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CME / ABIM MOC / CE

Does Exposure to Green Spaces Decrease Risk for Hospitalization for Parkinson Disease?

  • Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 2/24/2023
  • Valid for credit through: 2/24/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, neurologists, nurses, nurse practitioners, pharmacists, physician assistants and other clinicians who care for patients at risk for dementia and Parkinson disease.

The goal of this activity is for members of the healthcare team to be better able to evaluate the impact of environmental variables on admissions for chronic neurologic conditions.

Upon completion of this activity, participants will:

  • Assess how changes in socioeconomic deprivation in neighborhoods can affect patterns of mortality
  • Evaluate the impact of environmental variables on hospitalizations for Parkinson’s Disease
  • Outline implications for the healthcare team


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News Author

  • Pauline Anderson

    Freelance writer, Medscape

    Disclosures

    Pauline Anderson has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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CME / ABIM MOC / CE

Does Exposure to Green Spaces Decrease Risk for Hospitalization for Parkinson Disease?

Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/24/2023

Valid for credit through: 2/24/2024, 11:59 PM EST

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Clinical Context

There are good data that environmental and social factors play a major role in the risks for cardiovascular disease (CVD) and cancer, the 2 most important causes of mortality in the United States. In a study conducted by Xiao and colleagues in 2018 and published in the American Journal of Epidemiology[1], they evaluated how changes in socioeconomic deprivation in US neighborhoods affected risk for mortality among middle-aged and older adults.

The study examined 288,555 adults between the ages of 51 and 70 years who did not move from their US residence between 1990 and 2000. Researchers used census data to track neighborhood socioeconomic deprivation. Researchers' hypothesis that mortality rates would shift inversely to changes in socioeconomic deprivation was proven correct. Improvements in neighborhood deprivation in poor areas improved mortality rates by over 10%. This effect was stronger among women vs men, particularly among women with chronic illnesses; however, when relatively affluent neighborhoods developed higher rates of deprivation, mortality rates rose, and this latter effect was particularly pronounced among men.

The built environment and green space are variables that affect mortality, but there are less data on their influence on important chronic neurologic illnesses. The current study by Klompmaker and colleagues addresses this deficit.

Study Synopsis and Perspective

Exposure to natural environments may lower hospitalizations for patients with neurodegenerative disorders, new research suggests.

In a large, open-cohort study, living in areas rich with greenery, parks, and waterways (blue space) was linked to fewer hospitalizations for Parkinson disease (PD), and residing near green spaces was associated with fewer hospitalizations for Alzheimer disease and related dementias (ADRD).

These results should be useful to policymakers and urban planners, lead study author Jochem O. Klompmaker, PhD, postdoctoral researcher, department of environmental health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, told Medscape Medical News.

They also provide clinicians with more evidence of the importance of being close to nature and of encouraging patients to take more walks, Klompmaker noted.

"If they live near a park, that could be a good place to be more physically active and reduce stress levels," he said.

The findings were published December 1 in JAMA Network Open.[2]

3 Natural Environments

Alzheimer disease and PD are the most prevalent neurologic diseases in the United States and will likely become even more common owing to longer life expectancy, the investigators noted.

Because there are no cures for ADRD or PD, it is important to identify modifiable risk factors, they added.

Previous research has shown an association between environmental exposures and AD and PD; however, past studies focused mainly on greenery.

The current study examined associations between ADRD and PD hospital admissions and 3 natural environments: parks, blue space, and green space.

The study included about 61.7 million fee-for-service Medicare beneficiaries aged at least 65 years and living in the United States.

Researchers examined first hospital admissions with a primary or secondary discharge diagnosis of ADRD or PD. There were 7,737,609 such hospitalizations for ADRD and 1,168,940 for PD from 2000 to 2016.

The study used zip codes to determine exposures. To measure greenness, the investigators used satellite images to calculate the normalized difference vegetation index (NDVI). The NDVI ranges from −1 to 1, with larger values indicating higher levels of live vegetation, which could include trees, gardens, and agricultural crops.

For park exposure, the researchers used the US Geological Survey Protected Areas Database to determine land types likely used by the public for outdoor recreation, such as playgrounds and basketball courts. They calculated the percentage park cover for each zip code.

Blue space includes surface water, such as rivers and lakes. The researchers used satellite image data to calculate spatially weighted mean blue space values for each zip code.

Covariates included age, sex, race/ethnicity, and Medicaid eligibility as a proxy for low socioeconomic status (SES). Additional SES indicators included median household income, Klompmaker noted.

Hazard ratios for NDVI and percentage park cover were expressed per interquartile range (IQR) difference. The investigators compared HRs of blue space cover (≥ 1%) with the reference category (< 1% blue space cover).

Differences by Exposure

Results showed that NDVI was associated with a decrease in ADRD hospitalizations after adjustment for potential confounders (HR 0.95 [95% CI: 0.94, 0.96] per IQR increase).

There was no evidence of an association between percentage park cover and blue space cover with ADRD hospitalization; however, all 3 exposures were associated with a decrease in PD hospitalizations after adjustments. The HRs were 0.94 (95% CI: 0.93, 0.95) for NDVI, 0.97 (95% CI: 0.97, 0.98) for percentage park cover, and 0.97 (95% CI: 0.96, 0.98) for blue space cover of at least 1%.

Zip codes with higher NDVI had lower air pollution levels, which may explain part of the effect, said Klompmaker.

"When we adjust for air pollution, we saw effects of greenness became less strong," he added.

Results by neighborhood SES differed between exposures. For example, for PD hospitalization, associations of percentage park cover were greatest in low-SES zip codes, whereas associations of NDVI were greatest for zip codes with higher SES.

When evaluating associations only in urban zip codes, researchers found that associations were similar to those of the full cohort. This was "a little surprising," as previous studies showed that associations were generally stronger in urban areas, Klompmaker noted.

It is not clear why outcomes for ADRD and PD varied, he added.

"PD and AD are different diseases, so there may be different relations between specific exposures," he said.

Further analysis showed that more exposure to natural environments could decrease hospitalizations.

"Not a Stretch"

Commenting for Medscape Medical News, Michael S. Okun, MD, chair of neurology at University of Florida Health, Gainesville, Florida, and medical advisor for the Parkinson's Foundation, said the results make sense.

"Natural environments have been associated with less cardiac disease and less depression; and it would not be a stretch to consider there are less neurodegenerative disease hospitalizations when folks spend time in natural environments," said Okun, who was not involved with the research.

He noted the conflicting results from studies of natural environments as being potentially associated with neurodegenerative diseases.

"One tricky element has been controlling for air pollution in urban areas," he said.

Still, exposure to natural environments may reduce stress, restore attention, and increase activity and social interactions, all of which improve cognition, said Okun.

The study was funded by grants from the National Institute of Environmental Health Sciences, the National Institute on Aging, the National Heart, Lung, and Blood Institute, and the National Institute on Minority Health and Health Disparities. Klompmaker received a grant from the National Institutes of Health during the conduct of the study. Okun has disclosed no relevant financial relationships.

Study Highlights

  • Adults aged ≥ 65 years with Medicare insurance between 2000 and 2016 were eligible for analysis.
  • The main study outcomes were hospital admissions for ADRD and PD. Researchers identified admissions in a database of diagnostic codes.
  • There were 3 principal study variables, all measured at the level of participants' zip code:
    • Green space, as measured by the NDVI. This measurement uses infrared studies of satellite images.
    • Park space, as measured by the US Geological Survey Protected Area Database.
    • Blue space, as measured by Joint Research Centre Global Surface Water data set.
  • The main study outcome was how these 3 variables interacted with admissions for ADRD and PD. Researchers adjusted study results to account for calendar year, region, county-level smoking status, and a number of demographic variables.
  • The ADRD and PD cohorts each included > 61 million adults. Over three-quarters of adults were between the ages of 65 and 74 years, and 55.2% were women; 84.4% of adults were White, and 8.8% were Black.
  • Researchers found > 7.7 million first-time admissions for ADRD and nearly 1.2 million admissions for PD over the study period.
  • Urban location was associated with a lower concentration of green space but increased density of park space.
  • Higher amounts of green space but not park space or blue space was associated with a lower risk for ADRD admissions. For each IQR increase in the measurement of green space, the HR for ADRD admission was 0.95 (95% CI: 0.94, 0.96).
  • All 3 environmental variables were inversely associated with the risk for PD admission.
  • A subgroup analysis limited to Black adults found that more green space was associated with a lower risk for ADRD and PD admissions, but park space failed to significantly alter these risks.
  • Green space had its biggest impact on ADRD and PD admissions among patients who were eligible for Medicaid, indicating lower economic status. In contrast, blue space was only associated with lower risk for admissions among patients noneligible for Medicaid, indicating higher economic status.
  • In an analysis limited to urban areas, no environmental factors affected the risk for ADRD admission, but increases in green space and blue space were associated with lower rates of PD admission.

Clinical Implications

  • A previous study by Xiao and colleagues found inverse relationships between mortality rates and changes in neighborhood socioeconomic deprivation. Improvements in neighborhood deprivation in poor areas improved mortality rates by over 10%. This effect was stronger among women vs men, particularly women with chronic illnesses; however, when relatively affluent neighborhoods developed higher rates of deprivation, mortality rates rose, and this latter effect was particularly pronounced among men.
  • In the current study by Klompmaker and colleagues examining the effects of green space, park space, and blue space, only green space concentration was significantly inversely associated with reductions in first admissions for both ADRD and PD. Green space had its biggest impact on ADRD and PD admissions among patients who were eligible for Medicaid, indicating lower economic status.
  • Implications for the healthcare team: When counseling older adults, members of the healthcare team should reinforce the health benefits of regular walks and exposure to parks and green spaces.

 

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