436 - Cognitive Self-Testing, Pneumococcal Vaccine, A Good Laugh

From the Literature

1)  Self-testing for Cognitive Function

The detection of dementia is on the minds of our older patients and their loved ones who have important questions to answer about their future. Unfortunately, the US Preventive Services Task Force has found that there is insufficient evidence to recommend screening for dementia for two main reasons – lack of a good quality screening test and lack of evidence of benefit to early detection.

A study from Ohio State compared the Self-Administered Gerocognitive Examination (SAGE) to the Mini Mental State Examination (MMSE) in a retrospective study of 424 subjects. SAGE has previously been shown to have a 95% specificity and 79% sensitivity for dementia. It was tested in a cohort of patients along the spectrum of cognitive impairment from subjective cognitive decline (SCD) to minimal cognitive impairment (MCI) to Alzheimer’s disease. These 655 attendees of the Memory Clinic were assessed consecutively, and the exclusion criteria narrowed the pool to a sample of 424 older patients with MCI and dementia, but of note, mixed dementia and non-Alzheimer’s dementia patients were excluded. The SAGE and the MMSE were routinely administered to all patients, but the final diagnosis of MCI and dementia were made using a comprehensive battery of tests that did not include either of the study tests.

The researchers tracked patients for over 6 1/2 years. In most of the analyses, SAGE and MMSE performed similarly, but the researchers found that SAGE picked up statistically significant decline 6 months earlier than MMSE in the MCI-converting-to-dementia groups and in the dementia group. The cohort included some patients who were started on medications during the study, but the results for these patients were averaged in with the rest.

Of note, this was an internally funded investigation of a paper version of this scale, but Ohio State owns the patient for the test and is commercializing it.

John’s Comments: This test may indeed have some utility down the road, but a six-month-earlier detection of conversion of MCI to dementia is of unclear benefit to me. The retrospective nature of the study and the limited applicability of the findings render this study less compelling. I asked Dr. Brian Unwin, MD, Professor of Medicine at Virginia Tech Carilion School of Medicine and Section Chief for Geriatrics and Palliative Care at the Carilion Clinic for his thoughts: “I don’t see this as a breakthrough…Virtually any test is better than the MMSE in detecting MCI or early dementia. So, saying the SAGE test is better isn't saying much. It takes longer to do the SAGE, but the test properties are better than MMSE and it can be self-administered.” He, too, was concerned about the influence of commercialization.

Reference:

Scharre DW, Chang S ing, Nagaraja HN, Wheeler NC, Kataki M. Self-Administered Gerocognitive Examination: longitudinal cohort testing for the early detection of dementia conversion. Alzheimer’s Research & Therapy. 2021;13(1):192. Link

From the Centers for Disease Control and Prevention (CDC)

2)  Changes in the Pneumococcal Vaccination Schedule … Again …

Please don’t shoot the messenger, here, OK?

Last year, the FDA approved Pfizer’s PCV20 and Merck’s PCV 15 vaccination products to add to our anti-pneumococcal arsenal. The CDC’s Advisory Committee on Immunization Practices spent 2021 considering how to integrate these new vaccines into our current pneumococcal vaccination strategy for adults. There are no recommendations for use of these two new vaccines in children right now.

Remember that the primary point of pneumococcal vaccination in adults is to prevent invasive pneumococcal disease - bacteremia, meningitis, and bacteremic pneumonia. There have been recommendations based on age (65 and over), chronic medical conditions (COPD, diabetes, heart disease, etc.), and immunocompromising conditions (chronic steroid use, leukemia, cerebrospinal fluid leak, etc.). The most recent regimens have been confusing because of the need to differentiate the indications, schedule the two vaccinations appropriately, and find the right words to be able to conduct the shared decision-making conversation recommended for some potential vaccine candidates.  All that will be a bit easier now, although there will be some bumps in the transition.

The basic recommendations:

●     The two, equally recommended options are:

○     PCV20, or

○     PCV 15 followed by PPSV23 in one year (but at least 8 weeks if there is an immunocompromising condition and you want to vaccinate sooner).

●     Patients who are below age 65:

○     One of the two options in anyone with a chronic condition OR an immunocompromising condition (There is no difference between the indications any longer and these are the same lists of conditions as in the current recommendations).

●     Patients who are age 65 and over:

○     One of the two options.

●     Patients who have had some pneumococcal vaccination before but now adopting the new schedule:

○     Previous PPSV23 - PCV 20 or PCV 15 one year later.

○     Previous PCV13 - just use the PPSV23 to complete the series.

○     Completed series for any age or indication, no recommendation to use either.

Note, there is no shared decision making involved in these recommendations. The ultimate recommendation was made after considerable discussion about details of immunogenicity against certain serotypes and some complex cost-effectiveness modeling. PCV20 had better evidence for health and cost savings compared to PCV15 + PPSV23, but in the clinical studies, they both met criteria for approval and there was sufficient health benefit and cost savings for the ACIP to recommend both. The single vaccine strategy was noted to be appealing for obvious reasons and may prevent inequities from arising should patients not complete both vaccines because of access, insurance, or income issues.

John’s Comments: The new recommendations should simplify things with pneumococcal vaccines considerably, and even the “catch up” recommendations for those already partially vaccinated with the previous strategies are pretty simple. I personally am in favor of the simplest, PCV20 strategy.

References:

●     Kobayashi M. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71. Link

●     Advisory Committee on Immunization Practices. Meeting of the Advisory Committee on Immunization Practices. Centers for Disease Control and Prevention; 2021. Accessed February 14, 2022. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  We Could All Use a Good Laugh …

“Laughter is the shortest distance between two people.”  Victor Borge, entertainer

When’s the last time you had a really good laugh?  Recently one of my PeerRxMed buddies and I were talking about some of our COVID patient care challenges and frustrations, and somehow the conversation went sideways and we suddenly both found ourselves laughing so much it “hurt.”  When I had finally regained my breath and wiped the tears from my eyes, I found myself sharing between giggles, “Wow!  It’s been a long time since I’ve laughed like that.  Thanks, I really needed it.”  

“Yeah,” they said, “me too.” 

Hopefully, it hasn’t been a “long time” for you, but we all could likely use a good laugh, and then another, and another.  With the cumulative heaviness of the past 2 years, many of us are experiencing a significant “laughter deficit.” 

Gelotology (the study of laughter) has found profound physiological and psychological effects of laughter, including benefits for our heart, lungs, and muscles and the release of endorphins which relieve stress, soothe tension, and elevate our mood.   And those benefits extend from the giggle, chuckle, and belly laugh all the way to the guffaw, howl, and cachinnation (raucous laughter).

But perhaps the most important benefit of laughter is that it connects us to each other.  Indeed, laughter research (Gelotology, remember?) has validated that laughter is indeed “contagious,” and the endorphin release induced by social laughter reinforces neural pathways that support formation, reinforcement, and maintenance of social bonds. 

So how can we have more of those “I really needed that” moments?  By placing ourselves in laughter-inducing circumstances!  This could involve surrounding ourselves with funny people, watching funny films, videos or television, reading funny books, telling jokes or funny stories, or playing with children and allowing their natural silliness to rub off on us.  There is even a practice called “laughter yoga” that involves prolonged, voluntary laughter and which in my experience produces that same wonderful laughter-induced endorphin buzz and profound sense of connection with the other participants that we’ve come to expect from “real laughter.” 

So this week, why not make an intention to laugh, preferably with someone else, at least once each day.  Not only will doing so elevate your mood and help bring you out of any COVID-induced funk you might be experiencing, but you’ll bring them along for the ride and help break down two years of “social distancing.”  Oh, and it will be a whole lot of fun.  And right now, we could all really use some of that … 

References:  Here are a few videos to get you started:

·         Baby Laughter video compilation:  Baby Laughter

·         Laughter Yoga – Short Introduction:  Laughter Yoga

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org