Geriatric medicine

Dr Linda Calabresi
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A diet well-known for lowering blood pressure can also help older patients lose fat without sacrificing muscle, according to new research. In a small study involving 36 older obese adults, researchers found that a 12-week program of controlled-feeding that included lean red meat three times a day not only resulted in significant weight loss and loss of body fat but also preserved muscle strength and function - an important determinant of good health.

Prof Paul O'Toole
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As our global population is projected to live longer than ever before, it’s important that we find ways of helping people live healthier for longer. Exercise and diet are often cited as the best ways of maintaining good health well into our twilight years. But recently, research has also started to look at the role our gut – specifically our microbiome – plays in how we age.

Helen Rawson
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This week, the aged care royal commission looks at diversity in aged care, an issue becoming increasingly relevant to both residents and the staff who care for them. Diversity includes gender, sexual orientation, religion and social background. The issue is important because if we aim to offer older people and families choice and control in aged care, we must meet the diverse needs of all older people. Australia’s rich diversity is reflected in its older population. In 2016, more than one-third (37%) of Australians aged 65 and over were born overseas and one-fifth (20%) were born in a non-English speaking country. These figures have increased continually since 1981, when one-quarter (25%) of older people were born overseas.

Expert/s: Helen Rawson
A/Prof Joachim Sturmberg
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Last week’s hearings at the aged care royal commission in Brisbane looked at regulation in aged care. While rules and regulations are designed to safeguard residents, bureaucratic “red tape” also contributes to the failings in aged care. The fear among nursing home staff of failing a review visit by an Aged Care Quality and Safety Commission surveyor has been known to shift the focus from care for residents to meeting paper trail requirements.

A/Prof Michael Woodward AM
Monographs iconMonographs

This article discusses how GPs can improve the vaccination coverage among older Australians which is currently poor despite the ready availability, safety and effectiveness of these vaccines. Written by A/Prof Michael Woodward AM, MB, BS, MD, FRACP, and A/Prof John Litt MB, BS, DRACOG, MSc(Epid), FRACP, FAFPHM, PhD

Dr Linda Calabresi
Clinical Articles iconClinical Articles

If you look after patients in an aged care facility you should really have a look at this resource. It’s from the Australian Government’s Department of Health and it basically gives you all you need to know about the most recent initiative to ensure high standard of care in these facilities. From July 1, all aged care facilities that receive government subsidies for the services they provide will need to collect and provide data on three specific adverse outcomes that residents might experience. Specifically the government is asking these facilities to record information on pressure injuries, use of physical restraint and unplanned weight loss because these are indicators of clinical quality, or more exactly indicators of poor clinical quality. Every three months residential facilities will need to submit this Quality Indicator (QI) data to the Department of Health which will generate a report. So where do GPs fit in? According to the resource information, GPs will need to get involved in making sure facilities proactively respond to this QI information. The actions GPs are being asked to take are mainly about getting engaged in the programme – ask questions, ask to see the 3-monthly QI reports and help with the interpretation of the information from these reports. It will also be important that GPs contribute ideas on how to improve care. Even though this new initiative is only looking at three indicators, and there are many more that could be considered such as pain and falls, these three were chosen because they each have a broad impact across a number of other care areas – these are the canaries in the mine so to speak. Improve these and a whole lot of other areas of care improve as well. It’s not our usual type of recommended resource but if you’re a GP looking after patients in aged care you will recognise how this initiative could be very important to the health of our elderly patients. Check it out.   >> Access the resource here

Lyn Phillipson & Louisa Smith
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The Royal Commission into Aged Care has unleashed a spate of claims of system failure within the residential aged care sector. Now, as the commission shifts its focus to care in the community, we’re also seeing claims of failure within the home care packages program. This scheme aims to support older people with complex support needs to stay at home. But what we’ve got is a market-based system where the processes involved in accessing support and managing services are making it difficult for vulnerable older Australians to receive the care they want. If this system is to be workable, older people need better information and more personalised supports to enable choice and control – especially those with complex needs.

Consumer directed care

A growing number of older Australians are receiving home care subsidised by the government. During the 2017-18 financial year, 116,843 people accessed home care packages.

From July 1 2015, all home care packages have been delivered on what’s called a Consumer Directed Care basis. This means that, theoretically, home care providers must work with consumers to design and deliver services that meet their goals and care needs, as determined by an Aged Care Assessment Team. However, in reviewing the active steps outlined in the government pathway to access a package, we must consider the person who is navigating this path. They are frail older people with complex support needs, often seeking help at times of crisis. These include the growing number of older Australians living with multiple medical conditions and complex age-related syndromes such as dementia. After a person has been assessed, they will receive a letter informing them they are eligible. However, due to long waiting lists, this does not provide them with immediate access to care; most wait many months before they are actually assigned a package by My Aged Care. When they eventually receive a letter confirming their package, the consumer will be approached by various service providers. They will need to sign a complex contract with their chosen provider. If the consumer is feeling frustrated and confused during these early stages, this is only the beginning. The recent marketisation of home care means managing their own care requires going through impersonal, centralised provider systems.
The Conversation, CC BY-ND

People need clear information to choose a provider

The first thing people assigned a home care package need to do is choose a care provider. There are now close to 900 different providers offering home care packages. This includes not-for-profits, as well as a growing number of for-profit providers competing for new business.

In reality, however, few older people research different providers. Once they’re assigned a home care package, their name is placed on a centralised database accessible by all registered service providers. The person then receives unsolicited phone calls from the sales teams of different providers, offering their services and trying to make appointments to come and visit. For consumers, this represents a shift from a familiar government model of care provision to a market model. Research shows consumers often don’t understand consumer directed care, and this can leave them vulnerable to the forceful marketing tactics employed by some providers. It can also make negotiating a complex contract with legal, financial and personal implications very difficult. To make informed choices between providers, people need accessible information. There is currently insufficient information for older people and their families to compare services on indicators of quality (such as the number of complaints agencies receive, the training of staff, the types of specialist services they offer, and so on). To address this gap, the government must commit to collecting and publishing data on home care quality. This would drive service improvement and increase people’s ability to make informed choices between different providers.

Service and administrative fees

To make informed choices, people also need to be able to compare services on the basis of price. The average profit per client for home care package providers was A$2,832 in 2016-17, but there’s significant variability between providers’ fees. For example, the use of people’s individual care budgets to cover administration or case management fees ranges between 10-45% of their total package. High fees and administrative costs may reveal the profit-driven motives of a few unscrupulous providers. Because of administrative fees, many people are spending a high portion of their individual budgets on case management to support their care. While there’s evidence case management can provide clinical benefits for older people, in the context of the current home care funding model, it may also leave people with less money for direct care services than they need.

People need support to manage their packages

We’re currently looking at the experiences of people with dementia using home care packages. Unsurprisingly, we’re finding that while they are grateful for the services they’re receiving, they are having a difficult time managing their care. For some this may be due to their limited decision-making capacity, but for many, their choice and control is being limited as much by the service model. For example, to enable providers to compete in the open market, many have adopted central 1800 numbers to support people to manage their services. This means if consumers want to change something, they are funnelled through this system. Think about your own experience of service helplines, such as with telephone or energy companies. Now consider a woman with dementia who needs to call a 1800 number to change the time of her shower so she can see her doctor. Rather than communicating with a local and known case manager, she now needs to speak to someone she doesn’t know and who is not familiar with her care needs. Instead of facilitating choice and control, this demand on the consumer to constantly articulate their needs to unfamiliar people means many are frustrated, and some are even opting out of services.

How can we improve things?

The three words the government associates with consumer directed home care are choice, control and markets. But the system doesn’t foster control. Although consumers technically have choices, the marketised and bureaucratic approaches of service providers make it difficult for consumers to articulate and receive support for their personal choices. The processes, information and supports available to assist older people and their families are inadequate to facilitate the type of choices and control one might associate with “consumer directed” care. There’s an urgent need to improve the processes for accessing timely home care packages, particularly for those with complex support needs. This includes the quality and accessibility of information, resources and decision-making tools. There’s also a significant need for training, advocacy and impartial support for choice, particularly for people with limited decision-making capacity, such as those living with dementia. Research and practice in aged care and disability in other settings provide extensive resources for person-centred planning and decision making which could be adapted for use in our home care system.The Conversation Lyn Phillipson, NHMRC-ARC Dementia Development Fellow, University of Wollongong and Louisa Smith, Research Fellow at AHSRI, University of Wollongong This article is republished from The Conversation under a Creative Commons license. Read the original article.
Dr Jo Marchant
Clinical Articles iconClinical Articles

Is there real science in the spiritualism of meditation? Jo Marchant meets a Nobel Prize-winner who thinks so. It’s seven in the morning on the beach in Santa Monica, California. The low sun glints off the waves and the clouds are still golden from the dawn. The view stretches out over thousands of miles of Pacific Ocean. In the distance, white villas of wealthy Los Angeles residents dot the Hollywood hills. Here by the shore, curlews and sandpipers cluster on the damp sand. A few metres back from the water’s edge, a handful of people sit cross-legged: members of a local Buddhist centre about to begin an hour-long silent meditation. Such spiritual practices may seem a world away from biomedical research, with its focus on molecular processes and repeatable results. Yet just up the coast, at the University of California, San Francisco (UCSF), a team led by a Nobel Prize-winning biochemist is charging into territory where few mainstream scientists would dare to tread. Whereas Western biomedicine has traditionally shunned the study of personal experiences and emotions in relation to physical health, these scientists are placing state of mind at the centre of their work. They are engaged in serious studies hinting that meditation might – as Eastern traditions have long claimed – slow ageing and lengthen life.

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Elizabeth Blackburn has always been fascinated by how life works. Born in 1948, she grew up by the sea in a remote town in Tasmania, Australia, collecting ants from her garden and jellyfish from the beach. When she began her scientific career, she moved on to dissecting living systems molecule by molecule. She was drawn to biochemistry, she says, because it offered a thorough and precise understanding “in the form of deep knowledge of the smallest possible subunit of a process”. Working with biologist Joe Gall at Yale in the 1970s, Blackburn sequenced the chromosome tips of a single-celled freshwater creature called Tetrahymena (“pond scum”, as she describes it) and discovered a repeating DNA motif that acts as a protective cap. The caps, dubbed telomeres, were subsequently found on human chromosomes too. They shield the ends of our chromosomes each time our cells divide and the DNA is copied, but they wear down with each division. In the 1980s, working with graduate student Carol Greider at the University of California, Berkeley, Blackburn discovered an enzyme called telomerase that can protect and rebuild telomeres. Even so, our telomeres dwindle over time. And when they get too short, our cells start to malfunction and lose their ability to divide – a phenomenon that is now recognised as a key process in ageing. This work ultimately won Blackburn the 2009 Nobel Prize in Physiology or Medicine. In 2000, she received a visit that changed the course of her research. The caller was Elissa Epel, a postdoc from UCSF’s psychiatry department. Psychiatrists and biochemists don’t usually have much to talk about, but Epel was interested in the damage done to the body by chronic stress, and she had a radical proposal. Epel, now director of the Aging, Metabolism and Emotion Center at UCSF, has a long-standing interest in how the mind and body relate. She cites as influences both the holistic health guru Deepak Chopra and the pioneering biologist Hans Selye, who first described in the 1930s how rats subjected to long-term stress become chronically ill. “Every stress leaves an indelible scar, and the organism pays for its survival after a stressful situation by becoming a little older,” Selye said. Back in 2000, Epel wanted to find that scar. “I was interested in the idea that if we look deep within cells we might be able to measure the wear and tear of stress and daily life,” she says. After reading about Blackburn’s work on ageing, she wondered if telomeres might fit the bill. With some trepidation at approaching such a senior scientist, the then postdoc asked Blackburn for help with a study of mothers going through one of the most stressful situations that she could think of – caring for a chronically ill child. Epel’s plan was to ask the women how stressed they felt, then look for a relationship between their state of mind and the state of their telomeres. Collaborators at the University of Utah would measure telomere length, while Blackburn’s team would measure levels of telomerase. Blackburn’s research until this point had involved elegant, precisely controlled experiments in the lab. Epel’s work, on the other hand, was on real, complicated people living real, complicated lives. “It was another world as far as I was concerned,” says Blackburn. At first, she was doubtful that it would be possible to see any meaningful connection between stress and telomeres. Genes were seen as by far the most important factor determining telomere length, and the idea that it would be possible to measure environmental influences, let alone psychological ones, was highly controversial. But as a mother herself, Blackburn was drawn to the idea of studying the plight of these stressed women. “I just thought, how interesting,” she says. “You can’t help but empathise.” It took four years before they were finally ready to collect blood samples from 58 women. This was to be a small pilot study. To give the highest chance of a meaningful result, the women in the two groups – stressed mothers and controls – had to match as closely as possible, with similar ages, lifestyles and backgrounds. Epel recruited her subjects with meticulous care. Still, Blackburn says, she saw the trial as nothing more than a feasibility exercise. Right up until Epel called her and said, “You won’t believe it.” The results were crystal clear. The more stressed the mothers said they were, the shorter their telomeres and the lower their levels of telomerase. The most frazzled women in the study had telomeres that translated into an extra decade or so of ageing compared to those who were least stressed, while their telomerase levels were halved. “I was thrilled,” says Blackburn. She and Epel had connected real lives and experiences to the molecular mechanics inside cells. It was the first indication that feeling stressed doesn’t just damage our health – it literally ages us.

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Unexpected discoveries naturally meet scepticism. Blackburn and Epel struggled initially to publish their boundary-crossing paper. “Science [one of the world’s leading scientific journals] couldn’t bounce it back fast enough!” chuckles Blackburn. When the paper finally was published, in the Proceedings of the National Academy of Sciences in December 2004, it sparked widespread press coverage as well as praise. Robert Sapolsky, a pioneering stress researcher at Stanford University and author of the bestselling Why Zebras Don’t Get Ulcers, described the collaboration as “a leap across a vast interdisciplinary canyon”. Mike Irwin, director of the Cousins Center for Psychoneuroimmunology at the University of California, Los Angeles, says it took a lot of courage for Epel to seek out Blackburn. “And a lot of courage for Liz [Blackburn] to say yes.” Many telomere researchers were wary at first. They pointed out that the study was small, and questioned the accuracy of the telomere length test used. “This was a risky idea back then, and in some people’s eyes unlikely,” explains Epel. “Everyone is born with very different telomere lengths and to think that we can measure something psychological or behavioural, not genetic, and have that predict the length of our telomeres? This is really not where this field was ten years ago.” The paper triggered an explosion of research. Researchers have since linked perceived stress to shorter telomeres in healthy women as well as in Alzheimer’s caregivers, victims of domestic abuse and early life trauma, and people with major depression and post-traumatic stress disorder. “Ten years on, there’s no question in my mind that the environment has some consequence on telomere length,” says Mary Armanios, a clinician and geneticist at Johns Hopkins School of Medicine who studies telomere disorders. There is also progress towards a mechanism. Lab studies show that the stress hormone cortisol reduces the activity of telomerase, while oxidative stress and inflammation – the physiological fallout of psychological stress – appear to erode telomeres directly. This seems to have devastating consequences for our health. Age-related conditions from osteoarthritis, diabetes and obesity to heart disease, Alzheimer’s and stroke have all been linked to short telomeres. The big question for researchers now is whether telomeres are simply a harmless marker of age-related damage (like grey hair, say) or themselves play a role in causing the health problems that plague us as we age. People with genetic mutations affecting the enzyme telomerase, who have much shorter telomeres than normal, suffer from accelerated-ageing syndromes and their organs progressively fail. But Armanios questions whether the smaller reductions in telomere length caused by stress are relevant for health, especially as telomere lengths are so variable in the first place. Blackburn, however, says she is increasingly convinced that the effects of stress do matter. Although the genetic mutations affecting the maintenance of telomeres have a smaller effect than the extreme syndromes Armanios studies, Blackburn points out that they do increase the risk of chronic disease later in life. And several studies have shown that our telomeres predict future health. One showed that elderly men whose telomeres shortened over two-and-a-half years were three times as likely to die from cardiovascular disease in the subsequent nine years as those whose telomeres stayed the same length or got longer. In another study, looking at over 2,000 healthy Native Americans, those with the shortest telomeres were more than twice as likely to develop diabetes over the next five-and-a-half years, even taking into account conventional risk factors such as body mass index and fasting glucose. Blackburn is now moving into even bigger studies, including a collaboration with healthcare giant Kaiser Permanente of Northern California that has involved measuring the telomeres of 100,000 people. The hope is that combining telomere length with data from the volunteers’ genomes and electronic medical records will reveal additional links between telomere length and disease, as well as more genetic mutations that affect telomere length. The results aren’t published yet, but Blackburn is excited about what the data already shows about longevity. She traces the curve with her finger: as the population ages, average telomere length goes down. This much we know; telomeres tend to shorten over time. But at age 75–80, the curve swings back up as people with shorter telomeres die off – proof that those with longer telomeres really do live longer. “It’s lovely,” she says. “No one has ever seen that.” In the decade since Blackburn and Epel’s original study, the idea that stress ages us by eroding our telomeres has also permeated popular culture. In addition to Blackburn’s many scientific accolades, she was named one of Time magazine’s “100 most influential people in the world” in 2007, and received a Good Housekeeping achievement award in 2011. A workaholic character played by Cameron Diaz even described the concept in the 2006 Hollywood film The Holiday. “It resonates,” says Blackburn. But as evidence of the damage caused by dwindling telomeres piles up, she is embarking on a new question: how to protect them.

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At first, the beach seems busy. Waves splash and splash and splash. Sanderlings wheel along the shoreline. Joggers and dog walkers amble across, while groups of pelicans hang out on the water before taking wing or floating out of sight. A surfer, silhouetted black against the sky, bobs about for 20 minutes or so, catching the odd ripple towards shore before he, too, is gone. The unchanging perspective gives a curious sense of detachment. You can imagine that the birds and joggers and surfers are like thoughts: they inhabit different forms and timescales but in the end, they all pass. There are hundreds of ways to meditate but this morning I’m trying a form of Buddhist mindfulness meditation called open monitoring, which involves paying attention to your experience in the present moment. Sit upright and still, and simply notice any thoughts that arise – without judging or reacting to them – before letting them go. For Buddhists this is a spiritual quest; by letting trivial thoughts and external influences fall away, they hope to get closer to the true nature of reality. Blackburn too is interested in the nature of reality, but after a career spent focusing on the measurable and quantifiable, such navel-gazing initially held little personal appeal and certainly no professional interest. “Ten years ago, if you’d told me that I would be seriously thinking about meditation, I would have said one of us is loco,” she told the New York Times in 2007. Yet that is where her work on telomeres has brought her. Since her initial study with Epel, the pair have become involved in collaborations with teams around the world – as many as 50 or 60, Blackburn estimates, spinning in “wonderful directions”. Many of these focus on ways to protect telomeres from the effects of stress; trials suggest that exercise, eating healthily and social support all help. But one of the most effective interventions, apparently capable of slowing the erosion of telomeres – and perhaps even lengthening them again – is meditation. So far the studies are small, but they all tentatively point in the same direction. In one ambitious project, Blackburn and her colleagues sent participants to meditate at the Shambhala mountain retreat in northern Colorado. Those who completed a three-month course had 30 per cent higher levels of telomerase than a similar group on a waiting list. A pilot study of dementia caregivers, carried out with UCLA’s Irwin and published in 2013, found that volunteers who did an ancient chanting meditation called Kirtan Kriya, 12 minutes a day for eight weeks, had significantly higher telomerase activity than a control group who listened to relaxing music. And a collaboration with UCSF physician and self-help guru Dean Ornish, also published in 2013, found that men with low-risk prostate cancer who undertook comprehensive lifestyle changes, including meditation, kept their telomerase activity higher than similar men in a control group and had slightly longer telomeres after five years. In their latest study, Epel and Blackburn are following 180 mothers, half of whom have a child with autism. The trial involves measuring the women’s stress levels and telomere length over two years, then testing the effects of a short course of mindfulness training, delivered with the help of a mobile app. Theories differ as to how meditation might boost telomeres and telomerase, but most likely it reduces stress. The practice involves slow, regular breathing, which may relax us physically by calming the fight-or-flight response. It probably has a psychological stress-busting effect too. Being able to step back from negative or stressful thoughts may allow us to realise that these are not necessarily accurate reflections of reality but passing, ephemeral events. It also helps us to appreciate the present instead of continually worrying about the past or planning for the future. “Being present in your activities and in your interactions is precious, and it’s rare these days with all of the multitasking we do,” says Epel. “I do think that in general we’ve got a society with scattered attention, particularly when people are highly stressed and don’t have the resources to just be present wherever they are.”

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Inevitably, when a Nobel Prize-winner starts talking about meditation, it ruffles a few feathers. In general, Blackburn’s methodical approach to the topic has earned a grudging admiration, even among those who have expressed concern about the health claims made for alternative medicine. “She goes about her business in a cautious and systematic fashion,” says Edzard Ernst of the University of Exeter, UK, who specialises in testing complementary therapies in rigorous controlled trials. Oncologist James Coyne of the University of Pennsylvania, Philadelphia, who is sceptical of this field in general and describes some of the research on positive psychology and health as “morally offensive” and “tooth fairy science”, concedes that some of Blackburn’s data is “promising”. Others aren’t so impressed. Surgeon-oncologist David Gorski is a well-known critic of alternative medicine and pseudoscience who blogs under the name of Orac – he’s previously described Dean Ornish as “one of the four horsemen of the Woo-pocalypse”. Gorski stops short of pronouncing meditation as off-limits for scientific inquiry, but expresses concern that the preliminary results of these studies are being oversold. How can the researchers be sure they’re investigating it rigorously? “It’s really hard to do with these things,” he says. “It is easy to be led astray. Nobel Prize-winners are not infallible.” Blackburn’s own biochemistry community also seems ambivalent about her interest in meditation. Three senior telomere researchers I contacted declined to discuss this aspect of her work, with one explaining that he didn’t want to comment “on such a controversial issue”. “People are very uncomfortable with the concept of meditation,” notes Blackburn. She attributes this to its unfamiliarity and its association with spiritual and religious practices. “We’re always trying to say it as carefully as we can… always saying ‘look, it’s preliminary, it’s a pilot’. But people won’t even read those words. They’ll see the newspaper headings and panic.” Any connotation of religious or paranormal beliefs makes many scientists uneasy, says Chris French, a psychologist at Goldsmiths, University of London, who studies anomalous experiences including altered states of consciousness. “There are a lot of raised eyebrows, even though I’ve got the word sceptic virtually tattooed across my forehead,” he says. “It smacks of new-age woolly ideas for some people. There’s a kneejerk dismissive response of ‘we all know it’s nonsense, why are you wasting your time?’” "When meditation first came to the West in the 1960s it was tied to the drug culture, the hippie culture,” adds Sara Lazar, a neuroscientist at Harvard who studies how meditation changes the structure of the brain. “People think it’s just a bunch of crystals or something, they roll their eyes.” She describes her own decision to study meditation, made 15 years ago, as “brave or crazy”, and says that she only plucked up the courage because at around the same time, the US National Institutes of Health (NIH) created the National Center for Complementary and Alternative Medicine. “That gave me the confidence that I could do this and I would get funding.” The tide is now turning. Helped in part by that NIH money, researchers have developed secularised – or non-religious – practices such as mindfulness-based stress reduction and mindfulness-based cognitive therapy, and reported a range of health effects from lowering blood pressure and boosting immune responses to warding off depression. And the past few years have seen a spurt of neuroscience studies, like Lazar’s, showing that even short courses of meditation can forge structural changes in the brain. “Now that the brain data and all this clinical data are coming out, that is starting to change. People are a lot more accepting [of meditation],” says Lazar. “But there are still some people who will never believe that it has any benefit whatsoever." Blackburn’s view is that meditation is a fair topic to study, as long as robust methods are used. So when her research first pointed in this direction, she was undaunted by concerns about what such studies might do to her reputation. Instead, she tried it out for herself, on an intensive six-day retreat in Santa Barbara. “I loved it,” she says. She still uses short bursts of meditation, which she says sharpen her mind and help her to avoid a busy, distracted mode. She even began one recent paper with a quote from the Buddha: “The secret of health for both mind and body is not to mourn for the past, worry about the future, or anticipate troubles but to live in the present moment wisely and earnestly.” That study, of 239 healthy women, found that those whose minds wandered less – the main aim of mindfulness meditation – had significantly longer telomeres than those whose thoughts ran amok. “Although we report merely an association here, it is possible that greater presence of mind promotes a healthy biochemical milieu and, in turn, cell longevity,” the researchers concluded. Contemplative traditions from Buddhism to Taoism believe that presence of mind promotes health and longevity; Blackburn and her colleagues now suggest that the ancient wisdom might be right.

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I meet with Blackburn in Paris. We’re at an Art Nouveau-themed bistro just down the road from the Curie Institute, where she is on a short sabbatical, arranging seminars between groups of scientists who don’t usually talk to one another. In a low, melodious voice that I strain to hear through the background clatter, the 65-year-old tells me of her first major brush with Buddhist thinking. In September 2006, she attended a conference held at the Menla Mountain Buddhist centre, a remote retreat in New York’s Catskill mountains, at which Western scientists met with Tibetan-trained scholars including the Dalai Lama to discuss longevity, regeneration and health. During the meeting, the spiritual leader honoured Blackburn’s scientific achievements by inducting her as a “Medicine Buddha”. If Epel’s psychiatry research had been another world, the scholars’ Eastern philosophy seemed to Blackburn more alien still. Over dinner one evening, while explaining to the other delegates how errors in the gene for telomerase can cause health problems, she described genetic mutation as a random, chance event. That’s dogma for Western scientists but not for those trained in the Tibetan worldview. “They said ‘oh no, we don’t regard this as chance’,” says Blackburn. For these holistic scholars, even the smallest events were infused with meaning. “I suddenly thought, whoa, this is a very different world from the one I’m on.” But instead of dismissing her Eastern counterparts, she was impressed, finding the Dalai Lama to have “a very good brain”, for example. “They’re scholarly in a very different way, but it is still good-quality thinking,” she explains. “It wasn’t ‘God told me this’, it was more ‘let’s see what actually happens in the brain’. So there are certain elements of the approach that I am quite comfortable with as a scientist.” Blackburn isn’t tempted to embrace the spiritual approach herself. “I’m rooted in the physical world,” she says. But she combines that grounding with an open mind towards new ideas and connections, and she seems to love breaking out of established paradigms. For example, she and Epel have shown that the effects of stress on telomeres can be passed on to the next generation. If women experience stress while pregnant, their children have shorter telomeres, as newborns and as adults – in direct contradiction of the standard view that traits can only be passed on via our genes. In the future, information from telomeres may help doctors decide when to prescribe particular drugs. For example, telomerase activity predicts who will respond to treatment for major depression, while telomere length influences the effects of statins. In general, however, Blackburn is more interested in how telomeres might help people directly, by encouraging them to live in a way that reduces their disease risk. “This is not a familiar model for the medical world,” she says. Conventional medical tests give us our risk of particular conditions – high cholesterol warns of impending heart disease, for example, while high blood sugar predicts diabetes. Telomere length, by contrast, gives an overall reading of how healthy we are: our biological age. And although we already know that we should exercise, eat well and reduce stress, many of us fall short of these goals. Blackburn believes that putting a concrete number on how we are doing could provide a powerful incentive to change our behaviour. In fact, she and Epel have just completed a study (as yet unpublished) showing that simply being told their telomere length caused volunteers to live more healthily over the next year than a similar group who weren’t told. Ultimately, however, the pair want entire countries and governments to start paying attention to telomeres. A growing body of work now shows that the stress from social adversity and inequality is a major force eroding these protective caps. People who didn’t finish high school or are in an abusive relationship have shorter telomeres, for example, while studies have also shown links with low socioeconomic status, shift work, lousy neighbourhoods and environmental pollution. Children are particularly at risk: being abused or experiencing adversity early in life leaves people with shorter telomeres for the rest of their lives. And through telomeres, the stress that women experience during pregnancy affects the health of the next generation too, causing hardship and economic costs for decades to come. In 2012, Blackburn and Epel wrote a commentary in the journal Nature, listing some of these results and calling on politicians to prioritise “societal stress reduction”. In particular, they argued, improving the education and health of women of child-bearing age could be “a highly effective way to prevent poor health filtering down through generations”. Meditation retreats or yoga classes might help those who can afford the time and expense, they pointed out. “But we are talking about broad socioeconomic policies to buffer the chronic stressors faced by so many.” Where many scientists refrain from discussing the political implications of their work, Blackburn says she wanted to speak out on behalf of women who lack support, and say “You’d better take their situations seriously.” While arguments for tackling social inequality are hardly new, Blackburn says that telomeres allow us to quantify for the first time the health impact of stress and inequality and therefore the resulting economic costs. We can also now pinpoint pregnancy and early childhood as “imprinting periods” when telomere length is particularly susceptible to stress. Together, she says, this evidence makes a stronger case than ever before for governments to act. But it seems that most scientists and politicians still aren’t ready to leap across the interdisciplinary canyon that Blackburn and Epel bridged a decade ago. The Nature article has engendered little response, according to a frustrated Epel. “It’s a strong statement so I would have thought that people would have criticised it or supported it,” she says. “Either way!” “It’s now a consistent story that the ageing machinery is shaped at the earliest stages of life,” she insists. “If we ignore that and we just keep trying to put band-aids on later, we’re never going to get at prevention and we’re only going to fail at cure.” Simply responding to the physical symptoms of disease might make sense for treating an acute infection or fixing a broken leg, but to beat chronic age-related conditions such as diabetes, heart disease and dementia, we will need to embrace the fuzzy, subjective domain of the mind. This article first appeared on Mosaic and is republished here under a Creative Commons licence.

Expert/s: Dr Jo Marchant
Suzanne Dyer
Clinical Articles iconClinical Articles

A new study out today has found residents with dementia in aged-care facilities that provide a home-like model of care have a better quality of life and fewer hospitalisations than those living in more standard facilities. We also found the benefits of a home-like model were provided without an increase in running costs. Our study compared home-like models (which have up to 15 residents per unit and free access to outdoor areas) to more standard residential care, where a large number of people are housed in one building. In 2011, around half of all facilities in Australia had places for more than 60 residents, and the average size is growing. The World Health Organisation has stated smaller home-like residential care settings “hold promise for older people, family members and volunteers who provide care and support”. But Australia is lagging behind other countries in offering alternative models of residential aged care.
Read more: There's no need to lock older people into nursing homes 'for their own safety'

What is a home-like model of care?

Most older people with dementia want to stay at home as long as they can. When this is no longer possible, they move into residential aged-care facilities, which become their homes. These residential facilities, or nursing homes, frequently adopt a model of care that emphasises individuality. This is known as person-centred care. But delivering this model may require more staff or a different mix of staff, which may be difficult to deliver with current funding. So standard aged-care facilities in Australia often have some similarities to health facilities, with designated staff areas and centralised kitchens. Access to outdoor areas, particularly for people with dementia, may depend on the availability of staff. Despite adhering to philosophies such as person-centred care, the scheduling of this care and of meals often lacks flexibility. The problems are compounded when residential care is used for multiple purposes ranging from palliative care to providing care for people with dementia. The needs of these two groups are quite different and the lack of focus makes delivering quality care a challenge. Evidence shows the physical design of the residential aged-care environment may play an important role in the well-being of residents, particularly those living with dementia. Internationally, there is a move towards providing care in facilities that feel more like a home and promote independence. Such models of residential aged care generally have:
  • flexibility in daily routines – for example, the time people get dressed and eat
  • opportunity for residents to participate in domestic activities such as meal preparation
  • access to outdoor spaces
  • clusters of smaller living units (up to, say, 15 residents in each)
  • care staff assigned to living units for continuity of care and development of relationships between staff and residents.

Read more: God’s waiting room? Life needs to be valued in nursing homes

What we found

Our study was specifically designed to include people with dementia and their family members. People with dementia are not often included in research studies. It included 541 participants from 17 not-for-profit residential aged-care facilities in four different states in Australia. They had been residents for a year or longer. These facilities were all considered high quality. This means they had lower hospitalisation rates for potentially avoidable conditions than the national performance target. And more than 80% of residents in the standard care facilities indicated they felt as safe as they wanted and that their environment was as clean and comfortable as they wanted. Around one-quarter of people in the study lived in a facility with a home-like model of care. All of them were living with dementia. The study found residents in home-like models of care had a better quality of life, as rated by the residents themselves or their family members. They also had a 68% lower rate of being admitted to hospital and 73% lower rate of having an emergency department presentation. We have previously shown residents who lived in a home-like model were 52% less likely to be exposed to potentially inappropriate medications. These are medications where the potential harms may outweigh the benefit, such as antipsychotics or relaxants, but are still often prescribed to older people in residential care. The benefits for residents were provided with similar running costs for the home-like and the standard models of care. However, the costs excluded differences in the build of the facilities. Initial establishment costs are likely to be higher, due to the requirement for more space per resident.
Read more: There is extra funding for aged care in the budget, but not enough to meet demand

Rethinking models of care

Funding arrangements don’t incentivise Australian aged-care providers to offer variety in terms of models of care. Government funding is provided based on the assessed care needs of the residents, rather than the preferred model of care or resident outcomes. Funding supplements are available to care providers for reasons such as residents’ financial hardship or risk of homelessness and to small, rural aged-care service providers, but none are available for offering an alternative model of care. The ConversationThe Australian government plans to improve the aged-care system to offer “choice and flexibility”. This is crucial, but we also need to improve choice and variety in residential aged-care models. Suzanne Dyer, Senior Research Fellow, Flinders University and Stephanie Harrison, Postdoctoral research fellow, Flinders University This article was originally published on The Conversation. Read the original article.
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Want to preserve your brain function into old age? Cut down on the booze. That’s the conclusion of a large, longitudinal study just published in JAMA Psychiatry. After comparing more than 200 alcohol dependent adults with a similar number of healthy adults, over a 14 year period, the US researchers concluded alcohol-dependence accelerated the cortical ageing process even if the alcohol habit developed later in life. They found, through a series of MRIs that alcohol dependence (as per the DSM-IV criteria) resulted in more rapid frontal lobe deterioration than that which just occurred with age, regardless of gender. As part of the study the researchers also looked at whether comorbidities such as drug use or hepatitis C infection made a difference to the decline in cognitive function. And while they found they compounded the shrinkage of the frontal lobe, the actual deficits in the frontal cortex seemed to be associated chiefly with the alcohol. “We observed a selectivity of frontal cortex to age-alcoholism interaction beyond normal aging effects and independent of deficits related to drug dependence,” they said. Also, the researchers found that the deterioration was more associated with current drinking habits  than the cumulative effect of many years of alcohol abuse. People who had become alcohol dependent later in life were just as vulnerable as people whose alcohol use disorder started when they were younger. “The accelerated volume deficits in the older alcohol-dependent participants could not readily be attributed to more years of heavy drinking, given that many had a late onset of their disorder and lower lifetime alcohol consumption estimates than their early-onset counterparts,” the study authors said. So, it appears the frontal cortex, which is that part of brain that helps people plan, reason, modify behaviours and problem solve is the most vulnerable to damage in people with alcohol use disorder. Add this to the fact the frontal cortex deterioration associated with aging, is fundamentally responsible for the deterioration in executive function that limits an elderly person’s ability to function and live independently, and you have a recipe for disaster for those older people who drink to excess. What does this all mean? An accompanying editorial makes the take home message quite clear. “Given the rapidly growing aging population… it is critical that we improve and implement strategies to address alcohol misuse among older drinkers. As Yoda might say, “Protect their brains, we must.” Ref: JAMA Psychiatry. Published online March 14, 2018. doi:10.1001/jamapsychiatry.2018.002 JAMA Psychiatry. Published online March 14, 2018. doi:10.1001/jamapsychiatry.2018.0009