The Washington Post - USA (2020-10-20)

E4 EZ EE THE WASHINGTON POST.TUESDAY, OCTOBER 20 , 2020

joint health

BY LAURIE ARCHBALD- PANNONE

The number of cases of demen-
tia in the United States is rising as
baby boomers age, raising ques-
tions for boomers themselves and
also for their families, caregivers
and society. Dementia, which is
not technically a disease but a
term for impaired ability to think,
remember or make decisions, is
one of the most feared impair-
ments of old age.
Incidence increases dramati-
cally as people move into their
90s. About 5 percent of those 71 t o
79 have dementia, and about 37
percent of those about 90 live
with it.
Older people may worry about
their own loss of function as well
as the cost and toll of caregiving
for someone with dementia. A
2018 study estimated that the
lifetime cost of care for a person
with Alzheimer’s, the most com-
mon form of dementia, to be
$329,360. That f igure, too, will no
doubt rise, putting even more
burdens on family, Medicare and
Medicaid.
There’s also been a good deal of
talk and reporting about demen-
tia in recent months because of
the presidential election. Some
voters have asked whether one or
both candidates might have de-
mentia. But is this even a fair
question to ask? When these
types of questions are posed —

adding further stigma to people
with dementia — it can unfairly
further isolate them and those
caring for them. We need to un-
derstand dementia and the im-
pact it has on more than 5 million
people in the United States who
now live with dementia and their
caregivers. That number is ex-
pected to triple by 2060.
First, it is important to know
that dementia cannot be diag-
nosed from afar or by someone
who is not a doctor. A person
needs a detailed doctor’s e xam for
a diagnosis. Sometimes, brain
imaging is required.
And, forgetting an occasional
word — or even where you put
your keys — does not mean a
person has dementia. There are
different types of memory loss
and they can have different
causes, such as other medical
conditions, falls or even medica-
tion, including herbals, supple-
ments and anything over-the-
counter.
Older people wonder and wor-
ry about “senior moments” and
the memory loss they perceive in
themselves and others. I see pa-
tients like this every week in my
geriatric clinic, where they tell
me their stories. They forget a
word, get lost in a story, lose keys
or can’t remember a name. De-
tails vary, but the underlying
concern is the same: Is this de-
mentia?

Normal memory loss

As we age, we experience many
physical and cognitive changes.
Older people often have a de-
crease in recall memory. This is
normal.
Ever have trouble fetching a
fact from the deep back part of
your “mind’s Rolodex”? Suppose
you spot someone at the grocery
store you haven’t seen in years.
Maybe you recognize the face, but
don’t remember their name until
later that night. This is normal,
part of the expected changes with
aging.
What’s more of a potential
problem is forgetting the name of
someone you see every day; for-
getting how to get to a place you
visit frequently; or having prob-
lems with your activities of daily
living, like eating, dressing and

hygiene. When you have troubles with memory — but they don’t inter- fere with your daily activities — this is called mild cognitive impairment. Your primary care doctor can diagnose it. But sometimes it gets worse, so your doctor should follow you closely if you have mild cognitive impairment. You want to note the timing of any impairment. Was there a gradual decline? Or did it happen all of a sudden? This too you should discuss with your doctor, who might recommend the MoCA, or Montreal Cognitive As- sessment, which screens for memory problems and helps de- termine whether more evalua- tion is needed. Also, the Centers for Disease Control and Prevention lists problems in these areas as possible signs of dementia: l Memory. l Attention. l Communication. l Reasoning, judgment and problem solving. l Visual perception beyond typical age-related changes in vi- sion.

More severe issues When memory loss interferes with daily activities, see your doctor about what to do and how to make sure you’re safe at home. There are numerous types of severe memory loss. Dementia tends to be a slow-moving pro- gression that occurs over months or years. Delirium is more sudden and can occur over hours or days, usually when you have an acute illness. Depression can also cause memory changes, particularly as we get older.

Dementia, other brain issues Alzheimer’s is the most common type of dementia, followed by vascular dementia. They have similar symptoms: confusion, getting lost, forgetting close friends or family, or an inability to do calculations like balance the checkbook. Certain medical conditions — thyroid disorders, syphilis — can lead to dementia symptoms, and less common types of dementia can have different kinds of symptoms. Alzheimer’s h as a distinct set of symptoms often associated with certain changes in the brain. Focusing on safety and appro- priate supervision, particularly in the home, is critical for all people with dementia. Your doctor or a social worker can help you find support. It’s also important to be aware of two other things that can lead to decreased mental functioning — delirium and depression. Delirium, a rapid change in cognition or mental functioning, can occur in people with an acute medical illness, such as pneumo- nia or even covid- 19 infection. Delirium can occur in patients in the hospital or at home. Risk for delirium increases with age or previous brain injuries; symptoms include decreased attention span and memory issues. Depression can happen at any time, but it’s more common with aging. How can you tell if you’re depressed? Here’s one simple def- inition: when your mood remains low and you’ve lost interest or joy in activities you once loved. Sometimes people have recur- ring episodes of depression; sometimes, it’s prolonged griev- ing that becomes depression. Symptoms include anxiety, hope- lessness, low energy and problems with memory. If you notice signs of depression in yourself or a loved one, see your doctor. If you have any thoughts of harming yourself, call 911 to get help instantly. Any of these conditions can be frightening. But even more frightening is unrecognized or unacknowledged dementia. You must, openly and honestly, discuss changes you notice in your memory or thinking with your doctor. It’s the first step toward figuring out what is happening and making sure your health is the best it can be. And, as with any disease or disease group, dementia is not a “character flaw,” and the term should not be used to criticize a person. Dementia is a serious medical diagnosis — ask those who have it, the loved ones who care for them or any of us who treat them. Having dementia is challeng- ing. Learn what you can do to support those with dementia in your own community. [email protected]

Laurie Archbald-Pannone, who specializes in geriatric medicine, is an associate professor of medicine at the University of Virginia. This article was originally published on theconversation.com.

PERSPECTIVE

Dementia is more than

occasionally forgetting

Memory loss happens

as we age. Dementia is

more multifaceted.

ISTOCK

When memory loss

interferes with daily

activities, see your

doctor about what to do

and how to make sure

you’re safe at home.

pany. “My right knee hurt, but I ran through the pain. But my knee would swell, and it was impacting my stride.” In January, he finally had an MRI, which showed he had torn his meniscus, a common sports injury to the cartilage that cush- ions the area between the shin- bone and thighbone. But there was more. The scan also revealed an area under the kneecap where the cartilage had worn away, which often portends full-blown osteoarthritis — and possible knee replacement — years later. Unlike bone, which has the ability to heal, cartilage cannot restore itself once injured. Until recently, Oates had few options, one of them to give up running entirely with the hope that his knee would not further deteriorate. He couldn’t live with that. “Running is my Z en time,” he says. “I couldn’t take a ‘you can’t run again.’ ” To day, however, he says he hopes to benefit from a relatively new and innovative technique that regenerates cartilage from a sample of cells taken from his knee and grown in a lab, where they are embedded on a collagen membrane. The surgeon then im- plants the membrane back into the knee, where new cartilage tissue forms over time. “It’s the first procedure that uses a patient’s own knee cartilage cells to try to regrow cartilage that has been lost or dam- aged,” says Seth Sherman, associate professor of orthopedic surgery at Stanford University Medical Center and chair of the Sports Medicine/Arthroscopy Committee for the American Academy of Orthopaedic Sur- geons. Sherman points out that the approach, approved by the Food and Drug Administration in 2016, has been in use for years in other countries with “robust evidence” to support its efficacy. “ That’s w hy I like to use it,” Sherman says. “It’s a huge deal.” It’s unclear how many of these cartilage-restoring operations have been performed in the Unit- ed States since its introduction here, but experts say its use is rapidly growing. “There are over a thousand of these procedures performed yearly in the United States,” says Joseph Barker, the Raleigh orthopedic surgeon who operated on Oates. “This new technology is certainly increasing in popularity as more surgeons become aware of it and are trained in perform- ing the procedure. The number of cases has been steadily increasing by about 25 percent a year since 2017.” The procedure is among the latest examples of regenerative

CARTILAGE FROM E1

medicine, a budding field that relies on the body’s natural properties to promote healing and restore function. “Regenerative medicine and orthopedic surgery are starting to work together,” says John Ferrell, a D.C.-area sports medicine physician who specializes in regenerative treatments. “Even though its current application is still limited, I see it ushering in a new era of the combination between the two practices, which is very exciting.” Barker extracted the cartilage cells while repairing Oates’s meniscus, and implanted the membrane into Oates’s knee in Sep- tember. “The beauty of this procedure — why it is so great and cutting edge — is that you can restore an area that has no cartilage left by putting in a patient’s own normal cells,” Barker says. “When it’s all done, it’s a completely normal knee.” The downside is that the treat- ment requires two procedures — one to remove the cells and a second to put them back — and a long, restrictive recovery period that can take as much as a year before full function returns. Ini- tially, the patient must lie flat in bed (hooked up to a continuous passive motion machine to prevent scar tissue from forming) for as long as six weeks to allow the cells to adhere to the bone and proliferate. “Those cells are like newborn babies in there,” says Nicholas

DiNubile, a Pennsylvania orthopedic surgeon. “If you put weight on them, they won’t grow.” Oates, who underwent the implant on Sept. 8, spent six weeks flat on his back in bed. He has since progressed from two crutches to one, and hopes to be using a cane before the end of the month. He’s also wearing a straight leg brace for the next few months. Full recovery — which includes a gradual return to easy daily activities, followed by moderate moves, such as walking or pool running, and then full sports functioning, such as running — takes nine to 12 months following surgery. But experts believe the alternative is worse. When the lesions are left un- treated, they become larger, often causing damage on the other side of the knee, “and that’s essentially arthritis,” says Barker, who also is a team physician for the Carolina Hurricanes hockey team and North Carolina State University. The name of the procedure is a mouthful — autologous cultured chondrocytes on porcine collagen membrane — commonly called MACI. “With it, you can hold off and maybe prevent the development of arthritis, as well as a knee replacement,” Barker says. “It’s a significant advancement in the prevention of arthritis.” It’s not for those with full- blown osteoarthritis, since there must be normal surrounding car-

tilage remaining for the implant to heal appropriately. Also, MACI cannot correct the underlying spurs and cysts that can develop with arthritis. “By then, it’s too late to use it,” DiNubile says. “You can fix those potholes early on, but you can’t repave the whole road. It’s a way to replace cartilage before it becomes debilitating osteoarthritis, and it’s a g ame-changer. It’s a bout saving knees, not replacing them.” The ideal candidates are ages 18 to 55, who are physically active and have isolated areas of cartilage loss. “The treatments depend less on your actual age, but the age of your joints and your expectations and activity levels,” Sherman says. “MACI can be used on any part of the knee joint, on any cartilage defect in the knee. It preserves the joint, restores the cartilage, allowing the patient to return to his or her sports, or other activities, pain-free.” The manufacturer of MACI is Vericel, a company based in Cam- bridge, Mass., that develops cell therapies. The company cultures the cartilage cells and produces the cell-embedded membrane. To be sure, insurance policies vary, but insurance typically covers some or most of the procedure — which can be expensive — costing about $30,000 or more, experts say. Studies suggest i t is more effec- tive than another procedure, mi- crofracture surgery, often used before cartilage cell regeneration came along. It involves creating small holes in the bone under the cartilage defect that stimulate the growth of fibrocartilage, a type of cartilage that resembles scar tissue. Fibrocartilage isn’t as strong or durable as hyaline cartilage, the native cartilage found in the knee and the type that MACI produces, experts say. “Former high level athletes or college athletes who do pounding sports — football players, soccer players — used to do microfrac- ture surgery,” Ferrell says. “The area would look better at f irst, but it wouldn’t last. As soon as they started to run and jump and play on it, they would have symptoms again.” While so far limited to the knee, experts think eventually the procedure could help restore cartilage lost in other joints, for example, shoulders, ankles or hips. “The hope is that this is just the beginning,” Barker says. Oates is upbeat, despite know- ing he will be sidelined from running for most, if not all, of the coming year. “It’s a minor setback,” he says. “I see the ultimate reward as bigger than the sacrifice.” [email protected]

Cartilage for the joints can be renewed

FAMILY PHOTO Matt Oates, 41, of Raleigh, N.C., after a cartilage-restoring operation. The procedure is an example of regenerative medicine, which relies on the body’s natural properties to restore function.

this small but lively tributary of mainstream science, as co-author of a 2018 review of knuckle-cracking studies in the journal Clinical Anatomy. Oskouian and his three colleagues pored over 26 sometimes- -contradictory papers regarding the mechanisms and effects of knuckle cracking, beginning with a 1911 German treatise titled “On the Dispute About Joint Pres- sure.” He did so, he said, after becoming fascinated by the uni- versal inability of his students through the years to explain what makes that cracking noise. Modern scholars now agree that bones themselves aren’t cracking, but rather that the movement creates a bubble of gas in the synovial fluid lubricating the joints. Researchers still don’t know if it is the bubble’s forma- tion or subsequent pop that makes the noise, but Oskouian said the mechanics are similar to a chiropractor’s “adjustment” of the spine, which also elicits a cracking sound. Joining with several of their predecessors, Oskouian and his colleagues concluded that researchers have yet to show any reliable association between knuckle cracking and arthritis. A 2017 study of 30 knuckle crackers offered evidence that the habit even increased range of motion. But that still doesn’t give knuckle-crackers a pass — espe- cially not if they do it a lot and for a long time, or have a preexisting problem. “Knuckle cracking over the years will cause repetitive trauma to the joints and cartilage,” Oskoui- an said in a telephone interview.

KNUCKLES FROM E1 Studies he cited in his review suggest that long-term knuckle cracking can cause significant damage short of arthritis, stress- ing and ultimately degenerating cartilage. In 2017, a team of Turk- ish scientists who examined 35 people who cracked their knuckles more than five times a day found that while it didn’t appear to affect grip strength, it was associated with a thickening of the metacarpal cartilage, a potential early sign of damage that can lead to osteoarthritis.

A more ambitious 1990 study of 300 participants over 45, including 74 habitual knuckle crackers, found that while, again, the crackers had no greater rates of arthritis, they were more likely to have swollen hands and, in this case at least, weaker grips. “Habitual knuckle cracking re- sults in functional hand impairment,” concluded the two au- thors, based at the former Mount Carmel Mercy Hospital in De- troit. For good measure, they also noted that habitual knuckle crackers were also more likely to do manual labor, bite their nails, smoke and drink alcohol. Orthopedists vary in how seri- ously they regard knuckle cracking as a health threat. Oskouian ventured that the habit is prob-

ably harmless for most people, adding that most of his patients seem to abandon the practice after a few years or so. Yet for perhaps as much as 10 percent of the population, who suffer from a preexisting problem such as rheumatoid arthritis, an inflammatory disorder, knuckle cracking is particularly ill-ad- vised, warned Charles Kallina, an assistant professor of surgery at the Te xas A&M College of Medi- cine who acknowledged that he cracks his own knuckles on occa- sion. “I cannot in good faith recommend it as a rule,” Kallina said. Over the years, dogged researchers have exposed knuckle crackers’ knuckles to grip-tests, X-rays and MRIs. In one of the more offbeat endeavors, in 2018, a Stanford chemical engineer col- laborated with a researcher from the Hydrodynamics Laboratory in Palaiseau, France, to produce “A Mathematical Model for the Sounds Produced by Knuckle Cracking.” Even so, the most persistent member of this cottage industry of knuckle studiers is a Southern California retired allergist named Donald L. Unger. In 1998, Unger wrote a wry letter to the journal Arthritis & Rheumatism titled “Does knuckle cracking lead to arthritis of the fingers?” “During the author’s child- hood,” he began, “various re- nowned authorities (his mother, several aunts, and later his mother-in-law [personal communication]) informed him that cracking his knuckles would lead to arthritis of the fingers.” Rebelliously determining to test that hypothesis, Unger, for the next 50 years, cracked the knuckles of his left hand at least

twice a day — ultimately, as he calculated, “at least 36,50 0 times,” while cracking his right- hand knuckles “rarely and spon- taneously.” At the end of that half-century, he said, he compared his two hands, and on finding arthritis in neither of them, concluded “there is no apparent relationship between knuckle-cracking and the subsequent development of arthritis of the fingers.” Eleven years later, Unger’s one- man research was honored with an “Ig Nobel” prize, a parody award featured at an event at Harvard University. Unger, then 83, traveled across the country to receive it, joining other winners including a team of Swiss scientists who experimented on hu- man cadavers to find out if it would be less injurious to be hit over the head with a full beer bottle or an empty one. In his earlier letter, Unger warned that his experiment called into question the wisdom behind other parental dictums, including the benefits of eating spinach. Kallina, the Te xas hand-surgeon, agreed — up to a point. “This may be somewhat similar to how parents tell you not to cross your eyes, or they’ll stay t hat way,” he said. In other words, as he suggested, sometimes elders in- tentionally hand down medical myths to try to scare their off- spring into dropping an irritating habit. Still, Kallina maintained his warning for the general public: Unless you get a doctor to confirm you have no preexisting conditions, it would be a lot safer to twiddle your thumbs. [email protected]

Habitual knuckle cracking m ay impair your hands

“Knuckle cracking over

the years will cause

repetitive trauma to the

joints and cartilage.” Rod Oskouian, neurosurgeon

The Washington Post - USA (2020-10-20)

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