Midlife blood pressure, plasma β-amyloid, and the risk for Alzheimer disease: the Honolulu Asia Aging Study

β-Amyloid (Aβ), a vasoactive protein, and elevated blood pressure (BP) levels are associated with Alzheimer disease (AD) and possibly vascular dementia. We investigated the joint association of midlife BP and Aβ peptide levels with the risk for late-life AD and vascular dementia. Subjects were 667 Japanese-American men (including 73 with a brain autopsy), from the prospective Honolulu Heart Program/Honolulu Asia Aging Study (1965-2000). Midlife BP was measured starting in 1971 in participants with a mean age of 58 years; Aβ was measured in specimens collected in 1980-1982, and assessment of dementia and autopsy collection started in 1991-1993. The outcome measures were prevalent (present in 1991-1993) and incident AD (n=53, including 38 with no contributing cardiovascular disease) and vascular dementia (n=24). Cerebral amyloid angiopathy, β-amyloid neuritic plaques, and neurofibrillary tangles were evaluated in postmortem tissue. The risk for AD significantly increased with lower levels of plasma Aβ (Aβ1-40 hazard ratio: 2.1 [95% CI: 1.4 to 3.1]; Aβ1-42 hazard ratio: 1.6 [95% CI: 1.1 to 2.3]). Evidence of interaction between diastolic BP and plasma Aβ (1-40 P(interaction)<0.05; 1-42 P(interaction)<0.07) levels indicated that the Aβ-related risk for AD was higher when BP was higher. Low plasma Aβ was associated with the presence of cerebral amyloid angiopathy (P(trend)<0.05) but not the other neuropathologies. Aβ plasma levels start decreasing ≥15 years before AD is diagnosed, and the association of Aβ to AD is modulated by midlife diastolic BP. Elevated BP may compromise vascular integrity leading to cerebral amyloid angiopathy and impaired Aβ clearance from the brain.     

A Call for an Integrated Biopsychosocial Model to Address Fundamental Disconnects in an Emergent Field: An Introduction to the Special Issue on “Sexuality and Aging”

This special issue of Ageing International is designed to highlight the clinicians, researchers, and public policy makers who focus upon the intersection of sexuality and aging. A theoretical, biopsychosocial model is introduced in response to a variety of apparent paradoxes in the field (e.g., although nearly 1 in 5 new AIDS cases are among adults over the age of 65, no federally funded programs exist for HIV prevention among this age group, and although virtually all findings in the literature are based upon men and women from North American and Western European nations, China boasts the largest population of older adults worldwide). Consistent with this integrated approach, contributors to the special issue provide emergent information in relation to HIV and AIDS among older men and women, cross-cultural perspectives on sexuality and aging within Chinese and Ugandan culture, sexuality within the context of long-term care, and clinical approaches to erectile dysfunction. Directions for future research also are offered.     

Obesity in South and Southeast Asia—A new consensus on care and management

Obesity is a chronic disease in which the abnormal or excessive accumulation of body fat leads to impaired health and increased risk of mortality and chronic health complications. Prevalence of obesity is rising rapidly in South and Southeast Asia, with potentially serious consequences for local economies, healthcare systems, and quality of life. Our group of obesity specialists from Bangladesh, Brunei Darussalam, India, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka, Thailand, and Viet Nam undertook to develop consensus recommendations for management and care of adults and children with obesity in South and Southeast Asia. To this end, we identified and researched 12 clinical questions related to obesity. These questions address the optimal approaches for identifying and staging obesity, treatment (lifestyle, behavioral, pharmacologic, and surgical options) and maintenance of reduced weight, as well as issues related to weight stigma and patient engagement in the clinical setting. We achieved consensus on 42 clinical recommendations that address these questions. An algorithm describing obesity care is presented, keyed to the various consensus recommendations.     

Preparing for an “Insured” Old Age: Insurance Purchase and Self-Support in Old Age in Rural China

This article explores an emerging trend among young and middle-aged rural couples in Northeast China who have purchased recently marketized commercial insurance as a way to prepare for self-support in old age. It discusses how the commercial insurance industry has created a rural elder-care market among a population that traditionally relied on family for support in old age. It also delves into the ways in which the transformations of intergenerational exchange and family structure and a lack of health care access have contributed to the preparation for self-support in old age and have thus fostered the creation of a rural elder-care market for the insurance industry. This emerging trend reveals a transition from traditional family support to a combination of multiple ways of elder care, in particular self-support in old age. It also suggests that while the Chinese state is facing a pressing issue of supporting an increasing aging population and the Chinese family is coping with the burden of elder care, the insurance industry is playing an increasing role in elder care in China.     

What is new in the 2018 Chinese hypertension guideline and the implication for the management of hypertension in Asia?

The new Chinese hypertension guideline comprehensively covers almost all major aspects in the management of hypertension. In this new guideline, hypertension remains defined as a systolic/diastolic blood pressure of at least 140/90 mm Hg. For risk assessment, a qualitative approach is used similarly as in previous Chinese guidelines according to the blood pressure level and the presence or absence of other risk factors, target organ damage, cardiovascular complications, and comorbid diseases. The therapeutic target is 140/90 mm Hg in general, and if tolerated, especially in high‐risk patients, can be more stringent, that is, 130/80 mm Hg. However, a less stringent target, that is, 150/90 mm Hg, is used in the younger (65‐79 years, if tolerated, 140/90 mm Hg) and older elderly (≥80 years). Five classes of antihypertensive drugs, including β‐blockers, can be used either in initial monotherapy or combination. The guideline also provided information on the management of hypertension in several special groups of patients and in the presence of secondary causes of hypertension. To implement the guideline recommendations, several nationwide hypertension control initiatives are being undertaken with new technology. The new technological platforms hopefully will help improve the management of hypertension and generate scientific evidence for future hypertension guidelines, including a possible Asian hypertension guideline in the near future.     

Historical and Global Perspectives on Social Policy and “Aging in Community”

This article provides an introduction to the special issue of Ageing International on Aging in Community by putting related issues in perspective in order to maintain a comprehensive understanding of the changing fields of aging, family, community, and social policy. Going beyond a current trend of “aging in place” (AIP), it reviews community care that once dominated social policy dialog in the United Kingdom, as well as community service that was once regarded as a main solution to the social issues of reformist China. The case of the United States is also highlighted by reviewing a scholarly interest in social support. By citing America’s “non-system” of community support for disabled elderly persons, the article recognizes an outstanding feature of AIP, that is, the “buy-in” from industry or the commercial sector in terms of its role in promoting aging at home. Other key social policy issues as seen in previous debates that baffled policy-makers in various countries, however, remain to be addressed in the much changed environment of the 21st century.     

Clinicopathologic Features and Treatment Outcomes in Cronkhite–Canada Syndrome: Support for Autoimmunity

Background and Aims  

Cronkhite–Canada syndrome (CCS) is a noninherited condition, associated with high morbidity, and characterized by gastrointestinal hamartomatous polyposis, alopecia, onychodystrophy, hyperpigmentation, and diarrhea. All features may respond to immunosuppressive therapy, but little is known about the etiology. An autoimmune origin has been suggested but not proved. From a retrospectively selected cohort, we evaluated clinicopathologic features, including immunostaining for IgG4 (an antibody associated with autoimmunity), and therapeutic outcomes in a cohort of CCS patients to provide further insights into this disease.     

Dying on the Streets: Homeless Persons’ Concerns and Desires about End of Life Care

Background There is little understanding about the experiences and preferences at the end of life (EOL) for people from unique cultural and socioeconomic backgrounds. Homeless individuals are extreme examples of these overlooked populations; they have the greatest risk of death, encounter barriers to health care, and lack the resources and relationships assumed necessary for appropriate EOL care. Exploring their desires and concerns will provide insight for the care of this vulnerable and disenfranchised population, as well as others who are underserved. Objective Explore the concerns and desires for EOL care among homeless persons. Design Qualitative study utilizing focus groups. Participants Fifty-three homeless persons recruited from agencies providing homeless services. Measurements In-depth interviews, which were audiotaped and transcribed. Results We present 3 domains encompassing 11 themes arising from our investigation, some of which are previously unreported. Homeless persons worried about dying and EOL care; had frequent encounters with death; voiced many unique fears, such as dying anonymously and undiscovered; favored EOL documentation, such as advance directives; and demonstrated ambivalence towards contacting family. They also spoke of barriers to EOL care and shared interventions to improve dying among the very poor and estranged. Conclusions Homeless persons have significant personal experience and feelings about death, dying, and EOL care, much of which is different from those previously described in the EOL literature about other populations. These findings have implications not only for homeless persons, but for others who are poor and disenfranchised. Potential Financial Conflict of Interest None disclosed     

Autoimmune liver diseases in the Asia–Pacific region: Proceedings of APASL symposium on AIH and PBC 2016

During the 25th annual meeting of the Asia–Pacific Association for the Study of the Liver (APASL 2016) in Tokyo, we organized and moderated an inaugural satellite symposium on the autoimmune liver diseases, autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC). Following the keynote lecture by John M. Vierling (USA), speakers from the Asia–Pacific region provided an up-to-date perspective on the epidemiology, clinical practice and research in AIH and PBC in the Asia–Pacific region. Although epidemiology and clinical features of AIH seem to be similar in East Asia compared to those in western countries, the majority of patients with AIH are detected at an advanced stage and have higher mortality rates in South Asia, indicating an unmet need for earlier diagnosis and the initiation of appropriate immunosuppressive treatment. PBC is more commonly seen in Australia and East Asia. As of 2016, clinical practice guidelines (CPG) for PBC have been published in Japan and China. Ursodeoxycholic acid (UDCA) is recommended as a first-line therapy by both CPG. Nevertheless, one of the unmet therapeutic needs in PBC is the treatment of patients refractory to or intolerant of UDCA. It is of interest that the prevalence of chronic hepatitis B (CHB) in PBC patients was low in Taiwan and mainland China where the prevalence of CHB is very high. In this review, we overview this exciting and epoch-making symposium.     

Effects of Aging and Drugs on Myocardial β-Adrenergic Receptors in M-SHRSP and SHRSP

Myocardial β-adrenergic receptors were measured in membrane fractions from malignant SHRSP (M-SHRSP), SHRSP and WKY at different ages using [3H]-dihydroalprenolol (DHA) as a radioligand. The effects of isoproterenol (ISP) and chemical sympathectomy (6-hydroxydopamine treatment) on myocardial β-receptors were also investigated in 10 and 24 week-old SHRS and WKY to examine the effects of hypertension and aging on receptor regulation. The number of myocardial β-receptors in M-SHRSP at 4 weeks of age (W) and 10 W were significantly lower than those in age-matched SHRSP and WKY. In addition, the values in SHRSP at 4 and 10 W were significantly lower than those in age-matched WKY, but the numbers in SHRSP at 1, 24 and 48–54 W were not significantly different from age-matched WKY. The dissociation constant and activity of 5′-nucleotidase, which is a marker enzyme of cell membrane, were not significantly different among the three groups. ISP treatment significantly reduced the numbers of myocardial β-receptors in 10 week-old SHRSP and 10 and 24 week-old WKY, but did not in 24 week-old SHRSP. The extent of this decrease of β-receptors was lower in 10 week-old SHRSP than in 10 week-old WKY, and it was also lower in 24 week-old WKY than 10 week-old WKY. 6-Hydroxydopamine treatment significantly increased the number of myocardial β-receptors in 10 and 24 week-old WKY, but did not in SHRSP. The extent of this increase of β-receptors was lower in 24 week-old WKY than in 10 week-old WKY. These results suggest that the decrease of myocardial β-receptor numbers in 4 and 10 week-old M-SHRSP and SHRSP does not appear to be genetically determined, but rather is caused by accelerated sympathetic activity, and that the regulation of myocardial β-receptor is impaired in young and aged SHRSP and in aged WKY.     

Introduction to health economics and decision-making: Is economics relevant for the frontline clinician?

In a climate of escalating demands for new health care services and significant constraints on new resources, the disciplines of health economics and health technology assessment (HTA) have increasingly been turned to as explicit evidence-based frameworks to help make tough health care access and reimbursement decisions. Health economics is the discipline of economics concerned with the efficient allocation of health care resources, essentially trying to maximize health benefits to society contingent upon available resources. HTA is a broader field drawing upon several disciplines, but which relies heavily upon the tools of health economics and economic evaluation. Traditionally, health economics and economic evaluation have been widely used at the political (macro) and local (meso) decision-making levels, and have progressively had an important role even at informing individual clinical decisions (micro level).The aim of this paper is to introduce readers to health economics and discuss its relevance to frontline clinicians. Particularly, the content of the paper will facilitate clinicians' understanding of the link between economics and their medical practice, and how clinical decision-making reflects on health care resource allocation.