by Ashley McPhee, PharmD Candidate and Lisa Hutchison, PharmD, MPH, University of Arkansas for Medical Sciences  (UAMS) College of Pharmacy

Herpes zoster, commonly known as shingles, is a viral infection that causes a painful rash. The rash usually occurs on one side from the middle of the back toward the chest, but it can occur in other areas as well. Shingles is the result of reactivation of the existing but undeveloped varicella zoster virus (VZV). This is the virus that causes chickenpox.1 Nearly all older adults have the VZV dormant in their nervous system because they were exposed to chicken pox as a child.2 Protection from reactivation is dependent on cell-mediated immunity. This type of immunity decreases as we age, if we have certain diseases, or medications. An example of disease and medications include Human immunodeficiency virus (HIV) and high dose steroid treatment. The average age for shingles to occur is about 64 years.1
Current 2017 Centers for Disease Control (CDC) guidelines recommend shingles vaccination. This vaccine (Zostavax©), is a live, attenuated vaccine. This means that the vaccine is living and produces disease, but it has been weakened so that it produces immunity but not illness.3 Currently, the CDC recommends that adults ages 60 years and older get one dose of the vaccine. They should get it even if they have had shingles before. Since the vaccine is live, patients who are pregnant, have severe immunodeficiency, or on systemic immunosuppressive therapy should not receive it. In addition, patients with malignant conditions such as those that affect bone marrow or patients with HIV and a CD4+ T-lymphocyte count less than 200 cells/µl should also not receive the vaccine.4 These individuals may not be able to mount a response to the virus to create antibodies.

However, a new shingles vaccine (Shingrix©) will soon be available. This vaccine is a non-live, recombinant subunit containing a piece of the Herpes zoster virus that will stimulate the immune system most efficiently. The new vaccine is given intramuscularly in two separate doses, and is indicated for patients 50 years and older. This vaccine was shown to produce the desired effect 90% of the time, across all age groups.2 The previous vaccine was only about 50% effective.3 t In October 2017 the CDC’s Advisory Committee on Immunization Practices  (ACIP) voted in favor of recommending this new vaccine for patients who are 50 years and older even if they have received Zostavax previously. They also determined that Shingrex© would be preferred over Zostavax© for these individuals.2  One concern is that the trials with this vaccine did not include patients who were immunocompromised.5 The vaccine is not live, so this should not necessarily be a contraindication for vaccination. However, ACIP does mention immunocompetence as part of their requirement for recommendation at this time.2 It is possible the recommendation will change based on post-marketing data after the general population has been receiving the vaccine. For now, it provides a great alternative vaccine for patients who were previously not eligible due to age, providing more effect.

References:
1. Dworkin, R. H., Johnson, R. W., Breuer, J., et al. Recommendations for the Management of Herpes Zoster. Clinical Infectious Diseases. 2007; 44(1):S1–S26.
2. Shingrix approved in the US for prevention of shingles in adults aged 50 and over. 2017. https://www.gsk.com/en-gb/media/press-releases/shingrix-approved-in-the-us-for-prevention-of-shingles-in-adults-aged-50-and-over/
3. Shingles (Zoster): Questions and Answers Information about the disease and vaccine. http://www.immunize.org/catg.d/p4221.pdf
4. Immunization Schedules. 2017. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
5. Highlights of Prescribing Information. 2017. https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF

 

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

This is my first “From the Director’s desk” article from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. I am excited as we begin this year of grant activities and what this year holds for us. I have rather large shoes to fill with Dr. Chernoff handing the reigns of this grant to me in July of this year, but am very confident in that she has been an exceptional mentor to me for the past decade (or more) and is still by my side helping and guiding with sage advice! Thank you Dr. Chernoff for conceptualizing and implementing the AGEC initiatives for success and for your knowledge and leadership. The geriatric field and practitioners have benefited greatly from your contributions!

As we begin the final year of this three year grant, we are starting with well-established and multiple programs and partners. We are still working with our academic partners the University of Central Arkansas and Arkansas State University, the UAMS Centers on Aging (formally the AAI), the UAMS Regional Programs (formally the AHECs), AARP, CareLink, CHI McAuley Senior Center, Mainline Clinic in Lincoln County, the Arkansas Department of Aging and Adults Services, multiple long-term care facilities and many others! During the past 2 years, with the new mandate of the GWEP to include community members, we have dramatically expanded our partners and our aging network. I firmly believe that this expansion has strengthened our impact on care of older adults.

We have also strengthened our original mission to train healthcare professionals and students of the healthcare professions in the field and science of Geriatrics. We have also expanded this group to include first responders (police, firefighters, EMTs, paramedics) and direct care workers. In addition, we are constantly seeking new and innovative ways to reach and teach these audiences. We are reaching more and more as we have evolved from paper based and face-to-face trainings to more on-line and web-streaming activities. We are constantly searching for ways that health professionals want to learn, so if you have an idea, please let us know!

 

by Alicia S. Landry, PhD, RDN, LDN, SNS, Nina Roofe, PhD, RDN, LD, FAND, Andreina Guedez, MS, Dietetic Intern, Taylor Sherrill, MS, Dietetic Intern, University of Central Arkansas

Patients who have been diagnosed with dementia or Alzheimer’s disease (AD) often experience unintentional weight loss. Malnutrition and unintentional weight loss may lead to the loss of ability to do activities of daily living related to meal consumption such as using feeding utensils and chewing/swallowing.¹ Complications of malnourishment include greater infection rate, anemia, hypotension, and increased level of difficulty in healing wounds and pressure ulcers.

In patients who have a chronic illness, achieving or maintaining healthy body weight is critical. Healthy fats along with antioxidants, vitamins, and minerals are essential for optimal well-being and improved cognitive function. Unfortunately, patients diagnosed with AD or dementia often experience challenges related to meal consumption.¹ Patients may be unable to self-feed or have loss of taste and swallowing function which makes food unappealing whether at home, assisted living, or in skilled nursing facilities. General recommendations to increase meal consumption in patients with AD or dementia include minimizing distractions, providing feeding assistance, modifying consistencies of food, or providing appetite stimulants. After seeing first-hand the challenges related to mealtimes and the resultant effects of diminished nutrient consumption in patients with AD or dementia, two graduate level dietetic interns committed to researching nutrient consumption in these patients.

Music therapy, defined as the use of music and its elements (sound, rhythm, melody, and harmony) as an intervention to optimize quality of life and improve health and wellbeing, ^{2, 3} has been used as a form of non-pharmacological treatment for patients with AD and dementia. Benefits of music therapy include improvement in recalling personal memories, common knowledge such as colors and events, general cognitive function, and increasing ability to speak plainly.³ Music therapy may provide an approach to increasing meal consumption in patients diagnosed with AD or dementia; ⁴ therefore, the purpose of this study was to determine the impact of music on meal consumption in individuals diagnosed with AD and dementia.

Noon meal consumption was measured over the course of six days; three with music and three without. The highest average means, on day two (527.47 g) and day four (625.27 g), were both days in which music was played for the participants. However, after computing means for music and non-music days, there was no significant difference between average meal consumption with or without music. There were several limitations noted in the research but providing music therapy may still be a promising alternative therapy. In future research, evaluating the administration of music (i.e. headphones, ambient noise), consistency of music playing (i.e. every meal, every day for a week), and type of music (i.e. classical, swing, jazz) are important considerations.

A second graduate student noted that since the prevalence of dementia has increased, innovative prevention/treatment strategies are even more relevant to provide cost savings and alleviate caretaker burden. Use of antioxidant vitamins to improve cognitive function in older adults has been examined to a limited extent.⁵ Quantifying current consumption of these vitamins (i.e., Vitamin C, Vitamin E, and β-carotene) in dementia patients is needed so that caretakers know if supplementation to the normal diet is warranted.

The researcher collected menus from a long term care facility for three days and then collected percentage eaten for all items offered for breakfast, lunch, and dinner, as well as age and diagnosis. Patients in this study met recommendations for Vitamin C and β-carotene; however, Vitamin E was deficient, providing some evidence that antioxidant vitamin intake in meals was not optimum.

Megadoses of antioxidant vitamins have shown an improvement in cognitive function; ^{5, 6} thus, dietary intake would need supplementation in order to achieve therapeutic effects in these patients. In facilities such as the one where this study was conducted, implementing use of standardized recipes and menu items like carrots, plant-based oils, citrus fruits, bell peppers, and other antioxidant rich foods could be one way to increase intake of Vitamin C, Vitamin E, and β-carotene in patients with AD or dementia.

While encouraging students to conduct research in settings like this may seem intimidating to mentors and advisors, rewards to the students and relationship building with the community are benefits. Unintended (but positive) outcomes from this research included updating menus for residents, reevaluating methods of meal service, and conducting presentations for long term care directors on ways to incorporate music therapy in daily activities for patients with AD or dementia. The students have been able to gain professional skills, research experience, and valuable community contacts through the process.

Finally, recognizing the impact that meal consumption may have on the health and well-being of a patient diagnosed with AD or dementia is critical to improving health and well-being. The incorporation of music during mealtimes along with appropriate vitamin supplementation may improve nutrient intake in patients with AD and dementia and thus warrants further research.

 

References:

1. Gillette-Guyonnet S, Nourhashemi F, Andrieu S, De Glisezinski I., Ousset, PJ, Riviere D, Vellas B. Weight loss in Alzheimer Disease. Am J Clin Nutr 2000; 71: 637s-642s.
2. Li C, Liu C, Yang Y, Chou M, Chen C, Lai C. Adjunct effect of music therapy on cognition in Alzheimer’s Disease in Taiwan: A pilot study. Neuropsychiatr Dis Treat 2015; 291. doi:10.2147/ndt.s73928
3. Simmons-Stern NR, Budson AE, Ally BA. Music as a memory enhancer in patients with Alzheimer’s Disease. Neuropsychologia; 2010, 48(10): 3164-3167. doi:10.1016/j.neuropsychologia.2010.04.033.
4. Fukui H, Arai A, Toyoshima K. Efficacy of music therapy in treatment for the patients with Alzheimer’s Disease. Int J Alzheimers Dis; 2012: 2012:531646. doi:10.1155/2012/531646.
5. Li Y, Liu S, Man Y, Li N, Zhou Y. Effects of Vitamin E and C combined with β-carotene on cognitive function in the elderly. Experimental & Therapeutic Medicine 2015; 9(4): 1489-1493. doi: 3892/etm.2015.2274
6. Viveky N, Toffelmire L, Thorpe L, Billinsky J, Alcorn J, Hadjistavropoulos T, Whiting SJ. Use of vitamin and mineral supplement in long-term care home residents. Appl Physiol Nutr Metab 2012; 37(1): 100-105. doi: 1139/H11-141

 

 

 

J.E. Camp MSN, APRN, AGCNS-BC, Edited by Linda Tate, PhD, APRN, ACNS-BC

Arkansas State University

Is it warm where you are? The temperature outside may be hot enough to melt the pavement but it is still hot enough to have to rethink outside jogging.  If you are looking for indoor ways to work or if you like to exercise with your friends, Drums Alive® may be a great option. This is a music-based program which is grounded in science.

Drums Alive® takes place in a class room full of bright colored, large inflated rubber balls which sit neatly on top of small baskets. To begin class, everyone sits in a chair, in front of their “ball” drum.  All are given drumsticks and small, pool noodles.  The teacher, Mrs. Samantha Hollis, led the group while everyone else followed her directions.  Everyone got to “beat” the drum and even use a couple of dance steps, all to the cadence of the very upbeat and entertaining music.

Drums Alive® helped to work up a sweat and provided a good workout. Exercising in a class like this can raise the heart rate, increase breathing and provide added health benefits that can result from such exercise if done consistently.  The health benefits can include better heart health through stress management, blood fat and sugar reduction.  One study determined that drumming “is a worthy alternative to more traditional forms of exercise (De La Rue, Draper, Potter & Smith, 2013, p. 868).”  De La Rue et al (2013) pointed out that this was true for their study with rock/pop. Romeo, Coburn, Brown & Galphin (2016, p. 35) study results showed “heavy metal drumming” met certain guidelines for aerobic fitness. While participants in the studies were younger adults, according to the handout from Drums Alive©, participants can benefit “whether are young, old, healthy or ill (UAMS COANE, 2017).”

If you are looking for exercise for you or for your patients that is fun and evidence-based, then Drums Alive® may be for you.   These classes are held at many Centers on Aging across Arkansas:  For information contact:

Samantha Hollis, BSN, RN

Drums Alive® Trainer

870-207-7595

SHollis@UAMS.edu

 

References:

De La Rue, S. E., Draper, S. B., Potter, C. R., & Smith, M. S. (2013). Energy expenditure in rock/pop drumming.  International journal of sports medicine, 34(10), 868-872.  Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23559410

Drums Alive. (2017). Discover the drummer in you.  Retrieved from http://www.drums-     alive.com/

Romero, B., Coburn, J., Brown, L. & Galphin, A. (2016). Metabolic demands of heavy metal

drumming. International Journal of Kinesiology and Sports Science, 4(3), pp. 32-36.

Retrieved from  http://www.journals.aiac.org.au/index.php/IJKSS/article/view/2567

The University of Arkansas for Medical Sciences (UAMS) Center on Aging-Northeast

(COANE). (n.d.). Drums Alive®. Little Rock, AR: UAMS Donald W. Reynolds Institute

on Aging.

Google links to the song information:

https://www.google.com/#q=greased+lightning+1978+by+written+by

https://www.google.com/#q=sittin+on+the+dock+of+the+by+1984+by+written+by

https://www.google.com/#q=withc+doctor+by+19+by+written+by

https://www.google.com/#q=foot+loose+by+1984+by+written+by

 

by Ashley Bizzell, PharmD Candidate, & Lisa C Hutchison, PharmD, MPH 

University of Arkansas for Medical Sciences

Older adults with diabetes find it more difficult to control their blood glucose and reach target hemoglobin A1C values.  One reason they have more difficulty is the difference in pharmacokinetics that medications have in older adults, specifically changes in absorption, distribution, metabolism, and excretion. Antidiabetic medications in particular can cause serious consequences in older adults if not prescribed and used appropriately; following literature recommendations and guidelines can be helpful to ensure both efficacy and safety of these drugs in elderly patients.

One major concern for older adults is their risk for hypoglycemia with antidiabetic medications. This can lead to serious consequences including increased risk for falls, fractures, and central nervous system decline.  For these reasons, target hemoglobin A1C (Hgb A1C) goals are less stringent in older adults where clinicians should aim for a Hgb A1c of 7.5 to 8% as compared to less than 7% for younger adults.¹

After the target Hgb A1C has been determined, therapy must be selected.  If lifestyle changes are inadequate to reach target Hgb A1C, diabetes can be managed with different classes of medications.  However, one must recognize which medications to avoid in older adults, especially in those with renal insufficiency, cardiovascular disease, or polypharmacy. Sulfonylureas such as glipizide and glyburide should be used with caution in older adults as they pose an increased risk for hypoglycemia. The AGS Beers Criteria specifically recommends against the use of glyburide in older adults as the risk for hypoglycemia is too high.² Another class of concern are the insulins which can be very effective for controlling blood glucose, but can also be problematic  in the elderly patient. First, insulins are currently only available for subcutaneous injectable administration, which can be difficult for elderly patients with physical or cognitive impairment.  Long-acting insulins such as insulin glargine or insulin detemir are preferred forms of insulin for older adults as these insulins have a decreased risk for hypoglycemia and allow for easier regimens with fixed doses only once or twice a day in contrast to short-acting insulins such as insulin lispro or insulin aspart which can have more complex regimens.³  Although insulin can be used safely to manage blood glucose in older adults, the AGS Beers Criteria recommends against the use of insulin sliding scales for chronic management as this dosing regimen carries an increased risk of hypoglycemia.²

Metformin remains a first line agent for diabetes that is relatively safe and effective.  This is a preferred option in older adults unless renal insufficiency is present.  The most common adverse effects of metformin are diarrhea, nausea, and vomiting.  Recent studies alert clinicians to the risk of vitamin B₁₂ and folic acid deficiency, recommending testing before signs or symptoms of deficiency are evident.⁴ These micronutrients should be monitored annually along with hemoglobin and renal function.

Glucagon-like peptide-1 (GLP-1) agonists, including exenatide and liraglutide, have also been used safely and effectively in older adults, however there are no studies specifically in the older adult population. Dipeptidyl peptidase-4 (DPP-4) inhibitors including sitagliptin and saxagliptin are also considered relatively safe in older adults. Because their actions are glucose dependent, they have low risk for hypoglycemia with similar efficacy to other classes.³   However, GLP-1agonists and DPP-4 inhibitors require dosing adjustments in patients with renal insufficiency.

When treating older adults for diabetes, one must use an individualistic approach with added caution in this population due to multiple co-morbidities. Guides such as the AGS Beers Criteria can help guide decisions for the busy clinician.

 

 

References:

1. “AGS Beer’s Criteria for Potential Inappropriate Medication Use in Older Adults.” The American Geriatrics Society, 2015. Accessed 26 July 2017.

2. “American Diabetes Association Standards of Medical Care in Diabetes—2017.” The Journal of Clinical and Applied Research and Education, Diabetes Guidelines, vol. 40, no. 1, Jan. 2017, p. S50. Accessed 26 July 2017.

3. Kim, Kyung S., Soo K. Kim, Kyung M. Sung, Yong W. Cho, and Seok W. Park. “Management of Type 2 Diabetes Mellitus in Older Adults.” Diabetes and Metabolism Journal, 2012, pp. 336-44. Accessed 26 July 2017.

4. Kancherla, V, Elliott, JL, Patel BB, et al. “Long-term Metformin Therapy and Monitoring for Vitamin B12 Deficiency Among Older Veterans.”  J Am Geriatr Soc, 2017, 65:1061-6.

 

 

 

By Regina V. Gibson, PhD, MALS, RN, CHES

AGEC/GWEP Program Coordinator

Elder abuse is any form of mistreatment that results in harm or loss to an older person; it is an important public health problem. A 2017 study based on the best available evidence from 52 studies in 28 countries from diverse regions, including twelve low- and middle-income countries, estimated that, over the past year, 15.7% of people 60 years and older were subjected to some form of abuse. This is likely to be an underestimation, as only one in 24 cases of elder abuse is reported, in part because people are often afraid to report cases of abuse to family, friends, or to the authorities (Elder Abuse Fact Sheet, 2017)

As more people are living longer, the issue of elder abuse is now getting the attention of law enforcement, and medical and research communities. In the United States, the 2010 Census recorded the greatest number and proportion of people age 65 and older in all of decennial census history: 40.3 million, or 13% of the total population and this “Boomer Generation” effect will continue for decades (Research: Statistics/Data) .The aging population will require more care and protection than is currently available or possible (Elder Abuse, 2017) and will also be more susceptible to various forms of abuse (physical, financial, emotional, psychological, neglect, fraud, and scams) (Nina Plonka, 2013).

Old age can be described as both a family and a societal burden. Some older adults age gracefully and remain independent, living in their own homes well into their 90s. These older adults are able to manage their affairs and are not hindered by debilitating diseases or severe cognitive issues. However, many older adults often find themselves having to live with a relative when they are no longer able to take care of themselves due to decreasing mental capability as seen in those with dementia, or chronic debilitating diseases. Additionally, it may be necessary for some older adults to be placed in long term care facilities. Sadly there are also older adults without family support who live alone. These are the people who are more susceptible to loneliness, isolation, depression, and/or self-neglect, the latter of which is a form of abuse. Neglect, the failure of caregivers to fulfill their responsibility to provide needed care, may be an issue. Perpetrators may be paid attendants, family members, employees of long term care facilities or others.

When speaking of elder abuse, there are older adults who are particularly vulnerable because of memory impairments, communication abilities, and loss of judgment.

Many people with dementia are unable, frightened, or embarrassed to report abuse. As dementia progresses, so does the risk of all types of abuse. Abuse among this population is a hidden offence, perpetrated by people on whom they depend (Research: Statistics/Data).

Unless mandated reporters do what they are obligated to do, many cases of abuse go unreported.  There is a long list of mandated reporters listed in the 2010 Arkansas Code § 12-18-402 (2010 Arkansas Code). The bottom line, however, is that anyone who suspects that an older adult is being abused, has an obligation to report it.

It is understandable that caring for impaired family members, especially those with dementia is stressful, but these stresses should never be an excuse for elder abuse or neglect. Thankfully there are resources available for caregivers to work through the stress of caring for a loved one. Locally, in Arkansas, AARP offers an excellent comprehensive Caregiver Resource Guide. (Resources).  Other resources for caregivers include Adult Protective Services, Arkansas Area Agencies on Aging (AAA), Arkansas Department of Human Services Division of Aging and Adult Services, Long-Term Care Ombudsman, and the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging, and Alzheimer’s Arkansas, just to name a few (Arkansas Caregiver Resource Guide, 2017).

This article in no way completely describes all of the types of abuse that may be inflicted on older adults, but it is intended to raise awareness that elder abuse continues to be a problem that must be continually addressed.

 

 

References:
1. 2010 Arkansas Code. (n.d.). JUSTIA. Retrieved August 08, 2017, from http://law.justia.com/codes/arkansas/2010/title-12/subtitle-2/chapter-18/subchapter-4/12-18-402

2. Arkansas Caregiver Resource Guide. (2017, August 15). Little Rock, Arkansas, USa. Retrieved from http://www.aarp.org/content/dam/aarp/home-and-family/caregiving/2016/2016-03/ar-caregivers-resource-guide-nov-2015.pdf

3. Elder Abuse. (2017, March 30). National Institute of Justice. Washington, District of Columbia, USA. Retrieved August 03, 2017, from https://www.nij.gov/topics/crime/elder-abuse/Pages/welcome.aspx

4. Elder Abuse Fact Sheet. (2017, June). World Health Organization. Retrieved August 15, 2017, from http://who.int/mediacentre/factsheets/fs357/en/

5. Neglect and Self-Neglect. (2008). National Committee for the Prevention of Elder Abuse. White Plains, New York, USA. Retrieved August 03, 2017, from http://www.preventelderabuse.org/elderabuse/neglect.html

6. Nina Plonka, R. B. (2013, June 19). 6 Types of Elder Abuse in our Society. Caregiver Services. Miami, Florida, USA. Retrieved August 08, 2017, from http://www.csicaregiver.com/blog/6-types-of-elder-abuse-in-our-society/

7. Paley, A. (2011, December 04). Manging Medications for Elderly Patients. Pharmacy Times Newsletter. Cranbury, New Jersey, USA. Retrieved August 02, 2017, from http://www.pharmacytimes.com/news/managing-medications-for-elderly-patients

8. Research: Statistics/Data. (n.d.). National Center on Elder Abuse. Alhambra, California, USA. Retrieved August 03, 2017, from https://ncea.acl.gov/whatwedo/research/statistics.html#perpetrators

9. Research: Statistics/Data. (n.d.). National Center on Elder Abuse. Retrieved August 15, 2017, from https://ncea.acl.gov/whatwedo/research/statistics.html

10.Resources. (n.d.). Center of Excellence on Elder Abuse & Neglect. Irvine, CA, USA. Retrieved August 15, 2017, from http://www.centeronelderabuse.org/resources.asp

11. What is Elder Abuse? (n.d.). National Committee for the Prevention of Elder Abuse. White Plains, New York, USA. Retrieved August 02, 2017, from http://www.preventelderabuse.org/elderabuse/

By Ronni Chernoff, PhD, FAND, FASPEN, AGEC/GWEP Director

The Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program, has entered the third year of a 3-year grant. As we look forward to a new grant cycle at the end of 2017, we are making some changes to position us for new funding for the future. There will be some inevitable changes. The AGEC Director (Dr. Ronni Chernoff) will be retiring in June, 2018. To assure a smooth transition she has handed the reign to the Associate Director (Dr. Robin McAtee) effective July 1, 2017. Dr. McAtee is a PhD-prepared nurse who has had a notable career as a nurse, hospital administrator, and educator. She has worked on the Arkansas Aging Initiative as Associate Director and is responsible for replicating the care-giver training grant at the rural centers on aging. She has worked on the AGEC activities since 2010, and has worked very closely with Dr. Chernoff during the past two years. There is no doubt she will do an outstanding job.

Our year two progress report was recently submitted and we are proud to announce that we exceeded all of our goals for the time frame. We are already working on ideas for a new grant cycle; in preparation for a new grant submission in early 2018 for 2018-2021 funding, we have developed a statewide needs assessment. We really want, need and appreciate your input and ideas. Please think about what information or experiences you would like to have to provide better care to our older adult patients. The needs assessment survey is available on our webpage so please respond to it! The more input we have, the more valuable our future events will be for you. In the meantime, feel free to e-mail your suggestions for topics and programs to agec@uams.edu or post a note on our website page.

Our junior faculty fellows, Dr. Lisa VanHoose (physical therapy faculty at UCA) and Dr. Upendra Kar (research faculty in the UAMS College of Pharmacy) both recently attended the International Association for Geriatrics and Gerontology meeting in San Francisco. We anticipate great things from both of them and are delighted to be able to offer them this opportunity.

We continue to offer video teleconferences four times/year; to sponsor Alzheimer’s disease-focused geriatric grand rounds twice yearly; offer Arkansas Geriatric Education Mentors and Scholars (ARGEMS) for health care professionals; host the Summer Institute for faculty members who want an update on geriatric content; sponsor training for first responders, community members, and others. The next AGEC event will be a video teleconference on Elder Justice: Recognizing and Responding to Elder Abuse, part of our Patient Safety series, that will be broadcast on October 11. For those interested in education and programs in geriatrics, more information can be obtained at our website, www.agec.org,

As we plan ahead, we would love to hear from you about what you would like to know more about. Please take the time to answer the questions on line or using the mailed survey if you were randomly selected.

We all wish you a very happy and successful new academic year and look forward to your participation in one or more of our programs. Hope to see you soon!

Upendra K Kar¹, PhD, Jonathan A Laryea², MD, William C Mustain², MD, Jason Scott Mizell², MD, Dr. Martin Hauer-Jensen¹  , and Dr. Daohong Zhou¹  Division of Radiation Health, Department of Pharmaceutical Sciences, ²Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR

Ageing leads to a progressive deterioration of structure and function of all organs over the time. The progressive accumulation of senescent cells and impairment of stem cells i.e. decline in their ability to maintain homoeostasis is well known in aging. Intestinal homeostasis is regulated by proliferation and differentiation of cycling intestinal stem cells (ISCs). ISCs are nested within a niche consisting of a wide variety of cell types including immune cells, mesenchymal fibroblasts & myofibroblasts, and endothelial cells. Niche-generated signals work in a concert with intrinsic stem cell properties to regulate the stem cell behavior. Senescence of endothelial cells leading to impairment in vascular functionality and neo-angiogenic capability is well documented. In this study we investigated the biological changes in endothelial cells induced to senescence by irradiation. Human Umbilical Vein Endothelial Cells (HUVEC) were exposed to various doses of irradiation i.e. 2Gy to 10Gy. The induction of senescence was noted by BrdU incorporation and senescence-associated β galactosidase” (SA-β-gal) staining.

Induction of senescence led to up regulation of Reactive Oxygen Species (ROS) level which was investigated by MitoSOX Red, peroxidized lipid sensor BODIPY and superoxide anion radicals (DHE MFI). Interestingly these senescent cells also displayed increase in DNA damage which was revealed by γH2AX foci assay. Senescence lead to induction of inflammation, impairment in tissue regenerative processes and immune-mediated clearance. As these features are the hallmark of aging research on senesce is on forefront, because understanding senescence will open the doors to understand the complexity of aging.

This work was supported by Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number “P20 GM109005” and Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1QHP28723.

References:
1. Methods Mol Biol. 2017;1612:97-105. doi: 10.1007/978-1-4939-7021-6_7.
2. Nat Med. 2016 Jan;22(1):78-83. doi: 10.1038/nm.4010. Epub 2015

by Stacy E Harris DNP, APRN, ANP-BC, University of Central Arkansas (UCA)

The University of Central Arkansas hosted the grand opening of the Nabholz Center for Healthcare Simulation (NCHS) on December 9, 2016. The NCHS is located on the second floor of the Doyne Health Science Center (DHSC) and includes 1,341 square feet of newly created simulation area and 4,132 square feet of remodeled clinical laboratory space. The new simulation area consists of two rooms designed to replicate a hospital setting. One patient room has the ability to be transformed into a rehabilitation room with bathroom and home-like features. Each patient room is connected to a control room. The control room is where instructors use audio and video technology to control the high-fidelity patient manikins and run patient care scenarios. Besides storage areas, the new NCHS has two debriefing rooms where students watch their peers perform a patient-care scenario by observing the case via a smart TV. After the scenarios, the students and instructors discuss and debrief the scenario. The NCHS uses uniquely designed clinical experiences to bring students into real-world environments through simulation.

Currently, the senior nursing students are using an evolving simulation case: patient admitted to an emergency room setting with stable chest pain that worsens eventually leading to an Intensive Care Unit admission with a diagnosis of myocardial infarction. The patient scenario deteriorates requiring Advance Cardiac Life Support (ACLS). This type of simulation helps develop competency in high stakes skills in a low pressure environment. One of the Interprofessional simulations involves occupational and physical therapy students assessing patient stability. The simulated case has the patient’s vital signs becoming gradually unstable. The goal of the scenario is to improve communication between the different healthcare disciplines to better meet patient needs.

The nurse practitioner students collaborated with senior exercise science students in a splinting workshop. In the workshop, exercise science instructors presented information about casting, splinting, and musculoskeletal injuries followed by hands-on splinting and casting simulation in the NCHS. Other simulations are based on specific disease states. The occupational therapy instructors have focused on competency testing over assessment of autonomic dysreflexia and seizures disorders.

The NCHS is providing a wide range of activities for students in the College of Health and Behavioral Sciences. Opportunities vary from assessing patients, designing and implementing interprofessional interventions and evaluating patient outcomes in various clinical situations across the life span. Students use clinical reasoning to make clinical judgments and key decisions that impact the patient’s care. Students are also given the opportunity to learn about and perform specific skills (such as medication administration or sterile procedures). The emphasis of the NCHS is providing students with opportunities to develop competency in skills and situations before entering real-world healthcare environments. The NCHS provides learning opportunities for students in nursing, physical therapy, occupational therapy, family and consumer sciences, communication sciences and disorders, health sciences, and psychology. The simulation program is being developed by representatives from all departments within the College of Health and Behavioral Sciences.

by Andi Daniel, PharmD Candidate 2017 and Lisa C. Hutchison, PharmD, MPH

At some point during the disease progression, 20 to 40% of patients with Parkinson’s disease (PD) experience hallucinations or delusions, referred to as Parkinson Disease Psychosis (PDP). This commonly occurs about 10 years after PD onset.1, 2 Hallucinations are thought to be a result of overstimulation of serotonin receptors, specifically 5-HT2A, or potentiated by overstimulation of dopamine D2 receptors.4 Other potential causes should be addressed in a patient, such as a dementia-related, medication-induced, or delirium-induced hallucinations. But if these causes are ruled-out, therapy directed at PDP can be considered. Historically, PDP has been managed with the atypical antipsychotics, clozapine or quetiapine, which have been considered probably effective and possibly effective, respectively.3 In April 2016, the FDA approved a new agent, pimavanserin (Nuplazid), specifically for PDP. While all three drugs are considered antipsychotics, their targeted receptor activity is different, which explains differences in effectiveness and adverse effects. Clozapine and quetiapine exhibit antagonistic activity on histamine-1 receptors, which causes somnolence, and alpha-1 receptors, which causes orthostatic hypotension. Pimavanserin does not affect either of these receptors. All three agents affect the serotonin receptor 5-HT2A although pimavanserin is a reverse agonist, and it will depress activity of the receptor as well as block its activation (see table).

	Clozapine	Quetiapine	Pimavanserin
Dopamine-2 receptor	Antagonist	Antagonist
Histamine-1 receptor	Antagonist	Antagonist
5-HT1A  receptor		Antagonist
5-HT 2A receptor	Antagonist	Antagonist	Inverse agonist/ antagonist
Alpha-1 receptor	Antagonist	Antagonist
Alpha-2 receptor		Antagonist
Adverse Effects	Granulocytopenia Somnolence Tachycardia Orthostatic hypotension	Somnolence Orthostatic hypotension Weight gain QTc prolongation	Peripheral edema Confusion Nausea, constipation

Among the atypical antipsychotics, clozapine was effective in decreasing the hallucinations of PDP, but it did not show much benefit for delusions. Of note, clozapine has five black box warnings (e.g., severe neutropenia, CNS depression, seizures/ seizure disorder, cardiomyopathy, bone marrow suppression). Because of the potential for granulocytopenia, patients are required to get weekly blood laboratory which makes therapy difficult.

Quetiapine, is considered to be a first line agent for PDP, primarily due to reduced serious adverse effects compared to clozapine, and lack of weekly blood monitoring requirements.5 It is described as “possibly effective” because of eight open label trials where 80% of treated patients showed improvement. Also, quetiapine was compared to clozapine in another study, and showed similar efficacy in reducing psychosis.6 However, in five placebo-controlled trials, only one showed improvement but patients with delusions were excluded from that study, limiting its generalizability.

Pimavanserin significantly decreased psychosis in patients with PDP when compared to placebo in a 6-week study. It was also beneficial in reducing delusions associated with PDP compared to placebo.8, 9 Furthermore, pimavanserin has a favorable adverse effect profile. The most common adverse effects are peripheral edema (7%), confusion (6%), and nausea (7%). Since the medication is still new to the market, it is important to monitor and assess its long term safety. In addition, the Average Wholesale Price is listed as $2340 per month, which limits affordability. Pimavanserin is supplied in 17 mg tablets with a recommended dose of 34 mg once daily except in patients on certain interacting drugs where the lower dose of 17 mg should be used. Although it is new to the market, pimavanserin has short term data confirming benefit in the management of PDP. Support for clozapine and quetiapine in PDP is not as strong and both have significant adverse effects. Given this evidence, pimavanserin may well become the drug of choice for treatment of PDP.

References:

1. FeÂnelon, G., et al. “Hallucinations in Parkinson’s disease. Prevalence, phenomenology and risk factors. 2000.” Brain 123: 733-45.
2. Lee, Angela H., and Daniel Weintraub. “Psychosis in Parkinson’s disease without dementia: Common and comorbid with other non‐motor symptoms.” Movement Disorders 27.7 (2012): 858-863.
3. Miyasaki, J. M., et al. “Practice Parameter: Evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology.” Neurology 66.7 (2006): 996-1002.
4. Kumar, Santosh, Subhash Soren, and Suprakash Chaudhury. “Hallucinations: Etiology and clinical implications.” Industrial psychiatry journal 18.2 (2009): 119.
5. Tarsy, D. “Management of comorbid problems associated with Parkinson disease.” UpToDate (2015).
6. Shotbolt, Paul, Mike Samuel, and Anthony David. “Quetiapine in the treatment of psychosis in Parkinson’s disease.” Therapeutic advances in neurological disorders 3.6 (2010): 339-350.
7. Fernandez, Hubert H., et al. “Quetiapine improves visual hallucinations in Parkinson disease but not through normalization of sleep architecture: results from a double-blind clinical-polysomnography study.” International Journal of Neuroscience119.12 (2009): 2196-2205.
8. Cummings, Jeffrey, et al. “Pimavanserin for patients with Parkinson’s disease psychosis: a randomised, placebo-controlled phase 3 trial.” The Lancet 383.9916 (2014): 533-540.
9. Yasue, Ichiro, et al. “Serotonin 2A Receptor Inverse Agonist as a Treatment for Parkinson’s Disease Psychosis: A Systematic Review and Meta-analysis of Serotonin 2A Receptor Negative Modulators.” Journal of Alzheimer’s Disease 50.3 (2016): 733-740.