Chadley Uekman

Speech Entrainment: A Promising Approach for Aphasia

by Richelle Weese, M.S. CCC-SLP, University of Central Arkansas, Department of Communication Sciences and Disorders

Conversational partners naturally adapt their verbal and nonverbal communicative actions to mimic, or more closely resemble each other. This is called speech, or rhythmic, entrainment (Borrie & Liss, 2014). Speech entrainment (SE) is important for understanding normal speech production, but can also be used as a rehabilitative technique for those individuals who need help with their communicative functions. Speech Entrainment (SE), is a therapeutic technique being utilized to improve communication with patients suffering from aphasia and is showing promise in other neurologic conditions.

The premise of SE is an audiovisual speech model, in which patients are exposed to audio-visual speech stimuli and instructed to mimic the stimuli, enabling them to produce fluent speech in real time (Fridriksson, J., Hubbard, H. I., Hudspeth, S. G., Holland, A. L., Bonilha, L., Fromm, D., & Rorden, C., 2012). Entrainment is evident in various aspects of speech, including speaking rate, utterance durations, pitch properties, voice intensity, voice quality, and dialectal features (Borrie & Liss, 2014).

With entrainment being a natural feature of human communication, the question is being raised regarding the likelihood that SE would be successful if used as a therapeutic tool in other neurologic communicative disorders. UCA Speech-Language Hearing Center is conducting a study in SE. Currently four clients have undergone therapy sessions utilizing SE. Although results are in the early stages of analyzation for specifics, preliminary findings are promising. Two patients with both expressive aphasia and verbal apraxia have increased their overall phrase length, reduced “robotic” prosody features, and improved articulatory precision. Two clients completed SE that focused on improving cognitive-linguistic skills for memory, targeting recall of family and friend names, with one client showing an improved ability to now recall all five children, their spouses, and grandchildren names.

The applications for SE are encouraging. Socializing and independence are deeply rooted in successful communication. We are seeing some of those results in our participants as they engage in group activities with other participants, play games with their grandchildren, or independently order a meal at a restaurant. SE tasks have been personally chosen to target goals chosen by each participant. Speech entrainment, regardless of the precipitating event leading to the communication issue, is a promising tool that is leading to communication effectiveness and improved quality of life.

References:
Borrie, S.A., Liss, J.M. (2014). Rhythm as a Coordinating Device: Entrainment With Disordered Speech Journal of Speech, Language, and Hearing Research, June 2014, Vol. 57, 815-824. doi:10.1044/2014_JSLHR-S-13-0149

Fridriksson, J., Hubbard, H.I., Hudspeth, S.G., Holland, A.L., Bonilha, L., Fromm, D., & Rorden, C. (2012). Speech entrainment enables patients with Broca’s aphasia to produce fluent speech. Brain, 135 (12), 3815-2829.

Creating a Gerontology-focused Health Fair

New CNHP ASU Logo

by Jessica E. Camp, MSN, APRN, AGCNS; Addie N. Fleming, MNSc, RN, CCRN; Valerie Fielder, BS, CDP, and Samantha M. Hollis, BSN, RN, CDP
Edited by Dr. Susan Hanrahan and Dr. Linda Tate
Arkansas State University, UAMS Center on Aging Northeast & Schmieding Home Caregvier Training Program, St. Bernards Medical Center

The committee designed a health screening event for older adults, their caregivers, and professionals that provide care to older adults. Northeast Arkansas has a large number of elderly, care givers, and a large variety of professional services. The event was designed to bring everyone together. It was planned for November to increase attendance by avoiding other area events and in conjunction with National Family Caregiver Month. The Fair gathered more than 200 patients and 90 vendors from the community. This article shares the successes of the event and the opportunities for next year.

Advisory Panel
The Center on Aging had a vision for the event. The mission and vision were shared with the team during recruitment and revisited at the initial meeting. An advisory panel consisted of the many health professionals, community members, university faculty and leaders from services for older adults in the area was invited to participate.

Health Screenings
The local university, ASU, provided a great foundation for creating a health screening event.

The physical therapy department provided “timed up and go” (TUG) screenings aimed at identifying balance issues and risk for falling. Social work faculty provided anxiety and depression screenings. Communication Disorders students provided hearing screens in a private room. Nursing students provided blood pressure checks, height, and weight and body mass index screenings. Dietary Approaches to Stop Hypertension (DASH) diet education was given verbally and in writing to persons at risk for or currently experiencing hypertension. Exercise, weight loss and the DASH diet can help control chronic illnesses, such as heart disease and diabetes, making it important information to share with older adults and their caregivers (Cash & Glass, 2015, p. 1047).

The Arkansas Department of Health provided vaccinations based on the Center for Disease Control and Prevention (CDC) recommendations for adults and older adults (Cash & Glass, 2015, pp.18-21). Hilltop Eye Care and Southern Eye Associates provided vision screenings and education on cataracts and glaucoma. St. Bernard’s Imaging Center conducted bone density screenings as well as total cholesterol, anemia, and glucose laboratory screenings. Higginbotham Family Dental provided dental screenings. Additional professionals were invited and provided services or information about services.

Transportation
Transportation for the public was not available to the event. This was noted by some persons unable to attend as a barrier. Requests to public transportation and local churches to enlist transportation assistance were not met. For the 2018 event, negotiations are in process.

Communication
Some screening groups left before the event ended which participants complained about. Critical conversations with the voluntary service professional groups will need to take place early in the planning of the 2018 event to ensure the professionals stay for the whole event, which could include shortening the event.

A secondary communication issue was not being able to hear announcements made at the event stage. With exciting activities such as the mayor’s appearance and a physician’s panel, it was difficult for the audience to hear anywhere past the first row of vendors. This is an opportunity that can be corrected for the 2018 Senior Expo (Larsen, 2018).

Professionals
Health professionals, caregivers, and patients were targeted to receive education during the event. Several vendors voiced a desire to attend the planned educational sessions, but were unable because they were also manning a booth at the event. In post-event discussions, it was decided that a separate educational event targeting health professionals could be a solution.

Vendors
While the volume of local vendors involved in the first annual event surpassed the goal, there were still challenges. Discussions with leaders of another local annual health fair shared tactics that prevented vendors from leaving their event early, such as imposing fines or not inviting them to future events.

In summary, these services met the needs of many older adults. Senior Health Fairs bring value to the intended audience. Targeted health fairs, such as this one, provide more opportunities for older adults to interact with health professionals in the community. With the success of the first event, the 2^nd Annual UAMS Center on Aging Northeast’s Senior Expo is scheduled for November 9, 2018.

References:

Cash, J. C. & Glass, C. A. (2016). Adult-gerontology practice guidelines. New York: Springer Publishing Company.

Larsen, P. (2018). Lubkin’s chronic illness: Impact and illness. Burlington, MA: Jones & Bartlett Publishing.

Rhoads, J. & Peterson, P. S. (2018). Advanced health assessment and diagnostic reasoning (3^rd ed.). Burlington, MA: Jones & Bartlett Publishers.

From the Director’s Desk

by Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative at UAMS

Hello from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. As we enter into the winter of 2018, there is snow on the ground and temps are single digits, but the sun is shining! It is exciting to start a new year as we enter the last six months of this grant. We are anxiously awaiting the release of a request for proposal from HRSA so we can apply for another grant, but delays are inevitable it seems as the US government struggles to approve a fiscal year budget!

Fall was a busy time as we continued our programming in education with our partners. We had two video-teleconferences/webinars with over 150 attendees at each program. Being able to broadcast our programs on-line/webinar is really helping us to reach more individuals, especially those in rural areas and those who can’t leave work to attend in person. Our academic partners, ASU and UCA, were also busy reaching thousands of students with geriatric content during the fall semester! We continue to seek new ways to reach and teach these audiences and if you have any suggestions, please let us know.

During November, National Family Caregiver Month, we partnered with the UAMS Schmieding Home Caregiving Training Program to host a panel discussion regarding family caregiving. Donna Terrell (a former caregiver for her daughter) from FOX 16 was the moderator, Les Warren (a legislator from Hot Springs), Beth Coulson (a former judge who serves on the board of several community organizations), and Dr. Sybil Hampton (a former educator and former President of the Winthrop Rockefeller Foundation) who all had extensive experience caring for elderly parents, served as panelists. It was a well-attended and engaging event that culminated in presenting awards to 6 deserving family caregivers from all across the state!

As spring approaches, our community programs will blossom! Tai Chi, diabetic empowerment education programs, healthy cooking, dementia experiences, and many others are all planned and scheduled. We also have exciting events scheduled for professionals and direct care workers such as certified dementia training and new webinars! Please keep close tabs on our website for upcoming events! See you in the spring!!!

Statins: When Do the Benefits Outweigh the Risks in the very Elderly?

by Taylor J Neeley and Lisa C Hutchison, PharmD, MPH, UAMS

High quality studies show that statins significantly reduce all-cause mortality in older patients with established cardiovascular disease (CVD). One meta-analysis included approximately 20,000 patients between ages 65 and 82 with coronary heart disease who received either placebo or statin. There was a 22% decrease in all-cause mortality over 5 years in the statin group vs. placebo. The meta-analysis also revealed significant risk reductions in cardiovascular mortality, nonfatal myocardial infarction, and strokes of around 30% each. ¹

However, the benefits for patients 75 years and older without CVD are less clear because major statin trials have excluded patients greater than 75. Very few trials have included patients over 70 years of age, and evidence for patients >80 is largely limited and conflicting.² For example, in the Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial (ALLHAT-LLT), initiation of pravastatin 40 mg for primary prevention in patients 65 years and older showed no risk reduction in cardiovascular events.⁴ However, in the Prospective Study of Pravastatin in Elderly at Risk (PROSPER) trial, patients of ages 70-82 with at least one cardiovascular risk factor (hypertension, smoking, and/or diabetes) were randomized to either pravastatin 40 mg or placebo. There was a significant reduction in major vascular events (stroke, fatal or non-fatal MI) in pravastatin group vs. placebo. ⁵

So, guidelines provide no specific recommendations for statin therapy in the middle and oldest old without CVD. Despite the lack of information, approximately 39% of patients 79 and older are on statin therapy for primary prevention of cardiovascular events. ³

Because this population is known to be more vulnerable to adverse drug effects, we see hospitalizations due to statin-induced rhabdomyolysis is 5 times more likely in patients 65 and older versus younger patients.²Even moderate muscle pain, a common side effect of statins, could cause already frail patients to increase their fall risk and/or immobility. And in rare cases, statins cause confusion and memory loss, especially with atorvastatin, lovastatin, simvastatin. Fortunately, these effects are reversible upon discontinuation.^{6, 7}

More research of statin benefits vs. risks, specifically in patients 75 and older at risk for CVD, are needed. So for now, patient-centered decision-making is key when the evidence is unclear.

Current ACC/AHA guidelines recommend that in patients >75 with established CVD

Begin statin therapy, but at a moderate intensity. There is strong evidence of statin cardiovascular benefit in this population.
In patients already well established on a high intensity statin with no complications, this may be continued. ⁸

In patients > 75 without established cardiovascular disease:

The decision to initiate a statin should be individualized and should weigh in heavily on patient concerns and goals. ²
- Factors that may support initiation of a statin:
  - Few comorbidities,
  - > 1 cardiovascular risk present
  - Patient priority to minimize cardiovascular risk
- Factors that may support avoiding statin initiation:
  - High comorbidities
  - Only 1 cardiovascular risk present
  - History of myopathy
  - Severe dementia
  - Frailty
  - High risk of drug-drug interactions
  - Patient priority to avoid pill burden
  - Patient priority to avoid adverse drug effects
  - Life expectancy < 1 year
In patients already well established on a statin with no complications, this may be continued.

Finally, in all elderly patients initiated on a statin, monitoring for adverse side effects should be a priority due to increased risks. Reassessment of factors such as development of dementia, frailty, and life expectancy should be made after starting therapy as these may change overtime and affect the decision to continue.

References:

Ross SD, Allen IE, Connelly JE, Korenblat BM, Smith ME, Bishop D, Luo D. Clinical Outcomes in Statin Treatment TrialsA Meta-analysis. Arch Intern Med.1999;159(15):1793–1802. doi:10.1001/archinte.159.15.1793
Pletcher, M. J., Coxson, P. G., Thekkethala, D., Guzman, D., Heller, D., Goldman, L., & Bibbins-Domingo, K. Statins for Primary Prevention in Older Adults.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2):S1-45.
ALLHAT Officers and Coordinators for the ALLHAT Col- laborative Research Group. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs. usual care: the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALL- HAT-LLT). JAMA 2002; 288: 2998–3007.
Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in eld- erly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360: 1623–1630.
Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet2010;376:1670-81.
Haag MD, Hofman A, Koudstaal PJ, et al. Statins are associated with a reduced risk of Alzheimer disease regardless of lipophilicity. The Rotterdam Study. J Neurol Neurosurg Psychiatry 2009;80:13-7.
Lambert, M. (2014). ACC/AHA Release Updated Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD Risk. American family physician, 90(4), 260.

Fun Fiesta at the Faulkner County Senior Center

Students in Nutrition Services Administration fed about 200 seniors this November. The class planned and executed a theme meal with a fiesta flair. Decorations included balloons, pinatas, streamers, and more. The menu was confetti slaw, seasoned green beans, fiesta rice, taco salad casserole, and pound cake with fruit compote. We would like to say THANK YOU very much to the Arkansas Geriatric Education Collaborative, which is funded by the Health Resources and Services Administration’s Geriatric Workforce Enhancement Program, for helping us produce such a wonderful meal and serve seniors in our community.

Visit UCA’s website and see the full story: http://uca.edu/facs/2017/12/01/fun-fiesta-at-the-faulkner-county-senior-center/

UCA Faculty and Students reach out to the community

UCA reached out to the community during Falls Awareness Month this past September. Watch their segment on KTHV on the importance of falls prevention with older adults. Dr. Letha Mosley presented during AGEC’s “Patient Safety: Carfit and Low vision – Older adults” continuing education program this past year. We are proud to partner with UCA and their work to improve the quality of health to our older adults in Arkansas.

Click here to Watch – KTHV Falls Prevention Story

CE Event – Nov. 2 Communication Impairment with Persons with Alzheimer’s Disease

Applicable CE documents will be posted soon.

Unable to attend in person? Live Streaming link here: AGEC Collaborate Channel or attend at a participating remote location.

Topic: Communication Impairment with Persons with Alzheimer’s Disease
Speaker: Richard Zraick, PhD
Professor and Chair of Department of Communication and Disorders, University of Central Florida

Objectives: After attending this presentation, the learner should

• be able to describe tools to assess language deficits, and facilitate communication in persons with Alzheimer’s disease

• be able to cite general communication tips for communicating with persons with Alzheimer’s disease.

• be able to describe some dementia-related impairments that compound language deficits in persons with Alzheimer’s disease.

Date: November 2, 2016
Time: 8:00 a.m. – 9:00 a.m.
Location: Donald W. Reynolds Institute on Aging, Jo Ellen Ford Auditorium

Accreditation: The University of Arkansas for Medical Sciences (UAMS) College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation: The UAMS College of Medicine designates this live activity for a maximum of one AMA PRA Category 1 credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

1.0 contact hour for pharmacists, physical therapists, dietitians and health educators have been approved. Nursing, social workers, long-term care providers have been filed with the appropriate accrediting organizations. Determination is pending.

Faculty Disclosure of Financial Relationships: The planner, Dr. Ronni Chernoff, of this RSS have no financial relationships with commercial interests to disclose

The speaker(s) of this RSS has no financial relationships with commercial interests to disclose.

Commercial Support Acknowledgement: This CME activity receives no commercial support.

Rural Programs RSS Survey: http://learnondemand.org

CE Event – Nov. 9 How the Caregiver Experience can Postively Impact The Patient Experience

Applicable CE documents will be posted soon.

Unable to attend in person? Live Streaming link here: AGEC Collaborate Channel or attend at a participating remote location.

Topic: How the Caregiver Experience can Positively Impact The Patient Experience
Speaker: John Schall, CEO of Caregiver Action Network

Objectives: After attending this presentation, the learner should

• be able to describe who family caregivers are and what they do in terms of ADLs and IADLs

• be able to list the interests and needs of family caregivers in a hospital setting

• be able to recall practical steps to more fully engage family caregivers in the hospital stay and in discharge planning

Date: November 9, 2016
Time: 8:00 a.m. – 9:00 a.m.
Location: Donald W. Reynolds Institute on Aging, Jo Ellen Ford Auditorium

FREE Continuing Education

Faculty Disclosure of Financial Relationships: The planner, Dr. Ronni Chernoff, of this RSS have no financial relationships with commercial interests to disclose

The speaker(s) of this RSS has no financial relationships with commercial interests to disclose.

Commercial Support Acknowledgement: This CME activity receives no commercial support.

Rural Programs RSS Survey: http://learnondemand.org

Ageless Grace® Events for Personal Practice and Certification

Ageless Grace® Events for Personal Practice and Certification

Location: UAMS Institute on Aging, 629 Jack Stephens Dr. / Little Rock, AR 72205, First Floor

PART I: Personal Practice Seminar – Learn to include Ageless Grace in your daily life (4 hours of *CE) – (required for Educator certification)

Thursday, Dec. 1, 8 a.m. to noon, $55.00

PART I & II: Educator Certification – Become certified to teach Ageless Grace (includes DVDs, book & cards) (14 hours required for certification)

Thursday, Dec. 1, AND Friday, Dec. 2, 8 a.m. to 4:30 p.m. each day, $380

FREE Public Class: Thursday, Dec. 1, 11 a.m. to 11:30 a.m., UAMS Institute on Aging

REGISTER: http://agelessgrace.com/training-events/little-rock-ar-december-1-2-2016/

The Center for Distance Health is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Participation in this educational activity provides up to 14.0 hours of continuing nursing education credit. Attendance at the entire class and completion of an evaluation is required to receive contact hours.

All other accreditations managed by the Arkanss Geriatric Education Collaborative. Determination is pending

SEE our flyer below for more details:

Proton-Pump Inhibitors as Potentially Inappropriate Medications in Older Adults

Arkansas Geriatric Education Collaborative

By: Janna Hawthorne, PharmD, University of Arkansas for Medical Sciences

In October 2015 the American Geriatrics Society (AGS) released updates to the 2012 version of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. A. new class of drugs, proton-pump Inhibitors (PPIs), was added to the 2015 AGS Beers Criteria as potentially inappropriate in older adults.(1) PPIs are clinically indicated for use in acute ulcers, gastroesophageal reflux disease, erosive esophagitis, hypersecretory conditions, prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, and treatment of Helicobacter pylori infections.(2)

Commonly prescribed, and also available over-the counter, PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and pantoprazole (Protonix). In 2015, it was reported that esomeprazole (Nexium) was the fourth highest prescribed medication in the United States, ranking with 15.2 million prescriptions annually.(3) The warning with PPIs in the 2015 AGS Beers Criteria is based upon studies which indicate that PPI use longer than eight weeks in the elderly population can put them at increased risk for developing Clostridium difficile infection (CDI) and can lead to bone loss and fractures.(1) In this update, the evidence suggesting potential for inappropriate use of PPIs in older adults is high with the strength of recommendation being strong. (1) A high quality of evidence implies that the studies were well-conducted, well-designed, and looked at the population in question. The strong recommendation informs us that the benefits of not using this class of medications outweighs the risk that is apparent with its use.(1)

The enhanced risk of Clostridium difficile infection is due to the potent acid suppressing nature of PPIs. Low acidity within the stomach provides ingested bacteria an environment in which they can flourish. If Clostridium difficile bacteria colonize the stomach, they can overpower the normal gut flora and produce toxins that lead to intestinal injury and inflammation.(2) The injury and inflammation that develop from this exposure will produce extensive diarrhea that could lead to dehydration, delirium, and other critical conditions within the elderly population. In a 2012 meta-analysis looking at the association of PPIs with development of Clostridium difficile infection, data showed that for every 3,925 patients taking a chronic PPI, one person will develop a Clostridium difficile infection, nearly twice the normal incidence of CDI.(4)

PPIs also have the added concern for increased bone loss and subsequent fracture. Theories suggest that calcium must have acid in order to be absorbed from the stomach. Therefore, the acid suppressing manner of PPIs may result in decreased calcium absorption and subsequent loss of bone mineral density (BMD).(5) Elderly women lose BMD at a rate of 10% per decade after menopause and elderly men decline at the same rate later in life. With the great decline in BMD simply due to aging alone, anything to exacerbate this decline could result in tremendous complications, such as hip fracture. In 2015 a meta-analysis was published that looked at the risk of fracture as associated with the use of PPIs. Data from this meta-analysis reported a 26% increase in hip fractures in patients who take PPIs chronically. The risk of spine and any-site fracture also increased by 58% and 33% respectively.(5)

High-risk patients who have erosive esophagitis, Barrett’s esophagitis, pathological hypersecretory conditions, are on oral corticosteroids or prolonged use with NSAIDs, or have demonstrated need for maintenance therapy may benefit from chronic PPI use.(1) If a patient does not have a medical indication for chronic use of PPIs, therapy should be tapered and discontinued. The first step in discontinuation of therapy would be to decrease the daily dose to the lowest dose possible. After a few weeks of the lowest possible dose, the PPI should be discontinued. After discontinuation, the patient should self-monitor for relapse of symptoms such as heartburn, indigestion, and chest pain. If symptoms recur, you may initiate a trail trial period of 4-8 weeks of the lowest possible dose of a preferred PPI or initiate therapy with a histamine2-receptor antagonist. The patient should then be followed closely and another trial of discontinuation should be tried.(6)

References:

1. American Geriatric Society 2015 Beers Criteria Update Expert Panel (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of American Geriatric Society, 63, 2227-2246. doi: 10.1111/jgs.13702
2. Kapadia, A., Wynn, D., & Salzman, B. (2010). Potential adverse effects of proton pump inhibitors in the elderly. Clinical Geriatrics. 18(7), 24-31.
3. Brown. T. (2015). 100 best-selling, most prescribed branded drugs through March. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/844317
4. Tleyjeh, I., Bin Abdulhak, Aref., Riaz, M., Alasmari, F., Garbati, M., AlGhamdi, M., Rahman Khan, A., Al Tannir, M., Erwin, P., Ibrahim, T., AlLehibi, A., Baddour, L., & Sutton, A. (2012). Association between proton pump inhibitor therapy and Clostridium difficile infection: a contemporary systematic review and meta-analysis. Plos One. 7(12), 1-12.
5. Zhou, B., Huang, Y., Li, H., Sun, W., & Liu, J. (2015). Proton-pump inhibitors and risk of fractures: an update meta-analysis. Osteoporosis International, 26(10), 1-9. doi: 10.1007/s00198-015-3365-x
6. PPIs in older people—do you know the risks? (2014, January), Health News and Evidence. Retrieved from http://www.nps.org.au/publications/health-professional/health-news-evidence/2014/ppi-risks-in-older-peopleProin