Smoking harms nearly every organ of the body and diminishes a person’s overall health. Millions of persons in the US suffer from smoking caused health problems. Smoking is a leading cause of death from cancer. It causes cancers of the lung, esophagus, larynx, mouth, throat, kidney, bladder, pancreas, stomach, and cervix, as well as acute myeloid leukemia.

Not only actually smoking, but smoky environments put older persons at particular risk. In addition to serving as a heart attack trigger, secondhand smoke can prompt or worsen a range of preexisting health conditions common among older adults. Advancing age is the most powerful independent risk factor for cardiovascular disease; risk of stroke doubles every decade after age 55 (World Health Organization). Secondhand smoke is a known cause of chronic lung ailments such as bronchitis, pneumonia and asthma, which can have a great impact on nonsmokers. For seniors with asthma, secondhand smoke can trigger and intensify asthma attacks.

The reasons elders offer for not giving up smoking are many and varied. An important one among these is an entrenched and erroneous belief in older adults that at an advanced age quitting offers no benefit. Strong research based evidence suggests that smoking cessation even late in life not only adds years to life, but also improves quality of life. Regardless of their age, smokers can substantially reduce their risk of disease, including cancer, by quitting.

Ask your elderly patients to reconsider and take a look at the following benefits:

• Within 20 minutes of smoking the last cigarette, blood pressure drops to a level close to that before it and the temperature of hands and feet increases to normal.
• After 8 hours, the blood carbon monoxide level drops to normal.
• After 24 hours, the chance of having a heart attack decreases.
• Within 3 months, circulation improves and lung function increases up to 30%.
• In 1 to 9 months, coughing, sinus congestion, fatigue, & shortness of breath decrease.
• Cilia regain normal function in lungs, increasing the ability to handle mucus. Cilia are then able to clean the lungs, and thereby reduce infection.
• After 10 years, the lung cancer death rate is about 1/2 that of a smoker’s and the risk of cancer of the mouth, throat, esophagus, bladder, kidneys, and pancreas decreases.
• By 15 years, the risk of coronary heart disease is that of a nonsmoker’s.

Beside the listed benefits, quitting smoking lowers the risk of diabetes, improves blood vessels function, and helps the heart and lungs. Quitting at any age can give back years of life that would be lost by continuing to smoke.

Now more products than ever are available to help elders to quit, including nicotine replacement therapy and Zyban. Talk to your patients about quitting and/or ask them to call the Arkansas Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669). It is confidential, free, and available 24/7 in English and Spanish. When tobacco users call, they receive:

• Non-judgmental expert support from a Quit Coach® to help make a plan to quit tobacco.
• Ongoing Quit Coach® support via phone or online, tailored to the specific needs of all tobacco users, including smokeless tobacco users.

Unlimited access to Web Coach™, an interactive, online e-community that offers tools to quit, social support and information about quitting.

Customized, motivational e-mails sent throughout the quitting process.

Help with identifying the best cessation aid, as well as dose and duration. Some aids can be mailed directly to the tobacco user’s home, including free patches and lozenges (while supplies last).

Referral to local community resources and/or benefits offered through employers or health plans.

Printed Quit Guides – a series of workbooks that offer guidance and support throughout the quitting process.

If you’ve tried to quit before and weren’t successful, don’t give up. Keep trying. It’s never too late to quit.

– ARCC Staff

As part of this effort to broaden and update knowledge about Alzheimer’s Disease, we will  co-sponsor a four-hour conference with the Oaklawn Senior Health Center on Aging. The conference will take place at National Park Community College from 10 am to 2 pm.

The AGEC has also planned several outreach programs. Specific information for them can be found on our website or by calling the office both of which are listed in this issue. All of the above mentioned educational events carry continuing education credits for physicians, pharmacists, nurses, dietitians, long-term care workers and others. In the past, attendees voiced concerns about the number of credits awarded to them for attending our events. We do not control the credits awarded. The decision is made by the credentialing board of the specific discipline for each event. Consequently, credits awarded vary from discipline to discipline.

Enrollment for Summer Institute, to be held in May is open now for health professionals teaching in institutions of higher education. AR-GEMS and Geriatrics in the 21^st Century are both open year round since both programs are web-based and self-study. To inquire or enroll in any of these please visit our website: www.agec.org.

“The radio was a clue. You can’t really think hard about what you’re doing and listen to the radio at the same time. Maybe they didn’t see their job as having anything to do with hard thought, just wrench twiddling. Their speed was another clue. They were really slopping things around in a hurry and not looking where they slopped them. More money that way—if you stop to think that it usually takes longer or comes out worse. But the biggest clue seemed to be their expressions. They were hard to explain. Good-natured, friendly, easy-going, and uninvolved.  They were like spectators. There was no identification with the job. They were outside of it – detached, removed.  They were involved in it, but not in such a way as to care.” (Pirsig, 1974, pp.23-24)

When I reread this novel some years ago, I did so purposely to reflect on how we as a community of healthcare providers, work with our patients. I began to wonder how many of my patients, after a swallowing function evaluation, might have said words similar to Pirsig’s to a companion. I remembered the times when in the midst of “good-natured, easy-going, and uninvolved” patient care. I have joked with the radiologist about the lousy Razorback football game or said “TGIF! What a week!” I reflected on how my comments might have impacted the patients who had entrusted me with their care, not to mention how they affected my ability to properly focus on the magnitude of the task in which I was…“involved.”

Patient-centered care is receiving increased attention now, and rightly so. The patient is the most important, and often forgotten, aspect of evidence-based practice, which dictates not only appropriate use of the evidence, but also the impact of clinical experience and the needs, desires, and abilities of the patient. As we proceed to define what “patient-centered care” actually means, introspection is imperative.

We can learn many valuable lessons from the practices of Zen Buddhism. Patient-ZENtered care” means that one is “mindful” in working with patients. It means that you identify with the patient, rather than detaching yourself and you understand their situation as well as their needs and desires. It means you are able to not only provide objective data from a battery of tests, but utilize your own clinical experience and evidence from extant research to establish the initial framework for a conversation about the potential diagnoses and treatments to consider. Once this is established, the ensuing practitioner/patient dialogue should be one of reciprocal, mindful commitment. If we find, from time to time, our patients are not as committed as we would like them to be in their treatments, perhaps a look inside ourselves could shed light on the causative mechanisms.

“Patient ZENtered care” is more than a job … more than outcomes … more than numbers and quality assurance. It should be viewed as a privilege, not a right. Only through our knowledge, our concern for the patient, and our ability to grasp the significance of the moments in which we co-exist as practitioners and patients can we begin to appreciate the responsibility with which we are entrusted and intuit with our patients, the appropriate direction of care. In the Department of Communication Sciences and Disorders at UCA, our goal is to increase emphasis on patient-centered care with our students and use team-based activities to promote thought and reflection. In addition, the College of Health and Behavioral Sciences has initiated research projects to examine different ways of looking not only at patients and how they view their care, but also at health professionals as clinicians and at the personal traits that drive them towards a particular style of providing care.

– Gary H. McCullough, PhD, CCC-SLP

Reference:

Pirsig, RM (1974). Zen and the Art of Motorcycle Maintenance. New York: Bantam.

The patch is a thin, two-layer transdermal matrix system consisting of a flexible tan-colored backing film and a self-adhesive drug matrix layer to be applied to clean, dry, hairless skin. The system is designed to deliver rotigotine continuously for the 24 hours that the patch is worn and patches are available in 1, 2, 3, 4, 6 and 8 mg/24 hours ranging in size from 5 cm² to 40 cm². According to UCB Pharma, approximately 45% of the drug is released within 24 hours, but an independent study showed that the absolute bioavailability was only 37%. Rotigotine is approximately 89.5% protein-bound and extensively metabolized in the liver. The manufacturer recommends no dose adjustment for renal or moderate hepatic impairment and no dose adjustment for the elderly ages 65 to 80, although increased sensitivity may be seen.

For early Parkinson’s disease, RTS should be started at 2 mg/24 hours and can be titrated up to the highest recommended dose of 6 mg/24 hours. For advanced Parkinson’s disease, the patch may be started at 4 mg/24 hours and titrated up to 8 mg/24 hours. Titrations should be no more than a 2 mg increase in patch strength once a week. Rotigotine may be considered first line therapy in early Parkinson’s disease because like other dopamine agonists, it may have the ability to delay levodopa therapy and its associated motor complications. In more advanced patients, concomitant use with levodopa therapy may decrease associated “off” problems. For RLS, an initial dose of 1 mg/24 hours is recommended with titration of 1 mg/24 hours weekly up to a maximum of 3 mg/ 24 hours. Compared to immediate release oral medications, RTS may provide an advantage in patients with RLS because the patch allows for a lower maximum concentration, which may reduce the chance of side effects.

When discontinuing RTS, daily doses should be reduced by 2 mg/24 hours and 1 mg/24 hours every other day respectively, until complete withdrawal. As with other dopamine receptor agonists, side effects have been reported. The adverse reactions associated with rotigotine mirror those of other dopamine agonists with the inclusion of possible skin reactions. RTS has another disadvantage. It is a costly option with online prices from $250-$500 a month.

In conclusion, RTS is a safe and effective alternative for the treatment of early and advanced Parkinson’s disease as well as RLS. It may also provide a certain benefit to patients with a heavy pill burden and those whose compliance is an issue.

Domestic violence experienced by older people may fall into one of three common categories. The first is commonly known as “domestic violence grown old.” It exists in cases where domestic violence has begun early in a relationship and continued into old age. This form of domestic violence often does not stop until the abuser is no longer physically or mentally capable of inflicting abuse and/or intimidation. The cycle of violence is particularly difficult to interrupt in this form of abuse because it has existed for an extended period of time and the victim is often resigned to his/her fate as a battered person. Victims often experience hopelessness and helplessness and see no option but to continue in the abusive relationship.

The second form of domestic violence involving elders may be referred to as “late onset domestic violence”, because it begins in old age. The relationship involved may have grown increasingly strained through the years causing the start of domestic violence to occur when the partners are past 65 years of age. Domestic violence of this type is likely to be linked to retirement, disability, changing roles of family members, or sexual changes, such as erectile dysfunction or decreasing interest in sex. Health problems of one intimate partner late in life may produce a situation in which one partner becomes the caretaker of the other with increasing strain on the relationship.

The third type of domestic violence experienced by elders occur when older people enter into an abusive relationship late in life. In this case, the victim may have had previous relationships that were happy and healthy, but late in life entered unknowingly into a relationship in which the new partner was violent toward them. Potential for escape from the relationship is more likely in this situation than in the previous two, because the victim understands that healthy relationships are possible for him/her.

In all of these types of domestic violence, the perpetrators are spouses or intimate partners, the majority are men, and oftentimes drugs or alcohol are abused by one or both partners. At risk victims are usually women whose relationships with their spouses or partners were abusive or strained when they were younger. Also at risk are older women who enter into intimate relationships late in life.

Elder domestic abuse may present in the healthcare setting in a number of different ways. Battering consists of physical, sexual, and emotional abuse and screening should include nonphysical traumatic complaints as well as physical injuries. Physical neglect, inappropriate dress for the time of year, signs of poor hygiene, and malnutrition are causes for concern and should raise the suspicions of the healthcare provider. Mismanagement of funds may be difficult to identify unless the patient indicates that he or she is unable to purchase groceries or other necessities due to lack of money, which someone else controls. Depression, withdrawal, and suicide attempts by an elder patient who believes that he/she is worthless and is a burden for the caregiver may result from demeaning, humiliating, and degrading verbal abuse.

Intervention by healthcare providers can make the difference between safety and increasing risk of harm to elder victims of domestic abuse. Mandatory reporting of suspected abuse to Adult Protective Services and/or local law enforcement enhances protection for the victim. Contributing to violence against elder victims are dependency needs, failing health, isolation, and stressed caregivers. Therefore, discharge planning for elder victims of violence should involve linking and networking with appropriate home care or residential treatment facilities and resources. If caregiver stress is a factor, services for the caretaker, including respite services, support groups, and ongoing monitoring may be required to decrease the potential for further abuse. Relocation of the victim may be necessary to protect him/her from harm.

Awareness of domestic violence in the older population and education of those who come into contact with potential victims of domestic violence is imperative to halting the cycle of abuse. Risk assessment and screening for domestic violence can save lives. Partnerships with community services contribute to holistic care and empowerment for victims of all ages. The Elder Maltreatment Assessment tool can be accessed at: http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf

This is important in the realm of geriatrics because the majority of persons identified are peri and post menopausal women. BMS is most commonly seen in the anterior mucosa or soft tissue regions of the mouth and the lateral posterior borders of the tongue. This would include the tip of the tongue, the front of the roof of the mouth, and the inside lower lip.

For secondary BMS, a systematic review of the following clinical factors should be undertaken: the fit of a prosthesis or the possibility of an allergic reaction to the material it is made from; trauma to the area, chemical irritants such as rinses, toothpastes, foods, preservatives, additives or flavorings; galvanic reactions from any metals in the mouth; par functional activities such as tongue habits; low salivary flow for any reason; oral infections, primarily candidal, but possibly bacterial or viral; lichen planus; benign tongue lesions such as geographic tongue; deficiencies such as the B vitamins, zinc, folate and iron; endocrine disorders and hormonal deficiencies; esophageal reflux; neuropathies and neuralgias; medication induced (cited most often with the use of antihypertensives, specifically ACE inhibitors); and during chemotherapy.

Primary BMS will be diagnosed when clinical evaluations and laboratory tests do not identify a specific cause for the burning. This condition is often linked in the research to periods of high psychological distress and various psychological disorders. The symptoms often follow the pattern of worsening as the day progresses and also when life becomes more stressful for the patient.

Treatment for secondary BMS lies in treating the underlying cause. However, like the etiologic cause for primary BMS, treatment is also not fully understood or many times reached to the patient’s full satisfaction. Klasser et al categorize treatment strategies as behavioral, topical or systemic approaches. Studies show that cognitive behavioral therapy can decrease the symptoms and make them more tolerable for the patient. Topical can consist of palliative strategies such as staying away from things that increase the burning such as rinses, alcohol and spicy or acidic foods, chewing gum to increase salivary flow and capsaicin or lidocaine as analgesics during severe times. A topical form of clonazepam has also been shown to improve the symptoms in some studies.

The medications available for primary BMS meet with varying degrees of success. They include anxiolytics, anticovulsants, MOAs, antipsychotics, hormone replacement and others. Treatment should always include making the patient aware of all the factors that might trigger or aggravate the affliction, helping them understand the complexity of BMS without diminishing  the importance of their symptoms, but help them realize ways to reduce the symptoms.

Alert/warning systems rather than stimulating hearing stimulate vision with flashing lights or touch with shaking or vibration. They are used with smoke detectors, door bells, fire alarms, ringing telephones, burglar alarms and severe weather alerts. ALDs can also be adapted to alert about oven and microwave tones and alarm clocks. Telephone and telecommunications applications range from in-line amplifiers to specialty telephones with increased output levels to Telecommunication Devices for the Deaf (TDDs). Radio and television ALDs enable the user to enjoy home entertainment through either hard-wired applications or any number of wireless applications including induction loop, FM, infrared, and bluetooth technologies. Personal communication devices are very useful for individuals with dexterity problems or who have been unsuccessful with conventional personal hearing aids. They use many technologies used in radio and television devices and often benefit persons in short or long-term care facilities, particularly elders.

Frequent questions asked about ALDs are:

Who uses assistive listening devices? 

They are typically used by people with some residual hearing or who are hearing impaired. People who have difficulty hearing speech or certain sounds in noisy situations may benefit from using an ALD. Additionally, people who require a louder sound level than comfortable for others around may use ALDs. These devices minimize background noise, reduce distance effect between the sound source and person with hearing loss and override poor acoustics such as echo.

Is an ALD the same as a hearing aid? 

No. Though both may have similar components (e.g., microphone, amplifier, etc.), a hearing aid combines all the components into one device worn on the body or in the ear. Some ALDs may have a microphone that can be placed near the sound source to capture more of the targeted sound and less of the background noise. The user listens to the amplified signal through speakers, headphones or their hearing aid or cochlear implant (with or without a coupling device).

Can a hearing aid or a cochlear implant and an ALD be used at the same time? 

Some ALDs can be used together while others need to be used alone. To use hearing aids with other equipment typically requires using the built-in telecoil,“T”coil, switch to reduce or eliminate feedback or squeal. Cochlear implants require a patch cord (DAI or Direct Audio Input) or a“T”coil switch to use with ALDs.

What types of ALD and accessories are available? 

Several are available depending on the environment, the need for privacy, and how the user will interface with the system. No one system is good for all environments and all have pros and cons regarding use and features. ALD technology can be integrated into public address (PA) or sound amplification system to transmit the sound directly to a person. Four general types of systems are: induction loop (IL), FM (frequency modulation), infrared (IR), and sound field amplification systems.

Two frequently asked questions concerning ALDs are:

With whom should I talk about getting an ALD? 

An audiologist is usually the professional to counsel an individual on the type of personal ALD and the best suited to couple with the device the individual wears.

Are ALDs required by law in certain places? 

ALDs for public places are covered under Title III of the 1990 Americans with Disabilities Act (ADA), unless a facility can prove that to provide them creates an undue hardship. Public places include movie theaters, museums, and public classes. The ADA specifies that ALD receivers be provided at no cost and specifies the number of receivers that must be provided depending on the number of seats (4% rule). The provision of ALDs may also be included under ADA Title I (employment accommodations) and Title II (accommodations provided by state and local governments), Section 504 of the Rehabilitation Act of 2009.

• D. Mike McDaniel, PhD
  Professor, Communication Disorders

The FDA has been collecting post-market data for several years regarding the issue of statin-related cognitive impairment. Analysis of this data reveals that cognitive impairment due to statins occurs in all age groups and with all statin products. Impairment has occurred among individuals who have used statins for a short time period as well as those who had been taking the medication for years. The most commonly reported symptom was a “fuzzy” feeling or an inability to focus. The good news is that symptoms of cognitive impairment were generally mild and reversible upon cessation of the statin.

Statins were originally proposed as having a possible beneficial effect on impaired cognition. Although evidence has not been fully established, the theory has been that statins could prevent the development of Alzheimer’s Disease and vascular dementias. The risk of developing dementia increases with increased levels of cholesterol; therefore, lowering cholesterol levels could potentially decrease the risk of developing dementia. However, other theories involve statin effects on such factors as anti-inflammatory effects, antioxidant effects, antithrombotic effects and vasculoprotective properties.

Using new clinical data, researchers are evaluating theories to explain the possible negative effects on cognition. The most common theory being discussed focuses on the relationship between cholesterol and myelin within the brain. Cholesterol plays a major role in the membrane permeability of myelin. If statins interfere with cholesterol synthesis in the brain, myelin formation and function are altered, leading to neuronal conduction deficits. These deficits would ultimately lead to impaired cognition.

Whether statins are beneficial in preventing cognitive impairment or have negative effects on cognition, remains unclear. Specific patient groups may benefit from using statins while others may not. Statins are a commonly used medication among elderly patients, a group which is at an increased risk of cognitive impairment. When considering possible causes of a decline in cognitive functioning, the patient, as a whole, should be assessed. Concomitant conditions and medications, including statins, could be important factors that that need to be reviewed. If statins are a possible cause, stopping the medication and monitoring for improvement is recommended for 1 to 3 months. Reassessment and potentially re-challenge with statins is suggested.

While new risks for statins are now known, more data supports their benefit in preventing cardiovascular events. Cessation of this medication could have far greater consequences on the patient’s heart than the negative effects it has on cognition.

–By Cally Morrow and Lisa C Hutchison, PharmD, MPH, BCPS

Currently we are recruiting individuals age 55 or older who are willing to participate. Of special interest are those individuals who have a sense that their memory is declining or who have been diagnosed with cognitive problems. Participants can expect to spend about 2 hours at the Speech Language Hearing Center on the UCA campus in Conway. However, if transportation is a problem, a member of the research team will go to the volunteer’s home. Volunteers will be asked to provide basic information including age, place of residence, educational background and any medical history of neurological disease or disability that might influence the results of the study (stroke, dementia, head injury, Parkinson’s disease, etc.). Also, brief tests will be given to insure that volunteers have sufficient hearing and vision to participate. Participants will receive a small stipend for their time and effort.

Study participants complete tasks, which most individuals find enjoyable,that assess language and cognitive skills. The primary test administered is the Arizona Battery for Communication Disorders (ABCD) that is authored by Dr. Bayles. It evolved from three NIH-supported longitudinal studies of aging, language and cognition and is used nationally and internationally by speech-language pathologists (SLPs) to quantify cognitive-linguistic function. As their name suggests, SLPs are trained to assess language and the cognitive features of MCI. They can play a crucial role in early detection. Not only do they routinely see adults for hearing screening, but they also routinely evaluate individuals admitted to residential facilities, hospitalized or seen in clinics as a result of other communication disorders. The research at UCA is expected to result in the development of a simple and pleasant way to screen individuals for MCI that can be used by professionals nationwide.

Recruitment efforts for this study began in August and will continue until participation reaches 150-200 persons. Participants in the study might learn of a hearing problem or difficulty with thinking. If such were the case, a member of the research team will provide them with information about potentially beneficial services. At this time, 10 students in the Department of Communication Sciences and Disorders have already been trained and are part of the research team. Involvement in this research project should provide SLP students with an increased appreciation for elders in our population and skills that will help them be more effective SLPs in the future

The Institutional Review Board for the Protection of Human Subjects at UCA has reviewed and approved this project. For further information or if you wish to participate, please call (501) 450- 5488 or email kmccullo [at] uca [dot] edu.

– Kathryn Bayles, PhD
    Kim McCullough, PhD

Saliva has many redeeming properties. It works to lubricate the oral cavity, break down food, provide minerals to the teeth and has antimicrobial effects. Mucins are included in the makeup of saliva. When the more liquid or wet components of saliva are depleted or not well manufactured due to dehydration, the mucinous component serves as a good reservoir for infection and saliva becomes then much harder for the patient to clear. Unfortunately, much of the beneficial properties of saliva can be negated when the secretion is dehydrated.

Occurrence of inspissated secretions is more common in the following instances. For younger patients this would include asthma, severe allergies and cystic fibrosis. For geriatric patients being dehydrated and being constant mouth breathers in general leads to an increase of this condition. Reduced salivary flow is quite common in older adults due to medications. In cases of elders who also are constant mouth breathers, or on ventilators, the likelihood of seeing the buildup of inspissated secretions in the mouth is great. For patients who are tube fed, a decreased salivary flow may occur because little oral stimulation leads to less saliva.

Figure 1 is an example of a patient with this build up of dried secretions. Figure 1: Courtesy of Dr. Linda Niessen If a caregiver has not seen this before it can be shocking and may lead to a request for the evaluation for a suspicious oral lesion. The dried secretions often will not wipe off easily, which adds to the suspicion. To remove them, take a 4×4 gauze that is soaked with warm water to the point of saturation, but not dripping, hold it on the lesion for about 1 minute, and then gently wipe. Do this gently, as the tissue underneath can easily tear, causing longer term discomfort for the patient. Two to three gentle wipes in this fashion will usually clean the mouth well.

Figure 2 (page 7) shows the clean mouth after removal of these inspissated secretions. In order to prevent the recurrence of this build up, patients should be advised to follow a twice daily regimen of gently cleaning the oral cavity by wiping it with warm water and then lubricating the tissue. A gel such as Oralbalance® made by Laclede or even a more generic lubricating jelly such as KY® can be used in the mouth. Some dental practitioners recommend using the 0.12% chlorhexidine rinse to swab the mouth.

This is acceptable, but due to the high alcohol content of the rinse, it can be more drying to the tissue. for that reason, it is desirable to follow this with some lubricating jelly. Providing this level of care should no only afford the patient an increased quality to life, but also possibly a reduction in poor systemic outcomes.

- Gretchen Gibson, DDS, MPH