This past May, the AGEC and the South Arkansas Center on Aging (SACOA) in El Dorado co-sponsored a one-day conference on "Exercise and Nutrition for Older Adults." Nicholas Hays, PhD and Kellie Coleman, MS addressed exercise topics and Beverly McCabe, PhD, RD and Ronni Chernoff, PhD, RD discussed the nutrition needs of older adults. The response to the program was wonderful - close to 80 persons attended, and we have received inquiries about presenting the same program elsewhere in the state.

In May, we also held the AR-GEMS Summer Institute (SI). Four faculty members, representing UALR, UCA, UA Fayetteville and UA Ft. Smith, completed 24 hours of didactic sessions. The lectures, provided by UAMS/ CAVHS faculty and staff, contained up to date information on geriatric topics. Presently, the SI participants are in the process of completing 36 hours of clinical experiences.

The 14 new surgical residents at UAMS received training on the specific needs of the older patient prior, during and after a surgical event. The training sessions were held June 27-29. Drs. Neena Goel, Larry Johnson, Dennis Sullivan, K. Morgan Sauer and M. Ali Syed presented the information to the residents.

We are now accepting applications for the Fall 2005 AR-GEMS program. If you are interested in participating in this program please contact Soledad H-D Jasin, PhD at 501-257-5551 or jasinsoledadhd@uams.edu.

Four Arkansas Community Health Centers (CHCs) are participating in a HRSA grant titled "Continuing Education for Bioterrorism Preparedness of Health Professionals." The grant provides education on bioterrorism preparedness for health care practitioners and paraprofessionals across the state. This education is particularly important to healthcare providers in the CHCs who are involved in treating the elderly, because elders tend to present different symptoms than the younger population, are at greater risk of major complications and time is of the essence in making a diagnosis and implementing treatment. CHCs participating in the grant are Mainline, East Arkansas, Healthy Connections and Boston Mountain. Regional CE Managers provide bioterrorism continuing education and training for a multidisciplinary healthcare workforce in Arkansas, serve as coordinators in their regions and are the liaison in their area with the grant's project staff.

One Bioterrorism Regional CE Manager who stands out for her accomplishments is Hilda Douglas of Healthy Connections. Since her appointment in October 2004, she has worked diligently to become the bioterrorism expert in her region by attending numerous bioterrorism conferences and self-study. Ms. Douglas organized a regional conference in August 2004 hosted by Healthy Connections at the DeQueen/Mena Educational Coop that drew more than 80 people, including nursing students and faculty from UA Cossatot. In June 2004, she collaborated with Dr. BJ Landis from the Ft. Smith AHEC and provided Emergency Preparedness to M*A*S*H Camp students in Mena. Together with Ft. Smith Bomb Squad Instructor, John Miller, she has taught law enforcement officials and emergency response personnel and has assisted during the explosives demonstration at the firing range. Ms. Douglas will teach Introduction to Explosives at the Arkansas State Police academy in November. She recently coordinated with the Arkansas Department of Emergency Management to provide Student Emergency Response Team (SERT) Training for 80 High School students. Student response teams are established and will be receiving further training on school response next month. The school and students will be an active part of the upcoming community drill.

The Geriatric Research, Education and Clinical Center (GRECC) at the Central Arkansas Veterans Healthcare System (CAVHS), the Arkansas Geriatric Education Center (AGEC), the Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences (UAMS), and the Office of Continuing Medical Education at UAMS jointly sponsored Best Practices in the Continuum of Care: Hip Fractures on April 27, 2005. Seven experts including: Randy Bindra, MD; Donald L. Bodenner, MD, PhD; Jennifer Dillaha, MD; Johannes M. Gruenwald, MD; Patrick Kortebein, MD; Dennis Sullivan, MD; and Bruce Troen, MD addressed the topic of the hip fractures.

… quick response and surgery within 24 hours are essential.

Hip fractures are one of the most serious health problems facing our aging population and cause considerable functional disability and decreased capacity for independent living. The highest incidence of hip fractures occurs in Northern Europe, North America, and Australia. The United States has approximately 300,000 hip fractures a year, and by 2040 the number should rise to between 512,000-840,000. Because 15% of Arkansas population is over 65, a better understanding of the cause and treatment of hip fractures is of utmost importance and a major socioeconomic challenge. Arkansans at the greatest risk will be white females over the age of 85. Among nonwhites, persons of Asian descent have < incidence than African-Americans. Adults who do not perform weight-bearing exercise or perform muscle-loading activities are twice as likely to sustain a hip fracture.

Risk factors vary and are of particular importance to the older patient population. Ninety percent of hip fractures are associated with falls, in particular, lateral falls with high impact. Diseases associated with the elderly (hypertension, arthritis and diabetes) and body size characteristics increase the risk for falls.  A height > 65 in, a low body mass and a high waist-to-hip increases the risk of hip fracture.  The low muscle mass and weak muscle of elders may increase the severity of the trauma and also decrease the force required for a fracture. Other risk factors include low bone density/mass, impaired cognition, perception, and vision.

Non-pharmaceutical strategies to prevent hip fractures include strengthening bones, avoiding falls, cushioning for falls and education of staff and patients. Bones can be strengthened through diet, exercise, lifestyle changes (moderate alcohol intake, < 3 cups of coffee a day and no smoking), and medical treatment. Diet should include 100-1500 mg/day of calcium combined with 600-800 IU/day of Vitamin D. Intrinsic and extrinsic strategies help to avoid falls. Intrinsic strategies involve muscle and balance retraining, vision correction, sensible footwear, a walking cane in adverse weather, and periodic medication review. Extrinsic strategies relate to ”fall proofing” the patient's living environment by removing floor obstacles; installing grab bars and handrails; and improving lighting throughout the home. Both hip protectors and floor coverings soften the impact of falls. Hip, which can reduce fractures by approximately 40%, must be worn 24/7, and patient compliance is an issue. Education should focus on increasing awareness and diagnosis of osteoporosis.  The National Osteoporosis Foundation recommends testing for all women 65 and over , women on HRT for a prolonged period, all women who are considering therapy for osteoporosis and for whom BMD test results would influence the decision, all postmenopausal women who present with fractures, and all postmenopausal women under 65 who have at least one additional risk factor for osteoporosis.

Dr. Bruce Troen describing the
basic science of osteoporosis.

Three common locations for hip fractures are: femoral neck, intertrochanteric, and subtrochanteric fracture. Hip fractures are classified according to the garden or the Pauwels classification. ER management of a patient presenting with hip fracture should emphasize quick response, with surgery within 24 hours. Systemic factors that influence the healing of a fracture are age, hormones, functional activity, nerve function, and drug regiment. Local factors that influence the fracture healing process are the degree of trauma, extent of bone loss, related vascular injury, the type of bone involved, the degree of immobilization, the presence of infection, and the local pathological conditions. The predictive factors for functional outcome after surgical treatment are patient age, fracture type, any acute care complications, the functional status at rehab admission, emotional status, and the social support system available. An interdisciplinary team that includes geriatric, orthopedic and nursing specialists, dieticians, social workers, psychologists, and occupational therapists should coordinate surgical treatment. Discharge planning should begin before the surgery occurs, and be carefully coordinated.

The goals of post surgery rehabilitation should be to improve functional independence, prevent complications, and return patient to previous living environment. The selection of the rehabilitation setting is determined by previous living setting, previous function, tolerance for therapy, expected functional recovery, family/social support, and insurance coverage. The key elements taught in any setting are falls prevention education, transfer technique, ambulation with weight bearing, activities of daily living such as dressing, bathing, grooming, etc., and use of assistive devices.

So what do we tell our patients? It is never too late to build healthier bones! Promoting a healthy lifestyle in our older population in Arkansas will benefit of all our citizens.

With programs in Jonesboro, West Memphis, Beebe, and Mountain Home, the Arkansas State University (ASU) College of Nursing and Health Professions offers many opportunities to area residents who wish to pursue a career in nursing or to obtain a higher degree. The programs at ASU reflect the commitment of the Nursing faculty to the concept of educational mobility. They allow a person with no previous nursing experience or a Licensed Professional Nurse (LPN) to earn an associate degree; an LPN to become an registered nurse (RN); or an RN to earn a Bachelor of Science in Nursing (BSN). All of the ASU nursing programs insure that students acquire geriatric knowledge commensurate to their educational level.

The Associate of Applied Science in Nursing (AASN) program is offered at ASU - Mountain Home and at Mid-South Community College in West Memphis, AR. It is four semesters long and by the spring semester students begin clinical training in various health care facilities. The AASN emphasizes the provision and management of direct patient care to individuals with common, well-defined problems. Once a student earns an AASN degree, he/she becomes eligible to take the NCLEX-RN exam for Registered Nurse Licensure. LPNs simply wanting to pursue an RN degree may do so at the following campuses: ASU - Jonesboro, ASU - Mountain Home, and ASU - Beebe.

The RN-to-BSN program provides a flexible approach for RNs to earn a Bachelor of Science in Nursing (BSN) by featuring on-line courses and reduced clinical hours. Clinical experiences are tailored to fit the students' needs. Through extensive study the BSN graduate acquires a well-delineated and broad knowledge base for practice. He or she designs, manages and coordinates patient care. Furthermore, the BSN nurse gains teaching, research and management skills that are the foundation for leadership positions and graduate education.

This fall, ASU will offer a nurse refresher course on-line designed for nurses planning to return to practice. For information about the programs, visit the web site at
http://conhp.astate.edu/Nursing/, call (870) 972-3074 or email lrazer@astate.edu.

Traditional non-steroidal anti-inflammatory drugs (NSAIDS), such as aspirin, ibuprofen, and naproxen, inhibit both cyclooxygenase (COX) -1 and -2. The inhibition of COX-1 is associated with an increased risk for stomach ulcers and reduced platelet aggregation, while the analgesic effects are more associated with COX-2 inhibition. Because of the relative high risk of ulcers with traditional NSAIDS that are non-selective COX inhibitors, the COX-2 inhibitors became popular drugs because they were thought to be safer. Valdecoxib (Bextra), rofecoxib (Vioxx) and celecoxib (Celebrex) decrease the activity of COX-2 but have less effect on COX-1. This action decreases inflammation and pain associated with osteoarthritis, rheumatoid arthritis, and acute pain while potentially avoiding adverse gastrointestinal effects. Rofecoxib and valdecoxib are much more selective for COX-2 than celecoxib.

In late 2004, Merck announced the voluntary withdrawal of rofecoxib from the market because data from clinical trials showed an increased risk of cardiovascular events, such as heart attack and stroke, in patients taking rofecoxib compared to those taking placebo. The removal of rofecoxib from the market triggered a closer look at the safety profile of all COX-2 inhibitors. Valdecoxib was also removed from the market this year but celecoxib remains available.

Information about the potential cardiovascular risk with celecoxib was reported in two clinical trials, the Adenoma Prevention with Celecoxib (APC) cancer trial and the Prevention of Spontaneous Adenomatous Polyps Trial (PreSAP). The APC trial demonstrated 2.5-3.4 times the risk of cardiovascular events associated with celecoxib as compared with placebo depending upon the dose. The average duration of treatment in the trial was 33 months. In PreSAP, patients were taking celecoxib or placebo and no greater cardiovascular risk was demonstrated. Another long term study available with celecoxib is the Celecoxib Long-Term Arthritis Safety Study (CLASS), in which about 8000 patients were randomized in a comparison of celecoxib to ibuprofen or diclofenac for the treatment of osteoarthritis and rheumatoid arthritis. Patients were followed for approximately one year. This study also did not reveal a difference in cardiovascular risk.

However, none of these studies were designed to accurately assess cardiovascular risk. Pfizer announced plans to sponsor a new celecoxib trial to assess the safety of celecoxib in osteoarthritis patients at high risk for cardiovascular disease. The study will enroll more than 4000 patients with osteoarthritis who have had a recent heart attack. The study will assess the effects of celecoxib on inflammation and cardiovascular events but results will not be available for at least two years.

So how does this affect our choices for pain management in patients with an increased risk for gastrointestinal bleeding? Celecoxib is still an alternative, particularly in patients who do not have cardiovascular disease. As another option, some data supports the use of a traditional NSAID such as naproxen along with a proton pump inhibitor. The best course is to minimize the dose and duration of any NSAID use as much as possible. We must monitor patients on NSAIDs closely, assuring they are aware of the possible adverse events common to this class of agents.

References

1. American College of Rheumatology.  Update: Safety Issues Related to NSAIDs and COX-2 Inhibitors. (accessed 2005 Feb 24).

2. Schuna AA, Badawi O, Weart CW.  NSAIDs: Remaining GI Protective Options Limited.  APhA Drug Info Line, 2005; 6:1.

3. U.S. Food and Drug Administration. FDA Statement on the Halting of a Clinical Trial of the Cox-2 Inhibitor Celebrex. (accessed 2005 Feb 24).

4. Celebrex. An Important Message About Recent Celebrex News.
   (accessed 2005 Feb 24).

5. Vioxx. Merck Announces Voluntary Worldwide Withdrawal of Vioxx. (accessed 2005 Feb 24).

Earlier this year, you may have heard about the dental research article that made the evening news. This article looked at the link between periodontal ("gum disease or pyorrhea") and cardiovascular disease (CVD). For many years dentistry has known and talked about the systemic effects that oral infections may have on the rest of the body. Several studies have shown an increased incidence of pre-term low birth-weight babies in women with severe periodontal disease.

We know that patients who are genetically predisposed to periodontal disease and who also have diabetes that is not well controlled, can suffer a more devastating case of periodontal disease. Edentulism, for which periodontal disease is most often a factor, is much more prevalent in patients with diabetes. The good news is that even in these patients, the destruction of periodontal disease can be halted with professional intervention and improved home care.

Unfortunately, many of the risk factors that are related to periodontal disease such as smoking, stress and diabetes are also risk factors for CVD. However, many of the studies have statistically controlled for other or "confounding" risk factors and still reported a very strong relationship between periodontal disease and atherosclerosis and stroke.

Past studies have used oral measurements of the results of this infection to measure the severity of periodontal disease. These measurements include how much bone was destroyed, how many teeth were lost or how much attachment is lost between the gum and tooth. Until recently, they have not looked at the specific cause or bacteria related to this infectious disease. Another issue is that C-reactive protein, which is a systemic marker for inflammation, is seen with periodontal disease, and has been shown to predict future CVD as well. Could it just be a link of chronic infection and not related to the specific periodontal infection?

This is where the most recent study starts to show us a more specific link. In the February 2005 issue of Circulation, Desvarieux et al. presented data that looked at the relationship between specific periodontal-causing microorganisms and sub- clinical atherosclerosis (thickening of the lining of the arteries, leading to smaller lumen or opening where blood flows). Because the researchers measured amounts of several different types of oral bacteria, they were able to find a positive relationship between thicker arterial walls and both the amount and type of oral bacteria. The group of oral bacteria related to periodontal disease was also the group of bacteria with the strongest relationship to arterial wall thickening. Interestingly, this relationship was independent of the measurement of C-reactive protein, leading the researchers to hypothesize that this may be evidence of periodontal-causing bacteria playing a direct role in atherosclerosis.

The important question that needs answering is: what does this mean to health care providers and consumers? The authors of the Circulation article answer it well in their closing paragraph: "…these findings could be of public health importance because they raise the possibility that atherosclerotic damage possibly could be reduced and perhaps reversed through selective control of pathogenic periodontal bacteria by antimicrobial or immunologic means." Since older adults are at greater risk for cardiovascular disease, stroke and diabetes, they should pay particular attention to their oral health to possibly halt the atherosclerotic process. So keep brushing and flossing for a healthy mouth and a healthy body.

In collaboration with the Arkansas Bioterrorism Continuing Education Partnership, the Arkansas Geriatric Education Center (AGEC), the GRECC at CAVHS and the DWR Institute on Aging at UAMS hosted a video teleconference (VTC) on April 13, 2005 in EDII-B107 at UAMS.  Twenty four sites throughout the State and VA facilities in Alexandria, LA; Jackson, MS and New Orleans, LA received the VTC.

Aubrey J. Hough, Jr., MD, Distinguished Professor and Associate Dean for Translational Research and Special Projects at the UAMS College of Medicine traced the historical roots of bioterrorism and inferred from them a prognosis for the future. The earliest recorded use of a bioweapon dates from c. 1000 BC when the Assyrians poisoned enemy wells with rye ergot - a fungal toxin. In the antiquity, the use of poison arrows is often mentioned.  Records from China reveal the existence of formulae to produce poisonous smoke to use against enemies. Rustic, but effective bioweapons, are the contamination of enemy water supplies with diarrhea causing agents and with decomposing bodies of animals.  Hurling objects such as clay pots with serpents, scorpion loaded bombs or human bodies infected with plague were all used as weapons.  During a peace conference in 1763, the Delaware Indians received as gifts blankets with smallpox.  Such blankets caused the decimation of Missouri River tribes.  WW I brought the widespread use of mustard gas and WW II horrific experiments on humans with such agents as typhoid, dysentery and anthrax. Post WW II, all major powers developed lethal and incapacitating biological agents and biotoxins.  For terrorists, biological weapons are weapons of choice because they are easy to obtain, produce and delivery and they can be disseminated in a stealth fashion over a large area. The list of scenarios where biological weapons might be used is a work in progress since terrorists create new ones as their need arises. Quoting from Faulkner, Dr. Hough concluded that looking at bioterrorism "only reveals to man his own folly and despair; and victory is an illusion of philosophers and fools.”

Preparedeness is the key to efficient response in a bioterrorist attack.

Dr. Jeanne Y. Wei, Professor and Executive Chair of the DW Reynolds Department of Geriatrics at the UAMS College of Medicine and GRECC Staff Physician at Central Arkansas Veterans Healthcare System (CAVHS) focused on the impact of bioterrorism in the elderly.  As a group older adults tend to have comorbidities that increase their vulnerability to infectious and toxic agents and delay in treatment is more costly.  They also react differently to these agents than younger adults, for they may have no fever or specific symptoms and this makes the proper diagnosis more difficult. The stress associated with bioterrorism threats or attacks may cause delirium and impair cognitive function in the elderly. Infections and toxins may lead to serious cardiovascular complications such as hypoxemia, arrythmias, cardiomyopathy, acute coronary syndrome, septic shock, disseminated intravascular coagulopathy and endocarditis.  The elderly should prepare for a bioterrorist event by having readily available 3 gals. of water per person, non-perishable food, can and bottle openers, 2 flashlights and a battery operated radio or television as well as replacement batteries. In addition, they should have comfortable protective layers of clothing, a cell phone and cash.  Medical supplies needed are a first aid kit, lists of medicines, dosages and schedules included, and allergies; medical devices and batteries for them; physician and relative's phone numbers; information sources; Medicare cards; health items used daily, such as an oxygen tank. By helping healthcare providers to recognize public healthcare emergencies and establishing a methodology to meet the acute care needs of the elderly, especially the cognitively impaired, the risk of bioterrorism in the elderly should decrease.

"Chemical Terrorism Awareness” was the topic of Dr. Margie A. Scott"s presentation. The Professor and Vice-Chair in the Department of Pathology at the UAMS College of Medicine, Chief of the Pathology and Laboratory Service and Coordinator of Bioterrorism Preparedness at CAVHS discussed three types of chemical warfare agents - nerve, vesicants and riot control agents. Nerve agents (Tabun, Sarin, Soman and VX) penetrate skin, eyes and lungs; produce loss of consciousness, seizures, apnea and even death depending on the amount; and are the most toxic of the chemical agents. Nerve agents act by attacking muscarinic receptor sites (glands and smooth muscles) and/or nicotinic receptor sites (skeletal muscle secretions). The sign and symptoms of exposure to nerve agents vary depending on whether the exposure was in the form of vapor or liquid while the intensity of the symptoms depends on the concentration of the agent and length of exposure. Antidotes used to treat exposure are atropine, 2-PAMCI and diazepam. Half-dose antidote autoinjectors for geriatric and pediatric use have been available since February 2004. Vesicant (Blister) agents damage the eyes, skin, respiratory system and cause other systemic effects.  The best initial treatment is decontamination.  One of them, sulfur mustard, better known as “mustard” is a systemically toxic, fast acting agent with a latent period between exposure and effect. No specific antidote exists.  Lewisite, another blister agent, is fast acting but the symptoms are immediate and BAL antidote is available.  Dr. Scott noted that the need for standardization of procedural protocols and communication between responsible agencies as well as in depth training of first responders and healthcare personnel is imperative to be able to respond in the event of a biochemical accident or terrorist attack.

Rebecca E. Martin, MD, Associate Professor of Medicine, Division of Infectious Diseases at the UAMS College of Medicine and Medical Director of the Ebert Diagnostic Unit at CAVHS addressed the possible use of infectious diseases as agents of bioterrorism. Infectious diseases such as smallpox and bubonic fever are old potential agents of bioterrorism, but there is a host of emerging diseases for which little or nothing can be done. Dr. Martin focused on 1) SARS, 2) avian flu, 3) viral hemorrhagic fevers and 4) variant Creutzfeld-Jakob disease (vCJD), but warned others will continue to surface. 1) SARS, a new coronavirus, emerged in China in early 2003 and by July had spread to 31 countries on 5 continents, had infected 8098 persons and had close to 10% mortality.  Coronaviruses infect humans and animals and present with common cold symptoms and mild GI illness.  SARS was probably transmitted by exotic animals handled by restaurant workers while preparing food. Once the virus passed to humans (zoonosis) it was spread by air, droplets or in direct contact from person to person. No effective treatment or vaccine is available.  Strict contact, plus eye protection, and airborne isolation are required.  2) Avian influenza (H5N1) or “bird flu” is a greater public threat than SARS.  In 2003, it had an outbreak in Asia and more than100 million birds were destroyed. Although only 43 cases were reported in Thailand and Vietnam, as of March 2005, the mortality rate was a frightening 72%. Bird flu does not spread efficiently between humans, but if the virus gains such ability, a pandemic – much like the “Spanish flu” pandemic, which caused 50 million deaths with 50% of those among young adults – could be in store. 3) Viral hemorrhagic fevers (VHF) spread by coming into contact with an infected host or by insect bites. Considered “Category A Bioterrorism Agents” are filoviruses (i.e. Ebola, Marburg) and arenaviruses (i.e. Lassa, Machupo). Other VHFs are bunyviruses (i.e. Hantavirus) and flaviviruses (i.e. Yellow fever, Dengue).  Treatment for these is mainly supportive.  Strict body fluids contact isolation and airborne isolation are required. Autopsies are not recommended, embalming should be avoided and cremation or immediate burial in airtight bag is prescribed. 4) vCJD or “human mad cow disease” is a degenerative fatal brain disorder transmitted through consumption of contaminated cow products or blood transfusions.  No treatment exists and the outcome is death. Since the four infectious diseases discussed can cause illness with high morbidity or mortality, large-scale public health preparedness needs to be underway.