Monique F. Miller

With Americans’ increasing life expectancy, the CDC has established a public health initiative to maintain cognitive health, which is necessary for both healthy aging and quality of life.

 Of course, the brain is essential, directing and organizing critical thinking and execution of plans, among other things. The CDC defines cognition as a “combination of mental processes that includes the ability to learn new things, intuition, judgment, language, and remembering.”

 When any of these processes diminish, patients develop cognitive impairment.

The CDC estimates that more than 16 million adults 18 years and older live with cognitive impairment.

 Risk factors include aging, chronic health conditions, education level, family history, head injury, and physical inactivity.

 But cognitive impairment is not an inevitable part of aging. In fact, investigators have determined healthy lifestyle behaviors that may decrease the likelihood of suffering cognitive impairment later in life (see table 1.)

Multiple studies have evaluated the connection between cognitive impairment and high blood pressure (HBP), as hypertension is a risk factor for dementia. A recent study included 499 dementia-free individuals who had HBP and were being treated with antihypertensive medications in midlife adulthood. The results showed significant increases in white matter hyperintensity volume, which is associated with cognitive decline, and smaller brain volumes in patients aged 69 to 71 years.

 Investigators frequently observe white matter hyperintensities on brain magnetic resonance imaging scans of patients older than 60 years. These hyperintensities are associated with an increased likelihood of cognitive impairment and dementia.

 To minimize confounding effects within the study, the study protocol included only patients of the same age and geographic locations. The investigators also evaluated patients’ blood pressures prospectively, at ages 36, 43, 53, 60 to 64, and 69, to include data from early adulthood, midlife, and early late-life adulthood.

 They concluded that a strong association exists between midlife blood pressure and late-life cerebral small vessel disease and cognitive impairment later in life.

Physical activities with reported benefits include aerobic exercise/ endurance, balance training, resistance training, balance, and tai chi.

 Investigators suggest that physical activity enhances blood flow and neuronal connectivity, increases brain volume, and reduces chronic disease risk.

 They have also concluded that physical activity is associated with improvements in attention and processing speed, executive function, and memory.

Cognitive impairment ranges from mild cognitive impairment (MCI) to dementia.

 Individuals’ locations along this spectrum determine their ability to complete normal activities of daily living and to care for themselves.

 Individual presentations of cognitive impairment differ, but table 2 lists common signs.

 Overall, this impairment affects the ability to live a normal life. As a result, determining a better treatment or preventing cognitive impairment is paramount to improving the lives of the affected aging population.

The FDA has not approved any drugs or other treatments for MCI, but the agency has approved drugs to treat Alzheimer disease, known as acetylcholinesterase inhibitors (eg, donepezil, galantamine, and rivastigmine), and an N-methyl-D-aspartate glutamate receptor antagonist (memantine).

 Both classes aim to improve cognitive performance, increase quality of life, and slow memory loss in Alzheimer disease.

 Common adverse effects that patients may experience with acetylcholinesterase inhibitors include diarrhea, nausea, and vomiting. When these adverse effects are intolerable, prescribers recommend memantine.

With more Americans living longer lives, cognitive impairment has become a growing health concern. Individuals can combat this decline by being mentally and physically active, making dietary changes, and remaining socially engaged. 

 is a PharmD candidate at the University of Connecticut in Storrs. 

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Articles

Few drugs are available to address cognitive decline, but dietary changes, mental and physical activity, and social engagement can all help.

CDC Makes Recommendations for Preserving Brain Health

Pain is the main reason Americans access the health care system, according to the National Institutes of Health.

 Pharmacists, as the most accessible health care providers,

 should know about and recommend the most effective pain management.

Opioids are often prescribers’ go-to for pain management. Originally extracted from the poppy plant, opioids are known as powerful painkillers.

 But scientific evidence proves otherwise, according to the National Safety Council and a Cochrane review. Opioids relieve mild to moderate pain but have been proven less effective than OTC ibuprofen for most types of pain, with the exception of cancer, discussed below.

The issues clinicians see with opioids are their adverse effects (AEs), including addiction, confusion, constipation, dependence, dry mouth, drowsiness, nausea, tolerance, and vomiting.

But research indicates that opioids are more effective for psychotherapeutic effects, such as anxiety and depression, than for pain.

Pharmacists’ recommendations for pain management should be both effective and safe, which describes OTC medications, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Common NSAID classes include acetic acids (diclofenac, indomethacin, and ketorolac), COX-2 inhibitors (celecoxib), propionic acids (ibuprofen, ketoprofen, and naproxen), and salicylates (aspirin).

 Study results show that the combination of acetaminophen and ibuprofen is more effective in treating pain’s associated emotional distress than opioids.

Safety is always a concern. NSAIDs’ common AEs include gastrointestinal (GI) irritation, GI ulcers, and negative effects on renal function.

 Because it is neither an NSAID nor an opioid, acetaminophen avoids many AEs. However, it does carry a risk of liver toxicity.

To prove efficacy scientifically, many researchers have evaluated the number needed to treat (NNT), comparing several analgesics (table 1).

 NNT is the number of people who must be treated with a chosen intervention for 1 person to receive the desired effect.

 For this reason, a lower NNT is desirable, as this would signify a more potent medication.

Selecting the best treatment for each patient can be challenging. To do so accurately, pharmacists must first consider patient-specific issues that may affect medication selection (table 2).

Pain treatment is fraught with myth and uncertainty (table 3). For back pain, specifically sciatica, researchers found that opioids were ineffective.

 For dental pain, researchers found that the best recommendation is 325 mg of acetaminophen and 200 mg of ibuprofen daily after tooth extraction.

 And for severe pain, researchers found that NSAIDs and opioids were both effective.

Opioids are found to be beneficial in the short term but are ineffective in the treatment of chronic pain, which is defined as pain lasting longer than 4 months.

Recommendations for chronic pain include nonpharmacologic and pharmacologic treatment. Nonpharmacologic treatments include acupuncture, cognitive behavioral therapy, exercise therapy, peer support, and weight loss.

 When nonpharmacologic therapy is insufficient to improve pain, consider nonopioid pharmacologic therapies, such as acetaminophen, anticonvulsants, antidepressants, and NSAIDs.

 The general recommendation is, if and when opioids are used, prescribers should also prescribe nonopioids and nonpharmacologic therapy.

Cancer pain is a specific subset of chronic pain and has unique recommendations. For mild cancer pain, the recommendation is acetaminophen and NSAIDs. Opioids are used for more severe pain or when acetaminophen and NSAIDs are no longer effective. This is the only time that opioids are effective in cancer. Regarding end-of-life pain, opioids are not used to treat the pain but instead to relieve anxiety and treat depressions acutely.

 is a PharmD candidate at the University of Connecticut in Storrs.

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Pharmacists can help patients by recommending the most effective and safest therapies.