Changing patterns of neurological mortality in the 10 major developed countries – 1979–2010

Low Intensity Electromagnetic Fields Act via Voltage-Gated Calcium Channel (VGCC) Activation to Cause Very Early Onset Alzheimer's Disease: 18 Distinct Types of Evidence

Electronically generated electromagnetic fields (EMFs) including those used in wireless communication such as cell phones, Wi-Fi and smart meters, are coherent, producing very high electric and magnetic forces which act on the voltage sensor of voltage-gated calcium channels to produce increases in intracellular calcium [Ca2+]i. The calcium hypothesis of Alzheimer's disease (AD) has shown that each of the important AD-specific and nonspecific causal elements are produced by excessive [Ca2+]i. [Ca2+]i acts in AD via excessive calcium signaling and the peroxynitrite/oxidative stress/inflammation pathway which are each elevated by EMFs. An apparent vicious cycle in AD involves amyloid-beta protein (A) and [Ca2+]i. Three types of epidemiology each suggest EMF causation of AD including early onset AD. Extensive animal model studies show that low intensity EMFs cause neurodegeneration including AD, with AD animals having elevated levels of A, amyloid precursor protein and BACE1. Rats exposed to pulsed EMFs every day are reported to develop universal or near universal very very very early onset neurodegeneration including AD; these findings are superficially similar to humans with digital dementia. EMFs producing modest increases in [Ca2+]i can also produce protective, therapeutic effects. The therapeutic pathway and peroxynitrite pathway inhibit each other. A summary of 18 different findings is provided, which collectively provide powerful evidence for EMF causation of AD. The author is concerned that smarter, more highly pulsed "smart" wireless communication may cause widespread very, very early onset AD in human populations.

Increasing epilepsy-related mortality: A multiple causes of death study in Northern Italy

PURPOSE

to assess the burden of epilepsy as the underlying or contributory cause of death, to investigate time trends in mortality with epilepsy, and to examine the main associated comorbidities.

METHODS

All deaths from January 1, 2008 to December 31, 2019 with any mention of epilepsy were retrieved from the mortality register of the Veneto Region (Italy). The average annual percent change (AAPC) in age-standardized mortality rates was estimated by log-linear models. The association between mention of epilepsy and of selected disease categories in death certificates was assessed by conditional logistic regression.

RESULTS

Any mention of epilepsy was reported in 5,907 death certificates; of these, epilepsy was selected as the underlying cause in 1,020 decedents. Deaths with epilepsy represented 0.8% of total mortality in 2008-2011, increasing to 1.3% in 2016-2019. The AAPC was 4.7% for males (95% CI 3.0-6.4, p<0.001) and 6.2% for females (95% CI 4.5-7.9, p<0.001). A strong association was found between mention of epilepsy and meningitis/encephalitis, congenital anomalies/cerebral palsy and other paralytic syndromes, central nervous system tumours, cerebrovascular diseases, and dementia/Alzheimer.

CONCLUSIONS

The present analysis from Southern Europe confirms recent reports limited to the UK and the US on increasing epilepsy-related mortality rates. aging of the population and the growing prevalence of neurological disorders are among long-term causes of this unfavorable trend; further studies on mortality data and other health archives are warranted.

21st Century Early Adult (55-74) Deaths from Brain-Disease-Deaths Compared to All Other Cause Mortality in the Major Western Countries - Exposing a Hidden Epidemic

OBJECTIVES

To examine early adult deaths (EAD) - people aged 55-74 due to brain disease deaths (BDD) compared to all other causes (AOC) in the 21st century in 21 major Western countries (MWC).

METHOD

EAD are below MWCc average life expectancy. All mortality drawn from the latest WHO data. The three global BDD categories consist of mental and behaviour disorder, nervous diseases and Alzheimer and other dementias. Mortality rates per million are analysed for people 55-74 years and total age-standardised death rates (ASDR). BDD rates between 2000-2015 compared against AOC of deaths for EAD and ASDR. Confidence Intervals determine any significant difference AOC and BDD over the period 2000-15, plus an examination of EAD in six separate global mortality categories.

RESULTS

EAD: The separate BDD categories for EAD significantly positively correlated, validating their combination as BDD. Every country's AOC 55-74 rates fell substantially, but fourteen country's BDD rose substantially (>20%) and all MWC countries BDD rose significantly more than AOC. ASDR: All nations total AOC fell substantially, whereas seventeen BDD rates rose substantially and every country's BDD significantly increased compared to AOC deaths. Six other EAD mortalities, circulatory, cancer, respiratory, compared to BDD produced Odds Ratios ranging from 1:1.54 to 1:2.36 such were the marked differences over the period.

DISCUSSION

Positive news is that AOC are down across all investigated countries in the 21st century. However, the extent of the EAD rises in just 16 years indicates that these BDD conditions are starting earlier suggesting multiple interactive environmental factors impacting upon brain related diseases.

7-Amidocoumarins as Multitarget Agents against Neurodegenerative Diseases: Substitution Pattern Modulation

This study explores the potential of 7-amidocoumarins as multitarget agents against Parkinson's and Alzheimer's diseases, by modulating the substitution patterns within the scaffold. Sixteen compounds were synthesized via 7-amino-4-methylcoumarin acylation, and in vitro evaluation of the molecules against hMAO-A, hMAO-B, hAChE, hBuChE and hBACE1 was performed. Five compounds turned out to be potent and selective hMAO-B inhibitors in the nanomolar range, six displayed inhibitory activity of hMAO-A in the low micromolar range, one showed hAChE inhibitory activity and another one hBACE1 inhibitory activity. MAO-B reversibility profile of 7-(4'-chlorobenzamido)-4-methylcoumarin (10) was investigated, with this compound being a reversible inhibitor. Neurotoxicity on motor cortex neurons and neuroprotection against H₂ O₂ were also studied, corroborating the safety profile of these molecules. Finally, theoretical ADME properties were also calculated, showing these molecules as good candidates for the optimization of a lead compound. Results suggest that by modulating the substitution pattern at position 7 of the scaffold, selective or multitarget molecules can be achieved.

Gut dysbiosis, leaky gut, and intestinal epithelial proliferation in neurological disorders: towards the development of a new therapeutic using amino acids, prebiotics, probiotics, and postbiotics

Here we offer a review of the evidence for a hypothesis that a combination of ingestible probiotics, prebiotics, postbiotics, and amino acids will help ameliorate dysbiosis and degeneration of the gut, and therefore promote restoration of nervous system function in a number of neurological indications.

Relationship between the use of electronic devices and susceptibility to multiple sclerosis

Multiple sclerosis (MS) is an autoimmune condition influenced by both genetic and environmental factors. Dirty electricity generated by electronic equipment is one of the environmental factors that may directly or indirectly impact MS susceptibility. The current Study aimed to evaluate the relationship between the usage time of electronic equipment and susceptibility to MS in North-West Iranian people. This approach was carried out upon 471 MS-diagnosed patients and 453 healthy participants as control group in East Province of Azerbaijan. By utilizing structured questionnaires, the information of all participants about usage status of some electronic devices was obtained. Data were analyzed by IBM SPSS Statistics version 18.0 and the quantitative variables were analyzed by Chi Square and Independent sample t tests. P values below or equal to 0.05 were considered as significant. Among the evaluated items in this approach, the utilization of cell phones and satellite television dishes were significantly higher in MS patients (p < 0.001, p = 0.07). Furthermore, a correlation was observed between sleeping with cell phone and/or laptop under the pillow (p = 0.011) and MS disease; however, there was no significant differences between MS patients and controls in computer using and television watching. Our study reinforces the concept that the utilization of some electronic devices and the continuous exposure to dirty electricity would increase the risk of MS disease thereupon by enhancing the cognizance of adverse effects of dirty electricity and reducing the time spent over electronic devices during adolescence and adulthood the occurrence probability of MS could be declined.

Are rises in Electro-Magnetic Field in the human environment, interacting with multiple environmental pollutions, the tripping point for increases in neurological deaths in the Western World?

Whilst humans evolved in the earth's Electro-Magnetic-Field (EMF) and sun-light, both being essential to life but too much sun and we burn. What happens if background EMF rise to critical levels, coinciding with increasing environmental pollutants? Two of the authors can look back over 50 clinical years and appreciate the profound changes in human morbidity across a range of disparate conditions - autoimmune diseases, asthma, earlier cancer incidence and reduced male sperm counts. In particular have been increased autism, dyslexia, Attention Deficit Hyperactivity Disorder and neurological diseases, such as Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Parkinson's Disease, Early Onset Dementia, Multiple System Atrophy and Progressive Supranuclear Palsy. What might have caused these changes-whilst genetic factors are taken as given, multiple environmental pollutants are associated with neurological disease although the mechanisms are unclear. The pace of increased neurological deaths far exceeds any Gompertzian explanation - that because people are living longer they are more likely to develop more age-related problems such as neurological disease. Using WHO global mortality categories of Neurological Disease Deaths (NDD) and Alzheimer's and Dementia deaths (Alz), updated June 2018, together they constitute Total Neurological Mortality (TNM), to calculate mortality rates per million for people aged 55-74 and for the over-75's in twenty-one Western countries. Recent increases in American people aged over-75's rose 49% from 1989 to 2015 but US neurological deaths increased five-fold. In 1989 based on Age-Standardised-Deaths-Rates America USA was 17th at 324 pm but rising to 539 pm became second highest. Different environmental/occupational factors have been found to be associated with neuro-degenerative diseases, including background EMF. We briefly explore how levels of EMF interact upon the human body, which can be described as a natural antennae and provide new evidence that builds upon earlier research to propose the following hypothesis. Based upon recent and new evidence we hypothesise that a major contribution for the relative sudden upsurge in neurological morbidity in the Western world (1989-2015), is because of increased background EMF that has become the tipping point-impacting upon any genetic predisposition, increasing multiple-interactive pollutants, such as rises in petro-chemicals, hormone disrupting chemicals, industrial, agricultural and domestic chemicals. The unprecedented neurological death rates, all within just twenty-five years, demand a re-examination of long-term EMF safety related to the increasing background EMF on human health. We do not wish to 'stop the modern world', only make it safer.

The reliable measurement of temporal trends in mortality attributed to epilepsy and status epilepticus in Northern Ireland between 2001-2015

PURPOSE

Epilepsy mortality is of considerable public health concern, as a leading cause of premature neurological death. Recent English and Welsh mortality data suggests a falling mortality rate where epilepsy was the underlying cause of death, predominantly due to a reduction in status epilepticus (SE) mortality. We sought to validate this finding in Northern Ireland.

METHODS

Officially recorded death certificate data related to epilepsy and SE were obtained from the Northern Ireland statistics and research agency. Data were analysed from 2001 to 2015. The outcomes were the age-adjusted mortality rate for epilepsy and SE. External validation of SE deaths was carried out using data from an intensive care national audit and research centre database.

RESULTS

From 2001 until end of 2015, epilepsy was recorded at death certification in 1484 cases. 458 deaths were considered due to epilepsy. Among 75 in whom SE was recorded, SE was the cause of death in 46 patients. External validation found 103 total deaths related to SE in ICU departments in Northern Ireland, suggesting an overall under-ascertainment of officially recorded statistics. With respect to the 2013 European Standard Population, the mean age-adjusted mortality rate for epilepsy was 1.9 (95% C.I. 1.73-2.07) per 100,000 person years. For SE the mean age-adjusted mortality rate was 2.1 (95% C.I. 0.15-0.27) per 100,000 person years.

CONCLUSIONS

Death certification in SE is likely to be an underestimate of the reality. Further efforts are urgently needed to determine the extent of SE-related deaths and all deaths in patients with epilepsy.

New Insights into Microglia-Neuron Interactions: A Neuron's Perspective

Microglia are the primary immune cells of the central nervous system. However, recent data indicate that microglia also contribute to diverse physiological and pathophysiological processes that extend beyond immune-related functions and there is a growing interest to understand the mechanisms through which microglia interact with other cells in the brain. In particular, the molecular processes that contribute to microglia-neuron communication in the healthy brain and their role in common brain diseases have been intensively studied during the last decade. In line with this, fate-mapping studies, genetic models and novel pharmacological approaches have revealed the origin of microglial progenitors, demonstrated the role of self-maintaining microglial populations during brain development or in adulthood, and identified the unexpectedly long lifespan of microglia that may profoundly change our view about senescence and age-related human diseases. Despite the exponentially increasing knowledge about microglia, the role of these cells in health and disease is still extremely controversial and the precise molecular targets for intervention are not well defined. This is in part due to the lack of microglia-specific manipulation approaches until very recently and to the high level of complexity of the interactions between microglia and other cells in the brain that occur at different temporal and spatial scales. In this review, we briefly summarize the known physiological roles of microglia-neuron interactions in brain homeostasis and attempt to outline some major directions and challenges of future microglia research.

Correction of Huntington's Disease Phenotype by Genistein-Induced Autophagy in the Cellular Model

Huntington’s disease (HD) is a monogenic disorder, caused by mutations in the HTT gene which result in expansion of CAG triplets. The product of the mutated gene is misfolded huntingtin protein that forms aggregates leading to impairment of neuronal function, neurodegeneration, motor abnormalities and cognitive deficits. No effective cure is currently available for HD. Here we studied effects of genistein (trihydroxyisoflavone) on a HD cellular model consisting of HEK-293 cells transfected with a plasmid bearing mutated HTT gene. Both level of mutated huntingtin and number of aggregates were significantly decreased in genistein-treated HD cell model. This led to increased viability of the cells. Autophagy was up-regulated while inhibition of lysosomal functions by chloroquine impaired the genistein-mediated degradation of the mutated huntingtin aggregates. Hence, we conclude that through stimulating autophagy, genistein removes the major pathogenic factor of HD. Prolonged induction of autophagy was suspected previously to be risky for patients due to putative adverse effects; however, genistein has been demonstrated recently to be safe and suitable for long-term therapies even at doses as high as 150 mg/kg/day. Therefore, results presented in this report provide a basis for the use of genistein in further studies on development of the potential treatment of HD.

Controlled population-based comparative study of USA and international adult [55-74] neurological deaths 1989-2014

Objectives

A population‐based controlled study to determine whether adult (55‐74 years) neurological disease deaths are continuing to rise and are there significant differences between America and the twenty developed countries 1989‐91 and 2012‐14.

Method

Total Neurological Deaths (TND) rates contrasted against control Cancer and Circulatory Disease Deaths (CDD) extrapolated from WHO data. Confidence intervals compare USA and the other countries over the period. The Over‐75's TND and population increases are examined as a context for the 55‐74 outcomes.

Results

Male neurological deaths rose >10% in eleven countries, the other countries average rose 20% the USA 43% over the period. Female neurological deaths rose >10% in ten counties, averaging 14%, the USA up 68%. USA male and female neurological deaths increased significantly more than twelve and seventeen countries, respectively. USA over‐75s population increased by 49%, other countries 56%. Other countries TND up 187% the USA rose fourfold. Male and female cancer and CDD fell in every country averaging 26% and 21%, respectively, and 64% and 67% for CDD. Male neurological rates rose significantly more than Cancer and CCD in every country; Female neurological deaths rose significantly more than cancer in 17 countries and every country for CDD. There was no significant correlation between increases in neurological deaths and decreases in control mortalities.

Conclusions

There are substantial increases in neurological deaths in most countries, significantly so in America. Rises in the 55‐74 and over‐75's rates are not primarily due to demographic changes and are a matter of concern warranting further investigation.

The impact of positive, negative and neutral stimuli in a virtual reality cognitive-motor rehabilitation task: a pilot study with stroke patients

Background

Virtual Reality (VR) based methods for stroke rehabilitation have mainly focused on motor rehabilitation, but there is increasing interest in integrating motor and cognitive training to increase similarity to real-world settings. Unfortunately, more research is needed for the definition of which type of content should be used in the design of these tools. One possibility is the use of emotional stimuli, which are known to enhance attentional processes. According to the Socioemotional Selectivity Theory, as people age, the emotional salience arises for positive and neutral, but not for negative stimuli.

Methods

For this study we developed a cognitive-motor VR task involving attention and short-term memory, and we investigated the impact of using emotional images of varying valence. The task consisted of finding a target image, shown for only two seconds, among fourteen neutral distractors, and selecting it through arm movements. After performing the VR task, a recall task took place and the patients had to identify the target images among a valence-matched number of distractors. Ten stroke patients participated in a within-subjects experiment with three conditions based on the valence of the images: positive, negative and neutral. Eye movements were recorded during VR task performance with an eye tracking system.

Results

Our results show decreased attention for negative stimuli in the VR task performance when compared to neutral stimuli. The recall task shows significantly more wrongly identified images (false memories) for negative stimuli than for neutral. Regression and correlation analyses with the Montreal Cognitive Assessment and the Geriatric Depression Scale revealed differential effects of cognitive function and depressive symptomatology in the encoding and recall of positive, negative and neutral images. Further, eye movement data shows reduced search patterns for wrongly selected stimuli containing emotional content.

Conclusions

The results of this study suggest that it is feasible to use emotional content in a VR based cognitive-motor task for attention and memory training after stroke. Stroke survivors showed less attention towards negative information, exhibiting reduced visual search patterns and more false memories. We have also shown that the use of emotional stimuli in a VR task can provide additional information regarding patient’s mood and cognitive status.

Mortality from Alzheimer's disease in Brazil, 2000-2009

Alzheimer's disease is the most prevalent type of dementia in the elderly worldwide. To evaluate the mortality trend from Alzheimer's disease in Brazil, a descriptive study was conducted with the Mortality Information System of the Brazilian Ministry of Health (2000-2009). Age and sex-standardized mortality rates were calculated in Brazil's state capitals, showing the percentage variation by exponential regression adjustment. The state capitals as a whole showed an annual growth in mortality rates in the 60 to 79 year age bracket of 8.4% in women and 7.7% in men. In the 80 and older age group, the increase was 15.5% in women and 14% in men. Meanwhile, the all-cause mortality rate declined in both elderly men and women. The increase in mortality from Alzheimer's disease occurred in the context of chronic diseases as a proxy for increasing prevalence of the disease in the population. The authors suggest healthcare strategies for individuals with chronic non-communicable diseases.

Neurological deaths of American adults (55-74) and the over 75's by sex compared with 20 Western countries 1989-2010: Cause for concern

Background:

Have USA total neurological deaths (TNDs) of adults (55–74) and the over 75's risen more than in twenty Western Countries?

Methods:

World Health Organization TND data are compared with control mortalities cancer mortality rates (CMRs) and circulatory disease deaths (CDDs) between 1989–1991 and 2008–2010 and odds ratios (ORs) and confidence intervals calculated.

Results:

Neurological Deaths – Twenty country (TC) average 55–74 male rates per million (pm) rose 2% to 503 pm, USA increased by 82% to 627 pm. TC average females rose 1% to 390 pm, USA rising 48% to 560 pm. TC average over 75's male and female increased 117% and 143%; USA rising 368% and 663%, significantly more than 16 countries. Cancer mortality – Average 55–74 male and female fell 20% and 12%, USA down 36% and 18%. TC average over 75's male and female fell 13% and 15%, the USA 29% and 2%. Circulatory deaths – TC average 55–74 rates fell 60% and 46% the USA down 54% and 53%. Over 75's average down 46% and 39%, USA falling 40% and 33%. ORs for rose substantially in every country. TC average 75's ORs for CMR: TND male and females were 1:2.83 and 1:3.04 but the USA 1:5.18 and 1:6.50. The ORs for CDD: TND male and females TC average was 1:3.42 and 1:3.62 but the USA 1:6.13 and 1:9.89.

Conclusions:

Every country's neurological deaths rose relative to the controls, especially in the USA, which is a cause for concern and suggests possible environmental influences.

A pilot study to assess effects of long-term inhalation of airborne particulate matter on early Alzheimer-like changes in the mouse brain

Exposure to air pollutants, including particulate matter, results in activation of the brain inflammatory response and Alzheimer disease (AD)-like pathology in dogs and humans. However, the length of time required for inhalation of ambient particulate matter to influence brain inflammation and AD pathology is less clear. Here, we studied the effect of 3 and 9 months of air particulate matter (<2.5 μm diameter, PM2.5) exposure on brain inflammatory phenotype and pathological hallmarks of AD in C57BL/6 mice. Using western blot, ELISA, and cytokine array analysis we quantified brain APP, beta-site APP cleaving enzyme (BACE), oligomeric protein, total Aβ 1-40 and Aβ 1-42 levels, inducible nitric oxide synthase (iNOS), nitrotyrosine-modified proteins, HNE-Michael adducts, vascular cell adhesion molecule 1 (VCAM-1), glial markers (GFAP, Iba-1), pre- and post- synaptic markers (synaptophysin and PSD-95), cyclooxygenase (COX-1, COX-2) levels, and the cytokine profile in PM2.5 exposed and filtered air control mice. Only 9 month PM2.5 exposure increased BACE protein levels, APP processing, and Aβ 1-40 levels. This correlated with a concomitant increase in COX-1 and COX-2 protein levels and a modest alteration in the cytokine profile. These data support the hypothesis that prolonged exposure to airborne particulate matter has the potential to alter brain inflammatory phenotype and promote development of early AD-like pathology.

Association between neurological disorders, functioning, and mortality in the elderly

OBJECTIVES

In aging populations, the prevalence of neurological disorders increases, which imposes high population burden in terms of mortality, disability, and impaired quality of life. The aim of this study was to assess the prevalence of common neurological disorders and signs and their association with functioning and mortality in an elderly general population.

MATERIALS AND METHODS

We used data from the Memory and Morbidity in Augsburg Elderly (MEMO) project, a population-based study of 385 individuals aged ≥65. The prevalence of neurological disorders and signs was assessed by physical examination and medical interview. The basic and instrumental activities of daily living were assessed (ADL, IADL). We assessed the association of neurological disorders and signs with everyday functioning and prospectively analyzed their relationship with mortality.

RESULTS

We observed considerably impaired functioning for cases with stroke, TIA, PD, and mild motor parkinsonian signs (MMPS). All-cause mortality was significantly increased in participants with stroke and MMPS, even after adjusting for co-variables (HR = 2.71 and 1.80, respectively).

CONCLUSIONS

We found that not only specific neurological disorders, but also earlier symptoms are related to impaired functioning and predict mortality in the elderly. These findings have potential clinical relevance for screening and early detection of individuals at risk.

Diminished brain resilience syndrome: A modern day neurological pathology of increased susceptibility to mild brain trauma, concussion, and downstream neurodegeneration

The number of sports-related concussions has been steadily rising in recent years. Diminished brain resilience syndrome is a term coined by the lead author to describe a particular physiological state of nutrient functional deficiency and disrupted homeostatic mechanisms leading to increased susceptibility to previously considered innocuous concussion. We discuss how modern day environmental toxicant exposure, along with major changes in our food supply and lifestyle practices, profoundly reduce the bioavailability of neuro-critical nutrients such that the normal processes of homeostatic balance and resilience are no longer functional. Their diminished capacity triggers physiological and biochemical 'work around' processes that result in undesirable downstream consequences. Exposure to certain environmental chemicals, particularly glyphosate, the active ingredient in the herbicide, Roundup(®), may disrupt the body's innate switching mechanism, which normally turns off the immune response to brain injury once danger has been removed. Deficiencies in serotonin, due to disruption of the shikimate pathway, may lead to impaired melatonin supply, which reduces the resiliency of the brain through reduced antioxidant capacity and alterations in the cerebrospinal fluid, reducing critical protective buffering mechanisms in impact trauma. Depletion of certain rare minerals, overuse of sunscreen and/or overprotection from sun exposure, as well as overindulgence in heavily processed, nutrient deficient foods, further compromise the brain's resilience. Modifications to lifestyle practices, if widely implemented, could significantly reduce this trend of neurological damage.

Use of the interRAI CHESS scale to predict mortality among persons with neurological conditions in three care settings

Background

Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions.

Methods

Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories.

Results

CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings.

Conclusions

CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.