involving dozens of muscles. According to their research, pianists who learned and practiced their art from an early age had elevated amounts of myelin. This finding suggests that when people learn new skills, myelination might occur. Earlier studies indicated that brains of patients diagnosed with senile dementia had lowered amounts of myelin.

The emphasis, though, is the importance of embracing the complex and novel. And Joe Hardy, PhD, a cognition neuroscientist who develops brain plasticity training programs, says some common-sense advice from physicians is not based on good evidence. "They often recommend doing crossword puzzles," he says. "But evidence suggests that crossword puzzles are not helpful."

Hardy has been developing brain games for the San Francisco-based company Posit Science. The games -- the Brain Fitness Program and Insight -- have been tested in several randomized clinical trials funded by the National Institutes of Health. The results indicate that the brain age clock can roll back 10 years. "The key thing in terms of exercise for the brain: You need to do new things, thus forming new paths," he says.

Some have even compared this new era in brain health to the 1950s, when heart health came to the fore. "New things are coming out all the time, and we are going to see a revolution in brain health," Hardy says. "I think this is going to change the way people age."