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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_358"
                     title="Poststroke Antidepressant Boosts Mental Agility (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/Strokes/tb/18240?impressionId=1265787166444"
                     
      &lt;p&gt;Antidepressants in the first months after a stroke may aid cognitive recovery for patients without depression, according to a randomized trial analysis.&lt;/p&gt;
&lt;p&gt;Global cognitive function scores improved significantly more with escitalopram (Lexapro) than with problem-solving therapy or placebo (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), according to Ricardo E. Jorge, MD, of the University of Iowa in Iowa City, and colleagues.&lt;/p&gt;
&lt;p&gt;Memory scores rose significantly higher with the antidepressant as well (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), with both effects independent of those on depression, they reported in the February &lt;em&gt;Archives of General Psychiatry&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Adjunctive restorative therapies administered during the first few months after stroke, the period with the greatest degree of spontaneous recovery, reduce the number of stroke patients with significant disability,&quot; the researchers concluded.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; target=&quot;_blank&quot;&gt;primary analysis&lt;/a&gt; of the trial, reported in the &lt;em&gt;Journal of the American Medical Association on&lt;/em&gt; May 28, 2008, showed that prophylactic escitalopram treatment would prevent poststroke depression in one patient for every 7.2 treated &lt;em&gt;(P&lt;/em&gt;&amp;lt;0.001 compared with placebo). That article ultimately raised a controversy over an undisclosed conflict of interest.&lt;/p&gt;
&lt;p&gt;Escitalopram is a selective serotonin reuptake inhibitor (SSRI). Since serotonin plays a role in neuroplastic changes in the developing brain as well as in depression, Jorge&apos;s group analyzed whether there might be such an effect after a stroke.&lt;/p&gt;
&lt;p&gt;The study randomized patients to double-blind treatment with escitalopram (10 mg/d under age 65 or 5 mg/day age 65 and older) or placebo or unblinded problem-solving therapy (12 sessions of going through steps to arrive at a course of action for a patient-selected problem).&lt;/p&gt;
&lt;p&gt;The intent-to-treat analysis included 129 patients treated starting within the first three months after their mild to moderate severity stroke and who did not meet criteria for major or minor depression.&lt;/p&gt;
&lt;p&gt;Overall, global cognitive functioning was significantly changed between groups as measured on the Repeatable Battery for the Assessment of Neuropsychological Status (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After controlling for change in depression score and type of stroke, escitalopram was associated with the best cognitive recovery, an adjusted mean change of 9.9 points compared with 1.9 for problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01) and 4.0 for placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;Similarly, for delayed memory scores on the same test battery, escitalopram came out on top (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After adjustment for depression score change and stroke mechanism, the antidepressant was associated with an 11.2 point improvement in delayed memory, compared with a change of -0.7 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 3.9 with placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;On test of immediate memory, escitalopram again yielded the best recovery.&lt;/p&gt;
&lt;p&gt;The researchers found mean improvement of 13.4 points with the antidepressant compared with 2.0 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 7.2 with placebo (&lt;em&gt;P&lt;/em&gt;=0.04), after adjustment for time between stroke and treatment, depression score change, and stroke type.&lt;/p&gt;
&lt;p&gt;These mental benefits appeared to have an impact on functional status as well.&lt;/p&gt;
&lt;p&gt;Cognitive domain scores on the Functional Independence Measure were better for escitalopram-treated patients than those who didn&apos;t get the drug (&lt;em&gt;P&lt;/em&gt;=0.05), as were memory domain scores on the same measure (&lt;em&gt;P&lt;/em&gt;=0.03).&lt;/p&gt;
&lt;p&gt;At baseline, the global cognitive functioning and delayed and immediate memory scores were nonsignificantly lower in the antidepressant group than in the other two groups, which could have biased the results.&lt;/p&gt;
&lt;p&gt;However, the treatment effects appeared to be real, Jorge explained in an interview.&lt;/p&gt;
&lt;p&gt;In an unpublished regression analysis, the baseline scores were not a significant covariate. &quot;If [the results were] related only to the difference in baseline, this would be significant but it wasn&apos;t,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Moreover, with an initially lower score it might have been expected that the escitalopram-treated group would have had a lower score at the end of the study than the other groups, added co-author Robert G. Robinson, MD, also of the University of Iowa.&lt;/p&gt;
&lt;p&gt;But that wasn&apos;t the case, he said in an interview. With regard to delayed memory, for example, &quot;the escitalopram-treated group went from the most impaired to the best performing.&quot;&lt;/p&gt;
&lt;p&gt;The researchers didn&apos;t compare end scores for the escitalopram, problem solving therapy, and placebo groups, but they were: &lt;ul&gt; &lt;li&gt;For global cognitive functioning 89.8, 89.1, and 91.0 points, respectively&lt;/li&gt; &lt;li&gt;For delayed memory, 96.6, 89.1, and 94.2, respectively&lt;/li&gt; &lt;li&gt;For immediate memory, 95.1, 94.9, and 98.5, respectively&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The treatment showed no effect on other individual cognitive measurements, including those for attention, language, and IQ. Nor were there significant differences in changes in occupational or living conditions.&lt;/p&gt;
&lt;p&gt;Although SSRIs such as escitalopram have been associated with hospitalization for GI bleeding and falls in prior studies, these complications did not occur in Jorge&apos;s study.&lt;/p&gt;
&lt;p&gt;&quot;Long-term administration of SSRIs appears to be an effective and safe treatment option to improve cognitive outcomes among patients with cerebrovascular disease,&quot; they concluded in the &lt;em&gt;Archives&lt;/em&gt; paper.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study was limited by lack of CT or MRI scans and the younger age of escitalopram-treated patients, compared with other groups. That may have been a source of bias, although age did not appear to be a significant factor in the trial results.&lt;/p&gt;
&lt;p&gt;In this analysis, the researchers emphasized that the trial was not financially supported in any way by any drug company  --  a declaration hinting at the controversy that brewed last year over failure of one of the authors of the original &lt;em&gt;JAMA&lt;/em&gt; article to &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; target=&quot;_blank&quot;&gt;properly disclose ties&lt;/a&gt; to Forest Pharmaceuticals, which makes escitalopram.&lt;/p&gt;
&lt;p&gt;Another scientist who discovered that omission published the information in a competing journal, inducing &lt;em&gt;JAMA&lt;/em&gt; to issue a gag rule on reporting of undisclosed conflicts of interest. That policy encourages those who discover such conflicts to report them to &lt;em&gt;JAMA&apos;s&lt;/em&gt; editors but prohibits them from disclosing the conflicts publicly pending an investigation by the journal.&lt;/p&gt;
&lt;p&gt;In the current analysis, the disclosure statement indicated that co-author Robertson, had received honoraria and speakers&apos; bureau fees from Forest, with the caveat that &quot;none of the design, analysis, or expenses (including the cost of medications) of this study were supported by monies, materials, or any intellectual input from Forest Laboratories.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported solely by a grant from the National Institute of Mental Health.&lt;/p&gt;&lt;p&gt;Jorge reported having received travel awards to participate in national meetings from the former Hamilton Pharmaceutical Company and Avanir Pharmaceutical Company.&lt;/p&gt;&lt;p&gt;Co-authors reported financial conflicts of interest with Merck, NMT Medical, Eli Lilly, Centocor, Sanofi-Bristol-Meyers-Squibb, Boerhringer-Ingelheim, Schering-Plough, AstraZeneca, and GlaxoSmithKline, the former Hamilton Pharmaceutical Company, Avanir Pharmaceutical Company, Lubeck, Forest Laboratories, and Pfizer.&lt;/p&gt;&lt;p&gt;No pharmaceutical company donated medications for or had any financial interest in the study.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_148"
                     title="SCCM: Sedating Drugs May Slow Elders&apos; Recovery (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17973?impressionId=1265787166444"
                     
      &lt;p&gt;MIAMI BEACH  --  Elderly patients sedated with morphine or haloperidol (Haldol) in surgical intensive care units were less likely to to be discharged to their homes and more likely to be discharged to a nursing facility than patients given other sedatives, often resulting in a poorer quality of life, researchers reported here.&lt;/p&gt;
&lt;p&gt;Patients who received morphine were 2.57 times more likely to be discharged to a nursing home, rehabilitation center, or a skilled nursing facility (&lt;em&gt;P&lt;/em&gt;=0.029), Carrie Miller, MS, CRNP of the Hospital of the University of Pennsylvania in Philadelphia, told attendees at the annual meeting of the Society of Critical Care Medicine.&lt;/p&gt;
&lt;p&gt;Patients who were given haloperidol were 12.46 times more likely to be discharged to one of those facilities rather than to their home.&lt;/p&gt;
&lt;p&gt;Similarly, the risk of having a significantly reduced function from baseline admission was five times greater if the patient had received haloperidol (&lt;em&gt;P&lt;/em&gt;=0.044) and 2.76 times more likely if the patient had received morphine (&lt;em&gt;P&lt;/em&gt;=0.011), Miller said.&lt;/p&gt;
&lt;p&gt;&quot;While older adults frequently require medications to treat pain, anxiety, and delirium, little is know about the effects these medication have on older adults&apos; functional ability or quality of life,&quot; Miller said.&lt;/p&gt;
&lt;p&gt;To shed some light on the question, she and her colleagues evaluated 114 patients in three surgical ICUs. Mean age was about 75, some 60% were men, and 85% were white. Overall, 37% were undergoing general surgical procedures, while 35% had undergone vascular procedures and 16% were trauma patients.&lt;/p&gt;
&lt;p&gt;Patients&apos; level of consciousness and delirium status were assessed daily and information about medication use was gleaned from the ICU flow sheet and the computerized administration record.&lt;/p&gt;
&lt;p&gt;The most frequently used narcotic in the surgical ICU was fentanyl (Duragesic), administered to 77 patients; the most frequently used sedative was midazolam (Versed); and the most frequently used antipsychotic was haloperidol.&lt;/p&gt;
&lt;p&gt;Miller and her colleagues noted that use of propofol (Diprivan) appeared to be associated with better outcomes as far as discharge to one&apos;s home was concerned.&lt;/p&gt;
&lt;p&gt;They noted that there was &quot;considerable discrepancy&quot; between medication usage and dosage recorded on the patients&apos; flow sheet and medication administration record. &quot;Researchers and clinicians should consider that administered prn medications may not always be recorded on the nursing flow sheet,&quot; they concluded.&lt;/p&gt;
&lt;p&gt;The study did not control for confounding variables such as the severity of illness or comorbidities that may have affected outcomes, Miller said.&lt;/p&gt;
&lt;p&gt;&quot;This is an interesting study,&quot; said Suzan Streichenwein, MD, a private practice geriatric psychiatrist in West Palm Beach, Fla. &quot;It would be valuable for future studies to include the severity of illness or more specific details about the type of surgery relative to the dosages of morphine used and its influence on the discharge functional outcomes.&lt;/p&gt;
&lt;p&gt;&quot;Tests diagnosing mild cognitive impairment and/or dementia preop versus postop as well as the time period under anesthesia in relation to outcomes would also be helpful,&quot; said Streichenwein, who was not involved in the study.&lt;/p&gt;
&lt;p&gt;Streichenwein told &lt;em&gt;MedPage Today&lt;/em&gt; that other possible confounding factors require further studies in this area.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;None of the clinicians had relevant financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_130"
                     title="Dementia, Hypertension Linked Again (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Cardiology/Hypertension/tb/17944?impressionId=1265787166444"
                     
      Another study has found that hypertension may contribute to increased risk of dementia, this time with evidence of actual brain abnormalities.&lt;br&gt;
&lt;br&gt;Data from an offshoot of the Women&apos;s Health Initiative found that participants&apos; baseline blood pressure was strongly correlated with volume of lesions in their brains&apos; white matter, according to Lewis Kuller, MD, DrPH, of the University of Pittsburgh, and colleagues.&lt;br&gt;
&lt;br&gt;Along with earlier studies linking blood pressure to clinical dementia, the evidence &quot;supports tight control of blood pressure levels, especially beginning at younger and middle age as a possible and perhaps only way to prevent dementia,&quot; Kuller and colleagues concluded online in the &lt;em&gt;Journal of Clinical Hypertension&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;One study reported in 2006 found that successful hypertension control reduced the risk of dementia, while another reported the following year indicated that uncontrolled high blood pressure increased the risk. (See &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Hypertension/3037&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Hypertension/3037&quot; target=&quot;_blank&quot;&gt;Blood Pressure Medication May Benefit Older Brains&lt;/a&gt; and &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/VASCOG/6147&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/VASCOG/6147&quot; target=&quot;_blank&quot;&gt;VAS-COG: Hypertension Linked to Cognitive Decline in Older Patients&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Kuller and colleagues analyzed data collected from 1,424 participants in the Women&apos;s Health Initiative who agreed to undergo MRI scans performed an average of eight years after starting the trial. Blood pressure was measured at baseline and annually throughout the trial.&lt;/p&gt;
&lt;p&gt;About half the women had been assigned to placebo in the trial, which primarily was designed to test two hormone replacement regimens. Some 436 received a combination of conjugated equine estrogen and medroxyprogesterone acetate, while the remainder received the equine estrogen alone.&lt;/p&gt;
&lt;p&gt;Kuller and colleagues found significant relationships between baseline systolic blood pressure and abnormal white matter lesion volumes as measured with MRI.&lt;/p&gt;
&lt;p&gt;Among participants not taking blood pressure medications, the lesion volume averaged 4.07 cm&lt;sup&gt;3&lt;/sup&gt; for those with baseline pressure of less than 100 mm Hg, compared with 5.20 cm&lt;sup&gt;3&lt;/sup&gt;among those with systolic pressure of 140 mm Hg or higher (&lt;em&gt;P&lt;/em&gt;=0.0044 for trend).&lt;/p&gt;
&lt;p&gt;A similar but weaker relationship was seen for lesion volumes according to systolic pressure at the last available measurement (&lt;em&gt;P&lt;/em&gt;=0.03) among subjects who were not on antihypertensive therapy.&lt;/p&gt;
&lt;p&gt;Baseline systolic pressure was also significantly correlated with lesion volumes in women taking blood pressure drugs, Kuller and colleagues reported.&lt;/p&gt;
&lt;p&gt;Women with baseline pressure below 100 mm Hg had lesion volumes averaging 5.56 cm&lt;sup&gt;3&lt;/sup&gt; whereas those with pressures of 140 mm Hg or higher at baseline had average lesion volume of 6.09 mm Hg (&lt;em&gt;P&lt;/em&gt;=0.002 for trend).&lt;/p&gt;
&lt;p&gt;There was a nonsignificant trend toward higher lesion volumes with increasing systolic pressure at the last measurement.&lt;/p&gt;
&lt;p&gt;After adjusting for age, race, treatment assignment, total cranial volume, clinical site, and time from study termination to MRI scan, the researchers found that women with normal blood pressure (&amp;lt;140/90 mm Hg) had lower lesion volumes, not only in their white matter but also in the basal ganglia, than participants with high blood pressure.&lt;/p&gt;
&lt;p&gt;The finding held both for baseline blood pressure measurements and for pressure at the last available evaluation (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001 for all comparisons).&lt;/p&gt;
&lt;p&gt;High baseline blood pressure, though not later measurements, was also significantly correlated with the number of brain regions containing abnormal white matter lesions (&lt;em&gt;P&lt;/em&gt;=0.035).&lt;/p&gt;
&lt;p&gt;Regions in which high blood pressure seemed to promote abnormal lesions most strongly included frontal, parietal, and temporal lobes in both hemispheres. The frontal lobes in particular have been associated with vascular dementia and abnormal performance on cognition tests.&lt;/p&gt;
&lt;p&gt;Occipital lobes and the corpus callosum did not appear significantly affected, the MRI data indicated.&lt;/p&gt;
&lt;p&gt;&quot;The association of blood pressure levels with white matter abnormalities years before the MRI is consistent with a long incubation period for the development of the white matter abnormalities,&quot; Kuller and colleagues wrote.&lt;/p&gt;
&lt;p&gt;They said their findings are also consistent with earlier observations that midlife blood pressure is more strongly related to dementia later on than is blood pressure measured at older ages.&lt;/p&gt;
&lt;p&gt;Kuller and colleagues cautioned that it remained uncertain whether blood pressure treatment can prevent development of white matter abnormalities. Nor is it clear what the most appropriate blood pressure targets should be, or what type of treatment may be best.&lt;/p&gt;
&lt;p&gt;&quot;We have only suggestive evidence that the progression of white matter lesions can be slowed by blood pressure-lowering therapy,&quot; they wrote, calling for more clinical trials to clear up these issues.&lt;/p&gt;
&lt;p&gt;Nevertheless, they concluded, &quot;a prudent clinical approach at present would encourage maintaining as low a blood pressure as possible, especially beginning in young and middle ages, in order to possibly prevent dementia as well as stroke. There are no other potentially effective preventive therapies.&quot;&lt;/p&gt;
&lt;p&gt;Study limitations included a lack of MRI data on brain infarcts, no corroborating clinical data on cognitive performance, and, of course, the trial&apos;s restriction to women.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Wyeth funded the data analysis in this study. The Women&apos;s Health Initiative was sponsored by the National Heart, Lung, and Blood Institute.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_117"
                     title="ARBs Linked to Lower Dementia Risk (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Neurology/AlzheimersDisease/tb/17928?impressionId=1265787166444"
                     
      Older patients treated with an angiotensin receptor blocker (ARB) had a significantly lower risk of dementia and nursing home admission than patients treated with other cardiovascular drugs, data from a large prospective cohort study showed.&lt;br&gt;
&lt;br&gt;The incidence of dementia was 20% to 24% lower, and nursing-home admissions were reduced by half among patients on ARBs, Benjamin Wolozin, MD, PhD, of Boston University, and colleagues reported online in &lt;em&gt;BMJ&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Results were similar when patients were categorized by dementia or the more specific diagnosis of Alzheimer&apos;s disease, suggesting the ARBs&apos; benefits involved more than cardiovascular effects.&lt;br&gt;
&lt;br&gt;&quot;It&apos;s reasonable to conclude that the ARBs are acting in part by helping with stroke, but I doubt that&apos;s the only reason,&quot; Wolozin said in an interview.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;We looked at blood-brain barrier penetration, and the ARBs that get into the brain seem to help a little more than the ARBs that don&apos;t. That&apos;s consistent with what some other people have seen with ACE inhibitors.&quot;&lt;/p&gt;
&lt;p&gt;Several comprehensive summaries have described the role of the renin-angiotensin system (RAS) in Alzheimer&apos;s disease and the effects of RAS inhibitors on cognitive function. Moreover, studies have shown associations between ARB therapy and preservation of cognitive function.&lt;/p&gt;
&lt;p&gt;Preclinical and clinical evidence suggests ARBs help maintain cognitive function by mechanisms unrelated to antihypertensive effects, the authors wrote.&lt;/p&gt;
&lt;p&gt;But the relative effects of ARBs and angiotensin-converting enzyme (ACE) inhibitors on dementia outcomes had not been studied carefully.&lt;/p&gt;
&lt;p&gt;To address the issue, Wolozin and colleagues analyzed a Veterans Affairs administrative database covering 2002 to 2006. The analysis included 819,419 patients ages 65 or older with cardiovascular disease.&lt;/p&gt;
&lt;p&gt;The study population was grouped by type of cardiovascular medication received: ARBs, ACE inhibitors (primarily lisinopril), and other cardiovascular drugs.&lt;/p&gt;
&lt;p&gt;The primary outcome was time to diagnosis of Alzheimer&apos;s disease or dementia. Disease progression was defined as the time to nursing home admission or death among patients with preexisting Alzheimer&apos;s disease or dementia.&lt;/p&gt;
&lt;p&gt;The mean age of the population was about 74, and 98% of the patients were men. The authors reported that 819,491 participants were evaluable for study of Alzheimer&apos;s disease and 799,069 for dementia. About 12,000 patients were treated with ARBs, 93,000 with lisinopril, and 714,000 with other cardiovascular drugs.&lt;/p&gt;
&lt;p&gt;Comparison of Alzheimer&apos;s incidence showed a 19% reduction with ARBs versus ACE inhibitors, including lisinopril, (HR 0.81, 95% CI 0.68 to 0.96, &lt;em&gt;P&lt;/em&gt;=0.016) and a 16% reduction versus other cardiovascular drugs (HR 0.84, 95% 0.71 to 1.00, &lt;em&gt;P&lt;/em&gt;=0.045).&lt;/p&gt;
&lt;p&gt;New cases of dementia were 19% lower with ARBs than with lisinopril and other ACE inhibitors (HR 0.81, 95% CI 0.73 to 0.90, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 24% lower than other cardiovascular drugs (HR 0.76, 95% CI 0.69 to 0.84, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Among patients with preexisting Alzheimer&apos;s disease, treatment with an ARB was associated with a 49% reduction in the rate of nursing home admission (HR 0.51, 95% 0.36 to 0.72, &lt;em&gt;P&lt;/em&gt;=0.0001) and a 17% reduction in death (HR 0.83, 95% CI 0.71 to 0.97, &lt;em&gt;P&lt;/em&gt;=0.022).&lt;/p&gt;
&lt;p&gt;The authors found a dose-response effect of ARBs on dementia incidence, as higher doses were associated with lower rates of dementia. The association held true for analysis of individual drugs in the class.&lt;/p&gt;
&lt;p&gt;Analyses of combination RAS-inhibiting therapy also showed lower rates of Alzheimer&apos;s disease, dementia, and nursing home admission among patients treated with an ARB and an ACE inhibitor compared with either class of drug alone.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Retirement Research Foundation and the Casten Foundation.&lt;/p&gt;&lt;p&gt;The authors disclosed no relationships aside from those involving the funding sources for the study.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_108"
                     title="Gene Variant Linked to Lower Dementia Risk (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Neurology/Dementia/tb/17915?impressionId=1265787166444"
                     
      A genetic variant associated with higher HDL cholesterol levels may protect against the development of dementia and Alzheimer&apos;s disease, a preliminary study showed.&lt;br&gt;
&lt;br&gt;Older individuals who had a substitution of valine for isoleucine on both alleles of the cholesteryl ester transfer protein (&lt;em&gt;CETP&lt;/em&gt;) gene were 72% less likely to develop dementia during follow-up (&lt;em&gt;P&lt;/em&gt;=0.02), according to Richard Lipton, MD, of Albert Einstein College of Medicine in New York City, and colleagues.&lt;br&gt;
&lt;br&gt;Those with the variant were also 69% less likely to develop Alzheimer&apos;s disease specifically (&lt;em&gt;P&lt;/em&gt;=0.04), the researchers reported in the Jan. 13 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Although causal relationships could not be established, Lipton speculated that the genetic variant could be protective by reducing vascular risk factors, which are also risk factors for the two most common forms of dementia, Alzheimer&apos;s disease and multi-infarct dementia.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;In addition,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;, &quot;we know &lt;em&gt;CETP&lt;/em&gt; is expressed in the brain and there&apos;s at least some possibility that this genetic variant plays a direct protective role against the accumulation of amyloid, although that is really speculative.&quot;&lt;/p&gt;
&lt;p&gt;Polymorphisms in the &lt;em&gt;CETP&lt;/em&gt; gene, which is involved in reverse cholesterol transport, have been associated with longer life and improved cognition in a sample of Ashkenazi Jews. But other studies have yielded conflicting results.&lt;/p&gt;
&lt;p&gt;The substitution of valine for isoleucine at codon 405 effectively inhibits the gene&apos;s function and results in higher levels of HDL cholesterol.&lt;/p&gt;
&lt;p&gt;To see whether this variant is associated with successful brain aging, in addition to aging in general, Lipton and his colleagues turned to the Einstein Aging Study, a prospective study of adults 70 and older living in the Bronx, one of New York City&apos;s five boroughs.&lt;/p&gt;
&lt;p&gt;All 523 adults included in the current analysis were free from dementia at baseline and underwent annual neuropsychological and neurological testing.&lt;/p&gt;
&lt;p&gt;Overall, 45% of the participants were heterozygous for the amino acid substitution for valine, 21% were homozygous for the substitution, and 34% were homozygous for the original gene configuration with isoleucine instead of valine.&lt;/p&gt;
&lt;p&gt;At baseline, cognitive performance on tests of episodic memory, attention, and psychomotor speed were similar between the three genotype groups.&lt;/p&gt;
&lt;p&gt;However, in a longitudinal analysis, valine homozygotes had a significantly slower decline in episodic memory than isoleucine homozygotes (0.22 points slower per year of age, &lt;em&gt;P&lt;/em&gt;=0.03) after controlling for sex, education, race/ethnicity, comorbidities, and presence of the &lt;em&gt;APOE &lt;/em&gt;&amp;#949;4 allele, which has been associated with an increased susceptibility for Alzheimer&apos;s disease.&lt;/p&gt;
&lt;p&gt;Lipton and his colleagues noted that this difference is small because the memory test is scored on a 48-point scale.&lt;/p&gt;
&lt;p&gt;There were no significant differences between the groups in performance over time on the tests of attention and psychomotor speed.&lt;/p&gt;
&lt;p&gt;During a mean follow-up of 4.3 years, 40 individuals developed dementia  --  35 had probable or possible Alzheimer&apos;s disease.&lt;/p&gt;
&lt;p&gt;Compared with isoleucine homozygotes, valine homozygotes had lower risks of dementia (HR 0.28, 95% CI 0.10 to 0.85) and Alzheimer&apos;s disease (HR 0.31, 95% CI 0.10 to 0.95).&lt;/p&gt;
&lt;p&gt;If confirmed in future studies, the findings could have clinical implications in the long term, Lipton said.&lt;/p&gt;
&lt;p&gt;He noted that there are drugs in development that inhibit &lt;em&gt;CETP&lt;/em&gt;, largely for the HDL-raising benefits. The effects of these drugs might mimic the biochemical phenotype of the variant evaluated in the current study.&lt;/p&gt;
&lt;p&gt;&quot;So perhaps those drugs ... might play a role in promoting healthy brain aging as well, although certainly that has not been shown,&quot; he said.&lt;/p&gt;
&lt;p&gt;The researchers noted some caveats in their paper, including the need for other longitudinal studies with greater numbers of incident dementia cases and the possible misclassification of dementia and Alzheimer&apos;s disease.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The Einstein Aging Study is supported by the National Institute on Aging. Lipton&apos;s co-authors reported receiving support from the NIA, from grants from the Einstein Clinical and Translation Science Award and the National Center for Research Resources, and from the NIH Roadmap for Medical Research.&lt;/p&gt;&lt;p&gt;Lipton reported receiving compensation from Advanced Bionics, Allergan, AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Cierra, Endo, GlaxoSmithKline, Minster, Merck, Neuralieve, Novartis, and Ortho-McNeil and receiving research funding from Allergan, Ortho-McNeil, Minster, Endo, GlaxoSmithKline, Merck, Neuralieve, and ProEthics. He reported that none of these relationships pertain to the material presented in the current study.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
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