Educational outreach programs, video teleconferences (VTCs), conferences and the AR-GEMS Coaching and Mentoring workshop have kept the AGEC busy this Fall. We visited Hot Springs on January 14th for a Geriatric Mental Health Outreach Program, which was jointly sponsored by the Oklahoma Geriatric Education Center and the Oaklawn Senior Health Center.

Our VTCs for the Spring have been scheduled. On January 27, the topic will be Impact of Health Literacy on Elders and on March 15, Thomas Griebling, MD, Assistant Professor and Vice-Chair Urology, University of KansasMedical Center will speak on the diagnosis, treatment and management of incontinence in the older population.

Letters to Deans of institutions of higher education in Arkansas will be mailed soon to invite participants to the Summer Institute. This program is designed to update knowledge and skills of health professionals teaching in institutions of higher education.

We are also accepting applications for the AR-GEMs Spring program, which is a self-study program geared towards practicing health professionals. If you would like to participate in either of these programs, please contact: jasinsoledadhd@uams.edu or visit www.agec.org

Dr Gauri Bhattacharya, ASU Social Work Department, has been busy with publications related to Indian immigrants to the United States. In one of his recently published papers, he describes some significant implications for the older adults in this population and immigrant health policies.

Dr Bhattacharya and co-author Dr Tazuko Shibusawa published “Experience of aging among immigrants from India to the United States: Social Work practice in a global context,” in the peer-reviewed international Journal of Gerontological Social Work, July 2009, Vol. 52, pp: 445-462. In this article, they examined aging of immigrants as a critical component in the health dynamics of the nation’s aging population. Using the life-span development perspective, the authors analyzed the impact of globalization and transnational connections on the aging experiences of two sub groups within the Indian-American community. These two subgroups were Indians who came to the United States at age 65 or older (LLIs) and those who came at an earlier (ELIs) age. Although the groups share the same ethnic/cultural identity and age range, their experiences of aging differed in terms of their education, work experience in the US, understanding of the US health care system and available health care services. According to this study’s findings, community-based health promotion programs need to focus on intra-group diversity, pre- and post-immigration sociocultural environments, health and illness beliefs and the extent of social networking in global and transnational contexts in order to understand the different pathways that aging dynamics may take.

Though teeth won’t turn gray with age, they still age with the rest of our body. Much of what we see as “old teeth” is actually the result of disease over time, but some changes are to be expected as we age. The rate of edentulism or total lack of teeth has decreased greatly over the last few years. Since now only 27% of those over age 64 in the United States are edentulous, we are seeing a record number of aging teeth.

Teeth have two primary layers of hard tissue, which are the enamel and the dentin. The enamel, or outer layer on the crown of the teeth, is the white surface we most associate with the look of teeth. Use of teeth over many years obviously causes wear in various forms. Teeth wear differently based on the way people bite, what they consume and even cultural and geographic issues. Over time, enamel not only thins with wear, but also becomes more brittle. In addition, as the tooth changes, we note less moisture in the tubules and structure. Fluoride incorporated into a tooth over time makes the enamel stronger, but can also increase the brittleness. Consequently, older teeth have more cracks and craze lines and these can stain. Fortunately, outer stains respond to some of the bleaching techniques. The brittleness, on the other hand, added to the fact that many “older” teeth have had fillings over the years makes teeth prone to fractures.

Dentin, or inner layer of hard tissue of the teeth, is softer than enamel and is the material that forms the pulp or nerve chamber and makes up the bulk of the root of teeth. Because it is softer, the dentin layer is more susceptible to the spread of cavities. Whereas enamel is not replaced in the course of life, dentin continues to be added to the tooth due to normal stimulus and trauma to the tooth. This addition of dentin along with some of the thinning of the enamel is why we often note our teeth yellowing with age. Bleaching can improve this to a point, but not to the extreme white that we could have reached at younger ages. Dentin is made of tubules that close up as more dentin is laid down. These tubules are openings between the outside environment and the nerves or pulp. As they close, people feel less and less stimulus from the outside. In other words, teeth will be less sensitive to hot, cold or sweet, that might have been more bothersome at a younger age.

Finally, the canal in the center of the tooth that houses the nerve, as well as the nerve tissue undergoes changes with age. The secondary dentin added to the tooth narrows the canal and progressively insulates the nerve from the outside of the tooth. As stated earlier, this results in less likelihood of pain or discomfort from outside stimuli. The loss of sensation can benefit a patient when undergoing minor dental repairs since anesthesia might not be needed to complete the work and the patient is thus spared from the dreaded numbness during a dental visit. However, this can also make it difficult for older persons to note a dental problem such as cavities or periodontal disease, until it is too late to save the tooth. Like other systems of the body, the reparative capabilities of the pulp are lessened as we age. If there is an injury to the pulp such as a tooth fracturing, or a cavity extending to near or slightly into the pulp, the pulp will most likely die, meaning the tooth will need either a root canal or extraction to relieve the infection and pain.

Teeth wear and age as does the rest of the body. However, teeth were intended to last a lifetime. With today’s preventive measures and care options people can have their smile for a lifetime. For a more complete review of the topic of age related changes on natural teeth, please refer to the following article, which was consulted for this column: An G. Normal aging of teeth. Geriatrics & Aging. 2009;12(10):513-17.

It is well known that age-related changes occur in memory related abilities (Ostrosky-Solis and Jaime, 1997). As people age, their ability to remember and recall “slows down.”

Memory deficits represent a common complaint in people over 60, and particularly in individuals over 70. In elders, memory impairment represents a significant factor partially responsible for their limitations in everyday activities. The ability to recall names has been singled out as one of the most noticeable and most frustrating changes. Research suggests that the disuse of purposeful and efficient retrieval strategies may play a role in the decline. Despite these changes, researchers (Cohen & Faulkner, 1984) have found that memory in old age is “good in parts.” These “parts” include what is known as procedural memory. This type of memory relies on the unconscious retrieval of past experiences through habit or procedure. The purpose of the current project was to educate seniors regarding the types of memory and teach them strategies for retrieving information that they could not readily remember. 

As a service-learning opportunity, four UCA Speech-language pathology students administered memory and word-finding skills tests as well as hearing screenings to 27 seniors (ages 70-100). After testing, eight weeks of treatment was provided. During two weekly one-hour sessions, seniors received information and training on how to improve or maintain their current level of memory and word-finding skills. Each of the strategies and activities were chosen to provide the participants with an opportunity to strengthen their memory and word-finding abilities, as well as practice newly learned strategies. Four specific memory strategies were introduced. The first strategy was called Association. This strategy refers to linking information to be learned with something that is already known or familiar. So, learning builds on learning. Thinking of examples or re-wording are ways to associate what someone already knows with new information. The second strategy was Categorization. Research has shown that people are able to recall more information if it is categorized or grouped in some way. The third strategy was Visualization. This is the process of picturing in your mind the given or needed information. The last strategy was Reverbalization. Participants were encouraged to either write down or repeat back information. For each of these strategies, therapeutic activities included education about memory and the strategy. Participants then were given opportunities to use their newly learned skills.

At the end of the program, re-testing was conducted to determine if any functional change in skills had occurred. Results indicated that seniors who participated in the training performed better on the post-test measures than on the pre-test measures. This outcome was not surprising because one thing that research shows consistently is that beliefs about one’s own memory performance contribute to actual memory ability. It appears that the memory training these seniors received had an empowering effect on them. 

In conclusion, participation provided a stimulating, rewarding and fun experience for the seniors. The students that worked with them benefitted greatly by having the opportunity to engage one-to-one and by observing the effect of the intervention. Additionally, this project embodied part of the mission of the UCA College of Health and Behavioral Sciences, which is to offer and promote outreach to seniors in the area.

The treatment of unintentional weight loss in the elderly gives rise to worsening overall health outcomes such as malnutrition, functional impairment and increased morbidity and mortality. Weight loss is common in the elderly patient due to depression, decreased food intake and certain medical conditions. The National Center for Health Statistics reported in 2006 that approximately 30-50% of nursing home residents have below average body weight and low serum albumin. The Centers for Medicare and Medicaid Services (CMS) require an assessment of residents for weight loss. According to CMS guidelines, a loss up to 5% a month of total weight requires further action. Although evidence is limited for appetite stimulation, both megestrol acetate and mirtazapine are frequently used.

Megestrol acetate (Megace) is a synthetic progestin used for advanced breast and endometrial cancers. Early weight loss data came from cancer patients trials in the early 1990s. Reported weight gains of this trial were 5 kg and were observed as early as 7 days and lasted as long as 4 weeks.

The largest controlled trial in the elderly had 69 nursing home patients enrolled with a megestrol dose of 800 mg/day for 12 weeks and follow up of 13 weeks. Until week 20 (8 weeks after megestrol was discontinued), results showed no significant weight gain versus placebo. After 12 weeks, significant improvements were seen in overall enjoyment and sense of well-being.

Mirtazapine (Remeron) has a primary effect on serotonin and histamine receptors. It was associated with a mean 2.4 kg weight gain after the first week of therapy in those taking it for depression. Its underlying mechanism for weight gain is unclear, although it is thought to be associated with increased plasma levels of TNF-alpha, TNF receptors, and leptin. In one study, mirtazapine was compared with sertraline, a different class of antidepressant, in 50 elderly patients for 4 months where the mirtazapine caused a 2.65 lb increase and sertraline caused a 2.68 lb increase. Although it is shown to increase weight, it is only appropriate to consider its use when depression is present in elderly individuals.

Adverse effects of these drugs can be significant. With megestrol acetate, diarrhea, flatulence, rash, hypertension, and headache are common. Rarely, deep vein thrombosis has been reported. With mirtazapine, sedation, dry mouth, constipation, and fatigue can be expected. Finally, these agents are quite costly at $12 per day for megestrol and $2 per day for mirtazapine.

The American Geriatric Society states that no FDA-approved drugs are available for weight gain in older adults; and all drugs used for appetite have substantial potential adverse events. Megestrol and mirtazapine have shown to increase weight gain in the elderly population. However, further clinical trials are needed to examine safety and efficacy of these drugs for unintentional weight loss. Evaluation of the underlying cause of weight loss and the individual patient need reviewing.

References

1. Fox, Carol B, et.al. Megestrol Acetate and Mirtazapine for the Treatment of Unplanned Weight Loss in the Elderly. Pharmacotherapy. 2009; 29:383-97.
2. Golden, Adam G, et.al. University of Miami Division of Clinical Pharmacology Therapeutic Rounds: Medications Used to Treat Anorexia in the Frail Elderly. American Journal of Therapeutics. 2003; 10(4): 292-8.

Our Fall video teleconferences (VTCs) recorded some of the highest attendance number in the ten years we have been offering them. “Parkinson’s in Older Adults,” held on 9/17/09, had 270 attendees spread across Arkansas, Texas and Louisiana. Eugene C. Lai, MD, PhD, Director, Parkinson’s Disease Research, Education and Clinical Center, VA Medical Center, Houston, TX and Professor of Neurology at Baylor College of Medicine, was the speaker for the program. Dr Lai described the classical clinical features, the associated motor and non-motor symptoms, the incidence and epidemiology of Parkinson’s Disease (PD). Some general considerations about PD are that among neurodegenerative disorders it is the 2nd most progressive and the most common movement related disorder. It is a complex disease with an unclear pathogenesis, variable symptoms and a misdiagnosis rate of about 10-25%.

The presence of unilateral symptom onset, characteristic resting tremor, narrow based gait with stooped posture, reduced arm swing with tremor and significant sustained levodopa effect supports a diagnosis of PD. Treatment options for PD include pharmaco- and non-pharmacological treatments and surgical interventions. Drug therapy aims at providing patients with neuroprotection, improving symptoms, controlling advance symptoms and managing adverse effects. Supportive treatment for PD involves facilitating physical activity, a well-balanced and suitable diet and social engagement. Surgical treatment involves the use of deep brain stimulation, which can be effective for medically refractory PD tremor. Since many treatment options are available, the management of PD needs to be matched to the patient’s physical needs and the stage of his disease.

The “Diabetes in Older Adults – Update” VTC had 205 in attendance including some attendees from Louisiana and Mississippi. Donald L. Bodenner, MD, PhD, Associate Professor, DW Reynolds Department of Geriatrics at UAMS and Staff Physician at CAVHS, Little Rock, presented alarming statistics: 50% of diabetic elders are undiagnosed; an additional 23% of persons 65-75 have impaired glucose tolerance, 1/2 of all Type 2 diabetes patients are over 65 and 10% of of elders have Type 1 diabetes. Diabetes is reaching epidemic proportions and the cost of managing the disease is enormous. Diabetes may result in neuropathy, retinopathy, renal and cardiovascular complications. Dr Bodenner emphasized the need to individualize treatment. He urged the management not just of glucose, but also of the ABC (A1C, Blood pressure and Cholesterol) while not forgetting to check the eyes, teeth and feet; mental state; vaccinations; and antiplatelet therapy.

The second speaker, Mary Sha Moriarty, APN, CDE, CAVHS, Little Rock, addressed the design of insulin regimens and their use to adjust doses. The goal of regimen design should be to maintain constant glucose levels. But just injecting insulin is not enough. The starting daily insulin dose is .25 units/Kg and up to 1 unit/Kg and must be adjusted incrementally to meet the needs of the patient. It is imperative to know the GOAL blood sugar to monitor it properly.

A good regimen demands knowing where the problems are and getting to their root cause and making changes systematically. This requires sustained patient-provider interaction and a commitment to details. Ms Moriarty reviewed the outcomes of three recent trials aimed at determining the effect of lowering A1C. In summary, the trials show that treatment to lower A1C did not decrease cardiovascular events and that intensive treatment resulted in hypoglycemia and weight gain.

The 24th annual Nutrition & Aging Conference, held on September 23-24, in Little Rock, at the Holiday Inn Airport focused on Nutrition, Macronutrients and Chronic Disease.

Jane Kerstetter, PhD, RD reviewed the protein requirements to optimize bone health in older adults. The amount of dietary protein is a minimal factor with adequate calcium and vitamin D intake. When calcium and vitamin D are insufficient, at least 1gm protein/kg/body weight is recommended to support calcium absorption. Focusing on protein in the diet of elders, Robert R. Wolfe, PhD noted that about 1/3 of those over 65 consume less than the RDA of 0.8 gms protein/kg/day. Increasing the protein intake of elders is crucial to slow the loss of muscle and body mass. Also addressing protein intake, Barbara Nicklas, PhD discussed dietary protein intake and caloric restriction. Despite concerns by some physicians of inviting frailty while lowering BMI, Dr Nicklas supported weight loss interventions that combined calorie restriction and resistance training. These have been shown to improve global physical function without loss of muscle strength even with a loss of muscle mass.

Dennis Sullivan, MD focused on the loss of lean body mass during acute illnesses. He noted that more research is needed to determine what interventions are most effective in a given patient to preserve or replete body mass and physiologic function. William Evans, PhD reviewed the causes and effects of sarcopenia. With age, visceral fat and adipokine levels increase while insulin resistance lowers the muscle protein synthesis rate. Dr Evans noted the importance of strength training and adequate vitamin D levels to increase muscle strength and power in elders.

David R. Thomas, MD, FACP, AGSF, GSAF made specific recommendations about nutritional requirements to promote healing of pressure ulcers. In addressing diabetes in elders, Medha Munshi, MD remarked that while ideal A1C is below 7%, attaining such number might place elders at risk for falls from hypoglycemia. In fact, a higher A1C and blood glucose level are acceptable for frail older adults, those with life expectancies of less than than five years and those with advanced comorbidities. Insulin resistance and exercise in relation to obesity and disability were reviewed by Alice S. Ryan, PhD. Many factors affect accumulation of abdominal fat. Visceral adipose tissues of 100-110 cm2 are predictive of adverse lipid (HDL, TG) and diabetes risk factors in women. Elders should make exercise and weight loss part of their lifestyle to maintain normal weight ranges and better metabolic control.

Teresa Fung, ScD, RD discussed the Mediterranean Diet and risk of cardiovascular disease. The diet results in risk reduction of CVD and mortality as well as improving the risk factors for CVD. According to Emily B. Levitan, ScD, eggs, sodium and high fat dairy products tend to increase the risk of heart failure while whole grains lower the risk. Dr Levitan presented the DASH diet as a plan to lessen CVD risks. After reviewing the link between metabolism and obesity, Eric Ravussin, PhD concluded that energy balance is the sum of macronutrient balances, metabolic inflexibility is a probable cause of weight gain and food intake and weight gain are inversely related to carbohydrate balance.

In his presentation, Dariush Mozaffarian, MD, DrPH, FACC noted that trans fatty acids, which affect the function of multiple cell types, appear to have a unique relationship to insulin-resistance and the metabolic syndrome pathways. Dana E. King, MD, MS discussed fiber and other nutrients in CVD prevention. The best source of fiber is not known but 20 g/day of it is recommended to lower CVD risk.