Alzheimer Disease: Treatment of Cognitive and Functional Symptoms.

Alzheimer disease is a progressive, neurodegenerative disorder characterized by the accumulation of amyloid beta plaques and hyperphosphorylated tau proteins. Alzheimer disease affects cognitive function, leading to memory loss and impairment in activities of daily living. Approximately 6.9 million people in the United States 65 years and older live with Alzheimer disease, a number expected to double by 2060. Although there is no cure for Alzheimer disease, treatments are available to manage symptoms. Tools such as the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria aid in identifying major neurocognitive disorders. The evaluation involves a comprehensive medical history, cognitive examinations, and collateral information. Nonpharmacologic interventions focus on psychosocial approaches, with music, sensory stimulation, and validation therapies showing some evidence of reducing responsive behaviors. Pharmacologic management, such as acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) and the N-methyl-d-aspartate receptor antagonist memantine, targets symptom relief and disease progression. Vitamin E does not improve cognition but may mitigate functional decline. Brexpiprazole has been approved in the United States for treating agitation associated with Alzheimer disease. Anti-amyloid monoclonal antibody treatments are approved for mild cognitive impairment and mild Alzheimer disease, but they are controversial and safety concerns exist. Ineffective therapies include ginkgo biloba, nonsteroidal anti-inflammatory drugs, omega-3 fatty acids, and statins.

Analyzing Potential Interactions Between Complementary and Alternative Therapies, Over-the-Counter, and Prescription Medications in the Older Population.

BACKGROUND: The escalating use of complementary and alternative medicine (CAM) raises concerns, particularly among geriatric patients taking multiple medications. Notably, the doubled chance of major drug interactions between prescription and over-the-counter (OTC) drugs in older adults underscores the need for further research. This study aimed to evaluate clinically significant CAM and prescription medication interactions in a geriatric clinic, emphasizing the growing importance of understanding CAM implications in health care. METHODS: A 2-year cross-sectional study, approved by the Institutional Review Board, enrolled 420 participants aged 65 and older from a geriatric primary care clinic. Participants completed a survey, and pharmacy students conducted chart reviews to evaluate potential CAM products and prescription medication interactions. RESULTS: Among the 420 participants-who were predominantly White females and who were taking supplements, OTC medications, or both-15.6% experienced potential drug interactions. Ginkgo biloba, garlic, and calcium were common contributors to major, moderate, and minor interactions, respectively, among supplements. Meanwhile, ibuprofen was among the contributors to major and moderate interactions among OTC medications. Most supplements and OTC medications were disclosed to health care professionals. However, there was a lack of investigation by health care professionals regarding CAM use, emphasizing a discrepancy between patient-reported and physician-inquired CAM usage. CONCLUSION: This study highlighted the significant use of CAM and/or OTC medications, particularly among vulnerable older adults, revealing a concerning 15.6% rate of potential drug interactions. The findings emphasized the need for awareness among health care practitioners and standardized CAM surveys to enhance accuracy and patient safety.

Exploring the Interplay Between Lifestyle Medicine and Oral Health: A Bidirectional Relationship.

Lifestyle medicine, characterized by its evidence-based approach, recognizes the profound impact of lifestyle choices on overall health. The six pillars of lifestyle medicine encompass nutrition, physical activity, stress management, sleep, avoidance of risky substances, and social connections. While their significance in promoting general health is well-established, their specific influence on oral health is an area of growing interest. A balanced and nutritious diet contributes to strong teeth and healthy gums, while regular physical activity enhances blood circulation and salivary flow, which is vital for maintaining optimal oral health. Effective stress management techniques can mitigate oral health issues related to anxiety and bruxism. Quality sleep supports oral health, allowing for tissue repair and immune system rejuvenation. Avoiding risky substances like tobacco and excessive alcohol consumption reduces the risk of oral diseases such as periodontitis and oral cancer. Lastly, social connections and supportive networks positively influence oral health by promoting positive oral hygiene behaviors and providing access to dental care resources. Understanding the impact of lifestyle medicine's six pillars on oral health offers valuable insights for healthcare professionals and individuals seeking to improve their oral well-being.

Optimizing Education to Improve COVID-19 Vaccination Rates in a Federally Qualified Health Center.

INTRODUCTION: COVID-19 vaccination hesitancy is prevalent in underserved communities, and family medicine clinics can combat hesitancy with vaccine education. However, due to general misinformation, physicians hesitate to educate patients because doing so can create conflict. METHODS: A series of resident-run, team-based quality improvement projects were conducted at a federally qualified health center every 4 months between June 2021 and May 2022. First, staff documentation of vaccine status was addressed. Second, physician and staff education about COVID-19 vaccines was completed along with motivational interview training to avoid conflict with patients. Third, patient COVID-19 vaccine education was addressed. RESULTS: After Cycle 1, COVID-19 vaccine documentation status increased the number of patients who completed the vaccination series from 1% to 22%. Cycle 2 showed an increase in COVID-19 vaccination rate after health care team education. This reflected an increase from 35% to 76% of residents reporting that they discussed COVID-19 vaccines with unvaccinated patients after the intervention. Cycle 3 fought vaccine misinformation by educating patients. Most patients heard information about COVID-19 vaccines from friends and family (95%), social media (90%), and the news (80%). Physician confidence in providing COVID-19 vaccine education to patients increased from 2.8 (< somewhat confident) to 4.3 (moderately confident) out of 5 over 3 plan-do-study-act cycles. DISCUSSION: Vaccination rates were tracked alongside physician surveys regarding the experience of offering the vaccine to patients. Vaccination rates steadily increased over time, and physicians became more confident in COVID-19 vaccine discussions with patients. CONCLUSION: Primary care physicians are needed to approach public health concerns, such as vaccination completion, but ongoing education is also needed to promote confidence in health care pathways.

Cryptorchidism (Undescended Testicle).

Cryptorchidism refers to an undescended testicle, the most common genitourinary malformation in male children. It is diagnosed with history and physical examination findings, and primary care physicians play a key role in the early identification of the condition. Early surgical intervention reduces the risk of testicular cancer and preserves fertility. Patients should be referred for surgical intervention at six months of age or at the time of diagnosis if the child is older. After surgery, patients require lifelong surveillance and counseling regarding fertility implications and increased risk of testicular conditions. Patients with bilateral undescended testicles that are nonpalpable should undergo endocrinologic evaluation for sexual development disorders. Retractile testicles are a variant of cryptorchidism and should be monitored annually until puberty, when acquired ascent becomes unlikely due to greater testicular volume. Based on expert opinion, all patients with a history of cryptorchidism should undergo annual clinical examination and be taught self-examination techniques for early detection of testicular cancer.

Inadequate sleep & obesity: Breaking the vicious cycle.

Poor sleep negatively affects hormones that govern the food reward system and can interfere with weight-loss programs. Obesity in turn restricts sleep. Which treatments have shown promise?

Delirium in Older Persons: Prevention, Evaluation, and Management.

Delirium is an acute disturbance in attention, cognition, and awareness that fluctuates over time. Delirium is characterized by three subtypes: hyperactive, hypoactive, and mixed. It occurs in 11% to 25% of older adults in inpatient settings and is associated with a significant financial burden. Older age, multiple comorbidities, recent surgery, and polypharmacy are independent risk factors for delirium. The diagnosis is clinical but can be challenging due to overlapping symptoms with dementia and depression. The Confusion Assessment Method is a screening tool that is 94% to 100% sensitive haloperidol because of their faster onset of action and fewer adverse effects. Patients hospitalized with prolonged delirium have approximately three times the chance of dying in the following year compared with patients with a quick resolution of delirium or no symptoms; therefore, prevention and early detection should be emphasized.

Respiratory Symptom Evaluation in Adults: Chronic Cough.

In adults, chronic cough is a nonproductive or productive cough lasting longer than 8 weeks. Coughing is a reflex to clear the lungs and airways, but repetitive, long-term coughing can cause chronic irritation and inflammation. Approximately 90% of chronic cough diagnoses have common nonmalignant etiologies, including upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis. In addition to history and physical examination, initial evaluation for chronic cough includes pulmonary function testing and chest x-ray to assess the lungs and heart and for fluid overload, and evaluate for neoplasm or lymph node enlargement. If the patient has red flag symptoms, such as fever, weight loss, hemoptysis, or recurrent pneumonia, or has persistent symptoms despite optimal drug treatment, advanced imaging with chest computed tomography scan is indicated. Management of chronic cough includes identifying and managing the underlying cause as outlined in the American College of Chest Physicians (CHEST) and European Respiratory Society (ERS) guidelines for chronic cough. In diagnoses of refractory chronic cough with uncertain etiology and a negative evaluation for life-threatening causes, cough hypersensitivity syndrome should be considered and managed with gabapentin or pregabalin and a trial of speech therapy.

Respiratory Symptom Evaluation in Adults: Wheezing.

Wheezing is a common presenting concern in the primary care setting, but its etiology can be elusive. Wheezing is associated with many disease processes, but most commonly, asthma and chronic obstructive pulmonary disease. Initial tests for wheezing typically include a chest x-ray and pulmonary function testing with bronchodilator challenge. Advanced imaging to evaluate for malignancy should be considered in patients older than 40 years with a significant history of tobacco use and new-onset wheezing. A trial of short-acting beta agonists can be considered while awaiting formal evaluation. Because wheezing is associated with reduced quality of life and increased health care costs, it is essential to develop a standardized evaluation of this common concern and expeditiously manage symptoms.

Respiratory Symptom Evaluation in Adults: Dyspnea.

Dyspnea is a common presenting symptom that may derive from pulmonary or extrapulmonary origins. Dyspnea may develop from exposure to drugs or environmental and occupational factors, so a thorough history and physical examination may help differentiate the cause. Chest x-ray followed by chest computed tomography scan if needed is recommended as the initial imaging test for pulmonary-related dyspnea. Nonpharmacotherapy options include supplemental oxygen, self-management with breathing exercises, and airway interventions with rapid sequence intubation in emergency situations. Pharmacotherapy options include opioids, benzodiazepines, corticosteroids, and bronchodilators. After the diagnosis is identified, treatment focuses on optimizing dyspnea symptoms. Prognosis depends on the underlying condition.

Respiratory Symptom Evaluation in Adults: Hemoptysis.

Hemoptysis is the expectoration of blood from the lower respiratory tract and has an extensive differential diagnosis that can be divided into pseudohemoptysis, infectious, neoplastic, vascular, autoimmune, and drug-related categories. Pseudohemoptysis is the expectoration of blood from a different source and needs to be ruled out. Clinical and hemodynamic stability must be established first. Chest x-ray is the initial imaging examination for all patients with hemoptysis. However, advanced imaging, such as a computed tomography scan, is helpful for further evaluation. Management aims to ensure patient stabilization. Most diagnoses are self-limited, but bronchoscopy and transarterial bronchial artery embolization can be used to manage massive hemoptysis.

The Impact of the Six Pillars of Lifestyle Medicine on Brain Health.

Dementia is growing exponentially worldwide. Unfortunately, the treatment available does not reverse any type of cognitive impairment. As a result, healthcare professionals are focusing on other evidence-based options, such as lifestyle medicine (LM). Current evidence demonstrates improvement in neurocognitive decline by applying the six pillars of LM, which include plant-based nutrition, physical activity, stress management, avoidance of risky substances, restorative sleep, and social connections. Plant-based nutrition has a positive impact on cognition by decreasing the risk for Alzheimer's disease (AD) with high adherence to the Mediterranean-Dietary Approach to Systolic Hypertension (DASH) Intervention for Neurodegenerative Delay (MIND). Physical activity also might prevent neurocognitive decline by increasing fibronectin type III domain-containing protein 5 (FNDC5) and Irisin in the hippocampus, which increases energy expenditure and prolongs endurance. Additionally, higher perceived stress in adulthood and the use of risky substances such as alcohol, nicotine, and opioids are significantly associated with developing mild cognitive impairment and all-cause dementia. Furthermore, there is a positive correlation between poor sleep and social isolation with a rapid progression in cognitive decline. Lifestyle changes have a substantial impact on brain health. Therefore, the focus should always be on prevention as the primary treatment tool.

Common Sleep Disorders Affecting Older Adults.

Sleep disorders in older adults increase with aging, likely due to increased sleep latency, decreased sleep efficiency, and total sleep time. Common sleep issues include chronic insomnia, circadian rhythm sleep-wake disorders, sleep-related movement disorders, and sleep-disordered breathing. Diagnostic tools, such as a comprehensive sleep history and questionnaires, or a sleep log for more specific complaints, are commonly used. Polysomnography is not recommended as a routine test; however, it can be used for abnormal behaviors during sleep or if treatment fails. Sleep disorder management is based on the etiology and may include nonpharmacological and pharmacological alternative treatments. For example, nonpharmacological management for chronic insomnia and some sleep disorders may consist of cognitive behavioral therapy, sleep hygiene education, relaxation therapy, sleep restriction, light therapy, and stimulus control therapy. Because the quality of evidence for pharmacological treatment is poor, the medication choice should be based on shared decision-making between the practitioner and the patient, with limited prescription.

Conventional Versus New Treatment: Comparing the Effects of Acetylcholinesterase Inhibitors and N-Methyl-D-Aspartate Receptor Antagonist With Aducanumab.

Alzheimer's dementia (AD) is the most common major neurocognitive impairment and the fifth leading cause of death in older adults in the United States. The diagnosis is clinical; however, laboratory tests and imaging frequently rule out secondary causes of dementia. Unfortunately, the treatment available for AD does not reverse dementia, but it may help improve the symptoms and slow the progression of the disease. The conventional treatment - acetylcholinesterase inhibitor (AChEI) therapy and N-methyl-D-aspartate (NMDA) receptor antagonist - is considered to enhance executive function, overall cognition, and activities of daily living. AChEIs such as donepezil, rivastigmine, and galantamine are approved for mild-to-moderate dementia. Furthermore, memantine, an NMDA receptor antagonist, is authorized for moderate-to-severe dementia. Aducanumab, the newest drug available, is an amyloid-beta (Aß) monoclonal antibody approved only for mild AD. Treatment with either AChEIs or memantine is more cost-effective than aducanumab and the best supportive care. Aducanumab has particular recommendations with strict monitoring and several adverse effects, including amyloid-related imaging abnormalities. The most common adverse effects of AChEIs and memantine include gastrointestinal symptoms, dizziness, confusion, and headaches. Therefore, monitoring should be performed periodically at the clinician's discretion for clinical response and tolerability of medication. Conventional therapies are only for symptom management but are still beneficial to patients and caregivers. Unfortunately, at this time, aducanumab's risks outweigh the benefits with a questionable approval process by the Food and Drug Administration (FDA). However, given the potential disease-modifying capabilities of aducanumab, other disease-modifying options may become available by possibly reducing inflammation, preventing Aß plaques from clumping, or keeping tau proteins from tangling.

Improving Cervical Cancer Screening Rates at an Urban Federally Qualified Health Center Family Medicine Residency Clinic.

Background Family medicine residency clinics and underserved Federally Qualified Health Center clinics often have lower rates of cervical cancer screening (CCS). Methods A series of resident-run, team-based quality improvement projects were conducted to iteratively improve CCS rates in an urban Federally Qualified Health Center in a high-need and high-demand region. Results The authors were able to improve CCS rates from 52.2% to 66.3% through 6 quality improvement projects. Conclusion Improving the clinical workflows and systems to promote better rates of CCS likely requires a series of changes, however, promoting CCS in the usual clinic workflow, regardless of the reason for visit, demonstrated the greatest gains in CCS in our setting.

B Vitamins: Functions and Uses in Medicine.

B vitamins are a group of 8 water-soluble vitamins. The body does not store them, so they need to be replaced daily. B vitamins are found in animal proteins, dairy products, leafy green vegetables, and beans. Overall, their function can generally be divided into catabolic metabolism, leading to energy production, and anabolic metabolism, resulting in bioactive molecules. They are critical cofactors for axonal transport, synthesis of neurotransmitters, and many cellular metabolic pathways. B vitamins are cofactors for many essential enzymes involved in the biosynthesis of RNA and DNA. B vitamin deficiencies have been considered as etiological factors in the development of various neurologic disorders and a broad spectrum of pathological states. Reductions in food intake and absorption efficiency in some populations, including the geriatric population, may warrant attention to their dietary B vitamin levels. Most B vitamins are generally safe even at intake levels reached with fortified food or supplements.

Substance Use Disorder in Older Adults: Mini Review.

With an estimated prevalence of 4%, substance abuse amongst persons who are 65 years and older is increasing. The most common substances abused are alcohol, prescription drugs such as opiates and benzodiazepines (BZD), and over-the-counter (OTC) medications. This increase is believed to be partially endorsed by the baby boomer generation, born between 1946 to 1964, who had significant exposure to alcohol and drugs at a younger age. Substance abuse is difficult to recognize in the older adults, but once identified, presents its own challenges as only 18% of substance abuse treatment programs are designed for this growing population. Substance abuse overall may increase the risk of fractures secondary to recurrent falls, memory loss, sleep disturbances, anxiety, and depression. In this article, we will review the signs and symptoms, risk factors, screening tools, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria, and challenges of treating substance abuse in the older adults.

HIV-Associated Conditions in Older Adults.

Geriatric practices will see more people living with human immunodeficiency virus (HIV), as their life expectancy is close to the general population due to effective antiretroviral therapy (ART). Geriatricians focus more on HIV-associated, non-acquired immunodeficiency syndrome (AIDS) disorders than HIV alone. We will review the most common chronic illnesses and conditions associated with aging and HIV. Even though fall frequency in older adults living with HIV is similar to or lower than in people without HIV, fall assessment is appropriate, especially in the high-risk elderly living with HIV. HIV also impacts motor function and memory loss, especially in advanced cases. ART doesn't cross the blood-brain barrier, leading to major neurocognitive disorders with age. The etiology of HIV and cardiovascular disease (CVD) is multifactorial, including the effect of ART. Pitavastatin and pravastatin cause fewer interactions with ART. While the treatment for HIV decreases the risk of opportunistic infections, it may cause several bone-related abnormalities, including low bone mineral density (BMD), osteoporosis, and fractures. Polypharmacy is associated with disability and mortality and may increase the risk of ART drug-drug interaction. The oral health status of HIV-infected patients is commonly inadequate, and the presence of dental care managers may improve clinical outcomes and increase medication adherence. Furthermore, people aging with HIV (PAWH) have an increased mortality risk when co-infected with coronavirus disease 2019 (COVID-19). In summary, older adults living with HIV may face unique challenges. Therefore, providing comprehensive medical care and psychosocial support through an interdisciplinary team can significantly impact their lives.

A Common Concern With a Rare Diagnosis: Pancreatic Neuroendocrine Neoplasms.

Pancreatic neuroendocrine neoplasms (pNENs) are rare, representing only a small percentage of all pancreatic tumors. We report the clinical and radiological features of pNENs. Intraoperative pathology confirmed pNENs with clear margins and the patient did not require adjuvant chemoradiation. The patient is currently doing well and being closely monitored due to the high risk of relapse.