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Douglas A Jabs, M.B.A., M.D., M.S.

https://www.hopkinsmedicine.org/profiles/results/directory/profile/10004967/douglas-jabs

As a result prehypertension and lupus purchase toprol xl 25 mg on line, mold toxin exposure in the indoor en vironment is predominantly through the digestive tract and not respiratory system arteria ulnar cheap toprol xl 25 mg with amex. Since mold toxin exposure in the indoor environment is predominantly through the digestive tract and not res piratory system arrhythmia knowledge a qualitative study 100mg toprol xl visa, the thousands of studies on illnesses caused by ingesting mold toxins (mycotoxins) are appli cable to indoor environmental exposure to mold blood pressure keto proven 100mg toprol xl. There is a great deal of accepted, non-controversial medical science on mycotoxin exposure via the digestive tract including concrete proof of cancer, immune suppres sion; neurological impairment; and harm to intestinal lining & gut microflora and other serious ailments. Historically it has been claimed that it is not possible to establish thresholds for exposure levels of indoor mold. Toxin producing molds are always present in water damaged homes and are always producing toxins. As a re sult, mold exposure in the indoor environment is pre dominantly through the digestive tract and not respira tory system. Evaluation of the amount of exposure speaks to the concept first articulated in the 16th century by Swiss-German alchemist Paracelsus that ?dose makes the poison i. In the 21st century we know ?the dose and the host make the poison because susceptibility among those exposed var ies extensively. Indoor mold even at moderately high concentrations does not typically result in illness or even irrita tion to those not mold sensitive, which is the majority of people. However, breathing even very low concentrations of indoor mold can affect the sensitive (atopic), especially the young, the aged, those suffering from allergies or asthma and those with other illnesses or sensitivities that challenge or compromise their immune systems. Illness promoting indoor mold problems are typically subtle and not visible; otherwise they are quick ly fixed. So, the affected individual sees what appears to be a clean environment with perhaps a whiff of mustiness (odor from growing mold) but feels for some reason worse in the indoor environ ment than out. Mold hidden inside of walls even if extensive, if there is no active water source so the mold is no longer active, does not generally result in illness or irritation because mold exposure (see Mold Ba sics) is limited. Exposure to indoor mold toxins requires that the toxin containing mold spores be air borne so they can be inhaled. Generally speaking, mold trapped inside of walls results in limited ex posure to occupants. Example of white toxic mold hiding in the fiber Invisible unless the air handler is first removed. Fixing (remediating) the problem/ damaged house or office is generally straightforward when the problem is properly diagnosed. Oftentimes repair of the individual is not so simple and will require treatment under Doctor supervision. Bacteria and endotoxins and other factors besides mold may also be involved in causing indoor irrita tion and illness as a result of indoor dampness/ water damage. For an excellent review of the many illness-promoting factors involved in damp or water damaged buildings see: Biocontaminants and Complexity of Damp Indoor Spaces. Main Mycotoxin Exposure Pathways Eating: People are constantly being ex posed to significant levels of mold tox ins via their diet when they eat grains, meat, farmed fish, poultry and many fruits. Generally the level of mycotoxin exposure through the food chain, at least in the U. Breathing: the human respiratory tract can be considered to consist of two regions: (1) Upper airway. The (toxin laden) mold spores that land in the upper airway adhere to the airway mucous lining. Once embedded in the mucous, the spores are rapidly cleared from the airway and are deposited in the digestive tract for later excretion. Mycotoxins absorbed from the digestive tract will enter the blood stream and directly affect the body. But often more important is the indirect affect on the body by damage occurring to gut bacteria/ mi croflora because mycotoxins are strongly bacteriocidal. Therefore gut related problems from mold toxin exposure can be particularly common. The principal route of exposure from breathing mold toxins is via the gut and not the lungs. Subsequently, a common result of elevated mycotoxin exposure is damage to gut microflora. Most inhaled mold spores are quickly cleared from the upper airway before reaching the lungs. But as we shall see in the next section, continued exposure to elevated levels of mycotoxins can affect a whole lot more than just gut bacteria. There is a great deal of accepted, non-controversial medi cal science on mycotoxin exposure via the digestive tract including concrete proof of cancer, immune suppression; neurological impairment; and harm to intestinal lining and gut microflora and other serious ailments. While there is limited research on mold toxins that enter the lungs, there are literally thousands of scientific articles on illnesses resulting from mold toxins that enter the body through the digestive system (are eaten. One of the best reviews is Mycotoxins: Risks in Plant, Animal, and Human Systems by the U. This is one of the six mold toxins regulated in foods produced in and imported into the E. Trichothecenes inhibit protein synthesis and have many acute effects, including anemia and infant pulmonary hemorrhage. Carcinogenic Mycotoxins Several common molds produce very strong cancer causing agents. Aspergillis flavus, which grows on peanuts and corn (and in homes), produces the potent carcinogen Aflatoxin (causes liver can cer). Fusarium mold which grows on corn produces the carcinogen Fumonisin B1 and causes esophageal cancer. Esophageal cancer from Fumonisin B1 contaminated corn is observed in peo ple living in Italy, Iran, Kenya, Zimbabwe, United States and Brazil. Government but currently five non-cancer causing mold tox ins, the ones most commonly found on corn and grains, are strictly regulated by the E. Other mycotoxins affect diverse organs including skin, lungs, liver, kidneys etc in both people and animals. Many such as Gliotoxin (produced by the common indoor molds Aspergillus fumigatus, A. Gliotoxin is a well studied mold toxin and has long been fingered as the main chemical player contributing to the vir ulence of A. For studies on how the mold toxin Gliotoxin can compromise human im mune system response see the following links (? Although not common, molds have been found growing in the brain as well as the lungs. The Thrasher paper has an excel lent, concise review of molds and their secondary metabolites (toxins/immunosuppresives). Neurotoxic Mycotoxins Some commonly occurring mold toxins can cause Neurological problems such as: Hheadaches, short term memory loss, attention deficit problems, anxiety, neurological impairment in children and other problems. It is well established that some mycotoxins (toxins from Stachybotrys and Tricho derma both molds commonly found in water damaged homes) are neurotoxic and exposure to such neurotoxins can result in some degree of neurological impairment. Note that unless the individual is removed from the mycotoxin laden environment, or the environment is fixed, the individual cannot heal. Mycotoxins and the Gastrointestinal Tract Gut Microflora: Many or most mycotoxins of concern (including the well known mold toxin Penicil lin) exhibit strong anti-bacterial affects (bacteriocidal). Chronic exposure to even very low levels of these bacteriocidal toxins (at mold levels in many homes) can damage the good gut bacteria that make up our gut micro flora. When the gut microflora become out of balance as a result of mycotoxin exposure (dysbiosis), many adverse health effects can result includ ing: a shift toward intestinal aerobic bacteria such as observed in inflammatory bowel diseases; obesity (additional obesity links,, ?); as well as yeast/Candida overgrowth in the gut. Yeast/Candida secretes the powerful immunosuppressive Gliotoxin (the same causative agent pro duced by Aspergillus molds resulting in Invasive Aspergillosis) and Candida also secretes proteins so it can attach itself permanently to the intestinal lining. No carb/ no sugar diets, anti-fungals, probiotics and sometimes fecal transplants (all under Doctor supervision) are solutions to yeast over-growth. Again, unless the sick individual is removed from the mycotoxin laden environment they will not get better no matter how brilliant the doctor! Therefore no carb/ no sugar diets will be naturally low in consumed/ eaten mycotoxins. Note that research has shown that organic grains and fruits are often high in mycotoxins because an tifungals are not used during the growth cycle or after harvest. Intestinal Epithileum: An excellent review on the impact of mycotoxins on the lining of the intes tine (Modulation of Intestinal Functions Following Mycotoxin Ingestion) can be found here.

Most countries have low or no disparities complete primary school compared with 21% of between girls and boys in the development outcomes the poorest boys hypertension knowledge test cheap 50 mg toprol xl with visa. In Sudan arterial order 50mg toprol xl amex, 69% of the poorest boys complete generally manifested at a later stage in life (see primary education compared with 37% of the Figures 8 and 9) hypertension guidelines jnc 7 purchase toprol xl 50mg online. The study also found that hypertension goals jnc 8 purchase 50mg toprol xl overnight delivery, in the populous countries of India and Nigeria, girls compared with girls in general, even boys from score lower than boys underlining through weight poorer families in rural areas were twice as likely to of numbers the signifcance of this issue. In the poorest households that in seven of the ten worst performing countries of reduces to 16 girls for every 100 boys. Figure 10 our dataset, girls lag behind boys, suggesting that in shows how gender and household asset levels situations of extreme vulnerability, girls are often interact so that girls remain at a greater disadvantage left behind. In some regions of the gender disparities persist in education at all wealth world, such as Latin America and the Caribbean, levels in Afghanistan. In Asia, India and Nepal have the highest absolute difference between boys and girls, with boys scoring higher, though the difference between boys and girls in these two countries is less than four points. An estimated 117 million women were slightly higher for boys, due to innate biological missing from the global population in 2010 as a result 5 of prenatal sex selection, mostly in China and India. However, a notable exception to the general pattern of higher male mortality in the There are no major gender disparities in rates of under-fve group is in South Asia indicative of stunting below the age of fve. In many settings, women are denied Early marriage and lack of investment in family the right to make decisions about their health and planning is driving early and closely spaced births, that of their children, and may need to seek approval and underlies a growing proportion of maternal and and be accompanied by male relatives if they need child deaths. Complications during pregnancy and childbirth are Early marriage also makes girls more vulnerable now the second cause of death for 15?19-year to sexually-transmitted infections girls aged old girls globally. For example, in discriminatory practices, also limit pregnant Nigeria, young girls who develop vesicovaginal adolescent girls access to education in many or rectovaginal fstula as a result of childbirth are places. For example, despite continued calls often forced from their homes by their husbands, from local civil society organisations, in Sierra leading to their stigmatisation. It is estimated that Leone pregnant girls are not allowed to attend between 400,000 and 800,000 women in Nigeria schools and take exams, and are thus effectively live with this condition, with 20,000 new cases excluded from the mainstream education every year. In confict situations, boys their children earn through work, boys are often more are also more likely to be targeted for recruitment likely to take on a role of breadwinner than girls, and into armed groups, and often do not go back to school again even after they are demobilised. Ali, 15, and Nassim, ten, support the family by working the family were given registration papers when when work is available as agricultural labourers. Nassim, his sister, Yasmeen, 15, and his brother, Imad, eight, all have a visual impairment. There are lots of students at the school here, but teachers won?t let me join them ?All of my children are falling behind; no one cares because of my sight. On average, displacement create new groups of excluded 12 children out of 100 die before their children. Children who did not face exclusion ffth birthday in confict-affected situations, compared with six out of 100 in non-confict in the past see their life options and access contexts. As child crises and in refugee situations, are exposed to refugees or ?internally displaced children, a higher number of health risks, infectious and they face new barriers to their survival and communicable diseases and lower than normal learning: the destruction and collapse of nutritional intakes, putting them at greater risk schools and health systems; homelessness; of malnutrition. In Yemen, 41% of the children the loss of identity papers; and the neglect of under fve are stunted because of malnutrition, basic needs in refugee settings. The malnutrition rate in the Doro For those children who were already suffering refugee camp in South Sudan rose from 12% in the effects of exclusion pre-crisis, their situation February 2014 to 18% in March 2014. With1 affected areas make up 36% of out-of-school the length of confict-induced displacement now 6 primary age children worldwide. At the same time, girls may be host communities cannot cope with the increased removed from school to take on the role of caregiver demand. In other situations, displaced children and or their families may arrange for them to marry early, their families may be discriminated against on the either as a means of protection or a way to relieve basis of their status and are not actively provided increasing fnancial pressures. Research carried out by Save the Children in Iraq Or they may be living in refugee camps, which are found that school attendance of refugee children often under-resourced and unable to cope with outside of camps is as low as 42% for boys and 51% the scale of demand. Displaced families livelihood for girls, while attendance rates for young people opportunities will have also drastically reduced 15?17 is as low as 10%. Schools in refugee camps may either on account of crisis or their need to move not even be seen as safe spaces in Za?atari camp around, and they may not be able to afford to access in Jordan, 25% of families surveyed in 2015 indicated health services to the extent they were able to in that they thought schools in the camp were unsafe the past. The overwhelming majority of these and bilateral agencies, including: children came from Guatemala, El Salvador, and. Strengthen national child protection Honduras three countries that are experiencing systems. To interrupt this vicious circle, repatriated children the roots of this violence are deep and there need stronger psychosocial and economic are no easy solutions. A Mitu, age eight, lives with her parents in a village trained teacher helped Mitu make friends and take in Rangpur in Bangladesh. Her parents attended parenting disability, which meant she had diffculties learning sessions, where they were encouraged to treat to talk. Certain groups of children to be higher among minority ethnic groups for may be left out of offcial statistics due to example, Aboriginal and Torres Strait Islander children in Australia aged 0?14 are more than twice as likely fnancial constraints, or because of a political to have a disability as non-indigenous children. In this section we draw on secondary children often face a ?double jeopardy?: girls with material to consider the health and education disabilities, for example, are at a higher risk of violence and neglect than girls who do not have a disability. While offcial statistics and estimates are poor, children with disabilities are disproportionately represented in the group of out-of-school children. Partly as a result of this, some stands at 97%, only 12% of children offcially areas of a country may be underrepresented, registered with disabilities are enrolled in mainstream leaving certain groups of children such as education. Evidence of disparities between them could lead to shows that these negative attitudes are a barrier not unrest. However, a shortage of qualifed personnel poverty tends to be higher in slum neighbourhoods, to address the needs of children with disabilities and and this could explain some variation in health and a lack of infrastructure has meant that the majority nutrition outcomes, the same study found higher of children with disabilities fail to enjoy their rights. In Egypt, many families living in slums 250 million people worldwide living in cities who do keep their daughters at home to protect them from not feature into national surveys. What evidence sexual harassment, but by doing so they also deny does exist shows deep inequalities between children these girls the chances to learn, develop, work and living in informal urban settlements and street 13 participate in social life. A survey of unaccompanied migrant children in South A recent study of 45 countries estimates infant Africa found 80% were living in informal settings or mortality to be 5% in slum neighbourhoods and 3% in shacks; 14% on the street; and only 5% in formal non-slum, urban neighbourhoods. Such laws may also prohibit too are born free and equal and I stand shoulder-to access to critical health information or prohibit shoulder with them in their struggle for human rights. One form of exclusion receiving increasing Within the household, discrimination against and recognition is that experienced in all parts of the stigmatisation of children and young people with world by children and young people with diverse diverse genders and sexualities may result in abuse genders and sexualities. Stereotypes their families would accept them for who they are for girls and boys restrict the opportunities and or that they can speak openly about their sexual choices of children and young people, and leave orientation or gender identity at home. Criminalisation of consensual same-sex conduct A lack of availability and awareness of social services, and stigmatising behaviours associated with such compounded by the inability to afford those which do conduct along with the mistaken belief that non exist, puts these youth at additional risk. What keeps conforming identities can be ?cured or changed these young people on the street is a desire to live as by force deny these young people recognition as they are, to fnd a community that accepts them and full, equal members of society and has the potential to escape exclusion experienced at home. Black families because of the data and the basic health and have higher rates of low birth-weight babies education indicators we have used. Black mothers are less likely to receive prenatal care However, exclusion and discrimination are not than are White mothers, and Black children confned to low and middle-income countries. In terms of Western context to refer to minority groups 24 education, students from minority ethnic and that were and still are being left behind. While poor minority ethnic Aboriginal and Torres Strait Islander students groups tend to gain better school test results from a low socioeconomic class. Aboriginal and 33 than poor White children, ethnic minorities Torres Strait Islander children are more than continue to fnd it harder to fnd employment twice as likely to be developmentally vulnerable 34 26 upon graduating from school or university. In Canada indigenous children trail non-indigenous the high levels of social exclusion in wealthier children on practically every measure of well countries suggest that tackling exclusion requires being: family income, educational attainment, water more than increased access to health and quality, infant mortality, health, suicide, crowding education systems. And it points up the Save the Children found that Status First Nations need to address discriminatory practices and children living in poverty are three times more attitudes, which prevail in spite of mature likely to live in a home that requires major repairs non-discriminatory laws and watchdogs. These Each guarantee consists of three strands, shown barriers must be tackled systematically at household, in Table 3. For some groups, such as To meet this challenge and to achieve the prize of indigenous peoples, the right to accessing education ensuring no child is left behind we call on leaders or health services does not necessarily translate in all countries to make Three Guarantees to into a strict defnition of ?taking part in society All Children: eg, through participation in fnancial or labour markets, or through mainstream education that is 1. Equal treatment each of these strands be adapted to the country and group context. The agenda reached agreement on its outcome document, features 17 Sustainable Development Goals the Addis Ababa Action Agenda. This commitment has been central for all, including health, education, energy, water to the global discussion and is a signifcant and sanitation. I was so excited to deliver these messages where she spoke at various events about the and to collaborate with children from all around challenges facing children in Tanzania.

The safe distribution of human faeces (toilets) and a clean water supply is important hypertension range generic toprol xl 50 mg free shipping. Hepatitis B can be prevented by routinely immunising all children with hepatitis B vaccine heart attack while running discount toprol xl 100 mg visa. Mothers who have jaundice before or during pregnancy must be identifed for special management blood pressure chart kpa buy discount toprol xl online. When you have completed this unit you should be able to: 11-2 Which are the common intestinal blood pressure is order discount toprol xl online. The eggs have a very characteristic shape and can be easily recognised if a sample of stool is examined under a microscope. With heavy a garden fertiliser, children can swallow and infections, bunches of roundworms can be seen in a plain abdominal X-ray. Roundworm mebendazole or albendazole if acute abdominal eggs can survive in soil for years. Playing or pain is present as treatment increases the worms crawling in contaminated soil or eating raw tendency to migrate and may precipitate bowel vegetables that have not been washed may obstruction. This is a major public health problem in many 11-6 How can roundworms cause chest parts of South Africa. Children with roundworm larvae in From here they make their way up the bronchi the lungs present with a dry cough or wheeze. In the small bowel the roundworm larvae mature into adult note A high eosinophil count in the peripheral blood (10% or more) is typical. Roundworm infection can be treated with Many children with roundworms appear either: healthy and have no symptoms. Large numbers of worms in the bowel can cause problems: 11-8 How can infection with roundworms be prevented? Rectal prolapse may occur with very heavy for children between the ages of 2 and 5 infections. With prolapse, the worms may years in communities with poor hygiene and be seen attached to the rectal mucosa. Deworming has been found to Whipworm infection can cause iron defciency improve the learning capacity and growth of anaemia. Mebendazole or albendazole, as given for recommended in communities where roundworms roundworms are common. They are are especially common where children sleep short, thin worms (about 4 cm) that attach or play together in crowded conditions. Adult themselves to the mucosa of the large bowel female worms pass out the anus at night to lay where they cause bleeding. As with roundworms, eggs are ingested Pinworms are common even where hygiene (swallowed) with soil. A piece of sticky tape Mebendazole or albendazole, as for (Sellotape) should be placed against the anus roundworm infection. The common tapeworms that infect the HookWorms human gut are the pork and, to a lesser degree, the beef tapeworm. They are very long (up to 5 metres) segmented worms that grow 11-17 What are hookworms? Tapeworm moist climates such as northern KwaZulu segments flled with eggs are excreted in Natal and the Mozambique coast. With human stools and later may be swallowed poor sanitation, hookworm eggs in the stool by animals (pigs or cows). Once bloodstream to the muscles of the animals the skin is penetrated, hookworms behave like where they become tapeworm cysts. Eating roundworms as they enter the bloodstream infected, uncooked meat of these animals and travel via the lungs to get into the small completes the life cycle of the tapeworm when bowel. The worms attach to the bowel mucosa the eggs hatch, resulting in adult worms living and cause bleeding. Most tapeworms result from eating poorly cooked pork which is infected with tapeworm cysts. Good sanitation, safe water, hand-washing 11-22 How is tapeworm infection and washed vegetables will reduce the risk of diagnosed? Treatment of Mebendazole orally 100 mg twice daily for 7 neurocysticercosis in hospital is with steroids and days. HydAtid diseAse If possible, animals should be slaughtered in a registered abattoir where all meat is inspected 11-26 What is hydatid disease? This is caused by the dog tapeworm which Terefore, avoid eating raw or partially cooked can occur in the gut of dogs. Other dogs can then Human stools must be disposed of safely be infected with tapeworms by eating the raw so that it cannot be eaten by pigs. Parts of the Eastern If eggs of the dog tapeworm are swallowed by Cape of South Africa are particularly heavily humans instead, the eggs hatch in the human contaminated with tapeworm eggs. Tese large cysts may cause In villages, pigs must be prevented from eating clinical problems (hydatid disease) and will human faeces. Sometimes the eggs of the pork tapeworm, especially mutton or goat meat which is which have been passed in human faeces, are infected with the cysts of the dog tapeworm. In the brain they form many small tape worm Hydatid disease results when children swallow cysts (neurocysticercosis) which cause fts the eggs of the dog tapeworm. Tapeworm cysts in the brain parasites 187 Treatment is with mebendazole or albendazole 11-29 What is the treatment of giardia daily for 6 weeks. The prevention, diagnosis and treatment of It is best to avoid infection with giardia by sandworm infection is discussed in Unit 12. Giardiasis is an infection with a single-celled Amoebiasis is an infection caused by a single organism (protozoa) called giardia. The cysts celled organism (protozoa) called an amoeba of giardia are swallowed in contaminated food which infects the large bowel. Giardia lives in the small bowel and are passed in the stool from where they can cysts are passed in the stool. The cysts in human contaminate food or water causing infection in stools contaminate the soil and nearby water. Terefore, the provision of toilets and note Giardia lamblia is the cause of giardiasis. However, with heavy infection the child develops loose, 11-31 What are the clinical features of foul-smelling, watery stools. However, the infection resolves in a few days but it may heavy infection causes abdominal discomfort become chronic. Chronic giardiasis may cause and dysentery with blood and mucus in the chronic diarrhoea with malabsorption leading stools. This presents with an enlarged tender It is difcult to confrm the diagnosis by liver. Metronidazole (Flagyl) 200 mg 3 times daily note Giardia is a common cause of ?travellers for 5 days. Never pass urine or stool near a stream or Bilharzia (schistosomiasis) is a disease caused dam. Always use a clean, safe source of water for Bilharzia of the bladder is the most common drinking and washing. Always wash raw vegetables or salads Eggs of the bladder parasite are passed in the before eating. Avoid eating meat which has not been the parasite can infect and multiply in a special thoroughly cooked. From here the parasites enter the method of reducing the number of infected bloodstream and are carried to the bladder. Damage can extend to the rest of the Safe toilets and clean water will prevent infection urinary tract, resulting in urinary obstruction with most intestinal parasites. Most intestinal parasites can be efectively Bilharzia of the bladder is common in South treated with oral mebendazole or albendazole. Some require a single dose (roundworms, whipworms and pinworms) but others need a daily dose for a number of days (tapeworms). With more severe infection, the classical sign is terminal haematuria (blood seen in the urine towards 11-40 What is malaria?

Biomarkers are “parameters (physiological heart attack 90 year old discount 25 mg toprol xl, biochemical blood pressure up and down quickly cheap 100mg toprol xl overnight delivery, anatomic) that can be measured in vivo and that reflect specific features of disease related pathophysiological processes” (Jack et al blood pressure 80 60 toprol xl 50mg generic. A further problem with the use of biomarkers as a diagnostic tool is that biomarkers have been primarily studied in Caucasian populations hypertension 2015 buy toprol xl 100mg with amex, and research is needed in diverse populations (Dubois, Padovani, Scheltens, Rossi, & Dell’Agnello, 2016; Jack et al. Currently, biomarkers are employed in research, but not in clinical care (Sullivan, 2018). Neuropsychological evaluation is effective for diagnosing probable Alzheimer’s disease, but is costly, time-consuming, and potentially frustrating for the patient. A detailed neuropsychological assessment may take up to eight hours to complete when the assessment includes a thorough diagnostic interview and full neuropsychological test battery (University of North Carolina Department of Neurology, n. The amount of time required to complete a neuropsychological assessment may be difficult for the individual due confusion, stress, and fatigue induced by testing. Individuals who reside in rural areas may be unable to obtain neuropsychological assessments, as professionals who are qualified to administer tests typically reside in urban areas. Professionals who are administering the assessment may also experience difficulty in gathering an accurate medical history from patients with memory deficits. Benefits may be emotional and interpersonal, medical, or financial (Boller & Barba, 2001; Brinkman et al. Emotional and Interpersonal Benefits Early diagnosis allows the patient and caretakers to plan for the future while symptoms are mild, so informed decisions can be made regarding treatment options, finances, and driving ability (Makizako et al. Additionally, diagnosis during this stage allows patients and their families to explore education and support programs, leading to enhanced patient and caregiver well-being. The inclusion of aerobic exercise, mental stimulation, and social activity may also decrease the progression of cognitive decline (Langa & Levine, 2014). Unfortunately, the decline of a patient’s cognitive functioning typically goes unnoticed for several years, and by the time of diagnosis and treatment, the patient is too impaired to reap the full benefits of medication (Brinkman et al. Early diagnosis also allows the patient and family members to consider different treatment options and decide what will be most beneficial for the patient. Psychological benefits may occur from the knowledge that one is contributing to important research, even if novel medication proves ineffective for the patient (Alzheimer’s Association, 2018). Savings would result from reduced Medicare and Medicaid expenditures, out-of-pocket expenses, and private insurance expenses (Alzheimer’s Association, 2018; Sullivan, 2018). Early diagnosis would aid in the savings through financial planning, early treatment options, and implementation of beneficial health behaviors. It has been shown to have a sensitivity of 78% when discriminating between healthy adults and adults with mild dementia (Gomez & White, 2006), but doesn’t consider the patient’s education level. Disruptions in semantic memory have been shown to be strongly correlated with Alzheimer’s disease and other dementias (Maseda et al. Additionally, both qualitative and quantitative aspects of the Boston Verbal Fluency Test are considered to be important in understanding the deteriorated cognitive processes of dementia patients; however, examining qualitative components of the Boston Verbal Fluency Test is subjective and time-consuming (Gomez & White, 2006). Computerized tests have been developed to combat the problems with traditional dementia screening measures. Measures such as the Computerized Assessment of Mild Cognitive Impairment (Saxton et al. The aim of these computerized tests is to provide a comprehensive assessment that combats the logistical and practical problems associated with traditional neuropsychological assessment (Fillit et al. Computerized dementia assessments should strive to be simple and rapid, but maintain adequate sensitivity and specificity (Maruff et al. Research indicates that for individuals to be considered competent in neuropsychology and neuropsychological assessment, he or she must have obtained graduate and professional training, have expert knowledge regarding the brain behavior relationship, have the required skills and knowledge regarding the neuropsychological assessments they may administer, be able to competently communicate neuropsychological findings and test results, and have the knowledge and skills needed for neuropsychological intervention (Hessen et al. Including a dementia screening as part of an elderly person’s routine physical examination would allow for better treatment for the patient, and better management of financial resources as only those who showed signs of impairment would be referred for lengthier, more costly neuropsychological assessment (Hammers et al. Short tests are preferable as they induce less fatigue for the patient and are able to be administered repeatedly, which is important in measuring cognitive decline over time (Hammers et al. Specifically, low-cost, self-administered screening measures designed for use in a primary care office are needed to identify individuals in the preclinical stage of dementia, where pharmacologic interventions are most effective (Rao, 2018). In fact, this longitudinal study discovered that concurrent neuropsychological assessment was better able to account for variance in patients’ self maintenance abilities than single measures of cognitive status (Atchison et al. Specifically, self-administered computerized tests will increase rapidly in use as they have many cost effective and standardization benefits (Bauer et al. Advantages of self-administered computerized measures include: ability to be administered without highly-trained staff (Bauer et al. Although some may be concerned about the feasibility of older adults using self-administered technology, research demonstrates that older adults are welcoming of and able to respond to computerized self-administered tests (Collerton et al. Research indicates that dementia patients are accepting of technology, as long as there is minimal new learning required of them (Rosenburg, Wingard, Kottorp, & Nygard, 2012). Other computerized dementia assessments have been developed and show promise, which may lead some to question the need for another assessment. First, research suggests that computerized self administered measures designed to be used by elderly individuals should employ a touch screen computer monitor in order to decrease the difficulty of interactions between the patient and the computerized test (Tornatore, 2005). GrayMatters employs a touch-screen monitor in accordance with the current research. Second, according to the American Psychological Association (1999), computerized assessments should meet the same psychometric standards as examiner-administered tests (Bauer et al. GrayMatters has been previously established as an empirically supported computerized assessment (Brinkman et al. Third, GrayMatters presents directions both orally and visually, and administration requires only twenty minutes. The GrayMatters system was designed to measure memory and executive functioning, which have previously been established as key domains in identifying cognitive impairment and dementia. There is also some research that suggests that visual memory tasks may be more sensitive to the identification of mild cognitive impairment than verbal memory tasks (Alladi, S. Images of objects are presented on the computer screen and patients are verbally instructed to study the pictures. The images are then removed from the screen, and one picture is presented to the patient while he or she is asked, through both verbal and written cues, to choose whether the picture (challenge picture) was one of the images just presented. The patient is cued to touch either the Yes or No button as their response to the question. The first trial has a high likelihood of the patient responding correctly, with only two images presented simultaneously for five seconds and challenge items presented after a delay of five seconds. Eleven additional sets of images are shown on the computer screen, and each of these sets has four images presented simultaneously. In these sets, two challenge pictures are presented simultaneously after a five-second delay, and the participant again responds by selecting either the Yes or No button. There are an equal number of correct and incorrect challenge items presented to the patient. Trials 5 through 8 and trials 9 through 12 are comparable in difficulty level; however, in trials 9 through 12, patients are given simple distractor tasks during the delay interval to decrease the opportunity to replay the images in their mind. The distractor tasks are also completed via the touch screen monitor on the computer. There are four tasks, each consisting of different rules, which are presented via the computer to the patient. The pictures of the hands are mirror images of the same hand, which ensures that the pictures are equated visually. The patient is asked to touch the hand that he or she believes a coin can be found under. After the participant responds, the hand is flipped to either show a coin or an empty hand. The visual cue is presented in text version on the computer screen, and the same instructions are presented in the visual and oral format. The response is correct on the first trial regardless of which hand the patient selected. There are 25 individual trials unless a patient responds correctly to five trials sequentially, which denotes that the patient reached the success criterion. After 25 trials, which is the failure criterion, or reaching the success criterion, the patient begins a second task that utilizes a non-alternating rule. The patient’s first response is again considered correct regardless of which hand is chosen. The criteria for success and failure are the same under this rule as the previous rule. The previously used delay period between trials is discontinued under this rule and all subsequent rules in order to shorten the overall assessment time, as the primary interest in these rules involves the patient’s ability to shift cognitive sets after learning the first rule. This rule is called the Shape Alternation rule and uses a blue circle and a red square as stimuli.

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