bluuebunny/crossref_metadata_2025 huggingface dataset:
The Concept of Mindfulness in Integrative Preventive Medicine
Authors: Aikens Kim , Shapiro Shauna
Published: December 2017

This chapter discusses mindfulness as it applies to integrative preventive medicine. Defining mindfulness as the awareness that arises through intentionally attending in an open, caring, and discerning way, the chapter proposes three core mindfulness elements: intention, attention, and attitude. It explores the potential application of mindfulness to primary, secondary, and tertiary prevention. The chapter looks at the impact of mindfulness on health promotion and examines mindfulness as a secondary prevention strategy, particularly in hypertension and diabetes. It then addresses tertiary prevention and the impact of mindfulness in chronic disease. Lastly, mindfulness as a preventive strategy for psychological well-being is explored. Overall, there is strong evidence suggesting that mindfulness is positively associated with healthy lifestyle as well as improvements in depressive symptoms, stress, anxiety, quality of life, physical outcomes, and positive psychological health.
The Role of Spirituality in Integrative Preventive Medicine
Authors: Schwartz Gary E.
Published: December 2017

Substantial research documents a positive association between religious practice and improved health and well-being. Research on the relationship between spirituality and health is less developed but also positive. Generally speaking, Western science and medicine explain these positive associations via psychological and social mechanisms rather than spiritual (or “metaphysical”) ones. However, contemporary theory and research in consciousness science, including research on near-death experiences and life after death, are pointing to a profound paradigm change in science, shifting from conventional materialist models of nature and the cosmos to postmaterialist models. This chapter introduces the reader to the emerging postmaterialist paradigm in science and considers some of its important implications for understanding and applying spirituality in integrative preventive medicine.
The Role of Nutrition in Integrative Preventive Medicine
Authors: Willett Walter C.
Published: December 2017

Until recently, and still today in low-income countries, undernutrition during pregnancy and early childhood was a major cause of mortality. However, in recent decades, noncommunicable diseases account for the majority of premature deaths both in the United States and globally. Although dietary factors have been identified as the most important causes of this, physicians and other healthcare providers are taught little about nutrition in medical school or fellowship training. In conventional medical practice almost no attention is given to knowing what a patient is eating or providing dietary guidance that has the potential to improve dramatically their long-term health. This chapter describes what we know about the elements of a healthy diet and how these elements can be combined into an overall dietary pattern for the prevention of major illness and promotion of well-being. A brief section considers ways that this knowledge can be integrated into preventive healthcare.
The Role of Exercise in Integrative Preventive Medicine
Authors: Roizen Michael F. , Roizen Jeffrey D.
Published: December 2017

Eighty observational association studies and several controlled trials provide strong evidence that exercise, done in appropriate amounts and with appropriate techniques, can dramatically enhance well-being and decrease morbidity and mortality. This chapter summarizes the available evidence so that healthcare providers can write rational prescriptions for physical activity for patients that allow minimal activity for maximum health benefit. In brief, doing four physical activities weekly—(1) any kind, (2) strength building, (3) bone strengthening (jumping), and (4) stamina building—and avoiding prolonged (> 1 hr) inactivity by walking for two minutes every hour—provides maximal morbidity and mortality benefit.
Reversing Chronic Diseases Using Lifestyle Medicine
Authors: Brown Benjamin R.
Published: December 2017

Many of the most common chronic diseases in the Western world are now preventable and even reversible using comprehensive lifestyle changes; this has spawned a new field named lifestyle medicine. Lifestyle medicine is a subset of integrative preventive medicine that focuses on changing the four or more core behaviors: nutrition, movement, relaxation, and social support. The diseases that have been shown to be reversible include even severe coronary heart disease, type 2 diabetes, hypertension, obesity, hyperlipidemia, and early-stage prostate cancer. Many forces are converging that make this the right idea at the right time. This chapter focuses on reviewing randomized-controlled trials and demonstration projects illustrating both the medical effectiveness and cost-effectiveness of lifestyle medicine as a new paradigm of healthcare—one that integrates the best of conventional treatments such as drugs and surgery with the power of comprehensive lifestyle changes.
Midlife Transitions—The Integrative Preventive Medicine Approach to the Evaluation and Management of Menopause and Andropause
Authors: Geyer Cynthia , Brewer Steven
Published: December 2017

Much more has been written about the pros and cons of hormone therapy for women in menopause than has been studied for men in andropause. In two separate sections, this chapter explores those pros and cons in more detail, as well as how to customize recommendations for individuals. Alternative modalities for managing symptoms are discussed, along with the key lifestyle interventions such as resistance training that can counter some of the physical changes associated with declining hormone levels. Attending to the emotional changes that may accompany menopause and andropause is an important component of working with women and men in this time of their lives. A whole-person approach, incorporating preventive and lifestyle medicine practices, may help shift concerns about aging and hormonal changes into a window of opportunity to embrace this next stage of life in as healthy and vibrant a way as possible.
Integrative Medicine and Public Policy
Authors: Briggs Josephine P.
Published: December 2017

This chapter, “Integrative Medicine and Public Policy,” summarizes the public resources supporting the development of integrative medicine and some of the policy and regulatory implications of the model of integrative care that starts with the personal perspective of the patient. This chapter focuses on patient self-education, research on complementary health approaches and the development of an evidence-base for the practice of integrative medicine, professional standards for integrative medicine for complementary and alternative medicine providers, and the costs of complementary and alternative medical care and reimbursement practices. The promise of integrative medicine more effectively engaging patients in their own self care could lead to better outcomes at lower cost, with improved patient satisfaction and adherence.
Cardiovascular–Pulmonary Interactions
Authors: Kreit John W.
Published: December 2017

Intramural pressures within a tube or circuit determine the rate and direction of flow, whereas the transmural pressure of an elastic structure determines its volume. In Chapter 1, we applied these principles when talking about the pressure needed to overcome viscous forces and elastic recoil during ventilation. In this chapter, we use them to explain changes in blood flow between two portions of the circulatory system and changes in the volume and size of the heart chambers. Cardio–Pulmonary Interactions provides an overview of essential cardiovascular physiology as well as an in-depth discussion of how and why changes in pleural, alveolar, lung transmural, and intra-abdominal pressure during spontaneous and mechanical ventilation can alter right and left ventricular preload, afterload, and stroke volume, cardiac output, and blood pressure. The chapter also reviews the beneficial and detrimental effects of positive end-expiratory pressure (PEEP) on cardiovascular function.
Ventilator Alarms—Causes and Evaluation
Authors: Kreit John W.
Published: December 2017

When a patient is intubated and placed on mechanical ventilation, the clinician must write a series of ventilator orders. It’s important to recognize though, that several other parameters are typically set by the respiratory therapist without direct physician input. The most important are the critical values that will trigger a ventilator alarm. ICU ventilators constantly monitor many machine and patient-related variables, including airway pressure, flow rate, volume, and respiratory rate, and it seems like there’s an alarm for almost everything. While it’s true that some alarms are of little or no significance, others may indicate an important and potentially life-threatening problem. Ventilator Alarms—Causes and Evaluation describes important ventilator alarms and how each is set and triggered. It also reviews how to determine the cause of each ventilator alarm and how to correct the identified problems.
In Vivo Circuit Analysis
Authors: Bowman Ryan , Schwennesen Hannah , Dzirasa Kafui , Hultman Rainbo
Published: December 2017

Breakthroughs in understanding neural circuit activity hold much promise for developing next generation therapeutics for psychiatric disorders. Determination of how dynamic activity is coordinated across brain regions to effect specific behavioral function (or dysfunction) enables the development of therapeutics with increased specificity and fewer side effects. This chapter discusses methodologies for measuring neural circuit activity in humans and in animal models, and describes a bidirectional research pipeline whereby studies in humans are followed by tightly controlled studies in animal models that can then be applied back to humans. Targeted neural circuit manipulations from these studies are already being applied to a wide range of therapeutic strategies.
Neuromodulation and Psychiatric Disorders
Authors: Goodman Wayne K. , George Mark S.
Published: December 2017

An increasing number of approaches permit psychiatrists to directly stimulate the brain. Such therapies are sometimes referred to as neuromodulation, as psychiatrists can either excite or inhibit neuronal firing in the brain. This chapter reviews two such technologies—transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS). Both techniques have FDA approval and are moving into mainstream therapeutic use. Daily prefrontal TMS for 4–6 weeks is FDA approved for treating depression, with minimal side effects. It is now accepted in most treatment algorithms as an approach for patients who have not responded to medications or talking therapy. DBS has virtually replaced ablative neurosurgery for use in medication-refractory movement disorders such as Parkinson’s Disease (PD), where it has the advantages of being reversible (explantable) and adjustable. DBS is now being studied in severe psychiatric conditions, such as intractable obsessive-compulsive disorder (OCD) and treatment resistant depression (TRD).
The Neurobiology of Sleep
Authors: Tononi Giulio , Cirelli Chiara
Published: December 2017

Sleep is required for health and well-being, and consumes roughly one-third of a human’s lifetime, yet its functions remain incompletely understood. This chapter provides an overview of so-called sleep architecture—the stages and cycles that characterize sleep, including rapid eye movement (REM) and non-REM periods. Also discussed are the numerous regions of brain and neurotransmitters that control the induction of sleep, the transitions between REM and non-REM sleep cycles, and wakefulness. Key brain systems include GABAergic neurons in the pre-optic area, the neuropeptide orexin in lateral hypothalamic neurons, histaminergic neurons in the hypothalamus, monoaminergic (norepinephrine and serotonin) and acetylcholinergic nuclei in the brainstem, and the brain’s adenosine system, all of which work in integrated circuits to control sleep and wakefulness. Overlaid on sleep-wake cycles are circadian rhythms, and the crucial role played by the suprachiasmatic nucleus in entraining such rhythms to environmental light.
Genetics of Schizophrenia and Bipolar Disorder
Authors: Charney Alexander , Sklar Pamela
Published: December 2017

Schizophrenia and bipolar disorder are the classic psychotic disorders. Both diseases are strongly familial, but have proven recalcitrant to genetic methodologies for identifying the etiology until recently. There is now convincing genetic evidence that indicates a contribution of many DNA changes to the risk of becoming ill. For schizophrenia, there are large contributions of rare copy number variants and common single nucleotide variants, with an overall highly polygenic genetic architecture. For bipolar disorder, the role of copy number variation appears to be much less pronounced. Specific common single nucleotide polymorphisms are associated, and there is evidence for polygenicity. Several surprises have emerged from the genetic data that indicate there is significantly more molecular overlap in copy number variants between autism and schizophrenia, and in common variants between schizophrenia and bipolar disorder.
Neuroimaging of Psychotic Disorders
Authors: Heckers Stephan , Woodward Neil , Öngür Dost
Published: December 2017

Neuroimaging of psychotic disorders began in the 1970s with studies of brain structure, followed by studies of blood flow, glucose metabolism, and receptor chemistry. More recently, studies of functional activation, connectivity, and neurotransmission have been added. The widespread availability of MRI has liberated researchers from the constraints of postmortem research and the limitations of inferring brain abnormalities through neurochemical effects in plasma or urine. Neuroimaging researchers aim to establish diagnostic markers, explain abnormal mental states, test anatomical and neurochemical models, and study the association of risk genes with brain abnormalities. Most studies have been cross-sectional and limited in size. But the ability to assess patients longitudinally and with large-scale study designs will ensure a prominent position for this research domain in the study of psychotic disorders.
Animal and Cellular Models of Psychotic Disorders
Authors: Pletnikov Mikhail V. , Ming Guo-Li , Ross Christopher A.
Published: December 2017

Animal and cell models are experimental systems developed to study particular aspects of a disease, as no model can accurately reflect all features of the disease. In this critical review we mention some of the nongenetic models but focus on genetic mouse models, evaluate their advantages and limitations, and comment on potential new prospects for the field. The ability to reprogram somatic cells from patients and unaffected donors to induced pluripotent stem cells (iPSCs) has the potential to substantially enhance our knowledge of normal cellular development and disease pathogenesis. The use of cell and animal models will help elucidate basic cellular and molecular mechanisms of pathogenesis, which will enable the development of targeted therapeutic approaches.
Diagnosis and Epidemiology of Depression
Authors: Van Dam Nicholas T. , Iacoviello Brian M. , Murrough James W.
Published: December 2017

Depressive disorders are among the most disabling medical illnesses worldwide and limited efficacy of currently available medication and psychotherapy treatments adds to this large public health burden. In the current chapter, we consider findings from several large-scale health surveys to estimate the burden of illness, and review the current data available regarding prognosis, psychiatric and medical comorbidities, and socio-demographic factors influencing the prevalence and course of depression. We also consider emerging alternative methods of conceptualizing depression and other mental disorders that emphasize a dimensional rather than categorical approach. Increasing attention to such approaches in the design of psychiatric research related to depression may lead to an improved understanding of depression and more effective treatments.
Genetics of Depression
Authors: Levinson Douglas F. , Nichols Walter E.
Published: December 2017

Major depressive disorder (MDD) is a common and heterogeneous complex trait. Twin heritability is 35%–40%, perhaps higher in severe/recurrent cases. Adverse life events (particularly during childhood) increase risk. Current evidence suggests some overlap in genetic factors among MDD, bipolar disorder, and schizophrenia. Large genome-wide association studies (GWAS) are now proving successful. Polygenic effects of common SNPs are substantial. Findings implicate genes with effects on synaptic development and function, including two obesity-associated genes (NEGR1 and OLFM4), but not previous “candidate genes.” It can now be expected that larger GWAS samples will produce additional associations that shed new light on MDD genetics.
Neuroimaging of Depression
Authors: Bertocci Michele A. , Phillips Mary L.
Published: December 2017

This chapter illustrates the historical progression, methodological approaches, and current neurobiological understanding of depression, the first leading cause of mental and behavioral disorder disability in the United States. We describe and position, in relation to depressive symptoms, the complex abnormalities that depressed adults and youth show concerning neural function during tasks and at rest, structural abnormalities, as well as key neurotransmitter, neuroreceptor, and metabolic abnormalities that have been examined in the literature. We also describe newer findings and methods such as differentiating between unipolar and bipolar depression and applying machine learning to individual prediction. Finally, we provide suggestions for future study.
Animal Models of Mood Disorders
Authors: Alcantara Lyonna F. , Parise Eric M. , Bolaños-Guzmán Carlos A.
Published: December 2017

Animal modeling has advanced our understanding of the underlying pathophysiology of human neuropsychiatric disorders and facilitated development of safer, more efficient medications. Similar to humans with depression, rodents exposed to various stress paradigms exhibit aberrant responses to rewarding stimuli, along with hormonal and immunological dysregulation. Development of more complex models, such as social defeat, has led to a firmer grasp of the mechanisms mediating resilience and susceptibility to stress; and adapted versions of social defeat have yielded insights into how emotional stress influences development of mood disorders. This chapter focuses on stress-induced models of mood disorders and outlines how a depression-like phenotype is induced and tested in rodents.
New Approaches for Treating Depression
Authors: Nestler Eric J.
Published: December 2017

Several obstacles have impeded the introduction of new antidepressant medications over the past six decades. These obstacles include our still rudimentary knowledge of the biological basis of depression, as well as difficulties in evaluating the therapeutic efficacy of new putative antidepressant mechanisms in pathophysiologically distinct subtypes of the syndrome. Despite these obstacles, several tangible steps can be taken to advance depression treatment moving forward. The field needs to continue to take advantage of serendipitous discoveries in humans, such as the demonstration of rapid antidepressant effects of ketamine. Re-establishing experimental pharmacology in humans, to make it possible to establish the actions of new mechanisms in people, is essential, combined with the judicious use of a growing range of chronic stress models in animals. We anticipate that, with these approaches, the field can at long last breakthrough the logjam of discovery and introduce new treatments for depression over the next decade.
Current Treatments for Depression
Authors: Krystal John H. , Charney Dennis S.
Published: December 2017

Depression is among the most common and disabling medical disorders worldwide. Pharmacotherapy plays an important role in its treatment, although only half of all depressed patients show full remission with currently available therapies. This chapter reviews the most common pharmacotherapies with respect to their mechanisms of action, efficacy, tolerability, and safety. It also considers pharmacologic approaches to treatment-resistant symptoms of depression including adjunctive pharmacotherapies and the emerging rapid-acting antidepressants. An important focus of current research is to devise biological measures that direct a given patient to an effective form of treatment. Depression research is at a very exciting phase that will have important consequences for affected patients and for society overall.
Diagnosis and Epidemiology of Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders
Authors: Stein Murray B. , Keough Meghan E. , Roy-Byrne Peter P.
Published: December 2017

The anxiety, obsessive-compulsive, and trauma- and stressor-related disorders are, together, the most common class of mental disorders. From a systematic review of prevalence studies across 44 countries, the global current prevalence for the DSM IV anxiety disorders was estimated at 7.3% (95% CI 4.8%–10.9%), suggesting that one in 14 people around the world at any given time has an anxiety disorder. Women are approximately twice as likely as men to have an anxiety disorder. Anxiety disorders are a substantial contributor to the heavy burden of disease conveyed by mental and substance use disorders worldwide, where they are second only to depressive disorders in years-lost-to-disabilility.
Genetics of Anxiety Disorders
Authors: Otowa Takeshi , Roberson-Nay Roxann , Bekhbat Mandakh , Neigh Gretchen N. , Hettema John M.
Published: December 2017

This chapter provides a broad overview of the state of research in the genetics of the major anxiety disorders (ADs). They exhibit moderate familial aggregation and heritability due to genetic risk factors that are shared between them as well as those that are disorder-specific. Many candidate gene association studies have been published, with a small set of genes that have been consisted validated for their role in one or more anxiety phenotypes. Genome-wide association studies of ADs are in their infancy, with a handful of published studies for each disorder so far and more to come conducted by large consortia. Animal studies provide a promising complimentary approach that demonstrate concurring evidence across species supporting the involvement of particular biological systems in anxiety-related behaviors.
Animal Models and Assays Probing Anxiety Related Behaviors and Neural Circuits
Authors: Tasan Ramon , Singewald Nicolas
Published: December 2017

Anxiety tests and models in rodents are useful tools to reveal neurochemical, cellular, and molecular underpinnings of normal and pathological anxiety-related behaviors, as well as novel treatment targets. While anxiety models are generated by various approaches such as selective breeding, anxiety tests most commonly involve unconditioned approach avoidance tasks and conditioned learning paradigms, both characterized by inherent advantages and limitations, in particular their predictive value for specific anxiety disorders. To further improve the validity and translatability of preclinical anxiety testing, it is promising that some anxiety-relevant endophenotypes have now been investigated using similar tests in rodents and humans and that the involved neural pathways and mechanisms overlap considerably in both species.
Population ageing in Asia
Authors: Peng Du , Ting Cao
Published: December 2017

Decline in fertility, mortality, and rapid population migration has contributed to the structural changes of population in Asia. By the mid-twenty-first century, Asia will become the oldest region in the world with more than half (62%) of the world’s older population. While the pace of ageing differs across Asia, all countries/areas will face challenges to sustaining economic growth, while at the same time responding to a rising demand for social welfare and pension, health, and medical care—particularly long-term care and social services. It becomes increasingly recognized that relying on the role of family or the government to provide support for elders is not only unreliable but also costly. Policy and innovative initiatives should be made to emphasize collaboration among individuals, families, communities in enhancing home- and community-based care, creating an enabling environment, as well as supporting older persons’ participation in society.
Population ageing in Arab countries
Authors: Sibai Abla Mehio , Rizk Anthony
Published: December 2017

To varying degrees, Arab countries are experiencing demographic shifts towards ageing populations. This is brought about by a region-wide decline in mortality and fertility rates and a surge in life expectancy over the last few decades. Future projections indicate a much faster pace of population ageing with subsequent rectangularization of the population pyramid. Rapid urbanization, increased tobacco consumption, nutrition transition, and reduced physical activity have contributed towards the rise of non-communicable diseases in later life. Of significance are the high levels of diabetes and obesity in oil-rich countries. Meanwhile, geriatrics and gerontology remain nascent fields in most medical and nursing schools. Some of the most pressing needs include building population-based databases, emphasizing geriatric and gerontology programmes, embracing a holistic patient-centred approach to care supported by coordinated referrals to specialized follow-up, capitalizing on the role of the family and intergenerational support systems, and encouraging civil society organizations of older persons.
Models of healthcare for older people
Authors: Pitkala Kaisu , Gladman John , Connolly Martin
Published: December 2017

Older people are major users of health and social care in many developed countries, and so all health and social care systems in such countries need to be fit for older users such as those with deafness, blindness, or dementia. Despite this, specific services for older people with the most complex or challenging problems have developed. These models of healthcare for older people are diverse. They can deal with both acute and chronic health problems including rehabilitation. They can be provided in or across community, long-stay, and hospital settings, and often involve a wide range of professionals. They have developed in different ways in different countries. This chapter describes specific models of older people’s care, and outlines the role of geriatricians and other professionals in the models.
Age-friendly environments and their role in supporting Healthy Ageing
Authors: Officer Alana Margaret , Warth Lisa , Keating Norah , Beard John R.
Published: December 2017

This chapter explores the role of age-friendly environments in supporting healthy ageing. Environments are important determinants of the trajectories of intrinsic capacity and functional ability over a person’s life course and into older age. Several domains of functional ability are particularly important in later life. We explore the importance of environments in enhancing three domains of functional ability: the ability to meet basic needs, to be mobile, and to build and maintain relationships. The chapter concludes with implications of an environmental approach to Healthy Ageing for geriatric medicine. These are new perspectives on holistic views of older persons in their environment, on making health services more age-friendly and on working collaboratively to achieve better outcomes.
Dementia specialist care units
Authors: Palm Rebecca , Bartholomeyczik Sabine
Published: December 2017

Dementia specialist care units (DSCUs) provide care for people with dementia and severe challenging behaviour who live in nursing homes. They are an alternative care setting within traditional nursing homes. By providing certain physical design features, employing staff with additional dementia expertise and training, enhancing psychosocial care, and focusing on the active involvement of families, these units aim to improve the quality of life of people with dementia and their families. However, research has not demonstrated a clear benefit of DSCUs for people with dementia to date. Nevertheless, they are regarded as an essential pillar of dementia long-term care services and are a topic of several national dementia strategies.
Frailty in older adults
Authors: Walston Jeremy
Published: December 2017

Frailty is most often conceptualized as an age-related medical syndrome with a biological basis that results in substantial vulnerability stressors and adverse health outcomes. It is increasingly thought of as the geriatric syndrome that underlies all other geriatric syndromes. Multiple measurement tools have been developed that have helped to differentiate frail from more robust or resilient older adults; and these tools enabling the characterization of and consequences of frailty, as well as its underlying biology. The recognition of frailty as a condition of advanced vulnerability has led to the development of interventions and novel approaches to integrate frailty into clinical practice. The following chapter describes the conceptualization of frailty, surveys the vast array of tools used to identify frailty, provides demographic information and epidemiological characterizations of causes and consequences of frailty, identifies important biological and environmental drivers of frailty, and describes the clinical efforts underway to better utilize frailty tools.
Vitamin D: its role in health and disease in older people
Authors: Bischoff-Ferrari Heike A.
Published: December 2017

Vitamin D deficiency contributes to the risk of sustaining a hip fracture in two ways: with specific receptors in muscle tissue, its lack causes muscle weakness and thereby promotes the risk of falling; and with specific receptors in the intestine, its lack impairs calcium metabolism causing secondary hyperparathyroidism and thereby bone loss. Vitamin D supplementation reduces fracture risk and appears to have other health benefits including an effect on mortality. In this chapter, we focus on the translation of the new intake recommendations of vitamin D for the senior population aiming at a 30% reduction of falls and hip fractures based on evidence from double-blind randomized controlled trials. We also discuss other health benefits of vitamin D and recent findings from meta-analyses suggesting that based on clinical trial findings, vitamin D supplementation may reduce mortality between 4 to 7%.
Gait disorders
Authors: Studenski Stephanie , VanSwearingen Jessie
Published: December 2017

Mobility is fundamental for living. As walking is the most common form of mobility for humans, disorders of gait impact multiple aspects of our existence, including independence, social function, health, and the ability to explore and understand ourselves in relation to the world. Because of the breadth of the impact of gait disorders, the intent of this chapter is to provide clinicians with an adequate background in the basic physiology and mechanics of normal gait, and an observational approach to recognize deviations from the normal pattern-types of gait abnormalities. While the type of gait disorder does not directly lead to the treatment prescription, we describe various approaches to the management (including assistive devices) and rehabilitation that may have potential to impact related gait abnormalities. Lastly, we highlight rising concerns and directions in the assessment and management of subclinical gait problems in walking.
Common fractures in older adults
Authors: Hagino Hiroshi , Kondo Akiko
Published: December 2017

Among elderly individuals worldwide, the incidence of fractures is highest in the vertebrae, followed by the hips and distal forearms. There is a wide variation in global hip fracture incidence rates, with the rates in women approximately twice those in men. These rates are low in people under 70 years old, and increase exponentially with age thereafter. There are large geographic and secular changes in incidence of most common fragility fractures, for reasons that are not fully understood. Morbidity and mortality increases are associated with all fragility fractures, although to varying degrees depending on the site of the fracture. The mean decline in quality of life is greater in patients with hip fractures, than those with vertebral or distal forearm fractures.
Vasculitides in older people
Authors: Régent Alexis , Guillevin Loïc
Published: December 2017

Vasculitides are a heterogeneous group of diseases, defined by vessel inflammation with fibrinoid necrosis of the arterial wall, giant-cell infiltration, and/or granuloma. Patients with giant cell arteritis (GCA) often have headaches, polymyalgia rheumatica, and vision symptoms in a context of moderately impaired health. Microscopic polyangiitis symptoms are very diverse, including alveolar haemorrhage, rapidly progressive glomerulonephritis, skin ulcers, mononeuritis multiplex, muscle, and joint pain. Other vasculitides, such as granulomatosis with polyangiitis (Wegener’s) (GPA) or cryoglobulinemic vasculitis occur less frequently in older patients. Diagnoses are based on clinical manifestations, laboratory results, imaging findings, and the established classification of vasculitides according to vessel size and histological findings. The treatment regimen, based on glucocorticoids and immunosuppressants, is chosen according to diagnosis and predictable outcome, and adapted to the patient’s age and concomitant comorbidities.
Management of common types of arthritis in older adults
Authors: Galloway James B. , Scott David L.
Published: December 2017

The main forms of inflammatory arthritis are rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. They are long-term disorders and consequently their prevalence increases with age; the lifetime risk of developing rheumatoid arthritis is over 3% in women. Their characteristic features comprise joint pain, swelling, and tenderness, morning stiffness, and general symptoms such as malaise. Polyarthritis is commoner in rheumatoid arthritis. The ESR and C-reactive protein levels are high in active arthritis. The main radiological finding is erosive disease. Symptomatic treatment includes analgesics and non-steroidal anti-inflammatory drugs. Disease-modifying drugs (DMARDs) change the course of these diseases; their main use is in rheumatoid arthritis. Biologic drugs help when other treatments are insufficient; they include tumour necrosis factor inhibitors which benefit all types of inflammatory arthritis, and other biologics targeting B- and T-cells are mainly used in rheumatoid arthritis. The risks of adverse events and drug toxicity are higher in elderly patients.
Ageing with HIV
Authors: Justice Amy
Published: December 2017

Human Immunodeficiency Virus (HIV) infection, in the era of combination antiretroviral therapy, has become more common among middle-aged and older individuals. Diagnosis and rapid initiation of antiretroviral therapy to suppress the virus below detectable levels are urgent priorities in management. Once achieved, those ageing with HIV infection can expect to live many years, but they remain at increased risk for HIV-associated non-AIDS (HANA) conditions compared to demographically similar uninfected individuals. Because HANA conditions include several forms of cancer, cardiovascular disease, liver disease, and kidney disease, the clinical management of those ageing with HIV is complicated by multimorbidity and polypharmacy at an earlier age than those ageing without HIV infection. The study of ageing with HIV infection may improve our understanding of the effects of long-term viral infection on the ageing process.
Vaccines against viral infections
Authors: McElhaney Janet E.
Published: December 2017

A decline in immune function and increased susceptibility to infection is a hallmark of ageing. Influenza is foremost among these infections with 90% of deaths occurring in older adults despite widespread vaccination programmes. Common medical conditions and mental and psychosocial health issues, as well as degree of frailty and functional dependence may all contribute to the loss of immune responsiveness to infections and vaccination. The interactions of immune senescence, persistent cytomegalovirus infection, inflammaging (chronic elevation of inflammatory cytokines), and dysregulated cytokine production pose major challenges to the development of new or more effective vaccines. This chapter describes viral infections that have the greatest impact in older adults, age-related changes in the immune system that contribute to loss of vaccine responsiveness, available vaccines against influenza and herpes zoster and the need for vaccines against other viruses, and strategies for improving vaccine effectiveness to address the public health need for ‘vaccine preventable disability’.
Integration of vaccination of older adults in a life course programme
Authors: Michel Jean-Pierre , Lang Pierre-Olivier , Aspinall Richard
Published: December 2017

Vaccines represent the medical intervention that has yielded the greatest benefit on human health and longevity. By focusing on life course immunization, it appears easy to demonstrate how child, adolescent, and younger adult vaccinations have impacted on and lowered the burden of vaccine preventable infectious diseases in older populations. Many epidemiological examples from influenza, pertussis, and pneumococcal vaccinations in young age groups testify the importance of community protection at the level of oldest adults, a population who exhibit immunosenescent defects. In parallel, the low vaccine coverage rate of healthcare workers disadvantages their old patients as much as themselves and their relatives. Thus, a vaccination programme focusing only on old adults will never really be effective if the global population does not recognize that infection threats persist all over the world.
Cell biology and carcinogenesis in older people
Authors: Fülöp Tamas , Anisimov Vladimir N. , Rodier Francis , Extermann Martine
Published: December 2017

The most important risk factor for cancer is age and many age-associated molecular and cellular changes explain this relationship. The most important aspect of this relationship is the passage of time, which enables the multihit mutation process, resulting in the development of clinical cancer and contributing to the altered physiological environment that allows the full manifestation of these molecular mutations. At the cellular level, the double-edged sword process of cellular senescence will substantially contribute by creating an inflammatory milieu that supports increased tumorigenesis. Genomic instability that is closely related to cellular senescence, as well as epigenetic changes, will also play an important role. Nevertheless, there are strategies to decrease the lifelong increase of cancer incidence via nutrition, exercise, genetic manipulations, and pharmacological interventions. The discovery of biomarkers in the perspective of personalized medicine will also be a major breakthrough to improve cancer prevention and treatment in older people.
Multidisciplinary management, including chemotherapy of solid tumours (lung, breast, and colon)
Authors: Battisti Nicolò Matteo Luca , Extermann Martine
Published: December 2017

Cancer is a common disease in geriatric patients and its biology and prognosis are affected by age. The comprehensive geriatric assessment addresses the complex management of the older population, which is still underrepresented in clinical trials despite its rapid expansion in Western countries. Thus, it is crucial to develop a multidisciplinary approach to geriatric oncology care considering functional disability, competing comorbidities, cognitive impairment, nutritional status, psychosocial distress, and polypharmacy as major issues. Fit elderly breast cancer patients should be treated similarly to younger women, whereas the management of frail patients should be individualized. Special considerations may apply to the postoperative treatment of elderly colon cancer patients, and in the setting of metastases, toxicities, and quality of life should be balanced. The same concerns are valid for the management of lung cancer in elderly patients. Accordingly, geriatricians should be aware of oncological approaches and oncologists should be trained in geriatric management.
Cardiac and vascular ageing
Authors: Ota Hidetaka , Akishita Masahiro
Published: December 2017

There is a continuum of expression of cardiac structural and functional alterations that occurs with ageing in healthy humans, and these age-associated cardiac changes seem to be relevant to the increase in left ventricular hypertrophy, chronic heart failure, and arrhythmia that are commonly observed with increasing age. This chapter describes the structural and functional changes in the ageing process of the heart and blood vessels, and provides an overview of representative cardiovascular disease caused by ageing including hypertension, atherosclerosis, and heart failure. In addition, an outline of interventions that have be utilized to prevent and treat ageing related cardiovascular diseases is provided.
Hypertension in older adults
Authors: Rakugi Hiromi , Kawai Tatsuo
Published: December 2017

Hypertension is very common in older adults and highly clinically relevant to manage as it remains a strong risk factor of cardiovascular diseases and cognitive decline. Active reduction in hypertension in even the very oldest adults has demonstrated efficacy in the prevention of cardiovascular and cerebrovascular diseases and reduction in hip fracture. Hypertension in older adults is characterized by high prevalence of isolated systolic hypertension, increased fluctuation of blood pressure, and having various comorbidities which affect not only management of hypertension but also activities of daily living and quality of life. It is important to pay attention to these characteristics for diagnosis of hypertension, introducing lifestyle modification, selection who should be treated with antihypertensive drugs, choice of antihypertensive drugs, and setting the target blood pressure. This careful management is especially required in the very old or frail, and those with cognitive dysfunction.
Ischaemic heart disease
Authors: Rafanelli Martina , Orso Francesco , Marchionni Niccolò
Published: December 2017

Advancing age is associated with changes in vascular and cardiac properties that increase the likelihood of atherosclerosis, which is the basic pathophysiological mechanism in most of the clinical presentations of ischaemic heart disease (IHD). Recovery, once the tissue’s damage has occurred, is more difficult because of age-related changes in damage responsiveness. Clinical management of IHD in older people is complicated by atypical presentation that often makes the diagnosis challenging and causes treatment delay. The management of acute coronary syndromes (ACS) and stable coronary artery disease in this population should be driven by current clinical guidelines, even though older people are poorly represented in clinical trials. The choice of pharmacological therapy needs a careful balance between risks and benefits. Given the increase in morbidity and mortality in older patients with ACS, aggressive risk factor modification is vital for decreasing recurrent events.
Heart failure: definitions, investigation, and management
Authors: Cleland John G. F. , Baxter John
Published: December 2017

Heart failure is among the most common chronic debilitating conditions among older adults. The diagnosis is complex and usually made late, only after severe symptoms develop. Natriuretic peptides (BNP or NT-proBNP) are the key to early diagnosis of heart failure and echocardiography to its cause; most commonly ventricular dysfunction [either with a reduced (HFrEF) or preserved (HFpEF) left ventricular ejection fraction] or valve disease. For patients with HFrEF, pharmacological treatment with angiotensin converting-enzyme (ACE) inhibitors and mineralo-corticoid receptor antagonists and for those in sinus rhythm beta-blockers and ivabradine have transformed prognosis. For patients with a QRS duration >140 msec, cardiac resynchronization with atrio-biventricular pacing should be considered. Iron deficiency should be sought for and treated. For patients with HFpEF, robust evidence that treatments improve outcome is lacking but for symptoms, the pharmacological treatment of HFpEF and HFrEF may be rather similar.
Neuropsychological evaluation of cognition
Authors: Tuokko Holly , Smart Colette
Published: December 2017

This chapter describes the components of a comprehensive neuropsychological evaluation including the approaches taken and domains of importance for the performance-based measurement of cognitive functions in older adults. Normative and non-normative factors associated with the ageing process that may be of importance in the interpretation of the neuropsychological information are briefly described. These include normative changes associated with ageing, medical disorders affecting cognition, and characteristic patterns of cognitive impairment. The integration of the neuropsychological performance-based information with information obtained from other sources is discussed. In closing, we address the interpretation of the neuropsychological evaluation in relation to the purpose for which it was undertaken, as well as a conceptual framework for intervention in older adults with cognitive or neuropsychiatric impairments.
Management of comorbidities in dementia patients
Authors: Gold Gabriel , Zekry Dina
Published: December 2017

Despite recent evidence for a marked decrease in dementia incidence over the past decades, it is highly likely that the absolute number of people with dementia will continue to increase as a function of population ageing. Furthermore, two-thirds of the population with dementia live in developing countries where this entity is already responsible for 25% of cases with severe incapacity. Thus, dementia will remain a worldwide public health concern in the twenty-first century. Interaction between comorbidities and dementia is complex: are comorbidities dementia- or age-related? Presentation of illness is atypical in older populations but particularly so in individuals with dementia. How should one then detect and measure the comorbidity burden, what is the best management and the most ethically correct approach to decision-making? This chapter will review current knowledge in the field and discuss basic principles that can be applied to ensure optimal care of comorbidities in people with dementia.
Functional psychoses
Authors: Agüera-Ortiz Luis
Published: December 2017

Psychotic symptoms are more common in older people than in any other age. The most frequent psychotic disorders in older people are juvenile-onset schizophrenia in ageing patients, psychosis in Alzheimer’s disease, and the late- and very late-onset schizophrenia-like psychosis. Drug treatment of all types of psychosis is essential and often achieves similar levels of efficacy than in younger adults. The treatment of choice for any psychotic condition is atypical antipsychotics. Rather than being based on specific diagnosis, the choice of drug must be highly personalized, depending on the efficacy for the particular patient, drug’s profile of adverse effects, medical comorbidities, and concomitant medications. Attention should be paid to the emergence of adverse effects that are in general more frequently found with conventional than with atypical antipsychotics. Clinical and psychological management includes the need to establish a therapeutic alliance with the patient and ensure adherence to treatment in the long term.